The significance of routines in nursing practice

Improvised use of a digital tool for social interaction in a Norwegian care facility during the COVID-19 pandemic: an exploratory study

Background

Digital tools for social communication have been deployed in care facilities during the COVID-19 pandemic to facilitate social connectedness between older people and their next of kin in a safe manner. This study explores how and why health care professionals facilitate the ad hoc and prompt use of a technology for social communication, known as KOMP, in care facilities in western Norway to promote communication and social engagement among residents and their next of kin during the crisis.

Methods

To investigate the perspectives and practices of health care professionals, we conducted focus groups, individual interviews, and participant observation in public short- and long-term care facilities in western Norway. An explorative investigation with inductive content analysis was applied to analyse interview transcripts and fieldnotes from participant observation.

Results

The resulting qualitative data reveal that prompt implementation of interactive technology to cope with social distancing during the pandemic added new routines to the staff workload. Using this interactive technology entailed new forms of collaborative work among residents, next of kin, health care professionals and technology facilitators. Additionally, the staff articulated a sense of responsibility towards using KOMP as a meaningful and practical tool for social communication in an extraordinary period of reduced social contact.

Conclusions

Improvised implementation of KOMP as an interactive technology shapes work routines, introduces new tasks and creates additional responsibilities. Despite creative efforts by health care staff, however, using KOMP remains constrained by the physical and cognitive abilities of its users. We suggest that health care managers ask a deceptively simple question when introducing novel technologies in health care contexts, namely: what kind of invisible work do these devices entail?

Untenable Expectations: Nurses’ Work in the Context of Medication Administration, Error, and the Organization

We explored nurses’ work in the context of medication administration, errors, and the organization. Secondary analysis of ethnographic data included 92 hours of non-participant observation, and 37 unstructured interviews with nurses, administrators, and pharmacists. Think-aloud observations and analysis of institutional documents supplemented these data. Findings revealed the nature of nurses’ work was characterized by chasing a standard of care, prioritizing practice, and renegotiating routines. The rich description identified characteristics of nurses’ work as cyclical, chaotic and complex shattering studies that explained nurses’ work as linear. A new theoretical model was developed, illustrating the inseparability of nurses’ work from contextual contingencies and enhancing our understanding of the cascading components of work that result in days that spin out of the nurses’ control. These results deepen our understanding why present efforts targeting the reduction of medication errors may be ineffective and places administration accountable for the context in which medication errors occur.

Understanding the decision-making of critical care nurses when restraining a patient with psychomotor agitation secondary to hyperactive delirium: A 'Think Aloud' study

AIMS & OBJECTIVES

This study aimed to explore the decision-making processes undertaken by critical care nurses when considering restraint to manage a patient with psychomotor agitation secondary to hyperactive delirium.

BACKGROUND

Psychomotor agitation is frequently cited as clinical rationale for initiating chemical or physical restraint. Despite the presence of clinical guidance for restraint in critical care, wide variations in nursing and prescribing practice are evident. Nurses are the primary decision makers when initiating restraint, but little is known about this process and influencing factors.

DESIGN

A pragmatic qualitative approach was used to explore critical care nurses' decision-making processes.

METHODS

A 'think aloud' approach was undertaken. Audio-visual vignettes featuring simulated patients were used as stimulus to elicit decision-making processes from thirty critical care nurses and practitioners. The COREQ checklist was followed.

RESULTS

Five themes relating to restraint were identified: Intrinsic beliefs and aptitudes; Handover and labelling; Failure to maintain a consistent approach; Restraint might be used to replace vigilance; The tyranny of the now.

CONCLUSIONS

Restraint was more frequent when staffing ratios were reduced below 1:1 and opportunities for vigilance reduced. Participants described physical and psychological exhaustion when caring for a patient with delirium and how this might lead to restraint to create 'space' for respite. Variations in practice were evident and restraint use appears rooted in custom and culture rather than objective assessment.

RELEVANCE TO CLINICAL PRACTICE

The lack of pre-emptive management for hyperactive delirium and reduced staffing ratios lead to the decision to restrain to preserve safety in acute agitation. The struggle to manage agitated behaviour is associated with nurse burnout and reduced engagement with therapeutic management methods, suggesting the need for psychological and educational support for clinical staff. Delirium is an important and debilitating form of organ dysfunction which should be collaboratively managed by the multi-disciplinary team.

