Being in the world of the suffering patient: a challenge to nursing ethics

Victims of disaster: can ethical debriefings be of help to care for their suffering?

Victims of disaster suffer, not only at the very moment of the disaster, but also years after the disaster has taken place, they are still in an emotional journey. While many moral perspectives focus on the moment of the disaster itself, a lot of work is to be done years after the disaster. How do people go through their suffering and how can we take care of them? Research on human suffering after a major catastrophe, using an ethics of care perspective, is scarce. People suffering from disasters are often called to be in distress and their emotional difficulties 'medicalised'. This brings them often into a situation of long term use of medication, and one can wonder if medication is of help to them in the long run. In our paper, we will explore another moral perspective, focusing on the importance of the victims' narrative and their lived experiences. We will use Paul Ricoeur's phenomenological reflections from 'Suffering is not the same as pain' for conceptualizing human suffering and how to apply it to victims of disaster. Ricoeur suggests that suffering is not a quantity that can be measured, but a characteristic that should be studied qualitatively in interpersonal and narrative contexts. Above all, the perspective of care and listening could offer an opportunity to reconcile people from their loss and suffering.

A Theoretical Approach to Documentation of Care

The purpose of this column is to present a theoretical background for understanding nursing care documentation. The theory used was Eriksson’s theory of health and suffering. An adaptation of Gadamer’s hermenuetic method was used to apply the theory to a way of thinking about clinical practice. The hermeneutic dialogue took place between Eriksson’s caring science texts and clinical nursing practice. The dialogue shows that relating different dimensions of the patient’s health and suffering to the dimensions of care seems to provide the necessary prerequisites for the development of a theoretical background for the documentation of care. It also allows the patient’s views and experiences to be revealed in the documents related to nursing care.

The Dialectic Tension Between ‘Being’ and ‘Not Being’ a Good Nurse

The aim of this hermeneutic study was to gain a broader understanding of nurses’ workload and what characterizes a nurse’s experience in terms of the various levels of intensity of nursing care. Twenty-nine nurses participated in seven focus groups. The interpretation process took place in six different phases and the three laws of dialectics were used as interpretation rules. An optimal nursing care intensity level can be understood as a situation characterized by the balance between the intensity of care needed by patients and the external and internal factors of the current nursing care situation. The nurses’ work situation can be understood as a dialectic struggle between ‘being’ and ‘not being’ a good nurse; this can be said to be the underlying root metaphor. Nursing care can be understood as consisting of ‘complex and meaningful caring situations’. Dialectics can be used as a fruitful method of revealing the complexity of clinical reality.

Documentation of Individualized Patient Care: a qualitative metasynthesis

The aim of this study was to increase understanding of how individual patient care and the ethical principles prescribed for nursing care are implemented in nursing documentation. The method used was a metasynthesis of the results of 14 qualitative research reports. The results indicate that individualized patient care is not visible in nurses’ documentation of care. It seems that nurses describe their tasks more frequently than patients’ experiences of their care. The results also show that the structure of nursing documentation and the forms or manner of recording presupposed by the organization may prevent individual recording of patient care. In order to obtain visibility for good patient-centred and ethical nursing care, an effort should be made to influence how the content of nursing care is documented and made an essential part of individual patient care. If the content of this documentation does not give an accurate picture of care, patients’ right to receive good nursing care may not be realized.

Fragility—The Price of Renewed Life. Patients Experiences of Open Heart Surgery

Background: Open heart surgery often implies a threat to life and is associated with fear and anxiety. It is also a strong encroachment on body and integrity and adjusting life afterwards could be difficult. Despite improvements in treatment the patients' reactions appear to be unchanged. Introducing a lifeworld perspective would supply a different kind of knowledge based upon the patients' own experiences coloured by their linguistic usage and bodily expressions.

Aim: The aim of this study was to describe patients' experiences of open heart surgery in a lifeworld perspective.

Method: Fourteen patients treated with coronary artery bypass surgery and/or heart valve operation were in-depth interviewed in 2003. The phenomenological method was used for the interviews as well as for the analysis. The informants reflected on their experiences of the illness, meetings with health care, family relations and wishes for the future.

Findings: The essence of the phenomenon was fragility. Fragility was understood through the following categories: distance, uncertainty, vulnerability, reliance and gratitude.

Conclusions: Patients want to be treated as unique individuals. They ask for more dialogues with the staff. Awareness of their supposed lifelong fragility implies that health care staff acquires an open and holistic approach.

Patient Experiences of Loneliness: An Evolutionary Concept Analysis

Loneliness is a painful experience for patients. To clarity the concept of patient loneliness, this study undertook an evolutionary concept analysis based on a literature search in the main relevant databases. We identified 7 dimensions in adult patients' experiences of loneliness. These dimensions of loneliness have different causes and theoretical foundations, which have different implications for patient care. Patients may be lonely in their different relationships, including those with nurses and doctors. Loneliness in relation to health care professionals is a new application of the concept of loneliness that provides a useful starting point for future research.

