Rita Schreiber

Existential Suffering in the Palliative Care Setting: An Integrated Literature Review

CONTEXT Existential and spiritual concerns in relation to palliative end-of-life care have received increasing attention over the past decade. OBJECTIVES To review the literature specifically related to existential suffering in palliative care in terms of the significance of existential suffering in end-of-life care, definitions, conceptual frameworks, and interventions. METHODS A systematic approach was undertaken with the aim of identifying emerging themes in the literature. Databases using CINAHL (1980-2009), MEDLINE (1970-2009), and PsychINFO (1980-2009) and the search engine of Google Scholar were searched under the key words existential suffering, existential distress, existential pain, palliative and end of life care. RESULTS The search yielded a total of 156 articles; 32% were peer-reviewed empirical research articles, 28% were peer-reviewed theoretical articles, and 14% were reviews or opinion-based articles. After manually searching bibliographies and related reference lists, 64 articles were considered relevant and are discussed in this review. Overall analysis identifies knowledge of the following: 1) emerging themes related to existential suffering, 2) critical review of those identified themes, 3) current gaps in the research literature, and 4) recommendations for future research. Findings from this comprehensive review reveal that existential suffering and deep personal anguish at the end of life are some of the most debilitating conditions that occur in patients who are dying, and yet the way such suffering is treated in the last days is not well understood. CONCLUSION Given the broad range of definitions attributed to existential suffering, palliative care clinicians may need to be mindful of their own choices and consider treatment options from a critical perspective.

Keeping it together: how women use the biomedical explanatory model to manage the stigma of depression.

Although considerable research has been conducted on women who are depressed, the actual experiences and voices of women have not been central to this research. Therefore little is known about how women make sense of depression as they live with and manage it in their daily lives. Our purposes in doing this study were to (1) examine how women experience and manage depression and treatment, and (2) investigate the core components of womens explanatory models of depression (including beliefs about etiology, onset of symptoms, pathophysiology, course of illness, and treatment needs). We interviewed 43 women living in a small city in Western Canada who had sought treatment within the previous five years. Data were analyzed using the constant comparison method of grounded theory. In this paper we will focus on the core concept, Keeping it Together, and its three supporting categories, (1) Taking Up a Biomedical Explanation for Depression, (2) Using the Biomedical Explanatory Model (BEM) to Manage the Stigma of Depression, and (3) The Inadvertent Effects of Adopting a BEM.

Wandering in the dark: women's experiences with depression.

In North America, rates of depression for women are consistently higher than for men. This phenomenon is poorly understood; nonetheless, the use of grounded theory to investigate womens experiences with depression, treatment, and recovery revealed some unexpected findings. In this article I discuss findings resulting from examination of data from three grounded theory studies of women and depression. In all, data were collected through participant observation and more than 70 interviews and the study sample included participants varying in race, marital status, cultural background, and sexual orientation between 18 to 69 years of age, and included both mothers and nonmothers. Findings included the presence in women of an internal dialogue, reinforcing the philosophical origins of the method in symbolic interactionism; oppression and marginalization of womens experiences; the impact of violence in womens lives; the roles of treatment and learning; and the hope of recovery. I will finish by identifying some questions arising from the findings.

YOUNG WOMEN'S HEALTH CONCERNS: REVEALING PARADOX

Because of the numerous physical, psychological, and social changes that take place for adolescents, the risk of engaging in life-threatening behavior is greater than at any other time in their life-span. Community workers identified the invisibility of adolescent women (ages 16–24) in their health-related programs and sought to rectify this. To discover the unmet health concerns of adolescent women, eight focus groups were held with a diverse group of adolescent women. Forty-two adolescent women, including adolescent mothers, women of color, attendees at a drop-in youth center, high school and university students, and employed persons participated. While most women attended one focus group, some participants attended two. Using Spradleys ethnographic method, we identified two overarching themes shared by the adolescent women. These themes included feeling invisible and struggling with independence. Our findings underscore the invisibility of adolescent womens lived experiences and concerns within most research agendas.