Anticipated nursing care as perceived by nursing students: Findings from a qualitative study

AIM

To explore the perceptions of nursing students on the phenomenon of anticipated nursing care.

DESIGN

A descriptive-qualitative study was performed in 2019 according to the Consolidated Criteria for Reporting Qualitative Research principles.

METHODS

Data were collected using 16 face-to-face, audio-recorded interviews across four Italian Bachelor of Nursing degrees. Then, content analysis was performed, identifying, analysing and describing the anticipated nursing care phenomenon as perceived by nursing students.

RESULTS

Administering medications, providing fundamentals of care, managing some clinical procedures, freeing up the patient's bed and starting the shifts early emerged as the most anticipated nursing interventions. Stable, older patients who were more functionally dependent were reported to receive some fundamental nursing care before the expected time, while older, stable and more independent patients were used to receiving medications in advance. Anticipated nursing care is triggered by factors at the time management, resource, programming, professional and organizational levels.

Nurses' experiences of being recruited and transferred to a new sub-intensive care unit devoted to COVID-19 patients

Aim

To describe the experiences of Italian nurses who have been urgently and compulsorily allocated to a newly established COVID‐19 sub‐intensive care unit.

Background

In the context of the COVID‐19 pandemic, no studies have documented the experience of nurses urgently reallocated to a newly created unit.

Method

A qualitative descriptive study. Twenty‐four nurses working in a sub‐intensive care unit created for COVID‐19 patients participated in four focus groups. Audio‐recorded interviews were verbatim‐transcribed; then, a thematic analysis was performed.

Results

The experience of nurses was summarized along three lines: (a) ‘becoming a frontline nurse’, (b) ‘living a double‐faced professional experience’ and (c) ‘advancing in nursing practice’.

Conclusions

Nurses who experienced being mandatorily recruited and urgently reallocated to a COVID‐19 unit lived through a mix of negative feelings in the early stages, a double‐faced situation during the episode and, at the end, the perception of global growth as a person, as a team and as a professional.

Implication for nursing management

Nurse managers could play a key role in identifying and preparing nurses in advance to mitigate their concerns and their sense of unpreparedness. The value attributed to nursing care should be promoted both during and after the current COVID‐19 pandemic.

Conceptualising Four Categories of Behaviours: Implications for Implementation Strategies to Achieve Behaviour Change

Background: Effectiveness of implementation strategies is influenced by the extent to which they are based on appropriate theories concerning the behaviours that the strategies intend to impact. Effectiveness may be limited simply because the strategies are based on theories that are limited in scope or are derived from partially inaccurate assumptions about the behaviours in question. It may therefore be important to combine insights from various theories to cover the range of influences on the behaviours that will be changed. Aim: This article aims to explore concepts, theories and empirical findings from different disciplines to categorise four types of behaviours and discuss the implications for implementation strategies attempting to change these behaviours. Influences on behaviours: Multilevel influences on behaviours are dichotomized into individual-level and collective-level influences, and behaviours that are guided by conscious cognitive processes are distinguished from those that rely on non-conscious processing. Combining the two dimensions (levels and cognitive modes) creates a 2 x 2 conceptual map consisting of four categories of behaviours. Explicitly conceptualising the levels and cognitive modes is crucial because different implementation strategies are required depending on the characteristics of the behaviours involved in the practise that needs to be changed. Conclusion: The 2 x 2 conceptual map can be used to consider and reflect on the nature of the behaviours that need to be changed, thus providing guidance on the type of theory, model or framework that might be most relevant for understanding and facilitating behaviour change.

Anticipated nursing care: findings from a qualitative study

Background

Contrary to Missed Nursing Care, some anecdotal data and sparse evidence has documented the tendency of nurses to anticipate some nursing interventions. However, no study has been conducted to date with the purpose of understanding this phenomenon and its underlying mechanisms and consequences. The aim of this study was to describe the phenomenon of delivering anticipated nursing care, its antecedents and consequences as perceived by nurses.

Method

A descriptive qualitative study. The Consolidated Criteria for Reporting Qualitative Research guidelines were followed. A purposeful sample of 17 clinical nurses and nurse managers working in three Italian hospitals were interviewed in depth in 2019. The audio-recorded interviews were verbatim transcribed and thematically analysed.

