Meanings of troubled conscience in nursing homes: nurses' lived experience.

BACKGROUND: Troubled conscience among nurses and other healthcare workers represents a significant contributor to healthcare worker moral distress, burnout and attrition. While research in this area has examined critical care in hospitals, less knowledge has been obtained from long-term care contexts such as nursing homes, despite widely recognised challenges with regard to vulnerable patients, increasing workload and maintaining workforce sustainability among nurses. OBJECTIVE: The aim of this study was to illuminate and interpret the meaning of the lived experience of troubled conscience among registered nurses (RNs) working in nursing homes. RESEARCH DESIGN: This qualitative research employed narrative interviews with eight nurses to obtain essential meanings of their lived experiences of troubled conscience. The interview texts were analysed using a phenomenological hermeneutic approach. ETHICAL CONSIDERATIONS: Participation was voluntary, informed and was conducted with written consent. The Norwegian Centre for Research Data approved the data processing of personal data. FINDINGS: The analysis uncovered two themes: (1) troubled conscience means abandoning ideals, with the subthemes: failing dependent patients; being disloyal to colleagues; being inadequate in the performance of work tasks and (2) troubled conscience means facing realities, with the subthemes: accepting being part of the system; responding to barriers. DISCUSSION: Troubled conscience meant experiencing continuous and simmering tension between one's ideals and realities and feeling a drive to preserve accountability and one's moral integrity. Endangered ideals were often under cross-pressure and included humanistic values, professional values, working life values and the values of the organisation. CONCLUSION: Nurses' troubled conscience refers to a struggle, but also a force that plays out at various levels and arenas in long-term care. Openness and dialogue about how professional values and the welfare state's intentions can be realised within the given framework are important for individual nurses' occupational health as well as the quality of care provided to patients.

Variations in drug-related problems detected by multidisciplinary teams in Norwegian nursing homes and home nursing care.

OBJECTIVE: Traditionally, nursing homes have been associated with suboptimal drug therapy and drug-related problems (DRPs). In contrast, less is known about drug safety in homecare. The aim of this study was to describe and compare DRPs in older persons across two care settings: nursing homes and home nursing care. DESIGN: Cross-sectional study using descriptive and inferential statistics. SETTING: Nursing homes (n = 5) and home nursing care units (n = 8) across nine municipalities in the middle of Norway. PARTICIPANTS: Multidisciplinary medication reviews for 61 nursing home residents and 93 patients receiving home nursing care performed over the 2013-2014 period, were mapped and examined (N = 154). MAIN OUTCOME MEASURES: DRPs classified by a Norwegian Classification Tool. RESULTS: In all, 740 DRPs were detected in the total sample, 227 in nursing homes and 513 in home nursing care. DRPs were significantly higher among patients receiving home-based care (Mean =5.5) compared to patients in nursing homes (Mean =3.7, p = 0.002). Among the problem categories, the need for additional drug was most frequent in nursing homes (p = 0.001), while documentation discrepancies reached the highest numbers in patients receiving home nursing care (p = 0.000). Additionally, patients in home nursing care had more problems concerning adverse reactions (p = 0.060); however, this was not statistically significant. Differences in DRP categories leading to changes in the patients' medication lists were also discovered. CONCLUSIONS: The frequency of unclear documentation and adverse reactions found in the homecare setting is alarming. This is an important issue given the trend in aged care towards caring people in their own homes. Further research is warranted to explore how different care settings may influence the safety of pharmacotherapy for older persons. Key Points Drug related problems are a significant cause of concern among patients receiving home nursing care as well as for patients living in nursing homes. The findings of this study showed that: •Significantly more DRPs were detected among patients receiving home nursing care than patients living in nursing homes. •While patients living in nursing homes were often undermedicated, documentation discrepancies were more frequent in home nursing care. •DRP categories leading to changes on the medication lists differed between the settings.

'Ethics Between the Lines' - Nurses' Experiences of Ethical Challenges in Long-Term Care.

In long-term care, ethical challenges are becoming increasingly apparent as the number of older patients with complex care needs increases, in parallel with growing demands for more cost-efficient care. Scarce resources, cross-pressure and value conflicts are associated with missed care, moral stress and nurses wanting to leave the profession. Through five focus group interviews, this study aimed to explore how nurses working in nursing homes and homecare services perceive, experience and manage ethical challenges in everyday work. Content analysis revealed three main themes: striving to do good; failing and being let down and getting rid of frustrations and learning from experiences. The nurses' morality was mainly expressed through emotions that arose in specific situations. Dedicated spaces for ethical reflection and leaders who recognize that organizational conditions affect the individual nurse-patient relationship are required. Facilitating ethical reflection is an important leadership responsibility, which may also require leaders to actually participate.