Caring for family members following suicide: Professionals' experiences of responsibility.

BACKGROUND: When a patient commits suicide while hospitalized in the psychiatric ward, the mental healthcare professionals (MHCPs) who have had the patient in their care encounter the family members immediately following the suicide. Professionals who encounter the bereaved in this first critical phase may have a significant impact on the grieving process. By providing ethically responsible and professionally competent care, they have the opportunity to influence what can alleviate and reduce suffering and promote health in a longer perspective. AIM: The aim of this study is to investigate MHCPs' experiences in the encounter with family members who has been bereaved by suicide. METHODS: Data material consists of text from in-depth interviews with six MHCPs belonging to a total of five different psychiatric units in two hospitals. The findings have emerged through analysis using a hermeneutical approach based on Gadamer's philosophical hermeneutics. ETHICAL CONSIDERATIONS: The study was approved by the Ombudsman for Privacy of the Norwegian Social Science Data Services and is based on informed consent and confidentiality. FINDINGS: Three themes emerged: Confirming the suffering. Creating encounter through dialogue. Providing consolation and reconciliation. Findings illuminate how MHCPs understand their responsibilities and how they act in the encounter with the bereaved following suicide. CONCLUSION: The participants appear to be led by the responsibility that grows through witnessing the suffering of the bereaved. Encountering the family member's aggression and threats against staff members is an ethical challenge to the professional's ability to confirm the bereaved, create dialogue and provide consolation and reconciliation at the start of their grieving process. MHCPs need to be aware of the different reactions and needs of family members following suicide. More research is needed about how to provide sensitive and flexible care in ways that can be perceived as helpful for those left behind.

Residents' experiences of paternalism in nursing homes.

BACKGROUND: Interest in strengthening residents' autonomy in nursing homes is intensifying and professional caregivers' experience ethical dilemmas when the principles of beneficence and autonomy conflict. This increased focus requires expanded knowledge of how residents experience decision-making in nursing homes and how being subject to paternalism affects residents' dignity. RESEARCH QUESTION/AIM: This study explored how residents experience paternalism in nursing homes. RESEARCH DESIGN: This study involved a qualitative interpretive design with participant observations and semi-structured interviews. The interpretations were informed by Gadamer's hermeneutics. PARTICIPANTS AND RESEARCH CONTEXT: Eleven residents were interviewed after a period of participant observation in two nursing homes. ETHICAL CONSIDERATIONS: The study was performed in accordance with the Helsinki declaration. The Regional Ethics Committee (REK) permitted the researcher to perform participant observation in the nursing homes. The use of audio recordings of interviews was registered and supervised by Sikt - Norwegian Agency for Shared Services in Education and Research. The resident's consent was assessed continuously. Three interviews were terminated for ethical reasons. FINDINGS: The resident interviews revealed that residents found it obvious for caregivers to possess the decision-making authority in nursing homes. When residents explained their views, three main themes emerged: (1) To be included even though caregivers make the decisions, (2) Surrender to dependency, and (3) Adherence to nursing home norms. CONCLUSIONS: Residents submit to their caregivers and give caregivers the responsibility and function as leaders. Paternalism was experienced as dignifying in situations where it contributed to residents being able to live according to second order desires and values, and when it implied respect and appraisal of residents' capabilities. Paternalism was experienced as debasing when residents felt left out, and when residents felt that their capabilities were underestimated. This also included their capability to withstand paternalistic influence.

'Hope as a lighthouse' A meta-synthesis on hope and hoping in different nursing contexts.

BACKGROUND: Hope has a contextual dimension and experiences of hope seem to be an important part of everybody's life irrespective of changing and challenging health conditions. However, less focus has been placed on the similarities and differences in the experiences of hope among patients and family caregivers in different contexts of suffering and health, such as the nursing contexts of acute and critical care, rehabilitation and long-term care and prevention and health promotion. AIM: This paper focuses on experiences of hope and hoping in different clinical nursing contexts, based on a meta-synthesis of seventeen empirical studies on hope and hoping. These studies highlight experiences of hope and advance our theoretical and clinical understanding of the phenomenon. METHODOLOGICAL FRAMEWORK: This study on hope and hoping from seventeen empirical research studies was based on a meta-synthesis, by clarifying and modifying the essence of hope and hoping, aiming to identify the unique conditions in the different clinical contexts. RESULTS: A new understanding of the empirical findings emerged from the text: Hope means transformation and hope is indispensable in the acute and critical nursing context, and hope as an inner flame and hope as a lighthouse related to rehabilitation and long-term care. Hope means pushing limits and expanding hope was experienced in the context of prevention and health promotion. CONCLUSIONS: According to the findings, dimensions of hope and hoping were always present but also influenced by contextual suffering and losses. IMPLICATIONS FOR PRACTICE: Hope means metaphorically a lighthouse, meaning a bright and shining centre, which must be promoted and protected in patients and their families.

