Risk, rationality and learning for compassionate care; the link between management practices and the 'lifeworld' of nursing

Your Body, My Business: Risk Governance in A Psychiatric Nursing Home

INTRODUCTION

A crucial long-term care resource for individuals with severe mental illness (SMI) in Taiwan is provided by psychiatric nursing homes. Given the higher incidence of physical illnesses and accidents among individuals with SMI, ensuring patient safety is an important aspect of quality care. However, there is limited literature exploring how the staff provides safe care for individuals with SMI.

AIM

Investigates how the staff in a psychiatric nursing home managed residents' activities to mitigate risks and reduce physical injuries.

METHOD

Using a qualitative approach and drawing from Foucault's concept of 'disciplinary power', data were collected from field observations and staff interviews.

RESULTS

Three themes emerged: (1) a gaze for efficiency, where checklists, timetables and spatial arrangements were used to efficiently manage residents' bodies; (2) controlling the deviant body, which entailed procedures to monitor and prevent risk behaviours and bodily signs through broad safety measures and (3) your body, my business, which described the reduced autonomy of residents over their behaviours as the responsibility largely shifted to the staff.

DISCUSSION

The predominant risk management framework, driven by safety considerations, comprises residents' autonomy and undermines compassionate caring.

IMPLICATIONS FOR PRACTICE

Risk management should actively involve both staff and residents in decision-making.

Understanding person-centered care within a complex social context: A qualitative study of Saudi Arabian acute care nursing

Policy reforms implemented in Saudi Arabia in recent years aim to modernize the culture and infrastructure of healthcare delivery and are expected to integrate person- and patient-centered care principles throughout the national healthcare system. However, in a complex multicultural environment where most nurses are international migrant workers, unique challenges emerge that frame the delivery of care. Better understanding is needed about what nurses perceive to be high-quality, person-centered care in Saudi Arabia and how they manage to enact it in practice. Semi-structured interviews were conducted with 21 nurses working in two tertiary hospitals in Riyadh, the capital city. Participants included Saudi citizens (n = 9) and expatriates (n = 12) who were asked to describe their perceptions of quality nursing care and explain the obstacles that they encounter in providing such care. Nurses reported extensive efforts to achieve individualized, empathetic, developmentally appropriate care. Their descriptions of care aligned with principles of patient-centeredness in care but were not separable from challenges at the patient, organizational, and regional levels, including staffing and supplies shortages, gaps in regional care coordination, inadequate language translation services, variability in cultural beliefs about healthcare communication, and overt discrimination against expatriate workers. Nurses reported creative strategies to achieve professional nursing values while navigating a dynamic landscape of constraints. The findings add to literature suggesting that person-centeredness in care cannot be understood outside the social and organizational conditions that shape it.

A facilitator's reflection on the democratizing potential of emancipatory practice development

Emancipatory practice development (ePD) is a practitioner-led research methodology which enables workplace transformation. Underpinned by the critical paradigm, ePD works through facilitation and workplace learning, with people in their local context on practice issues that are significant to them. Its purpose is to embed safe, person-centred learning cultures which transform individuals and workplaces. In this article, we critically reflect on a year-long ePD study in an acute care hospital ward. We explore the challenges of practice change within systems, building collective strength with frontline collaborations and leadership to sustain new learning cultures. Our work advances practice development dialogue through working closely with the underpinning theories. Our critique analyses how ePD can enact and sustain change within a complex system. We argue that ePD works to strengthen safety cultures by challenging antidemocratic practices through communicative action. By opening communicative spaces, ePD enables staff to collectively deliberate and reach consensus. Their raised awareness supports staff to resist ways of working which conspire against safe patient care. Sustainability of practice change is fostered by the co-operative democracies created within the frontline team and meso level enablement. We conclude that the democratising potential of ePDt generates staff agency at the frontline.

A visionary platform for decolonization: The Red Deal

In this study, we discuss the colonial project as an eliminatory structure of indigenous ways of knowing and doing that is built into Canadian social and health institutions. We elaborate on the role nursing plays in maintaining systemic racism, marginalization and discrimination of Indigenous Peoples. Based on historical practices and present-day circumstances, we argue that changing language in research and school curriculums turns decolonization into what Tuck and Yang call a 'metaphor'. Rather, we propose decolonization as a political project where nurses acknowledge their involvement in colonial harms and disrupt the assumptions that continue to shape how nurses interact with Indigenous people, including knowledge systems that perpetuate colonial interests and privilege. Decolonization requires nurses to understand the colonial practices that led to dispossession of land, erasure of knowledge, culture and identity, while upholding indigenous ways of knowing and doing in health, healing and living. As a political manifesto that liberates indigenous life from oppressive structures of colonialism and capitalism, The Red Deal is presented as a visionary platform for decolonization. The aim of this study is to articulate three dimensions of caretaking within The Red Deal as a framework to decolonize nursing knowledge development and practice. Based on the philosophical dimension embedded in The Red Deal that revoke norms and knowledge assumptions of capitalism that destroy indigenous ways of knowing and doing, we underscore an approach toward decolonizing nursing. Our approach rejects the apolitical nature of nursing as well as the unilateral western scientific knowledge approach to knowledge development and recognition. A critical emancipatory approach that addresses the socio-political and historical context of health care, recognizes dispossession of land and adopts a 'multilogical' vision of knowledge that gives space for representation and voice is needed for true decolonization of nursing.

