How may cultural and political ideals cause moral distress in acute psychiatry? A qualitative study.

BACKGROUND: There is growing public criticism of the use of restraints or coercion. Demands for strengthened patient participation and prevention of coercive measures in mental health care has become a priority for care professionals, researchers, and policymakers in Norway, as in many other countries. We have studied in what ways this current ideal of reducing the use of restraints or coercion and attempting to practice in a least restrictive manner may raise morals issues and create experiences of moral distress in nurses working in acute psychiatric contexts. METHODS: Qualitative interview study, individual and focus group interviews, with altogether 30 nurses working in acute psychiatric wards in two mental health hospitals in Norway. Interviews were recorded and transcribed. A thematic analytic approach was chosen. RESULTS: While nurses sense a strong expectation to minimise the use of restraints/coercion, patients on acute psychiatric wards are being increasingly ill with a greater tendency to violence. This creates moral doubt and dilemmas regarding how much nurses should endure on their own and their patients' behalf and may expose patients and healthcare personnel to greater risk of violence. Nurses worry that new legislation and ideals may prevent acutely mentally ill and vulnerable patients from receiving the treatment they need as well as their ability to create a psychological safe climate on the ward. Furthermore, persuading the patient to stay on the ward can cause guilt and uneasiness. Inadequate resources function as external constraints that may frustrate nurses from realising the treatment ideals set before them. CONCLUSIONS: Mental health nurses working in acute psychiatric care are involved in a complex interplay between political and professional ideals to reduce the use of coercion while being responsible for the safety of both patients and staff as well as creating a therapeutic atmosphere. External constraints like inadequate resources may furthermore hinder the healthcare workers/nurses from realising the treatment ideals set before them. Caught in the middle nurses may experience moral distress that may lead to physical discomfort, uneasiness and feelings of guilt, shame, and defeat. Pressure on nurses and care providers to reduce or eliminate the use of coercion and reduction of health care spending are incompatible demands.

Coping with moral distress on acute psychiatric wards: A qualitative study.

BACKGROUND: Nurses working within acute psychiatric settings often face multifaceted moral dilemmas and incompatible demands. METHODS: Qualitative individual and focus group interviews were conducted. ETHICAL CONSIDERATIONS: Approval was received from the Norwegian Social Science Data Services. Ethical Research Guidelines were followed. PARTICIPANTS AND RESEARCH CONTEXT: Thirty nurses working within acute psychiatric wards in two mental health hospitals. RESULTS: Various coping strategies were used: mentally sorting through their ethical dilemmas or bringing them to the leadership, not 'bringing problems home' after work or loyally doing as told and trying to make oneself immune. Colleagues and work climate were important for choice of coping strategies. DISCUSSION: Nurses' coping strategies may influence both their clinical practice and their private life. Not facing their moral distress seemed to come at a high price. CONCLUSIONS: It seems essential for nurses working in acute psychiatric settings to come to terms with distressing events and identify and address the moral issues they face. As moral distress to a great extent is an organisational problem experienced at a personal level, it is important that a work climate is developed that is open for ethical discussions and nourishes adaptive coping strategies and moral resilience.

Pre-decision regret before transition of dependents with severe dementia to long-term care.

BACKGROUND: To place a dependent with severe dementia in a nursing home is a painful and difficult decision to make. In collectivistic oriented societies or families, children tend to be socialised to care for ageing parents and to experience guilt and shame if they violate this principle. Leaving the care to professional caregivers does not conform with the cultural expectations of many ethnic groups and becomes a sign of the family's moral failure. RESEARCH DESIGN: Qualitative design with individual in-depth interviews with nurses, family members and dementia care coordinators in Norway, Montenegro, Serbia and South Africa. Braun and Clarke's six analytic phases were used. ETHICAL CONSIDERATIONS: The project was approved by the Regional Committee for Research, South-Eastern Norway; the Norwegian Centre for Research Data; the Ethics Committee; University of Limpopo, MEDUNSA Campus, South Africa; and by the local heads of the respective nursing homes or home care services. Interviewees were informed orally and in writing and signed an informed consent form. FINDINGS: Healthcare professionals tend to be contacted only when the situation becomes unmanageable. Interviewees talked about feelings of obligation, shame and stigma in their societies regarding dementia, particularly in connection with institutionalisation of family members. Many lacked support during the decision-making process and were in a squeeze between their own needs and the patients' need of professional care, and the feeling of duty and worry about being stigmatised by their surroundings. This conflict may be a source of pre-decision regret. CONCLUSION: Family caregivers need help to understand the behaviours of persons with dementia and how to access the formal and informal services available. Thus, they may provide effective support to patients and family carers alike. Supportive interventions for caregivers need to be tailored to meet the individual needs of both the caregiver and the persons with dementia.