Dignity in relationships and existence in nursing homes' cultures.

INTRODUCTION: Expressions of dignity as a clinical phenomenon in nursing homes as expressed by caregivers were investigated. A coherence could be detected between the concepts and phenomena of existence and dignity in relationships and caring culture as a context. A caring culture is interpreted by caregivers as the meaning-making of what is accepted or not in the ward culture. BACKGROUND: The rationale for the connection between existence and dignity in relationships and caring culture is that suffering is a part of existence, as well as compassion in relieving suffering, and ontological interdependency. AIM: To describe different expressions of dignity in relationships and existence in context of caring cultures from the perspective of the caregivers. RESEARCH DESIGN: The methodology and method are hermeneutic. The method used was to merge the theoretical preunderstanding as one horizon of understanding with empirical data. PARTICIPANTS AND RESEARCH CONTEXT: Focus group interviews with caregivers in nursing homes. ETHICAL CONSIDERATIONS: The principles of the Helsinki Declaration have been followed to, for example, preserve self-determination, integrity, dignity, confidentiality and privacy of the research persons. FINDINGS: Data interpretation resulted in four themes: Encountering existential needs that promote dignity in a caring culture; To amplify dignity in relationships by the creative art of caring in a caring culture; Violation of dignity by ignorance or neglect in a non-caring culture and The ethic of words and appropriated ground values in a caring culture. DISCUSSION: Dignity-promoting acts of caring, or dignity-depriving acts of non-caring are adequate to see from the perspective of dignity in relationships and existence and the caring culture. CONCLUSIONS: Dignity in relationships seems to touch the innermost existential life, as the existential life is dependent on confirmation from others.

The significance of hope as experienced by the next of kin to critically ill patients in the intensive care unit.

AIM: To examine and increase understanding of diverse aspects of hope as experienced by the next of kin when someone close to them is critically ill in intensive care unit (ICU). DESIGN: A qualitative study with a phenomenological approach. METHOD: The data were collected through five in-depth interviews with next of kin at the ICU in Central Norway. Data were interpreted to gain a deeper understanding on hope in an acute and critical context. RESULTS: The analysis presents five main themes: (i) hope for survival, (ii) hope is fostered by signs of improvement, (iii) hope keeps fear for the worst at bay, (iv) hope that things will turn out well and (v) hope for the return to a normal life. Hope kept next of kin going during a difficult time and was strengthened when they saw their close family member responding positively to treatment provided by the ICU.

Human dignity research in clinical practice - a systematic literature review.

BACKGROUND: This literature study describes caring science research on human dignity in different clinical practice. We already know a good deal about human dignity in nursing care but how do patients, nurses, healthcare professionals and next of kin experience human dignity in clinical practice? AIM: To summarise studies on human dignity to gain a deeper understanding of how it can be achieved in caring science research and to gain a broader understanding of the differences and similarities across caring contexts. The aim was also to gain a broader understanding of the differences and similarities of human dignity across different clinical practice. METHOD: The literature review re-analysed 28 empirical studies on human dignity are experienced from acute, psychiatric, elderly and rehabilitation care. The data analysis strategy was conducted in a systematic and critical way and consisted of a five-step method. RESULT: Maintaining dignity was described when caregivers had the time and the will to see and listen to patient and had the courage to see what they did not want to see, allowing their inner powers to act with the purpose of doing good. In elderly care, it was important that elderly persons are involved as members of society and experience respect, confidence, security and charity. Indignity was described when caregivers did not allow patients to have their will and when they had unethical attitudes, ignoring patients and creating powerlessness. The feeling of being abandoned and not being taken seriously are also described in elderly care. CONCLUSION: Findings show how caregivers fulfil their ethical responsibility by seeing, listening and being a part of the time and place. The will to do good includes the courage to preserve dignity and human value rests on being created as a human being. More research is needed about ethical and moral responsibility in clinical practice.

