Else Lykkeslet

Vulnerability in health care – reflections on encounters in every day practice

Vulnerability is a human condition and as such a constant human experience. However, patients and professional health care providers may be regarded as more vulnerable than people who do not suffer or witness suffering on a regular basis. Acquiring a deeper understanding of vulnerability would thus be of crucial importance for health care providers. This article takes as its point of departure Derek Sellmans and Havi Carels discussion on vulnerability in this journal. Through different examples from the authors research focusing on the interaction between health professionals and patients, existential, contextual, and relational dimensions of vulnerability are illuminated and discussed. Two main strategies in the professionals interactions with patients are described. The strategy that aims at understanding the patients or families from the professionals own personal perspective oftentimes ends in excess attention to the professionals own reactions, thereby impairing the ability to help. The other strategy attempts to understand the patients or families from the patients or families own perspective. This latter strategy seems to make vulnerability bearable or even transform it into strength. Being sensitive to the vulnerability of the other may be a key to acting ethically.

Methodological Problems Associated With Practice-Close Research

Within the health professions, it is not uncommon to investigate problems in ones field of practice, but researchers who study their own field are bound to encounter both ethical and methodological problems. In this article, the authors focus on some of the challenges in what they have chosen to call practice-close research. They focus on two issues within this area: the researchers ability to explicate his or her preconceptions and the researchers interaction with the participants in the study. It is difficult to treat these dimensions separately, as they border on and will influence each other. The discussion in the article of methodological challenges of practice-close research is based on experiences gleaned from a study in which the first author investigated her own practice.

Sensory stimulation—A way of creating mutual relations in dementia care

The overall aim of this 2-year Norwegian action research study was to improve the interaction between care workers and patients with dementia in a nursing home by means of sensory stimulation. Furthermore, the aim was to investigate how the staff experienced the interaction with patients suffering from behavioral and psychological symptoms of dementia before, under, and after introduction of sensory stimulation methods in clinical practice. An intervention program consisting of lectures and practical guiding in sensory stimulation was implemented. The care workers participated in group meetings to reflect on the progress. Focus group interviews and participant observations were conducted initially to map exciting practice, and at the end to evaluate potential changes in attitude and skills. Observation notes and interview transcripts were analyzed by means of thematic analysis which revealed a gradual emergence of person-centered care. A phenomenological life-world perspective may serve as a theoretical basis to deepen the understanding of the use of sensory stimulation.The overall aim of this 2-year Norwegian action research study was to improve the interaction between care workers and patients with dementia in a nursing home by means of sensory stimulation. Furthermore, the aim was to investigate how the staff experienced the interaction with patients suffering from behavioral and psychological symptoms of dementia before, under, and after introduction of sensory stimulation methods in clinical practice. An intervention program consisting of lectures and practical guiding in sensory stimulation was implemented. The care workers participated in group meetings to reflect on the progress. Focus group interviews and participant observations were conducted initially to map exciting practice, and at the end to evaluate potential changes in attitude and skills. Observation notes and interview transcripts were analyzed by means of thematic analysis which revealed a gradual emergence of person-centered care. A phenomenological life-world perspective may serve as a theoretical basis to deepen the understanding of the use of sensory stimulation.The overall aim of this 2-year Norwegian action research study was to improve the interaction between care workers and patients with dementia in a nursing home by means of sensory stimulation. Furthermore, the aim was to investigate how the staff experienced the interaction with patients suffering from behavioral and psychological symptoms of dementia before, under, and after introduction of sensory stimulation methods in clinical practice. An intervention program consisting of lectures and practical guiding in sensory stimulation was implemented. The care workers participated in group meetings to reflect on the progress. Focus group interviews and participant observations were conducted initially to map exciting practice, and at the end to evaluate potential changes in attitude and skills. Observation notes and interview transcripts were analyzed by means of thematic analysis which revealed a gradual emergence of person-centered care. A phenomenological life-world perspective may serve as a theoretical basis to deepen the understanding of the use of sensory stimulation.

‘Brightness in dark places’: Theatre as an arena for communicating life with dementia

The aim of this study was to use artistic expressions on a theatrical stage for communicating life with dementia, as portrayed in literary texts and to explore whether such communication would help relatives of people suffering from dementia gain knowledge of their situation. Life with dementia was portrayed through four theatre performances with actors reading excerpts from literary texts combined with music. Relatives were invited to the performances and to participate in focus groups following the events. Analysis revealed that the participants recognized episodes in the texts and were touched. This resulted in new knowledge. The aesthetic expression was of great significance. The use of the theatre stage as an arena for communicating knowledge became a meaningful experience. The performances enabled identification with roles on the stage, created a feeling of community with the audience and contributed to an experience of dignity.

