Promoting dignity in nursing education - How educators manoeuvre to promote dignity.

BACKGROUND: Dignity is a core value in nursing. One of the objectives in nursing education is to promote dignity and contribute to the students' discovery of this value. Research shows that dignity in nursing education is threatened, due to lack of attention and an increasing problem with incivility. PURPOSE: The study aims to explore how nursing educators experience their contribution in promoting dignity in nursing education. METHOD: Five focus group conversations were conducted with nursing educators, and Gadamer's philosophical hermeneutics was chosen as the study's scientific theoretical approach. FINDINGS: The educators experienced that they promoted dignity by safeguarding the dignity in the nursing profession in general, by promoting the dignity of the nursing students in particular, and through promoting dignity in challenging situations. CONCLUSION: The study emphasizes the importance of promoting dignity in nursing education. It found that the nursing educators promoted dignity by safeguarding the dignity of both the nursing profession and the nursing students, and by manoeuvring judiciously between these two when there was disharmony between them. By manoeuvring challenging situations using discretion, the ethical demand will be given room. Dignity can then be fulfilled between people in harmony with professional, social and cultural norms, and in that way promote dignity in nursing education.

Trust-building interventions to home-dwelling persons with dementia who resist care.

BACKGROUND: Providing care for a home-dwelling person with dementia who resists care is an ethical and practical complex and challenging task. Faced with a growing number of persons with dementia, the healthcare professional's understanding of how to best care for and prevent unnecessary use of coercion with persons with dementia is of key importance. RESEARCH AIM: The aim of this study was to explore the use of trust-building interventions in home-dwelling persons with dementia resisting care, as described by health professionals in documents of decisions of forced treatment and care. RESEARCH DESIGN: A qualitative thematic document analysis inspired by critical realism was conducted. PARTICIPANTS AND RESEARCH CONTEXT: Descriptions of trust-building interventions were extracted from 88 documents of forced treatment and care for home-dwelling persons with dementia, receiving home healthcare, in 2015 and 2016. ETHICAL CONSIDERATIONS: Approved by the Regional Committee for Medical and Health Research Ethics, reference number 2017/788, and controlled by the Norwegian Centre for Research Data, reference number 54897. The study adhered to the guidelines of the Declaration of Helsinki. FINDINGS: We found that "balancing safe care with the person's integrity" was an overarching theme that permeated the descriptions of trust-building interventions in the study. Three main themes were identified when the data were analyzed: safeguarding care, protecting integrity, and optimizing the environment. DISCUSSION AND CONCLUSION: Health professionals balanced on a thin line between care and integrity when met with resistance from person with dementia. However, the trust-building interventions used in the most challenging situations did not differ from the interventions used in general in dementia care. Two knowledge gaps were identified: how to perform appropriate assessments of situations of home-dwelling persons with dementia when met with resistance to care, and whether environmental initiatives may also benefit home-dwelling persons with dementia who are not easily cared for.

Dignity at stake in educational relations - The significance of confirmation.

INTRODUCTION: It is a goal in nursing education to promote students' dignity and facilitate this core value. Students' experience of dignity is shaped by the student-supervisor relationship. Literature shows limited knowledge about how nursing students experience their own dignity during education. RESEARCH AIM: The aim of the study is to develop an understanding of how nursing students experience their own dignity in relation to supervisors, and what significance these experiences have in education. RESEARCH DESIGN: Gadamer's philosophical hermeneutics was chosen as the approach, and narratives and qualitative interviews were conducted. The interpretation process was inspired by Fleming, Gaidys and Robbs. PARTICIPANTS AND RESEARCH CONTEXT: Nineteen nursing students in the final year of their education were included in the study. They represented six different campuses at three different educational institutions. The qualitative interviews took place at the educational institutions. ETHICAL CONSIDERATIONS: The research recommendations of the Declaration of Helsinki were followed. Access to the students was given by the educational institutions. All interested students signed a continuous informed consent. FINDINGS: Students' dignity was at stake in encounters with supervisors during education. Decisive for experience of dignity was the supervisor's ability to confirm the student through acknowledgment, reassurance and seeing them as individuals. Experienced dignity had a crucial impact on students' life courage and their ability to be present. DISCUSSION: The discussion emphasizes the vulnerable dignity of students, the importance of confirmation and the significance perceived dignity has. CONCLUSION: Students' experiences tilted between perceived dignity and offense, and placed students' dignity in a vulnerable position. Crucial for perceived dignity was the confirmation the students received from their supervisors. Perceived dignity gave the students courage and increased their ability to be present, which provided better opportunities for learning and development.