Living in hope and desperate for a miracle: NICU nurses perceptions of parental anguish

The birth of an extremely premature baby is a tragedy, and it is only natural that the parents will rely on the spiritual and religious beliefs that guide the rest of their lives. At this difficult time, parents with strong religious beliefs will hope for divine intervention and pray for a miracle. This paper outlines the difficulties experienced by neonatal nurses when caring for an extremely premature baby whose parents hold on to hope and their belief in divine intervention and a miracle. Data were collected via a questionnaire to Australian neonatal nurses and semi-structured interviews with 24 neonatal nurses in NSW, Australia. A qualitative approach was used to analyse the data. The theme of "hoping for a miracle" was captured by two sub-themes "praying for a miracle" and "oscillating between hope and despair". For some families, the hope of divine intervention seemed all consuming, and the nurses were witness to the desperation and disappointment of families when a miracle was not forthcoming.

It’s agony for us as well

Background:

Improved techniques and life sustaining technology in the neonatal intensive care unit have resulted in an increased probability of survival for extremely premature babies. The by-product of the aggressive treatment is iatrogenic pain, and this infliction of pain can be a cause of suffering and distress for both baby and nurse.

Research question:

The research sought to explore the caregiving dilemmas of neonatal nurses when caring for extremely premature babies. This article aims to explore the issues arising for neonatal nurses when they inflict iatrogenic pain on the most vulnerable of human beings – babies ≤24 weeks gestation.

Participants:

Data were collected via a questionnaire to Australian neonatal nurses and semi-structured interviews with 24 neonatal nurses in New South Wales, Australia.

Ethical consideration:

Ethical processes and procedures set out by the ethics committee have been adhered to by the researchers.

Findings:

A qualitative approach was used to analyse the data. The theme ‘inflicting pain’ comprised three sub-themes: ‘when caring and torture are the same thing’, ‘why are we doing this!’ and ‘comfort for baby and nurse’. The results show that the neonatal nurses were passionate about the need for appropriate pain relief for extremely premature babies.

Conclusion:

The neonatal nurses experienced a profound sense of distress manifested as existential suffering when they inflicted pain on extremely premature babies. Inflicting pain rather than relieving it can leave the nurses questioning their role as compassionate healthcare professionals.

Singularity and medicine: is there a place for heteronomy in medical ethics?

RATIONALE, AIMS AND OBJECTIVES

In medicine and in clinical practice, autonomy is opposed to heteronomy or paternalism. While autonomy comes down to free choice, independence or self-fulfillment, heteronomy or paternalism are associated with restraints from outside, lack of free choice or dependence. Despite several mediating concepts such as relational autonomy, this opposition stands firm in medical discourse.

METHODS AND RESULTS

Reflecting upon his own heart transplantation but also falling back upon the whole of his oeuvre, we want to analyze what the impact of Nancy's thought can be on the concept of autonomy in medicine. As in Nancy's theory, autonomy and heteronomy are intertwined, how then to understand the autonomous individual in a clinical context? Nancy developed in his book Corpus, the untranslatable French word 'expeausition' to express the exposure of surfaces to one another - playing on the term 'exposition': 'peau', in French, means skin. Skin is literally exposed to contact with another skin or surface. Such exposure and such contact is 'world' he argues, in the same way that a product exchange between two people is. Heteronomy therefore is constitutive for autonomy, not a restraint of it.

CONCLUSIONS

Analyzed from the work of French philosopher Jean-Luc Nancy, there is no such thing as autonomy because every 'self' or 'I' is always already intruded by something from outside. There is no autonomy without heteronomy, he argues and he therefore prefers to speak of an individual as being exposed to the outer world.

Human dignity in religion-embedded cross-cultural nursing

BACKGROUND

Although human dignity is an unconditional value of every human being, it can be shattered by extrinsic factors. It is necessary to discover the authentic meaning of patients' dignity preservation from different religious perspectives to provide professional cross-cultural care in a diverse setting.

RESEARCH OBJECTIVE

This article identifies common experiences of Iranian Muslim and Armenian Christian patients regarding dignified care at the bedside.

RESEARCH DESIGN

This is a qualitative study of participants' experiences of dignified care elicited by individual in-depth semi-structured interviews.

PARTICIPANTS AND RESEARCH CONTEXT

A purposeful sample of 10 participants (five Iranian Muslims and five Iranian Armenians) from various private and governmental hospital settings was chosen.

