Hermeneutic caring conversations in forensic psychiatric caring.

BACKGROUND:: In forensic psychiatric care, a hermeneutic caring conversation between caregivers and patients can improve health outcomes. The hermeneutic approach entails starting from the whole and involves openness for what is shown as well as paying attention to the different parts. One way to deepen these conversations is to take advantage of both the caregivers' and the patients' life experiences. RESEARCH QUESTIONS:: The purpose of the study is to discuss and reflect on what hermeneutic caring conversations can mean for a deepened understanding of the movement in the health processes of patients in forensic care, patients who are in deep suffering. RESEARCH DESIGN:: This study uses a hermeneutic methodology. Conversations with patients receiving care in forensic psychiatry are deepened using texts from philosophy, caring science, and poetry. The outcome emerges through a phase of creating patterns. PARTICIPANTS:: Three patients in forensic care. ETHICAL CONSIDERATIONS:: This study builds on a doctoral thesis approved by The Ethical Review Board at the Faculty of Medical and Health Sciences, Linköping, Sweden. FINDINGS:: Hermeneutic caring conversations provide a possibility for rich caring conversations with patients who are often not given a voice. These conversations are seen as ethical expressions of hermeneutic caring communion that affect patients' health processes in a positive way. DISCUSSION:: It takes courage and responsibility to initiate and conduct these conversations as the patients volunteer to share their suffering. In hermeneutic caring conversations, the caregiver's attitude is crucial for the transference of knowledge. CONCLUSION:: This study provides a preliminary outline for hermeneutic caring conversations. A caring culture that provides time and space to prepare hermeneutic caring conversations is a prerequisite for the implementation of hermeneutic caring conversations.

Toward Understanding Through Hermeneutic Letterwriting.

The authors present letterwriting as a hermeneutic research method in that it contributes to the methodological development within the hermeneutical research tradition in caring science. The hermeneutic methodology is inspired by Hans-Georg Gadamer. Hermeneutic letterwriting in accordance with Gadamer's thought is a form of dialogue in writing, where what is truthful about the thing itself is unveiled with the help of the language. Hermeneutic letterwriting is presented in five steps. As a method, hermeneutic letterwriting is appropriate for complex caring science issues, and it offers new opportunities for attaining a deeper understanding of the world of caring.

Longing - a dynamic power in the becoming of health when suffering from cancer.

BACKGROUND: The aim of the study was to gain understanding of existential longing in health and suffering as experienced by persons who have been affected by a cancer disease. The theoretical perspective of the study is K. Eriksson's theory of Caring Science. METHOD: Qualitative interviews with nine women with cancer were transcribed and interpreted using Gadamer's ontological hermeneutics. RESULTS: Four perspectives of longing when suffering from cancer are presented: Longing as a source to call upon for survival, Longing for the life prior to the illness, Longing directed towards deeper relations in everyday life, and Transcending longing moves towards the ultimate fulfilment. INTERPRETATION: The overall interpretation led to the following thesis about the dimension of longing in the human being: Longing is becoming in a movement towards reconciliation of life, and, Longing is becoming in a movement towards transcending life. CONCLUSION: The results show that there seems to be a dynamic power in longing that can transform suffering and create health.

Clinical caring science as a scientific discipline.

BACKGROUND: Clinical caring science will be described from a theory of science perspective. AIM: The aim of this theoretical article to give a comprehensive overview of clinical caring science as a human science-based discipline grounded in a theory of science argumentation. FINDINGS: Clinical caring science seeks idiographic or specific variations of the ontology, concepts and theories, formulated by caring science. The rationale is the insight that the research questions do not change when they are addressed in different contexts. The academic subject contains a concept order with ethos concepts, core and basic concepts and practice concepts that unites systematic caring science with clinical caring science. In accordance with a hermeneutic tradition, the idea of the caring act is based on the degree to which the theory base is hermeneutically appropriated by the caregiver. The better the ethos, essential concepts and theories are understood, the better the caring act can be understood. In order to understand the concept order related to clinical caring science, an example is given from an ongoing project in a disaster context. COMPREHENSIVE REFLECTION: The concept order is an appropriate way of making sense of the essence of clinical caring science. The idea of the concept order is that concepts on all levels need to be united with each other. A research project in clinical caring science can start anywhere on the concept order, either in ethos, core concepts, basic concepts, practice concepts or in concrete clinical phenomena, as long as no parts are locked out of the concept order as an entity. If, for example, research on patient participation as a phenomenon is not related to core and basic concepts, there is a risqué that the research becomes meaningless.

