Striking a professional balance: interactions between nurses and their older rural patients

Blurred lines: Ethical challenges related to autonomy in home-based care

BACKGROUND

Home-based care workers mainly work alone in the patient's home. They encounter a diverse patient population with complex health issues. This inevitably leads to several ethical challenges.

AIM

The aim is to gain insight into ethical challenges related to patient autonomy in home-based care and how home-based care staff handle such challenges.

RESEARCH DESIGN

The study is based on a 9-month fieldwork, including participant observation and interviews in home-based care. Data were analysed with a thematic analysis approach.

PARTICIPANTS AND RESEARCH CONTEXT

The study took place within home-based care in three municipalities in Eastern Norway, with six staff members as key informants.

ETHICAL CONSIDERATIONS

The Norwegian Agency for Shared Services in Education and Research evaluated the study. All participants were competent to consent and signed an informed consent form.

FINDINGS

A main challenge was that staff found it difficult to respect the patient's autonomy while at the same time practicing appropriate care. We found two main themes: Autonomy and risk in tension; and strategies to balance autonomy and risk. These were explicated in four sub-themes: Refusing and resisting care; when choosing to live at home becomes risky; sweet-talking and coaxing; and building trust over time. Staff's threshold for considering the use of coercion appeared to be high.

CONCLUSIONS

Arguably, home-based care staff need improved knowledge of coercion and the legislation regulating it. There is also a need for arenas for ethics reflection and building of competence in balancing ethical values in recurrent ethical problems.

"A becoming in the meeting": the interpretations of competence in home care from the perspectives of older people and registered nurses - a meta-ethnography

AIM

The aim of this meta-ethnography was to identify and synthesize qualitative studies focusing on older people's and registered nurses' interpretations of competence in home care.

METHODS

The meta-ethnography followed the six phases developed by Noblit and Hare (1988).

RESULTS

In Phase 6, the translation process of the included studies, three themes were identified: i) temporality-the feeling of being of value; ii) dignity-a person, not just a patient; and iii) mutuality of being-togetherness. A synthesis was developed, and the phrase "a becoming in the meeting" emerged.

CONCLUSION

The sense of becoming includes progress, which means becoming something other than before in relation with others and refers to what constitutes the meeting between the older person and the registered nurse working in home care. Competence originates from becoming in the meeting, and registered nurses should therefore value what they do and hold on to this aspect of caring competence that centres on a caring relationship. It is important for registered nurses working in home care to be able to cultivate a caring relationship.

"Friend-ish": Home Care Workers, "Social Labor" and Managing the Boundaries of the Carer Relationship

We examine how changes in home care work, with greater emphasis on social support, have led to corresponding changes in the forms of labor performed by home care workers. Drawing on interviews with fifty older adults, we find in addition to physical and emotional labor, workers may be increasingly expected to engage in a form of labor we term "social labor," in which they actively manage the boundary between the professional services they provide and the personal relationships that may develop. We find examples of such expectations include (1) following the lead of clients who set out terms of the relationship and degree of sociality, (2) managing the potential dual role of "support worker" and "friend," and (3) meeting social needs of clients vulnerable to isolation. As Government acknowledges the value of social support and companionship, greater attention is needed to this aspect of care work, with implications for workers and clients.

Nurses' experiences of encounters in home care: a phenomenological hermeneutic study

PURPOSE

nurses working in home care often encounter patients with multiple diagnoses in unpredictable environments. This may cause ethical and emotional challenges and influence nurses' daily work. The aim of this study was to illuminate the meaning of nurses' lived experiences of encountering patients in home care.

METHODS

narrative interviews were conducted with 11 nurses. These interviews were audiotaped and transcribed verbatim and analysed using a phenomenological hermeneutic approach.

FINDINGS

the findings are presented under three main themes: (1)"Being receptive to the other" (with subthemes "Caring about the encounter," and "Establishing trusting relationships"). (2) "Need to handle Handling the unpredictable" (with subthemes "Being alone in the encounter" and "Being experienced and competent"). (3) "Managing frustration" (with subthemes "Feeling insufficient" and "Feeling restricted". Having overall nursing responsibility challenged the nurse's self-confidence in providing care trustfully.

CONCLUSIONS

encountering patients in home care means relating to the other unconditionally, which aim to highlight patients' needs. Being a nurse in home care is both emotionally demanding and rewarding. Having the courage to face their own and the patients' vulnerabilities will entail the promotion of natural receptivity and responsiveness to patients' needs.