ETHICAL CONSIDERATIONS

This study was approved by the ethics committee of Tehran University of Medical Sciences. All the participants were provided with information about the purpose and the nature of the study, the voluntary condition of their participation in this study, and the anonymous reporting of recorded interviews.

FINDINGS

The common experiences of Christian and Muslim patients regarding dignity preservation emerged as "exigency of respecting human nobility" and "providing person-centered care."

DISCUSSION AND CONCLUSION

It is essential to recognize the humanness and individuality of each patient to preserve and promote human dignity in diverse cross-cultural settings. The findings support and expand current understanding about the objective and subjective nature of dignity preservation in cross-cultural nursing.

The interaction between the patient and nurse anesthetist immediately before elective coronary artery bypass surgery

PURPOSE

Establishing a purposive interaction with a patient who is in a vulnerable situation before coronary artery bypass graft (CABG) surgery poses a challenge for the nurse anesthetist. The aim of this study was to identify and describe the interaction between the patient and the nurse anesthetist immediately before elective CABG surgery.

DESIGN

An observational study using a grounded theory design was used.

METHODS

A theoretical selection of patients and nurse anesthetists was made. A total of 11 situations of patient/nurse anesthetist interaction were observed. The data were analyzed using the constant comparative method.

FINDINGS

A core category of reassurance emerged from other categories of continuity, confirmation, and control. Continuity was characterized by expedient anesthesia nursing of high quality, confirmation was related to communication in a trusting atmosphere, and control was associated with skilled nursing interventions in the thoracic operating theatre.

CONCLUSIONS

Reassurance can be achieved through a well-structured anesthesia nursing performance in the thoracic operating theatre, and by focusing on the patient and continuously giving him/her information during the preoperative preparation phase.

Nursing: The Skill and Art of Being in a Society of Multitasking

Multitasking, a media-driven bias toward dramatic scenarios, and an emphasis on meeting institutional goals in the form of documentation have led to a culture of action-based practice, which interferes with nurses’ ability to simply be with patients. In order for nurses to be fully present with their patients, the cultural norm of multitasking and the emphasis on doing must be reexamined within the context of patient care.

Research on ethics in nursing care for older people: A literature review

The aim of this review was to analyse the empirical studies that focus on ethics in nursing care for older people, scoping the need and areas for further study. A search of the MEDLINE and CINAHL databases (earliest to August 2009) was conducted using the the keywords: ethic* and nursing or care or caring and elderly or aged or older. After a four-stage process, 71 empirical articles were included in the review, with informants ranging from elderly people to relatives, caregivers, managers and students in care settings. The review focusses on the concepts, contexts, methods and validity of these studies. Based on the analysis, the reviewed research seems to be fragmented and multifaceted, focussing on selected issues such as autonomy, self-determination and informed consent. No large research programs or research traditions were found so it was not possible to draw any conclusions about suitable methods, study designs or instruments of measurement for use in this research area.

Experiences of intensive care unit diaries: 'touching a tender wound'

AIM

The aim of this study was to describe peoples' experiences of a personal diary written when they were critically ill and receiving care in an intensive care unit (ICU).

BACKGROUND

In some ICUs, diaries are written by the ICU staff and close relatives of those who are critically ill and mechanically ventilated, but there is a lack of studies that focus on the experiences of the formerly critically ill of personal diaries written when in an ICU.

METHODS

Qualitative personal interviews were conducted with nine people who were formerly critically ill. The interview texts were analysed using qualitative content analysis.

FINDINGS

From the analysis of the data, one theme emerged - touching a tender wound, with four categories: being afraid and being deeply touched, appreciating close relatives' notes, a feeling of unreality and gaining coherence. The participants were deeply touched when they read the diary for the first time. Parts of it were experienced as unreal, as if they were reading about someone else. The diary provided necessary knowledge about what had happened during the time when the participants were critically ill and from which they had only fragmented or no memories at all. Even though it aroused strong feelings, reading the diary was experienced as an important support for a long time after their stay in the ICU. Experiencing that one was not fully aware of what had happened and then reading about oneself being critically ill and about one's close relatives' experiences was interpreted as touching a tender wound.

CONCLUSIONS AND RELEVANCE TO CLINICAL PRACTICE

It is suggested that a diary may be a tool that can help formerly critically ill people to gain a sense of coherence concerning their critical illness experience, but reading it can be painful and demanding.

Home as place for healing

Although environment is a core concept in nursing, it has had little theoretical or empirical attention, especially related to healing. This article explores the following aspects of the meaning of healing as they relate to environment as place: (a) healing is grounded in suffering; (b) healing is active and requires presence of the patient and the nurse; and (c) healing is private, spiritual, and profound. Home is explored as a place for healing. The article explores implications for the study of meaning of home, when home is not a place for healing, and future directions for theory and research.

