Patients' perceptions of nurses' behaviour that influence patient participation in nursing care: a critical incident study.

Patient participation is an important basis for nursing care and medical treatment and is a legal right in many Western countries. Studies have established that patients consider participation to be both obvious and important, but there are also findings showing the opposite and patients often prefer a passive recipient role. Knowledge of what may influence patients' participation is thus of great importance. The aim was to identify incidents and nurses' behaviours that influence patients' participation in nursing care based on patients' experiences from inpatient somatic care. The Critical Incident Technique (CIT) was employed. Interviews were performed with patients (n = 17), recruited from somatic inpatient care at an internal medical clinic in West Sweden. This study provided a picture of incidents, nurses' behaviours that stimulate or inhibit patients' participation, and patient reactions on nurses' behaviours. Incidents took place during medical ward round, nursing ward round, information session, nursing documentation, drug administration, and meal.

Patients' perceptions of barriers for participation in nursing care.

BACKGROUND: In many Western countries as in Sweden, patients have legal right to participate in own care individually adjusted to each patient's wishes and abilities. There are still few empirical studies of patients' perceptions of barriers for participation. Accordingly, there is a need to identify what may prevent patients from playing an active role in own nursing care. Such knowledge is highly valuable for the nursing profession when it comes to implementation of individual patient participation. AIM AND OBJECTIVE: To explore barriers for patient participation in nursing care with a special focus on adult patients with experience of inpatient physical care. METHODOLOGICAL DESIGN AND JUSTIFICATION: Data were collected through 6 focus groups with 26 Swedish informants recruited from physical inpatient care as well as discharged patients from such a setting. A content analysis with qualitative approach of the tape-recorded interview material was made. ETHICAL ISSUES AND APPROVAL: The ethics of scientific work was adhered to. Each study participant gave informed consent after verbal and written information. The Ethics Committee of Göteborg University approved the study. RESULTS: The barriers for patient participation were identified as four categories: Facing own inability, meeting lack of empathy, meeting a paternalistic attitude and sensing structural barriers, and their 10 underlying subcategories. CONCLUSIONS: Our study contributes knowledge and understanding of patients' experiences of barriers for participation. The findings point to remaining structures and nurse attitudes that are of disadvantage for patients' participation. The findings may increase the understanding of patient participation and may serve as an incentive in practice and nursing education to meet and eliminate these barriers, in quality assurance of care, work organization and further research.

Relatives' information needs and the characteristics of their search for information--in the words of relatives of stroke survivors.

AIM AND OBJECTIVES: To explore relatives' information needs and the characteristics of their information-seeking process shortly after the stroke event and six months later. BACKGROUND: Providing relatives of stroke survivors with information is important, as lack of information increases their uncertainty and risk becoming the 'second patient in the family' and early death. Therefore, it is essential to be aware of relatives' information needs and information-seeking process the first six months after stroke. DESIGN: This qualitative study has a descriptive design. METHOD: Open-ended interviews were conducted with sixteen relatives after stroke survivor's admission to stroke unit and six months later with nine of these relatives. Data were analysed by means of content analysis. RESULTS: The identified information needs covered the spectrum from stroke survivor's medical condition because nurses' actions to relatives' changed health and life situation. Furthermore, relatives' information-seeking process was found to be related to their level of personal involvement, situational circumstances, different forms of knowledge and sources of information. CONCLUSIONS: Relatives' search for information emerges when health and lifestyle changes occur in survivors or themselves. It is important that this information affect them personally. Also, they need to develop different forms of knowledge when they cannot trust their own competences. As a result, instead of following established curricula based on their beliefs of relatives' information needs, nurses need to practice on identifying relatives' information needs. RELEVANCE TO PRACTICE: Different information needs and characteristics described in the study can serve as guidance in the development and implementation of pedagogical interventions to support relatives of stroke survivors. One pedagogical implication is to explore what a specific relative wants to know by how he/she talks or thinks about it. Thus, it must be taken into consideration that level of personal involvement, situational circumstances, sources of information and factual knowledge, understanding and skills are intertwined.