The relationship between religiosity/spirituality and quality of life among female Eritrean refugees living in Norwegian asylum centres.

BACKGROUND: Women are more vulnerable to mental health problems than men after migration, but little is known about the influence of religiosity/spirituality on their quality of life. The purpose of this study was to explore religiosity/spirituality, in relationships with various domains of quality of life, among female Eritrean refugees staying in Norwegian asylum centres. METHOD: A questionnaire assessing sociodemographic characteristics was used together with the World Health OrganizationQuality of Life - Spirituality, Religiosity and Personal Beliefs (WHOQOL-SRPB) questionnaire, which assesses religiosity/spirituality and domains of quality of life. A total of 63 adult female Eritrean refugees who had been granted asylum but were still living in asylum reception centres located in southern and central Norway participated. RESULTS: Religiosity/spirituality was independently associated with psychological quality of life (B = 0.367, p < .001), level of independence (B = 0.184, p = .028), social quality of life (B = 0.500, p = .003), environmental quality of life (B = 0.323, p < .001) and overall quality of life (B = 0.213, p < .001), but not with physical quality of life (B = 0.056, p = .679). There were no significant differences between religious affiliations on religiosity/spirituality or quality of life measures. CONCLUSION: Consistent with previous research, this study highlights the correlation between religiosity/spirituality and overall quality of life. We recommend a longitudinal follow-up study of similar populations, after they are resettled and integrated into their host countries, to understand the associations between quality of life and religiosity/spirituality over time.

Establishing a trusting nurse-immigrant mother relationship in the neonatal unit.

BACKGROUND: In the neonatal intensive care unit, immigrant parents may experience even greater anxiety than other parents, particularly if they and the nurses do not share a common language. AIM: To explore the complex issues of trust and the nurse-mother relationship in neonatal intensive care units when they do not share a common language. DESIGN AND METHODS: This study has a qualitative design. Individual semi-structured in-depth interviews and two focus group interviews were conducted with eight immigrant mothers and eight neonatal intensive care unit nurses, respectively. Data analysis was based on Braun and Clarke's thematic analytic method. ETHICAL CONSIDERATIONS: Approval was obtained from the hospital's Scientific Committee and the Data Protection Officer. Interviewees were informed in their native language about confidentiality and they signed an informed consent form. RESULTS: Trust was a focus for mothers and nurses alike. The mothers held that they were satisfied that their infants received the very best care. They seemed to find the nurses' care and compassion unexpected and said they felt empowered by learning how to care for their infant. The nurses discussed the mother's vulnerability, dependency on their actions, attitudes and behaviour. DISCUSSION: Lack of a common language created a challenge. Both parties depended on non-verbal communication and eye contact. The nurses found that being compassionate, competent and knowledgeable were important trust-building factors. The mothers were relieved to find that they were welcome, could feel safe and their infants were well cared for. CONCLUSION: The parents of an infant admitted to the neonatal intensive care unit have no choice but to trust the treatment and care their infant receives. Maternal vulnerability challenges the nurse's awareness of the asymmetric distribution of power and ability to establish a trusting relationship with the mother. This is particularly important when mother and nurse do not share a verbal language. The nurses worked purposefully to gain trust.

Mothers' Experiences and Perceptions of Facility-based Delivery Care in Rural Ethiopia.