An envisioning about the caring in listening.

The purpose of this article is to make visible further dimensions and uncover an envisioning about the caring in listening in the field of caring science, which may improve the care for the suffering human being, the patient. Eriksson's caritative theory of caring constitutes the starting point for this search for knowledge, while the research method is realised by a hermeneutic reading based on the philosopher of hermeneutics, Gadamer's thought. The research is realised by a reading of Fyodor Dostoyevsky's literary works. The literary characters Sonia in Crime and Punishment and Alyosha in The Brothers Karamazov, uncovers patterns of meaning-bearing units towards the caring and the interpretation of a more profound envisioning about the caring in listening. The uncovering and interpretation show that patients in their suffering long to meet a caregiver who listens without the least condemnation in their eyes and demeanour. Patients need a listening caregiver who shows compassion and who has the courage to remain in the struggle of suffering and to carry the patients through insupportable pain, guilt and shame. Through listening, it is possible to reawaken a numb heart, to take individuals who have gone through a good deal of suffering, from darkness, degradation, unendurable pain to the light and to awaken their zest for life and joy to live. Listening renews, delivers and transforms human beings so that they can begin to find a new direction in life and start living a life in accordance with their own fundamental order, purpose, essential decision and individuality. Listening takes patients out of their loneliness and unbearable suffering into communion and a life worth living.

The relation between the phenomena of disease, illness, and suffering.

Persons experiencing disease and illness experience suffering as well. How nurses assess patients' problems holistically has been debated a lot. This article suggests one possible way of assessing patients' situation as a whole by seeing patients' diseases in relation to suffering.

Nurse leaders' responsibilities in supporting nurses experiencing difficult situations in clinical nursing.

AIM: To make nurse leaders aware of different kinds of difficult situations in clinical nursing that may cause suffering to nurses and to discuss how nurse leaders can approach and alleviate this suffering. BACKGROUND: Difficult situations are a part of clinical nursing. Nurses are repeatedly exposed to situations that may cause them suffering and reduce their ability to serve the patients. METHOD: Data collection was based on a sample of semi-structured face-to-face deep interviews with eight nurses who were encouraged to narrate their lived experiences of difficult situations in clinical nursing. RESULTS: Nurses want to discuss issues connected to nursing and caring science that emerge in clinical nursing with their nurse leaders. Painful memories and thoughts are often related to patients struggling between life and death, the despair of families and friends, and their hovering between hope and hopelessness. The results do not support the notion that nurses would request other kinds of support or debriefing. CONCLUSIONS: The mission of nursing is to serve, console and alleviate human suffering. Nurse leaders carry a responsibility to create such evidence-based caring cultures that support the mission of nursing. Nurse leaders' understanding, sympathetic attitude, ethical value basis, personality and ability to discuss are important aspects for nurses. Through the support from nurse leaders, it seems possible to alleviate the nurse's suffering in clinical nursing. Implications for Nursing Management Nurse leaders' support creates a foundation for the nurses' professional development.

Concept determination of human dignity.

This study presents findings from an ontological and contextual determination of the concept of dignity. The study had a caritative and caring science perspective and a hermeneutical design. The aim of this study was to increase caring science knowledge of dignity and to gain a determination of dignity as a concept. Eriksson's model for conceptual determination is made up of five part-studies. The ontological and contextual determination indicates that dignity can be understood as absolute dignity, the spiritual dimension characterized by responsibility, freedom, duty, and service, and relative dignity, characterized by the bodily, external aesthetic dimension and the psychical, inner ethical dimension. Dignity exists in human beings both as absolute and relative dignity.

