An ethnographic study of human dignity in nursing practice

BackgroundThe ethical values of nursing are crucial to the provision of humane care. Human dignity is a core value that must be preserved in order to deliver such care. No studies to date have compared the perceptions of nurses and/or patients regarding the components of dignified care embedded in actual clinical practice.PurposeTo explore the delivery of dignified care by professional nurses. This was an ethnographic qualitative study combining inductive and deductive methods to identify emergent themes. A multicenter study carried out in the internal medicine units of four hospitals in Barcelona (Spain). Convenience sampling was used to recruit nurses from the four units.Setting and sampleMulticenter study carried out in the internal medicine units of four hospitals in Barcelona (Spain). Convenience sampling was used to recruit nurses from the four units.MethodWe conducted 158 hours of participant observation of 27 nurses. Semi-structured individual interviews were undertaken with 20 of these nurses, with data saturation being reached. Data were collected between September 2014 and May 2016 and were analysed using ATLAS.ti 7.2 for Windows.ResultsTwo themes emerged from the analysis: Delivering dignified care and Factors influencing the delivery of dignified care. The nurses regarded human dignity as one of the key values of their profession. However, there was a discrepancy between their perceptions of the care they offered and what they actually did, due mainly to a lack of awareness about their own practice. Respect, confidentiality, privacy and communication were identified as the key elements underpinning dignified care. Institutional policies were seen as the major obstacle to the delivery of humane care, the key issues being frequent shift rotations, a high patient-nurse ratio and excessive paperwork.ConclusionsThe results of this study underline the importance of delivering dignified care and the need to ensure that nurses' attitudes and behaviours are consistent with this goal. The ethnographic approach, combining participant observation with individual interviews, revealed discrepancies between nurses' perceptions of the care they offered, or should offer, and what they actually did. This suggests a need for professional forums in which nurses can become more aware of their own clinical practice.     

Culture and communication in Thai nursing: a report of an ethnographic study

Most nurses live and work in multicultural settings. Given the need for all nurses and health-care workers to communicate--with patients, with families and with other health-care professionals--the study of the relationship between culture and communication can help to inform practice. This paper offers the findings from an ethnographic study of culture and communication, carried out in Thailand. The aim of the study was to address the question: 'in what, if any, ways do Thai cultural issues influence interpersonal communication patterns in Thai nursing and Thai nursing education?'. Data were collected from a variety of sources, including direct and indirect observation, interviews and discussions and the literature on the topic. For the interviews, the sample was a convenience and purposive one made up of clinical nurses and nurse educators (n = 14). Those data were analysed with the aid of a computerised, qualitative data analysis program. Findings reported in this paper include those relating to 'Thainess', Buddhism, the nursing profession and nurse--patient/doctor--patient relationships. The report ends with a 'portrait' of Thai nursing communication. It is suggested that understanding the cultural aspects of nursing in various contexts can help nurses, internationally.     

An ethnographic study of differentiated practice in an operating room

An ethnographic study was conducted to investigate implementation of the clinical nurse III or team leader (TL) role as part of a newly executed nursing differentiated practice model. The six TLs studied were employed in the operating room (OR). Through participant observation, interviews, and document analysis, the TL role--as well as perceptions of the role by the TLs and OR staff--were studied. Problems related to performance of the role and its evolutionary process were delineated. Data analysis involved identifying categories and subcategories of data and developing a coding system to identify themes. Salient themes were related to the culture of the OR. Because of the OR's highly technical environment, the TLs defined their roles in relation to the organizational and technical needs of their surgical service. Refinement of surgeon "preference cards" and "instrument count sheets" was considered the initial priority for the TLs. Various controllable and uncontrollable factors were identified that affected implementation of the new TL role. Findings suggest that introduction of the role requires insight into setting and an emphasis on staging and orientation of employees to the new role.     

