Dignity in relationships and existence in nursing homes' cultures.

INTRODUCTION: Expressions of dignity as a clinical phenomenon in nursing homes as expressed by caregivers were investigated. A coherence could be detected between the concepts and phenomena of existence and dignity in relationships and caring culture as a context. A caring culture is interpreted by caregivers as the meaning-making of what is accepted or not in the ward culture. BACKGROUND: The rationale for the connection between existence and dignity in relationships and caring culture is that suffering is a part of existence, as well as compassion in relieving suffering, and ontological interdependency. AIM: To describe different expressions of dignity in relationships and existence in context of caring cultures from the perspective of the caregivers. RESEARCH DESIGN: The methodology and method are hermeneutic. The method used was to merge the theoretical preunderstanding as one horizon of understanding with empirical data. PARTICIPANTS AND RESEARCH CONTEXT: Focus group interviews with caregivers in nursing homes. ETHICAL CONSIDERATIONS: The principles of the Helsinki Declaration have been followed to, for example, preserve self-determination, integrity, dignity, confidentiality and privacy of the research persons. FINDINGS: Data interpretation resulted in four themes: Encountering existential needs that promote dignity in a caring culture; To amplify dignity in relationships by the creative art of caring in a caring culture; Violation of dignity by ignorance or neglect in a non-caring culture and The ethic of words and appropriated ground values in a caring culture. DISCUSSION: Dignity-promoting acts of caring, or dignity-depriving acts of non-caring are adequate to see from the perspective of dignity in relationships and existence and the caring culture. CONCLUSIONS: Dignity in relationships seems to touch the innermost existential life, as the existential life is dependent on confirmation from others.

Ethical challenges and lack of ethical language in nurse leadership.

BACKGROUND: In accordance with ethical guidelines for nurses, leaders for nurse services in general are responsible for facilitating professional development and ethical reflection and to use ethical guidelines as a management tool. Research describes a gap between employees' and nurse leaders' perceptions of priorities. OBJECTIVE: The purpose of this article is to gain deeper insight into how nurses as leaders in somatic hospitals describe ethical challenges. DESIGN AND METHOD: We conducted individual, quality interview with 10 nurse leaders, nine females and one male nurse aged 34-64 years. We used a hermeneutical approach to analyse the data. ETHICAL CONSIDERATIONS: The participants received oral and written information about the study. Participation in the study was voluntary, and the participants were given the opportunity to withdraw. All of them gave written consent. The Norwegian Centre for Research Data approved the research project. In addition, the head of the hospitals gave permission to conduct our study. FINDINGS: Four main areas were identified: deficient ethical language, conflicting demands on nurse leaders regarding staff management, concerns regarding young nurses' ethical consciousness and restricting factors on the creation of a climate of ethics. The nurse leaders experienced considerable pressure. An unexpected finding was the lack of - and even disregard for - an ethical language. DISCUSSION AND CONCLUSION: It is crucial to recognise ethics in all types of nursing approaches and to make it explicit. Ethical language must be implemented in nursing education. It must be recognised and used in clinical practice. RECOMMENDATIONS: We recommend further research be conducted into how nurses understand the concept of ethics and how to incorporate ethical principles into clinical nursing and nurse leadership.

The meaning of dignity when the patients' bodies are falling apart.

BACKGROUND: People with advanced cancer disease experience great bodily changes due to disease or treatment. They tend to feel ashamed when their bodies are subjected to such changes and they feel their dignity is threatened. AIM: To explore the patients' experiences of the bodily changes in relation to dignity. DESIGN: The study has a hermeneutic qualitative design. METHOD: Individual in-depth interviews and participant observations were conducted with 13 patients with advanced cancer disease at a hospice inpatient unit in Norway. Gadamer's ontological hermeneutics inspired the interpretation. RESULTS AND CONCLUSION: The patients' unpredictable, sick bodies forced the patients, or gave them the opportunity, to relate to their bodies in an honest way. The patients, living in interaction between suffering and health, strove to find dignity. The patients had a will to live and they experienced a love in their unruly bodies that both helped alleviate their suffering and give them an experience of enhanced dignity. It is important that nurses have insight into the consequences of bodily changes for the patients' experiences of dignity in health and suffering to provide good, dignified care.

Experience of companionship among family caregivers of persons with dementia: A qualitative study.