Therapeutic relationships: Making space to practice in chaotic institutional environments

WHAT IS KNOWN ABOUT THE SUBJECT?: While therapeutic relationships remain core to mental health nursing practice and patient recovery, increased managerialism and focus on risk has impacted nurses' therapeutic practice with patients. While there is anecdotal evidence of the impact there has been little research that demonstrates nurses experience of therapeutic engagement within the current context. WHAT THE PAPER ADDS TO EXISTING KNOWLEDGE?: The paper reports on qualitative research that highlights nurses' strong attempts to create the space for therapeutic engagement with clients. This research provides evidence of the constraints on practice imposed by new managerial processes and suggests potential means of responding to them. WHAT ARE THE IMPLICATIONS FOR PRACTICE?: Mental health nurses are committed to working therapeutically but struggle to balance this against new managerial demands imposed across many OECD countries. The New Zealand government has recently reported on positive changes to mental health provision but does not suggest changes to the structures that impede good practice. This research indicates that structural change is essential to therapeutic engagement. ABSTRACT: Introduction Increasing managerialism, driven in part by notions of risk, compromises the mental health nurses therapeutic engagement with clients potentially impacting their recovery. While the importance of therapeutic relationships in mental health recovery is acknowledged, there is little evidence about how managerial processes encroach on this relationship. Aim To explore mental health nurses experience of engaging in therapeutic relationships within the current practice environment. Method This paper utilized an interpretive phenomenological approach, using interviews with mental health nurses. Results Managerial processes significantly impacted the practice of nurses who struggled to make space for therapeutic relationships within a chaotic milieu. The chaos is associated with increasing austerity within the health system; this has resulted in high staff turnover and staff shortages. Discussion Managerial demands dominate the practice field at the expense of therapeutic engagement between nurses and clients ultimately affecting client recovery. While nurses' integrity means they desperately try to make space for the therapeutic work, they often become burnt out and disheartened. Implications for practice While nurses are often blamed for failures in the system, the structures that disable nurses in their attempts to practice therapeutically require urgent responses, strengthening professional organizations and engaging in democratic partnerships with consumer groups.

Reconciling economic concepts and person-centred care of the older person with cognitive impairment in the acute care setting

Person-centred care is a relatively new orthodoxy being implemented by modern hospitals across developed nations. Research demonstrating the merits of this style of care for improving patient outcomes, staff morale and organizational efficiency is only just beginning to emerge. In contrast, a significant body of literature exists showing that attainment of person-centred care in the acute care sector particularly, remains largely aspirational, especially for older people with cognitive impairment. In previous articles, we argued that nurses work constantly to reconcile prevailing constructions of time, space, relationships, the body and ethics, to meet expectations that the care they provide is person-centred. In this article, we explore key concepts of neo-liberal thought which forms an important back-story to the articles. Economic concepts, "efficiency" and "freedom" are examined to illustrate how nurses work to reconcile both the repressive and productive effects of economic power. We conclude the article by proposing a new research agenda aimed at building a more nuanced understanding of the messy actualities of nursing practice under the influences of neo-liberalism, that illuminates the compromises and adaptations nurses have had to make in response to economic power.

Strengthening nursing surveillance in general wards: A practice development approach

AIMS AND OBJECTIVES

To explore the context and culture of nursing surveillance on an acute care ward.

BACKGROUND

Prevention of patient deterioration is primarily a nursing responsibility in hospital. Registered nurses make judgements and act on emerging threats to patient safety through a process of nursing surveillance. Organisational factors that weaken nursing surveillance capacity on general wards increase the need for patient rescue at the end point of clinical deterioration with poorer outcomes. Yet little is known about cultures that enable and sustain ward nursing surveillance for patient safety.

DESIGN

Workplace observations and semistructured interviews using a critical lens as the first stage of a larger emancipatory practice development project.

METHODS

Researcher immersion including 96 hr of nonparticipant observation with 12 semistructured interviews during July-August 2017. This study adhered to the COREQ guidelines.