Autonomy conquers all: a thematic analysis of nurses' professional judgement encountering resistance to care from home-dwelling persons with dementia.

BACKGROUND: Adequate care support from home health care nurses is needed to meet the needs of an increasing number of home-dwelling persons with dementia and those who resist care. The decisions nurses make in home health care when encountering resistance from persons with dementia have an extensive impact on the quality of care and access to care. There is little research on what influences nurse's encounters with resistance to care from home-dwelling persons with dementia. RESEARCH AIM: To get insight into how nurses experience resistance to care from home-dwelling persons with dementia. METHODS: A qualitative research design using a thematic analysis was conducted following the six steps by Braun and Clarke. Data was gathered from three focus group and three individual interviews, and a total of 18 nurses from home health care participated. The interviews took place over a period of 5 months, from December 2020 to April 2021. ETHICAL CONSIDERATIONS: Approved by the Norwegian Centre for Research, reference number 515138 and by the research advisers and home care managers in each section of the municipality. RESULTS: Two main themes were identified: 1) Challenged by complex and inadequate care structures and 2) Adapting care according to circumstances. There were three subthemes within the first main theme: lack of systematic collaboration and understanding, insufficient flexibility to care, and the challenge of privacy. In the second main theme, there were three subthemes: avoid forced treatment and care to protect autonomy, gray-areas of coercive care and reduced care. The two main themes seemed to be interdependent, as challenges and changes in organizational structures influenced how nurses could conduct their care practices. CONCLUSION: Our findings indicate that nurses' responsibility to decide how to conduct care is downplayed when facing resistance. Further, their professional judgement is influenced by contextual factors and characterized by a strong commitment to avoid forced treatment and care. A continuous challenge is to safeguard shared decision-making at the same time as it is balanced against risks of severe health damage in home-dwelling persons with dementia. A fundamental question to ask is whether autonomy does conquer all, even when severe health damage is at stake.

The position of home-care nursing in primary health care: A critical analysis of contemporary policy documents.

Internationally, primary health care has in recent years gained a more central position in political priorities to ensure sustainable health care for the population. Thus, more people receive health care locally and in their own homes, where home-care nursing plays a large role. In this article, we investigate how home-care nursing is articulated and made visible in contemporary Norwegian policy documents. The study is a Fairclough-inspired critical discourse analysis seeking to uncover the position of nursing in the prevailing political ideologies on current primary health care. In the documents, we identified several complementary and conflicting understandings about home-care nursing. Home-care nursing is presented as a basic part of a municipality's health services, but at the same time, its content and contribution are unclear and almost invisible. We argue that the absence of nursing leads to significant perspectives being left out and tie this to the fact that some patient groups and tasks seem to be disadvantaged. The political placement of home-care nursing in the health-care landscape is thus not just about nursing as a professional practice but also concerns fundamental care values in our society in relation to disadvantaged groups and work tasks.

Discovering dignity through experience: How nursing students discover the expression of dignity.

INTRODUCTION: Dignity is a core value in nursing. Nursing education shall prepare students for ethical professional practice and facilitate insight into the phenomenon of dignity and its significance. There is limited knowledge about how nursing students discover dignity in their education. RESEARCH AIM: The aim of the study is to develop an understanding of how nursing students discover and acquire dignity. RESEARCH DESIGN: The study has a hermeneutic approach where qualitative interviews of nursing students were employed. The process of interpretation was inspired by text of Fleming, Gaidys and Robbs. PARTICIPANTS AND RESEARCH CONTEXT: Nineteen nursing students agreed to be included in the study, representing six different campuses at three different educational institutions. All were in the final year of their study. The interviews took place at the educational institutions. ETHICAL CONSIDERATIONS: The educational institutions facilitated recruitment of the students who signed voluntarily for participation and continuous informed consent. The study was approved by The Norwegian Center of Reporting Data (NSD). The research recommendations of the Declaration of Helsinki were followed. FINDINGS: The nursing students discovered the expression and significance of dignity through experiences, gained through introspection and in interaction with others during the education. DISCUSSION: The findings are discussed using Gadamer's concept of experience and how experiences can create new insight. In particular, the students' experiences with the inner ethical and external aesthetic dimension of dignity are discussed. CONCLUSION: The study shows that students discovered the inner ethical dignity through experiencing vulnerability, pride and shame. They discovered the external aesthetic dignity through incidents, where they experienced both to be confirmed and not to be confirmed, and through observation of good or bad role models. Crucial negative and positive experiences are important for discovering the expression and significance of dignity.

