Development of nurses’ abilities to reflect on how to create good caring relationships with patients in palliative care: an action research approach

Action research as a catalyst for change: Empowered nurses facilitating patient participation in rehabilitation

Based on action research as a practitioner-involving approach, this article communicates the findings of a two-year study on implementing patient participation as an empowering learning process for both patients and rehabilitation nurses. At a rehabilitation facility for patients who have sustained spinal cord injuries, eight nurses were engaged throughout the process aiming at improving patient participation. The current practice was explored to understand possibilities and obstacles to patient participation. Observations, interviews and logbooks, creative workshops and reflective meetings led to the development and testing of four new rehabilitation initiatives aimed at enhancing patient participation. This study suggests that skills of critical reflection from action research toolbox shed light on both the notion of patient participation and caring in nursing rehabilitation. By actively involving nurses in research, the knowledge development stems from practice and the solutions therefore became practice-oriented. In addition, the personal and professional development experienced by the involved nurses points to a secondary gain in the form of an analytical and reflective approach to complex issues in relation to patient participation, rehabilitation in general and the individual nurses' sense of professional pride.

Appreciative inquiry in a Norwegian nursing home: a unifying and maturing process to forward new knowledge and new practice

PURPOSE

Appreciative inquiry (AI) studies have proven to be useful in developing nursing knowledge and changing nursing practice. However, few AI studies have examined the meaning of participation over time among collaborating healthcare providers. Our aim was to explore and illuminate healthcare providers' participation over time in a Norwegian nursing home to develop new knowledge and practice, focusing on sensory gardens.

METHOD

Twenty healthcare providers participated in the 3 year AI study. Data were collected in fieldwork, interviews, and interventions. Saldañas' longitudinal analysis was applied.

RESULTS

The collaboration between the researcher and participants created insight of a relational room, which was named "the room of closeness". Participants' search for new arenas to apply the meaning of the room of closeness was found when focusing on the sensory garden. Their desire for joint development created a bottom-up perspective, the hallmark of successful AI.

CONCLUSION

Knowledge of participants' experiences may contribute to developing AI as a useful and transferable method, especially regarding co-creating participation, and may have implications for research and society. AI's strength-based approach may, however, lead to the neglect of data that are associated with problems, and complicate the assessment of success. Further research is therefore needed to develop AI.

Dealing with ethical and existential issues at end of life through co-creation

BACKGROUND

In research on co-creation in nursing, a caring manner can be used to create opportunities for the patient to reach vital goals and thereby increase the patient's quality of life in palliative home care. This can be described as an ethical cornerstone and the goal of palliative care. Nurses must be extra sensitive to patients' and their relatives' needs with regard to ethical and existential issues and situations in home care encounters, especially at the end of life.

AIM

The aim of this study was to explore nurses' experiences of dealing with ethical and existential issues through co-creation at the end of life in palliative home care.

RESEARCH DESIGN, PARTICIPANTS, AND RESEARCH CONTEXT

The material consisted of texts from interviews with 12 nurses in a home care context. A hermeneutical approach was used, and the method was inspired by a thematic analysis.

ETHICAL CONSIDERATIONS

Informed consent was sought from the participants regarding study participation and the storage and handling of data for research purposes. Ethical permission to conduct the study was given from organizations that participated in this study.

FINDINGS

A main theme and four subthemes emerged. The main theme was "Deep co-creative relationships are needed to manage ethical and existential issues at the end of life." A model was created to display the findings and relations between ethical issues and situations and the need for a deep trustful caring relationship to solve problems in palliative home care.

DISCUSSION

Together, the themes can be considered as a tool for learning and dealing with ethical and existential issues at the end of life in home care. The themes can also be seen as a part of nurses' ethical competence within this context.

CONCLUSION

The quality of life at the end of life can be improved through co-creation, despite difficult ethical and existential issues. Future research should focus on co-creation from the patients' perspective.

Cocreation as a Caring Phenomenon: Nurses' Experiences in Palliative Home Care

A new concept in palliative care, cocreation, appears to be a part of caring in nursing but has not yet been explored as a caring phenomenon. The aim was to, from a caring science perspective, explore how cocreation can be experienced as a phenomenon by nurses working in palliative home care. A hermeneutical approach and thematic analysis were used. The material consisted of texts from in-depth interviews with 12 nurses in a home care context. Informed consent regarding study participation and the storage and handling of data for research purposes were sought from participants. One main theme and 4 subthemes emerged. Cocreation can be viewed as an essential part of caring and being involved in patients' health and holistic care is a profound endeavor. Further research should focus on illuminating cocreation from patients' perspectives.