In Ethiopia, delivery wards are a part of primary healthcare services. However, although the maternal mortality rate is very high, approximately 50% of mothers use skilled birth attendants. This study focused on how women in a rural southern district of Ethiopia experience maternity care offered at the local delivery wards. In this qualitative, exploratory study, 19 women who had given birth in a healthcare facility were interviewed in 2019. Individual in-depth interviews were supplemented with observations conducted at 2 different delivery wards in the same district in 2020. Two main themes emerged from the thematic content analysis: increased awareness and safety were the primary reasons for giving birth at a healthcare facility, and traditions and norms affected women's birth experiences in public maternity wards. The main shortcomings were a shortage of medicine, ambulance not arriving in time, and lack of care at night. For some women, being assisted by a male midwife could be challenging, and the inability to afford necessary medicine made adequate treatment inaccessible. Providing continuous information gave the women a certain feeling of control. Strong family involvement indicated that collectivistic expectations were key to rural delivery wards. The healthcare system must be structured to meet women's needs. Moreover, managers and midwives should ensure that birthing women receive high-quality, safe, timely, and respectful care.

Providing safe maternity care under challenging conditions in rural Ethiopia: a qualitative study.

BACKGROUND: Women's health and the reduction in the global maternal mortality rate is a research priority worldwide. The aim of this study was to investigate the structural conditions that influence the maternity care provided for women in rural Ethiopia. METHODS: A qualitative descriptive study was conducted, composed of 28 individual in-depth interviews with midwives and women who had given birth during the past 8 months, and observations of maternity care at health centres and a primary hospital. A thematic analysis was conducted. RESULTS: The midwives do their utmost to save the lives of mothers and prioritise saving lives over providing compassionate care. Inadequate resources, such as equipment, medicine and water, affect the quality of care they provide for the birthing women. This creates a conflict between the midwives' ideals and what conditions allow them to do. Families and the women's network play important roles in providing care and support to the women who give birth in health facilities. CONCLUSIONS: Structural conditions make it difficult for Ethiopian midwives in rural areas to provide optimal maternity care. In addition to the availability of professional midwifery care, the expectant mothers' families and networks also tend to provide important support and care. Further studies on how to improve the quality of maternity care from the women's perspective are needed.

Communication as a non-technical skill in the operating room: A qualitative study.

AIM: The aim of this study was to explore how operating room nurses (ORNs) experience operating room (OR) team communication concerning non-technical skills. DESIGN: Based on the Scrub Practitioners List of Intraoperative Non-Technical Skill (SPLINTS), qualitative individual in-depth semi-structured interviews were conducted with 11 ORNs in a Norwegian university hospital. Braun and Clarke's six analytic phases for thematic data analysis were used. RESULTS: Surgeons being unprepared or demanding different instruments than the preoperative information indicates, cause stress and frustration. So does noise and brusquely or poor communication. Ensuring good information flow within the entire team is important. When silence is required, the ORNs communicate with gestures, looks and nods. Creating a positive and secure team culture facilitates discussions, questions and information sharing. CONCLUSION: Inappropriate dynamics, inaccurate and/or disrespectful communication and noise may reduce patient safety. Interdisciplinary team training may bring attention to the value of communication as a non-technical skill.

Non-technical skills in operating room nursing: Ethical aspects.

BACKGROUND: Non-technical skills are cognitive and interpersonal skills underpinning technical proficiency. Ethical values and respect for human dignity make operating room nurses responsible for nursing decisions that are clinically and technically sound and morally appropriate. AIM: To learn what ethical issues operating room nurses perceive as important regarding non-technical skills. RESEARCH DESIGN: Qualitative individual in-depth interviews were conducted. The interviews were analysed using Braun and Clarke's six phases for thematic analysis. PARTICIPANTS AND RESEARCH CONTEXT: Eleven experienced perioperative/operating room nurses working in an operating unit at a Norwegian university hospital. ETHICAL CONSIDERATIONS: Approval was given by The Norwegian Social Science Data Service in care of the hospital's Data Protection Officer. FINDINGS: Three main themes were found: respect and care for the patient, making the patient feel safe, and respect within the perioperative team. These features or themes, which incorporate collaboration and communication, are closely connected to patient safety. DISCUSSION: Defending the patient's dignity is part of caring for and respecting the patient. The manner in which the operating room team collaborates is important for the patient to feel safe and secure. Poor teamwork may have dire consequences. Reciprocal respect within the team includes respect for each other's tasks and responsibilities and to talk to one another in a friendly manner. CONCLUSION: Being respectful and contributing to a caring atmosphere are central ethical skills in the operating room. To patients, harmonious teamwork translates into a feeling of safety and being cared for. The nurses see respect and patient safety, and respect and reciprocal politeness among the members of the perioperative team as central ethical non-technical skills. Lack of respect influences the team negatively and is detrimental for patient safety. Good communication is an important safety measure during surgery and creates a feeling of good 'flow' within the operating room team.