Sámi and Norwegian nurses' perspectives on nursing care of Sámi patients: a focus group study on culturally safe nursing

Sámi people report less satisfaction with healthcare services than the majority population in Norway, and report that they seldom encounter culturally adapted health services. This study investigates Sámi and Norwegian nurses’ perspectives on culturally respectful and appropriate caring for Sámi patients in northern Norway. Six focus groups were conducted: three with Sámi-speaking nurses (n = 13) and three with Norwegian-speaking nurses (n = 10). Data were collected and analysed in line with Thorne’s interpretive descriptive methodology. Three overarching themes emerged from the interviews: (i) the importance nurses gave to establishing a connection and building trust with Sámi patients; (ii) nurses’ perceptions that in comparison to Norwegian patients Sámi patients could be less confrontational and direct, but that differences weren’t always apparent and (iii) the importance nurses described to understanding the cultural context of their Sámi patients. This study showed that Sámi and Norwegian nurses working in northern Norway were largely perceptive about and respectful of cultural differences between Sámi and Norwegian patients. Some emphasised, though, that Sámi patients were diverse and that interpersonal differences were as or more important than cultural differences. Some also felt that more understanding of Sámi culture would be helpful for enabling culturally respectful nursing care.

The relation between older adults’ trust beliefs in nursing home carers and adjustment to residential care

The study examined the relation between older adults’ trust beliefs in nursing home carers (NHCs) and adjustment to residential care. Seventy-six older adults (mean age = 83 years, standard deviation = 7 years from UK nursing homes completed standardised scales of trust beliefs in NHCs and adjustment to residential care (satisfaction with care-giving, social engagement in the nursing home, loneliness and a latent measure). As expected, trust beliefs in NHCs were linearly associated with adjustment to residential care on all measures. There were quadratic relations between trust beliefs in NHCs and on given measures of adjustment to residential care (latent measure, satisfaction with care-giving and loneliness). Adults with very high and those with very low trust beliefs in NHCs showed depressed levels on those measures of adjustment to residential care relative to older adults with the middle range of trust beliefs. The research highlights the importance of older adults’ trust beliefs in NHCs for adjustment to nursing homes. The findings show though, that older adults who hold very high, as well those who hold very low, trust beliefs in NHCs are at risk for lower levels of adjustment.

Staff's perspectives on the organization of homecare services to people with dementia-A qualitative study

Aims

The aim of the study was to explore the experiences of homecare staff about the impact of the organization of homecare services for people with dementia.

Design

This study has a qualitative, exploratory design based on a phenomenological‐hermeneutic approach, using individual in‐depth interviews with homecare staff to collect data.

Methods

A convenience sample of 14 homecare staff from five municipalities participated in the study. Main topics introduced: (a) how homecare services for people with dementia are organized and (b) challenges in respondents' everyday practice of caring for people with dementia. Interviews were conducted from October to December 2017.

Results

Three main themes were identified from the interviews. (a) Complexity and need for individualized facilitated homecare services; homecare services were described as complex in regard to both the patient and the service. The complexity of the service made it challenging to tailor the service to the individual patient. (b) The importance of trust and relationships; establishing trust in the relationship between the patient and the staff resulted in better‐quality care. This was crucial for identifying the patient's need for help. (c) Organizational challenges; homecare services could be vulnerable to changes in the organization. Practical tasks and following the daily scheduled task list were often prioritized at the expense of an individually tailored service.

Ethical challenges in home-based care: A systematic literature review

Because of the transfer of responsibility from hospitals to community-based settings, providers in home-based care have more responsibilities and a wider range of tasks and responsibilities than before, often with limited resources. The increased responsibilities and the complexity of tasks and patient groups may lead to several ethical challenges. A systematic search in the databases MEDLINE, CINAHL, and SveMed+ was carried out in February 2019 and August 2020. The research question was translated into a modified PICO (Population, Intervention, Comparison, and Outcome) worksheet. A total of 40 articles were included. The review is conducted according to the Vancouver Protocol. The main findings from the systematic literature review show that ethical challenges experienced by healthcare and social care providers in home-based care are related to autonomy and balancing ethical principles, decisions regarding intensity of care, challenges related to priority settings, truth-telling, and balancing the professional role. Findings regarding ethical challenges within home-based care are in line with findings from institutional healthcare and social care settings. However, some significant differences from the institutional context are also highlighted.