An ethnographic evaluation of a speciality training pathway for general practice nursing in the UK

AimsThe aim of the study was to evaluate the implementation and impact of the General Practice Nurse – Specialty Training (GPN-ST) programme across seven sites in one geographical location in the UK. The objectives were to understand, describe and evaluate: 1) the implementation of the ‘proof of concept’ training scheme; 2) the learning undertaken during the training; and 3) the impact of the training scheme on individual nurses. These objectives offer the opportunity to describe the potential return on investment for General Practices supporting nurses new to General Practice through the programme.BackgroundGeneral Practice Nurses (GPNs) play a vital role in delivering primary and community care. In the UK there is a shortfall in the GPN workforce. Unlike training for other clinical professions there is currently no standardised training pathway or entry route for nurses wishing to work in General Practice.An ethnographic evaluation was undertaken of a one-year speciality training programme (GPN-ST). The programme, aimed at nurses new to General Practice, included formal higher education training and funded supported learning and mentoring whilst in practice.MethodsA qualitative ethnographic evaluation was undertaken. Observations were conducted of programme implementation, network and education meetings in the scheme. In-depth, semi-structured, interviews and focus groups were conducted with a wide range of professionals (n = 40) including nurse mentors, nursing students, academic providers, commissioners and the programme managers. These data were supplemented by documentary analysis of meeting notes, learning materials, internal student feedback and locally collected evaluation material in line with ethnographic approaches to research. Kirkpatrick’s model for course evaluation and complimentary inductive emergent thematic analysis was used.FindingsThere is evidence of learning at every level of the Kirkpatrick model from reaction through to changes in behaviour and results in practice for patients. The speciality training route offered opportunities for deep learning for GPNs. The scheme offered a comprehensive career pathway to General Practice nursing which in turn benefited General Practices. Practices benefitted from confident, independent nurses who were able to contribute to patient care, practice safely and also contributed widely in the long-term for example in research, workforce development and mentoring.ConclusionsGeneral Practice needs to invest in developing a workforce of GPNs, there are significant benefits to investing in the development of GPNs through a training pathway. This scheme provides scope for application in other clinical settings as well in other countries where there is a gap in career progression into GP practices.Tweetable abstractGPNs play a vital role in delivering primary and community care. Unlike training for other clinical professions there is currently no standardised training pathway or entry route for nurses wishing to work in General Practice. There are significant benefits to investing in the development of GPNs through a training pathway     

Professional collegiality and peer monitoring among nursing staff: An ethnographic study

Background

Patient safety and professional self-regulation systems both rely on professional colleagues to hold each other accountable for quality of care.

Objectives

To understand how staff nurses manage variations in practices within the group, and negotiate the rules-in-use for quality of care, collegiality, and accountability.

Design/methods

Ethnographic case study; participant-observation, semi-structured interviews, policy analysis.

Setting

In-patient unit in an urban US teaching hospital.

Results

Explicit acknowledgment of conflicts and practice variations was perceived as risky to group cohesion. The dependence of staff on mutual assistance, and the absence of a system of group practice, led to the practice of “mutual deference”, a strategy of reciprocal tolerance and non-interference that gave wide discretion to each nurse's decisions about care.

Conclusions

Efforts to improve professional accountability will need to address material constraints and the organization of nursing work, as well as communication and leadership skills.     

Self-caring in Islamic culture of Muslim persons with ESRD and hemodialysis: An ethnographic study

Objective

Culture and religion may influence self-caring of persons with End Stage Renal Disease on hemodialysis therefore the study aimed to explore self-caring in an Islamic culture of Muslim persons living with End Stage Renal Disease undergoing hemodialysis.