When a common language is missing: Nurse-mother communication in the NICU. A qualitative study.

AIMS AND OBJECTIVES: To explore how communication in neonatal intensive care units (NICUs) between immigrant mothers and nurses take place without having a common language, and how these mothers experience their NICU stay. BACKGROUND: Admission of infants to NICU affects both parents and infants. Immigrant mothers constitute a vulnerable hospital population in need of culturally, linguistically and individually tailored information. DESIGN AND METHODS: The study had a qualitative design reported according to the COREQ criteria. Eight mothers who spoke neither Scandinavian nor English went through individual semi-structured interviews. Six mother-nurse interactions were observed, and eight nurses' experiences were explored through focus-group interviews. All interviews were audio recorded and transcribed verbatim. The analysis was thematic and hermeneutic in character. RESULTS: Interpreters were present during the consultations with the physicians, but rarely during the daily nurse-mother interactions. Nurses focused on daily routines, infant care guidance and mother-infant attachment. The mothers learned through demonstrations and hands-on guidance. Language barriers made it difficult to assess the mothers' understanding, but the mothers expressed that they felt adequately included in the care of their infant and well informed and guided. Even so, both mothers and nurses expressed desire to use interpreters more regularly. The pictorial communication boards available lacked important vocabulary needed in neonatal nursing contexts and their use furthermore interrupted the mother-nurse conversation. CONCLUSION: Body language, simple words, guesswork, trial and error characterised the nurse-mother interaction. The nurses adopted various communication strategies to help the mothers understand and give them a voice. Competent interpreters were used during meetings with physicians, but not during daily bedside guidance and information giving by nurses. RELEVANCE TO CLINICAL PRACTICE: Knowledge of immigrant mothers' and nurses' communication strategies and how both parties think, feel and act to overcome communication problem is necessary to improve clinical practice and reduce communication barriers.

Student nurses' learning outcomes through participation in a clinical nursing research project: A qualitative study.

100 bachelor students participated in a research project integrated in their clinical placements. They assessed patients admitted at a certain date/time regarding pain/pain intensity and risk of decubitus, falling and nutritional problems. In the current study is examined the students' learning experiences from participating in this project through focus group interviews. Data analysis of electronically recorded and transcribed interviews following Braun and Clarke's six phases of thematic analysis. Although pressed for time the students felt able to adapt their communication to patients' various situations, explain about the project, receive a signed consent form, and do the data collection. During the project they had honed their communicative skills, become more confident, and able to utilise their theoretical knowledge to reflect, observe, assess, and act. They were able to attune their communication to the various patients and create a trusting relationship which made the assessments possible in spite of the brevity of their meetings. In spite of this mainly interpersonal focus we trust that this first empirical research experience will enhance their ability to read and understand research papers. Furthermore, the students found they had learned a lot and acquired greater understanding of the connection between theory and practical patient work.

Moral distress in acute psychiatric nursing: Multifaceted dilemmas and demands.

