Recognizing and acknowledging end-of-life for patients with cancer - a balancing act. A qualitative study of doctors' and nurses' experiences.

PURPOSE: Doctors and nurses are central in the challenging task of end-of-life (EOL) care, and this study aims to explore and describe doctors' and nurses' experiences of recognition and acknowledgment of the end of life for patients with cancer. METHODS: A qualitative, explorative research design with individual interviews was carried out based on a semi-open interview guide. A total of 6 doctors and 6 nurses working in medical or surgical departments at a Norwegian University hospital were interviewed. The interviews were analyzed using qualitative content analysis. RESULTS: The study's findings highlight that recognizing and acknowledging patients with cancer as being at end-of-life is a challenging process. Three subthemes emerged from the analysis; the significance of being experienced, the significance of organizational structures, and the significance of having a common understanding. A main theme was analyzed further and abstracted from the subthemes; Being safe to manage the balancing act of recognizing and acknowledging the end of life. CONCLUSIONS: Much is at stake in the EOL setting, and healthcare professionals (HCP) must balance several aspects regarding EOL decisions. Striking the right balance in these situations is challenging. HCPs need a safety net through collaboration with, and support from, colleagues, supporting organizational structures and experience. Strengthening the safety net will have a clear impact on improving clinical practice to reduce futile treatment and provide high-quality EOL care for all dying patients in hospitals.

Nursing students' movement toward becoming a professional caring nurse.

BACKGROUND: Previous research mainly focuses on how to support nursing students in caring for the patient and on educators' views of students' development as professional caring nurses. Against this background, it is important to further investigate nursing students' perspectives on what it means to become a professional caring nurse. RESEARCH AIM: This qualitative systematic review study aims to identify and synthesize nursing students' perceptions on the meaning of becoming a caring nurse. RESEARCH DESIGN AND DATA SOURCES: Systematic data searches were conducted by using the electronic databases MEDLINE (Ovid), CINAHL (EBSCO), Academic Search Premiere (EBSCO), and Philosopher`s Index. In total, 13 studies met the inclusion and quality criteria. The articles were analyzed by a systematic review and a thematic synthesis according to Thomas and Harden. ETHICAL CONSIDERATION: The study followed good ethical practice guidelines outlined in the Northern Nurses' Federation. FINDINGS: The analysis resulted in eight descriptive themes and finally in three analytical themes: Becoming is to get in touch with one's inner ethic or ethos, Becoming is a movement between courage, understanding, and being touched, and Becoming is strengthened through caring role models and a learning culture. CONCLUSIONS: Becoming a professional caring nurse is seen as an ongoing movement toward a deeper understanding of oneself and one's being and bearing. This movement is enabled when nursing students have a sense of self-awareness, courage to stand in their vulnerability, and reflect on their responsibility, caring attitude, and inner values and ethics. The force of becoming is that the attention is directed beyond self to care for and feel empathy for others in a caring manner. Becoming is released through a caring relationship, external confirmation, and good role models. A lack of external support in the movement can potentially prevent the students from becoming a professional caring nurse.

Organizational structures influencing timely recognition and acknowledgment of end-of-life in hospitals - A qualitative study of nurses' and doctors' experiences.

PURPOSE: Healthcare personnel's timely recognition and acknowledgment of end-of-life (EOL) is fundamental for reducing futile treatment, enabling informed decisions regarding the last days or weeks of life, and focusing on high-quality palliative care. The aim of this study is to explore and describe nurses' and doctors' experiences of how organizational structures in hospitals influence timely recognition and acknowledgment of EOL. METHODS: A qualitative explorative design was applied, with data collected through 12 individual in-depth interviews using a semi-structured interview guide. A total of 6 nurses and 6 doctors were strategically recruited from medical and surgical wards in a Norwegian hospital. Qualitative content analysis was used. RESULTS: The analysis revealed the theme The importance of hospital organizational structures in timely recognition and acknowledgment of EOL and a subtheme comprising three areas of organizational structures influencing timely recognition and acknowledgment of EOL; Challenges to and demands of continuity, collaboration, and time. CONCLUSIONS: The study's results show challenges in identifying when cancer patients approach the last weeks and days of life within hospital wards. For nurses and doctors to be able to recognize and acknowledge EOL, continuity of care, collaboration, and time is needed. A fragmented healthcare system, with a predominant focus on treatment and cure, may prevent cancer patients from receiving timely palliative, care causing unnecessary suffering.

Strengths and challenges with spiritual care: Student feedback from the EPICC Spiritual Care Self-Assessment Tool.

