Lost in transformation? Reviving ethics of care in hospital cultures of evidence‐based healthcare

Drawing on previous empirical research, we provide an exemplary narrative to illustrate how patients have experienced hospital care organized according to evidence‐based fast‐track programmes. The aim of this paper was to analyse and discuss if and how it is possible to include patients’ individual perspectives in an evidence‐based practice as seen from the point of view of nursing theory. The paper highlights two conflicting courses of development. One is a course of standardization founded on evidence‐based recommendations, which specify a set of rules that the patient must follow rigorously. The other is a course of democratization based on patients’ involvement in care. Referring to the analysis of the narrative, we argue that, in the current implementation of evidence‐based practice, the proposed involvement of patients resembles empty rhetoric. We argue that the principles and values from evidence‐based medicine are being lost in the transformation into the current evidence‐based hospital culture which potentially leads to a McDonaldization of nursing practice reflected as ‘one best way’. We argue for reviving ethics of care perspectives in today's evidence practice as the fundamental values of nursing may potentially bridge conflicts between evidence‐based practice and the ideals of patient participation thus preventing a practice of ‘McNursing’.     

The challenges of caring in a technological environment: critical care nurses' experiences

Purpose. This paper presents and discusses the findings from a phenomenological study which illuminated the lived experiences of experienced critical care nurses caring within a technological environment. Background. While nursing practice is interwoven with technology, much of the literature in this area is speculative. Moreover, there is a debate as to whether and how ‘high tech’ and ‘high touch’ are reconcilable; this orientation is referred to as the optimism vs. pessimism debate. On a personal level, the motivation for this study came from the author's 13 years’ experience in the critical care area. Method. Following ethical approval, 10 experienced nurses from two cardiothoracic critical care units in Ireland participated in the study. A Heideggerian phenomenological methodology was used. Data collection consisted of unstructured interviews. A method of data analysis described by Walters was used. Findings. The findings provide research‐based evidence to illuminate further the optimistic/pessimistic debate on technology in nursing. While the study demonstrates that the debate is far from resolved, it reveals a new finding: life‐saving technology that supports the lives of critically ill patients can bring experienced nurses very close to their patients/families. The three main themes that emerged: ‘alien environment’, ‘pulling together’ and ‘sharing the journey’ were linked by a common thread of caring. Conclusion. Experienced critical care nurses are able to transcend the obtrusive nature of technology to deliver expert caring to their patients. However, the journey to proficiency in technology is very demanding and novice nurses have difficulty in caring with technology. Relevance to clinical practice. It is recommended that more emphasis be placed on supporting, assisting and educating inexperienced nurses in the critical care area and that the use of technology in nursing be given serious consideration.     

Facilitating safe care: a qualitative study of Iranian nurse leaders

Aim The purpose of this study was to explore and describe how nurse leaders facilitate safe care from the perspectives of both nurses and nurse leaders. Background The health-care system’s success in improving patient safety pivots on nursing leadership. However, there is a lack of knowledge in the international literature about how nurse leaders facilitate provision of safe care and reaching the goal of a safe health-care system. Method A qualitative design using a content analysis approach was applied for data gathering and analysis. In this study, 20 nurses (16 nurses and four head nurses) working in a referral teaching hospital in Tehran, Iran, were recruited through purposive sampling. Semi-structured interviews and 10 hours of structured observations were conducted to collect data. Results The data analysis resulted in three main themes: ‘providing environmental prerequisites for safe nursing practice’, ‘uniting and integrating health-care providers’, and ‘creating an atmosphere of safe care’. Conclusion The results indicate that to facilitate providing safe care, nurse leaders should improve nurses’ working conditions, develop the nurses’ practical competencies, assign duties to nurses according to their skills and capabilities, administer appropriate supervision, improve health-care providers’ professional relationships and encourage their collaboration, empower nurses and reward their safe practice. Implications for nursing management Approaching the challenge of patient safety requires the health-care system to combine its efforts and strategies with nursing leadership in its vital role of facilitating safe care and improving patient safety.     

