Maj-Britt Råholm

Being in the World of the Suffering Patient: a challenge to nursing ethics:

Ethics in caring is what we actually make explicit through our approach and how we invite the suffering patient into a caring relationship. This phenomenological study investigates suffering and health and how this presupposes a deeper reflection on ethics in caring. The aim was to try to discover, describe and understand how patients experience their life situation three years after undergoing surgery. The theoretical approach is based on central aspects of Eriksson’s caritative theory (i.e. the view of the person as body, soul and spirit). The informants were four women and four men aged between 55 and 77 years. The empirical material revealed suffering that was connected with both illness and life. Suffering involves experiences of grief, loneliness and struggling. Health implies a yearning for something beyond the current life situation, a yearning to experience some meaning in life. This leads to an awareness of unplumbed possibilities. Understanding the experiences of individual patients demands of us, as both researchers and nurses, to act, seeking after the scientific truth (i.e. a deeper reflection of the ontological, epistemological and methodological questions). The idea of responsibility helps us to interpret and meet the innermost desires of suffering patients in their true presence. Caritative caring ethics means ‘being there’, confirming patients’ absolute dignity; it is a manifestation of the love that ‘just exists’. Compassion requires an inner disposition to go with others to the places where they are weak, vulnerable, lonely and broken. An ontology of caring provides both a starting point and a context for reflection about ethics and the ethical life.

Nursing education in Denmark, Finland, Norway and Sweden – from Bachelor’s Degree to PhD

AIM This paper is a discussion of the similarities and differences in baccalaureate nursing education programme structures, content and pathways to postbaccalaureate education in the Scandinavian countries. BACKGROUND For the last three decades nursing education internationally, as well as in the Scandinavian countries, has experienced ongoing reforms. The driving forces behind these reforms have been efforts for professional development within nursing and to harmonize higher education in several European countries. DATA SOURCES The data were collected by a critical review of the guiding principles, national directives and educational structures and content of Bachelors degree programmes from 1990 to 2008 and of further educational levels in the four Scandinavian countries. DISCUSSION There are similarities as well as substantial differences in the educational structures, contents and lengths in the different nursing programmes. Nursing education is organized in the three cycles described in the Bologna Process, but there are differences regarding names and terms for degrees and allocation of European Credit Transfer System credits. IMPLICATIONS FOR NURSING Policymakers need to consider more carefully the directives in the Bologna Declaration when planning and implementing nursing programmes at Bachelors and postgraduate levels. Knowledge of the content and structure of nursing education in these countries may enhance development and cooperation between institutions. CONCLUSION A challenge for the ministries of education in the Scandinavian countries is to compare and coordinate nursing educational programmes in order to enable nursing students, educators, researchers and nurses to study and work in Scandinavia, Europe or even globally.

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.

Recognition as a valued human being: Perspectives of mental health service users

The acknowledgement of basic human vulnerability in relationships between mental health service users and professionals working in community-based mental health services (in Norway) was a starting point. The purpose was to explore how users of these services describe and make sense of their meetings with other people. The research is collaborative, with researcher and person with experienced-based knowledge cooperating through the research process. Data is derived from 19 interviews with 11 people who depend on mental health services for assistance at least three times a week. Data is analysed according to the Interpretative Phenomenological Analysis (IPA). Results confirm that reciprocity is fundamental for relationships, and that recognizing the individual entails personal involvement. The participants describe a struggle, and recognizing this struggle may help the professional to achieve a deeper understanding of the individual.

Call to Life: Exploring the Spiritual Dimension as a Dialectic Between Suffering and Desire Experienced by Coronary Bypass Patients

This article tries to conceptualize the nature of spirituality from a perspective of suffering and desire. The conception of hermeneutics and interpretation applied in this study was inspired by H. G. Gadamer. In this study the method used involved 2 focus groups. The result shows that the participants’ experiences can be likened to a sacred journey into the universe of spirituality visible in different stages: explicit suffering; concealed, unrevealed suffering; the inner space; belief; and serving in love. If the spiritual dimension of life is ignored, the patients are deprived of their dignity as human beings. Ontological evidence implies that this theory is reflected in the care of the unique patient where the spiritual dimension is explicitly brought out.

The substance of love when encountering suffering: an interpretative research synthesis with an abductive approach

AIM This study presents the results of an interpretative research synthesis undertaken to explore the essence of love when encountering suffering. The idea of caring as an expression of love and compassion belongs with ideas that have shaped caring for hundreds of years. Love and suffering are the core concepts in caring science and thus demand a basic research approach. METHODS The synthesis was undertaken by the interpretation of 15 articles focusing on love in different aspects, but within a caring science perspective. The research process was guided by a hermeneutical perspective with an abductive approach. RESULTS The substance of love, when encountering suffering, reveals itself in three themes: love as a holy power, love as fundamental for being and love as an ethical act, which are to be found, respectively, within three dimensions: love as holiness, love as a communion and love as an art. Love is a holy power and encompasses everything; it is the well of strength that heals. No human can exist without love: this points to the ethical responsibility one has as a neighbour. In the ethical act, love is evident in concrete caring actions. CONCLUSIONS The core of the substance of love within the three dimensions can be understood as agape. Agape connects and mirrors the dimensions, while at the same time it is clear that agape stems from and moves towards holiness, enabling love to be the ethical foundation when encountering suffering. Through the dimensions of love as communion and love as an art agape intertwine with eros forming caritas enabling the human being to move towards the dimension of holiness, which signifies becoming through suffering.