Home-care nurses' distinctive work: A discourse analysis of what takes precedence in changing healthcare services.

Ongoing changes in many Western countries have resulted in more healthcare services being transferred to municipalities and taking place in patients' homes. This greatly impacts nurses' work in home care, making their work increasingly diverse and demanding. In this study, we explore home-care nursing through a critical discourse analysis of focus group interviews with home-care nurses. Drawing on insights from positioning theory, we discuss the content and delineation of their work and the interweaving of contextual changes. Nurses hold a crucial position in home healthcare, particularly in ensuring care for sicker patients with complex needs. Assessing health needs, performing advanced care, and at the same time, providing customized solutions in various homes were identified as distinctive for home-care nurses' work. Changes have made nurses' work become driven by comprehensive tasks and acute medical needs that require much of their competence and time. Urgent care seems to take precedence in nurses' work, leaving less time and attention for other tasks such as conversations and support for coping with everyday life. This underlines the need to investigate and discuss the content and scope of nurses' work to help shape the further development of home-care nursing.

Balancing contradictory requirements in homecare nursing-A discourse analysis.

Aim: To explore prevailing discourses on nursing competence in homecare nursing to boost understanding of practice within this field. Design: A qualitative study with a social constructivist perspective. Methods: Six focus-group interviews with homecare nurses in six different municipalities in Norway. Adapting a critical discourse analysis, data were linguistically, thematically and contextually analysed in the light of theories on competence, institutional logic and discourses. Results: The analysis found homecare nursing to be a diverse and contradictory practice with ever-increasing work tasks. Presented as binary oppositions, we identified the following prevailing discourses: individualized care versus organizing work; everyday-life care versus medical follow-up; and following rules versus using professional discretion. The binary oppositions represent contradictory requirements that homecare nurses strive to balance. The findings indicate that medical follow-up and organizational work have become more dominant in homecare nursing, leaving less time and attention paid to relational and everyday-life care.

Reablement teams' roles: a qualitative study of interdisciplinary teams' experiences.

INTRODUCTION: Reablement is a service for home-dwelling older people experiencing a decline in health and function. The focus of reablement is the improvement of the person's function and coping of his or he valued daily activities. The health care professionals and the home care personnel are working together with the older person toward his goals. In reablement, health care personnel are organized in an interdisciplinary team and collaborate with the older person in achieving his goals. This organizing changes the roles of home care personnel from working almost alone to collaborating with different health care professionals. There is little scientific knowledge describing the roles of different health care professionals and home care personnel in the context of reablement. This study's objective is to explore and describe the roles of interdisciplinary teams in reablement services in a Norwegian setting. METHOD: Two interdisciplinary teams consisting of 17 health care professionals (i.e. occupational therapists, physiotherapists, nurses, and social educators) and ten home care personnel (auxiliary nurses and nursing assistants) participated in three focus group discussions. In addition, three interviews were conducted with occupational therapists, physiotherapists, nurses, and auxiliary nurses. The focus group discussions and the interviews were all digitally recorded, transcribed verbatim and analyzed using the qualitative content analysis. RESULTS: The health care professionals' main role was to be consultants and advisors, consisting of (1) planning, adjusting, and conducting follow-ups of the intervention; (2) delegating tasks; and (3) supervising the home care personnel. The home care personnel's main role was to be personal trainers, consisting of (1) encouraging and counseling the older adults to perform everyday activities; and (2) conveying a sense of security while they performed everyday activities. The role of interdisciplinary collaboration was a common role for both the health care professionals and the home care personnel. CONCLUSION: The health care professionals established the setting, and had the main roles of supervision, delegating tasks, and main responsibility for the intervention. The home care personnel accepted the delegations and had a main role as personal trainers. Their work changed from body care to encouraging and counseling the older person to perform activities themselves in a safe way. The health care professionals and the home care personnel collaborated closely across roles. The home care personnel experienced a shift in role from home care to a person-centered care. This was perceived as strengthening the health care identity of their role.

The relatives' voice: how do relatives experience participation in reablement? A qualitative study.