Nordic homecare nursing from the perspective of homecare nurses-a meta-ethnography

The pressure on homecare nursing in the Nordic countries has increased in recent years because of a reorganisation of healthcare systems that has put a focus on very early discharge from hospital as well as demographic changes. This article details an analysis of the findings of 13 published qualitative research reports about Nordic homecare nurses' experiences of their work. Using a process of meta-ethnography, the authors identify five themes within the primary research: home care as a professional practice on foreign ground; home care as a massive time constraint; home care as fair rationing; home care as relationships with relatives as fellow players or opponents; and home care as latent paternalism. These have two main implications for practice: homecare nurses should continuously be taught how to cooperate with partners who are emotionally involved; and also homecare nurses may benefit from training that focuses on the challenges of carrying out professional work in private settings.

Perceptions of sense of community and community engagement among rural nurses: Results of a national survey

BACKGROUND

Variations in rural nurses' sense of community and engagement in rural communities are poorly understood, although there is evidence that these are linked to community cohesion and perceived community resilience.

OBJECTIVE

The aim of our research was to develop descriptive profiles of rural nurses who exhibit a sense of community and community engagement at low, average, and high levels, based on occupational, personal, community, and regional characteristics. These results were linked to levels of cohesion and resilience.

DESIGN

A survey questionnaire, including established scales, demographic information, and information about rural nursing practice was administered to rural nurses.

SETTINGS

Rural communities in all provinces and territories in Canada outside the commuting zone of urban areas with 10,000 or more inhabitants.

PARTICIPANTS

Multi-level systematic stratified sampling was employed for the national survey. A subsample of 2116 Registered Nurses, Nurse Practitioners, and Licensed Practical Nurses comprised the participants for this analysis.

METHODS

The analysis was conducted in two stages: (1) in the first subset, those (n = 2116) whose primary work community was rural, remote, or rurban with less than 10,000 inhabitants were grouped into a nine-group typology based on low, average, and high tertiles of Psychological Sense of Community and Community Engagement. The second subset (n = 993) represented those in three groups: low-low, average-average, and high-high scores on the two indices. Significant differences between the three groups were identified based on occupational, personal, community, and regional characteristics. Chi Square, ANOVA, and correlation tests were applied as required.

RESULTS

Nurses with low scores on both Psychological Sense of Community and Community Engagement were more likely to be from larger communities, single or divorced and living and working in the North. Those with average scores on both scales have been in their nursing positions for more than 20 years, are middle aged and are satisfied with their home community. Nurses in the third group have high scores on both indicators; they are more likely to be from a smaller childhood communities, married or living common-law, and are in the late middle age group.

CONCLUSIONS

By focusing on the key variables or traits of nurses, modifiable recruitment and retention practices can be implemented. For example, it is important to recruit nurses who are from smaller communities. Other initiatives for nurses include matching community activities with the age and stage of the family and developing a welcoming strategy for the workplace and community for newly arrived nurses.

Caring in nursing homes to promote autonomy and participation

Background:

Autonomy and participation are threatened within the group of older people living in nursing homes. Evidence suggests that healthcare personnel act on behalf of older people but are still excluding them from decision-making in everyday care.

Objective:

The purpose was to describe registered nurses’ experience of caring for older people in nursing homes to promote autonomy and participation.

Research design:

A descriptive design with a phenomenological approach was used. Data were collected by semi-structured individual interviews. Analysis was inspired by Giorgi’s method.

Participants and research context:

A total of 13 registered nurses from 10 nursing homes participated.

Ethical considerations:

Ethical approval was obtained from the Regional Research Ethics Committee. Informed consent was achieved and confidentiality guaranteed.

Findings:

The essence of caring for older people in nursing homes to promote autonomy and participation consisted of registered nurses’ awareness of older people’s frailty and the impact of illness to support health and well-being, and awareness of acknowledgement in everyday life and trusting relationships. Paying attention to older people by being open to the persons’ wishes were aspects that relied on registered nurses’ trusting relationships with older people, their relatives and surrounding healthcare personnel. The awareness reflected challenges in caring to promote older people’s right to autonomy and participation in nursing homes. Registered nurses’ strategies, hopes for and/or concerns about development of everyday life in nursing homes were revealed and mirrored their engagement in caring for older people.

Discussion and conclusion:

Awareness of older people’s frailty in nursing homes and the importance of maintained health and well-being were described as the main source for promoting autonomy and participation. Everyday life and care in nursing homes needs to be addressed from both older people’s and healthcare personnel’s perspectives, to promote autonomy and participation for residents in nursing homes.