BACKGROUND: In this article, the sources and features of moral distress as experienced by acute psychiatric care nurses are explored. RESEARCH DESIGN: A qualitative design with 16 individual in-depth interviews was chosen. Braun and Clarke's six analytic phases were used. ETHICAL CONSIDERATIONS: Approval was obtained from the Norwegian Social Science Data Services. Participation was confidential and voluntary. FINDINGS: Based on findings, a somewhat wider definition of moral distress is introduced where nurses experiencing being morally constrained, facing moral dilemmas or moral doubt are included. Coercive administration of medicines, coercion that might be avoided and resistance to the use of coercion are all morally stressful situations. Insufficient resources, mentally poorer patients and quicker discharges lead to superficial treatment. Few staff on evening shifts/weekends make nurses worry when follow-up of the most ill patients, often suicidal, in need of seclusion or with heightened risk of violence, must be done by untrained personnel. Provision of good care when exposed to violence is morally challenging. Feelings of inadequacy, being squeezed between ideals and clinical reality, and failing the patients create moral distress. Moral distress causes bad conscience and feelings of guilt, frustration, anger, sadness, inadequacy, mental tiredness, emotional numbness and being fragmented. Others feel emotionally 'flat', cold and empty, and develop high blood pressure and problems sleeping. Even so, some nurses find that moral stress hones their ethical awareness. CONCLUSION: Moral distress in acute psychiatric care may be caused by multiple reasons and cause a variety of reactions. Multifaceted ethical dilemmas, incompatible demands and proximity to patients' suffering make nurses exposed to moral distress. Moral distress may lead to reduced quality care, which again may lead to bad conscience and cause moral distress. It is particularly problematic if moral distress results in nurses distancing and disconnecting themselves from the patients and their inner selves.

The influence of individualistic and collectivistic morality on dementia care choices.

BACKGROUND: If collectivistic-oriented family carers choose professional care for dependents with dementia, they risk being stigmatised as failing their obligation. This may influence dementia care choices. RESEARCH QUESTION: How may individualistic and collectivistic values influence choices in dementia care? METHOD: Qualitative design with in-depth interviews with a total of 29 nurses, 13 family members in Norway and the Balkans and 3 Norwegian dementia care coordinators. A hermeneutic content-focused analysis was used. ETHICAL CONSIDERATIONS: Ethical approval was obtained from the Regional Ethics Committee for Research, South-Eastern Norway, and the nursing homes' leadership. FINDINGS: Family domain reasons why institutionalisation of dependents with dementia was seen as a last resort: obligation towards family members, particularly parents; worry about other family members' reactions and inability to cope with the care for the person with dementia. Social domain reasons: feelings of shame and stigma regarding dementia, particularly in connection with institutionalisation of family members. DISCUSSION: Children's obligation towards their parents is an important aspect of the morality of collectivistic societies. Institutionalising parents with dementia may cause feelings of guilt and shame and worry about being stigmatised and ostracised. To avoid blame and rejection, caregiver(s) try to keep the fact that family members have dementia 'in the family'. The decision to accept professional healthcare for dependents with severe dementia or have them admitted to a geriatric institution was postponed as long as possible. CONCLUSION: Family care morality may constitute a significant barrier against seeking professional help for persons with dementia, a barrier based on the expectation that the family will care for their old, even when suffering from severe dementia. Hence, stigma and shame may significantly affect the provision of care. Culturally tailored information may encourage family carers to seek professional help before the disruptive influence of the disease makes institutionalisation the only feasible option.

Coping, resilience and posttraumatic growth among Eritrean female refugees living in Norwegian asylum reception centres: A qualitative study.

BACKGROUND: The links between migration and health are well documented. Being a refugee exacerbates migrants' vulnerability through trauma and loss. The aim of this study is to identify sources of resilience, coping and posttraumatic growth in female Eritrean refugees living in Norwegian asylum reception centres. METHOD: The study had a qualitative, descriptive and explorative design with two focus group interviews and 10 individual in-depth interviews. Participants included 18 female Eritrean refugees aged 18-60, who had obtained refugee status and were still living in an asylum reception centre. A content-focused hermeneutic analytic approach was used. RESULTS: Interviewees described the challenges of pre-flight and flight trauma, conditions at the refugee centre, communication difficulties and the 'endless' waiting for transfer to a municipality. To cope, they found it helpful to focus on the future and to think positively. Fellowship with and support from fellow Eritrean refugees were essential as they became a proxy family and provided a strong ethnic identity. Their religious belief also helped them cope and gave them hope for the future. DISCUSSION: The interviewees in this study perceived their psychological problems as a normal reaction to what they had been through. Religious belief was an important resilience factor, as was social support, especially from peers. CONCLUSION: The interviewees' coping was based on the realization of their psychological reactions being normal while doing their utmost to focus on their aims and hopes for the future.