We examined how caregivers experienced the influence of dementia on their relationships with afflicted family members. Family caregivers (n = 15; 11 women and four men; age 39-92 years) of people with dementia participated in semi-structured interviews. The data were analyzed according to Kvale and Brinkman. The analysis identified one overarching theme, experiences of companionship, and four subthemes, namely experiences of loss and loneliness; role change; communication alteration; and caring considerations and coping resources. The caregivers described their companionship with the family member, including warm feelings of reciprocity, as well as contradictory feelings, such as feelings of being burdened. They expressed a desire to continue caring for their relative and emphasized the positive aspects of their relationship. Knowledge about dementia, together with a good relationship with their ill family member, facilitated the caring role. These results highlight the importance of receiving information about dementia-related challenges and the implications of being a caregiver.

Hindrances to achieve professional confidence: The nurse's participation in ethical decision-making.

BACKGROUND: Research suggests that nurses generally do not participate in ethical decision-making in accordance with ethical guidelines for nurses. In addition to completing their training, nurses need to reflect on and use ethically grounded arguments and defined ethical values such as patient's dignity in their clinical work. OBJECTIVES: The purpose of this article is to gain a deeper understanding of how nurses deal with ethical decision-making in daily practice. The chosen research question is "How do nurses participate in ethical decision-making for the patient?" DESIGN AND METHOD: We use Gadamer's philosophical hermeneutics as well as Kvale and Brinkmann's three levels of understanding in interpreting the data material. Nine registered nurses were interviewed. ETHICAL CONSIDERATIONS: The Ombudsman of Norwegian Social Science Data and the head of the hospital approved the investigation. The participants received both oral and written information about the study and they gave their consent. We informed the participants that the participation was voluntary and that they were free to withdraw at any point in the course of the study. The requirement of anonymity and proper data storage was in accordance with the World Medical Association Declaration of Helsinki (1964). The participants were assured that privacy, and confidentiality would be duly protected. RESULTS: Four key themes emerged: (1) confusion in relation to professional and operational expectations of role, (2) ideal somnolence, (3) inadequate argumentation skills, and (4) compound pressure. CONCLUSION: Ethical ideals appear to be latent in the mindset of the participants; however, the main finding of this investigation is that nurses need to activate the ideals and apply them into practice. Furthermore, management needs to initiate professional reasoning and interdisciplinary discussions leading to common goals for patients.

The paradoxical body: A glimpse of a deeper truth through relatives' stories.

BACKGROUND: People with progressive cancer experience that their bodies change due to disease and/or treatment. The body is integral to the unity of the human being, a unity that must be perceived as whole if dignity shall be experienced. Relatives are in touch with the suffering bodies of their dear ones, physically, socially, mentally, and existentially, and thus the relatives' experiences of the bodies of their dear ones might yield insight into the concept of dignity. AIM: The aim of this study is to explore relatives' experiences of the patients' bodily changes from a perspective of dignity. RESEARCH DESIGN AND METHOD: A total of 12 relatives from a hospice in Norway were interviewed. Gadamer's ontological hermeneutics inspired the interpretation. ETHICAL CONSIDERATIONS: The principles of voluntariness, confidentiality, withdrawal, and anonymity were respected during the whole research process. The Norwegian Social Science Data Services approved the study. RESULTS AND CONCLUSION: The conversations about the body were conversations about ambivalent or paradoxical matters that shed light on the concept of dignity. The results show that the relatives got in touch with elements that otherwise would have remained tacit and unspoken, and which gave glimpses of a deeper truth, which might reveal the core of dignity. Furthermore, the relatives' confirmation of the ambivalence might be understood as a strong ethical obligation to treat the other with dignity. The confirmation may also reveal the relatives' unselfish love of the other, which can be understood as the core of ethics and ethos. Finally, the results reveal the relatives' limited insight into their dear ones' bodily changes, and we discuss the challenges of truly seeing the other. Body knowledge and the relationship between body and dignity as phenomena cannot be ignored and needs more attention and articulation in clinical nursing practice and in nursing research.

Tension between freedom and dependence-A challenge for residents who live in nursing homes.

AIMS AND OBJECTIVES: To present results from interviews of older people living in nursing homes, on how they experience freedom. BACKGROUND: We know that freedom is an existential human matter, and research shows that freedom remains important throughout life. Freedom is also important for older people, but further research is needed to determine how these people experience their freedom. The background for this article was a Scandinavian study that occurred in nursing homes; the purpose of the study was to gain knowledge about whether the residents felt that their dignity was maintained and respected. DESIGN: The design was hermeneutic, with qualitative research interviews. METHOD: Twenty-eight residents living in nursing homes in Denmark, Sweden and Norway were interviewed. Collecting tools used were an interview guide and also a tape recorder. Researchers in the three countries performed the interviews. The data were transcribed and analysed on three levels of hermeneutic interpretation. RESULTS: To have their freedom was emphasised as very important according to their experience of having their dignity taken care of. The following main themes emerged: (a) Autonomy or paternalism; (b) Inner and outer freedom; and (c) Dependence as an extra burden. CONCLUSIONS: Residents in a nursing home may experience the feeling of having lost their freedom. This conclusion has implications for healthcare professionals and researchers, as it is important for residents in nursing homes to feel that they still have their freedom. RELEVANCE TO CLINICAL PRACTICE: In clinical practice, it is important and valuable for the staff to consider how they can help older people feel that they still have their freedom.