A courageous journey: Experiences of migrant Philippine nurses in Norway.

AIMS AND OBJECTIVES: To explore how Philippine-educated nurses explain their choice of Norway as their migration destination and their experience with the credential assessment process in Norway. BACKGROUND: Norway has an increasing need for nurses, and nurses educated in non-EU countries are an important resource for the Norwegian health service. Philippine nurses compose the largest group of internationally educated nurses from outside the EU, but their Philippine nursing education is only credited as equivalent to 2 years in Norway. Migration is known to engender stressful experiences amongst migrant nurses, which may affect their health. However, studies on Philippine nurses' experiences of migrating to and working in Norway are lacking. DESIGN AND METHODS: The study used a hermeneutic design, conducting qualitative research interviews with ten Philippine nurses. All of them had a certification as auxiliary nurses, but not as registered nurses. The Consolidated Criteria for Reporting Qualitative Research is used. RESULTS: The nurses' choice of a migration country appeared to be both random and based on the opportunity to find well-paid work, as well as having acquaintances who had already migrated to Norway. The migrated Philippine nurses seemed experienced and competent. In Norway, they were disappointed as they felt undervalued. The nurses struggled to learn Norwegian, while striving for survival when acquiring jobs or accommodations. They were excluded from acting as legal nurses in the Norwegian healthcare system; they fulfilled the governmental requirements, but they were repeatedly rejected. The informants saw this as harsh, but still hoped to be successful. CONCLUSIONS: There is a need to facilitate effective language training and a well-founded, predictable system of credentialing. RELEVANCE TO CLINICAL PRACTICE: Attention should be paid to the integration of immigrants and safeguarding and strengthening the professional competence the nurses bring with them.

Nudging in nursing.

Nudging is a concept in behavioural science, political theory and economics that proposes indirect suggestions to try to achieve non-forced compliance and to influence the decision making and behaviour of groups and individuals. Researchers in medical ethics are currently discussing whether nudging is ethically permissible in healthcare. In this article, we examine current knowledge about how different decisions (rational and pre-rational decisions, major and minor decisions) are made and how this decision-making process pertains to patients. We view this knowledge in light of the nursing project and the ongoing debate regarding the ethical legitimacy of nudging in healthcare. We argue that it is insufficient to discuss nudging in nursing and healthcare in light of free will and patient autonomy alone. Sometimes, nurses must take charge and exhibit leadership in the nurse-patient relationship. From the perspective of nursing as leadership, nudging becomes a useful tool for directing and guiding patients towards the shared goals of health, recovery and independence and away from suffering. The use of nudging in nursing to influence patients' decisions and actions must be in alignment with the nursing project and in accordance with patients' own values and goals.

Tension between freedom and dependence-A challenge for residents who live in nursing homes.

AIMS AND OBJECTIVES: To present results from interviews of older people living in nursing homes, on how they experience freedom. BACKGROUND: We know that freedom is an existential human matter, and research shows that freedom remains important throughout life. Freedom is also important for older people, but further research is needed to determine how these people experience their freedom. The background for this article was a Scandinavian study that occurred in nursing homes; the purpose of the study was to gain knowledge about whether the residents felt that their dignity was maintained and respected. DESIGN: The design was hermeneutic, with qualitative research interviews. METHOD: Twenty-eight residents living in nursing homes in Denmark, Sweden and Norway were interviewed. Collecting tools used were an interview guide and also a tape recorder. Researchers in the three countries performed the interviews. The data were transcribed and analysed on three levels of hermeneutic interpretation. RESULTS: To have their freedom was emphasised as very important according to their experience of having their dignity taken care of. The following main themes emerged: (a) Autonomy or paternalism; (b) Inner and outer freedom; and (c) Dependence as an extra burden. CONCLUSIONS: Residents in a nursing home may experience the feeling of having lost their freedom. This conclusion has implications for healthcare professionals and researchers, as it is important for residents in nursing homes to feel that they still have their freedom. RELEVANCE TO CLINICAL PRACTICE: In clinical practice, it is important and valuable for the staff to consider how they can help older people feel that they still have their freedom.

