Arne Rehnsfeldt

The Nordic Tradition of Caring Science The Works of Three Theorists

The Nordic tradition of caring science has had a significant influence on healthcare research, healthcare education and clinical development in the Nordic countries from 1990 to the present. Theoretical contributions from the professors and scientists Katie Eriksson, Kari Martinsen and Karin Dahlberg form the basis for this paper. The tradition has established a paradigm of ethics, ontology and epistemology for the caring science domain. Short introductions present the scientific background of Eriksson, Martinsen, and Dahlberg, and show how interpretive teamwork has led to the formation of an intertwining of the essential qualities of the theories. The synthesis emphasizes caring science as a human science, and views caring as a natural phenomenon where the patient’s world, vulnerability, health, and suffering are primary. In the art and act of caring, relationships and dialogue are essential; they provide parameters where caring becomes visible in its absence.

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.

Significance of close relationships after the tsunami disaster in connection with existential health--a qualitative interpretive study.

BACKGROUND In an existential health perspective, the potential for recovery and development through natural life circumstances provides a factor to be taken into account. Earlier research on disaster-stricken people indicates that people create their own ways of recovering and that natural caring encounters (with family or friends) imply important health factors. AIM The aim of the study is to acquire an in-depth understanding of the significance of natural close relationships for survivors of the tsunami disaster in Southeast Asia in connection with the development of existential health and understanding of life in a long-term perspective. The sample consists of 19 persons afflicted by the 2004 tsunami in Southeast Asia, both Swedish tourists and relatives at home. Data were collected from interviews recurring five times during 2006. FINDINGS What is evidently seen is how the ontological aspects are expressed in data in relation to the existential and relational aspects. In concrete terms, this is understood when survivors say that their lives are completely changed (an ontological turn in their understanding of life). A change also occurs in the way they relate to others (a concrete existential turn), for example, in their families. When the findings on communion as an utterance of interdependence were read comprehensively, it was seen that human encounters in the aftermath of a disaster are not only about relationships but inherently affect peoples entire understanding of life both ontologically and existentially. Relationships with others and communion become a way of understanding or defining life. To conclude, in line with the aim of the study, the data suggest that relationships and communion with other people helped the survivors of the tsunami to discover a new understanding of life. It is also clear that natural encounters have had great importance for progress in existential health.

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.

The significance of small things for dignity in psychiatric care

Background: This study is based on the ontological assumption about human interdependence, and also on earlier research, which has shown that patients in psychiatric hospitals and their relatives experience suffering and indignity. Aim: The aim of this study is to explore the experience of patients and relatives regarding respect for dignity following admission to a psychiatric unit. Research design: The methodological approach is a phenomenological hermeneutic method. Participants and research context: This study is based on qualitative interviews conducted with six patients at a psychiatric hospital and five relatives of patients who experienced psychosis. Ethical consideration: Permission was given by the Regional Committee for Medical Research Ethics in Western Norway, the Norwegian Data Protection Agency and all wards within the hospital in which the patients were interviewed. Findings: The analysis revealed one main theme: ‘The significance of small things for experiencing dignity’ and four subthemes described as follows - ‘to be conscious of small things’, ‘being conscious of what one says’, ‘being met’ and ‘to be aware of personal chemistry’. Discussion and conclusion: Staff members seem not to give enough attention to the importance of these small things. Staff members need to explore this phenomenon systematically and expand their own understanding of it.

