1
|
Ryan E, Hore K, Power J, Jackson T. The relationship between physician burnout and depression, anxiety, suicidality and substance abuse: A mixed methods systematic review. Front Public Health 2023; 11:1133484. [PMID: 37064688 PMCID: PMC10098100 DOI: 10.3389/fpubh.2023.1133484] [Citation(s) in RCA: 10] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/29/2022] [Accepted: 02/09/2023] [Indexed: 04/03/2023] Open
Abstract
Introduction The World Health Organization defines burnout as a problem associated with employment, a category distinct from psychological disorders such as depression, anxiety, suicidality and disorders of substance abuse. Evaluating the association between burnout as an occupational exposure and psychological morbidity may indicate that burnout can act as an occupational risk factor for mental ill-health. The systematic review explores this relationship in physicians due to the increased risk in this population and the implications for healthcare delivery. Methods A mixed methods systematic review of the literature was conducted across Medline, Cinahl Plus, PsycInfo, Web of Science and The Cochrane Library. Databases were systematically searched using keywords relating to physician burnout and depression, anxiety, suicidality and substance abuse. Identified articles were screened for eligibility by two independent researchers. Data extraction was performed and studies assessed for risk of bias. Quantitative and qualitative results were integrated using a convergent segregated approach and results portrayed as a narrative synthesis. Results Sixty-one articles were included in the review. There was notable heterogeneity in the measurement and criteria used to define burnout limiting the assimilation of results. Despite this, all studies that measured the association between depression and burnout reported a significant association. Studies that reported association between burnout and anxiety were similarly uniformly consistent. Most studies that reported the association between burnout and suicidality indicated that a significant association exists however difficulty in measurement of suicidality may have influenced variability of results. The reported association between substance abuse and burnout was more variable, suggesting that any association is likely to be weak or influenced by other variables. Qualitative studies described the manifestations of chronic workplace stress as well as perceived links with psychological morbidity. These included lack of time for work-life balance, the contribution of professional relationships and a culture of invulnerability that exists among physicians. Conclusion The systematic review cannot conclude causality but suggests that physician burnout is associated with depression, anxiety and suicidality. Qualitative data provides insight into the nature of this association. The review indicates the need for longitudinal research and provides considerations for intervention strategies to prevent the development and progression of burnout. Systematic review registration https://www.crd.york.ac.uk/prospero/display_record.php?ID=CRD42020172938, identifier: CRD42020172938.
Collapse
Affiliation(s)
- Emer Ryan
- Department of Cardiothoracic Anaesthesia, Auckland City Hospital, Auckland, New Zealand
- Usher Institute, University of Edinburgh, Scotland, United Kingdom
- College of Anaesthesiologists of Ireland, Dublin, Ireland
| | - Kevin Hore
- College of Anaesthesiologists of Ireland, Dublin, Ireland
- Department of Anaesthesia, Great Ormonde Street Children's Hospital, London, United Kingdom
| | - Jessica Power
- Centre for Global Health, Trinity College, Dublin, Ireland
| | - Tracy Jackson
- Usher Institute, University of Edinburgh, Scotland, United Kingdom
| |
Collapse
|
2
|
Having allies—Experiences of support in people with stress-related exhaustion: A qualitative study. PLoS One 2022; 17:e0277264. [DOI: 10.1371/journal.pone.0277264] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/29/2021] [Accepted: 10/25/2022] [Indexed: 11/11/2022] Open
Abstract
Background
The number of people seeking care for symptoms of exhaustion and stress is a major concern in several countries. The condition is a challenging and life-changing experience, and a deeper understanding of support to help people on sick leave due to stress-related exhaustion in their early stages is needed to facilitate recovery.
Objective
The aim was to explore experiences of support in people with stress-related exhaustion being on sick-leave less than six months.
Method
A qualitative interview study was conducted with 12 participants (7 women and 5 men; aged 25–46 years) who were on sick leave that had not exceeded six months due to stress-related exhaustion. The participants were recruited from public healthcare centres in the western part of Sweden, and the intention was to reach them early in their ongoing sick leave period. The interviews were performed face-to-face and analysed using a phenomenological hermeneutical approach.
Results
The findings show that people affected by stress-related exhaustion struggle to maintain their dignity and define support in terms of allies who acknowledge their personhood and provide them helpful guidance. Participants expressed their needs to be taken seriously by professionals, family, and friends willing to engage in their situation. Lack of empathy and professional knowledge in the clinical encounter induced additional stress.
Conclusions
This study indicates that people affected by stress-related exhaustion need allies from their surrounding networks in their struggle to maintain their dignity. Our findings highlight that it is essential to acknowledge them as persons and establish an alliance to provide appropriate support based on each person’s specific situation, needs and resources. This approach can be facilitated in a partnership, as emphasized in person-centred care (PCC). PCC emphasizes the co-creation of care in partnership between the patient (often with relatives) and health care professionals which may imply a more collaborative view of health care in which patients are engaged as active partners in planning their care.
Collapse
|
3
|
Carletto S, Ariotti MC, Garelli G, Di Noto L, Berchialla P, Malandrone F, Guardione R, Boarino F, Campagnoli MF, Savant Levet P, Bertino E, Ostacoli L, Coscia A. Moral Distress and Burnout in Neonatal Intensive Care Unit Healthcare Providers: A Cross-Sectional Study in Italy. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2022; 19:ijerph19148526. [PMID: 35886379 PMCID: PMC9323986 DOI: 10.3390/ijerph19148526] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 06/14/2022] [Revised: 07/09/2022] [Accepted: 07/11/2022] [Indexed: 12/05/2022]
Abstract
Moral distress (MD) in healthcare providers is widely recognized as a serious issue in critical care contexts. It has the potential to have negative impacts on both personal and professional wellbeing, the quality of care provided and staff turnover. The aim of this study was to investigate the relationship between MD and burnout among neonatal intensive care unit (NICU) healthcare professionals and identify the possible factors associated with its occurrence. Participants were asked to complete an online survey, which covered sociodemographic and professional information and included two self-report questionnaires (Italian Moral Distress Scale-Revised and Maslach Burnout Inventory). The sample comprised 115 healthcare providers (nurses and physiotherapists: 66.1%; physicians: 30.4%; healthcare assistants: 3.5%) working in four NICUs located within the province of Turin, Italy. The results revealed overall low levels of MD, with no significant differences between nurses/physiotherapists and physicians. Nurses/physiotherapists showed a statistically significant higher percentage of personal accomplishment burnout (32.9%) compared with physicians (8.6%; p = 0.012). MD was associated with the emotional exhaustion dimension of burnout. Spirituality and/or religiousness was shown to be a moderating variable. Further research is needed to deepen our understanding of the correlation between MD and burnout and the role of spirituality and/or religiousness as moderators.
Collapse
Affiliation(s)
- Sara Carletto
- Department of Neuroscience “Rita Levi Montalcini”, University of Torino, 10126 Turin, TO, Italy;
- Clinical Psychology Unit, A.O.U. City of Health and Science of Torino, 10126 Turin, TO, Italy; (G.G.); (L.O.)
| | - Maria Chiara Ariotti
- Neonatal Intensive Care Unit of University of Torino, Sant’Anna Hospital, City of Health and Science, 10126 Turin, TO, Italy; (M.C.A.); (E.B.); (A.C.)
| | - Giulia Garelli
- Clinical Psychology Unit, A.O.U. City of Health and Science of Torino, 10126 Turin, TO, Italy; (G.G.); (L.O.)
| | - Ludovica Di Noto
- Formerly at the School of Medicine, University of Torino, 10126 Turin, TO, Italy;
| | - Paola Berchialla
- Department of Clinical and Biological Sciences, University of Torino, 10043 Turin, TO, Italy;
| | - Francesca Malandrone
- Department of Clinical and Biological Sciences, University of Torino, 10043 Turin, TO, Italy;
- Correspondence:
| | - Roberta Guardione
- Neonatal Care Unit, City of Health and Science University Hospital of Torino, 10126 Turin, TO, Italy; (R.G.); (M.F.C.)
| | - Floriana Boarino
- Neonatal Care Unit, Santa Croce Hospital ASL TO5, 10024 Moncalieri, TO, Italy;
| | - Maria Francesca Campagnoli
- Neonatal Care Unit, City of Health and Science University Hospital of Torino, 10126 Turin, TO, Italy; (R.G.); (M.F.C.)
| | - Patrizia Savant Levet
- Neonatal Intensive Care Unit, Maria Vittoria Hospital, ASL Città di Torino, 10144 Turin, TO, Italy;
| | - Enrico Bertino
- Neonatal Intensive Care Unit of University of Torino, Sant’Anna Hospital, City of Health and Science, 10126 Turin, TO, Italy; (M.C.A.); (E.B.); (A.C.)
| | - Luca Ostacoli
- Clinical Psychology Unit, A.O.U. City of Health and Science of Torino, 10126 Turin, TO, Italy; (G.G.); (L.O.)