RESULTS

We offer a metaphor of nursing surveillance as the threads that support the very fabric of acute care nursing work. These hidden threads enable nurses to weave the tapestry of care that keeps patients safe. This tapestry is vulnerable to internal and external forces, which weaken the structure, putting patients and staff at risk.

CONCLUSION

Understanding local context is essential to supporting practice change. This workplace observation challenges us to find ways to creatively engage nurses with the underlying cultural and systems issues that so often remain hidden from view in the deteriorating patient literature.

RELEVANCE TO CLINICAL PRACTICE

Building cultural values that strengthen nursing surveillance is a prerequisite for safe and effective hospital care. As such, practice-based research that empowers frontline nurses and teams to develop person-centred workplace cultures can hold the key to unlocking sustainable improvements in patient safety.

Compassionate leadership in palliative and end-of-life care: a focus group study

PURPOSE

The purpose of this study was to explore compassionate leadership with those involved in leading system-wide end-of-life care. Its purpose was to: define compassionate leadership in the context of palliative and end-of-life care; collect accounts of compassionate leadership activity from key stakeholders in end-of-life and palliative care; and identify examples of compassionate leadership in practice.

DESIGN/METHODOLOGY/APPROACH

Four focus groups involving staff from a range of healthcare organisations including hospitals, hospices and community teams were conducted to access the accounts of staff leading palliative and end-of-life care. The data were analysed thematically.

FINDINGS

The themes that emerged from the data included: the importance of leadership as role modelling and nurturing; how stories were used to explain approaches to leading end-of-life care; the nature of leadership as challenging existing practice; and a requirement for leaders to manage boundaries effectively. Rich and detailed examples of leadership in action were shared.

RESEARCH LIMITATIONS/IMPLICATIONS

The findings indicate that a relational approach to leadership was enacted in a range of palliative and end-of-life care settings.

PRACTICAL IMPLICATIONS

Context-specific action learning may be a means of further developing compassionate leadership capability in palliative and end-of-life care and more widely in healthcare settings.

ORIGINALITY/VALUE

This paper presents data indicating how compassionate leadership, as a form of activity, is envisaged and enacted by staff in healthcare.

The effect of organizational and personal variables on the ability to practice compassionately

BACKGROUND

Nursing governing bodies assert that compassion is essential to nursing practice. Despite the relevance compassion has in nursing, and ample theoretical literature, until now, there has been little empirical work conducted to examine the nature of compassion in nursing and how the expression of compassion in nursing practice may be affected.

OBJECTIVES

This study aimed to examine the personal and organizational variables that might affect nurses' ability to practice with compassion.

DESIGN

A predictive, non-experimental cross-sectional design was used to explore the relationships amongst the variables of structural and psychological empowerment, inter-professional collaboration, and compassion.

PARTICIPANTS

191 registered nurses of any age, with any length of experience, in any inpatient or outpatient unit, in any hospital (community, long term care, and teaching) with any education level participated in the study.

DATA COLLECTION

Data were collected via surveys sent to randomly chosen registrants from the College of Nurses of Ontario (Canada) Registry.

RESULTS

Statistically significant correlations were found amongst all the variables. A simple linear regression was calculated to predict the effect of the independent variables of structural empowerment, psychological empowerment, and inter-professional collaboration on the dependent variable compassion. All three had a statistically significant positive relationship to the dependent variable compassion.

DISCUSSION AND CONCLUSIONS

Each of structural empowerment, psychological empowerment, and inter-professional collaboration has been discussed in the literature as a possible predictor of compassion. This study shows that that is the case. This is critical information for both organizations and individual nurses to have, as currently there is an inclination to blame nurses for having insufficient compassion rather than considering there may also be environmental and structural reasons for nurses being unable to practice with compassion. With this study as a beginning, future studies could test for models of how these variables interact in order to make more informed decisions about how to enable compassionate nursing practice. These strategies as it turns out, may be both personal and environmental. This study is a step towards the building of nursing compassion literacy.

Management of type 2 diabetes mellitus in people with severe mental illness: an online cross-sectional survey of healthcare professionals

OBJECTIVES

To establish healthcare professionals' (HCPs) views about clinical roles, and the barriers and enablers to delivery of diabetes care for people with severe mental illness (SMI).

DESIGN

Cross-sectional, postal and online survey.

SETTING

Trusts within the National Health Service, mental health and diabetes charities, and professional bodies.

PARTICIPANTS

HCPs who care for people with type 2 diabetes mellitus (T2DM) and/or SMI in the UK.

PRIMARY AND SECONDARY OUTCOME MEASURES

The barriers, enablers and experiences of delivering T2DM care for people with SMI, informed by the Theoretical Domains Framework.

