Certified nursing assistants' perception of pain in people with dementia: a hermeneutic enquiry in dementia care practice.

AIMS AND OBJECTIVES: To interpret certified nursing assistants' perception of pain in people with dementia in nursing care practice. BACKGROUND: Detection and understanding of pain in people with dementia remains a challenge due to their difficulty in verbalising their pain. Nursing assistants provide daily nursing care and therefore play a vital role in pain detection. Nevertheless, pain research from the nursing assistants' perspective is sparse. DESIGN: A qualitative approach within the interpretive tradition was adopted. METHODS: Individual interviews with twelve certified nursing assistants, all working in dementia care, were conducted and interpreted using philosophical hermeneutics. RESULTS: Nursing assistants' perception of pain is on three levels. Each level consists of a theme. The first theme 'Being in the facing phase' refers to the initial perception of the person's expressions. The second theme 'Being in the reflecting phase' means ability to reflect more deeply on one's perception, together with other colleagues and next of kins. The third theme 'Being in the acting phase' means perception arising from preventive and protective care focusing on contributing to well-being. The themes served as a basis for comprehensive understanding, where perception of pain arises from closeness, compassion and dialogue based on personhood, accompanied by professional knowledge of pain and dementia. CONCLUSION: Nursing assistants' perception of pain is based on ethical concerns and on their own subjective pain experiences rather than on medical skills. Their perception derives from fundamental values that are important aspects of nursing care. Interdisciplinary solidarity may strengthen cooperation amongst CNAs and RNs to achieve best pain management practice. RELEVANCE TO CLINICAL PRACTICE: Attention to nursing assistants' perception of pain needs to be highlighted when they are front-line staff and have developed important pain detection skills. Their skills are essential complements and must be used in the development of pain management in dementia care practice.

What actions promote a positive ethical climate? A critical incident study of nurses' perceptions.

Few qualitative studies explore the phenomenon of positive ethical climate and what actions are perceived as promoting it. Therefore, the aim of this study was to explore and describe actions that acute care ward nurses perceive as promoting a positive ethical climate. The critical incident technique was used. Interviews were conducted with 20 nurses at wards where the ethical climate was considered positive, according to a previous study. Meeting the needs of patients and next of kin in a considerate way, as well as receiving and giving support and information within the work group, promoted a positive ethical climate. Likewise, working as a team with a standard for behaviour within the work group promoted a positive ethical climate. Future research should investigate other conditions that might also promote a positive ethical climate.

Children's experiences of procedural pain management in conjunction with trauma wound dressings.

AIM: This paper is a report of the experiences of children (5-10 years) of procedural pain when they underwent a trauma wound care session. BACKGROUND: Procedural pain in conjunction with trauma wound care often induces anxiety and distress in children. Children need to alleviate pain and avoid the development of fear in conjunction with examinations and treatments. The nurse could help children to reach this goal by using the comfort theory, which describes holistic nursing in four contexts: physical, psychospiritual, environmental and sociocultural. Few studies have focused on children's experiences of comforting activities in conjunction with trauma wound dressings. METHODS: This study was conducted between May 2008 and January 2010. Thirty-nine participants aged 5-10 were consecutively included in this study. The wound care session was standardized for all the participants, and semi-structured qualitative interviews with open-ended questions were conducted with all the children in conjunction with the procedure. All the interviews were transcribed verbatim and analysed with qualitative content analysis. FINDINGS: Four themes were identified: clinical competence, distraction, participation and security. The children were helped to reach comforting activities to enhance pain management. CONCLUSION: Children require more than just analgesics in wound care. They also need to experience security and participation in this context. When children feel clinical competence in wound care, they trust the nurse to carry out the wound dressing and instead can focus on the distraction that increases their positive outcomes.

Adolescents' and school nurses' perceptions of using a health and lifestyle tool in health dialogues.