Clinical application research through reflection, interpretation and new understanding - a hermeneutic design.

The implementation of theoretical knowledge in clinical practice and the implementation of good clinical practice into theory have been of interest in caring science for the last 30 years. The aim of this article was to elaborate and discuss a methodology named clinical application research. The method is grounded in a hermeneutical design inspired by Gadamer's philosophy. The methodology, clinical application research, has been used in a research project A life in dignity and experiences from the researchers forms the bases for the elaboration and discussion. The project was performed in collaboration with residents, family caregivers and healthcare providers at six nursing homes in Scandinavia. The material for this article is based on the previous research, that is the results from 10 different articles showing the meaning of dignity and indignity in daily life in nursing homes. Data were generated from 56 individual interviews and 18 focus-group interviews with a total of 40 staff members with five to eight participants at every interview session. By reflection, interpretation and new understanding our results provide knowledge about dignity and how to preserve dignity for older people in an appropriate ethical way. The methodology was relevant for the research project A life in dignity and relevant to caring practice in nursing homes as it opens new possibilities and new ways of thinking when performing dignified care to older people.

The significance of meaningful and enjoyable activities for nursing home resident's experiences of dignity.

BACKGROUND: Living in a nursing home may be challenging to the residents' experience of dignity. Residents' perception of how their dignity is respected in everyday care is important. AIM: To examine how nursing home residents experience dignity through the provision of activities that foster meaning and joy in their daily life. METHOD: A qualitative design was used and 28 individual semistructured interviews conducted with nursing home residents from six nursing homes in Denmark, Norway and Sweden. The data were analysed with qualitative content analysis. Independent ethical committees in all participating countries granted their approval for the study. FINDINGS: The participants highlight two dimensions of the activities that foster experiences of dignity in nursing homes in Scandinavia. These two categories were (i) fostering dignity through meaningful participation and (ii) fostering dignity through experiencing enjoyable individualised activities. CONCLUSION: Activities are important for residents to experience dignity in their daily life in nursing homes. However, it is important to tailor the activities to the individual and to enable the residents to take part actively. Nurses should collect information about the resident's preferences for participation in activities at the nursing home.

Fostering dignity in the care of nursing home residents through slow caring.

BACKGROUND: Physical impairment and dependency on others may be a threat to dignity. RESEARCH QUESTIONS: The purpose of this study was to explore dignity as a core concept in caring, and how healthcare personnel focus on and foster dignity in nursing home residents. RESEARCH DESIGN: This study has a hermeneutic design. Participants and research context: In all, 40 healthcare personnel from six nursing homes in Scandinavia participated in focus group interviews in this study. Ethical considerations: This study has been evaluated and approved by the Regional Ethical Committees and the Social Science Data Services in the respective Scandinavian countries. FINDINGS: Two main themes emerged: dignity as distinction (I), and dignity as influence and participation (II). DISCUSSION: A common understanding was that stress and business was a daily challenge. CONCLUSION: Therefore, and according to the health personnel, maintaining human dignity requires slow caring in nursing homes, as an essential approach.

The Dialectical Movement Between Deprivation and Preservation of a Person's Life Space: A Question of Nursing Home Residents' Dignity.

The aim of this study was to answer the question "What do nursing home residents do themselves in order to maintain their dignity?" Twenty-eight residents, 8 men and 20 women, aged 62 to 103 years, from 6 different nursing homes in Scandinavia were interviewed. The results showed that the residents tried to expand their life space, both physical and ontological, in order to experience health and dignity.

Caught in suffering bodies: a qualitative study of immigrant women on long-term sick leave in Norway.