Critical Care nurses' understanding of the NHS Knowledge and Skills Framework. An Interpretative Phenomenological Analysis

Aims: This small‐scale research study aimed to explore Critical Care nurses' understanding of the National Health Service (NHS) Knowledge and Skills Framework (KSF) in relationship to its challenges and their nursing role. Background: The NHS KSF is central to the professional development of nurses in Critical Care and supports the effective delivery of health care in the UK. KSF was implemented in 2004 yet engagement seems lacking with challenges often identified. Design: This qualitative study adopted an Interpretative Phenomenological Analysis framework. Method: Data were collected from five Critical Care nurses using semi‐structured interviews that were transcribed for analysis. Results: Two super‐ordinate themes of ‘engagement’ and ‘theory‐practice gap’ were identified. Six subthemes of ‘fluency’, ‘transparency’, ‘self‐assessment', ‘achieving for whom’, ‘reflection’ and ‘the nursing role’ further explained the super‐ordinate themes. Critical Care nurses demonstrated layers of understanding about KSF. Challenges identified were primarily concerned with complex language, an unclear process and the use of reflective and self‐assessment skills. Conclusions: Two theory‐practice gaps were found. Critical Care nurses understood the principles of KSF but they either did not apply or did not realize they applied these principles. They struggled to relate KSF to Critical Care practice and felt it did not capture the ‘essence’ of their nursing role in Critical Care. Relevance to clinical practice: Recommendations were made for embedding KSF into Critical Care practice, using education and taking a flexible approach to KSF to support the development and care delivery of Critical Care nurses.     

Implementation of evidence‐based practice by nurses working in community settings and their strategies to mentor student nurses to develop evidence‐based practice: A qualitative study

The aim of the study was to explore how community nurses apply the best available evidence to their practice, and how they mentor student nurses to conceptualize and implement evidence‐based practice in community settings. In the UK, the expansion of health‐care provision in the community has supported the development of highly skilled community nurses. However, there is limited literature regarding the strategies used by community nurses to implement evidence‐based practice and mentor student nurses to conceptualize evidence‐based practice in community placements. An exploratory qualitative approach applying inductive reasoning to focus group data was used. As a result, nurses working for a community NHS Foundation Trust in South England with a mentor qualification were invited to participate in one of the seven focus groups, 33 nurses participated. Data were analyzed with thematic analysis. The themes discussed in this paper are: ‘our practice is evidence‐based’ as guidelines and policies provided structure, but occasionally stifled autonomous clinical decision‐making, and ‘time’ as a barrier and facilitator to mentoring student nurses in community settings. In conclusion, nurses need to develop the ability to incorporate patients' needs and wishes within evidence‐based care. Time was a facilitator for some community mentors, but protected time is required to complete the necessary practice documentation of student nurses.     

Barriers to evidence-based nursing: a focus group study

Title. Barriers to evidence‐based nursing: a focus group study Aim. This paper reports a study to explore the barriers to evidence‐based nursing among Flemish (Belgian) nurses. Background. Barriers obstructing the call for an increase in evidence‐based nursing have been explored in many countries, mostly through quantitative study designs. Authors report on lack of time, resources, evidence, authority, support, motivation and resistance to change. Relationships between barriers are seldom presented. Methods. We used a grounded theory approach, and five focus groups were organized between September 2004 and April 2005 in Belgium. We used purposeful sampling to recruit 53 nurses working in different settings. A problem tree was developed to establish links between codes that emerged from the data. Findings. The majority of the barriers were consistent with previous findings. Flemish (Belgian) nurses added a potential lack of responsibility in the uptake of evidence‐based nursing, their ‘guest’ position in a patient’s environment leading to a culture of adaptation, and a future ‘two tier’ nursing practice, which refers to the different education levels of nurses. The problem tree developed serves as (1) a basic model for other researchers who want to explore barriers within their own healthcare system and (2) a useful tool for orienting change management processes. Conclusion. Despite the fact that the problem tree presented is context‐specific for Flanders (Belgium), it gives an opportunity to develop clear objectives and targeted strategies for tackling obstacles to evidence‐based nursing.     

