The nature of nursing research: dissertations in the Nordic countries, 2003.

Nursing and caring research has followed various paths in different countries and there are diverse views regarding the central phenomena in nursing science. An overview of Nordic nursing and caring science from 1974 to 2000 revealed that conceptualizations and design of enquiry differed. It therefore was of interest to investigate the overall picture regarding more recent and present doctoral dissertations on this subject. The aim of this study was to investigate the locus of interest and the content of current nursing and caring research in Nordic doctoral dissertations within the field presented during 2003. A total of 26 doctoral dissertations were read and studied. The analysis was inspired by Kim's metaparadigmatic typology of four domains for structuring nursing knowledge. The investigation shows that the research in these dissertations, with some exceptions, was oriented towards phenomena belonging to the client domain (18 dissertations). Less knowledge has been gained in the client-nurse (two dissertations); four dissertations were categorized within the practice domain and environment domain includes two dissertations. The research conducted was primarily oriented towards pragmatic aspects and the practical application of knowledge, whereas basic research aiming at defining an autonomous science is exceptional. This means that scientific knowledge regarding and forming the discipline's unique perspective and value system could still be in evolution. A combination of a carefully and well-designed research practice, reflecting the need to further research and investigate new theoretical regions would appear to constitute the direction forward.

Complexity and contradiction: home care in a multicultural area.

The aim of this study was to explore the meaning of experience for home-care nurses in a multicultural area of Sweden. Interviews and group discussions with a team of five home-care nurses were interpreted in accordance with a hermeneutical perspective. The meaning was expressed in connection with the complexities of place, and space for care. Contradictions developed from diversities of perspectives incorporated in this particular multicultural area. Nurses saw themselves as mediators and allowed complexity to be considered in order to manage care. They took on responsibility of creating a 'space of care', while the organizational structures of home care were perceived as something outside the care praxis. Making contradictions evident renders an intermediary caring strategy feasible.

General practitioners' views on consultations with interpreters: a triad situation with complex issues.

OBJECTIVE: To study a group of general practitioners' (GPs) views on cross-cultural consultations through interpreters in primary healthcare in Sweden. DESIGN: Two group interviews and three personal interviews with experienced GPs regarding clinical consultation through interpreters were carried out. The interviews were transcribed and analysed and the text was categorized according to content analysis. SETTING: Primary healthcare. SUBJECTS: Eight GPs were interviewed. MAIN OUTCOME MEASURES: The response and opinions of the GPs. RESULTS: In the analysis it appeared that an optimal clinical encounter demands an active role by all participants involved in the consultation. The interpreter has to strive after being a stable neutral information bridge, and has a balancing role between the GP and the patient. The GP has to be open to cultural inequalities and recognize consultation through an interpreter as a part of her/his job. The patient needs to be an active and visible participant, not hiding behind the interpreter. Common obstacles and imperfections to reach the best possible triad were discussed. Additionally, practical assets in the encounter were delineated. Accurate physical placing of the persons in the room, adequate length of consultation time, and using the same interpreter from one visit to another were mentioned as factors influencing the outcome of the consultation. CONCLUSION: Barriers in cross-cultural communications could originate from all persons involved, the interpreter, the GP, and the patient, as well as from tangible factors. Ways to reduce misunderstandings in GP-patient encounters through interpreters are suggested.

Communicative barriers and resources in nursing homes from the enrolled nurses' perspective: A qualitative interview study.

BACKGROUND AND OBJECTIVES: Managing communicative disability is a pervasive issue in long-term care facilities. The aim of this study was to explore how enrolled nurses experience their everyday interactions with residents in nursing homes, particularly focusing on interactions with residents with communicative disability. DESIGN: A qualitative exploratory design including content analysis was used. PARTICIPANTS AND SETTING: Eight individuals working at six nursing homes in western Sweden were interviewed. METHOD: The interviews were semi-structured with questions about the participants' experiences in communicating with residents, feelings associated with interactions involving residents with communicative disability, meaning ascribed to interactions, and factors influencing interactions. The interviews were analysed using content analysis. RESULTS: A dynamic interplay between interpersonal relations, daily interactions and the managing of communicative disability was revealed. The enrolled nurses had good knowledge of supportive strategies and an awareness of the importance of the development of personal relationships with residents in order to facilitate interaction. However, factors in the environment presented barriers to communication. CONCLUSIONS/IMPLICATIONS: The organisation and physical environment of nursing homes prevent the enrolled nurses from taking full advantage of the communicative resources they have in interaction with residents with communicative disability, hence affecting staff-resident relationships and the delivery of person-centred care.

Expressive metaphors in cancer narratives.