AIM: To explore qualitative data from students' self-reported competencies in spiritual care gathered during testing of a student self-assessment tool based on the EPICC Spiritual Care Education Standard. DESIGN: Reflexive thematic analysis of qualitative data from a multinational study on validating a new self-assessment tool. METHODS: The EPICC Spiritual Care Education Standard for competency in spiritual care was developed to enhance nurses' and midwives' ability to provide spiritual care by creating a baccalaureate education standard for spiritual care competencies. Spiritual care researchers then developed a self-assessment tool to raise student awareness of spirituality and track personal and professional growth in spiritual care competency. The EPICC Spiritual Care Competency Self-Assessment Tool, tested at eight universities in five countries, provided many opportunities for student comments, resulting in rich qualitative data presented here. RESULTS: Themes related to strengths, weaknesses and areas for improvement. Identified strengths were similar across countries: caring attitudes, general knowledge of caring and compassion and good communication skills. Weaknesses/challenges touched on spirituality as overlooked in some cultures but part of life for others, complex questions were hard to understand, and self-assessment tools are common for some and rare for others. Areas for improvement included need for knowledge of religious and other deeply held beliefs and for greater spiritual assessment skills. Similarities across countries related to basic training in communication and compassionate care for nurses globally. Differences lay in the challenges and/or barriers for spiritual care and may relate to cultures within countries and/or university test sites. RELEVANCE TO CLINICAL PRACTICE: The Tool raises awareness of spirituality among students and working nurses, providing an accessible way to self-check personal and professional growth in spiritual care competencies, which increases student and nurse capacity to become more knowledgeable and skilled in facilitating spiritual care, thus be role models for students at the intersection of spirituality and health.

Developing and testing the EPICC Spiritual Care Competency Self-Assessment Tool for student nurses and midwives.

AIMS AND OBJECTIVES: To develop and psychometrically test a self-assessment tool that measures undergraduate nursing and midwifery students' perceptions of spiritual care competence in health care practice. BACKGROUND: Spiritual care is part of nurses/midwives' responsibility. There is a need to better benchmark students' competency development in spiritual care through their education. The EPICC Spiritual Care Education Standard served as groundwork for the development of the EPICC Spiritual Care Competency Self-Assessment Tool. DESIGN: Cross sectional, mixed methods design. A STROBE checklist was used. METHODS: The Tool (available in English, Dutch and Norwegian) was developed by an international group. It was tested between July-October 2020 with a convenience sample of 323 nursing/midwifery students at eight universities in five countries. The Tool was tested for validity using Kaiser-Meyer-Olkin (KMO) test, exploratory and confirmatory factor analysis, one-way ANOVA and independent samples t test. The reliability was tested by Cronbach's alpha coefficient. Qualitative data were analysed using thematic analysis. RESULTS: The KMO test for sampling adequacy was 0.90. All, but two, items were related to the same factor. Cronbach's alpha coefficient for the Tool was 0.91. Students found the Tool easy to use, and they gained new insights by completing it. However, students felt that some questions were repetitive and took time to complete. CONCLUSIONS: The Tool has construct and discriminant validity, and high internal consistency (is reliable). In addition, students found the Tool useful, especially in early stages of education. RELEVANCE TO CLINICAL PRACTICE: The Tool affords student nurses and midwives the opportunity to self-evaluate their knowledge, skills and attitudes about spirituality and spiritual care. The Tool offers students, educators and preceptors in clinical practice a tangible way of discussing and evaluating spiritual care competency.

Health professionals' reflections on existential concerns among people with obesity.

PURPOSE: This study aimed to describe health professionals' reflections on existential concerns among people with obesity when attempting to support them in their lifestyle change processes. For many of those affected by obesity, the condition becomes lifelong and causes existential concerns. The health professionals' reflections on existential concerns among people with obesity may influence central aspects of their practice and their patients' well-being. METHODS: Eighteen health professionals with relevant health education working in three different treatment programmes for people with obesity were recruited for three focus group interviews. The interviews were analysed and interpreted using a model for interpretation of meaning at three levels with a phenomenological-hermeneutical approach. FINDINGS: The analysis identified three themes. The health professionals reflected on existential concerns among people with obesity in terms of patients' repressed emotional difficulties and lack of self-respect. In addition, they reflected on their own experiences of powerlessness when presented with people with obesity's existential concerns. CONCLUSION: The present study provides valuable insights into reflections on existential concerns among people with obesity, based on health professionals' descriptions. We believe that these insights add to the existing literature and have consequences for how people with obesity are met and cared for.

Reassured on a background of vulnerability - people with microvascular angina 12 months after high-intensity physical exercise program.