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 need for methodological development within qualitative clinical caring research

The next issue of Scandinavian Journal of Caring Sciences will contain a supplement which main theme is on development of research methodologies. The arguments and discussion in this editorial are not related to the papers in this issue of the journal and thus stands on its own. In this editorial, we will discuss qualitative methodology in special. We recognize the necessity of using quantitative methods in nursing and caring sciences. There is important research using quantitative methodologies as for example within quality of life and so on. However, in this paper, we want to highlight questions regarding qualitative research methodologies. Polit & Beck (1) explain naturalistic methods and qualitative research in this way: Naturalistic methods of inquiry deal with the issue of human complexity by exploring it directly. Researchers in naturalistic traditions emphasize the inherent depth of humans, their ability to shape and create their own experiences, and the idea that truth is a composite of realities. Consequently, naturalistic investigations emphasize understanding the human experience as it is lived, usually through the careful collection and analysis of qualitative materials that are narrative and subjective (p. 17). An aim of naturalistic and qualitative inquiry is to grasp the holistic, dynamic and individualistic aspect of human phenomena experienced in health care, nursing and caring sciences. Some characteristics of a qualitative design are that it is flexible and that there is always a need to adjust the design according to what happens during the data collection period. Glaser (2) calls this ‘theoretical sampling’ in grounded theory where one adjust whom to have as informants or new settings in accordance with what has already been found empirically from the earlier informants. Another characteristic is that qualitative design often uses multiple data sampling methods, data sampling triangulation, for example both interviews that are transcribed to text and observation with field notes as text. These transcripts of text are analysed by qualitative methods, such as hermeneutic interpretation, qualitative content analyses and constant comparative analysis until one reach a grounded theory, phenomenological analysis or discourse analysis to mention some. A main aim of the qualitative design whether one uses one or another method of analysis is to be holistic and to understand a phenomenon and grasp the whole as well as it is possible for humans to grasp holistically and describe this through text such as narratives themes or categories. Nordic College of Caring Science (NCCS), which is the owner of Scandinavian Journal of Caring Sciences, arranged in April 2010 its annual conference. Professor Slettebø (3) wrote an editorial December 2009 presenting this year’s conference. The theme for the conference 2010 was ‘Methodological innovations from a human science perspective’. One main discussion was how to improve methodologies to grasp the unique in caring situations. Nursing and caring phenomena focus on the unique individual, and the research should develop knowledge regarding these unique phenomena. But how can the researcher make valid and transfer knowledge from one case to other relevant cases? Some of the key-note speaker’s points will shortly be referred to as an example on how NCCS by the conference has highlighted methodological issues in caring sciences. Professor and Nurse Marit Kirkevold, in her key-note speech, argued for more case-oriented research where the unique in the nursing context could be transparent and open for research. Nursing and caring is not about the general but about the unique and the relational meeting between carer and the cared-for. Our methodologies should fit these unique phenomena and describe and prescribe how to act in the meetings to create a caring environment for the cared-for. Another key-note speaker, professor and philosopher Anders Lindseth, argued that this may be done through a method focusing on reflection. The caring sciences need to reflect upon our genuine scientific discipline and what the disciplines’ genuine area of praxis and research are. By hermeneutic and phenomenological reflection upon unique situations in caring practice, we may find appropriate ways to explore caring science as discipline. Professor and Nurse Ingegerd Bergbom as the first key-note speaker discussed the necessity of exploring methods that give answer to the problem phenomena in caring sciences. She argued that the context is a part of understanding when or how caring may be helpful or not for the cared-for. And an important issue is that our problem at hand must be decisive for what method we should use. To explore caring phenomena, central elements such as narratives, texts and pictures/videos may be used to find the real essence of the unique phenomena in nursing and caring sciences. Here, the phenomenological, the case studies and the hermeneutical methodologies will be helpful. We will further in this editorial especially discuss hermeneutical methodology and link it to the humanistic and naturalistic research in caring sciences. This editorial is written from the overall perspective viewing health and caring sciences as humanistic sciences.

Love in Connectedness: A Theoretical Study

Spirituality is important when caring for the whole human being. Earlier research found Love in connectedness to be a core category in spirituality. The study aim is to deepen our understanding of Love in connectedness, and contribute to the theoretical knowledge development of the concept of spirituality from a caring science perspective. The method was a review of 20 research articles concerning connectedness and love, which were interpreted through a Gadamerian-based hermeneutical approach. Emerging themes were three forms of connectedness, compassion, and the risk of losing love in caring for the patient. In addition, we reflected on love and ethics, based on the writings of Tillich. According to Tillich, love is a drive toward unity of the separated. This drive can be seen in both connectedness with others, in connectedness with something larger than oneself, and may indirectly apply to connectedness with oneself. We find that both connectedness and love are key concepts in caring for the patient.