The human being's spiritual experiences in a mental healthcare context; their positive and negative meaning and impact on health--a hermeneutic approach.

The study aims at describing different meanings of patients' spiritual experiences and their impact on patients' health in mental healthcare. The different contents of patients' spiritual experiences are often understood by caregivers as the expressions of patients' religious speculation. The study has a hermeneutic approach, inspired by Gadamer. Its theoretical pre-understanding is Caring Science perspective, according to which the human being is a unity of body, psyche and spirit. The sources are 32 stories selected from William James' book (1956) The Varieties of Religious Experience. They are hermeneutically interpreted and discussed in the light of international research on patients' spirituality to gain a deeper understanding. The results are three main themes: (i) the positive meanings of spirituality, (ii) the negative meanings of spirituality and (iii) the both negative and positive meaning of spirituality. Therefore, it is a very important task for mental caregivers to address patients' spiritual dimension to help them adequately.

Hermeneutic reading of classic texts.

The purpose of this article is to broaden the understandinfg of the hermeneutic reading of classic texts. The aim is to show how the choice of a specific scientific tradition in conjunction with a methodological approach creates the foundation that clarifies the actual realization of the reading. This hermeneutic reading of classic texts is inspired by Gadamer's notion that it is the researcher's own research tradition and a clearly formulated theoretical fundamental order that shape the researcher's attitude towards texts and create the starting point that guides all reading, uncovering and interpretation. The researcher's ethical position originates in a will to openness towards what is different in the text and which constantly sets the researcher's preunderstanding and research tradition in movement. It is the researcher's attitude towards the text that allows the text to address, touch and arouse wonder. Through a flexible, lingering and repeated reading of classic texts, what is different emerges with a timeless value. The reading of classic texts is an act that may rediscover and create understanding for essential dimensions and of human beings' reality on a deeper level. The hermeneutic reading of classic texts thus brings to light constantly new possibilities of uncovering for a new envisioning and interpretation for a new understanding of the essential concepts and phenomena within caring science.

The meaning of reconciliation: women's stories about their experience of reconciliation with suffering from grief.

INTRODUCTION: Grief can be seen as a form of suffering. In this study grief was not only defined as loss, but as the process of inner suffering caused of some kinds of loss. We must recognise the importance of increased understanding for patient reconciliation with grief to expand earlier formulated knowledge about health and suffering. The aim of this study was to illuminate the meaning of reconciliation among women suffering from grief. METHODS: A qualitative explorative design with a hermeneutic narrative approach was used to analyse and interpret the interviews. Caring theory about health, suffering and hermeneutical philosophy about understanding provided the point of departure for the analysis. The study was approved by an ethical research committee. RESULTS: Findings reveal different plots that give light to the meaning of reconciliation in the different phases of analysis. In the women's narratives the meaning of reconciliation is a process to a new way of seeing, but also to opening and transition from the experience of grief and suffering to the experience of health and wholeness. CONCLUSIONS: Reconciliation has a progressive form and the meaning of reconciliation cannot be seen as synonymous or homogenous but an understanding of reconciliation as a heterogenic synthesis of health and suffering. Understanding the reconciliation process will enable nurses to plan and provide professional care, based on caring science.

Latching onto life: living in the area of tension between the possibility of life and the necessity of death.

AIM: To present one of the findings from a large-scale hermeneutic research project focusing on promoting a deeper understanding of health and suffering because of serious cancer disease. BACKGROUND: Although suffering is a main concern for caring science, there is limited research focusing on the suffering of the patients with a serious cancer disease from the patients' perspective and few studies focusing on the patient's health resources and the dialectic between these. DESIGN: The study has a hermeneutic design inspired by Gadamer's ontological hermeneutics. METHOD: Fifteen Norwegian patients with cancer disease were interviewed. They were informed about the seriousness of their situation and that there was no more curative treatment to offer. RESULTS: The results show that the patients lived their lives in a dialectic oscillation, a struggle between health and suffering. They expressed health through striving towards normal life, aspiring for hope, taking responsibility for their own life and experiencing belongingness with their next of kin. Suffering was expressed through experiences of bodily aversion, uncertainty and fear of the future, sorrow and needs, anxiety, despair and loneliness. The patients were lonely in this struggle, as conversations about existence and death did not occur, neither with the nurses nor with their next of kin. Death remained veiled in silence. CONCLUSIONS: In confronting one's own death, there seems to be striving for health, striving for wholeness and for becoming a self in a life dominated by suffering. Becoming a self implies a desire to be a responsible human being and to experience integrity and dignity in life despite increasing dependency on others. RELEVANCE TO CLINICAL PRACTICE: There seems to be a great need in clinical practice to give priority to, and increase, the consciousness and competence of nurses to see and respond to the spiritual/existential concerns of patients with a serious cancer disease.