When people with dementia are perceived as witches. Consequences for patients and nurse education in South Africa.

AIMS AND OBJECTIVES: To explore and describe the link between culture and dementia care with the focus on the influence of the belief in dementia as witchcraft and people with dementia as witches. BACKGROUND: In South Africa, especially in townships and rural areas, dementia is often perceived as connected to witchcraft rather than to disease. Persons labelled as witches-mostly older women-may be bullied, ostracised, beaten, stoned, burned, even killed. METHOD: One strand of findings from a larger international study is presented with in-depth qualitative interviews of one close family member and seven nurses caring for patients with severe dementia in nursing homes in Tshwane in South Africa. A hermeneutic analytic approach was used. RESULTS: Two main themes are found, namely "Belief in witchcraft causing fear of persons with dementia" and "Need of knowledge and education." Fear of and violence towards people with dementia are based on the belief that they are witches. Some of the nurses had also held this belief until they started working with patients with dementia. There is a great need for education both among healthcare workers and the populace. DISCUSSION: The "witch" belief prevents seeking professional help. As nursing homes tend to be private and expensive, professional dementia care is virtually unattainable for the poor. Dementia needs a more prominent place in nursing curricula. Nurses as educators need to know the local culture and language to be accepted in the various communities. They need to visit families affected by dementia, give awareness talks in churches, schools and clinics and facilitate support groups for carers of people with dementia in the local language. CONCLUSION: Improved nurses' education in gerontology and geriatric care is needed. Trained specialist nurses may work as mediators and help eradicate the witchcraft beliefs connected to severe dementia.

Patient participation: causing moral stress in psychiatric nursing?

AIM: The aim of this study was to explore psychiatric nurses' experiences and perspectives regarding patient participation. Patient participation is an ambiguous, complex and poorly defined concept with practical/clinical, organisational, legal and ethical aspects, some of which in psychiatric units may cause ethical predicaments and moral stress in nurses, for instance when moral caring acts are thwarted by constraints. METHODS: An explorative quantitative pilot study was conducted at a psychiatric subacute unit through three focus group interviews with a total of nine participants. A thematic analytic approach was chosen. Preliminary empirical findings were discussed with participants before the final data analysis. Ethical research guidelines were followed. RESULTS: Patient participation is a difficult ideal to realise because of vagueness of aim and content. What was regarded as patient participation differed. Some interviewees held that patients may have a say within the framework of restraints while others saw patient participation as superficial. The interviewees describe themselves as patient's spokespersons and contributing to patients participating in their treatment as a great responsibility. They felt squeezed between their ethical values and the 'system'. They found themselves in a negotiator role trying to collaborate with both the doctors and the patients. Privatisation of a political ideal makes nurses vulnerable to burn out and moral distress. CONCLUSION: Nurses have a particular ethical responsibility towards vulnerable patients, and may themselves be vulnerable when caught in situations where their professional and moral values are threatened. Unclear concepts make for unclear division of responsibility. Patient participation is often a neglected value in current psychiatric treatment philosophy. When healthcare workers' ethical sensibilities are compromised, this may result in moral stress.

Moments of joy and delight: the meaning of traditional food in dementia care.