Examining the Nexus Between Grounded Theory and Symbolic Interactionism

Grounded theory is inherently symbolic interactionist; however, not all grounded theory researchers appreciate its importance or benefit from its influence. Elsewhere, we have written about the intrinsic relationship between grounded theory and symbolic interactionism, highlighting the silent, fundamental contribution of symbolic interactionism to the methodology. At the same time, there are significant insights to be had by bringing a conscious awareness of the philosophy of symbolic interactionism to grounded theory research. In this article we discuss the symbolic interactionist concepts of mind, self, and society, and their applicability in grounded theorizing. Our purpose is to highlight foundational concepts of symbolic interactionism and their centrality in the processes of conducting grounded theory research.

MORAL SURVIVAL IN A NONTHERAPEUTIC ENVIRONMENT

The aim of this study was to examine the ethical decision-making process used by a group of psychiatric and mental health nurses in Canada. Researchers used the constant comparative method of grounded theory to simultaneously collect and analyze data. Data were collected through the use of focus groups of experienced psychiatric and mental health nurses. In addition to focus groups, participant observation and a number of formal and informal interviews were conducted. The contingency for the nurses in this study was the degree of support for professional nursing practice within the cultural context in which they worked. Moral survival in nontherapeutic environments was identified as the basic social process by which the nurses attempted to manage or ameliorate their ethical difficulties in their workplaces. Survival strategies included the doctor-nurse game, covering your backside, running interference, doctor-bashing, administration bashing, scapegoating, and the breakdown of teamwork. The findings revealed nursing strategies that were aimed at surviving in what were perceived as nontherapeutic environments. These strategies are morally significant because the dilemmas concern a moral responsibility that cannot be delegated to others. The moral dilemmas are whether to (a) promote ones own survival or to take care of patients, and (b) be held responsible for ones own actions or to place responsibility on others.

Understanding and helping depressed women

A grounded theory study was conducted to examine the process of recovery for women who have been depressed. The purpose of this study was to enhance our understanding of the recovery process of women with depression by exploring the womens experience directly. The study found that the basic social psychological process of womens recovery from depression could be summarized as (re)defining the self. (Re)Defining the self differs significantly from the common conceptualisations of depression recovery, which focus on signs and symptoms without consideration of the woman or the social context in which her life is situated. (Re)Defining the self is a model that considers the woman as a holistic organism existing within a complex network of social interactions. Because (re)defining the self provides a new perspective for understanding womens experience with depression, there are significant implications for the way we provide nursing care. This paper discusses those implications.

Doing the Best I Can Do: Moral Distress in Adolescent Mental Health Nursing

The purpose of this research was to explore the process used by mental health nurses working with adolescents to ameliorate the experience of moral distress. Using grounded theory methodology, a substantive theory was developed to explain the process. All the incidents that led to the experience of moral distress were related to safety and resulted in the nurses asking themselves the question, “Is this the best I can do?” Engaging in dialogue was the primary means nurses used to work through the experience of moral distress. Engaging in dialogue was an ongoing process, and nurses sought out dialogue with a variety of people as they tried to make sense of their experience. Participants identified qualities of dialogue that were helpful or unhelpful as they sought to resolve their moral distress. Participants who had a positive experience of dialogue were able to answer the “Is this the best I can do” question satisfactorily and continue working with adolescents with a renewed focus on the therapeutic relationship. Participants who had a negative experience of dialogue are unable to answer the question and either left the unit or agency or talked about leaving.

CLUEING IN: A GUIDE TO SOLVING THE PUZZLE OF SELF FOR WOMEN RECOVERING FROM DEPRESSION

Clueing in, a process constructed from data collected from women recovered or recovering from depression, seems to be a salient variable in reaching full recovery. While depression and its recovery are composed of a number of highly complex processes, when women clue in, or come to a cognitive and emotional realization of themselves in relation to their world, they seem able to put in place the final piece of the puzzle of who they are, that is, what is their true self. For women to reach full recovery, it seems necessary for them to discover the difference between what and who they are and are not responsible for in their lives. Clueing in is one component of a model of recovery developed from a grounded theory study conducted with 21 women during 1993 to 1995.

Teaching Feminist Group Process Within a Nursing Curriculum

Nurse educators are challenged to develop emancipatory teaching approaches that will create opportunities for students to develop their own praxis. In particular, the authors faced the challenge of teaching feminist group process within a curriculum based on phenomenology, feminism, and critical social theory. In this article, we discuss the challenges and rewards of teaching nursing and other students about feminist process through the creation of experiential learning opportunities. In addition, we highlight recommendations based on our own praxis.