- Department of Clinical and Biological Sciences, University of Torino, 10043 Turin, TO, Italy;
| | - Alessandra Coscia
- Neonatal Intensive Care Unit of University of Torino, Sant’Anna Hospital, City of Health and Science, 10126 Turin, TO, Italy; (M.C.A.); (E.B.); (A.C.)
| |
Collapse
|
4
|
Liu X, Chen J, Wang D, Li X, Wang E, Jin Y, Ma Y, Yu C, Luo C, Zhang L, Liu C, Zhou Y, Yang L, Song J, Bai T, Hou X. COVID-19 Outbreak Can Change the Job Burnout in Health Care Professionals. Front Psychiatry 2020; 11:563781. [PMID: 33363480 PMCID: PMC7753007 DOI: 10.3389/fpsyt.2020.563781] [Citation(s) in RCA: 31] [Impact Index Per Article: 7.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/19/2020] [Accepted: 11/06/2020] [Indexed: 11/13/2022] Open
Abstract
Background: The outbreak of COVID-19 in China was a sudden bio-disaster, which may bring a negative impact on the job burnout of health care professionals (HCPs). Objective: We aim to find out the association factors, especially those closely related to this outbreak, of job burnout in Chinese HCPs. Method: The cross-sectional survey about HCPs' job burnout based on a network platform was conducted in high and low infection regions during the COVID-19 outbreak in China. The demographic characteristics, medical-work-related factors, risk of getting infected due to occupational exposure, and family factors were collected by the self-reported questionnaire. The Chinese version of the Maslach Burnout Inventory (CMBI) and the Trait Coping Style Questionnaire (TCSQ) were employed in this study to evaluate the job burnout and coping style, respectively. Furthermore, statistical analysis was done to find out the associated factors of job burnout. Results: We collected 880 complete questionnaires from doctors and nurses from February 9, 2020 to February 11, 2020. In this study, the positive rates of three dimensions of burnout (emotional exhaustion, depersonalization, and reduced personal accomplishment) and overall burnout were 9.09, 50.57, 56.59, and 73.98%, respectively. After the statistical analysis, we found that several factors can independently affect the dimensions. Working in the high infection region and negative coping styles can affect all three dimensions at once. More night shift quantity and having symptoms could increase emotional exhaustion and depersonalization, while higher work intensity and senior title could increase emotional exhaustion and reduce personal accomplishment, respectively. Conclusion: The rate of moderate and severe burnout had increased due to the outbreak. More attention should be paid to burnout in HCPs, especially those with negative coping. There were some potential ways to reduce burnout, such as reducing their workload and providing better protection from the virus.
Collapse
Affiliation(s)
- Xinghuang Liu
- Division of Gastroenterology, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Jie Chen
- Division of Gastroenterology, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Dongke Wang
- Division of Gastroenterology, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Xin Li
- Department of Paediatrics, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Erchuan Wang
- Division of Gastroenterology, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Yu Jin
- Division of Gastroenterology, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Yanling Ma
- Department of Respiratory and Critical Care Medicine, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Cheng Yu
- Ultrasonic Department, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Chang Luo
- Division of Gastroenterology, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Lei Zhang
- Division of Gastroenterology, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Chuang Liu
- Wuhan Estrip Tech Co., Ltd., Wuhan, China
| | | | - Ling Yang
- Division of Gastroenterology, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Jun Song
- Division of Gastroenterology, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Tao Bai
- Division of Gastroenterology, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Xiaohua Hou
- Division of Gastroenterology, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| |
Collapse
|
5
|
Grimell J, Nilsson S. An advanced perspective on moral challenges and their health-related outcomes through an integration of the moral distress and moral injury theories. MILITARY PSYCHOLOGY 2020; 32:380-388. [PMID: 38536263 PMCID: PMC10013254 DOI: 10.1080/08995605.2020.1794478] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/16/2020] [Accepted: 07/06/2020] [Indexed: 10/23/2022]
Abstract
Both the models of moral distress and of moral injury place an emphasis on various types of moral challenges that may violate the individual's conscience, evoking moral emotions. Yet, there appears to be great conceptual confusion as regards both scholarly perspectives. The purpose of this article is to further elaborate on the qualitative content and conceptual demarcations of the theories of moral injury and moral distress. In the light of this theoretical elaboration, we propose an integrated moral distress and injury scale that provides a more holistic overview of these moral challenges. We suggest that the utility and applicability of the moral injury and moral distress theories may benefit from the integration of these concepts. A practical implication of our theoretical understanding is that processes of recovery, which involve moral dimensions, are complex. In line with this understanding, we advocate a holistic approach to health and well-being among military service members and Veterans.
Collapse
Affiliation(s)
- Jan Grimell
- Amsterdam Centre for the Study of Lived Religion, Vrije Universiteit, Amsterdam, The Netherlands
| | - Sofia Nilsson
- Leadership Centre, Department of Security, Strategy and Leadership, Swedish Defence University, Karlstad, Sweden
| |
Collapse
|
6
|
Feinberg M, Ford BQ, Flynn FJ. Rethinking reappraisal: The double-edged sword of regulating negative emotions in the workplace. ORGANIZATIONAL BEHAVIOR AND HUMAN DECISION PROCESSES 2020. [DOI: 10.1016/j.obhdp.2020.03.005] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
|
7
|
An Y, Yang Y, Wang A, Li Y, Zhang Q, Cheung T, Ungvari GS, Qin MZ, An FR, Xiang YT. Prevalence of depression and its impact on quality of life among frontline nurses in emergency departments during the COVID-19 outbreak. J Affect Disord 2020; 276:312-315. [PMID: 32871661 PMCID: PMC7361044 DOI: 10.1016/j.jad.2020.06.047] [Citation(s) in RCA: 160] [Impact Index Per Article: 40.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/08/2020] [Revised: 06/25/2020] [Accepted: 06/30/2020] [Indexed: 12/15/2022]
Abstract
BACKGROUND Frontline medical staff exposed to the novel coronavirus disease (COVID-19) could be psychologically and mentally exhausted. This study examined the prevalence of depressive symptoms (depression hereafter) and their correlates and the association between depression and quality of life (QOL) in Emergency Department (ED) nurses during the COVID-19 pandemic in China. METHODS This national, cross-sectional online survey was conducted between March 15 and March 20, 2020 in China. Depression and QOL were measured using the 9-item Patient Health Questionnaire, and the World Health Organization Quality of Life Questionnaire-Brief Version, respectively. RESULTS The overall prevalence of depression in 1103 ED nurses was 43.61% (95% CI=40.68-46.54%). Multiple logistic regression analysis revealed that working in tertiary hospitals (OR=1.647, P=0.009), direct patient care of COVID-19 patients (OR=1.421, P=0.018), and current smokers (OR=3.843, P<0.001) were significantly associated with depression. After controlling for covariates, nurses with depression had an overall lower QOL compared to those without (F(1,1103)=423.83, P<0.001). CONCLUSION Depression was common among ED nurses during the COVID-19 pandemic. Considering the negative impact of depression on quality of patient care and nurses' QOL, a heightened awareness of, and early treatment for depression for frontline ED nurses should be provided.