AIMS AND OBJECTIVES: To learn about the meaning of traditional food to institutionalised patients with dementia. BACKGROUND: Traditional food strengthens the feelings of belonging, identity and heritage, which help persons with dementia to hold on to and reinforce their cultural identity and quality of life. Taste is more cultural than physiological. Dietary habits are established early in life and may be difficult to change. Being served unfamiliar dishes may lead to disappointment and a feeling of being betrayed and unloved. DESIGN AND METHOD: The three studies presented have a qualitative design. In-depth interviews of family members and nurses experienced in dementia care were conducted in South Africa and among ethnic Norwegians and the Sami in Norway. Content-focused analysis, hermeneutic in character, was used to enable the exploration of the thoughts, feelings and cultural meaning described. RESULTS: Traditional foods created a feeling of belonging and joy. Familiar tastes and smells awoke pleasant memories in patients and boosted their sense of well-being, identity and belonging, even producing words in those who usually did not speak. CONCLUSIONS: In persons with dementia, dishes remembered from their childhood may help maintain and strengthen cultural identity, create joy and increase patients' feeling of belonging, being respected and cared for. Traditional food furthermore improves patients' appetite, nutritional intake and quality of life. To serve traditional meals in nursing homes demands extra planning and resources, traditional knowledge, creativity and knowledge of patients' personal tastes. RELEVANCE FOR CLINICAL PRACTICE: This study provides insight into culture-sensitive dietary needs of institutionalised patients with dementia. The cultural significance of food for feeling contentment and social and physical well-being is discussed. Besides helping to avoid undernutrition, being served traditional dishes may be very important to reminiscence, joy, thriving and quality of life.

Joy, happiness, and humor in dementia care: a qualitative study.

People with advanced dementia can still enjoy life. Even if their language is impaired and they live in the moment, it should still be possible for them to live a life of pleasure and joy. A pilot study was conducted to learn more about these individuals' experiences, but because of the decline in their access to language, it was necessary to have others speak on their behalf. Analysis of findings was based on a hermeneutic approach inspired by Ricoeur (1981). Central findings were that all the interviewees emphasized humor and interacting with other people as a source of happiness.

Caring for ethnic minority patients: a mixed method study of nurses' self-assessment of cultural competency.

BACKGROUND: Research shows that nurses tend to be lacking cultural competence, which may influence treatment and care for ethnic minority patients negatively. PURPOSE: To investigate how Medical Unit nurses and Psychiatric Unit nurses assess their own competency concerning patients with minority backgrounds. The topics covered are: intercultural knowledge, knowledge of medical traditions and differences in illness etiology, symptom assessment, and in-service education and availability of advice. These topics are seen in relation to the nurses' years of work experience. METHODS: Three focus group interviews were conducted before the development of a Likert-type questionnaire containing six topics and a total of 35 statements. 145 Medical Unit nurses (90%) and 100 Psychiatric Unit nurses (81%) returned the questionnaire. SPSS was used to analyze the quantitative data; hermeneutic thematic analysis was used for the qualitative data. RESULTS: Both the Medical Unit nurses and the Psychiatric Unit nurses indicated that knowledge about illness and treatment philosophies other than Western biomedicine was inadequate. The respondents also found symptom assessment difficult, and they were offered little, if any, in-service education. Work experience added little substantive knowledge. CONCLUSION: Experience alone does not equip nurses with adequate knowledge for intercultural symptom assessment and culturally competent treatment and care. Formal education, in-service classes, courses, feedback and access to relevant information are needed together with reflection upon clinical practice.

Pain relief, spiritual needs, and family support: three central areas in intercultural palliative care.

OBJECTIVE: The purpose of this study was to draw out and coalesce the topic-specific information found in research literature regarding the provision of culturally sensitive palliative practice. METHOD: This was a literature study and Gadamerian hermeneutic text analysis. RESULTS: It is more difficult to assess the level of pain in ethnic minority patients, and healthcare providers may become frustrated and interpret pain symptoms as fabrication. These patients are more likely to receive inadequate pain medication. Physical symptom management has become the priority in palliative care, but pain must also be viewed from the perspective of its social, cultural, and spiritual significance. Collectivist values may lead to an other-reliant and dependent coping style. This and religious demands may cause the family to rally around the patient. Many dying patients wish to be cared for at home by their families, but as the patient often has complex needs, the family may not be able to cope with the patient's care. SIGNIFICANCE OF RESULTS: Formal education and in-service programs are needed for healthcare providers, together with empirical studies regarding how to achieve more culturally appropriate care in intercultural palliative practice. The immigrant population needs to be educated about cancer and the various kinds of palliative and hospice care offered in the society in which they now live.