Digital ethical reflection in home nursing care: Nurse leaders' and nurses' experiences.

BACKGROUND: Nurse leaders increasingly need effective tools that facilitate the prioritisation of ethics and help staff navigate ethical challenges and prevent moral distress. This study examined experiences with a new digital tool for ethical reflection, tailored to improve the capabilities of both leaders and employees in the context of municipal long-term care. AIM: The aim was to explore the experiences of nurse leaders and nurses in using Digital Ethical Reflection as a tool for ethics work in home nursing care. RESEARCH DESIGN: The study employed a qualitative design, incorporating individual and focus group interviews for data collection. Qualitative content analysis was used to analyse the data. PARTICIPANTS AND RESEARCH CONTEXT: The participants comprised six nurse leaders and 13 nurses, representing six home care zones across two Norwegian municipalities. ETHICAL CONSIDERATIONS: The study involved informed, voluntary participation and was approved by the Norwegian Agency for Shared Services in Education and Research. FINDINGS: Four themes were developed: a constant walk on the edge between engagement and discouragement and lost in translation describe the process, while tuning in to the ethical dimension and navigating ethical uncertainties illuminate the experienced significance of Digital Ethical Reflection. CONCLUSION: Success with Digital Ethical Reflection in home nursing care depends on clear leadership planning, nurses' understanding of the tool's purpose, and active use of digital registrations. Support from ethically interested nurses enhances overall engagement. Further research is needed to explore the potential of Digital Ethical Reflection as an additional tool in long-term care ethics work.

Adapting to home care in Norway: A longitudinal case study of older Adults' experiences.

This study aimed to describe how older adults with complex health problems manage their everyday lives in their own homes and how they interact with given home care. In this multiple-case study, a total of 14 individual interviews were conducted with five older adults over the course of one year. Deductive and inductive content analyses were performed. Three descriptive categories were each identified in the deductive ('home care as interpersonal continuity', 'home care as information continuity' and 'home care as management continuity') and inductive analyses ('Lack of social contact with carers', 'Desire to be heard throughout the care process' and 'Carers are short on time'). Quality home care services are difficult to realize if interpersonal interaction is subordinated to effective task-solving.

Thinking strategies used by registered nurses during drug administration in nursing homes-An observational study.

AIM: To explore registered nurses' thinking strategies during the drug administration process in nursing homes. DESIGN: An exploratory qualitative design. METHODS: Eight registered nurses, one male and seven female, in five nursing home wards in Mid-Norway were observed during 15 drug dispensing rounds (175 drug dispensing episodes). Think Aloud sessions with follow-up individual interviews were conducted. The Think Aloud data were analysed using deductive qualitative content analysis based on Marsha Fonteyn's description of 17 thinking strategies. Interview data were used to clarify missing information and validate the content of Think Aloud data. RESULTS: The registered nurses used all 17 thinking strategies described by Fonteyn, including several variants of each strategy. The three most frequent were 'providing explanations', 'setting priorities' and 'drawing conclusions'. In addition, we found two novel thinking strategies that did not fit into Fonteyn's template, which were labelled 'controlling' and 'interacting'. Among all strategies, 'controlling' was by far the most used, serving as a means for the registered nurses to stay on track and navigate through various interruptions, while also minimising errors during drug dispensing. CONCLUSION: The study highlights the diverse thinking strategies employed by registered nurses in nursing homes during medication administration. The findings emphasise the multifaceted nature of medication administration and underscore the importance of skilled personnel in ensuring medication safety. Recognising the significance of these findings is crucial for maintaining patient well-being and upholding medication safety standards in healthcare settings. RELEVANCE TO CLINICAL PRACTICE: Understanding the thinking strategies employed by registered nurses can inform training programmes and enhance the clinical judgements of health care professionals involved in medication administration, ultimately leading to improved patient outcomes and reduced medication errors in practice. PATIENT OR PUBLIC CONTRIBUTION: Patients were involved in this study as recipients of drugs which the nurses distributed during the observations. The patients were involved as a third party and consent to the observations was either given by the patients themselves or relatives in cases where the patient was not competent to consent. No personal information was collected about the patients. REPORTING METHOD: The reporting of this study adhered to the COREQ checklist.