PURPOSE: Physical activity is recommended for patients with coronary microvascular dysfunction, however, avoided due to fear about the heart. The aim is to achieve an understanding of the meaning of physical activity one year after participating in a high-intensity exercise training program. METHOD: Twelve people were interviewed using a phenomenological hermeneutic approach. RESULTS: Four themes were formulated and revealed that one year after participating in high-intensity exercise training participants had an awareness of the meaning of the project, their chest pain and daily life: Being reassured, Daily life's impact on chest pain and continuing doing high-intensity exercise training, A strengthened body and mind, Being part of a group of people with similar problems.Comprehensive understanding was formulated as "Being reassured according being physically active in a background of vulnerability". CONCLUSION: This study indicates that by going through the high-intensity exercise training program the person regains more unity with the lived body and an unfolding life. A person-centred approach is suggested including an underlying dimension of vulnerability. A lifeworld led care means meeting the patient in their way of relating to the world bodily and existentially. Taking this understanding into consideration will advance the requirements for establishing person-centred care.

Therapeutic writing in a programme for binge eating disorder-A tool to come closer to clarifying feelings.

INTRODUCTION: Therapeutic writing involving affect consciousness (AC) can be used to put difficult topics into words. In this study, we investigated how patients with binge eating disorder (BED) experienced therapeutic writing and AC in the context of cognitive behavioural therapy. The elements were included in an existing cognitive behavioural therapy group programme and the participants' experiences investigated qualitatively. AIM: To investigate therapeutic writing as experienced by patients in the context of a BED group programme focusing on AC. METHOD: A phenomenological, hermeneutic design with semi-structured interviews was employed. Eight participants were recruited after completing the BED programme at a Community Mental Health Centre on the West Coast of Norway. FINDINGS: Four sub-themes emerged: Struggling to achieve a flow in the writing process, Deeper understanding of eating patterns through writing, Moving specific feelings towards the surface by writing and Greater insight into oneself as a human being by shared writing. Based on the sub-themes, one main theme was developed: Therapeutic writing in a binge eating disorder programme means focusing on oneself as a human being by becoming closer to one's feelings. CONCLUSION: Therapeutic writing offered in treatment for BED involves individual movements at different levels, including processes of awareness of feelings, cognitions and oneself as a human being.

The meaning of reflection for understanding caring and becoming a caring nurse.

BACKGROUND: Reflection is essential for students to learn and understand caring, their formation as human and caring beings, and their ability to meet patients in a caring way. Consequently, to facilitate nurse students' development into professionals, learning support is needed where the focus is on understanding caring and becoming caring nurses. AIM AND RESEARCH QUESTIONS: The exploratory study aim is to gain knowledge of the meaning of reflection in first-term nursing education, and how reflection grounded in caring theory can deepen the students' understanding of caring and their professional formation of becoming a caring nurse. METHOD: Data consisted of individual written reflections and were collected from 64 nursing students from Norway, who had completed their instruction in caring theories and participated in four reflection groups where they reflected on caring and becoming a caring nurse. A thematic analysis was used. FINDINGS: The results are based on the three main themes, Reflection provides an understanding of caring by developing a language for caring; Reflection provides an understanding of seeing the person behind the illness; and Reflection contributes to increased self-understanding and awareness of oneself as a caring nurse. CONCLUSIONS: Instruction in caring theories and participation in reflection groups, with reflection grounded in caring theory, has a key function in facilitating students' development of a language for caring in nursing and appropriation of caring theory. The appropriation of caring theory provides a foundation for the nurse students to see themselves within a broader perspective and is important for mutual support in the professional formation of becoming a caring nurse. The expected outcome of such integration is a nursing curriculum that progressively supports the development of nursing students professionally and personally in the formation of becoming a caring nurses.

Cancer survivorship: existential suffering.

PURPOSE: This study aimed to explore and describe existential experiences after cancer treatment. METHOD: An exploratory phenomenological hermeneutical design was used following in-depth interviews with 21 people. RESULTS: The study revealed experiences of multifaceted suffering in the form of limitations in everyday life, inner struggles, and bearing the burden alone. CONCLUSIONS: Existential suffering after cancer treatment was revealed as like being in a process of transition, in an intermediate state, as moving between suffering and enduring, and alternating between alienworld and homeworld. A new and broader professional perspective is needed to establish rehabilitation services based on multifaceted experiences of suffering. This means a shift in focus from biomedical symptoms towards understanding of existential meaning for the person.

Homeworld/Alienworld: a qualitative study about existential experiences after cancer treatment.