Enjoying tactile touch and gaining hope when being cared for in intensive care--a phenomenological hermeneutical study.

Touch has been a part of the healing process in many civilisations and cultures throughout the centuries. Nurses frequently use touch to provide comfort and reach their patients. The aim of this study was to illuminate the meaning of receiving tactile touch when being cared for in an intensive care unit. Tactile touch is a complementary method including the use of effleurage, which means soft stroking movements along the body. The context used to illuminate the meaning of receiving tactile touch was two general intensive care units (ICUs). Six patients, who have been cared for in the two ICUs, participated in the study. A phenomenological-hermeneutical method based on the philosophy of Ricoeur and developed for nursing research by Lindseth and Norberg [Lindseth A, Norberg A. A phenomenological hermeneutical method for researching lived experience. Scandinavian Journal of Caring Sciences, 2004;18:145-53] was chosen for the analysis. Data consisted of narratives, which were analysed in three recurring phases: naïve understanding, structural analyses and comprehensive understanding. Two main themes were found: being connected to oneself and being unable to gain and maintain pleasure. The comprehensive understanding of receiving tactile touch during intensive care seems to be an expression of enjoying tactile touch and gaining hope for the future. This study reveals that it is possible to experience moments of pleasure in the midst of being a severely ill patient at an ICU and, through this experience also gain hope.

The outcome of tactile touch on stress parameters in intensive care: a randomized controlled trial.

The study aimed to investigate the effects of a five-day tactile touch intervention in order to find new and unconventional measures to moderate the detrimental influence of patients' stressors during intensive care. The hypothesis was that tactile touch would decrease stress indicators such as anxiety, glucose metabolism, blood pressure, heart rate and requirements of sedative drugs and noradrenalin. A randomized controlled trial was undertaken with 44 patients, which were assigned either to tactile touch or standard treatment (a rest hour). Observations of the stress indicators were made before, during and after the intervention or standard treatment. The study showed that tactile touch led to significantly lower levels of anxiety. The circulatory parameters suggested increased circulatory stability indicated by a reduction in noradrenalin requirement. The results need to be further validated through studies with larger sample sizes.

The outcome of tactile touch on oxytocin in intensive care patients: a randomised controlled trial.

AIM: To explore the effects of five-day tactile touch intervention on oxytocin in intensive care patients. The hypotheses were that tactile touch increases the levels of oxytocin after intervention and over a six-day period. BACKGROUND: Research on both humans and animals shows a correlation between touch and increased levels of oxytocin which inspired us to measure the levels of oxytocin in arterial blood to obtain information about the physiological effect of tactile touch. DESIGN: Randomised controlled trial. METHOD: Forty-four patients from two general intensive care units, were randomly assigned to either tactile touch (n = 21) or standard treatment--an hour of rest (n = 23). Arterial blood was drawn for measurement of oxytocin, before and after both treatments. RESULTS: No significant mean changes in oxytocin levels were found from day 1 to day 6 in the intervention group (mean -3.0 pM, SD 16.8). In the control group, there was a significant (p = 0.01) decrease in oxytocin levels from day 1 to day 6, mean 26.4 pM (SD 74.1). There were no significant differences in changes between day 1 and day 6 when comparing the intervention group and control group, mean 23.4 pM (95% CI -20.2-67.0). CONCLUSION: Our hypothesis that tactile touch increases the levels of oxytocin in patients at intensive care units was not confirmed. An interesting observation was the decrease levels of oxytocin over the six-day period in the control group, which was not observed in the intervention group. RELEVANCE TO CLINICAL PRACTICE: Tactile touch seemed to reduce the activity of the sympathetic nervous system. Further and larger studies are needed in intensive care units to confirm/evaluate tactile touch as a complementary caring act for critically ill patients.

Like a shadow--on becoming a stroke victim's relative.