'Fleeing' as a Strategy for Navigating Resistance in Patient Encounters within Forensic Care.

The aim of this study was to describe the phenomenon of "fleeing the encounter when facing resistance" as experienced by carers working in forensic inpatient care. Qualitative analysis, namely reflective lifeworld research, was used to analyze data from open-ended questions with nine carers from a Swedish regional forensic clinic. The data revealed three meaning constituents that describe the phenomenon: shielding oneself from coming to harm or harming the other, finding one's emotional balance or being exposed, and offering the patient emotional space and finding patience. The carers described their approaches in the encounters with the patients as alternating between primitive instincts and expectant empathy in order to gain control and deal with the interaction for their own part, for that of the patient, and for that of their colleagues. The phenomenon of fleeing the encounter when facing resistance was intertwined with carers' self-perception as professional carers. Negative encounters with patients evoked feelings of shame and self-blame. A carer is a key person tasked with shaping the care relationship, which requires an attitude on the part of the carer that recognizes not only the patient's lifeworld but also their own.

A Meta-Ethnographic Review of Forensic Psychiatry Inpatient Care. Nursing Staff Experiences of the Nurse-Patient Encounter.

AIM: The aim of this review was to synthesise qualitative research into how nurses perceive and experience encountering patients in forensic inpatient care. REVIEW METHOD: This review followed the steps of meta-ethnography developed by Noblit and Hare. DATA SOURCES: Twelve studies, published from 2011 to 2021, were identified through a search of relevant databases in December 2021. FINDINGS: The synthesis revealed three third-order and 10 second-order constructs during the translation of concepts in the studies. These are: Adopting the patient's perspective (liberation, comprehension and resistance), Action (security, trust, flexibility and predictability) and Activation (afraid or safe, involved or indifferent and boundaries). Further, a line of argument was developed which indicates that in forensic psychiatry inpatient care, nurses experience having to deal with internal and external resistance that affects their freedom of choice in the creation of a caring relationship. CONCLUSION: The encounter is experienced as a continuous process in which the foundation is laid for the encounter (approach), the encounter unfolds and develops (action) and the nurse experiences the encounter (activation). The process is intertwined with and takes place in a context where care is influenced by the duality of the task (task), the culture of care (context), the patient's expression (patient) and the nurse's own impression of the patient's expression (oneself). IMPLICATIONS: Professional communities should support initiatives that can strengthen nurses' self-awareness and provide opportunities for reflection on practice, which will both benefit the resilience of the nursing staff and the quality of care for patients in this setting.

Digital ethical reflection in long-term care: Leaders' expectations.

BACKGROUND: Healthcare leader support and facilitation for ethics work are of great importance for healthcare professionals' handling of ethical issues, moral distress, and quality care provision. A digital tool for ethical reflection in long-term care was developed in response to the demand for appropriate tools. RESEARCH AIM: This study aimed to explore healthcare leaders' expectations of using a digital tool for ethical reflection among their home nursing care staff. RESEARCH DESIGN: A qualitative research design with vignettes and focus group interviews was used. The data were analyzed using reflexive thematic analysis. PARTICIPANTS AND RESEARCH CONTEXT: The sample comprised ten healthcare leaders from municipal long-term care in Norway. ETHICAL CONSIDERATIONS: Participation was voluntary and based on informed consent. The Norwegian Agency for Shared Services in Education and Research approved this study. FINDINGS: The analysis resulted in the development of three themes representing leaders' expectations of the tool: (i) giving staff a voice, (ii) revealing ethics in practice, and (iii) keeping the pot boiling. DISCUSSION: Leaders must be informed about the ethical issues experienced to engage in supportive measures for their staff. Digital channels can increase the democratization, safety, and efficiency of communication between employees and leaders and increase awareness of ethical aspects in daily care work. The leaders had positive expectations of employees' activities and benefits from using the tool for ethical reflection. However, they admitted that realizing the tool's potential to ensure continuity in ethics work requires considerable organizational and leader involvement. CONCLUSIONS: This study shows that healthcare leaders are open to digital solutions for managing ethics work in home nursing care. Both opportunities and important prerequisites for successfully implementing the digital tool were identified.

