Patient‐centeredness in long‐term care of older patients – a structured interview

Aim. The aim of this study was to describe assessments of older people about patient‐centeredness in the long‐term care of Estonian hospitals, and to determine correlations between patients’ assessments and their socio‐demographic characters. Background. Patient‐centeredness increases patients’ satisfaction and enhances their recovery. Still, patients’ opinions are not always taken into account. Method. A cross‐sectional study included 111 older people in long‐term care of 14 Estonian hospitals. Data were collected in 2008 by means of structured interviews. Results. What patients agreed most was that they were given enough opportunity to carry out activities they were capable of performing themselves. Two thirds of participants had not been sufficiently consulted on who would be providing their care. Half of the participants were not given sufficient opportunity to decide what kind of care was needed and how they would receive it. The more assistance patients needed in daily living activities, the less they considered the care as patient‐centred. Conclusions. From the perspective of older people, the patient‐centeredness in Estonian long‐term care is above average. Providing patient‐centred long‐term care in Estonian hospitals deserves more attention. Relevance to clinical practice. Older people should be more involved in decision‐making, especially those who need more assistance in daily living activities.     

Curbing the urge to care: A Bourdieusian analysis of the effect of the caring disposition on nurse middle managers’ clinical leadership in patient safety practices

BackgroundNurse managers play an important role in implementing patient safety practices in hospitals. However, the influence of their professional background on their clinical leadership behaviour remains unclear. Research has demonstrated that concepts of Bourdieu (dispositions of habitus, capital and field) help to describe this influence. It revealed various configurations of dispositions of the habitus in which a caring disposition plays a crucial role.ObjectivesWe explore how the caring disposition of nurse middle managers’ habitus influences their clinical leadership behaviour in patient safety practices.DesignOur paper reports the findings of a Bourdieusian, multi-site, ethnographic case study.SettingsTwo Dutch and two American acute care, mid-sized, non-profit hospitals.ParticipantsA total of 16 nurse middle managers of adult care units.MethodsObservations were made over 560 h of shadowing nurse middle managers, semi-structured interviews and member check meetings with the participants.ResultsWe observed three distinct configurations of dispositions of the habitus which influenced the clinical leadership of nurse middle managers in patient safety practices; they all include a caring disposition: (1) a configuration with a dominant caring disposition that was helpful (via solving urgent matters) and hindering (via ad hoc and reactive actions, leading to quick fixes and ‘compensatory modes’); (2) a configuration with an interaction of caring and collegial dispositions that led to an absence of clinical involvement and discouraged patient safety practices; and (3) a configuration with a dominant scientific disposition showing an investigative, non-judging, analytic stance, a focus on evidence-based practice that curbs the ad hoc repertoire of the caring disposition.ConclusionsThe dispositions of the nurse middle managers’ habitus influenced their clinical leadership in patient safety practices. A dominance of the caring disposition, which meant ‘always’ answering calls for help and reactive and ad hoc reactions, did not support the clinical leadership role of nurse middle managers. By perceiving the team of staff nurses as pseudo-patients, patient safety practice was jeopardized because of erosion of the clinical disposition. The nurse middle managers’ clinical leadership was enhanced by leadership behaviour based on the clinical and scientific dispositions that was manifested through an investigative, non-judging, analytic stance, a focus on evidence-based practice and a curbed caring disposition.     

Cancer nurses narrating after conversations with cancer outpatients: how do nurses’ roles and patients’ perspectives appear in the nurses’ narratives?