At the mercy of others – for better or worse

Many elderly people spend their remaining days in nursing homes and are thus affected by issues pertaining to a good life in a nursing home. The Norwegian study presented in this article aimed to gain greater knowledge and understanding of the significant factors associated with a good life in a nursing home. Qualitative in-depth interviews with six nursing home residents aged 80 to 96xa0years were conducted to collect data. The aim of the analysis was to identify typical aspects related to a good life in a nursing home according to descriptions provided by nursing home residents. The findings identified both physical and psychosocial elements, and the following three main themes emerged: receiving help when the body fails is good, meaningful days despite loss and limitations, and time as a friend or foe. In conclusion, our findings indicate that it is important to understand that a good life has a deeper meaning because it challenges the existential preconditions for life.

Foresight and awareness of incipient changes in a patient' clinical conditions: Perspectives of intensive care nurses

OBJECTIVESnThe aim of this study was to explore the phenomenon of becoming aware of incipient changes in patient condition from the perspectives and experiences of intensive care nurses.nnnRESEARCH METHODOLOGYnThis study involved close observations of and in-depth interviews with 11 experienced intensive care nurses. The text was analysed using a hermeneutic phenomenological method that was inspired by van Manen.nnnSETTINGnThis study was undertaken at two different high-technology intensive care units (ICUs) in Norwegian university hospitals.nnnFINDINGSnNurses formed images of individual patients composed of signs (of changes in a patients condition) that were sensory, measurable, and manifested as the mood of the nurse. The signs may be viewed as separate from and opposed to one another, but they are tightly interwoven and interact with one another. Care situations are powerful stimuli for the patient, and it is of great importance for nurses to become aware of signs in these situations. Nurses also ascribe that following the patient over time is important for becoming aware of signs.nnnCONCLUSIONnAn awareness of incipient changes in patient clinical condition requires understanding the ever-changing dynamics of patient condition and dialogic images composed of signs. Care situations and the following of patients through shifts are essential in enabling nurses to detect these signs.

A painful experience of limited understanding: healthcare professionals’ experiences with palliative care of people with severe dementia in Norwegian nursing homes

BackgroundPeople dying with dementia have significant healthcare needs, and palliative care, with its focus on comfort and quality of life, should be made available to these patients. The aim of this study was to explore and increase knowledge of healthcare professionals’ experiences with palliative care to people with severe dementia in nursing homes.MethodsTo describe the phenomenon under investigation, we used a phenomenological research approach grounded in the philosophy of Husserl. Data were collected using in-depth interviews with 20 healthcare professionals from four Norwegian nursing homes.ResultsThe general meaning structure of the healthcare professionals’ experiences with providing palliative care to people with severe dementia is painfulness, due to their limited understanding of patients’ individual modes of expression. The painfulness is illustrated by the following themes: challenges related to “reading” the patients’ suffering, coming up short despite occasional success, handing the patients over to strangers, and disagreeing on the patients’ best interests. The healthcare professionals struggled to understand patients by “reading” their suffering. Occasionally, they succeeded and were able to calm the patients, but they often had the feeling of coming up short in situations related to pain relief and coping with behavioural symptoms, such as aggression and rejection of care. They also found it painful when the weakest patients were moved from the sheltered unit to a somatic long-term unit and were handed over to strangers who did not know the patients’ ways of expression. Although the healthcare professionals emphasized the importance of good collaboration with the patients’ relatives to ensure the best possible palliative care, they frequently found themselves in difficult situations when they disagreed with the family on the patients’ best interests.ConclusionsWe found healthcare professionals’ experiences of providing palliative care to people with severe dementia to be painful. To be able to understand the patients better, long-term familiarity and knowledge of how to “read” and observe patients with severe dementia are necessary. Openness in cooperation with the patients’ relatives and with the professional team may increase healthcare professionals’ understanding of the patients’ situations and hence improve the quality of care.

Perceived barriers and facilitators in providing palliative care for people with severe dementia: the healthcare professionals’ experiences

BackgroundDementia has become a major public health issue worldwide due to its rapidly increasing prevalence and an increasing number of dementia-related deaths in long-term care facilities. The aim of this study was to examine health professionals’ experiences of potential barriers and facilitators in providing palliative care for people with severe dementia in long-term care facilities.MethodsThis was a qualitative descriptive study. The data were collected from four focus groups and 20 individual in-depth interviews with healthcare professionals from four Norwegian nursing homes. The data were analysed by thematic text analysis, as described by Braun and Clarke.ResultsThe major findings indicate that healthcare professionals experience a lack of continuity as the main barrier to facilitating palliative care. Time pressure and increased efficiency requirements especially affect the weakest and bedridden residents with dementia. The healthcare professionals feel conflicted between wanting to spend more time caring for each individual resident and feeling pressure to help everyone. Although resources are scarce, dying residents are always given priority by healthcare professionals, either by the hiring of extra personnel or the reorganization of tasks in a way that facilitates someone staying with the terminal resident. Advanced care planning was highlighted as a facilitator in providing palliative care, but the extensive use of temporary staff among nurses and doctors and the relocation between the sheltered and long-term wards threaten the continuity in planning and providing palliative care.ConclusionsThe findings indicate that healthcare professionals experienced several structural barriers that prevented the provision of palliative care to people with severe dementia in long-term care facilities. Increasing demands for economic rationality lead to a lack of continuity of care. Organizational changes, such as measures to increase the competence and the proportion of permanent employees and the prevention of burdensome end-of-life transitions, should be implemented to improve continuity and quality of care.