Specialist and Primary Physicians' Experiences and Perspectives of Collaboration While Caring for Palliative Patients-A Qualitative Study.

Increasing numbers of people living with chronic and life-limiting diseases are actualising a greater need for palliative care. Physicians are an important provider for identifying the need for palliation, and effective follow-up requires physician collaboration across different service levels. This study aimed to explore and describe how physicians in hospitals and municipalities experience their roles and interactions in the care of palliative patients. Pair interviews were performed with seven physicians working in hospitals, primary care and nursing homes in Mid-Norway. Systematic text condensation was used to analyse the data, resulting in three main themes: The boundaries of palliative care, Alternating understandings of roles and Absence of planning. The physicians' interactions with palliative patients appeared as a fragmented distribution of tasks rather than a real collaboration with shared responsibility. At both levels, the physicians seemed to assume withdrawn roles as a reaction to unclear and unspoken expectations and to avoid interfering with others' responsibilities. Moreover, their understanding of palliative care and which groups should be included varied. Realising a collaboration between physicians that is beneficial for both patients and physicians, greater openness and real arenas for discussion and decision-making support are required.

Registered nurses' exposure to high stress of conscience in long-term care.

BACKGROUND: In long-term care, registered nurses and other care providers often experience tensions between ideals and realities in the delivery of services, which can result in stress of conscience. Burnout, low quality of care and a tendency to leave the profession are perceived as consequences. OBJECTIVES: This study aimed to identify the socio-demographic and work-related factors associated with a high level of stress of conscience, particularly between nursing occupations. RESEARCH DESIGN: A cross-sectional survey was conducted among care providers who worked in Norwegian nursing homes and home care services in the spring of 2021. The sample consisted of 950 registered nurses and 1143 other care providers. Data were collected online using the Stress of Conscience Questionnaire (SCQ). ETHICAL CONSIDERATIONS: Participation was voluntary and based on consent. The study was approved by the Norwegian Center for Research Data. RESULTS: Registered nurses were nearly twice as likely to report high levels of stress of conscience compared to other care providers in long-term care. In addition, being a female, living alone, caring for their own children, working in an institution (versus home based), working >75% time, working shifts, not having scheduled meetings for ethical reflection and working in municipalities with a higher population density were factors associated with a high level of SCQ score. DISCUSSION: Knowledge of factors that increase the risk of high SCQ scores in registered nurses provides opportunities for prevention. Managers in long-term care should pay more attention to how work is distributed between the occupational groups and should facilitate real opportunities for ethical reflection. CONCLUSIONS: The results of this study show that registered nurses have particular exposure to high levels of stress of conscience compared to other care providers in long-term care. Particular attention should be paid to registered nurses working in nursing homes.

Developing and Testing Digital Ethical Reflection in Long-Term Care: Nurses' Experiences.