Acute--an ambiguous concept in healthcare.

The aim of this study was to explore the concept acute semantically. The concept is being used both in clinical and theoretical contexts, without questioning whether a clear meaning of the concept has been established. The analysis has been applied according to the semantic analysis strategy of the philosopher (and pedagogue) Koort (1975). First, the results show that the concept of acute has had an unclear meaning and perception in the Norwegian language. Second, the synonyms indicate two different contents. The experiences and events that occur acute might be experienced as 'sharp' and 'intense'. The synonyms point also at time, such as quick, rapid and swift. Third, it reveals that the shortlived experience as synonym does have a very little binding to the concept acute. The occurence that began suddenly is not meant to subside the same way as it began.

The tune of want in the loneliness melody--loneliness experienced by people with serious mental suffering.

The prime purpose of this article is to present the results of a study of the significance of loneliness in patients with serious psychiatric disease, who live alone at home. This empirical study lasted about 1 year. Participatory observation, talks with the researcher and conversational qualitative interviews were employed. There were eight informants with serious psychiatric illnesses who lived alone in a large city. Throughout the year, a gradual and deeper understanding of the informants' loneliness was sought through the interpretation process. Want as a common fate become visible as an ideographical invariance through summative discussions about the right to life. The results have implications for caring and nursing practice.

Do patients receive care if they are perceived as patients able to cope?

The aim of this study was to show how patients' reactions in periods of crisis of acute illness influenced and made the learning process more difficult. Eleven patients with first-time acute cardiac infarction were interviewed. Many of the patients expressed the positive dimensions of having had cardiac infarction. This was especially true in the case of the younger patients. They stressed the opportunity of taking time-out from a stressed life as a new opportunity. The patients wished to be viewed as competent individuals. They reported getting very little help from their healthcare professionals, and were indeed self-therapeutic while they were in hospital. The question is therefore asked whether the patients receive care if they are perceived as patients able to cope.

Is loneliness a psychological dysfunction? A literary study of the phenomenon of loneliness.

The purpose of this investigation was to explore how loneliness is described in literature and research. The study employed a hermeneutic approach rooted in the ideology of humanistic science in a caritative nursing tradition. Data sampling for the study was completed over two different periods of time (1998 and 2004). The main findings are that loneliness is understood as a complex dimension in our lives and it can be experienced at many levels. Through the survey of the theoretical material, loneliness may be understood as a structural dimension of existence and not as an illness. The deep dimension of loneliness, however, can entail suffering that is possibly so intolerable that it may turn towards becoming an illness. Loneliness is assumed as something we are, an ontological structure in our existence. Loneliness can therefore be turned into suffering as well as into health. It is perhaps in the silent reflective loneliness that we paradoxically develop a greater understanding of the benefits of togetherness. Our conclusion is therefore, that the phenomenon of loneliness is not a psychological dysfunction.

Sacrifice: an ethical dimension of caring that makes suffering meaningful.