Mental health nursing: Daring to be different,special and leading recovery‐focused care?

How mental health nursing is differentiated from other disciplines and professions, and what special contribution mental health nurses make to health services, is a question at the heart of contemporary practice. One of the significant challenges for mental health nurses is identifying, developing and advancing those aspects of their practice that they consider differentiate them in the multi‐disciplinary mental health care team and to articulate clearly what a mental health nurse is and does. This paper draws on data from interviews with 36 mental health nurses in Australia who identified their practice as autonomous. Participants were asked the question, “What's special about mental health nursing?” Constructivist grounded theory techniques were applied to the research process. Findings were formulated and expressed as the ‘Ten P's of the professional profile that is mental health nursing’, which are ‘present’, ‘personal’, ‘participant partnering’, ‘professional’, ‘phenomenological’, ‘pragmatic’, ‘power‐sharing’, ‘psycho‐therapeutic’, ‘proud’ and ‘profound’. The combined elements of the findings present a theoretical construct of mental health nursing practice as something distinctive and special. It provides a model and exemplar for contemporary practice in mental health nursing, embracing the role of mental health nurses in the health care workforce as being well placed as providers of productive and effective care.     

Living with dying: a hermeneutic phenomenological study of the work of hospice nurses

Aims. (i) Explore the meaning of comfort care for hospice nurses. (ii) Provide an understanding of how this work is pursued in the hospice setting. (iii) Examine the means by which hospice nurses provide comfort to hospice patients. Background. The concepts of ‘comfort’ and ‘comfort care’ have long been a subject for examination by nurse researchers. The paper provides an overview of selected, relevant literature in this area. The methods used by nurse researchers have almost always been qualitative, and have focused on the meaning of nursing care for dying patients, from both nurses’ and patients’ perspectives. Design and methods. The paper reports a hermeneutic phenomenological study of the work of 15 hospice nurses based in one hospice in the north of England. Sampling was purposive, and data were collected by means of semi‐structured interviews. A reflective diary was also kept. The interpretation of data was guided by phenomenological and hermeneutic methodology. Results. The nurses interviewed spoke openly about their experiences of working with hospice patients. They saw the relief of suffering through ‘comfort care’ as an important element of their work. The findings are presented under three thematic headings: ‘Comfort and relief’, ‘Peace and ease’ and ‘Spirituality and meaning’. Conclusion. Hermeneutic phenomenology is an important method for uncovering the complex realities of nursing work. The nurses’ perspectives on ‘comfort care’ they offer to patients were revealed by the data presented here, which were interpreted to offer a unique perspective on this type of nursing work. Relevance to clinical practice. These findings offer insights to nurses in both hospice and other settings; they give a number of perspectives on the nature of ‘comfort care’ and the meanings attached to it by experienced hospice nurses’.     