AIM AND OBJECTIVE: To describe and explore adolescents' and nurses' perceptions of using a health and lifestyle tool in health dialogues in the School Health Service. BACKGROUND: In Sweden, dialogues concerning health and lifestyle are offered to adolescents aged 14 years with the purpose of encouraging an interest in a healthy lifestyle. A health and lifestyle tool including a health questionnaire and a health profile has recently been developed, with the aim of facilitating the communication about health and lifestyle in these dialogues. DESIGN: Qualitative descriptive design. METHOD: Twenty-nine adolescents and 23 nurses participated in focus group interviews, which were subjected to qualitative content analysis. RESULTS: The health and lifestyle tool was perceived as constituting a structure for the dialogues and as a clear and applicable starting point, focusing on individual aspects. The tool contributed to an understanding of the health situation and to the transmittal of health information on an individual as well as a group level. CONCLUSION: The tool was perceived as constituting a useful structure for the dialogues about health and lifestyle. When it was used the individual's health and lifestyle were concretised, which opened up for a dialogue and different aspects of health and lifestyle were detected. However, in some cases the outcome of the tool could be conceived as a stringent assessment and thereby complicate the dialogues. RELEVANCE TO CLINICAL PRACTICE: The use of a tool, such as the one used in this study, is one way to improve the dialogues in the School Health Service, allowing them to be more focused on the individual's needs and to detect aspects that would otherwise not be so easily detected. The implications of this study include using the findings to guide counselling sessions in the schools and other health care settings.

Managing mealtime tasks: told by persons with dementia.

AIM: To capture the self-description of managing mealtime tasks by persons with dementia. BACKGROUND: There are several factors that negatively affect food intake in persons with dementia that may increase the risk of developing malnutrition. Difficulties in managing daily activities increase gradually and mealtime tasks like food shopping, cooking and eating often become troublesome. Still, little is known about how persons with dementia themselves experience this issue. DESIGN: A qualitative study with an ethnographic approach. METHOD: Ten women and five men aged 69-86 with dementia were interviewed. Interviews were carried out in the informants' own homes and a thematic analysis was performed. RESULTS: The informants described that they wanted to be independent and that the memory loss was not affecting them to a great extent. Old habits and routines, as well as newly developed strategies, helped them manage mealtime tasks despite the disease. Informants were satisfied with their current situation, even though it sometimes meant that they had changed their way of managing mealtime tasks, for instance receiving meals-on-wheels. CONCLUSIONS: Persons with dementia seem to be able to manage mealtime tasks and these activities were based on old habits and routines. Independence was highly valued and managing mealtime tasks seems to be one way to appear independent. RELEVANCE TO CLINICAL PRACTICE: It is important for caregivers to understand that persons with dementia might not express difficulties in managing mealtime tasks for fear of losing their independence. It is, therefore, important to create a trustful relationship even before problems arise to be able to support the persons when necessary.

Moral distress and ethical climate in a Swedish nursing context: perceptions and instrument usability.

AIMS AND OBJECTIVES: The aim was fivefold: to describe Swedish nurses' perceptions of moral distress and determine whether there were differences in perceptions depending on demographic characteristics and to describe the usability of the Moral Distress Scale in a Swedish context. Further, the aim was to describe Swedish nurses' perceptions of ethical climate and the relationship between moral distress and ethical climate. BACKGROUND: Moral distress has been studied for more than two decades and the Moral Distress Scale is the most widely used instrument for measuring it. Moral distress has mainly been studied in relation to nurses' characteristics, but increasing attention has been paid to contextual aspects, such as ethical climate, that could be associated with moral distress. DESIGN: Descriptive, with a quantitative approach. METHODS: The study used two questionnaires: the Moral Distress Scale and the Hospital Ethical Climate Survey. The study was carried out at two hospitals in Sweden and included 249 nurses. RESULTS: Both level and frequency of moral distress were low, however level of moral distress was high in situations when the patient was not given safe and proper care. Generally, the frequency of moral distress was lower than the level. Of the situations on the Moral Distress Scale, 13 of the 32 were considered irrelevant by 10-50% of the participants. The more positive the ethical climate was perceived to be, the less frequently morally distressing situations were reported. CONCLUSIONS: Since a positive ethical climate was associated with less frequent occurrences of moral distress, it should be investigated what contributes to a positive ethical climate. To be used in a Swedish context, the Moral Distress Scale needs further revision. RELEVANCE TO CLINICAL PRACTICE: Open dialogues at wards are encouraged regarding what practices contribute to a positive ethical climate.