Is there a common experience? Somali new mothers' childbirth experiences in Norway and the United States.

BACKGROUND: Due to civil war, Somalis immigrants have settled in Norway and the United States. Large families are valued among Somalis and Somali women continue to give birth in their new countries. Research studies have been conducted with Somali immigrant new mothers in Norway and Minnesota, United States to understand perceptions of their childbirth experience. PURPOSE: The purpose of this qualitative study was to compare the childbirth experiences of Somali immigrant mothers in the United States and Norway to make recommendations to improve health care practice. DESIGN: This paper presents a comparison of two research studies in order to identify and explain similarities and differences between cross-cultural immigrant populations. RESULTS: Both studies identified themes related to the importance of family support in the postpartum period, fear of Cesarean delivery, and relationships with nurses. These studies give recommendations for nurses on how to provide culturally sensitive care for Somali new mothers. CONCLUSIONS: Implications for practice are that nurses should develop trusting relationships with Somali mothers and facilitate cultural and religious practices. Information regarding support resources in the community should be provided to Somali mothers throughout the perinatal period.

Clinical application research through reflection, interpretation and new understanding - a hermeneutic design.

The implementation of theoretical knowledge in clinical practice and the implementation of good clinical practice into theory have been of interest in caring science for the last 30 years. The aim of this article was to elaborate and discuss a methodology named clinical application research. The method is grounded in a hermeneutical design inspired by Gadamer's philosophy. The methodology, clinical application research, has been used in a research project A life in dignity and experiences from the researchers forms the bases for the elaboration and discussion. The project was performed in collaboration with residents, family caregivers and healthcare providers at six nursing homes in Scandinavia. The material for this article is based on the previous research, that is the results from 10 different articles showing the meaning of dignity and indignity in daily life in nursing homes. Data were generated from 56 individual interviews and 18 focus-group interviews with a total of 40 staff members with five to eight participants at every interview session. By reflection, interpretation and new understanding our results provide knowledge about dignity and how to preserve dignity for older people in an appropriate ethical way. The methodology was relevant for the research project A life in dignity and relevant to caring practice in nursing homes as it opens new possibilities and new ways of thinking when performing dignified care to older people.

The significance of meaningful and enjoyable activities for nursing home resident's experiences of dignity.

BACKGROUND: Living in a nursing home may be challenging to the residents' experience of dignity. Residents' perception of how their dignity is respected in everyday care is important. AIM: To examine how nursing home residents experience dignity through the provision of activities that foster meaning and joy in their daily life. METHOD: A qualitative design was used and 28 individual semistructured interviews conducted with nursing home residents from six nursing homes in Denmark, Norway and Sweden. The data were analysed with qualitative content analysis. Independent ethical committees in all participating countries granted their approval for the study. FINDINGS: The participants highlight two dimensions of the activities that foster experiences of dignity in nursing homes in Scandinavia. These two categories were (i) fostering dignity through meaningful participation and (ii) fostering dignity through experiencing enjoyable individualised activities. CONCLUSION: Activities are important for residents to experience dignity in their daily life in nursing homes. However, it is important to tailor the activities to the individual and to enable the residents to take part actively. Nurses should collect information about the resident's preferences for participation in activities at the nursing home.

Fostering dignity in the care of nursing home residents through slow caring.

BACKGROUND: Physical impairment and dependency on others may be a threat to dignity. RESEARCH QUESTIONS: The purpose of this study was to explore dignity as a core concept in caring, and how healthcare personnel focus on and foster dignity in nursing home residents. RESEARCH DESIGN: This study has a hermeneutic design. Participants and research context: In all, 40 healthcare personnel from six nursing homes in Scandinavia participated in focus group interviews in this study. Ethical considerations: This study has been evaluated and approved by the Regional Ethical Committees and the Social Science Data Services in the respective Scandinavian countries. FINDINGS: Two main themes emerged: dignity as distinction (I), and dignity as influence and participation (II). DISCUSSION: A common understanding was that stress and business was a daily challenge. CONCLUSION: Therefore, and according to the health personnel, maintaining human dignity requires slow caring in nursing homes, as an essential approach.