The justification of caring science

This journal is living thanks to the efforts of the first generation of Nordic caring and nursing scientists. We have to be grateful for all of this work that has contributed significantly to today0s situation with caring science as an academic discipline in every university, with professors and many scholars all contributing to good research and health care. The term caring science is used here in order to demonstrate that the discipline is not related to a specific profession. The concept nursing science is problematic as it may indicate that it is nurses that do research, but if nursing is seen in the present participle form with the same meaning as caring, nursing science is interchangeable with caring science. In the field of empirical research, one can see a huge development in international collaborations, in advanced method development and also in the amount of international scientific publications from Nordic scholars in caring science. At the same time, a tradition of basic research and theory development in health care has grown in the Nordic countries. Alongside this positive development accounted for above, we also see a worrying tendency that many scholars almost deny that there exists a discipline of caring science worldwide and have very little knowledge of its base of ontology, theories and concepts. Also in the clinical field, caring science is seldom a basis for patient care, at least not in the Nordic countries. It is said that the scientific perspective is too far away from what happens in the clinical field. Why is this so? One reason for not accepting caring science as an (autonomous) discipline is that the scientific subject and the profession are mixed together. If the professional perspective is dominant, it seems more natural to build the science from a multidisciplinary perspective with different subjects as medicine, psychology, sociology, etc. On the other hand, if we have a disciplinary perspective on caring science, it is the ontology and ethos that primarily defines the scientific subject and gives focus to the research performed and theory development. If, for example, the goal of the discipline is to protect life and health, caring science can mainly do this by protecting the inner or existential life and health of the patient. Medicine protects life and health by medical measures and should do so. Caring science is justified by finding its own disciplinary point of departure and from there on defining its field of research. ‘Clinical caring science’ as a scientific discipline situated closer to the praxis field than caring science is a way to transcend the theory–praxis gap. It studies clinical expressions of the theory base. Also, observed clinical phenomena are transferred back to the discipline in order to deepen the understanding of the phenomenon and thereby use this understanding for better patient care by application of that knowledge. Katie Eriksson, Kari Martinsen and Karin Dahlberg, scientists from Finland, Norway and Sweden, respectively, have with co-researchers contributed significantly to a theoretical basis of caring science, with a special focus on what we have chosen to call ‘the Nordic tradition of caring science’ (1). The research accounted for in the Nordic tradition of caring science shows how accurate a disciplinary perspective is in modern times. All three scholars concentrate on caring science as a human science as a basis for both patient care and science. A human science perspective with its close connection to existential matters and professional natural care (close to the natural lived experiences of the patients, relatives, etc.) gives caring science, a societal justification as no other discipline studies clinical phenomena from this perspective. In the article, it is concluded that it is relevant to talk about a Nordic tradition, where a joint view on the science0s core ontology and ethics seems to correspond. A human science perspective is essential to all three scholars with the patient and his/her world of health and suffering as a basis for a caring with openness, pliability, compassion and seeing with the heart0s eye. As authors, we conclude that this Nordic tradition with values, concepts and theoretical development will continue to grow and form basis for future research in caring science. Also research on self-care shows the importance of a disciplinary perspective. An example of this inspired by the Nordic caring science tradition is the empirical research where the concept of ‘self-care’ is studied, interpreted and discussed in women with chronic pain (2).Clinical data showed that the concept self-care had to be problematized as the clinical phenomena did not fit in with the concept. Clinical expression showed that compassion as a caring science concept had to be added in order to understand the existential transfer from passivity to self-care in the patients. Self-care is extended from Orem0s theory with an existential view and interpretation, saying that the relationship with caregivers and a caring environment seemed to be crucial for transition from passivity to self-care. In the article ‘Dressing an existential wound’ (3), people0s suffering and health in a long-term care perspective have been studied in the context of a disaster. Without research questions and interpretation of collected data from a caring science perspective, it would have been a fragmented understanding of data. This shows the

Clinical caring science as a scientific discipline

BACKGROUND Clinical caring science will be described from a theory of science perspective. AIM The aim of this theoretical article to give a comprehensive overview of clinical caring science as a human science-based discipline grounded in a theory of science argumentation. FINDINGS Clinical caring science seeks idiographic or specific variations of the ontology, concepts and theories, formulated by caring science. The rationale is the insight that the research questions do not change when they are addressed in different contexts. The academic subject contains a concept order with ethos concepts, core and basic concepts and practice concepts that unites systematic caring science with clinical caring science. In accordance with a hermeneutic tradition, the idea of the caring act is based on the degree to which the theory base is hermeneutically appropriated by the caregiver. The better the ethos, essential concepts and theories are understood, the better the caring act can be understood. In order to understand the concept order related to clinical caring science, an example is given from an ongoing project in a disaster context. COMPREHENSIVE REFLECTION The concept order is an appropriate way of making sense of the essence of clinical caring science. The idea of the concept order is that concepts on all levels need to be united with each other. A research project in clinical caring science can start anywhere on the concept order, either in ethos, core concepts, basic concepts, practice concepts or in concrete clinical phenomena, as long as no parts are locked out of the concept order as an entity. If, for example, research on patient participation as a phenomenon is not related to core and basic concepts, there is a risqué that the research becomes meaningless.

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.

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.