'I start my day by thinking about what we're going to have for dinner'--a qualitative study on approaches to food-related activities among elderly men with somatic diseases.

The aim of this study was to address the question of how older men with somatic diseases living in their own home approach the question of food-related activities (FRA). Further, any adaptations of these activities necessitated by effects of diseases and of altered life circumstances were explored. Interviews were conducted with a purposeful sample of 18 co-living and single-living men, 64-84 years old. They were diagnosed with Parkinson's disease, rheumatoid arthritis or stroke. In the analysis, a thematic framework was used. The findings revealed three food-related approaches, namely 'Cooking as a pleasure', describing joy in cooking; 'Cooking as a need', indicating no habits or skills in cooking; and 'Food is served', that is, being served meals by a partner. It was found that gender-related roles in particular, but also changed life circumstances, activity limitations, personal interests, and a wish to maintain continuity and independence, affected the men's approaches to these activities. This knowledge may be useful in attempts to facilitate and support FRA among elderly men with diseases. Health care efforts to promote FRA should preferably be individualised in respect to older men's approaches to these activities.

Management of healthy eating in everyday life among senior Europeans.

The aim of the present study is to explore how older people reflect on, make sense of and express their views about healthy eating messages and how they narrate these responses in relation to managing their diets along with strategies adopted in terms of existing food and meal patterns. This qualitative study draws on data from 564 in depth interviews collected as part of the European Union (EU)-funded project Food in Later life - Choosing foods, eating meals: sustaining independency and quality of life in old age. The two major areas studied related to the connection between food and health and management of a healthy everyday life. Eating healthy was regarded as an investment to ensure independence was kept as the transition of old age approached, but old age could also be a reason for not bothering about it. Participants described different ways that they simplified and organized in order to manage "healthy eating". When trying to support senior Europeans, those working in health and community services should take into account the situational context of the older person and be aware of the variation in their conceptualization of "healthy eating".

School-aged children's experiences of postoperative music medicine on pain, distress, and anxiety.

AIM: To test whether postoperative music listening reduces morphine consumption and influence pain, distress, and anxiety after day surgery and to describe the experience of postoperative music listening in school-aged children who had undergone day surgery. BACKGROUND: Music medicine has been proposed to reduce distress, anxiety, and pain. There has been no other study that evaluates effects of music medicine (MusiCure) in children after minor surgery. METHODS: Numbers of participants who required analgesics, individual doses, objective pain scores (Face, Legs, Activity, Cry, Consolability [FLACC]), vital signs, and administration of anti-emetics were documented during postoperative recovery stay. Self-reported pain (Coloured Analogue Scale [CAS]), distress (Facial Affective Scale [FAS]), and anxiety (short State-Trait Anxiety Inventory [STAI]) were recorded before and after surgery. In conjunction with the completed intervention semi-structured qualitative interviews were conducted. RESULTS: Data were recorded from 80 children aged 7-16. Forty participants were randomized to music medicine and another 40 participants to a control group. We found evidence that children in the music group received less morphine in the postoperative care unit, 1/40 compared to 9/40 in the control group. Children's individual FAS scores were reduced but no other significant differences between the two groups concerning FAS, CAS, FLACC, short STAI, and vital signs were shown. Children experienced the music as 'calming and relaxing.' CONCLUSIONS: Music medicine reduced the requirement of morphine and decreased the distress after minor surgery but did not else influence the postoperative care.

Health counselling: parental-oriented health dialogue -- an innovation for child health nurses.

The Health Curve, used by nurses in community-based health care, is an educational tool for conducting goal-directed dialogues concerning lifestyle and health. The aim of this study was to investigate how child health nurses experienced the Health Curve as a tool for conducting dialogues with parents. Fourteen nurses were interviewed. The data were analysed according to qualitative analysis. The results showed that nurses working in child health care experienced the Health Curve as a useful tool for conducting health dialogues with parents. Through their work with the Health Curve, the nurses gained a greater insight into, and understanding of, the families' health and life situation. The results indicated that working with the Health Curve could increase the opportunity for nurses to provide parents with support early in the process, helping the family to lead a healthy lifestyle.