Collapse
Affiliation(s)
- Ying An
- Department of Emergency, Beijing Tongren Hospital, Capital Medical University, Beijing, China
| | - Yuan Yang
- Unit of Psychiatry, Institute of Translational Medicine, Faculty of Health Sciences, University of Macau, Avenida da Universidade, Taipa, Macao SAR, China,Center for Cognition and Brain Sciences, University of Macau, Macao SAR, China,Institute of Advanced Studies in Humanities and Social Sciences, University of Macau, Macao SAR, China,Department of Psychiatry, Southern Medical University Nanfang Hospital, Guangdong, China
| | - Aiping Wang
- Department of Emergency, Beijing Tongren Hospital, Capital Medical University, Beijing, China
| | - Yue Li
- Department of Emergency, Beijing Tongren Hospital, Capital Medical University, Beijing, China
| | - Qinge Zhang
- The National Clinical Research Center for Mental Disorders & Beijing Key Laboratory of Mental Disorders Beijing Anding Hospital & the Advanced Innovation Center for Human Brain Protection, Capital Medical University, Beijing, China
| | - Teris Cheung
- School of Nursing, Hong Kong Polytechnic University, Hong Kong SAR, China
| | - Gabor S. Ungvari
- Division of Psychiatry, School of Medicine, University of Western Australia, Perth, Australia,University of Notre Dame Australia, Fremantle, Australia
| | - Ming-Zhao Qin
- Department of Geriatric Medicine, Beijing Tongren Hospital, Capital Medical University, Beijing, China
| | - Feng-Rong An
- The National Clinical Research Center for Mental Disorders & Beijing Key Laboratory of Mental Disorders Beijing Anding Hospital & the Advanced Innovation Center for Human Brain Protection, Capital Medical University, Beijing, China.
| | - Yu-Tao Xiang
- Unit of Psychiatry, Institute of Translational Medicine, Faculty of Health Sciences, University of Macau, Avenida da Universidade, Taipa, Macao SAR, China; Center for Cognition and Brain Sciences, University of Macau, Macao SAR, China; Institute of Advanced Studies in Humanities and Social Sciences, University of Macau, Macao SAR, China.
| |
Collapse
|
8
|
Abstract
INTRODUCTION Mental illness is a major concern in many countries. In Sweden, stress-related mental illness is currently the most frequent reason for sick leave. OBJECTIVE This study aimed to explore patients' experiences of stress-related exhaustion. DESIGN A qualitative study with interview data analysed using a phenomenological hermeneutic method. SETTING Participants were selected from public primary healthcare centres in a larger city in western Sweden. PARTICIPANTS Seven women and five men on sick leave from work due to stress-related exhaustion were included in the study. FINDINGS Stress-related exhaustion was experienced as a loss of access to oneself and one's context and feelings of being trapped and lost in life. The condition had a significant impact on personal identity, raised existential issues and was interpreted as facing a blind alley. Participants described a mistaken direction in life, being forced to stop, change direction and act differently. CONCLUSION Stress-related exhaustion is a challenging, life-changing existential experience that involves a crisis with an opportunity for new insights. Careful consideration of patients' narratives together with the expertise of healthcare professionals can be combined to improve health and optimise recovery based on individual's situation.
Collapse
Affiliation(s)
- Sara Alsén
- Institute of Health and Care Sciences, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
- Centre for Person-Centred Care (GPCC), University of Gothenburg, Gothenburg, Sweden
| | - Lilas Ali
- Institute of Health and Care Sciences, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
- Centre for Person-Centred Care (GPCC), University of Gothenburg, Gothenburg, Sweden
- Psychiatric department, Sahlgrenska University Hospital, Gothenburg, Sweden
| | - Inger Ekman
- Institute of Health and Care Sciences, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
- Centre for Person-Centred Care (GPCC), University of Gothenburg, Gothenburg, Sweden
| | - Andreas Fors
- Institute of Health and Care Sciences, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
- Centre for Person-Centred Care (GPCC), University of Gothenburg, Gothenburg, Sweden
- Research and Development Primary Health Care, Region Västra Götaland, Gothenburg, Sweden
| |
Collapse
|
9
|
Armitage-Chan E, May SA. Identity, environment and mental wellbeing in the veterinary profession. Vet Rec 2018; 183:68. [DOI: 10.1136/vr.104724] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/28/2017] [Revised: 02/12/2018] [Accepted: 06/04/2018] [Indexed: 11/03/2022]
Affiliation(s)
- Elizabeth Armitage-Chan
- LIVE Centre; Department of Clinical Science and Services; Royal Veterinary College; Hatfield UK
| | - Stephen A May
- LIVE Centre; Department of Clinical Science and Services; Royal Veterinary College; Hatfield UK
| |
Collapse
|
10
|
Martín-Del-Río B, Solanes-Puchol Á, Martínez-Zaragoza F, Benavides-Gil G. Stress in nurses: The 100 top-cited papers published in nursing journals. J Adv Nurs 2018. [PMID: 29516543 DOI: 10.1111/jan.13566] [Citation(s) in RCA: 26] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
AIM To identify and analyse the 100 most cited papers on stress in nurses published in nursing journals. BACKGROUND The number of citations an article receives is an index of its impact on the scientific community. An analysis of the most cited articles on stress in nursing would allow us to identify the most important articles and to obtain information about this area of knowledge. DESIGN A retrospective bibliometric analysis. DATA SOURCES In 2016, 111 journals belonging to the "nursing" category were identified in the Science and Social Science Citation Index. A search was performed of the Science Core Collection Website for articles on stress published in these journals. REVIEW METHODS The topic, type of article, publishing journal, countries and institutions of origin and year of publication were extracted from the articles. The impact factor, immediacy index, journal country and publisher and h index were collected from the Institute for Scientific Information. The citation density, citation tendency and Bradford's law were calculated. RESULTS They identified articles were mostly empirical quantitative studies with a transversal design, published from 1975 - 2011 in 23 journals. They were signed by 233 authors, most of whom are English-speaking from the USA and UK. The core distribution of the publications comprises a single journal, the Journal of Advanced Nursing. CONCLUSION The study of stress in nursing has shown increased visibility and recognition each decade. The most recent articles have the highest number of citations, are the highest in rank and have the higher citation densities.
Collapse
|
11
|
Kälvemark Sporrong S, Arnetz B, Hansson MG, Westerholm P, Höglund AT. Developing Ethical Competence in Health Care Organizations. Nurs Ethics 2016; 14:825-37. [PMID: 17901191 DOI: 10.1177/0969733007082142] [Citation(s) in RCA: 78] [Impact Index Per Article: 9.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Increased work complexity and financial strain in the health care sector have led to higher demands on staff to handle ethical issues. These demands can elicit stress reactions, that is, moral distress. One way to support professionals in handling ethical dilemmas is education and training in ethics. This article reports on a controlled prospective study evaluating a structured education and training program in ethics concerning its effects on moral distress. The results show that the participants were positive about the training program. Moral distress did not change significantly. This could be interpreted as competence development, with no effects on moral distress. Alternatively, the result could be attributed to shortcomings of the training program, or that it was too short, or it could be due to the evaluation instrument used. Organizational factors such as management involvement are also crucial. There is a need to design and evaluate ethics competence programs concerning their efficacy.
Collapse
|
12
|
Abstract
This article argues that teaching medical and nursing students health care ethics in an interdisciplinary setting is beneficial for them. Doing so produces an education that is theoretically more consistent with the goals of health care ethics, can help to reduce moral stress and burnout, and can improve patient care. Based on a literature review, theoretical arguments and individual observation, this article will show that the benefits of interdisciplinary education, specifically in ethics, outweigh the difficulties many schools may have in developing such courses.