BACKGROUND: As a group, cancer survivors experience significant vulnerability and existential challenges. The biomedical approach dominating health care is insufficient to meet such existential challenges in an individualistic, holistic way. OBJECTIVE: This study aimed to explore the existential experiences of those treated for different cancers. METHODS: An exploratory phenomenological-hermeneutical design was used to obtain an understanding of existential experiences after cancer treatment. Data were collected through in-depth interviews with 21 individuals who represented a purposive sample and were recruited from a cancer organisation. RESULTS: Three overriding themes emerged from the phenomenological-hermeneutical analysis are as follows: Experiencing an unfamiliar tiredness; Experiencing not being fully oneself; and Experiencing a feeling of being alone. CONCLUSIONS: Existential suffering after cancer treatment involves living on the edge of the old homeworld and the experience of a new alienworld. Individuals undergoing such suffering need a transformational process, from the alienworld to the homeworld, which must be supported by the healthcare system. IMPLICATIONS FOR PRACTICE: To facilitate the transformational process, healthcare professionals should communicate with patients throughout their cancer journey about how their existential experiences have been integrated into their lifeworld, allowing them to tell their own story from the perspective of lifeworld brokenness.

Experiences of longing in daily life and associations to well-being among frail older adults receiving home care: a qualitative study.

Purpose: All over the world, communities face the challenge of maintaining well-being among older adults. More specifically, understanding the resources required to establish and maintain well-being among community-dwelling older adults is an essential issue. Although longing from a caring science perspective is considered a driver for well-being, it has not yet been investigated among frail older adults. The aim of this study was to explore frail older adults' experiences of longing in daily life and the relation between longing and well-being from a caring science perspective. Method: The study uses a hermeneutical approach and follows a qualitative explorative design. The data comprises texts from 17 interviews with frail older adults and was analysed by content analysis. Results: The results uncovered three themes: Longing for social contacts; Longing for nature and Longing creativity, aesthetics, and music. Longing was positively related to well-being when the older adults were able to fulfil their longings. Conclusion: This study provides an understanding of the mechanisms of longing among frail older adults. Longing, here, is an inner resource for setting into motion the transition towards well-being. Further studies could focus on how frail older adults can be supported to combat the negative forms of longing in daily life.

Life after cancer treatment - existential experiences of longing.

Purpose: The study aimed to gain insight into existential longing as experienced by people treated for cancer. Method: An exploratory phenomenological-hermeneutical design was used, and data were collected through in-depth interviews with 21 people recruited from a cancer organization. Results: Three themes emerged: longing to be oneself, longing for relief from suffering, and longing for rootedness. The theoretical understanding of well-being developed by Todres and Galvin was used to illuminate how the life-fulfilling power of longing is inherent in dwelling-mobility. Conclusions: During the theoretical interpretation and discussion of these findings, a new analytic step revealed a state of uncertainty that can influence longing. The findings of this study may help fill the gap in the current health-care approach to cancer survivors by highlighting the importance of a new professional perspective of listening to patients describe their existential burden. Such an approach may create greater clarity and thereby allow longing to flow more freely towards future possibilities and well-being.

Living With Obesity: Expressions of Longing.

Those who are obese experience complex moral distress. The norm in Western societies is to be slim, and people living with obesity experience challenges under the gaze of society. They feel great vulnerability and the available treatments seldom meet individual needs. New concepts of embodiment need to be developed to include phenomenological investigations. There is limited knowledge about longing among those suffering from obesity. A deeper understanding of longing from an individual perspective is required to improve treatment. The aim of this study was to gain an in-depth understanding of the experiences of longing by those suffering from obesity. The research was approved by the Norwegian Regional Committees for Medical and Health Research Ethics. An explorative phenomenological-hermeneutical design was used. Qualitative interviews were conducted with 18 participants, all with body mass indexes in the range of 30 to 45, which were then analyzed using a phenomenological-hermeneutical approach. Three main dimensions of longing were revealed: longing for normality, longing for what was lost, and longing for simplicity in life. The health service needs to understand better the longings of obese individuals to help them live their lives in greater freedom, based on their own longings and self-care. Focusing on longing may reveal a person's true desires, and the longing may be a form of resistance to the disciplination of society.

Putting life on hold: lived experiences of people with obesity.