Results

‘Anticipated Nursing Care’ is delivered significantly earlier than when expected by nurses in their care plan, by patients, by caregivers and by other members of the team. Medication administration, mobilisation of patients, hygiene care, changes of dressing, vital parameter monitoring, blood sampling and administrative activities were reported as interventions delivered before rather than when expected. Clinically stable patients have been reported to be at risk of receiving anticipated nursing care. Individual values and attitudes, group attitudes of being always ready for the “unexpected”, implicit group norms to “leave the patients and the unit in order”, high workloads, intertwined activities and work processes inside the units, have been reported as reasons for Anticipated Nursing Care. Effects of this phenomenon have been reported at the patients’ and at the nurses’ level.

Conclusion

Anticipated Nursing Care occurs when nurses perform interventions earlier than expected according to an implicit or explicit decision and not as a consequence of a request. The phenomenon requires future studies to detect its diffusion and to accumulate evidence. Its presence in daily practice, if confirmed, suggests that Missed Nursing Care studies should also consider the combined effect of these two phenomena as, on one hand, there may be the tendency to postpone and, on the other hand, the tendency to anticipate interventions.

Impact of suicide on health professionals in psychiatric care mental healthcare professionals' perceptions of suicide during ongoing psychiatric care and its impacts on their continued care work

People who attempt suicide as well as those who actually take their own life often have communicated their suicidal thoughts and feelings to healthcare professionals in some form. Suicidality is one of the most challenging caring situations and the impacts of suicide care affect both the professional and personal lives of healthcare professionals. This study investigates how mental health professionals perceive suicide while providing psychiatric care and how this perception impacts their continued care work. This qualitative exploratory study includes 19 mental health professionals in psychiatry who had provided care for patients who had taken their own life. Analysis followed the principle of phenomenography. The findings reveal that these healthcare professionals experienced an internal conflict that affected them both personally and professionally. In response to these conflicts, the healthcare professionals developed strategies that involved a safety zone and increased vigilance. Those who were able to commute and balance a safe spot and learning to be more vigilant seem to have developed as a result of patient's suicide. These findings have the potential to help establish a post-suicide caring process where healthcare professionals learn to make better suicide assessments, become more open to talking about death with patients, and develop a humbler approach to understanding a patient's suicide.

Family members' prioritisation of care in residential aged care facilities: A case for individualised care

OBJECTIVES

To investigate family members' prioritisation of care in residential aged care facilities (RACFs).

INTRODUCTION AND BACKGROUND

Family members are often involved in the care of their older relatives even after these relatives transit to a RACF. Understanding family members' priorities regarding care (i.e., what is most important to them) can provide valuable insights into how to better meet residents' needs.

DESIGN

A multisite mixed-methods study comprising qualitative methods and Q methodology. The qualitative component of the study was guided by the COREQ checklist.

METHODS

Participants comprised 27 family members of residents living in one of five participating Australian RACFs. Participants rank-ordered 34 cards, each representing an aspect of care, on a predefined grid from "Least important" (-4) to "Most important" (+4). Participants also engaged in a think-aloud task, demographic questionnaire, post-sorting interview and semi-structured interview. Q data were analysed using inverted factor techniques to identify factors that each represent a portion of shared meaning. Factors were interpreted as viewpoints using data from the think-aloud task and interviews. These data were further analysed using inductive content analysis to reveal influences on prioritisation decision-making.

RESULTS

Three distinct viewpoints were identified through Q methodology: prioritisation of residents' physical needs, maintaining residents' independence, and human connection. Inductive content analysis revealed four influences on prioritisation decision-making: residents' capabilities and support requirements, unmet needs, family bridging the gaps, and family knowledge of residents.

CONCLUSIONS

The study indicated that to meet residents' needs and family members' priorities, individualised approaches to care are warranted. It also demonstrated the vital role family members play in residents' care when needs are not fully met.

RELEVANCE TO CLINICAL PRACTICE

Strategies to improve individualised care in clinical practice include flexibility of routines, supporting family members' involvement in care, workforce training focused on family-staff communication, and safer staffing ratios.

Value conflicts in perioperative practice

Background:

The foundation of all nursing practice is respect for human rights, ethical value and human dignity. In perioperative practice, challenging situations appear quickly and operating theatre nurses must be able to make different ethical judgements. Sometimes they must choose against their own professional principles, and this creates ethical conflicts in themselves.