Introduction: Nurses working in municipal long-term care face ethical challenges that can lead to moral distress and discomfort for the nurse and affect the quality of patient care. Tools and methods that contribute to increased ethical awareness and support for nurses dealing with moral issues are lacking. Technological innovations may be suitable for ethics work, but little research has been conducted on how such solutions could be designed or their potential benefit. Therefore, this study contributes knowledge about the development and testing of a digital tool for ethics support among nurses. Objective: To investigate how digital ethical reflection can support ethics work among nurses working in long-term care. Methods: A digital ethical reflection tool was designed and tested in nursing homes and home nursing care in collaboration with two Norwegian municipalities. The study used sequential explanatory mixed-methods design. Over a 6-week period, at the end of each shift, nurses digitally reported the ethical challenges they had experienced. Their responses and experiences were described using descriptive statistics. Additionally, focus group interviews were conducted and analyzed using reflexive thematic analysis (TA). Results: During the study period, 17 nurses reported a total of 223 registrations, with 24.8% stating that they had been in an ethically difficult situation. The digital reporting was perceived as practically applicable and helped to increase nurses' awareness of morally charged situations. The value of the registrations was found to depend on manager participation and the application of the obtained information. The participating nurses become aware that they lacked an arena for meaningful dialogue with and recognition from their manager. Conclusions: Information obtained through digital reflection can form the basis for ethical reflections at the departmental level. Digital reflection has the potential to become a tool for managers in their support for employees facing ethical challenges when providing long-term care.

"You Know Where the Boundary Is When You Cross It" - A Phenomenological Understanding of Vulnerability as Experienced by Carers in Forensic Inpatient Care.

In forensic nursing, carers must balance caring and limiting actions in encounters with patients. Interpreting suffering in others raises awareness of one's own vulnerability. Hence, the aim of this study was to describe the phenomenon of vulnerability as experienced by carers in forensic inpatient care. Nine participants were recruited at a major forensic hospital, and their narratives were analysed with a reflective lifeworld approach. The findings revealed that vulnerability was both a strength and a burden. Vulnerability comprised becoming aware of one's boundaries, being genuine and protecting oneself. Dealing with vulnerability enables carers to open up to patients.

The art of making the right exception to the "rule": Nurses' experiences with drug dispensing in nursing homes.

Nurses are key professionals in ensuring safe drug management in nursing homes, and their practice is regulated by a number of guidelines. The present study aimed to explore nurses' experiences of dispensing drugs to older people in nursing homes by using an exploratory qualitative design. Focus group interviews were conducted in three nursing homes in central Norway; the data were analyzed using qualitative content analysis. The results indicated that drug dispensing was perceived as a complicated process during which both anticipated and unforeseen challenges arose that influenced the nurses' abilities to follow professional standards. In these situations, the nurses had to apply their knowledge and make various adjustments based on conditions in the organization and the needs of individual patients. The findings have implications for facilitating nurses' working conditions and resources to avoid drug administration that limit the discretion of nurses and threaten patient safety in nursing homes.

Drug modification by nurses in Norwegian nursing homes: A cross-sectional study.

Crushing and dividing pills among older patients in nursing homes appears to be a common yet not harmless practice. Because few updates exist regarding the role of nurses and their dispensing of drugs in nursing homes, this study sought to describe the occurrence, methods, and causes of nurses' drug modification and to examine possible factors associated with drug modification in this context. A cross-sectional study of 273 dispensing episodes of solid oral drugs made by nurses, were observed during day and evening shifts. Modifications were made in 20.5% of the dispensing episodes, including 80.4% where alterations were made by crushing and 19.6% where alterations were made dividing. The most commonly reported reasons for modification were 'swallowing difficulties' (53.6%) and 'lack of understanding by the patient' (19.6%). The logistic regression analysis showed a significant association between the occurrence of drug modification and both cognitive impairment and administration method.

The path of compassion in forensic psychiatry.

We aimed to deepen our understanding of the concept of compassion in caring for patients with mental illness in forensic psychiatric inpatient care settings. Qualitative analysis was used to illuminate themes from interviews conducted with 13 nurses in a prior study. The audiotaped interviews, which had been transcribed verbatim, were analyzed following a hermeneutic approach. Results revealed the main theme of "being compassionate in forensic psychiatry is an emotional journey" and three themes. Overall, compassion was seen as a changeable asset, but also an obstacle when absent; sensitivity to one's own vulnerability is necessary to overcome that obstacle.