Nurses’ attitudes towards physical activity care among older people

Aims and objectives. To understand nurses’ attitudes towards physical activity care for older people in long‐term care facilities. Background. In long‐term care facilities, a common approach to daily physical activity is based on the identifiable portions of daily life during which the activity occurs. However, older people are at risk of falling when they perform daily physical activities. Nurses are the first‐line caregivers. What nurses’ think and do regarding older people’s participation in daily physical activities in long‐term care facilities is very important in terms of the clinical decision‐making regarding older people’s physical activity care. Design. An exploratory qualitative design. Methods. Twenty nurses with more than three years of clinical experience from 13 long‐term care facilities located in northern Taiwan were sampled purposively. Data were collected though semi‐structured interviews. The constant comparative data analysis method was used throughout the research. Results. Five themes emerged from the data analysis: ‘recognising the importance of participation in daily physical activity’, ‘encouraging participation in physical activity’, ‘respecting the autonomy of the residents regarding participation in physical activity’, ‘preventing falls’ and ‘facing a dilemma’. Conclusions. This study identifies that there is a conflict between the nurses’ perceptions of the residents’ daily physical activities, the risk of falls and encouraging greater independence. The majority of staff employed in long‐term care facilities is nursing personnel, and it is these nurses who have the most contact with the residents. It is therefore believed that nurses can make the greatest difference to the residents’ lives and support the quality of care if they can resolve this conflict. Relevance to clinical practice. The results suggest the need to increase the nurses’ knowledge base regarding the benefits of physical activity and also highlight the potentially adverse effect of restraint usage by nurses.     

Reflection in night nursing: a phenomenographic study of municipal night duty registered nurses’ conceptions of reflection

Aim. The aim of the study was to describe nurses’ conception of reflection in their working situation. Background. To be a municipal night duty registered nurse in Sweden means to shoulder nursing care responsibility for numerous units with older people in need of care. Two night nurses share nursing care responsibility for up to 1300 people. In nursing research, reflection is an often‐mentioned phenomenon discussed with advantages and benefits within the ‘traditional fields’ of nursing (hospital context). A question to ask is, how do night nurses having an untraditional amount of nursing care responsibility conceptualise and experience reflection in their working situation? Design. A phenomenographic methodology was used. Methods. Data were collected by interviewing all nurses (n = 7) in a medium‐sized municipality bordering a metropolitan area of Sweden. Results. The nurses’ conceptions of reflection are categorised as ‘Field of applications’ (an instrument for interpreting, a strategy for handling the working situation and an approach to learning) and ‘Field of prerequisites’ (presence facilitates reflection; flexibility implies reflection; courage in thought and activity increases reflection). Conclusion. The findings reveal that reflection in the nurses’ working situation is more than an instrument for learning, understanding and encouragement for change and improvement. Reflection is conceptualised as an instrument for interpreting nursing care situations, which requires courage and is facilitated by presence and flexibility. Reflection is also conceptualised as an approach to handling, managing and coping with a sometimes impossible working situation that includes nursing responsibility for hundreds of older people and can sometimes entail difficulties and stress. Relevance to clinical practice. The findings showed that reflection has a broader use than had earlier been described. Deliberate use of reflection could mean improved nursing practice. This guides nursing managers to pay attention to the phenomenon as an instrument for nursing care improvement.     

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.     

Implementing child-focused family nursing into routine adult psychiatric practice: hindering factors evaluated by nurses

Aims and objectives. The aim of this study is to describe nurses’ evaluations of factors that are hindering implementation of child‐focused family nursing (CF‐FN) into adult psychiatric practice. In addition, it explains the nurses’ evaluations of the hindering factors related to the hospital organizational structure, the individual nurse, nursing and family. Background. There is an increasing amount of families with dependent children in adult psychiatry. Although these families have long‐term benefits from preventive family interventions, implementation of CF‐FN is not routine mental health practice. Design and methods. Data were collected via a questionnaire‐survey completed by Registered Psychiatric Nurses (n = 223) and practical Mental Health Nurses (n = 88) from 45 adult psychiatric units in five Finnish university hospitals. The response rate was 51%. Results. Family‐related factors, such as families’ fears and lack of time, were considered as ‘most hindering’ to CF‐FN. Nurses who used a family‐centred approach and had further family education considered most of the factors as ‘less hindering’ in comparison to other nurses. Conclusion. To meet the needs of the families in mental health services, it is essential to develop nursing intervention methods such as CF‐FN. There is a need for further education and use of family‐centred care to develop this preventive approach. Relevance to clinical practice. The results of this study could be considered when developing mental health services and family interventions for families with parental mental illness.     

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.