Collapse
MESH Headings
- Attitude of Health Personnel
- Burnout, Professional/prevention & control
- Burnout, Professional/psychology
- Cooperative Behavior
- Curriculum
- Delivery of Health Care/ethics
- Education, Medical, Undergraduate/organization & administration
- Education, Nursing, Baccalaureate/organization & administration
- Ethics, Medical/education
- Ethics, Nursing/education
- Health Knowledge, Attitudes, Practice
- Health Services Needs and Demand
- Humans
- Interdisciplinary Communication
- Interprofessional Relations
- Models, Educational
- Morals
- Patient Care Team/organization & administration
- Philosophy, Medical
- Philosophy, Nursing
- Social Values
- Students, Medical/psychology
- Students, Nursing/psychology
- Teaching/organization & administration
Collapse
Affiliation(s)
- Stephen Hanson
- Department of Social Sciences, McNeese State University, PO Box 92335, Lake Charles, LA 70609, USA.
| |
Collapse
|
13
|
Chan IYS, Leung MY, Liu AMM. Occupational health management system: A study of expatriate construction professionals. ACCIDENT; ANALYSIS AND PREVENTION 2016; 93:280-290. [PMID: 26643649 DOI: 10.1016/j.aap.2015.11.003] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/30/2015] [Accepted: 11/01/2015] [Indexed: 06/05/2023]
Abstract
Due to its direct impact on the safety and function of organizations, occupational health has been a concern of the construction industry for many years. The inherent complexity of occupational health management presents challenges that make a systems approach essential. From a systems perspective, health is conceptualized as an emergent property of a system in which processes operating at the individual and organizational level are inextricably connected. Based on the fundamental behavior-to-performance-to-outcome (B-P-O) theory of industrial/organizational psychology, this study presents the development of an I-CB-HP-O (Input-Coping Behaviors-Health Performance-Outcomes) health management systems model spanning individual and organizational boundaries. The model is based on a survey of Hong Kong expatriate construction professionals working in Mainland China. Such professionals tend to be under considerable stress due not only to an adverse work environment with dynamic tasks, but also the need to confront the cross-cultural issues arising from expatriation. A questionnaire was designed based on 6 focus groups involving 44 participants, and followed by a pilot study. Of the 500 questionnaires distributed in the main study, 137 valid returns were received, giving a response rate of 27.4%. The data were analyzed using statistical techniques such as factor analysis, reliability testing, Pearson correlation analysis, multiple regression modeling, and structural equation modeling. Theories of coping behaviors and health performance tend to focus on the isolated causal effects of single factors and/or posits the model at single, individual level; while industrial practices on health management tend to focus on organizational policy and training. By developing the I-CB-HP-O health management system, incorporating individual, interpersonal, and organizational perspectives, this study bridges the gap between theory and practice while providing empirical support for a systems view of health management.
Collapse
Affiliation(s)
- I Y S Chan
- Department of Real Estate and Construction, The University of Hong Kong, Hong Kong, China.
| | - M Y Leung
- Department of Architecture & Civil Engineering, City University of Hong Kong, Hong Kong, China
| | - A M M Liu
- Department of Real Estate and Construction, The University of Hong Kong, Hong Kong, China
| |
Collapse
|
14
|
Cecil P, Glass N. An exploration of emotional protection and regulation in nurse-patient interactions: The role of the professional face and the emotional mirror. Collegian 2016; 22:377-85. [PMID: 26775524 DOI: 10.1016/j.colegn.2014.06.002] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
INTRODUCTION While interpersonal styles of nurse-patient communication have become more relaxed in recent years, nurses remain challenged in emotional engagement with patients and other health professionals. In order to preserve a professional distance in patient care delivery however slight, nurses need to be able to regulate their emotions. AIM This research aimed to investigate nurses' perceptions of emotional protection and regulation in patient care delivery. METHODS A qualitative approach was used for the study utilising in-depth semi-structured interviews and researcher reflective journaling. Participants were drawn from rural New South Wales. Following institutional ethics approval 5 nurses were interviewed and reflective journaling commenced. The interviews and the reflective journal were transcribed verbatim. RESULTS The results revealed that nurses' emotional regulation demonstrated by a 'professional face' was an important strategy to enable delivery of quality care even though it resulted in emotional containment. Such regulation was a protective mechanism employed to look after self and was critical in situations of emotional dissonance. The results also found that nurses experience emotional dissonance in situations where they have unresolved personal emotional issues and the latter was a individual motivator to manage emotions in the workplace. CONCLUSION Emotions play a pivotal role within nurse-patient relationships. The professional face can be recognised as contributing to emotional health and therefore maintaining the emotional health of nurses in practice. This study foregrounds the importance of regulating emotions and nurturing nurses' emotional health in contemporary practice.
Collapse
|
15
|
Poghosyan L, Boyd DR, Clarke SP. Optimizing full scope of practice for nurse practitioners in primary care: A proposed conceptual model. Nurs Outlook 2015; 64:146-155. [PMID: 26712385 DOI: 10.1016/j.outlook.2015.11.015] [Citation(s) in RCA: 33] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/07/2015] [Revised: 10/23/2015] [Accepted: 11/09/2015] [Indexed: 10/22/2022]
Abstract
BACKGROUND Nurse practitioners (NPs), if utilized to their optimal potential, could play a key role in meeting the growing demand for primary care. PURPOSE The purpose of this study was to propose a comprehensive model for maximizing NP contributions to primary care which includes the factors affecting NP care and patient outcomes and explains their interrelated impact. METHOD We synthesized the results of the published literature to develop a model, which emphasizes NP scope of practice regulations, institutional policies, NP practice environment, and NP workforce outcomes as determinants of NP care and patient outcomes. DISCUSSION Our model provides a framework to help explain how variations in scope of practice regulations at the state-level and institutional policies within organizations directly and indirectly influence the practice environment of NPs, NP workforce outcomes, and patient care and outcomes. CONCLUSION Aligning policy change, organizational innovations, and future research are critical to NP optimal utilization and patient care and outcomes.
Collapse
Affiliation(s)
| | | | - Sean P Clarke
- Connell School of Nursing, Boston College, Chestnut Hill, MA
| |
Collapse
|
16
|
Sabariego C, Murid Al-Kudwah H, Cieza A. Content Comparison of Patient-Reported Outcome Instruments Used to Measure Burnout. EUROPEAN JOURNAL OF PSYCHOLOGICAL ASSESSMENT 2015. [DOI: 10.1027/1015-5759/a000210] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
The aim of this article is to compare the content of patient-reported outcome (PRO) burnout measures and to examine the degree of overlap between them and psychosocial difficulties (PSD) experienced by persons with burnout. The most frequently used PRO and qualitative studies were identified in two systematic literature reviews. Psychosocial difficulties identified in both sources were standardized and a qualitative content comparison was performed. Seven PROs and seven qualitative studies were selected. Energy and drive, emotional functions and work were key themes of both sources. Disparities were observed for problems in areas such as sleep, attention or family relationships, which were reported in several qualitative studies, but are seldom addressed in PROs. Several areas important to persons with burnout, such as family relationships, are seldom measured by currently used PROs. From a biopsychosocial perspective, these instruments cannot therefore be considered comprehensive enough to capture the whole experience of burnout and should be improved.
Collapse
Affiliation(s)
- Carla Sabariego
- Department of Medical Informatics, Biometry and Epidemiology – IBE, Ludwig Maximilians University, Munich
| | - Hasnaa Murid Al-Kudwah
- Department of Medical Informatics, Biometry and Epidemiology – IBE, Ludwig Maximilians University, Munich
| | - Alarcos Cieza
- Department of Medical Informatics, Biometry and Epidemiology – IBE, Ludwig Maximilians University, Munich
- Faculty of Health and Social Sciences, University of Southhampton, UK
- Swiss Paraplegic Research, Nottwil, Switzerland
| |
Collapse
|
17
|
Bushby K, Chan J, Druif S, Ho K, Kinsella EA. Ethical tensions in occupational therapy practice: A scoping review. Br J Occup Ther 2015. [DOI: 10.1177/0308022614564770] [Citation(s) in RCA: 34] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Introduction Ethical tensions are an unavoidable part of occupational therapy practice. Given the significance of this, and the divergent nature of the literature, a need was identified for a systematic examination of the published literature on this topic. The purpose of this scoping review therefore was to identify, summarize, and describe existing literature on ethical tensions in occupational therapy practice. Method A comprehensive scoping review was conducted. In the initial search, 459 articles, spanning a 13-year time frame, were retrieved from six databases; 32 articles met the criteria for full review. Results Seven themes were identified that highlighted ethical tensions related to: (a) resource and systemic issues; (b) upholding ethical principles and values; (c) client safety; (d) working with vulnerable clients; (e) interpersonal conflicts; (f) upholding professional standards and (g) practice management. Conclusion This scoping review highlights a breadth of ethical tensions that have implications for practice, education, policy and research. It represents an important first step in mapping knowledge about ethical tensions in occupational therapy practice, and lays a foundation for future research directions.