Aim: The aim of this study was to contribute to knowledge of nursing practice in the cancer care field by exploring cancer nurses’ perceptions of conversations with cancer outpatients. Background: Current practice at cancer outpatient clinics in Norway is that nurses have planned conversations with patients and relatives as a follow‐up after patient–physician conversations about assessment and medical treatment. Little is known about nurses’ experiences of conversations in the ambulatory context. This study reports the experiences of initial patient–nurse consultations. Data were collected in 2006–2007. Design: A qualitative phenomenological hermeneutic study was performed. A purposive sample of 12 cancer nurses was selected for qualitative interviews where nurses were narrating about conversation experiences. Significance and meaning of conversation experiences were analysed within a hermeneutic perspective, inspired by Ricoeur. Anonymity and voluntary participation procedures were followed. Ethical approval for the study was obtained from the Regional Committee for Medical Research Ethics of the region. Findings: There were plots of nurses experiencing conversations as hard work, routine work or artistry. The nurses’ conceptualizations of their roles as an information provider, or patient‐centred caring role were rooted in rules of the nursing community or in humanistic caring ethics. Differences of nurses’ perceptions and experiences of conversations are explained by different attitudes and role appreciations. Conclusion: Cancer nurses’ role appreciation and meaning horizons are guiding their perceptions of patient–nurse communication. Feeling free to act in interplay with patients’ voices, the patients’ perspectives become foreground. There is an educational challenge here in terms of developing methods to help nurses to discover how their mental work and meaning horizons guide conversational practice.     

Police referrals to a psychiatric hospital: Experiences of nurses caring for police‐referred admissions

Police are a major source of referral to psychiatric hospitals in industrialized countries with mental health legislation. However, little attention has been paid to nurses' experience of caring for police‐referred patients to psychiatric hospitals. This study utilized a Heideggerian phenomenological framework to explore the experiences of nine nurses caring for patients referred by the police, through semistructured interviews. Two major themes emerged from the hermeneutic analyses of interviews conducted with nurse participants: (i) ‘expecting “the worst” ’; and (ii) ‘balancing therapeutic care and forced treatment’. Expecting ‘the worst’ related to the perceptions nurse participants had about patients referred by the police. This included two sub‐themes: (i) ‘we are here to care for whoever they bring in’; and (ii) ‘but who deserves care?’ The second theme balancing therapeutic care and forced treatment included the sub‐themes: (i) ‘taking control, taking care’; and (ii) ‘managing power’. The study raises ethical and skill challenges for nursing including struggling with the notion of who deserves care, and balancing the imperatives of legislation with the need to work within a therapeutic framework.     

Reframing the meaning of life and professional values: A theoretical framework of facilitating professional care for terminally ill patients

Professional values reflect nurses' understanding of how to deliver professional care, which might influence nurses' attitudes and caring behaviors during end‐of‐life care. However, limited research has been conducted to explore nurses' experiences of professional development during end‐of‐life care, and theoretical explanations are scarce about how nurses enact their professional values during the caring process. This study explored the social process of professional values involved in end‐of‐life care in the Chinese cultural context by adopting a constructivist grounded theory approach. Twenty semi‐structured in‐depth interviews with 15 nurses from three hospitals in southeastern China were conducted. A theoretical framework emerged when focusing on the social process of “reframing the meaning of life and professional values” to facilitate professional care for terminally ill patients. Three main categories were sequentially identified as “recognizing the dilemmas when caring for terminally ill patients,” “applying strategies to deal with values conflict,” and “reconstructing values.” This theoretical framework may be applied as a practical framework for equipping nurses with effective strategies to cultivate professional values, including the provision of adequate end‐of‐life knowledge, and a supportive workplace environment.     

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.     

Fostering the coexistence of caring philosophy and economics in today's health care system

For the past decade, several health care systems are undergoing continuous administrative restructuring, whose main objective is cost reduction. These changes often result in the patients' needs not being met because nurses are continuously affected by widespread budget cuts and staff downsizing. Have we reached a point, where we are setting aside our prime directive of patient well-being for the sake of finances? If so, are we at risk of forsaking our professional identity as nurses? The authors believe that caring management and economical constraints can coexist while promoting quality patient care. The purpose of this article is to show how nurse managers and administrators can facilitate caring practices while maintaining their financial responsibilities within the health care organization. This article suggests several strategies for assisting nurse managers in promoting caring in the health care environment.     