Nurses' Experiences of Documenting the Mental Health of Older Patients in Long-Term Care.

Nursing documentation is repeatedly reported to be insufficient and unsatisfactory. Although nurses should apply a holistic approach, they tend to document physical needs more often than other caring dimensions. This study aimed to describe nurses' experiences documenting mental health in older patients receiving long-term care. Individual interviews were conducted with nine nurses and were analyzed by content analysis. One main theme, two categories and seven sub-categories emerged. The findings showed that the nurses perceived mental health as an ambiguous phenomenon that could be difficult to observe, interpret, and agree upon. Thus, the nurses were uncertain about what concepts and words corresponded to their observations. They also struggled with finding the right words to create accurate and complete documentation without breaking confidentiality or diminishing the dignity of the patient. The findings are relevant for nurses in different types of healthcare services and in the educational context to ensure comprehensive nursing documentation.

"Looking for Deviations": Nurses' Observations of Older Patients With COPD in Home Nursing Care.

Nurses working in home care play a significant role in observing and identifying changes in the health status of patient with chronic obstructive pulmonary disease (COPD). The aim of this study was to explore and describe nurses' observations of older patients with COPD when providing home nursing care. In this qualitative explorative study, data were collected through observations of 17 home care visits using the think-aloud technique, followed up with individual interviews with the nurses. Qualitative content analysis was used to analyze the data. The findings showed that the nurses' observations (focus, methods, and interpretation) were characterized by their search for deviations from what they judged to be the patient's habitual state. The nurses did not use any tool or guidelines, nor did they follow a standard procedure. Instead, when observing and interpreting, they performed a complex process guided by their experience and knowledge of the patient, and the patient's individual and contextual circumstances. This knowledge contributes to warranted reflection on nurses' practice in this context to secure COPD patients' safety and quality of life.

Nurse managers' perspectives on working with everyday ethics in long-term care.

BACKGROUND: Nurse managers are expected to continuously ensure that ethical standards are met and to support healthcare workers' ethical competence. Several studies have concluded that nurses across various healthcare settings lack the support needed to provide safe, compassionate and competent ethical care. OBJECTIVE: The aim of this study was to explore and understand how nurse managers perceive their role in supporting their staff in conducting ethically sound care in nursing homes and home nursing care. DESIGN AND PARTICIPANTS: Qualitative individual interviews were performed with 10 nurse managers with human resources responsibilities for healthcare workers in four nursing home wards and six home nursing care districts. Content analysis was used to analyse the data. ETHICAL CONSIDERATIONS: The Norwegian Centre for Research Data granted permission for this study. FINDINGS: The analysis resulted in seven subcategories that were grouped into three main categories: managers' perception of the importance of the role, managers' experiences of exercising the role and managers' opportunities to fulfil the role. Challenges with conceptualizing ethics were highlighted, as well as lack of applicable tools or time and varying motivation among employees. DISCUSSION: The leaders tended to perceive ethics as a 'personal matter' and that the need for and benefit of ethical support (e.g., ethics reflection) depended on individuals' vulnerability, attitudes, commitment and previous experiences. The managers did not seem to distinguish between their own responsibility to support ethical competence and the responsibility of the individual employee to provide ethical care. CONCLUSIONS: Our findings suggest that nurse managers need support themselves, both to understand and to carry out their responsibilities to foster their staffs' ethical conduct. Supporting staff in conducting ethically sound care requires more than organizing meeting places for ethical reflection; it also requires greater awareness and understanding of what ethical leadership means.

Nurses' experiences of compassion when giving palliative care at home.