Collapse
Affiliation(s)
| | - Jody Chan
- Occupational Therapist, Western University, Canada
| | - Shawna Druif
- Occupational Therapist, Western University, Canada
| | - Kim Ho
- Occupational Therapist, Western University, Canada
| | | |
Collapse
|
18
|
Rushton CH, Stutzer K. Addressing 21st-Century Nursing Ethics: Implications for Critical Care Nurses. AACN Adv Crit Care 2015. [DOI: 10.4037/nci.0000000000000083] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/01/2022]
Affiliation(s)
- Cynda Hylton Rushton
- Cynda Hylton Rushton is Anne and George L. Bunting Professor of Clinical Ethics and Professor of Nursing & Pediatrics, Core Faculty, Berman Institute of Bioethics, Johns Hopkins University School of Nursing, and Johns Hopkins University School of Medicine, 1809 Ashland Ave, Baltimore, MD 21205 . Karen Stutzer is Assistant Professor of Nursing, College of Saint Elizabeth, Morristown, New Jersey
| | - Karen Stutzer
- Cynda Hylton Rushton is Anne and George L. Bunting Professor of Clinical Ethics and Professor of Nursing & Pediatrics, Core Faculty, Berman Institute of Bioethics, Johns Hopkins University School of Nursing, and Johns Hopkins University School of Medicine, 1809 Ashland Ave, Baltimore, MD 21205 . Karen Stutzer is Assistant Professor of Nursing, College of Saint Elizabeth, Morristown, New Jersey
| |
Collapse
|
19
|
Rushton CH, Stutzer K. Addressing 21st-century nursing ethics: implications for critical care nurses. AACN Adv Crit Care 2015; 26:173-6. [PMID: 25898885 PMCID: PMC4408874 DOI: 10.1097/nci.0000000000000083] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Affiliation(s)
- Cynda Hylton Rushton
- Cynda Hylton Rushton is Anne and George L. Bunting Professor of Clinical Ethics and Professor of Nursing & Pediatrics, Core Faculty, Berman Institute of Bioethics, Johns Hopkins University School of Nursing, and Johns Hopkins University School of Medicine, 1809 Ashland Ave, Baltimore, MD 21205 . Karen Stutzer is Assistant Professor of Nursing, College of Saint Elizabeth, Morristown, New Jersey
| | | |
Collapse
|
20
|
Sam Schonfeld I, Farrell E. Qualitative methods can enrich quantitative research on occupational stress: An example from one occupational group. ACTA ACUST UNITED AC 2015. [DOI: 10.1108/s1479-3555(2010)0000008007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/08/2023]
|
21
|
Falcó-Pegueroles A, Lluch-Canut T, Roldan-Merino J, Goberna-Tricas J, Guàrdia-Olmos J. Ethical conflict in critical care nursing: Correlation between exposure and types. Nurs Ethics 2014; 22:594-607. [PMID: 25335920 DOI: 10.1177/0969733014549883] [Citation(s) in RCA: 28] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
BACKGROUND Ethical conflicts in nursing have generally been studied in terms of temporal frequency and the degree of conflict. This study presents a new perspective for examining ethical conflict in terms of the degree of exposure to conflict and its typology. OBJECTIVES The aim was to examine the level of exposure to ethical conflict for professional nurses in critical care units and to analyze the relation between this level and the types of ethical conflict and moral states. RESEARCH DESIGN This was a descriptive correlational study. Central and dispersion, normality tests, and analysis of variance were carried out. PARTICIPANTS AND RESEARCH CONTEXT A total of 203 nurses were from two third-level teaching hospitals in Spain. Both centers are part of the University of Barcelona Health Network. Participants filled out the Ethical Conflict in Nursing Questionnaire-Critical Care Version. ETHICAL CONSIDERATIONS This investigation received the approval of the ethical committees for clinical investigation of the two participating hospitals. Participants were informed of the authorship and aims of the study. FINDINGS The index of exposure to ethical conflict was [Formula: see text]. The situations involving analgesic treatment and end-of-life care were shown to be frequent sources of conflict. The types of ethical conflict and moral states generally arranged themselves from lesser to greater levels of index of exposure to ethical conflict. DISCUSSION The moderate level of exposure to ethical conflict was consistent with other international studies. However, the situations related with family are infrequent, and this presents differences with previous research. The results suggest that there is a logical relationship between types of conflict and levels of exposure to ethical conflict. CONCLUSION The types of ethical conflict and moral states were related with the levels of exposure to ethical conflict. The new perspective was shown to be useful for analyzing the phenomenon of ethical conflict in the nurse.
Collapse
|
22
|
Hamaideh SH. Moral distress and its correlates among mental health nurses in Jordan. Int J Ment Health Nurs 2014; 23:33-41. [PMID: 23320816 DOI: 10.1111/inm.12000] [Citation(s) in RCA: 54] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 10/23/2012] [Indexed: 12/01/2022]
Abstract
Moral distress has received much attention in international nursing published work in recent years. However, in the published work, little is known about the moral distress of mental health nurses. The aims of this study were to examine the intensity level of moral distress, to identify the best predictors of moral distress, and to examine relationships of moral distress with burnout, job satisfaction, intention to leave the current job, and both demographic and work-related variables of that group. Employing a descriptive correlational cross-section design and a convenience sampling method, data were collected using the Moral Distress Scale for Psychiatric Nurses, Maslach Burnout Inventory, and Job Satisfaction Scale from 130 Jordanian mental health nurses working in the largest psychiatric hospital in Jordan. Results showed that the intensity level of moral distress was found to be moderately high, especially in an 'unethical conduct by caregivers' subscale. Age, income level, nurses' years of experience, and caseloads correlated significantly and negatively with moral distress, while educational level and intention to leave the current job correlated significantly and positively with moral distress. Interestingly, job satisfaction did not significantly correlate with moral distress. Income level, caseloads, burnout level, attending workshops in mental health, and educational level were the best predictors of moral distress. More studies on moral distress and continuing educational interventional programs aimed at minimizing the levels of moral distress and burnout at institutional and individual level are required.
Collapse
Affiliation(s)
- Shaher H Hamaideh
- Community and Mental Health Nursing Department, Faculty of Nursing, The Hashemite University, Zarka, Jordan; AlMaarefa College, Riyadh, Saudi Arabia
| |
Collapse
|
23
|
Dilworth S, Higgins I, Parker V, Kelly B, Turner J. Finding a way forward: a literature review on the current debates around clinical supervision. Contemp Nurse 2014; 45:22-32. [PMID: 24099223 DOI: 10.5172/conu.2013.45.1.22] [Citation(s) in RCA: 31] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
Nursing research increasingly calls for clinical supervision to support nurses and improve nursing practice. Despite this, clinical supervision is not well established in healthcare organisations. This paper employs a critical interpretive approach to review the clinical supervision literature. The review discusses the current debates and challenges exploring possible ways of moving beyond the current criticisms and limitations in the literature. The review concludes that despite some confusion about the quantifiable outcomes, clinical supervision presents a professionally enriching activity that provides a forum for sharing of knowledge and generation of shared understandings of health care. Through this shared experience it is possible that innovative and creative approaches to health care will be born.
Collapse
Affiliation(s)
- Sophie Dilworth
- School of Nursing and Midwifery, University of Newcastle, Callaghan, NSW, Australia
| | | | | | | | | |
Collapse
|
24
|
|
25
|
A Recommendation for Expanding the Definition of Moral Distress Experienced in the Workplace. ACTA ACUST UNITED AC 2013. [DOI: 10.1017/orp.2013.1] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
Despite the importance of moral distress in the nursing scholarship, little attention is paid to the phenomena in the psychological literature as an important occupational stressor. A factor limiting the application of moral distress to other occupational settings is its definitional features. First, a necessary condition of moral distress is the acknowledgment prior to behaviour initiation that behaviour will contravene personal moral ideals. Second, the definition of moral distress specifies that the inability to act in accordance with one's moral framework is driven by institutional constraints (non-autonomous behaviour). This article proposes that moral distress not be limited in these ways, and makes two central contributions to resolve this core problem. We offer a critique and extension of the conceptual definition of moral distress. Fourteen Australian medical doctors participated in a semi-structured interview regarding occupational morally distressing events. Medical doctors were chosen for our interviews because they are an occupational population with considerable decision-making autonomy. Based on the findings, two recommendations are made: (1) that the definition of moral distress is not limited to events where decision-making and behaviour is non-autonomous, and (2) moral distress should not be limited to occasions where the moral conflict is identified prior to decision-making or behaviour. An alternative definition of moral distress is proposed. We conclude that while organisational limitations are an important precipitate of moral distress, they are not a necessary condition for its emergence.