This article presents and interprets illness narratives, told by patients treated for cancer. The aim is to discuss the meaning of cancer metaphors. The interpretation focuses on the relationships of metaphors to bodily experience and to social and cultural levels. The experience of cancer and cancer therapy obviously involve the patient's body. To comprehend what is happening is a process full of uncertainty and obscurity. Metaphors, such as cancer "eating," are widespread and persistent while the meaning of that metaphor today mirrors new scientific and lay explanations of cancer and cancer treatment. Personal newly created metaphors express threatening experiences in which fear of losing oneself and fear of death are involved. Ambivalent hope in relation to treatment and caregivers is expressed. Creating new metaphors involves imaginatively using the available concepts and metaphors. Narrative communication gives access to patients' experiences of an unwanted and painful physiologic process leading to forced embodiment of sickness. Patients want consolation and must overcome solitude by articulating experience, being listened to, and, in this way, recreating and strengthening identity.

Being in a lived retreat--embodied meaning of alleviated suffering.

Meanings of alleviated suffering in persons living with life-threatening cancer are explored in this life-world phenomenologic study. In repeated conversations, 16 patients with cancer who were receiving palliative care shared their embodied experiences in personal narratives. When interpreting the narratives, the following meanings of experiencing alleviation of suffering were disclosed: an endurable body being independent and feeling at home, feelings of connectedness, taking a long view of the suffering, being lifted out of the suffering, and an inner peace. Movements that were found in alleviation were dampening the suffering, arousing a zest for life, and focusing on both the present and the patient's dignity. As an interpreted whole, alleviation of suffering was found to be an embodied experience of "being in a lived retreat." This is a symbolic place owned by the person and is experienced in either the company of others or solitude. This lived retreat can provide a feeling of being at home, creating peace, rest, confidence, and breathing space in the person's suffering. It means coping with the altered lived body and feeling dignified. This is a personal experience that is both intersubjectively created and dependent. The importance of openness and responsibility in palliative care is emphasized in the findings and the notion of control of suffering in palliative care is accordingly rejected.

Transcultural encounters in a medical ward in Sweden: experiences of health care practitioners.

The aim of this study was to explore the approach adopted by health care practitioners when handling transcultural encounters. The study was performed by means of action research, a reflective process led by practitioners and researchers working together to improve practice and solve problems. Data were collected through participant observations at a coronary unit in Sweden and group discussions with the health care professionals and were analyzed and interpreted using a hermeneutic approach. The narratives in the interview text illustrated a switch between three levels of understanding human behavior: the individual level (personality), the collective or group level (what is termed culture), and the universal level (human nature), focusing on differences in the first two and similarities in the third. This study highlights the importance of practitioners comprehending the complex relationship between individuality and cultural context and understanding cultural identity as being fluid and coexisting with other differences, such as class, education, gender, and age.

'A person of two countries'. Life and health in exile: Somali refugees in Sweden.

Meeting and treating patients from other countries and cultures constitutes a challenge for health care. The number of immigrants and refugees has seen a rapid increase in recent years in Sweden. Expectations and experiences of health and illness often differ among these immigrant groups compared with the inhabitants of the majority society. This paper examines the situation of Somali refugees living in a multicultural suburban area of a large city in southern Sweden, and the aim was to illuminate and document their thoughts and experiences in relation to health and illness. Thirteen interviews with Somalis of different sexes and ages were conducted in the informant's homes. A hermeneutic-phenomenological approach was used in the analysis. The findings revealed an essential theme - a life in exile - that permeated every subject that was discussed and talked about. This was expressed in the following aspects: longing for the homeland, pain - a companion in exile, prejudice and discrimination, family - comfort and trouble, religion and beliefs in Jinns. Complex feelings of bi-nationality and of being uprooted were expressed. Prior knowledge about the hardships involved in a life as a refugee may allow and increase the possibilities for better communication, increased trust and mutual respect in order to achieve a meaningful encounter with health care personnel.

Caring relationship in a context: fieldwork in a medical ward.

The aim of this study was to investigate how the caring relationship is formed in a medical context. The data were collected using participant observation with field notes and analysed by an interpretive phenomenological method. The context circumstances in a medical milieu demanded exacting efficiency and risks to oppress the caring relationship, subsequently causing demands in nursing practice. Three themes of the caring relationship were identified as respect for each other and for themselves, responsibility to reach out to each other and engagement. Patients' and nurses' awareness in encounters drove the forming of a caring relationship that went beyond the individual nurse and patient. This study implicates the importance of an understanding of how context circumstances create the foundation of the caring relationship.

An interpretive phenomenological method for illuminating the meaning of caring relationship.

This study is a part of a larger project in which the aim is to illuminate the meaning of the caring relationship between patients and nurses in daily nursing practice. Empirical studies in this area inspired from the interpretive phenomenological method are not commonly used. The aim of this paper is to describe how an interpretive phenomenological method was used to illuminate the meaning of the phenomenon caring relationship in daily nursing practice. Data were collected during 16 nursing care proceedings using participant observation with field notes, and in addition to that two interviews, one patient and one nurse. The interpretation moved back and forth between the whole and the parts in a dialectic process. Initial interpretive understanding of interviews and field notes, meaning units and comprehensive understanding were presented. Themes from the patient's interviews were competence, lack of continuity, strain and vulnerability. Themes from the nurse's interviews were competence and striving. Themes from the field notes were interactions towards a goal. The use of interpretive phenomenology offered an opportunity for learning to understand the meaning of the phenomenon caring relationship in daily nursing practice with both strengths and limitations. This study gave an understanding of the phenomenon through the illumination of the patient's and the nurse's thoughts, feelings and actions in the nursing care proceedings that led to a more profound knowledge about how they together create an encounter through their unique competence.