Ethical sensitivity and perceptiveness in palliative home care through co-creation

Background:

In research on co-creation in nursing, a caring manner can be used to create opportunities whereby the patient’s quality of life can be increased in palliative home care. This can be described as an ethical cornerstone and the goal of palliative care. To promote quality of life, nurses must be sensitive to patients’ and their relatives’ needs in care encounters. Co-creation can be defined as the joint creation of vital goals for patients through the process of shared knowledge between nurses, patients and their relatives.

Aim:

The aim of this study was to explore nurses’ experiences of caring encounters and co-creation in palliative home care from an ethical perspective.

Research design, participants, and research context:

A hermeneutical approach was used. The material consisted of texts from interviews with 12 nurses in a home care context. The method was inspired by thematic analysis.

Ethical considerations:

Informed consent was sought from the participants regarding study participation and the storage and handling of data for research purposes.

Findings:

An overall theme, a main theme and four sub-themes emerged. Through ethical sensitivity and perceptivity, nurses can balance their actions in the moment and change their nursing care actions according to the patient’s wishes through co-creation in encounters. Here the time is crucial, as the time needed is unique to each patient.

Discussion:

The themes together can be considered prerequisites for good palliative home care. If nurses fail to be sensitive and perceptive in encounters with dying patients, good palliative home care cannot be achieved. Ethical sensitivity and perceptiveness can also be considered a part of nurses’ ethical competence.

Conclusion:

Patients’ dignity can be preserved through ethical sensitivity and perceptiveness, which is fundamental for good palliative care. Co-creation from patients’ perspectives should be the focus of future research.

The theory of a co-creative process in advanced palliative home care nursing encounters: A qualitative deductive approach over time

AIMS AND OBJECTIVES

The aim of this study was to test the theoretical conceptualization of the co-creative process in home care nursing encounters over time.

METHOD AND DESIGN

This was a multiple case study with a deductive analysis of qualitative data over time, using interviews and observations collected from three cases.

RESULTS

The co-creative process was complex and contained main, sub- and micro-processes. Time was important and valuable, giving the patient and relatives space to adjust the process to their own pace. Some processes were worked on more intensively in accordance with the patients' and relatives' needs, and these are considered the main-process. The further developed theory of the co-creative process and its main, sub- and microprocesses can be understood as a concretization of how good nursing care can be performed within caring relationships in the context of advanced palliative home care.

Nurses respond to patients' psychosocial needs by dealing, ducking, diverting and deferring: an observational study of a hospice ward

BACKGROUND

Psychosocial support is considered a central component of nursing care but it remains unclear as to exactly how this is implemented in practice. The aim of this study was to provide a descriptive exploration of how psychosocial needs (PNs) of patients in a hospice ward are expressed and met, in order to develop an understanding of the provision of psychosocial support in practice.

METHODS

An embedded mixed-methods study was conducted in one hospice ward. Data collection included observations of patients' expressions of PNs and nurses' responses to those expressed PNs, shift hand-overs and multi-disciplinary meetings. Interviews about the observed care were conducted with the patients and nurses and nursing documentation pertaining to psychosocial care was collated. Descriptive statistical techniques were applied to quantitative data in order to explore and support the qualitative observational, interview and documentary data.

RESULTS

During the 8-month period of observation, 227 encounters within 38 episodes of care were observed among 38 nurses and 47 patients. Within these encounters, 330 PNs were expressed. Nurses were observed immediately responding to expressed PNs in one of four ways: dealing (44.2 %), deferring (14.8 %), diverting (10.3 %) and ducking (30.7 %). However, it is rare that one type of PN was clearly expressed on its own: many were expressed at the same time and usually while the patient was interacting with the nurse for another reason, thus making the provision of psychosocial support challenging. The nurses' response patterns varied little according to type of need.

CONCLUSIONS

The provision of psychosocial support is very complex and PNs are not always easily recognised. This study has allowed an exploration of the actual PNs of patients in a hospice setting, the way in which they were expressed, and how nurses responded to them. The nurses faced the challenge of responding to PNs whilst carrying out the other duties of their shift, and the fact that nurses can provide psychosocial support as an inherent component of practice was verified. The data included in this paper, and the discussions around the observed care, provides nurses everywhere with an example against which to compare their own practice.