Uncovering the Ethics of Suffering Using a Narrative Approach

The purpose of this article is to portray the ethics of suffering based on the published literature. Narrative use has become common in the fields of nursing education and curriculum development and in the determination of practice competencies. Understanding the ethics of suffering implies a hermeneutic movement between alienation and dedication. To understand the ethical significance of human suffering, the scene of suffering is described through the concepts of: to endure, to struggle, to sacrifice life and health, and to become. To respond, to discover, to approach, to touch and to shape patients' different patterns of life implies responsibility: to see, to affirm their dignity by being, and to express this in ethical words. Narration plays a crucial role in transforming suffering, that is, reformulating patients' stories. It is vital that educators should create a learning environment where students can find the courage and intention to be present and listen to patients' narratives.

Patients' experiences of recurrent depression

This study explores the lived experiences of individuals who are suffering from recurrent depression. Open interviews were conducted in Sweden with ten participants aged 19-67. Guided by the phenomenological method of Giorgi, data were analyzed within a Reflective Lifeworld Approach. The findings revealed a pattern of meaning, described as being alienated from oneself and others. Depression is described as an insidious disorder and participants described their experiences variously as elusive, extensive, complex, contradictory, paradoxical and stated that depression pervaded the person's whole lifeworld, involved both body and soul, and affected relationships with others. Relationships with others could be the reason for both wanting to live or to die. How best to confirm this form of suffering is something of a challenge to mental health care professionals.

The expression of caring within the perioperative dialogue: a hermeneutic study

BACKGROUND AND AIM

This article, which is based on a study conducted in a perioperative context in Sweden, focuses on nurse anaesthetists' and theatre nurses' descriptions of caring and how caring becomes visible to patients in the perioperative dialogue. The perioperative dialogue is the pre-, intra- and postoperative meeting between the nurse and patient in connection with the latter's surgery.

METHODS

Semi-structured interviews were conducted with 18 patients and 20 nurses, in which they described their experiences of perioperative dialogues. The interpretation process was based on Gadamer's philosophy of hermeneutics.

FINDINGS

The findings indicate that, as a caring act, the vow involves: promising to allow the patient to be him/herself, promising to safeguard the welfare of the patient and promising to guide the patient through the operation as well as taking responsibility for that which I have promised. From the patient's perspective, the nurse was someone who: cares about me, takes me seriously, creates a calm atmosphere and to whom I can hand over responsibility.

CONCLUSIONS

Four empirical assumptions were formulated in relation to the nurse's vow and how the nurse's caring became visible to the patients.

Health care implications and space allocation of research published in nursing journals

PURPOSE

To examine how research is disseminated through nursing journals and to examine characteristics of published research.

DESIGN

A cross-sectional descriptive survey was conducted with manuscripts from 78 nursing journals that publish research.

METHOD

The final issue for 1999 was examined. Pairs of independent raters content-analyzed all research manuscripts.

DISCUSSION

Research studies comprised 241 (42.9%) of the manuscripts and 51.4% of the journal space. Many empirical studies omitted validity and reliability. Few manuscripts reported the date for completion of data collection, and fewer than one third contained the length of time from acceptance to publication.

CONCLUSIONS

Enhanced instrumentation reporting, shorter time from data collection to publication, and an increase in journal space devoted to research might enable nurses to make more cutting-edge clinical decisions.

The ethics of the caring conversation

The aim of this study was to explore the ethical foundations for a caring The analysis is based on the ethics of Paul Ricoeur and deals with questions such as what kind of person the nurse ought to be and how she or he engages in caring conversations with suffering others. According to Ricoeur, ethics (the aim of an accomplished life) has primacy over morality (the articulation of aims in norms). At the ethical level, self-esteem and autonomy were shown to be essential for a person (nurse) to act with respect and responsibility. The ethical relationship of a caring conversation was found to metrical, because of the passivity inflicted by suffering. This asymmetry was found to be potentially unethical if not balanced with reciprocity. In the ethical context, the caring conversation is one in which the nurse makes room through the ethos of caritas for a suffering person to regain his or her self-esteem, and thus makes a good life possible.

Weaving the fabric of spirituality as experienced by patients who have undergone a coronary bypass surgery

When one is faced with a life-threatening event, spiritual issues become extremely important. The depth of one person's suffering is a unique experience. The relationship that developed between the interpretation of the answers of the coronary artery bypass patients and self-interpretation were the two directions in which this hermeneutic research moved forward within the hermeneutic circle. Central implications of the concept of spirituality emerging from this study are spirituality as meaning through gaining a new appreciation of life and health, spirituality as an inner strength through love and faith and in an ontological sense, spirituality as an inner strength through suffering and desire. Suffering invites one into the spiritual domain. Indeed, this concept raises important considerations for the development of caring knowledge about spirituality.