Collapse
|
26
|
Pye K. Exploring moral distress in pediatric oncology; a sample of registered practitioners. ACTA ACUST UNITED AC 2013; 36:248-61. [DOI: 10.3109/01460862.2013.812693] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
|
27
|
Weimand BM, Sällström C, Hall-Lord ML, Hedelin B. Nurses’ dilemmas concerning support of relatives in mental health care. Nurs Ethics 2013; 20:285-99. [DOI: 10.1177/0969733012462053] [Citation(s) in RCA: 28] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Relatives of persons with severe mental illness face a straining life situation and need support. Exclusion of relatives in mental health care has long been reported. The aim of this study was to describe conceptions of nurses in mental health care about supporting relatives of persons with severe mental illness. Focus group interviews with nurses from all levels of mental health care in Norway were performed. A phenomenographic approach was used. The nurses found that their responsibility first and foremost was the patient, especially to develop an alliance with him or her. Additional premises for supporting relatives were the context framing the nursing care, aspects of the actors, and relational concerns between them. Competing or contradictory demands were found within these premises. Two paths were identified concerning the nurses’ support of relatives: seeing the relative in the shadow of the patient or as an individual person.
Collapse
Affiliation(s)
- Bente M Weimand
- Akershus University Hospital, Norway; Karlstad University, Sweden
| | | | | | | |
Collapse
|
28
|
Rykkje LLR, Eriksson K, Raholm MB. Spirituality and caring in old age and the significance of religion - a hermeneutical study from Norway. Scand J Caring Sci 2012; 27:275-84. [DOI: 10.1111/j.1471-6712.2012.01028.x] [Citation(s) in RCA: 34] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
|
29
|
Falcó A. ¿Más conflictos éticos en tiempos de crisis económica? ENFERMERIA INTENSIVA 2012; 23:49-50. [DOI: 10.1016/j.enfi.2012.03.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/15/2012] [Accepted: 03/16/2012] [Indexed: 10/28/2022]
|
30
|
|
31
|
Jakobsen R, Sørlie V. Dignity of older people in a nursing home: narratives of care providers. Nurs Ethics 2010; 17:289-300. [PMID: 20444771 DOI: 10.1177/0969733009355375] [Citation(s) in RCA: 97] [Impact Index Per Article: 6.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
The purpose of this study was to illuminate the ethically difficult situations experienced by care providers working in a nursing home. Individual interviews using a narrative approach were conducted. A phenomenological-hermeneutic method developed for researching life experience was applied in the analysis. The findings showed that care providers experience ethical challenges in their everyday work. The informants in this study found the balance between the ideal, autonomy and dignity to be a daily problem. They defined the culture they work in as not supportive. They also thought they were not being seen and heard in situations where they disagree with the basic values of the organization. The results are discussed in terms of Habermas's understanding of modern society. Care settings for elderly people obviously present ethical challenges, particularly in the case of those suffering from dementia. The care provider participants in this study expressed frustration and feelings of powerlessness. It is possible to understand their experiences in terms of Habermas's theory of modern society and the concept of the system's colonization of the life world.
Collapse
Affiliation(s)
- Rita Jakobsen
- Lovisenberg Deaconal University College, Oslo, Norway.
| | | |
Collapse
|
32
|
Purc-Stephenson RJ, Thrasher C. Nurses' experiences with telephone triage and advice: a meta-ethnography. J Adv Nurs 2010; 66:482-94. [PMID: 20423383 DOI: 10.1111/j.1365-2648.2010.05275.x] [Citation(s) in RCA: 80] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/02/2023]
Abstract
AIMS This study is a meta-ethnography of nurses' experiences with telephone triage and advice and factors that facilitate or impede their decision-making process. BACKGROUND Telephone triage and advice services are a rapidly expanding development in health care. Unlike traditional forms of nursing practice, telenurses offer triage recommendations and advice to the general public without visual cues. DATA SOURCES Published qualitative research on telephone triage and advice were sought from interdisciplinary research databases (1980-2008) and bibliographical reviews of retrieved studies. REVIEW METHODS Our systematic search identified 16 relevant studies. Two researchers independently reviewed, critically appraised, and extracted key themes and concepts from each study. We followed techniques of meta-ethnography to synthesize the findings, using both reciprocal and refutational translation to compare similar or contradictory findings, and a line-of-arguments synthesis. RESULTS We identified five major themes that highlight common issues and concerns experienced by telenurses: gaining and maintaining skills, autonomy, new work environment, holistic assessment, and stress and pressure. A line-of-arguments synthesis produced a three-stage model that describes the decision-making process used by telenurses and highlights how assessments largely depend on the ability to 'build a picture' of the patient and the presenting health issue. CONCLUSION Telenurses experience a range of common concerns and issues which either impede or facilitate the decision-making process. Although 'building a picture' of the patient is key to making assessments over the telephone, final triage decisions are influenced by balancing the conflicting demands of being both carer and gatekeeper to limited healthcare services.
Collapse
|
33
|
Zakari N, Al Khamis N, Hamadi H. Conflict and professionalism: perceptions among nurses in Saudi Arabia. Int Nurs Rev 2010; 57:297-304. [DOI: 10.1111/j.1466-7657.2009.00764.x] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/01/2022]
|
34
|
|
35
|
Gustafsson G, Eriksson S, Strandberg G, Norberg A. Burnout and perceptions of conscience among health care personnel: A pilot study. Nurs Ethics 2010; 17:23-38. [DOI: 10.1177/0969733009351950] [Citation(s) in RCA: 51] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Although organizational and situational factors have been found to predict burnout, not everyone employed at the same workplace develops it, suggesting that becoming burnt out is a complex, multifaceted phenomenon. The aim of this study was to elucidate perceptions of conscience, stress of conscience, moral sensitivity, social support and resilience among two groups of health care personnel from the same workplaces, one group on sick leave owing to medically assessed burnout (n = 20) and one group who showed no indications of burnout (n = 20). The results showed that higher levels of stress of conscience, a perception of conscience as a burden, having to deaden one’s conscience in order to keep working in health care and perceiving a lack of support characterized the burnout group. Lower levels of stress of conscience, looking on life with forbearance, a perception of conscience as an asset and perceiving support from organizations and those around them (social support) characterized the non-burnout group.
Collapse
Affiliation(s)
| | | | | | - Astrid Norberg
- Umeå University and Ersta Sköndal University College, Sweden
| |
Collapse
|
36
|
Höglund AT, Helgesson G, Eriksson S. Ethical Dilemmas and Ethical Competence in the Daily Work of Research Nurses. HEALTH CARE ANALYSIS 2009; 18:239-51. [DOI: 10.1007/s10728-009-0126-z] [Citation(s) in RCA: 25] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/04/2009] [Accepted: 06/08/2009] [Indexed: 11/24/2022]
|
37
|
Lunardi VL, Barlem ELD, Bulhosa MS, Santos SSC, Lunardi Filho WD, Silveira RSD, Bao ACP, Dalmolin GDL. Sofrimento moral e a dimensão ética no trabalho da enfermagem. Rev Bras Enferm 2009; 62:599-603. [DOI: 10.1590/s0034-71672009000400018] [Citation(s) in RCA: 14] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/28/2008] [Accepted: 07/21/2009] [Indexed: 11/22/2022] Open
Abstract
Trabalhadores de enfermagem vivenciam problemas morais, dilemas morais e sofrimento moral, no seu cotidiano profissional. O sofrimento moral manifesta-se quando os trabalhadores apresentam dificuldades para executar situações moralmente adequadas, segundo suas consciências. O texto tem como objetivo enfocar o sofrimento moral dos trabalhadores de enfermagem e sua relação com problemas morais e dilemas morais, abordando conceitos, vivências de sofrimento moral e possíveis estratégias a serem adotadas para o seu enfrentamento. Enfocar o sofrimento moral provocado pelo enfrentamento de problemas e dilemas morais no trabalho da enfermagem parece fundamental, não apenas para desvelar um fenômeno ainda pouco conhecido, mesmo que vivenciado quase que diariamente, mas, também, para destacar a necessidade de problematização e valorização da dimensão ética do trabalho em saúde.