Stroke is the third leading cause of death and disability in the western world. Given the ageing population in Sweden, the number of people suffering from stroke is likely to increase in the future. Stroke alters the lives of both patients and their relatives. Few studies have explored first time affected relatives' experiences of suddenly becoming a relative to a stroke victim, before the relatives decide whether or not to become informal carers. The aim of this study was to illuminate the meaning of going from being just a relative to gradually becoming a relative to a stroke victim from the time of the stroke event and the first weeks on. Sixteen relatives were interviewed about their experiences regarding what it was like to become a relative of a stroke victim from the time of the onset of the illness to the day of the interview. Using a phenomenological hermeneutic method, two essential main themes emerged to describe the relatives' experience: (i) being in chaos and (ii) searching for order in chaos. The findings reveal that relatives reach a 'turning point'. The 'turning point' arises when the relatives stay close to the stroke victim, get aware of their own strength and actively seek out caregivers to restore order and stability to the chaotic situation they are in. At the 'turning point', the relatives start their journey to restore order and stability of the chaotic life situation. Caregivers need to pay more attention and be more sensitive to relatives to increase their possibilities of restoring order and stability in their lives. The results contribute to facilitating the caregivers' work by showing that the time is ripe for initiating pedagogical work when the relatives start to mobilise themselves.

Two sides of the coin - general practitioners' experience of working in multidisciplinary teams.

Multidisciplinary teamwork, defined as the collaboration between different professional groups to achieve a common purpose, is commonly regarded as a means to meet the complex tasks that medicine has to deal with today. However, many attempts to introduce the method in primary care have failed and this is supposed to be partly due to the fact that general practitioners (GPs) did not participate in the implementation of the method. The aim of this investigation was to get a deeper understanding of their attitude to teamwork by interviewing nine GPs at four Swedish health care centres, where successful teamwork had been ongoing since 1997. Themes and categories in the interviews were identified according to content analysis. Although the attitude in general was in favour of teamwork, four major themes: time-consuming versus time-saving; shared responsibility versus main responsibility; medical expert versus generalist; shared knowledge versus all knowing, could be identified, which all revealed ambivalence towards teamwork among the interviewees. It was concluded that, if teamwork is to be successfully introduced into primary care, the GPs' self-perception has to be taken into consideration as has the prestige and status associated with their traditional role and the benefits of teamwork to the profession of medicine. Apart from time, teamwork requires, professional supervision and doctors need to be trained in this method as early as in medical school.

Preserving dignity in caring for older adults: a concept analysis.

AIM: This paper is a report of a concept analysis of the meaning of preserving dignity. BACKGROUND: Preserving dignity, especially when caring for older adults, is essential when giving nursing care. There is a lack of clarity about what kinds of caring activities lead to preserved dignity. METHOD: Data were collected using several databases (CINAHL, Age Info, Libris, Medline, Pub Med, Psyc INFO and Blackwell Synergy) covering the years 1990-2005. The keywords used were 'dignity', 'human dignity', 'preserving dignity', 'elderly', 'aged', combined with 'patients/persons', 'caring relation' and 'nursing'. The analysis covered 53 articles, dissertations, reports and textbooks. FINDINGS: Dignity may be defined as a concept that relates to basic humanity. Dignity consists of inherent and external dimensions, which are common for all humans and at the same time are unique for each person, relating to social and cultural aspects. The attributes of preserving dignity are individualized care, control restored, respect, advocacy and sensitive listening. Antecedents are professional knowledge, responsibility, reflection and non-hierarchical organization. The consequences are strengthening life spirit, an inner sense of freedom, self-respect and successful coping. CONCLUSION: Preserving an older adult's dignity is complex. By using the attributes in, for example, nursing documentation, the action and value of preserving dignity could be made visible as a professional nursing activity.

Presence and availability: staff conceptions of nursing leadership on an intensive care unit.