From painful busyness to emotional immunization: Nurses' experiences of ethical challenges.

BACKGROUND: The professional values presented in ethical guidelines of the Norwegian Nurses Organisation and International Council of Nurses describe nurses' professional ethics and the obligations that pertain to good nursing practice. The foundation of all nursing shall be respect for life and the inherent dignity of the individual. Research proposes that nurses lack insight in ethical competence and that ethical issues are rarely discussed on the wards. Furthermore, research has for some time confirmed that nurses experience moral distress in their daily work and that this has become a major problem for the nursing profession. OBJECTIVES: The purpose of this article is to obtain a deeper understanding of the ethical challenges that nurses face in daily practice. The chosen research questions are "What ethical challenges do nurses experience in their daily practice?" RESEARCH DESIGN: We conducted a qualitative interview study using a hermeneutical approach to analyzing data describing nurses' experiences. Ethical considerations: The Norwegian Social Science Data services approved the study. Furthermore, the head of the hospital gave permission to conduct the investigation. The requirement of anonymity and proper data storage in accordance with the World Medical Association Declaration of Helsinki was met. METHOD AND RESULTS: The context for the study comprised three different clinical wards at a university hospital in Norway. Nine qualified nurses were interviewed. The results were obtained through a systematic development beginning with the discovery of busyness as a painful phenomenon that can lead to conflicts in terms of ethical values. Furthermore, the consequences compromising professional principles in nursing care emerged and ended in moral blindness and emotional immunization of the healthcare providers. Emotional immunization occurred as a new dimension involving moral blindness and immunity in relation to being emotionally touched.

Maintaining dignity in vulnerability: A qualitative study of the residents' perspective on dignity in nursing homes.

BACKGROUND: Older people, living in nursing homes, are exposed to diverse situations, which may be associated with loss of dignity. To help them maintain their dignity, it is important to explore, how dignity is preserved in such context. Views of dignity and factors influencing dignity have been studied from both the residents' and the care providers' perspective. However, most of these studies pertain to experiences in the dying or the illness context. Knowledge is scarce about how older people experience their dignity within their everyday lives in nursing homes. AIM: To illuminate the meaning of maintaining dignity from the perspective of older people living in nursing homes. METHOD: This qualitative study is based on individual interviews. Twenty-eight nursing home residents were included from six nursing homes in Scandinavia. A phenomenological-hermeneutic approach, inspired by Ricoeur was used to understand the meaning of the narrated text. RESULTS: The meaning of maintaining dignity was constituted in a sense of vulnerability to the self, and elucidated in three major interrelated themes: Being involved as a human being, being involved as the person one is and strives to become, and being involved as an integrated member of the society. CONCLUSION: The results reveal that maintaining dignity in nursing homes from the perspective of the residents can be explained as a kind of ongoing identity process based on opportunities to be involved, and confirmed in interaction with significant others.

The Dialectical Movement Between Deprivation and Preservation of a Person's Life Space: A Question of Nursing Home Residents' Dignity.

The aim of this study was to answer the question "What do nursing home residents do themselves in order to maintain their dignity?" Twenty-eight residents, 8 men and 20 women, aged 62 to 103 years, from 6 different nursing homes in Scandinavia were interviewed. The results showed that the residents tried to expand their life space, both physical and ontological, in order to experience health and dignity.

From Victim to Taking Control: Support Group for Bullied Schoolchildren.

School bullying is a serious problem affecting the victims in their daily lives at school. The aim of this study was to investigate whether support groups were able to help the victims of bullying to overcome their victim status and to explore what it means to be a member of a support group. An exploratory qualitative design, with individual and focus group interviews, was used. The sample consisted of 19 schoolchildren, aged 12-13 years, 3 of whom were victimized. Six individual interviews and three focus group interviews were conducted. Findings show that support groups contribute to the cessation of bullying and improvements remain 3 months later. The support groups experience feeling important and helping others. It is important for the school nurse and teachers to follow up with victimized children, in collaboration with their parents, to help the victim to no longer be a victim and to take control.

Meaning given to spirituality, religiousness and personal beliefs: explored by a sample of a Norwegian population.