Strengthening practical wisdom: mental health workers' learning and development

BACKGROUND

Practical wisdom, understood as knowing how to be or act in any present situation with clients, is believed to be an essential part of the knowledge needed to be a professional mental health worker. Exploring processes of adapting, extending knowledge and refining tacit knowledge grounded in mental health workers' experiences with being in practice may bring awareness of how mental health workers reflect, learn and practice professional 'artistry'.

RESEARCH QUESTION

The aim of the article was to explore mental health workers' processes of development and learning as they appeared in focus groups intended to develop practical wisdom. The main research question was 'How might the processes of development and learning contribute to developing practical wisdom in the individual as well as in the practice culture?'

RESEARCH DESIGN

The design was multi-stage focus groups, and the same participants met four times. A phenomenological hermeneutical method for researching lived experience guided the analysis.

PARTICIPANTS AND CONTEXT

Eight experienced mental health workers representing four Norwegian municipalities participated. The research context was community-based mental health services.

ETHICAL CONSIDERATIONS

The study was reported to Norwegian Social Data Services, and procedures for informed consent were followed.

FINDINGS

Two examples of processes of re-evaluation of experience (Association, Integration, Validation, Appropriation and Outcomes and action) were explored. The health workers had developed knowledge in previous encounters with clients. In sharing practice experiences, this knowledge was expressed and developed, and also tested and validated against the aims of practice. Discussions led to adapted and extended knowledge, and as tacit knowledge was expressed it could be used actively.

DISCUSSION

Learning to reflect, being ready to be provoked and learning to endure indecisiveness may be foundational in developing practical wisdom. Openness is demanding, and changing habits of mind is difficult.

CONCLUSION

Reflection on, and confrontation with, set practices are essential to building practice cultures in line with the aims of mental health services.

Why a carefully designed, nurse-led intervention failed to meet expectations: the case of the Care Programme for Palliative Radiotherapy

PURPOSE OF THE RESEARCH

Implement and evaluate the Care Programme for Palliative Radiotherapy (CPPR) in the Outpatient Clinic of the Department of Radiotherapy, Erasmus MC-Cancer Institute, Rotterdam, The Netherlands.

METHODS

Participatory Action Research (PAR). Qualitative descriptive design: participatory observations, semi-structured interviews with patients and professionals and focus groups with professionals; content analysis of documents.

SAMPLE

Patients with impending paraplegia due to metastatic spinal cord compression, nurse practitioners (NPs), nurse manager, staff and ward nurses, radiographers, radiotherapists and medical doctors.

KEY RESULTS

After a shift from inpatient to outpatient radiotherapy treatment, patients and healthcare professionals perceived shortcomings in the oncological chain care. The CPPR was developed in a participative way giving a key role to the NP. Evaluation after implementation of the programme showed that patients and professionals were predominantly positive about its effects. However, implementation was not sustained due to lack of institutional and managerial support.

CONCLUSIONS

The technological innovation far preceded the organisational changes needed to provide innovative, patient-centred care. Implementing this programme with a central role for the NP was seen as the solution to the problems identified. However, in spite of the systematic approach using PAR, the programme was not successful in bringing about sustained improvements. NPs fulfil a valuable role in the care and support of patients with palliative care needs but need institutional support. More attention should have paid to the organisational context. Involve all relevant actors; use a participatory approach to enhance commitment; ensure the support of management during the whole project.

Co-creating possibilities for patients in palliative care to reach vital goals--a multiple case study of home-care nursing encounters

The patient's home is a common setting for palliative care. This means that we need to understand current palliative care philosophy and how its goals can be realized in home-care nursing encounters (HCNEs) between the nurse, patient and patient's relatives. The existing research on this topic describes both a negative and a positive perspective. There has, however, been a reliance on interview and descriptive methods in this context. The aim of this study was to explore planned HCNEs in palliative care. The design was a multiple case study based on observations. The analysis includes a descriptive and an explanation building phase. The results show that planned palliative HCNEs can be described as a process of co-creating possibilities for the patient to reach vital goals through shared knowledge in a warm and caring atmosphere, based on good caring relations. However, in some HCNEs, co-creation did not occur: Wishes and needs were discouraged or made impossible and vital goals were not reached for the patients or their relatives. Further research is needed to understand why. The co-creative process presented in this article can be seen as a concretization of the palliative care ideal of working with a person-centered approach.