The effect of structural empowerment and perceived organizational support on middle level nurse managers' role satisfaction

BACKGROUND: The restructuring of Canadian health care organizations during the past decade has reduced the visibility of nursing leadership. This has resulted in job conditions that have disempowered nurse managers and influenced their ability to create positive work environments, mentor potential nurse leaders, and gain satisfaction in the leadership role. These conditions threaten the retention of a cadre of high quality nurse leaders in today's chaotic health care setting. OBJECTIVE: The purpose of this study was to examine the relationship between structural empowerment and perceived organizational support and the effect of these factors on the role satisfaction of middle level nurse managers. METHOD: A secondary analysis was conducted as part of a larger study of 126 middle level nurse managers working in Canadian acute care hospitals, randomly selected from the Ontario provincial registry. Eighty-four nurse managers responded to a questionnaire mailed to their home addresses. RESULTS: Structural empowerment was positively associated with middle level nurse managers' perceived organizational support. The combination of empowerment and perceptions of organizational support were significant predictors of middle level nurse managers' role satisfaction. CONCLUSIONS: The findings support R.M. Kanter's (1977, 1993; Men and Women of the Corporation. Basic Books, New York) contention that empowering work conditions have an impact on employees' feelings of support and sense of accomplishment at work. Positive perceptions of organizational support may play an important role in retaining current middle managers, and possibly attracting future leaders to management positions.     

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.     

Developing a self‐checklist of staff development behavior for associate nurse unit managers using the Delphi method

The most significant influence on nurses' professional growth is through work under direct guidance in clinical settings. Associate nurse unit managers perform direct patient care with the staff, as well as assist management work of nurse unit managers. They can be excellent role models for the staff. We examined their behaviors that help promote staff development, aimed to identify effective behaviors, and created a self‐checklist to evaluate them. We created 53 items to assess staff development behaviors, which were evaluated via a Delphi survey with 252 experts and a questionnaire survey with 124 associate nurse unit managers in Japan to evaluate whether the created item was appropriate. The results of the Delphi survey showed an agreement rate of over 90%, and associate nurse unit managers showed an acceptance rate of 82.6–99.2% for 40 of 53 items. Consequently, we created 40‐item self‐checklist of staff development behaviors for associate nurse unit managers with adequate validity. This checklist would be helpful for them to promote staff development while working in clinical settings and would contribute to enhancing the quality of nursing.     

Shaping positive work environments for nurses: the contributions of nurses at various organizational levels

This paper focuses on nurses' perceptions of their individual contributions to the work environment. Fourteen community hospitals participated in the study. A positive nursing work environment was selected in each agency by its Director of Nursing. Selection was based on subjective and objective criteria. All staff nurses, nurse managers and the director of nursing associated with these units were asked to respond to an open-ended question describing their perceived contributions to the work settings. Ninety-two nurses responded for a response rate of 42%. Overall the three themes of People, Practice and Place surfaced from 15 categories of responses. The same three themes surfaced for all three nurse groups but variation was noted with regards to the categories of contributions the groups most frequently reported within the theme. In this time of continuous change throughout the health care system, nurses need to be able to articulate and affirm their important contributions to the effective shaping of positive health care settings. A focus on contributions could assist with team building, leadership development and have an important impact on quality patient care outcomes.     

When caretaking competes with care giving: a qualitative study of full‐time working mothers who are nurse managers

Aim The purpose of this study was to explore the motivations and stresses associated with full‐time working mothers who practice as nurse managers. Background Full‐time work outside the home for mothers has been recognized as a circumstance which may present certain benefits and risks to family life. Nursing management is recognized as a high‐stress occupation, which may be filled by mothers who work full time. Little is known about the specific needs and stresses of full‐time nurse managers who are caring for children at home. Methods In‐depth interviews were conducted with 13 mothers who worked as nurse managers. Results Participants expressed challenges in several areas including balancing/separating work and home, self‐imposed advancement inhibitions, and constant giving. Challenges were offset by assets, which included complimentary roles, health insurance, added income, and professional and personal fulfilment. Conclusion Participants ‘wanted it all’, including the conveniences of part‐time employment and the benefits of full‐time employment. Implications for nursing management Full‐time nurse mangers with children at home experience unique tensions which characterize their work and home environments. Employers may assist nurses by adopting flexible scheduling, educational and child‐care support and assistance in negotiating work and home roles.     