AIMS AND OBJECTIVES: The aim of this article is to explore the meanings given to the words 'spirituality', 'religiousness' and 'personal beliefs' by a Norwegian sample of healthy and sick individuals. BACKGROUND: Studies show that a high proportion of nurses do not identify the spiritual needs of their patients, even if the nurses are educated to give care for the whole person, including the spiritual dimension. DESIGN: This study used an exploratory qualitative design. METHODS: Qualitative data generated from six focus groups were collected in southeast Norway. The focus groups were comprised of three groups of health professionals (n = 18) and three groups of patients from different institutions (n = 15). RESULTS: The group discussions revealed that the meanings of spirituality, religiousness and personal beliefs were interwoven, and the participants had difficulty in finding a common terminology when expressing their meanings. Many of the participants described the spiritual dimension with feelings of awe and respect. They were dependent on spirituality in order to experience balance in life and cope with life crises. CONCLUSION: The themes and categories identified by the focus group discussion highlights that spirituality ought to be understood as a multilayered dimension. An appreciation of the spiritual dimension and it's implication in nursing may help to increase health and decrease suffering. RELEVANCE TO CLINICAL PRACTICE: Health professionals need to be cognizant of their own sense of spirituality to investigate the spiritual needs among their patients. This study's focus group discussions helped both patients and health professionals to improve their knowledge regarding the meanings given to the spiritual dimension.

Family caregivers' experiences in nursing homes: narratives on human dignity and uneasiness.

This qualitative study focused on dignity in nursing homes from the perspective of family caregivers. Dignity is a complex concept and central to nursing. Dignity in nursing homes is a challenge, according to research. Family caregivers are frequently involved in their family members' daily experiences at the nursing home. Twenty-eight family caregivers were included in this Scandinavian cross-country, descriptive, and explorative study. A phenomenological-hermeneutic approach was used to understand the meaning of the narrated text. The interpretations revealed two main themes: "One should treat others as one would like others to treat oneself" and "Uneasiness due to indignity." Dignity was maintained in experiences of respect, confidence, security, and charity. Uneasiness occurred when indignity arose. Although family caregivers may be taciturn, their voices are important in nursing homes. Further investigation of family caregivers' experiences in the context of nursing homes is warranted.

The meaning of dignity in nursing home care as seen by relatives.

BACKGROUND: As part of an ongoing Scandinavian project on the dignity of care for older people, this study is based on 'clinical caring science' as a scientific discipline. Clinical caring science examines how ground concepts, axioms and theories are expressed in different clinical contexts. Central notions are caring culture, dignity, at-home-ness, the little extra, non-caring cultures versus caring cultures and ethical context - and climate. AIM AND ASSUMPTIONS: This study investigates the individual variations of caring cultures in relation to dignity and how it is expressed in caring acts and ethical contexts. Three assumptions are formulated: (1) the caring culture of nursing homes influences whether dignified care is provided, (2) an ethos that is reflected on and appropriated by the caregiver mirrors itself in ethical caring acts and as artful caring in an ethical context and (3) caring culture is assumed to be a more ontological or universal concept than, for example, an ethical context or ethical person-to-person acts. RESEARCH DESIGN: The methodological approach is hermeneutic. The data consist of 28 interviews with relatives of older persons from Norway, Denmark and Sweden. ETHICAL CONSIDERATIONS: The principles of voluntariness, confidentiality and anonymity were respected during the whole research process. FINDINGS: Three patterns were revealed: dignity as at-home-ness, dignity as the little extra and non-dignifying ethical context. DISCUSSION: Caring communion, invitation, at-home-ness and 'the little extra' are expressions of ethical contexts and caring acts in a caring culture. A non-caring culture may not consider the dignity of its residents and may be represented by routinized care that values organizational efficiency and instrumentalism rather than an individual's dignity and self-worth. CONCLUSION: An ethos must be integrated in both the organization and in the individual caregiver in order to be expressed in caring acts and in an ethical context that supports these caring acts.

Aspects of indignity in nursing home residences as experienced by family caregivers.

The overall purpose of this cross-country Nordic study was to gain further knowledge about maintaining and promoting dignity in nursing home residents. The purpose of this article is to present results pertaining to the following question: How is nursing home residents' dignity maintained, promoted or deprived from the perspective of family caregivers? In this article, we focus only on indignity in care. This study took place at six different nursing home residences in Sweden, Denmark and Norway. Data collection methods in this part of this study consisted of individual research interviews. Altogether, the sample consisted of 28 family caregivers of nursing home residents. The empirical material was interpreted using a hermeneutical approach. The overall theme that emerged was as follows: 'A feeling of being abandoned'. The sub-themes are designated as follows: deprived of the feeling of belonging, deprived of dignity due to acts of omission, deprived of confirmation, deprived of dignity due to physical humiliation, deprived of dignity due to psychological humiliation and deprived of parts of life.

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.