RESULTS

Respondents were 273 HCPs, primarily mental health nurses (33.7%) and psychiatrists (32.2%). Only 25% of respondents had received training in managing T2DM in people with SMI. Univariate analysis found that mental health professionals felt responsible for significantly fewer recommended diabetes care standards than physical health professionals (P<0.001). For those seeing diabetes care as part of their role, the significant barriers to its delivery in the multiple regression analyses were a lack of knowledge (P=0.003); a need for training in communication and negotiation skills (P=0.04); a lack of optimism about the health of their clients (P=0.04) and their ability to manage T2DM in people with SMI (P=0.003); the threat of being disciplined (P=0.02); fear of working with people with a mental health condition (P=0.01); a lack of service user engagement (P=0.006); and a need for incentives (P=0.04). The significant enablers were an understanding of the need to tailor treatments (P=0.04) and goals (P=0.02) for people with SMI.

CONCLUSIONS

This survey indicates that despite current guidelines, diabetes care in mental health settings remains peripheral. Even when diabetes care is perceived as part of an HCP's role, various individual and organisational barriers to delivering recommended T2DM care standards to people with SMI are experienced.

Using Appreciative Inquiry to develop, implement and evaluate a multi-organisation ‘Cultivating Compassion’ programme for health professionals and support staff

The ‘Cultivating Compassion’ project was developed in response to a research and innovation call relating to compassion training for National Health Service staff in the South East of England. The project aims included the following: the use of Appreciative Inquiry to develop, implement and evaluate a sustainable and evidence-based programme of compassion awareness training through engaging with a diverse group of health professionals and support staff; an evaluation of a ‘train the trainers’ approach; and an evaluation of ‘compassion lead’ roles and a multi-modal compassion toolkit. The project team included academics from two universities and one medical school, NHS staff from three separate organisations and service users. The participants recruited to the study included doctors, nurses, receptionists, chaplains and others working in close contact with service users from within four NHS organisations in the South East of England. The main findings from the project using thematic analysis from participant focus groups and interviews identified project enablers and inhibitors, the value of project resources, and shifts in perspectives. Project conclusions highlighted the importance of effective senior-level support and organisational leadership in cultivating compassion within a healthcare organisation and the importance of the integration of compassion-promoting resources within existing staff development initiatives.

Lying to ourselves: rationality, critical reflexivity, and the moral order as 'structured agency'

A report suggests that United States' army officers may engage in dishonest reporting regarding their compliance procedures. Similarly, nurses with espoused high ethical standards sometimes fail to live up to them and may do so while deceiving themselves about such practices. Reasons for lapses are complex. However, multitudinous managerial demands arising within 'technical and instrumental rationality' may impact on honest decision-making. This paper suggests that compliance processes, which operates within the social structural context of the technical and instrumental rationality manifest as 'managerialism', contributes to professional 'dishonesty' about lapses in care, sometimes through 'thoughtlessness'. The need to manage risk, measure, account, and control in order to deliver efficiency, effectiveness, and economy (technical rationality) thus has both unintended and dysfunctional consequences. Meeting compliance requirements may be mediated by factors such as the 'affect heuristic' and 'reflexive deliberations' as part of the 'structured agency' of nurses. It is the complexity of 'structured agency' which may explain why some nurses fail to respond to such things as sentinel events, a failure to recognize 'personal troubles' as 'public issues', a failure which to outsiders who expect rational and professional responses may seem inconceivable. There is a need to understand these processes so that nurses can critique the context in which they work and to move beyond either/or explanations of structure or agency for care failures, and professional dishonesty.

The missing two Cs – commodity and critique: Obscuring the political economy of the ‘gift’ of nursing

This discussion paper argues for understanding nursing care as a commodity within capitalist relations of production, ultimately as a product of labour, whose use value far exceeds its exchange value and price. This under-recognised commodification of care work obscures the social relationships involved in the contribution to the social reproduction of labour and to capital accumulation by nursing care work. This matters, because many care workers give of themselves and their unpaid overtime to provide care as if in a ‘gift economy’, but in doing so find themselves in subordinate subject positions as a part of the social reproduction of labour in a ‘commodity economy’. Thus they are caught in the contradiction between the ‘appearance’ and reality. A focus on the individual moral character of nurses (e.g. the UK’s 6Cs), may operate as a screen deflecting understanding of the reality of the lived experiences of thousands of care workers and supports the discourse of ‘care as a gift’. The commodification of care work also undermines social reproduction itself. Many nurses will not have tools of analysis to critique their subject positioning by power elites and have thus been largely ineffectual in creating change to the neoliberalist and managerialist contexts that characterise many healthcare and other public sector organisations. The implications of this analysis for healthcare policy and nursing practice is the need for a critical praxis (an ‘action nursing’) by nurses and nursing bodies, along with their allies, which may include patient groups, to put care in all its guises and consequences central to the political agenda.