Staff views on how to improve mealtimes for elderly people with dementia living at home.

Dementia commonly leads to difficulties in performing daily activities, which can also often affect the ability to prepare and eat meals. As a result, formal support to maintain good nutritional intake might be needed, but there is a lack of knowledge concerning how to support older persons with dementia living at home. The aim of this study was to explore and describe staff views on how to improve mealtimes for persons with dementia who are still living at home. A qualitative descriptive study was performed and data were collected during 2011-2012 through four focus group interviews with staff working in the homes of persons with dementia. Data were analyzed using inductive content analysis. The participants described several ways to improve mealtimes for persons with dementia and advocated adjustments facilitating the preservation of the persons' independence. Finding suitable actions calls for knowledge about the person and his/her individual situation. Proposed actions were enabling meals at home, taking over, and moving meals outside of the home. In addition, it was found that, the types of meals served to these persons should be as familiar to the individual as possible. The results of this study indicate the importance of using a person-centered approach and meeting the individual needs when supporting people with dementia in regards to their meals when living at home. Individualized care in the home may be expensive, however, it is fair to say that people who become malnourished and admitted to hospitals is even more costly. Furthermore, sharing and reflecting experiences and knowledge can assist staff to identify ways to manage complex situations. Therefore, the use of refection should be a part of staff members' everyday work.

Midwives' experiences of routine antenatal questioning relating to men's violence against women.

OBJECTIVE: to describe and use the experience gained by antenatal-care midwives who routinely questioned pregnant women about personally experienced violence. DESIGN: qualitative, using focus-group discussions. SETTING: antenatal care in a city in south-central Sweden. STUDY POPULATION: 21 midwives. DATA COLLECTION AND ANALYSIS: the midwives participated in any one of five focus-group discussions held by the same moderator and observer. The discussions were audiotaped, transcribed verbatim and analysed using qualitative content analysis. FINDINGS: the importance of routine questioning about violence was emphasised in all groups. Midwives felt they had failed in their duty when women were not questioned. The two main obstacles to such questioning were the delicacy of the subject and the routine of inviting the partner to all visits. The perceived delicacy underlined the need to devise a natural setting for the questioning. The midwives wanted to connect questions about abuse with related subjects routinely established in early pregnancy. As the partner was invited to every visit, it was not practicable to establish a procedure whereby the assessment was connected with a particular visit. Other obstacles included the following: time constraints, oversight, a preconceived notion of who might be a victim of abuse and language difficulties. The midwives emphasised the importance of training, easy access to support for abused women, and personal counselling for midwives. They described their role as raising awareness of the problem of male violence, reducing the shame of being abused, informing, giving emotional support and mediating help. KEY CONCLUSIONS AND IMPLICATIONS FOR PRACTICE: in order to ensure that the establishment of experience of violence is a routine enquiry in antenatal care, midwives must have a reasonable opportunity of carrying out such questioning. A routine that offers each woman a private consultation will ease the questioning and save time and distress.

Continuity of the self in later life: perceptions of informal caregivers.

The authors explore perceptions of informal caregivers of extremely elderly (80+) relatives or friends regarding the purpose of caregiving, including factors they considered important for the life satisfaction of the care recipients. They collected data mainly through qualitative interviewed and employed symbolic interactionism. The results revealed a general purpose of the informal caregiving: protection of the care recipient's self. This purpose was a significant aspect of the identified caregiving categories--social-emotional, proxy, and instrumental care--and the authors consider all four factors important for the care recipients' life satisfaction: activity, independence, and environmental and adaptive factors. Some informal caregivers gave forceful encouragement to care recipients in an attempt to get them to accept formal care and move to sheltered accommodation. This study underscores the value of informal caregiving and that the caregiving interaction should be balanced by reciprocity.

Health dialogues between pupils and school nurses: a description of the verbal interaction.