BACKGROUND: Compassion is seen as a core professional value in nursing and as essential in the effort of relieving suffering and promoting well-being in palliative care patients. Despite the advances in modern healthcare systems, there is a growing clinical and scientific concern that the value of compassion in palliative care is being less emphasised. OBJECTIVE: This study aimed to explore nurses' experiences of compassion when caring for palliative patients in home nursing care. DESIGN AND PARTICIPANTS: A secondary qualitative analysis inspired by hermeneutic circling was performed on narrative interviews with 10 registered nurses recruited from municipal home nursing care facilities in Mid-Norway. ETHICAL CONSIDERATIONS: The Norwegian Social Science Data Services granted permission for the study (No. 34299) and the re-use of the data. FINDINGS: The compassionate experience was illuminated by one overarching theme: valuing caring interactions as positive, negative or neutral, which entailed three themes: (1) perceiving the patient's plea, (2) interpreting feelings and (3) reasoning about accountability and action, with subsequent subthemes. DISCUSSION: In contrast to most studies on compassion, our results highlight that a lack of compassion entails experiences of both negative and neutral content. CONCLUSION: The phenomenon of neutral caring interactions and lack of compassion demands further explorations from both a patient - and a nurse perspective.

Controlling emotions-nurses' lived experiences caring for patients in forensic psychiatry.

Purpose: Nurses working in forensic psychiatry often encounter offenders who have a severe mental illness, which may cause ethical challenges and influence nurses' daily work. This study was conducted to illuminate the meaning of nurses' lived experiences of encounters with patients with mental illnesses in forensic inpatient care. Methods: This qualitative study employed narrative interviews with 13 nurses. Interviews were audiotaped and transcribed verbatim and analysed following a phenomenological-hermeneutic approach. Results: Four key themes were revealed: "Being frustrated" (subthemes included "Fighting resignation" and "Being disappointed"), "Protecting oneself" (subthemes included "To shy away," "Being on your guard," and "Being disclosed"), "Being open-minded" (subthemes included "Being confirmed," "Developing trust," and "Developing compassion"), and "Striving for control" (subthemes included "Sensing mutual vulnerability" and "Regulating oneself"). Further, working in forensic psychiatry challenged nurses' identity as healthcare professionals because of being in a stressful context. Conclusions: Dealing with aggressive patients with severe mental illnesses threatens nurses' professional identity. Nurses must attempt to empathize with patients' experiences and respond accordingly. Utilizing strategies rooted in compassion such as self-reflection, emotional regulation, and distancing themselves when necessary may enable nurses to more effectively respond to patients' needs.

The impact of shareholding networks for facilitating care in rural Thailand.

This study explored the existential meaning of being a participant in shareholding networks for the care of older people in Thailand. Ten older persons were interviewed about their experiences of participating in the networks. A reflective lifeworld perspective based on phenomenological philosophy was used. The findings show that participating in shareholding network activities entails an always-present existence of aging intertwined with life. Its constituents further describe the essential meaning of the phenomenon: "experience of improved self-management", "feeling of increased self-esteem", and "bridging a gap in the care of older people". Participation in shareholding network activities means keeping contact with oneself and being able to have a life that corresponds to how one perceives oneself to be and must therefore be understood from a holistic perspective. The present study recommends that older persons' need for support include places where safe and profound reflection on existential issues.

Meanings of Living in Lodgings During Senior High School.

Studies show that senior high school students living in lodgings (away from home) when attending high school are vulnerable to stress and mental health problems. Moving away from home at the age of 15-16 is a transition that might affect adolescents' well-being. The aim of this study is to explore the experience of living in lodgings during senior high school. In-depth interviews were conducted with 21 Norwegian lodgers of both genders between the ages of 16-18. Interviews were analyzed according to a phenomenological hermeneutical approach. Four main themes were identified: (a) striving between controlling time and being controlled by time, (b) striving between finding comfort in being alone and feeling left alone, (c) striving between being independent and being taken care of, and (d) striving between leaving and finding home. The findings illuminate many challenges experienced by lodgers. A raised awareness and preventive initiatives from school nurses are recommended.