Interactions between persons—Knowledge,decision making,and the co‐production of practice

There is now broad agreement that ideas like person‐centred care, patient expertise and shared decision‐making are no longer peripheral to health discourse, fine ideals or merely desirable additions to sound, scientific clinical practice. Rather, their incorporation into our thinking and planning of health and social care is essential if we are to respond adequately to the problems that confront us: they need to be seen not as “ethical add‐ons” but core components of any genuinely integrated, realistic and conceptually sound account of healthcare practice. This, the tenth philosophy thematic edition of the journal, presents papers conducting urgent research into the social context of scientific knowledge and the significance of viewing clinical knowledge not as something that “sits within the minds” of researchers and practitioners, but as a relational concept, the product of social interactions. It includes papers on the nature of reasoning and evidence, the on‐going problems of how to ‘integrate’ different forms of scientific knowledge with broader, humanistic understandings of reasoning and judgement, patient and community perspectives. Discussions of the epistemological contribution of patient perspectives to the nature of care, and the crucial and still under‐developed role of phenomenology in medical epistemology, are followed by a broad range of papers focussing on shared decision‐making, analysing its proper meaning, its role in policy, methods for realising it and its limitations in real‐world contexts.     

Re-reading nursing and re-writing practice: towards an empirically based reformulation of the nursing mandate

This article examines field studies of nursing work published in the English language between 1993 and 2003 as the first step towards an empirically based reformulation of the nursing mandate. A decade of ethnographic research reveals that, contrary to contemporary theories which promote an image of nursing work centred on individualised unmediated caring relationships, in real-life practice the core nursing contribution is that of the healthcare mediator. Eight bundles of activity that comprise this intermediary role are described utilising evidence from the literature. The mismatch between nursing's culture and ideals and the structure and constraints of the work setting is a chronic source of practitioner dissatisfaction. It is argued that the profession has little to gain by pursuing an agenda of holistic patient care centred on emotional intimacy and that an alternative occupational mandate focused on the healthcare mediator function might make for more humane health services and a more viable professional future.     

Pre-hospital emergency nurse specialist’s experiences in caring for patients with non-specific chief complaints in the ambulance – A qualitative interview study

BackgroundPre-hospital emergency nurse (PEN) specialists are faced with patients presenting with non-specific chief complaints (NSC) to the emergency medical service (EMS) on a daily basis. These patients are often elderly and one in three has a serious condition and their acuity is not recognized.ObjectiveThe aim of the current study was to explore PEN specialists’ experiences in caring for patients presenting with non-specific chief complaints.DesignA qualitative study design with eleven individual interviews of PENs, between 2018 and 2020. Qualitative content analysis was used.ResultsThe analyses generated three categories including subcategories. The categories were “Unexplained suffering”. “Systematic approach and experience enhances medical safety”. “Organizational processes can be optimized”. The relation between the categories compiled as ́In-depth systematic assessment is perceived to reduce suffering and increases patient safetý.ConclusionThe PENs experiences in caring for patients presenting with non-specific chief complaints show that an in-depth systematic assessment may lead to a meaningful caring encounter which enables the identification of the cause of the chief complaint. Experience and a systematic approach were considered as essential to enhance medical safety. This could be strengthened through feedback on the nurse's care provided by care managers and employers. To optimize organizational processes, the development of the opportunity to convey the patient to different levels of care can be an important component.     

Working in long-term care settings for older people with dementia: nurses' aides

Aim. This paper reports a study exploring the reasons for continuing to work among nurse aides who cared for older people with dementia in long‐term care settings in Taiwan. Background. High nurse aide turnover has been a major problem for many managers of long‐tem care facilities in Taiwan. Most studies on nurse aide turnover have focused on the factors on why they left, but little is known about their reasons for continuing to work in long‐term care settings in Taiwan. Methods. A qualitative research design was used. Sixteen nurse aides were interviewed individually using a semi‐structured interview guide and content analysis was used to identify the major themes in the data. Results. Five major themes emerged from interview data: monetary needs, relationships with residents, working environment, training opportunities and gratification (listed in order of frequency of occurrence). Conclusion. Nurse aides face challenges in caring for the increased number of older people with cognitive impairment and it is important to assess their perspectives towards their work in the changing environment. The findings suggest that it is essential for nursing managers to assess nurse aides’ needs to increase job retention and to improve the quality of resident care in long‐term care settings. Relevance to clinical practice. Careful appraisal of prospective nurse aides’ attitudes, regular training programmes in dementia care, adequate staffing and equipment, performance‐based pay rises and subsidized training are practical retention strategies for these nurse aides.     