A demand for high quality care has drawn attention to leadership issues. The nurse managing role has changed over the years and become more complex with a high burden of work. Few studies describe the perspective of 'those being lead'. The aim of this study was to describe staff conceptions about nursing leadership on an intensive care unit. Ten members of staff were interviewed and analysed according to a phenomenographical approach, focusing variations in how informants experience nursing leadership and make sense of the world around them. The findings show that nursing leadership was considered to be 'being present and available in daily work', 'supporting everyday practice', 'facilitating professional acknowledgement' and to 'improve care both as individuals and as a team'. Transformational leadership seemed to be suitable to meet the staff perspective. In such leadership communicative skills is a core to work with strong professionals by being present and available.

GPs' thoughts on prescribing medication and evidence-based knowledge: the benefit aspect is a strong motivator. A descriptive focus group study.

OBJECTIVE: To describe GPs' thoughts of prescribing medication and evidence-based knowledge (EBM) concerning drug therapy. DESIGN: Tape-recorded focus-group interviews transcribed verbatim and analysed using qualitative methods. SETTING: GPs from the south-eastern part of Västra Götaland, Sweden. SUBJECTS: A total of 16 GPs out of 178 from the south-eastern part of the region strategically chosen to represent urban and rural, male and female, long and short GP experience. METHODS: Transcripts were analysed using a descriptive qualitative method. RESULTS: The categories were: benefits, time and space, and expert knowledge. The benefit was a merge of positive elements, all aspects of the GPs' tasks. Time and space were limitations for GPs' tasks. EBM as a constituent of expert knowledge should be more customer adjusted to be able to be used in practice. Benefit was the most important category, existing in every decision-making situation for the GP. The core category was prompt and pragmatic benefit, which was the utmost benefit. CONCLUSION: GPs' thoughts on evidence-based medicine and prescribing medication were highly related to reflecting on benefit and results. The interviews indicated that prompt and pragmatic benefit is important for comprehending their thoughts.

Captured voices in cancer: experiences from networking between individuals with experiential and professional knowledge.

BACKGROUND: Patients needs and experiences attract increasing attention within health care. In order to generate knowledge about the voices that emerge from collaborative experiences between members of patient associations for cancer patients (PACP) and health care professionals (HCPs), we studied a permanent network aimed at improving cancer care through increased attention to the cancer patients' view and experiences. METHODS: Open-ended interviews were carried out with 16 individuals; 6 PACP members and 10 HCPs, and after transcription the texts were analysed by inductive content analysis. RESULTS: Four voices, which represent various experiences from networking, were identified; the hesitant voice, the enlightened voice, the liberated voice, and the representative voice. The hesitant voice reflects uncertainty experienced when the participants were exposed to different views and opinions within the network. The enlightened voice reflects new points of view and gain of knowledge. The liberated voice signifies trust, balance, and confidence related to individual experiences and responsibilities being viewed in a broader perspective. The representative voice is derived from the transformation of experiences and responsibilities through insight, understanding, and new perspectives. CONCLUSION: Networking between representatives for PACPs and HCPs may help the participants manage uncertainty, strengthen the patient's perspective and provide new views on common issues. The different voices identified in this study demonstrate that both PACP members and HCPs distanced themselves from their individual experiences in order to be perceived as unselfish and knowledgeable within the network. Although the climate was characterized by trustfulness, the members' unique positions need to be defined in order to obtain an optimal balance between the groups and prevent members' patient experiences of losing their character by learning to much from the HCPs. Increased understanding of the hesitant, the enlightened, the liberated, and the representative voices, and awareness of experiential versus professional knowledge of cancer may facilitate and probably improve future networking efforts.

Relatives in end-of-life care--part 2: a theory for enabling safety.