Collapse
|
38
|
Kristiansen L, Hellzén O, Asplund K. Swedish assistant nurses’ experiences of job satisfaction when caring for persons suffering from dementia and behavioural disturbances. An interview study. Int J Qual Stud Health Well-being 2009. [DOI: 10.1080/17482620600601187] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/23/2022] Open
|
39
|
Abstract
The influence of conscience on nurses in terms of guilt has frequently been described but its impact on care has received less attention. The aim of this study was to describe nurses' conceptions of the influence of conscience on the provision of inpatient care. The study employed a phenomenographic approach and analysis method. Fifteen nurses from three hospitals in western Sweden were interviewed. The results showed that these nurses considered conscience to be an important factor in the exercise of their profession, as revealed by the descriptive categories: conscience as a driving force; conscience as a restricting factor; and conscience as a source of sensitivity. They perceived that conscience played a role in nursing actions involving patients and next of kin, and was an asset that guided them in their efforts to provide high quality care.
Collapse
Affiliation(s)
- Annika Jensen
- School of Social and Health Sciences, Halmstad University, Campus Varberg, HOS, 432 80 Varberg, Sweden,
| | | |
Collapse
|
40
|
Gustafsson G, Norberg A, Strandberg G. Meanings of becoming and being burnout - phenomenological-hermeneutic interpretation of female healthcare personnel’s narratives. Scand J Caring Sci 2008; 22:520-8. [DOI: 10.1111/j.1471-6712.2007.00559.x] [Citation(s) in RCA: 28] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
|
41
|
Sand K, Loge JH, Berger O, Grønberg BH, Kaasa S. Lung cancer patients' perceptions of informed consent documents. PATIENT EDUCATION AND COUNSELING 2008; 73:313-317. [PMID: 18691845 DOI: 10.1016/j.pec.2008.06.011] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/07/2007] [Revised: 06/16/2008] [Accepted: 06/16/2008] [Indexed: 05/26/2023]
Abstract
OBJECTIVE To compare patients' perceptions and preferences of two different versions of informed consent documents. METHODS Patients eligible for a trial of palliative chemotherapy for lung cancer (N = 22) were randomly assigned to receive either an original consent document or a shortened version written for the present study. Semi-structured interviews were conducted after the patients had read the consent documents. The interviews were transcribed verbatim and analysed using qualitative content analysis. RESULTS Few differences between the two groups were found with respect to patients' assessment of the amount of content and the most important information in the documents. Information about disease and treatment seemed to be of most interest for the patients, while information about research aspects of the study such as financing, confidentiality and publishing (formalities) was judged to be of lesser relevance. Two patients who read the original document indicated that they treated the formalities as secondary. CONCLUSION Patients seemed to pay little attention to the research aspects, and thus risked to misunderstand the main point of the consent document. PRACTICE IMPLICATIONS The structure of consent documents should clarify for the readers that they are asked to take part in research, and that participation is voluntary.
Collapse
Affiliation(s)
- Kari Sand
- Department of Cancer Research and Molecular Medicine, Norwegian University of Science and Technology, St. Olavs Hospital, NO-7006 Trondheim, Norway.
| | | | | | | | | |
Collapse
|
42
|
Juthberg C, Eriksson S, Norberg A, Sundin K. Stress of conscience and perceptions of conscience in relation to burnout among care-providers in older people. J Clin Nurs 2008; 17:1897-906. [DOI: 10.1111/j.1365-2702.2007.02184.x] [Citation(s) in RCA: 72] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
|
43
|
Abstract
AIM This paper is a report of a study to describe co-workers' perceptions of signs preceding workmates' burnout. BACKGROUND Burnout engenders emotional and economic suffering, both individual and societal. It is therefore important to learn to recognize early signs to prevent burnout and co-workers, who have opportunities to recognize such signs, are valuable resources in this context. METHOD Fifteen interviews were conducted with nursing and medical staff in Sweden who had worked with a person who developed burnout. The interviews took place in 2004 and were analysed using a thematic content analysis. The narratives were obtained when co-workers already knew that their workmates were on sick leave because of burnout or had left their employment after sick leave because of burnout. FINDINGS The findings show that co-workers retrospectively recalled a multiplicity of signs. They perceived that the people concerned were struggling to manage alone, showing self-sacrifice, struggling to achieve unattainable goals, becoming distanced and isolated, and showing signs of falling apart. CONCLUSIONS Some of the signs preceding workmates' burnout may be difficult to interpret as signs of burnout, because they may be regarded as qualities which are to some extent encouraged in the prevailing culture. The findings provide a complex picture of these signs that will hopefully increase our awareness of and ability to recognize such signs to facilitate the possibilities of our helping in time. The sub-themes and themes in the present study may also serve as a basis for supervisors involved in supporting clinical staff.
Collapse
|
44
|
Abstract
AIM This paper aims to present the findings of a study designed to describe ethical dilemmas, in the form of conflicting values, norms and interests, which telenurses experience in their work. BACKGROUND Telephone nursing is an expanding part of health care. Telephone nurses in Sweden assess care needs, provide advice, support and information, and recommend and coordinate healthcare resources. Lately, ethical demands on healthcare professionals in general have increased. The reasons include new biomedical competence, an ageing population and constrained resources which have made priority setting a primary concern for doctors and nurses. When ethical problems arise, colleagues need open dialogue. Despite this, nurses lack such a dialogue. METHOD A purposeful sample of 12 female telenurses in Sweden was interviewed twice during 2004 and 2005. The transcribed interviews were analysed thematically. RESULTS Five themes were found: talking through a third party; discussing personal and sensitive problems over the phone; insufficient resources and the organization of health care; balancing callers' information needs with professional responsibility; and differences in judging the caller's credibility. CONCLUSION The present study has identified five different themes in which Swedish telenurses experience ethical dilemmas in their work. This shows how ethical dilemmas in various forms are present in telenursing. Questions of autonomy, integrity and prioritizing are particularly highlighted by the participating nurses. Telenurses in Sweden also experience new ethical demands due to a multicultural society. Although several of the identified dilemmas also occur in other areas of nursing we argue that these situations are particularly challenging in telenursing. RELEVANCE TO CLINICAL PRACTICE The work organization should provide opportunities for ethical competence-building, where ethical dilemmas in telenursing are highlighted and discussed. Such a strategy might lead to decreased moral uncertainty and distress among telenurses, with positive consequences for callers.
Collapse
Affiliation(s)
- Inger Holmström
- Department of Public Health and Caring Sciences, Uppsala Science Park, Uppsala University, Uppsala, Sweden.
| | | |
Collapse
|
45
|
Abstract
AIM This paper reports a study examining factors that may contribute to burnout among healthcare personnel. BACKGROUND The impact on burnout of factors such as workload and interpersonal conflicts is well-documented. However, although health care is a moral endeavour, little is known about the impact of moral strain. Interviews reveal that healthcare personnel experience a troubled conscience when they feel that they cannot provide the good care that they wish - and believe it is their duty - to give. METHODS In this cross-sectional study, conducted in 2003, a sample of 423 healthcare personnel in Sweden completed a battery of questionnaires comprising the Maslach Burnout Inventory, Perception of Conscience Questionnaire, Stress of Conscience Questionnaire, Social Interactions Scale, Resilience Scale and a personal/work demographic form. RESULTS Regression analysis resulted in a model that explained approximately 59% of the total variation in emotional exhaustion. Factors associated with emotional exhaustion were 'having to deaden one's conscience', and 'stress of conscience' from lacking the time to provide the care needed, work being so demanding that it influences one's home life, and not being able to live up to others' expectations. Several additional variables were associated with emotional exhaustion. Factors contributing to depersonalization were 'having to deaden one's conscience', 'stress of conscience' from not being able to live up to others' expectations and from having to lower one's aspirations to provide good care, deficient social support from co-workers, and being a physician; however, the percentage of variation explained was smaller (30%). CONCLUSION Being attentive to our own and others' feelings of troubled conscience is important in preventing burnout in health care, and staff need opportunities to reflect on their troubled conscience. Further research is needed into how a troubled conscience can be eased, particularly focusing on the working environment.