OBJECTIVE: The purpose of this study was to explore and describe the content of and the verbal interaction in health dialogues between pupils and school nurses. METHODS: Twenty-four health dialogues were recorded using a video camera and the conversations were analysed using the paediatric version of the Roter Interaction analysis system. RESULTS: The results showed that the age appropriate topics suggested by national recommendations were brought up in most of the health dialogues. The nurses were the ones who talked most, in terms of utterances. The pupils most frequently gave information about their lifestyle and agreed with the nurses' statements. The nurses summarised and checked that they had understood the pupils, asked closed-ended questions about lifestyle and gave information about lifestyle. Strategies aimed to make the pupil more active and participatory in the dialogues were the most widely used verbal interaction approaches by the nurses. CONCLUSION: The nurses' use of verbal interaction approaches to promote pupils' activity and participation, trying to build a partnership in the dialogue, could indicate an attempt to build patient-centred health dialogues. PRACTICE IMPLICATIONS: The nurses' great use of questions and being the ones leading the dialogues in terms of utterances point at the necessity for a nurses to have an openness to the pupils own narratives and an attentiveness to what he or she wants to talk about.

Registered Nurses´ View of Performing Pain Assessment among Persons with Dementia as Consultant Advisors.

BACKGROUND: Pain assessment in persons with dementia is well known as a challenging issue to professional caregivers, because of these patients´ difficulties in verbalising pain problems. Within municipal dementia care in Sweden, pain assessment has become problematic for registered nurses, as they have entered a new role in their nursing profession, from being clinical practitioners to becoming consultant advisers to other health care staff. AIM: To present municipal registered nurses´ view of pain assessment in persons with dementia in relation to their nursing profession as consultant advisers. METHODS: Purposive sampling was undertaken with 11 nurses invited to participate. Data were collected by focus groups. Qualitative content analysis was used to analyse the data. FINDINGS: Four categories were identified to describe registered nurses´ view of pain assessment: estrangement from practical nursing care, time consuming and unsafe pain documentation, unfulfilled needs of reflection possibilities, and collaboration and coordination. CONCLUSIONS: The performance of pain assessment through a consultant advising function is experienced as frustrating and as an uncomfortable nursing situation. The nurses feel resistance to providing nursing in this way. They view nursing as a clinical task demanding daily presence among patients to enable them to make accurate and safe assessments. However, due to the consultative model, setting aside enough time for the presence seems difficult to accomplish. It is necessary to promote the quality of systematic routines in pain assessment and reflection, as well as developing professional knowledge of how pain can be expressed by dementia patients, especially those with communication difficulties.

Daily life after moving into a care home--experiences from older people, relatives and contact persons.

AIMS AND OBJECTIVES: To describe older people's experiences of daily life at the care home after admittance with respect to their perceptions of participation in the decision to move. Furthermore, the aim was to study the experiences of their relatives and contact persons with respect to the daily life of the same residents. BACKGROUND: When older persons move into a care home, the whole family often play an important part. Thus, it is interesting to study how newly admitted older people, their relatives and staff members experience daily life in a modern care home. METHODS: Qualitative design. The participants comprised a purposive sample of 13 residents, recently admitted to a care home, 69-90 years old, both single living and married, both moving from their own homes and from different institutions. Interviews were carried out with the older people (n = 13), their relatives (n = 10) and contact persons (n = 11). RESULTS: The majority of the residents reported satisfaction with care home living. The relatives were also satisfied, secure and appreciated the privacy and homely atmosphere of the flat. The disadvantage of one-room flats was that the residents might have felt lonely. The relatives felt that the residents were bored, but few residents desired more activities, even if some of them longed for people to socialize with. For many older people, perhaps talking is the most important 'activity' at care homes. Concerning self-determination, some residents did not find it satisfactory. RELEVANCE TO CLINICAL PRACTICE: Staff members must pay attention to residents' need to talk with people. For many older people, talking is perhaps the most important 'activity' at care homes. Nurses must safeguard residents' self-determination. When residents are in control of their lives, they may become satisfied with time.

Health-care professionals' perceived trust in and willingness to recommend functional foods: a qualitative study.