AIM: To develop a goal-oriented praxis theory for enabling safety for relatives when an adult or older patient is close to end-of-life. BACKGROUND: This is the second part of a project focusing on the situation and needs of relatives in end-of-life care. Our interpretation of the existing corpus of knowledge pertaining to the needs of close relatives in this situation showed the significance of relatives' need for safety. METHOD: The theory was developed step-by-step, through triangulation of critical review of empirical research in the field, our own clinical experiences from end-of-life care, renewed literature searches and theoretical reasoning. THEORY: The foundation for the theory is taken from the ethical intention of the philosopher Paul Ricoeur. From this, the theory focuses on relatives in the context of end-of-life care with the goal of enabling safety. This is proposed by four aphorisms functioning as safety enablers and these are directed towards the professional's approach and attitude, the relative's concern for the patient, the specific situation for the relative and the patient's end-of-life period as a period in the life of the relative. RELEVANCE TO CLINICAL PRACTICE: Implications for end-of-life practice are considered and include aspects for promotion of just institutions in end-of-life care, the significance of negotiated partnership in end-of-life care, enabling safety for relatives living in existential and practical uncertainty in connection with end-of-life care and diversity of relatives' preferences as they live through this particular period.

Assisting teens with asthma to take command.

To meet and work with teenagers may be a challenge for caregivers as adolescence is a period when youths try to establish autonomy. Although asthma is an increasing problem worldwide, few studies have addressed professional caregivers' motives and actions. Therefore, the aim of this study was to describe professional caregivers' strategies in their work with teenagers with asthma. Grounded theory, inspired by Glaser, was used to uncover the phenomenon. The informants were seven professional caregivers who worked at an eight-day asthma camp for teenagers in Sweden. Participant observations and interviews were used, and the first author collected the data and participated in the activities. Findings show that professional caregivers' core concern is to assist teenagers with asthma to take command. This core concern gives rise to five strategies: showing respect, being at hand, promoting own responsibility, promoting to exceed boundaries and promoting reflections. In professional caregivers' attempt to assist teenagers to take command some differences are seen in the way they support boys and girls. One conclusion drawn from our study is that the provisional theory of 'Assisting teenagers with asthma to take command' is not only suitable for professional caregivers working at asthma camps; it may, in some degree, also be used as a source of inspiration for professional caregivers in other settings.

A transition from nurse to touch therapist--a study of preparation before giving tactile touch in an intensive care unit.

Tactile touch is a complementary therapy that is rarely undertaken in intensive care units (ICUs) in Sweden. This study was a part of a larger project that examines whether tactile touch can relieve the suffering of patients in the ICU. The aim of this study was to describe nurses' lived experience of preparation before giving tactile touch in an ICU. Four assistant nurses and one registered nurse, each with diplomas in tactile touch working at three different ICUs in Sweden, participated in the study. A phenomenological approach was chosen to achieve experience-based and person-centred descriptions. Data were collected through interviews and analysed following Giorgi's method. The main finding was that before providing tactile touch, the nurses needed to add the new role as touch therapists, to their professional one. The essential aspect being the transition from nurse to touch therapist. Findings included a general structure, with four constituents; a sense of inner balance, an unconditional respect for the patients' integrity, a relationship with the patient characterised by reciprocal trust, and a supportive environment. Furthermore, the study underlines the difficulties to integrate a complementary caring act, such as tactile touch, in a highly technological environment.

Not letting the disease get the upper hand over life: strategies of teens with asthma.

Adolescence is a period when teens normally revolt against being dependent. For teens with asthma this period may be even more difficult to deal with, as they also have to deal with their illness. Since few studies describe this phenomenon, the aim of this study was to provide a theoretical understanding of how teens with asthma manage their everyday life in relation to their disease. A grounded theory research design, according to Glaser, was used to uncover the phenomenon. The study was undertaken at a camp for teenagers with asthma during the summer of 2003. Twelve girls and 11 boys with moderate to severe asthma participated in the study. Participant observations and interviews were used, and the first author collected the data and participated in the activities. The findings reveal a theoretical model which shows that teens' core concern is not to let the disease get the upper hand over life. To manage this core concern the teens were found to use three strategies: keeping a distance to the disease, challenging the disease and taking the disease into consideration. Boys mainly kept a distance to the disease while girls mainly kept the disease into consideration. Challenging the disease seemed to be a strategy used by both girls and boys. The teens' strategies were not studied close to their everyday life, but a conclusion drawn from our study was that the provisional theory in many respects can be transferred to their everyday life, even though further research is needed to develop this provisional theory in other settings.