AIMS AND OBJECTIVES: This article explores the issues faced by immigrant women on long-term sick leave due to chronic pain, focusing on their personal perspectives on their daily lives, their bodies and their pain. BACKGROUND: An increasing number of immigrants in Norway present a challenge to the public health service, above all in relation to the health needs of immigrant women, many of whom risk having to take long-term sick leave due to chronic pain. DESIGN: This study has a qualitative design, with participant observation and in-depth interviews. METHODS: Participant observations were carried out from a sample of fourteen immigrant women in an outpatient clinic at a rehabilitation hospital. In addition, qualitative interviews were conducted after the rehabilitation period. A hermeneutic approach was used to understand the meaning of the narrated text. RESULTS: The analysis revealed one main theme, 'Bodies marked by onerous experiences', as well as two subthemes: 'It is in my body' and 'Invisible pain'. The immigrant women struggled with invisible, chronic pain, which they blamed on physically tiring workdays and stressful life situations. Furthermore, they felt that their experiences of discriminative attitudes at the workplace worsened their suffering. CONCLUSIONS: The chronic pain made the immigrant women suffer, because they experienced it as a threatening, incomprehensible and unreal force, without meaning or the ability to be controlled. Their own psychological distress exacerbated their pain. RELEVANCE TO CLINICAL PRACTICE: Immigrant women on long-term sick leave are likely to need special approaches that are closely adapted to their different backgrounds and their unique personal experiences. We recommend culturally appropriate family counselling and collaboration with employers at the women's workplaces.

The meaning of dignity in nursing home care as seen by relatives.

BACKGROUND: As part of an ongoing Scandinavian project on the dignity of care for older people, this study is based on 'clinical caring science' as a scientific discipline. Clinical caring science examines how ground concepts, axioms and theories are expressed in different clinical contexts. Central notions are caring culture, dignity, at-home-ness, the little extra, non-caring cultures versus caring cultures and ethical context - and climate. AIM AND ASSUMPTIONS: This study investigates the individual variations of caring cultures in relation to dignity and how it is expressed in caring acts and ethical contexts. Three assumptions are formulated: (1) the caring culture of nursing homes influences whether dignified care is provided, (2) an ethos that is reflected on and appropriated by the caregiver mirrors itself in ethical caring acts and as artful caring in an ethical context and (3) caring culture is assumed to be a more ontological or universal concept than, for example, an ethical context or ethical person-to-person acts. RESEARCH DESIGN: The methodological approach is hermeneutic. The data consist of 28 interviews with relatives of older persons from Norway, Denmark and Sweden. ETHICAL CONSIDERATIONS: The principles of voluntariness, confidentiality and anonymity were respected during the whole research process. FINDINGS: Three patterns were revealed: dignity as at-home-ness, dignity as the little extra and non-dignifying ethical context. DISCUSSION: Caring communion, invitation, at-home-ness and 'the little extra' are expressions of ethical contexts and caring acts in a caring culture. A non-caring culture may not consider the dignity of its residents and may be represented by routinized care that values organizational efficiency and instrumentalism rather than an individual's dignity and self-worth. CONCLUSION: An ethos must be integrated in both the organization and in the individual caregiver in order to be expressed in caring acts and in an ethical context that supports these caring acts.

"You get tired of remaining in a state of fear"- professionals' experiences of self-care facing suicidality in psychiatric wards.

AIM: The aim of this study is to explore mental healthcare professionals (MHCPs) experiences related to own emotions when encountering patients at risk of suicide in psychiatric wards and their family members. METHODOLOGY AND METHODS, PARTICIPANTS AND RESEARCH CONTEXT: This study has a qualitative explorative design. Data consist of texts from twelve in-depth interviews with MHCPs belonging to six units in two psychiatric wards. Data were interpreted using a hermeneutical approach based on Gadamer's philosophical hermeneutics. FINDINGS: Through an interpretation process, three themes emerged: Enduring own emotions, Balancing emotional engagement and the need to rest, and Being together in the community of colleagues. CONCLUSION: This study shows the importance of being aware of own anxiety facing suicidality. MHCPs have to work emotionally and cognitively so that care is not guided by anxiety but by collaboration with the patient and his family members. The study highlights the need for a culture in the mental health service in which the MHCP can reflect on own emotional reactions and thoughts in a collegial environment characterized by openness, generosity and collaboration.

A qualitative study of family members' perspectives regarding decision-making for nursing home residents' care.