Factors influencing medication adherence in South Asian people with cardiac disorders: An ethnographic study

BackgroundSouth Asians experience higher rates of cardiovascular disease than any other ethnic group. Some evidence suggests that South Asians may be less adherent to cardiac medication regimens than Whites residing in Canada. Identification of the key factors contributing to adherence may assist this growing population to optimize their cardiac health.AimTo explore key factors associated with adherence to cardiac medications among South Asian people with cardiac disease.MethodsEthnography was used to highlight population specific themes and domains related to medication adherence. Ethnographic observations were undertaken of patients, as well as their family (primary care) physicians and pharmacists (including their staff), while in physician offices and pharmacies. A purposive sample of patients (n = 8), as well as physicians (n = 3) and pharmacists (n = 2) underwent in-depth interviews. Field note and interview data were transcribed verbatim and analyzed using ethnographic domain and thematic analysis.ResultsThe patients relied on family members for instrumental support in remaining adherent with their medications. Relationships with healthcare professionals who demonstrated clear communication and cultural awareness was associated with enhanced medication adherence. Memory mechanisms needed to be individualized and were generally ‘low technology’. While prepackaging of medications enhanced adherence, patients who used them were less knowledgeable about their medications.ConclusionsHealthcare providers should understand the importance of including family members in the care of South Asian people with heart disease. They also need to appreciate that the quality of provider–patient relationships are important to South Asian patients and will influence adherence to healthcare regimens. Expanding the role of nurse in the primary healthcare team could provide a cost-effective means of enhancing medication adherence.     

Factors that influence case managers’ resource allocation decisions in pediatric home care: An ethnographic study

Background

Case managers make decisions that directly affect the amount and type of services home care clients receive and subsequently affect the overall available health care resources of home care programs. A recent systematic review of the literature identified significant knowledge gaps with respect to resource allocation decision-making in home care.

Methods

Using Spradley's methodology, we designed an ethnographic study of a children's home care program in Western Canada. The sample included 11 case managers and program leaders. Data sources included interviews, card sorts, and participant observation over a 5-month period. Data analyses included open coding, domain, taxonomic, and componential analysis.

Results

One of the key findings was a taxonomy of factors that influence case manager resource allocation decisions. The factors were grouped into one of four main categories: system-related, home care program-related, family related, or client-related. Family related factors have not been previously reported as influencing case manager resource allocation decision-making and nor has the team's role been reported as an influencing factor.

Conclusion

The findings of this study are examined in light of Daniels and Sabin's Accountability for Reasonableness framework, which may be useful for future knowledge development about micro-level resource allocation theory.     

Ethical,legal and professional accountability in emergency nursing practice: An ethnographic observational study

IntroductionAccountability in nursing practice is a concept that influences quality care, decision-making, safety standards and staff values. Therefore, understanding accountability and how it affects nursing practice could improve patient care and nurses’ working conditions.AimThe aim of this study was to find factors that influenced ethical, legal and professional accountability in emergency nursing practice.MethodsA qualitative ethnographic approach using participant observation through convenience sampling was employed as the data collection method, while ethnographic content analysis was used for data analysis.ResultsThe factors linked to nursing accountability found were classified into four main themes: daily dynamics, work environment evolution, customs and routines and bioethics principles’ application.DiscussionThe long-term effect of chronic high workload and crowding, which affects nursing accountability, could promote burnout in a junior ED workforce. Changes in the nurses’ working conditions need to be implemented to limit the workload to which an ED nurse is subjected to.ConclusionED nurses have to manage their accountability in difficult situations regularly, which followed patterns of four main themes across the majority of situations. Nonetheless, all those factors were influenced by nursing workload, an ever-present factor that was always considered by ED nurses during decision-making.     