Collapse
Affiliation(s)
- A L Glasberg
- Department of Nursing, Umeå University, Umeå, Sweden.
| | | | | |
Collapse
|
46
|
|
47
|
Hallin K, Danielson E. Registered nurses' experiences of daily work, a balance between strain and stimulation: a qualitative study. Int J Nurs Stud 2006; 44:1221-30. [PMID: 16844126 DOI: 10.1016/j.ijnurstu.2006.05.011] [Citation(s) in RCA: 53] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/12/2005] [Revised: 05/03/2006] [Accepted: 05/21/2006] [Indexed: 11/29/2022]
Abstract
BACKGROUND The challenges in the health care have given rise to a highly stressful work situation and a more complicated role for registered nurses (RNs). Qualitative studies about daily work as a whole is limited. It is therefore vital for future development of nursing knowledge and nursing education to recurrently investigate RNs' experiences of their ability to grasp and manage their daily work situation and to promote a high quality of care. AIM The aim of this study was to describe RNs' experiences of their daily work. METHODS AND PARTICIPANTS This follow up study was carried out involving 15 Swedish RNs 6 years after their graduation. Interviews, conducted with conversational strategy, were chosen for the data collection and content analysis was used to handle the interview texts. RESULTS The analysis resulted in a main theme 'to balance strain and stimulation', two themes and seven sub-themes. The first theme 'a stressful work situation' consisted of the sub-themes: 'to meet all demands', 'to be insufficient', 'to be unsure of oneself', and 'too little contact with patient'. The second theme 'a stimulating work situation' consisted of the sub-themes: 'to encounter patients and health care staff is enriching', 'to have the situation under control', and 'to have the skills necessary to be independent'. A pattern emerged throughout the themes, which showed that due to the increasing number of patients RNs' capacity for management, prioritising and planning out of team work, and performing exacting documentation diminished. CONCLUSION The RNs' daily work has been illustrated as a scale of balance that oscillated between strain and stimulation; an oscillation towards strain could lead to a vicious circle. The RNs need support from the start through nursing education and continuously in profession. This is a crucial issue for nursing education and health care sector.
Collapse
Affiliation(s)
- Karin Hallin
- Department of Health Sciences, Mid Sweden University, Ostersund, SE-831 25, Sweden.
| | | |
Collapse
|
48
|
Bégat I, Ellefsen B, Severinsson E. Nurses' satisfaction with their work environment and the outcomes of clinical nursing supervision on nurses' experiences of well-being - a Norwegian study. J Nurs Manag 2005; 13:221-30. [PMID: 15819834 DOI: 10.1111/j.1365-2834.2004.00527.x] [Citation(s) in RCA: 131] [Impact Index Per Article: 6.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
BACKGROUND Various studies have demonstrated that nursing is stressful and that the incidence of occupational stress-related burnout in the profession is high. AIM This descriptive-correlational study examined nurses' satisfaction with their psychosocial work environment, their moral sensitivity and differences in outcomes of clinical nursing supervision in relation to nurses' well-being by systematically comparing supervised and unsupervised nurses. METHODS Nurses were selected from two hospitals (n = 71). Data collection was by means of questionnaires and analysed by descriptive and inferential statistics. RESULTS The nurses' satisfaction with their psychosocial work environment was reflected in six factors: 'job stress and anxiety', 'relationship with colleagues', 'collaboration and good communication', 'job motivation', 'work demands' and 'professional development'. The nurses' perceptions of moral sensitivity comprised seven factors: 'grounds for actions', 'ethical conflicts', 'values in care', 'independence patient-oriented care', 'the desire to provide high-quality care' and 'the desire to provide high-quality care creates ethical dilemmas'. Nurses well-being were reflected in four factors 'physical symptom and anxiety', 'feelings of not being in control', 'engagement and motivation' and 'eye strain sleep disturbance'. The moral sensitivity 'ethical conflicts' were found to have mild negative correlations with psychosocial work environment 'job stress and anxiety professional development' and with 'total score' psychosocial work, moral sensitivity factor 'independence were correlated with psychosocial work factor 'relationships with colleagues' and 'total score', moral sensitivity were mildly correlated with 'collaboration and good communication and had a negative correlation to psychosocial work factor 'work demands'. In addition, significant correlations were found between the nurses' well-being profile and demographic variables, between 'engagement and motivation' and 'absence due to illness' and between 'time allocation for tasks', 'physical symptoms and anxiety' and 'age'. Mild significant differences were found between nurses attending and not attending group supervision and between 'physical symptoms and anxiety' and 'feelings of not being in control'. CONCLUSIONS We conclude that ethical conflicts in nursing are a source of job-related stress and anxiety. The outcome of supporting nurses by clinical nursing supervision may have a positive influence on their perceptions of well-being. clinical nursing supervision have a positive effect on nurses physical symptoms and their feeling of anxiety as well as having a sense of being in control of the situation. We also conclude that psychosocial work have an influence on nurses experience of having or not having control and their engagement and motivation.
Collapse
MESH Headings
- Adult
- Attitude of Health Personnel
- Burnout, Professional/psychology
- Clinical Competence
- Communication
- Conflict, Psychological
- Cooperative Behavior
- Factor Analysis, Statistical
- Health Facility Environment/organization & administration
- Health Knowledge, Attitudes, Practice
- Humans
- Interprofessional Relations
- Job Satisfaction
- Morals
- Motivation
- Norway
- Nursing Methodology Research
- Nursing Staff, Hospital/education
- Nursing Staff, Hospital/ethics
- Nursing Staff, Hospital/organization & administration
- Nursing Staff, Hospital/psychology
- Nursing, Supervisory/organization & administration
- Professional Autonomy
- Social Support
- Surveys and Questionnaires
- Time Management
- Workload
- Workplace/organization & administration
- Workplace/psychology
Collapse
Affiliation(s)
- Ingrid Bégat
- Department of Nursing, Health and Culture, University Trollhättan-Uddevalla, Sweden.
| | | | | |
Collapse
|
49
|
Holmström I, Larsson J. A tension between genuine care and other duties: Swedish nursing students' views of their future work. NURSE EDUCATION TODAY 2005; 25:148-155. [PMID: 15701541 DOI: 10.1016/j.nedt.2004.11.005] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/09/2004] [Accepted: 11/16/2004] [Indexed: 05/24/2023]
Abstract
There is a current need for nurses to take on new roles due to changing health care policies, economic cut-backs and shortage of staff. It is therefore important to study nursing students' view of their future profession. The theoretical framework was contemporary theories of competence development, which has shown that people's understanding of their work is expressed in their actions. The aim of this study was to describe nursing students' understanding of their future professional role in health care. A purposeful sample of 12 nursing students wrote narratives. The texts were condensed in five steps using the Empirical Phenomenological Psychological Method. The essence of the students' view of their future work was A tension between genuine nursing care and other duties. Four themes constituted this essence: professional status, working conditions and stress, evidence-based nursing contra holistic care, teamwork, co-operation and disrespect, and intensive care instead of geriatrics. This study highlights pedagogic and practical problems that need to be constructively addressed. The nursing students' eagerness to care in a holistic way needs to be acknowledged and used in a fruitful way. This core function of nursing needs to be integrated with up-to-date nursing research.
Collapse
Affiliation(s)
- Inger Holmström
- Department of Public Health and Caring Sciences, Section for Health Services Research, Uppsala Science Park, SE-751 85 Uppsala, Sweden.
| | | |
Collapse
|
50
|
Tveiten S, Severinsson E. Client supervision: Meaning and experiences from the perspective of Norwegian public health nurses. Nurs Health Sci 2004; 6:279-86. [PMID: 15507048 DOI: 10.1111/j.1442-2018.2004.00205.x] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
The aim of the present study was to examine the meaning and experiences of client supervision from the perspective of Norwegian public health nurses. The World Health Organization (WHO) states that new intervention strategies to improve public health are necessary. Supervision represents such a strategy. Three focus groups were interviewed twice. The data were analyzed by qualitative content analysis. The findings revealed three themes: (i) the meaning of the umbrella term client supervision; informing, teaching, giving advice and ensuring the quality of supervision; (ii) factors influencing supervision; the public health nurses' available time and competence and the clients' ability to be supervised; and (iii) events and content representing the complexity of conducting supervision. In conclusion, the width of the concept, the influencing factors and the complexity claim that public health nurses have competence to supervise.
Collapse
Affiliation(s)
- Sidsel Tveiten
- Akershus University College, Faculty of Nursing Education, Lillestrøm, Norway.
| | | |
Collapse
|