PURPOSE: We explored how family caregivers perceive decision-making regarding the care of nursing home residents. METHODS: This qualitative study used Flemming's Gadamerian-based research method. In person semi-structured interviews about decision-making concerning residents' care were conducted with 13 family members (nine women, four men) of residents of three Norwegian nursing homes. FINDINGS: The following themes emerged: Excessive focus on autonomy threatens resident wellbeing and safety. Resident wellbeing is the caregiver's responsibility. Resident wellbeing serves as a guiding principle. CONCLUSIONS: The family members of residents and the nursing home caregivers disagreed about the significance of upholding resident autonomy to respect residents' dignity. The family members held that not all instances where residents refused care reflect autonomy situations as care refusal often does not reflect the resident's true values and standards but rather, stems from barriers that render necessary care actions difficult. In situations where residents refuse essential care or when the refusal does not align with the residents second-order values, the family members suggested that caregivers strive to understand the causes of refusal and seek non-coercive ways to navigate it. Hence, the family members seemed to endorse the use of soft paternalism in nursing homes to safeguard residents' wellbeing and dignity.

Perspectives of health personnel on how to preserve and promote the patients' dignity in a rehabilitation context.

AIMS AND OBJECTIVES: To explore how healthcare personnel comprehend the term dignity and what they do to attend to, preserve and promote the dignity of patients in the rehabilitation context. BACKGROUND: Literature reveals that knowledge exists concerning the nature of dignity. Literature is scant on how health personnel think the reasons may be when patients do not maintain their dignity or how caregivers might improve and strengthen their concern in preserving and promoting the patients' dignity in a rehabilitation context. DESIGN: The study was explorative and descriptive, with content analysis of gathered empirical data. METHODS: Qualitative focus group interviews with representatives from the staff at three different rehabilitation centres were carried out. Professionals within different occupations were represented at the meeting: nurses, ergonomists, physiotherapists, psychologists, medical doctors, social workers, auxiliary nurses and speech therapists. RESULTS: Dignity is promoted when the patient himself becomes an active agent, when the patient's feelings and thoughts are respected, when the family of the patient is included and listened to, when the patient is free to make critical comment, when members of staff are able to cope with the patient's disabilities and when the aesthetic environment is attended to and enhanced. Dignity is not promoted when health personnel override or dominate patients, when health personnel focus merely on the patient's diagnosis and not the sick person and when health personnel and/or relatives try to impose their own values. CONCLUSION: The staff working in institutions to rehabilitate patients with head injuries and multiple sclerosis must be aware and sensitive to the importance of maintaining and supporting the patient's dignity and self-respect. RELEVANCE FOR CLINICAL PRACTICE: The results from this project confirm the importance of acknowledging the patient's self-worth as a human being, unconditionally. This might be essential in promoting and preserving the patients' dignity.

Aspects of indignity in nursing home residences as experienced by family caregivers.

The overall purpose of this cross-country Nordic study was to gain further knowledge about maintaining and promoting dignity in nursing home residents. The purpose of this article is to present results pertaining to the following question: How is nursing home residents' dignity maintained, promoted or deprived from the perspective of family caregivers? In this article, we focus only on indignity in care. This study took place at six different nursing home residences in Sweden, Denmark and Norway. Data collection methods in this part of this study consisted of individual research interviews. Altogether, the sample consisted of 28 family caregivers of nursing home residents. The empirical material was interpreted using a hermeneutical approach. The overall theme that emerged was as follows: 'A feeling of being abandoned'. The sub-themes are designated as follows: deprived of the feeling of belonging, deprived of dignity due to acts of omission, deprived of confirmation, deprived of dignity due to physical humiliation, deprived of dignity due to psychological humiliation and deprived of parts of life.

The solitary and uncertain learning process: A qualitative study of nursing students' experiences in the initial phase of the COVID-19 pandemic.

When the Coronavirus disease 2019 (COVID-19) pandemic broke out, the nursing students clinical practice period was abruptly interrupted by the lock down. The present study aimed to investigate the nursing students' learning experiences during the initial phase of the pandemic. A qualitative study was conducted investigating nursing students' written assignments (n = 48) of reflections according to their learning process. The qualitative data analysis revealed three main themes, namely the solitary and uncertain learning process; from collective learning process to digital devices; additional learning outcomes. The students' anxiety about the virus affected their motivation to study, but they also expressed enthusiasm and gratitude for having the opportunity to learn about the health system in a time of crisis. These results point towards the health care authorities can rely on nursing students' ability to take part and cover important emergency functions. The use of technology helped the students to achieve their learning objectives.