Assessing changes in a patient's condition – perspectives of intensive care nurses

Aim nTo explore the phenomenon of assessing changes in patients conditions in intensive care units from the perspectives of experienced intensive care nurses. n nBackground nProviding safe care for patients in intensive care units requires an awareness and perception of the signs that indicate changes in a patients condition. Nurses in intensive care units play an essential role in preventing the deterioration of a patients condition and in improving patient outcomes. n nDesign and methods nThis hermeneutic phenomenological study conducted close observations and in-depth interviews with 11 intensive care nurses. The nurses experience ranged from 7 to 28 years in the intensive care unit. Data were collected at two intensive care units in two Norwegian university hospitals. The analysis was performed using the reflective methods of van Manen. n nFindings nAn overarching theme of ‘sensitive situational attention’ was identified, in which the nurses were sensitive in relation to a patient and understood the significance of a given situation. This theme was further unfolded in four subthemes: (1) being sensitive and emotionally present, (2) being systematic and concentrating, (3) being physically close to the bedside and (4) being trained and familiar with the routines. n nConclusions nNurses understand each patients situation and foresee clinical eventualities through a sensitive and attentive way of thinking and working. This requires nurses to be present at the bedside with both their senses (sight, hearing, smell and touch) and emotions and to work in a concentrated and systematic manner. Knowledge about the unique patient exists in interplay with past experiences and medical knowledge, which are essential for nurses to understand the situation. n nRelevance to clinical practice nClinical practice should develop routines that enable nurses to be present at the bedside and to work in a concentrated and systematic manner. Furthermore, providing safe care requires nurses to be sensitive and attentive to each patients unique situation.AIMnTo explore the phenomenon of assessing changes in patients conditions in intensive care units from the perspectives of experienced intensive care nurses.nnnBACKGROUNDnProviding safe care for patients in intensive care units requires an awareness and perception of the signs that indicate changes in a patients condition. Nurses in intensive care units play an essential role in preventing the deterioration of a patients condition and in improving patient outcomes.nnnDESIGN AND METHODSnThis hermeneutic phenomenological study conducted close observations and in-depth interviews with 11 intensive care nurses. The nurses experience ranged from 7 to 28 years in the intensive care unit. Data were collected at two intensive care units in two Norwegian university hospitals. The analysis was performed using the reflective methods of van Manen.nnnFINDINGSnAn overarching theme of sensitive situational attention was identified, in which the nurses were sensitive in relation to a patient and understood the significance of a given situation. This theme was further unfolded in four subthemes: (1) being sensitive and emotionally present, (2) being systematic and concentrating, (3) being physically close to the bedside and (4) being trained and familiar with the routines.nnnCONCLUSIONSnNurses understand each patients situation and foresee clinical eventualities through a sensitive and attentive way of thinking and working. This requires nurses to be present at the bedside with both their senses (sight, hearing, smell and touch) and emotions and to work in a concentrated and systematic manner. Knowledge about the unique patient exists in interplay with past experiences and medical knowledge, which are essential for nurses to understand the situation.nnnRELEVANCE TO CLINICAL PRACTICEnClinical practice should develop routines that enable nurses to be present at the bedside and to work in a concentrated and systematic manner. Furthermore, providing safe care requires nurses to be sensitive and attentive to each patients unique situation.

ICU nurses and physicians dialogue regarding patients clinical status and care options—a focus group study

ABSTRACT Nurses and physicians work side-by-side in the intensive care unit (ICU). Effective exchanges of patient information are essential to safe patient care in the ICU. Nurses often rate nurse-physician communication lower than physicians and report that it is difficult to speak up, that disagreements are not resolved and that their input is not well received. Therefore, this study explored nurses’ dialogue with physicians regarding patients’ clinical status and the prerequisites for effective and accurate exchanges of information. We adopted a qualitative approach, conducting three focus group discussions with five to six nurses and physicians each (14 total). Two themes emerged. The first theme highlighted nurses’ contributions to dialogues with physicians; nurses’ ongoing observations of patients were essential to patient care discussions. The second theme addressed the prerequisites of accurate and effective dialogue regarding care options, comprising three subthemes: nurses’ ability to speak up and present clinical changes, establishment of shared goal and clinical understanding, and open dialogue and willingness to listen to each other. Nurses should understand their essential role in conducting ongoing observations of patients and their right to be included in care-related decision-making processes. Physicians should be willing to listen to and include nurses’ clinical observations and concerns.