Obesity presents challenges in everyday life, one of which involves the existential aspects of living life as a person with obesity. There is a need for understanding the existential experiences, but there is limited in-depth research about these experiences of people with obesity. The aim of this study was to gain deeper insight into the existential experiences of people dealing with obesity. We performed a qualitative study that included in-depth interviews with seven men and 14 women with obesity (body mass index ≥ 35 kg/m2 ) aged 18-59 years. The study took a phenomenological-hermeneutic approach in which the participants' own experiences formed the basis for understanding their lifeworld. The lived experiences of people dealing with obesity were characterised by several existential challenges. One overarching theme-Putting life on hold when struggling with obesity-was developed based on three themes: The body as an impediment to living the desired life, to being oneself and to moving on in life. These findings illustrate the complex existential experience of life, body and existence faced by people dealing with obesity. Based on these findings, we discuss whether people with obesity who experience 'putting life on hold' are attuned to live their life to the fullest in some areas. Their embodied experiences seem to challenge them to experience the joy of life, to appear as a whole self and to live life in the moment. Reflecting on obesity in the context of life and life phenomena seems to provide deeper insights into the existence of people living with obesity and may help to advance a more comprehensive approach in obesity health care.

Aspects of well-being when struggling with obesity.

Purpose: We aimed to gain deeper insight into how people struggling with obesity handle their life situation by addressing how well-being might unfold. For many people, obesity becomes a lifelong condition characterized by repeated weight fluctuations while their weight increases gradually. From an existential perspective, constantly waiting for weight loss can cause an experience of not reaching one's full potential. How people with obesity experience well-being, within their perceived limitations, is less reflected in previous research.Methods: We established a qualitative study using in-depth interviews with seven men and 14 women with obesity (body mass index 335 kg/m2) aged 18-59 years. The study had an exploratory design including a phenomenological-hermeneutic perspective, with a lifeworld approach.Results: Three themes describing aspects of well-being were developed: coming to terms with the body, restoring the broken relational balance and reorienting the pivot in life. The thematic findings were abstracted into a main theme: striving to make living bearable. The movement towards well-being can be seen as a struggle towards an experience of balance to make bearable living.Conclusions: We suggest that well-being as a dialectic between vulnerability and freedom might become a health-facilitating experience for people struggling with obesity.

Living with obesity - existential experiences.

Aims and objectives: The aim was to gain in-depth understanding about individuals' existential experiences of living with obesity. Background: People living with obesity face great vulnerability and existential challenges. The different treatments offered do not seem to meet the individual needs of persons with obesity. A deeper understanding of existential experiences from an individual perspective is needed to individualize treatment. Design: An exploratory phenomenological-hermeneutical design was used to gain a greater understanding of the existential experiences involved in living with obesity. Methods: The participants represented a convenient sample. 18 qualitative interviews were conducted and subjected to phenomenological-hermeneutical analysis. Results: Four themes emerged: shaped by childhood; captured by food; depressed by the culture; and judged by oneself. Conclusions: The burden of being obese can be experienced as being objectified and alienated as a human being. We need to turn towards a life-world perspective, seeing each human being as a living body to overcome objectification and alienation, and then move them towards becoming subjects in their own lives, through giving space for self-love. Health care workers need to assist persons living with obesity to reduce objectification and alienation. It is important to develop intervention that has an individual, holistic approach.

Between the patient and the next of kin in end-of-life care: A critical study based on feminist theory.

BACKGROUND:: For the experience of end-of-life care to be 'good' many ethical challenges in various relationships have to be resolved. In this article, we focus on challenges in the nurse-next of kin relationship. Little is known about difficulties in this relationship, when the next of kin are seen as separate from the patient. RESEARCH PROBLEM:: From the perspective of nurses: What are the ethical challenges in relation to next of kin in end-of-life care? RESEARCH DESIGN:: A critical qualitative approach was used, based on four focus group interviews. PARTICIPANTS:: A total of 22 registered nurses enrolled on an Oncology nursing specialisation programme with experience from end-of-life care from various practice areas participated. ETHICAL CONSIDERATIONS:: The study was approved by the Norwegian Social Science Data Service, Bergen, Norway, project number 41109, and signed informed consent obtained from the participants before the focus groups began. FINDINGS AND DISCUSSION:: Two descriptive themes emerged from the inductive analysis: 'A feeling of mistrust, control and rejection' and 'Being between hope and denial of next of kin and the desire of the patient to die when the time is up'. Deductive reinterpretation of data (in the light of moral distress from a Feminist ethics perspective) has made visible the constraints that certain relations with next of kin in end-of-life care lay upon the nurses' moral identity, the relationship and their responsibility. We discuss how these constraints have political and societal dimensions, as well as personal and relational ones. CONCLUSION:: There is complex moral distress related to the nurse-next of kin relationship which calls for ethical reflections regarding these relationships within end-of-life care.

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.