Objectives:

This study describes operating theatre nurses’ experiences of ethical value conflicts in perioperative practice.

Research design:

Qualitative design, narratives from 15 operating theatre nurses and hermeneutic text interpretation.

Ethical consideration:

The study followed ethical principles in accordance with the Helsinki Declaration and approval was granted by the local university ethics committee.

Findings:

The result showed that value conflicts arose in perioperative practice when operating theatre nurses were prevented from being present in the perioperative nursing process, because of current habits in perioperative practice. The patient’s care became uncaring when health professionals did not see and listen to each other and when collaboration in the surgical team was not available for the patient’s best. This occurred when operating theatre nurses’ competence was not taken seriously and was ignored in patient care.

Conclusion:

Value conflicts arose when operating theatre nurses experienced that continuity of patient care was lacking. They experienced compassion with the patient but still had the will and ability to be there and take responsibility for the patient. This led to feelings of despair, powerlessness and of having a bad conscience which could lead to dissatisfaction, and even resignations.

Clinical handover practices among healthcare practitioners in acute care services: A qualitative study

AIMS AND OBJECTIVES

To examine clinical handover practices in acute care services in Ireland. Objectives were to examine clinical handover practices between and within teams and between shifts, to identify resources and supports to enhance handover effectiveness and to identify barriers and facilitators of effective handover.

BACKGROUND

Clinical handover is a high-risk activity, and ineffective handover practice constitutes a risk to patient safety. Evidence suggests that handover effectiveness is achieved through staff training and standardised handover protocols.

DESIGN

The study design was qualitative-descriptive using inductive analysis.

METHODS

The study involved a series of focus group discussions and interviews among a sample of healthcare practitioners recruited from 12 urban and regional acute hospitals in Ireland. A total of 116 healthcare professionals took part in 28 interviews and 13 focus group discussions. We analysed the data using the directed content analysis method.

RESULTS

Data collection generated rich qualitative data, yielding five categories from which two broad themes emerged: "policy and practice" and "handover effectiveness." The themes and their associated categories indicate that there is limited organisational-level policy and limited explicit training in clinical handover, that medical and nursing handovers are separate activities with somewhat different purposes and different modes of execution, and that several factors in the acute care setting, including location, timing and documentation, act as either barriers or enablers to handover effectiveness.

CONCLUSION

The evidence in the current study suggests that clinical handover merits increased level of prominence in hospital policies or operating procedures. Medical and nursing handover practices represent distinct activities in their content and execution that may be related to cultural and organisational factors.

RELEVANCE TO CLINICAL PRACTICE

Achieving multidisciplinary team handover requires a change in embedded traditional practices. Several aspects of the clinical handover activities of nursing and medical staff appear to diverge from best-practice evidence.

Sustainability in care through an ethical practice model

Background:

While sustainability is a key concept in many different domains today, it has not yet been sufficiently emphasized in the healthcare sector. Earlier research shows that ethical values and evidence-based care models create sustainability in care practice.

Objective:

The aim of this study was to gain further understanding of the ethical values central to the realization of sustainability in care and to create an ethical practice model whereby these basic values can be made perceptible and active in care practice.

Research design:

Part of the ongoing “Ethical Sustainable Caring Cultures” research project, a hermeneutical application research design was employed in this study.

Participants:

Dialogues were used, where scientific researchers and co-researchers were given the opportunity to reflect on ethical values in relation to sustainability in care.

Findings:

An ethical practice model with ethos as its core was created from the results of the dialogues. In the model, ethos is encircled by the ethical values central to sustainability: dignity, responsibility, respect, invitation, and vows.

Discussion:

The model can be used as a starting point for ethical conversations that support carers’ reflections on the ethical issues seen in day-to-day care work and the work community, allowing ethical values to become visible throughout the entire care culture.

Conclusion:

It is intended as a tool whereby carers can more deeply understand an organization’s common basic values and what they entail in regard to sustainability in care.

An intervention targeting fundamental values among caregivers at residential facilities: effects of a cluster-randomized controlled trial on residents' self-reported empowerment, person-centered climate and life satisfaction

Background

In Sweden the national fundamental values for care of older people state that care should ensure that they can live in dignity and with a sense of well-being. Our hypothesis was that a caregiver intervention targeting the national fundamental values would improve perceived empowerment, person-centered climate and life satisfaction among older people living in residential facilities.