BACKGROUND: Reablement is an early and time-limited home-based model of rehabilitation intervention with an emphasis on intensive, goal-oriented, and multidisciplinary assistance for persons experiencing functional decline. When rehabilitation in general takes place in the person's own home, in contrast to an institution, relatives may have larger responsibilities in helping and supporting the family member. Although there is evidence, showing that family caregivers, such as spouses and children, experience burdens and demanding situations related to their caregiving role, there are currently few publications exploring relatives' experiences of participating in reablement. The aim of our study was to explore and describe how relatives in a community setting in Norway experienced participation in the reablement process. METHODS: Six relatives participated in semi-structured interviews. Qualitative systematic text condensation was used as the analysis strategy. RESULTS: Five themes emerged that summarized the relatives' experiences with reablement: 1) a wish to give and receive information, wish to be involved; 2) wish to be a resource in reablement process; 3) conflicting expectations; 4) have more free time to themselves; and 5) a lack of follow-up programs. CONCLUSION: Our findings highlight the involvement and collaborative process between health professionals, older adults, and relatives and have practical significance for health care services. To advance collaborative practices, the municipal health and social care services should consider establishing a system or a routine to foster this collaboration in reablement. Follow-up programs should be included.

Driving forces for home-based reablement; a qualitative study of older adults' experiences.

As a result of the ageing population worldwide, there has been a growing international interest in a new intervention termed 'reablement'. Reablement is an early and time-limited home-based intervention with emphasis on intensive, goal-oriented and interdisciplinary rehabilitation for older adults in need of rehabilitation or at risk of functional decline. The aim of this qualitative study was to describe how older adults experienced participation in reablement. Eight older adults participated in semi-structured interviews. A qualitative content analysis was used as the analysis strategy. Four main themes emerged from the participants' experiences of participating in reablement: 'My willpower is needed', 'Being with my stuff and my people', 'The home-trainers are essential', and 'Training is physical exercises, not everyday activities'. The first three themes in particular reflected the participants' driving forces in the reablement process. Driving forces are intrinsic motivation in interaction with extrinsic motivation. Intrinsic motivation was based on the person's willpower and responsibility, and extrinsic motivation was expressed to be strengthened by being in one's home environment with 'own' people, as well as by the co-operation with the reablement team. The reablement team encouraged and supported the older adults to regain confidence in performing everyday activities as well as participating in the society. Our findings have practical significance for politicians, healthcare providers and healthcare professionals by contributing to an understanding of how intrinsic and extrinsic motivation influence reablement. Some persons need apparently more extrinsic motivational support also after the time-limited reablement period is completed. The municipal health and care services need to consider individualised follow-up programmes after the intensive reablement period in order to maintain the achieved skills to perform everyday activities and participate in society.

The reablement team's voice: a qualitative study of how an integrated multidisciplinary team experiences participation in reablement.

BACKGROUND: Reablement is an early and time-limited home-based rehabilitation intervention that emphasizes intensive, goal-oriented, and multidisciplinary assistance for people experiencing functional decline. Few empirical studies to date have examined the experiences of the integrated multidisciplinary teams involved in reablement. Accordingly, the aim of this study was to explore and describe how an integrated multidisciplinary team in Norway experienced participation in reablement. METHODS: An integrated multidisciplinary team consisting of health care professionals with a bachelor's degree (including a physiotherapist, a social educator, occupational therapists, and nurses) and home-based care personnel without a bachelor's degree (auxiliary nurses and nursing assistants) participated in focus group discussions. Qualitative content analysis was used to analyze the resulting data. RESULTS: Three main themes emerged from the participants' experiences with participating in reablement, including "the older adult's goals are crucial", "a different way of thinking and acting - a shift in work culture", and "a better framework for cooperation and application of professional expertise and judgment". The integrated multidisciplinary team and the older adults collaborated and worked in the same direction to achieve the person's valued goals. The team supported the older adults in performing activities themselves rather than completing tasks for them. To facilitate cooperation and application of professional expertise and judgment, common meeting times and meeting places for communication and supervision were necessary. CONCLUSION: Structural factors that promote integrated multidisciplinary professional decisions include providing common meeting times and meeting places as well as sufficient time to apply professional knowledge when supervising and supporting older persons in everyday activities. These findings have implications for practice and suggest future directions for improving health care services. The shift in work culture from static to dynamic service is time consuming and requires politicians, community leaders, and health care systems to allocate the necessary time to support this approach to thinking and working.

The pendulum time of life: the experience of time, when living with severe incurable disease--a phenomenological and philosophical study.