The aim of this study was to investigate some Swedish dieticians', registered nurses' and physicians' thoughts about functional foods and their willingness to recommend such foods to patients. The health-care professionals were recruited to participate in one group interview with each profession. Participants were recruited through mailed invitations from primary care centers in Uppsala County district. The interviewed physicians and registered nurses, in contrast to the dieticians, expressed more skepticism and distrust about functional foods, their claimed effects on health and the research documenting these effects. The participating dieticians were more willing to recommend the products to patients than were the participating nurses and physicians. Differences in educational and professional background and level of proficiency in nutrition may have affected the disparate beliefs about functional foods among the interviewed groups. Confusion among patients could be a consequence but further research into these disparities is needed.

Relevance of philosophy of life and optimism for psychological distress among individuals in a stage where death is approaching.

The purpose was to investigate the relevance of philosophy of life as well as optimism for the psychological distress among Swedish individuals in a stage where death is approaching. Sixty-nine persons were included; of these were 42 patients newly diagnosed with advanced gastrointestinal cancer and 26 were partners to these patients. The participants' philosophy of life was studied through a semi-structured interview. The interview statements were subjected to content analysis. Optimism was measured by the Life Orientation Test and psychological distress by the Hospitality and Depression Scale. The results showed that optimistic respondents had less psychological distress. Two aspects of philosophy of life had relevance for such distress. These were wondering about why the cancer had occurred and having a feeling of being able to live a good life having or living near a person with advanced cancer. In conclusion, the above-mentioned aspects of philosophy of life as well as optimism have relevance for psychological distress among these individuals, which stress the importance that health-care staff address both patients' and their partners' concerns about their philosophy of life.

On loss of activity and independence, adaptation improves life satisfaction in old age--a qualitative study of patients' perceptions.

The purpose was to improve the understanding of factors are perceived by elderly people as important for their life satisfaction, during and after rehabilitation. Fifteen persons aged 80-94 years were interviewed while in hospital and on two follow-up occasions after discharge. Assessment of motor function using the General Motor Function assessment scale was used for descriptive purposes. Three themes emerged as important for life satisfaction: activity, independence and adaptation. Activity and independence were considered significant for life satisfaction. Basic activity preferences were related to care of one's own body and to social contacts. Control and influence over help and services were regarded as important. Different strategies for adaptation to the consequences of disease were used: reorganisation, interaction with caregivers, mental adaptation and mental activities (used as pastime and escape). Those with declined motor functions limited their activity preferences. A key finding was that pleasant past memories were actively recalled in an effort to achieve current life satisfaction. This adaptation strategy created a sense of life satisfaction, however with a potential risk for concealing dissatisfaction with conditions that might otherwise be correctable. Strategies for improving life satisfaction among old people in rehabilitation are suggested.

Food-related health perceptions and food habits among older women.

AIM: The aim of the present study was to explore food-related health perceptions and food habits among older women. BACKGROUND: Food-related health promotion has its main focus on disease prevention. With a holistic perspective on health, social and psychological aspects also need to be considered for total wellbeing. METHODS: Qualitative interviews, representing an ethnographic approach, were carried out with 18 women, aged 65-88, living alone or cohabiting, who independently managed shopping and cooking. Interviews were conducted at the women's homes, and analysed for coherent themes. The women also gave data on three days' eating and drinking in a food diary. FINDINGS; Two themes were found: 'A healthy slimming meal or the usual' and 'Meals -- a pleasure or an obligation'. The first theme summarized the women's health perceptions related to food, where the dominating view was fear of fat. Some also had a bad conscience about not eating according to recommendations. Use of low-fat products was not a predominant habit among these women. In the second theme, meals in fellowship were perceived as a pleasure, while women living alone tended to simplify cooking and eating. This was also reflected in their food habits, with fewer cooked meals, as well as events with coffee with cakes, compared with cohabiting women. CONCLUSIONS: Food-related health promotion must pay more attention to women living alone. Women who have lost their partners, may be at risk for poor nutritional intake as they often simplified the entire meal situation, while cohabiting women perceived food and cooking as a central task in their lives. One responsibility for nurses working in the community is to recognize and assess older women's deficient eating habits, assess them and plan eating together with the woman to prevent poor nutritional intake. Relatives and community staff could also be involved in this work.