Methods

The study was a cluster-randomized controlled trial with a pre- and one post-test design, conducted in 27 units (17 study units) at 12 residential facilities for older people in five municipalities in central Sweden. The units in each municipality were randomly assigned to intervention or control group. The caregiver intervention was carried out using an interpretative approach with eight guided face-to-face seminars, where self-reflection and dialogue were used. Data were collected using questionnaires. The number of residents was 43 (78 %) in the intervention group and 37 (71 %) in the control group. The Chi-square test and Mann-Whitney U-tests were performed to detect differences between groups and Wilcoxon signed rank tests to explore differences in change over time within groups. Furthermore, generalized estimating equation (GEE) models were used to study effects of the intervention controlling for clustering effects.

Results

Primary outcome measures were empowerment, person-centered climate and life satisfaction. In the intervention group, improvements at follow-up were found in residents’ self-reported empowerment (n = 42; p = 0.001, Median difference 4.0, 95 % CI 1.5;6.0), person-centered climate (n = 42; p ≤0.001, Median difference 8.0, 95 % CI 4.5;11.4) and life satisfaction regarding the factor quality of everyday activities (n = 40; p = 0.033, Median difference 9.7, 95 % CI 1.0;21.9) while disempowerment decreased (n = 43; p = 0.018, Median difference -1.3, 95 % CI -2.0;0.0). In the control group person-centered climate decreased (n = 37; p = 0.002, Median difference -8.5, 95 % CI -13.6;-3.0) and quality of everyday activities (n = 36; p = 0.012, Median difference -11.6, 95 % CI-21.7;-3.4). Change over time between groups was significant for empowerment (p = 0.001, Median difference 6.0, 95 % CI 3.0;9.0), disempowerment (p = 0.006, Median difference -2.0, 95 % CI -4.0;-1.0) and person-centered climate (p ≤ 0.001, Median difference 16.0, 95 % CI 9.7;23.0) and for life satisfaction regarding the factor quality of everyday activities (p = 0.002, Median difference 22.1, 95 % CI 8.2;37.4). Results of GEE confirmed earlier results; revealed interaction effects for empowerment (parameter estimate -5.0, 95 % CI -8.3;-1.8), person-centered climate (parameter estimate -16.7, 95 % CI -22.4;-10.9) and life satisfaction regarding the factor quality of everyday activities (parameter estimate -25.9, 95 % CI -40.3;-11.5).

Conclusion

When the Swedish national fundamental values were put into practice increases in empowerment, person-centered climate and quality of everyday activities were found among older people with intact cognitive ability living in residential facilities. Limitations to consider are the differences between the two groups at baseline, drop-outs and that neither the data collector nor the outcome assessors were blinded to group assignment of participants.

Trial registration

The study was registered in ISRCTN92658034 in January 2013.

Night-time continence care in Australian residential aged care facilities: findings from a grounded theory study

BACKGROUND

Continence care commonly disrupts sleep in residential aged care facilities, however, little is known about what staff do when providing continence care, and the factors that inform their practice.

AIMS

To describe nurses' and personal careworkers' beliefs and experiences of providing continence care at night in residential aged care facilities.

METHODS/DESIGN

Eighteen nurses and personal careworkers were interviewed about continence care, and 24 hours of observations were conducted at night in two facilities.

RESULTS/FINDINGS

Most residents were checked overnight. This practice was underpinned by staffs' concern that residents were intractably incontinent and at risk of pressure injuries. Staff believed pads protected and dignified residents. Decisions were also influenced by beliefs about limited staff-to-resident ratios.

CONCLUSION

Night-time continence care should be audited to ensure decisions are based on residents' preferences, skin health, sleep/wake status, ability to move in bed, and the frequency, severity and type of residents' actual incontinence.

'Because That's the Way It's Always Been Done': Reviewing the Nurse-Initiated Rules in a Mental Health Unit as a Step Toward Trauma-Informed Care

Acknowledgement of the effects of trauma in the lives of the mental health service user population is increasingly being recognised as an imperative for Mental Health services. 'Trauma-informed care' provides values to guide practice. Mental Health nurses are well placed to commence integrating trauma-informed care into everyday practice. This paper describes the process of reviewing the nurse-led rules in an acute inpatient mental health unit as one step toward providing a trauma-informed environment. Findings from questionnaires are used to highlight the applicability of the process to the underlying values of trauma-informed care. Consistency and transparency of rules is demonstrated as a nursing-led step toward establishing emotional safety and creating a trauma-informed environment.