The aim of this study was to gain a deeper understanding of the experience of time when living with severe incurable disease. A phenomenological and philosophical approach of description and deciphering were used. In our modern health care system there is an on-going focus on utilizing and recording the use of time, but less focus on the patient's experience of time, which highlights the need to explore the patients' experiences, particularly when life is vulnerable and time is limited. The empirical data consisted of 26 open-ended interviews with 23 participants receiving palliative care at home, in hospital or in a nursing home in Norway. The theoretical frameworks used are mainly based upon K. Martinsens philosophy of care, K. E. Løgstrup phenomenological philosophy, in addition to C. Saunders' hospice philosophy, L. Feigenberg's thanatology and U. Qvarnström's research exploring patient's reactions to impending death. Experience of time is described as being a movement that moves the individual towards death in the field of opposites, and deciphered to be a universal, but a typical and unique experience emerging through three integrated levels: Sense of time; where time is described as a movement that is proceeding at varying speeds. Relate to time; where the awareness of limited life changes the understanding of time to be more existential. Being in time; where limited time seems to clarify the basic living conditions and phenomena of life. The existence of life when the prospect of death is present is characterized by emotional swings that move within polarizing dimensions which is reflected in the experience of time illustrated as the moves of the pendulum in a grandfather clock. The diversity of the experience of time is oscillating between going fast or slow, being busy or calm, being unpredictable but predictable, safe or unsafe and between being good or bad, depending on the embodied situation of the individual.

Being in transit and in transition: the experience of time at the place, when living with severe incurable disease--a phenomenological study.

The aim of this study is to describe the experience of time as it presents itself at the place being situated when living with severe incurable disease and receiving palliative care. The empirical data consist of 26 open-ended interviews with 23 patients receiving palliative care at home, at a palliative day care, in a palliative bed unit in hospital or in a nursing home in Norway. A common meaning of a shifting space for living emerged from the analysis and was revealed through three different aspects: (i) Transition from a predictable to an unpredictable time: To live with severe incurable disease marks a transition to a changed life involving an ongoing weakened and altered body with bothersome symptoms making experience of time different and unpredictable. (ii) Transition between a safe and unsafe time: When time is unpredictable, feeling safe is revealed as essential to how time is experienced at the place being situated. (iii) To be in transition from a homely to a homeless existence: In a time of increased bodily weakness, unpredictable ailments and displacements, the sense of belonging to the place is revealed as significant to the experience of time. Not knowing where to be in a time of change is like an existential cry of distress where the foothold in existence is lost. The findings are discussed and interpreted as an embodied experience originating from the passage of time continually affecting life sometimes so fundamentally that it marks a transition to a changed space of life that is reflected in the experience of time.

Entering a world with no future: a phenomenological study describing the embodied experience of time when living with severe incurable disease.

This article presents findings from a phenomenological study exploring experience of time by patients living close to death. The empirical data consist of 26 open-ended interviews from 23 patients living with severe incurable disease receiving palliative care in Norway. Three aspects of experience of time were revealed as prominent: (i) Entering a world with no future; living close to death alters perception of and relationship to time. (ii) Listening to the rhythm of my body, not looking at the clock; embodied with severe illness, it is the body not the clock that structures and controls the activities of the day. (iii). Receiving time, taking time; being offered - not asked for - help is like receiving time that confirms humanity, in contrast to having to ask for help which is like taking others time and thereby revealing own helplessness. Experience of time close to death is discussed as an embodied experience of inner, contextual, relational dimensions in harmony and disharmony with the rhythm of nature, environment and others. Rhythms in harmony provide relief, while rhythms in disharmony confer weakness and limit time.

The (dis)appearance of the dying patient in generalist hospital and care home nurses' talk about the patient.

This article explores interview data from a study of 50 Norwegian generalist nurses' focus group accounts of caring for dying patients in the hospital and care home. An eclectic discourse analytic approach was applied to nurses' accounts of the patient and three discursive contexts of reference to the patient were identified: the 'taken as read' patient, the patient paired with particular characteristics and the patient as psychologically present. Talk about the patient falls mainly into the first two contexts, which position the patient in relation to three closely related discursive processes: individualization, anonymization and objectification. The third context presents the patient as a person with a particular identity. The analysis is discussed in a broader philosophical and sociological context in which we return to some of the theoretical work on death and dying of the 1990s and the topic of sequestration. We suggest that nurses' talk about the patient can be heard to participate in a continuing sequestration of the dying patient in healthcare institutions focused on 'result-oriented' care.