Nursing and public participation in health: an ethnographic study of a patient council

BACKGROUND: Conceptualisations of the nurse-patient relationship tend to view nursing as embodying an empowering approach to patients, one that places the service user perspective at the centre of decision-making. However, the relationship of nursing to public participation in health service planning and development has been under examined. AIMS: The aim is to explore the relationship of the nursing profession to public participation as enacted through a UK-based patient and public council, located in an acute hospital. The council was developed by nursing staff and aimed to achieve service user participation in strategic level health care decision-making. The views and experiences of participants and the applicability of the 'nurse-patient partnership' construct to public participation are considered. METHODS: The study employed integrative ethnography, involving multiple field methods: non-participant observation of council meetings, i.e. fourteen 3 h meetings (n=42 h); in-depth interviews with councillors (n=17) and with key hospital staff (n=18). A documentary review and mapping of the actions of the council was undertaken. RESULTS: A nurse-patient partnership was not initially intrinsic to the operation of the council or embedded in the perspectives of the nurse or patient participants. Professional vulnerability and the organisational context constrained the nursing response. Councillors and nursing staff moved to create a shared set of understandings in order to progress change in service organisation and delivery. Nurses' repositioning vis-à-vis the credibility of user experiences and status was central to the effective progression of the council. CONCLUSIONS: Partnership in public participation requires a shift by nurses' towards acceptance of members of the public functioning as informed, critical and powerful agents in health care decision-making. Equipping nurses with the skills to communicate with patient representatives in a position of interactional equality is likely to be a pre-requisite for successful engagement by nursing with public participation.     

Doing the month in a Taiwanese postpartum nursing center: An ethnographic study

Traditionally Chinese and Taiwanese postpartum women conducted postpartum ritual practices, called “doing the month,” at home. Today, many Taiwanese women undertake this ritual in postpartum nursing centers. However, little is known about how the traditional practices are being transformed in relation to contemporary health care in Taiwan. In this ethnographic study observations were carried out in a large post‐partum center attached to a major hospital in Taipei for nine months, and 27 postpartum women were interviewed. Data were analyzed using ethnographic approaches to extract codes and categories. Doing the month was reshaped by being relocated from the home to a healthcare setting. Midwives took on roles traditionally taken by family members, which had an impact on family roles and relationships. Some postpartum practices were maintained, based on traditional explanations. However, many were modified or challenged, based on explanations from contemporary scientific knowledge. Midwives need to be aware that there could be differences between their culture of care and the cultural values of the women they care for. This study informs culturally appropriate postpartum care and support for women with traditional and contemporary cultural beliefs and attitudes to doing the month in a range of healthcare contexts.     

Understanding nursing scope of practice: a qualitative study

Background

The past decade has seen increased patient acuity and shortened lengths of stays in acute care hospitals resulting in an intensification of the work undertaken by nursing staff in hospitals. This has ultimately led to a reconsideration of how nursing staff manage their work.

Aim

The aim of this study was to understand how medical and surgical nurses from two Australian hospitals conceive their scope of practice in response to the available grade and skill mix of nurses and availability of unlicensed health care workers and other health care professionals. By exploring these meanings, this study aimed to build an understanding of how nursing work patterns were shifting in the face of changing patient acuity, patient profiles and nursing skill mix.

Method

A constructivist methodology, using critical incident technique (CIT) was used to explore nurses’ role and scope of practice. Twenty nurses, 16 registered nurses (RNs) and four enrolled nurses (ENs), discussed significant events during which they perceived they were undertaking either patient care activities they should be undertaking, or activities that should have either been delegated or undertaken by a higher level of care provider.

Findings

Five themes emerged from the data: (1) good nurses work in proximity to patients providing total patient care; (2) safeguarding patients; (3) picking up the slack to ensure patient safety; (4) developing teamwork strategies; and (5) privileging patients without mental illness or cognitive impairment. A pattern woven throughout these themes was the idea of negotiation. RNs were struggling with the notions that direct patient care was sometimes not the best use of their time, and delegation did not equate with laziness.

Conclusion

Negotiation has become a fundamental aspect of nursing practice given the variety of nursing care providers currently employed in acute care settings. Negotiation has allowed nurses to redefine appropriate nurse–patient proximity, promote patient safety and find innovative ways of working in nursing teams.