Student nurses' experiences of preserved dignity in perioperative practice - Part I

BACKGROUND

In recent years, operating theatre nurse students' education focussed on ethical value issues and how the patient's dignity is respected in the perioperative practice. Health professionals are frequently confronted with ethical issues that can impact on patient's care during surgery.

OBJECTIVE

The objective of this study was to present what operating theatre nurse students experienced and interpreted as preserved dignity in perioperative practice.

RESEARCH DESIGN

The study has a descriptive design with a hermeneutic approach. Data were collected using Flanagan's critical incident technique.

PARTICIPANTS AND RESEARCH CONTEXT

Operating theatre nurse students from Sweden and Norway participated and collected data in 2011, after education in ethics and dignity. Data consisting of 47 written stories and the text were analysed with hermeneutical text interpretation.

ETHICAL CONSIDERATIONS

The study was conducted accordance with the Declaration of Helsinki and approved by a local University Ethics Research Committee.

FINDINGS

The findings revealed that students experienced that operating theatre nurses perserved patient's dignity in perioperative practice by being present for each other and making themselves known to the patient. Operating theatre nurses caring for the patient by being compassionate and preserved the patient privacy. The new understanding that emerged was that the operating theatre nurse students understood that the operating theatre nurse wanted to care for the patient like a human being.

DISCUSSION

In the discussion, we have illuminated how professional ethics may be threatened by more pragmatic and utilitarian arguments contained in regulations and transplant act.

CONCLUSION

Preserved dignity is an ethical and caring act. Ethical questions and how to preserve dignity in perioperative practice should be discussed more both in educations of healthcare professionals and in clinical practice.

Undignified care

Patient dignity in involuntary psychiatric hospital care is a complex yet central phenomenon. Research is needed on the concept of dignity’s specific contextual attributes since nurses are responsible for providing dignified care in psychiatric care. The aim was to describe nurses’ experiences of violation of patient dignity in clinical caring situations in involuntary psychiatric hospital care. A qualitative design with a hermeneutic approach was used to analyze and interpret data collected from group interviews. Findings reveal seven tentative themes of nurses’ experiences of violations of patient dignity: patients not taken seriously, patients ignored, patients uncovered and exposed, patients physically violated, patients becoming the victims of others’ superiority, patients being betrayed, and patients being predefined. Understanding the contextual experiences of nurses can shed light on the care of patients in involuntary psychiatric hospital care.

Aspects of care culture in municipal care for elderly people: a hermeneutic documentary analysis of reports of abuse

INTRODUCTION

Care culture is an important contextual factor in care practice. Care culture refers to a process of creating meaning out of tradition, horizon and bildung. The care culture is often taken into consideration in situations that go beyond the everyday routine, such as cases of abuse. In Sweden, health care professionals are obliged to document and report any suspected bad conditions. Although the reports have the potential to communicate underlying values and assumptions about the care culture, such studies have not been performed.

AIM

The aim of this study was to understand how elderly care abuse in institutions could be understood from a care culture perspective.

DESIGN AND METHODS

A hermeneutic documentary analysis was conducted on 269 incident reports concerning suspected mistreatment of the elderly in three municipalities in Sweden. The hermeneutic analysis followed a four-stage process: selecting and reading the text, setting out the context, closing the hermeneutic circle, and finally creating a conceptual bridge towards a critical understanding from a phenomenological lifeworld perspective.

FINDINGS

  The care of the elderly in the municipality was based on a social culture that placed residents' needs at the centre. Following routines were considered important in preventing mistreatment and were intended to ensure that all patients were treated fairly and equally. Care was described as task oriented and often lacking in interpersonal relations. From a phenomenological lifeworld perspective, it was interpreted that in the municipalities' care of the elderly, there was a focus on elderly people's freedom at the expense of the vulnerability aspects of well-being.

CONCLUSION

Raising awareness of the care culture underlying abuse could help to improve understanding of care practice. Change may be only possible when reflected on the existing perspectives underpinning the care culture, and integrate them into a broader framework for caring.