This article is intended to raise the question of whether sacrifice can be regarded stituting a deep ethical structure in the relationship between patient and carer. The significance of sacrifice in a patient-carer relationship cannot, however, be fully understood from the standpoint of the consistently utilitarian ethic that characterizes today's ethical discourse. Deontological ethics, with its universal principles, also does not provide a suitable point of departure. Ethical recommendations and codices are important and serve as general sources of knowledge when making decisions, but they should be supplemented by an ethic that takes into consideration contextual and situational factors that make every encounter between patient and carer unique. Caring science research literature presents, on the whole, general agreement on the importance of responsibility and devotian with regard to sense of duty, warmth and genuine engagement in caring. That sacrifice may also constitute an important ethical element in the patient-carer relationship is, however, a contradictory and little considered theme. Caring literature that deals with sacrifice/self-sacrifice indicates contradictory import. It is nevertheless interesting to notice that both the negative and the positive aspects bring out importance of the concept for the professional character of caring. The tradition of ideas in medieval Christian mysticism with reference to Lévinas' ethic of responsibility offers a deeper perspective in which the meaningfulness of sacrifice in the caring relationship can be sought. The theme of sacrifice is not of interest merely as a carer's ethical outlook, but sacrifice can also be understood as a potential process of transformation health. The instinctive or conscious experience of sacrifice on the part of the individual patient can, on a symbolic level, be regarded as analogous to the cultic or religious sacrifice aiming at atonement. Sacrifice appears to the patient as an act of transformation to achieve atonement and healing. Atonement then implies finding meaningfulness in one's suffering. The concept of sacrifice, understood in a novel way, opens up a deeper dimension in the understanding of suffering and makes caring in 'the patient's world' possible.

Caring conversations - psychiatric patients' narratives about suffering.

AIM: The aim of this study was to increase and deepen the understanding of how psychiatric patients in conversations with nurses narrate their experience of suffering. METHODS: Data were obtained in the years 2001-2002 by audio recording of 20 individual caring conversations between eight patients and three psychiatric nurses at a psychiatric outpatient unit in Sweden. Before the data were gathered the study was approved by a local research ethics committee. The methodology is inspired by the hermeneutics of Paul Ricoeur. The data is given a naïve reading which is followed by two structural analyses which explain the text. Finally, the structural analyses and the pre-understanding are confronted in a critical reflection. FINDINGS: In the patients' narratives, suffering was at first concealed under a façade that helps the patient to cope with suffering and with shame. As they moved along to a turning point, something happened that made them able to risk everything, i.e. their very selves, but also gave them the possibility of regaining vital parts of themselves that where lost when the façade was constructed. As they took the suffering upon themselves, they grew to be fully visible as human beings and healing was possible as a re-establishment of the interpersonal bridge. This not only meant that the sufferer became open for relationships with others or an abstract other, but also that an opening in the relationship with themselves occurred. CONCLUSIONS: If psychiatric patients are allowed to narrate freely they develop different plot structures, which can either hide or reveal suffering. Patients who could establish an answer to the why-question of suffering could also interpret their suffering in a way that enabled growth and reconciliation. In order to do so, they had to abandon the shelter of the façade and confront suffering and shame. This turning point opened them up to life-sustaining relationships with themselves as well as with abstract and concrete others.

Hermeneutics and narration: a way to deal with qualitative data.

Hermeneutics and narration: a way to deal with qualitative data This article focuses a hermeneutic approach on the interpretation of narratives. It is based on the French philosopher Paul Ricoeur's theory of interpretation but modified and used within a caring science paradigm. The article begins with a presentation of the theoretical underpinnings of hermeneutic philosophy and narration, as well as Ricoeur's theory of interpretation, before going on to describe the interpretation process as modified by the authors. The interpretation process, which consists of several stages, is exemplified and discussed using a single case from a larger study on suffering. The results of that study indicate that the struggle of suffering is perceived as a struggle formed between shame and dignity, and that nurses must engage in the process of preserving and restoring the dignity of their suffering patients. The authors suggest that Ricoeur's theory of interpretation is useful when trying to understand narrative data if the researcher realises that the process of distanciation, although central in Ricoeur's thinking, is not the goal of the process but rather a means to deal with the researcher's pre-understandings. According to Ricoeur, distanciation is accomplished by putting the context aside and dealing with the text 'as text' and thereby explaining its meaning. Explanation thus becomes the dialectic counterpart to understanding in the interpretation process. The researchers further argue that distanciation must be followed by reflection, where the interpretations are linked back to the empirical context.