Patients' existential situation prior to colorectal surgery.

AIM: The aim of this paper is to present a hermeneutic phenomenological study illuminating patients' existential situation prior to colorectal surgery. The intention was also to explore the value of the encounter between patient and nurse. BACKGROUND: Patients waiting for major surgery experience multifarious reactions. Emotions of anxiety, fears of the unknown, anaesthesia, cancer diagnosis and death can arise. Several earlier studies have reported the importance of information, coping strategies and the need to reduce anxiety and stress in relation to surgery. However, there is a lack of studies focusing on patients' existential situation in the preoperative phase. METHODS: Conversational interviews were conducted with 28 patients 1 week before their surgery during autumn 2002. Analysis of the data was influenced by van Manen's existential themes: lived space/spatiality, lived body/corporeality, lived time/temporality and lived relation/relationality. FINDINGS: Participants expressed either hope of increased spatiality or fear of restricted spatiality, according to whether they had a benign or malign diagnosis. Statements about lived time were also related to the diagnosis. Patients waiting for surgery for a benign diagnosis could use the time to relax and gather energy, while malignancy gave them high levels of anxiety and stress. Lived body experiences showed the ambivalence felt in entrusting one's body to professionals. Statements about lived relations drew attention to the need for considerate caregivers to enhance feelings of security and continuity. CONCLUSION: The existential situation of patients in a preoperative context was shown to be a state of uncertainty with regard to lived space, body, time and relation. The significance of meeting and talking to the nurse did not appear in the statements. The nurse was invisible. If nurses were to employ the existential themes proposed by van Manen in preoperative encounter with patients, their need for care might be more clearly identified and affirmed.

Clinical caring--the diary of a nurse.

AIMS AND OBJECTIVES: The aim of this study was to explore the content of individual acts of nursing care and to discuss how these context-specific acts relate to the concept of caring. DESIGN AND METHODS: The point of departure was a diary kept by a nurse on an oncology ward over a period of six months. Hermeneutic interpretation, including content analysis of verb phrases, was carried out to inspire reflection and discussion rather than to generalize. RESULTS: The verbs that occurred in the diary text represented three categories of acts: physical care, speech and reflection. CONCLUSIONS AND DISCUSSION: The diary text expresses the carer's acts as situated in a specific space and time through her presence, communication and reflection. The absence of bodies in this text points to the discourse of nursing as subjected to dualism and to the medical rules of knowledge. Caring emerges as experience-near action that through history is connected to situated knowledges, actual discourse and universal human condition. Relevance to clinical practice. This study demonstrated that caring acts are situated and conditioned and that they should therefore be researched in relation to the carers' acts and thoughts. This confirms the need for cooperation between researchers and clinical nurses in the quest of deepening our understanding of caring.

Developing clinical knowledge through a narrative-based method of interpretation.

The results of research using a narrative analysis provide new clinical knowledge, but the methods used are unknown to many readers. In this paper we present an example of how an analysis may be performed in practice. The purpose of the interpretation of this specific story was to develop clinical knowledge of how it is to live with chronic heart failure from a daily life perspective. The steps in the interpretation process, within the framework of Paul Ricoeur's Interpretation theory, were: (1) general or naïve reading, (2) distancing, (3) examination of discourse, (4) conjectures and questions, and (5) reflection over the whole. The demonstrated interpretation of the interview resulted in a theme called: "Struggling to comprehend medical information". This systematic way of working with narratives makes implicit assumptions about the relationship between meaning and language explicit. These themes can be used in everyday practice as clinical tools. Because of the interpretative nature of human understanding the experienced health professional will be capable of integrating evidence-based research findings and individual illness experience.

Interpreters' experiences of general practitioner-patient encounters.

OBJECTIVE: To study interpreters' experiences of problems in cross-cultural communication with special regard to the general practitioner (GP)-patient encounter. DESIGN: A focus-group interview with authorized interpreters was carried out. A phenomenographic method was used in the analysis. SETTING: Primary health care. RESULTS: The interpreters displayed a number of problems mainly related to the difficulty in balancing the triad relation (GP-patient-interpreter), the role of the interpreter in relation to other healthcare staff, the time aspects of the translation procedure, and the problems of diverse health beliefs and cultural inequalities. CONCLUSION: The interpreters notice a set of difficulties that need to be highlighted in order to improve consultations with cross-cultural GP-patient encounters.

Storied ethics: conversations in nursing care.

The purpose of this article is to discuss narration of ethical themes in nursing care. The text represents part of the findings of an ethnographic study aimed at description of everyday work on an oncology ward. Nurses on this ward are constantly involved in ethical care issues and narratives are told to share experiences. Of vital importance in ethical decision making is the perpetual creation of a mediating moral world constituted by daily experience. The need for making space in nursing for a continual learning conversation is expressed and in this I include writings of nursing theorists.