Nurses’ competencies in home healthcare: an interview study

Background

Nurses working in Home healthcare (HHC) are facing major challenges since more advanced care and treatment are increasingly being carried out in patients’ homes. The aim of this study has been to explore how nurses experience their competencies in HHC situations.

Methods

This study has a qualitative and explorative design. Ten nurses were interviewed and data was analyzed using content analysis.

Results

The themes “Being a capable nurse”, “Being a useful nurse” and “Being a subordinate and dependent nurse” were identified. Nurses want to be capable of taking care of patients, to develop their competencies and to perform their duties in the way required. They also want their work to be useful and to provide good and safe HHC. Finally, nurses want to improve HHC care by applying their competencies. Simultaneously, they are subordinate and dependent in relation to their manager and also dependent upon their manager’s interest in encouraging nurses’ competence development.

Conclusions

Nurses in HHC are responsible for many seriously ill patients and they want to contribute to good and safe patient care. To maintain patient safety, reduce the risk for burnout and staff turnover as well as to contribute to a sustainable development of the work, strategies for transferring competencies between nurses and efforts for competence development are needed.

     

The use of interdisciplinary seminars for the development of caring dispositions in nursing and social work students

Title. The use of interdisciplinary seminars for the development of caring dispositions in nursing and social work students. Aim. This paper is a report of a study to evaluate the influence of interdisciplinary seminars for undergraduate nursing and social work students on development of their understanding of the meaning of caring. Background. There is growing international interest in interprofessional education, which is believed to have the potential to improve patient care. If interprofessional education and subsequent collaboration are truly to be patient‐centred, it is important to identify a value base which creates a healthcare professional identity that facilitates collaboration. Caring, as a humanistic value, is found in both nursing and social work professionals. Method. A mixed method approach, primarily qualitative but with a quantitative component, was chosen for evaluation of the interprofessional seminars. The data were collected between 2007–2008 by videotape recordings of the sessions, follow‐up telephone interviews and a questionnaire. Findings. There was cultivation in the nursing students of a deeper understanding of caring based on openness and a non‐judgmental approach, learned from their social work counterparts. Reciprocally, social work students learned about the nursing students’ daily activities as they observed the natural process of trust and communication in the context of caring. Conclusion. Enhanced understanding of caring in practice is not possible via learning through a uni‐professional approach. Students’ reflections and dialogue enable their development of relation‐centred caring, particularly in the realm of biomedical and technical environments.     

Connecting patients,practitioners, and regulators in supporting positive experiences and processes of shared decision making: A progress report

This paper describes a novel approach to explore how regulators, working with patients and practitioners, may contribute to supporting person‐centred care and processes of shared decision making in implementing professional standards and reducing harms. Osteopathic patients report high levels of patient care. However, areas of consultations less likely to be rated as high included “fully understanding your concerns,” “helping you to take control,” and “making a plan of action with you,” suggestive of a paternalistic approach to care and a barrier to the effective implementation of standards. This programme explored how to support patients and practitioners to make more explicit what is important to support consultations with better communication in accordance with standards. A series of workshops took place involving approximately 80 participants, which explored and identified practitioner and patient values; these were themed to develop a common framework and tested using case studies. Aspects of what enables or presents a barrier to a positive consultation were further explored with real patient narratives, and a range of resources were subsequently developed, which may support patients and practitioners to make explicit what is important to them in a consultation. A series of approaches and tools were then developed for piloting including patient curriculum vitae; patient goal planner; patient animation to support preparation for an appointment; infographic: a patient poster or leaflet; practitioner reflective tool; and an audio recording to increase awareness and understanding of values‐based practice. In conclusion, a range of approaches may help to support patients and practitioners to make explicit what is important to them in a consultation. The next phase of our programme will use a range of methods including cluster sampling, pre‐testing and post‐testing with the Consultation and Relational Empathy (CARE) measure tool, and interviews and focus groups with users and practitioners to demonstrate impact.