Job satisfaction in relation to change to all-RN staffing.

BACKGROUND: A university hospital clinic changed from a mixed to only registered nurse staffing, to reduce the staff and to encourage a philosophy of patient centred care. The aim was to maintain the same level of service and quality of care at a lower cost. AIM: The main purpose of the study was to examine job satisfaction in relation to the change from mixed to only registered nurse staffing and reduction in number of staff. METHODS: Data were collected by an established questionnaire measuring job satisfaction. Non-parametric statistics were used to analyse the data. The questionnaire was distributed to 22 nurses on the ward on three occasions, covering a period of 3 years. RESULT: The experience of having time to plan patient care changed during the investigation period, from 'sometimes' to 'most often having time'. Nurses with longer work experience gave more verbal information to patients and perceived less stress. Information about job performance was more important to newcomers on the ward and became less important with time. However, quite a few have had regrets over choice of work and had considered non-caring work, nevertheless the results show no significant changes in overall job satisfaction.

Daily stress and concept of self in Swedish ambulance personnel.

INTRODUCTION: This study investigated the prevalence of post-traumatic stress symptoms among professional ambulance personnel in Sweden and investigated the question: "Does self-knowledge have influence on how well one copes with the effects of daily work exposure from such events?" Little is known about the variables that might be associated with post-traumatic stress symptoms in high-risk occupational groups such as ambulance service groups. METHODS: Data were gathered from ambulance personnel by means of an anonymous questionnaire. Survey responses of 362 ambulance personnel from the county of Västra Götaland were analyzed. A correlation was established between post-traumatic symptoms using the impact of event scale (IES-15) and the Professional Self-Description Form (PSDF). RESULTS: Of those who reported a traumatic situation, 21.5% scored > or =26 on the IES-15 subscale. Scores >26 indicate "PTSD caseness". There were significant differences on PSDF subscales between those presenting with or without post-traumatic symptoms. CONCLUSIONS: The mental health and emotional well-being of ambulance personnel appear to be compromised by accident and emergency work. The high prevalence of PTSD symptoms in ambulance personnel indicates an inability to cope with post-traumatic stress caused by daily work experiences.

Guilt, shame and need for a container: a study of post-traumatic stress among ambulance personnel.

Post-traumatic stress symptoms among ambulance personnel are regarded as a natural behaviour and reaction to working with the severely injured, suicides, injured children and dead people. The findings show that post-traumatic stress symptoms, guilt, shame and self-reproach are common after duty-related traumatic events. To handle these overwhelming feelings it is necessary to talk about them with fellow workers, friends or family members. By using another person as a container it is possible to internalise the traumatic experience. Poor and un-emphatic behaviour towards a patient and their relatives can have its origin in untreated traumatic experiences. Personnel in ambulance organisations who perform defusing, debriefing and counselling have to be informed of the importance that the roll of guilt and shame may play in the developing of post-traumatic stress symptoms.

Relations governed by uncertainty: part of life of families of a child with asthma.

This study identifies what influences and characterizes family relations in families of a child with asthma. Seventeen mothers of children aged between 6 and 16 years participated in audio-taped in-depth interviews. The researchers were inspired by grounded theory in data collection and data analysis. The core category that developed was being governed by disease-engendered uncertainty. The category mothers' availability was seen in two dimensions. The first dimension, mothers' being available for the child with asthma, created two subcategories: 1. control and 2. tight bonds. The second dimension, mothers' being less available for other family members, also created two subcategories: 3. being forsaken and 4. lack of understanding. Nursing implications are discussed in relation to the findings.