Patients' and Nurses' experiences of caring in nursing: An integrative literature review across clinical practices

AIM

To summarise, interpret and synthesize research findings on patients' and nurses' experiences of caring in nursing across clinical practices.

BACKGROUND

Caring is a universal element of nursing; however, economic restrictions often negatively impact health services, and time shortages and limited numbers of staff may characterize care encounters. It is unclear how these contextual conditions affect patients' and nurses' experiences of caring.

DESIGN AND METHODS

This integrative literature review covers papers published between 2000 and 2022. Four databases-PubMed, PsycINFO (via Ovid), MEDLINE (via Ovid) and CINAHL (via EBSCO)-were systematically searched for eligible papers in May 2022. The included studies were critically appraised. Content analysis was performed to interpret and synthesize the findings. In accordance with the EQUATOR guidelines, the PRISMA 2020 and PRISMA-S checklists were used. An Integrative review methodology guided the process.

FINDINGS

In total, 33 studies were included in the review. Three themes captured the experiences of caring in nursing: (1) the complexity of the nursing care context, (2) the professionalism of the nurse, and (3) the trusting patient-nurse relationship.

CONCLUSION

The experience of caring in nursing depended on nurses' competence and discretion in the personal encounter framed by the nursing context. The caring relationship was based on reciprocity, but it remains asymmetrical, as the nurse had the power and responsibility to empower the patient. Barriers, such as increased demands for efficiency and resource scarcity, may hinder the experience of caring in nursing.

IMPLICATIONS FOR THE PROFESSION AND PATIENT CARE

By promoting an ongoing discussion of caring in nursing, nurse management can systematically support nurses in reflecting on their practice in diverse and complex clinical contexts.

PATIENT OR PUBLIC CONTRIBUTION

No patient or public contribution was made due to the study design.

Hope that provides strength in illness-patients' perspectives: Nursing students' narratives after conversation with patients

BACKGROUND

The aim of this article is to explore sources of hope for patients by using patients' narratives and perspectives on how they find hope when facing illness. Hope enables people to endure suffering and can be critical to how people cope with illness. Hope is not a singular phenomenon, so nurses need to understand how to support the patients' sources of hope.

METHODS

We used a qualitatively descriptive design with qualitative content analysis. We examined reflective notes from 385 first-year nursing students after they had had a conversation with patients with disease experiences following Graneheim and Lundman's description of analysis. The conversation with the patients/persons was related to sources of hope and strength, who they turned to when they needed help, and if they were available. After the conversation, the students had to write a reflective log with a summary of the conversation.

RESULTS

We found four categories that explained how patients found hope: (1) relational hope, (2) spiritual hope, (3) hope in nature and (4) hope in oneself. Most of the patients found hope in more than one of these categories.

CONCLUSION

It is important for nursing to have knowledge about patients' narratives about how they build and sustain hope during times of illness. Nursing can contribute to promoting hope and thus alleviating patients' suffering. The four categories in this study can serve as a guide for nurses to assess and support patients' hope and encourage them to find their strength through different sources.

Endeavouring interplay: a grounded theory study of how nurse educators' work with simulation-based learning

BACKGROUND

Simulation-based learning is frequently used as a teaching and learning strategy in nursing and other health professions educations, and educators have a key role as facilitators. This facilitator role provides them with a particularly relevant perspective to help us understand and theorize around the essence of simulation-based learning, and how it is approached. This study aims to explore nurse educators' experiences and strategies in simulation-based learning.

METHOD

Data were collected in 2018-2021 using in-depth interviews with eight nurse educators. Transcripts were analysed through constant comparison using Classical Grounded Theory approach.

RESULT

The participants' main concern was how to Maximize students' learning-space in simulation. To resolve this, four strategies were identified: legitimizing simulation, self-development, preparing students, and tailoring simulation. Legitimisation, and self-development were found to be important prerequisites for developing the learning space and were therefore defined as the background or context of the theory. Nurse students were the focus of the two remaining categories, preparing students and tailoring simulation, and are thus defined as being in the foreground of the theory. The dynamics of these four strategies were captured in the Grounded theory of Endeavouring interplay.

CONCLUSION

The theory of Endeavouring interplay illustrates the complexity educators are encountering when aiming to optimize simulation as a learning space for nurse students. The strategies used are adapted to the organisational climate, available resources and context, and include striving to legitimize simulation, pursue self-development in the role as facilitator, help students prepare for simulation-based learning, and tailor the simulation to both contextual factors and individual student needs.

Strengths and challenges with spiritual care: Student feedback from the EPICC Spiritual Care Self-Assessment Tool

AIM

To explore qualitative data from students' self-reported competencies in spiritual care gathered during testing of a student self-assessment tool based on the EPICC Spiritual Care Education Standard.

DESIGN

Reflexive thematic analysis of qualitative data from a multinational study on validating a new self-assessment tool.

METHODS

The EPICC Spiritual Care Education Standard for competency in spiritual care was developed to enhance nurses' and midwives' ability to provide spiritual care by creating a baccalaureate education standard for spiritual care competencies. Spiritual care researchers then developed a self-assessment tool to raise student awareness of spirituality and track personal and professional growth in spiritual care competency. The EPICC Spiritual Care Competency Self-Assessment Tool, tested at eight universities in five countries, provided many opportunities for student comments, resulting in rich qualitative data presented here.

RESULTS

Themes related to strengths, weaknesses and areas for improvement. Identified strengths were similar across countries: caring attitudes, general knowledge of caring and compassion and good communication skills. Weaknesses/challenges touched on spirituality as overlooked in some cultures but part of life for others, complex questions were hard to understand, and self-assessment tools are common for some and rare for others. Areas for improvement included need for knowledge of religious and other deeply held beliefs and for greater spiritual assessment skills. Similarities across countries related to basic training in communication and compassionate care for nurses globally. Differences lay in the challenges and/or barriers for spiritual care and may relate to cultures within countries and/or university test sites.

RELEVANCE TO CLINICAL PRACTICE

The Tool raises awareness of spirituality among students and working nurses, providing an accessible way to self-check personal and professional growth in spiritual care competencies, which increases student and nurse capacity to become more knowledgeable and skilled in facilitating spiritual care, thus be role models for students at the intersection of spirituality and health.

Developing and testing the EPICC Spiritual Care Competency Self-Assessment Tool for student nurses and midwives

AIMS AND OBJECTIVES

To develop and psychometrically test a self-assessment tool that measures undergraduate nursing and midwifery students' perceptions of spiritual care competence in health care practice.

BACKGROUND

Spiritual care is part of nurses/midwives' responsibility. There is a need to better benchmark students' competency development in spiritual care through their education. The EPICC Spiritual Care Education Standard served as groundwork for the development of the EPICC Spiritual Care Competency Self-Assessment Tool.

DESIGN

Cross sectional, mixed methods design. A STROBE checklist was used.

METHODS

The Tool (available in English, Dutch and Norwegian) was developed by an international group. It was tested between July-October 2020 with a convenience sample of 323 nursing/midwifery students at eight universities in five countries. The Tool was tested for validity using Kaiser-Meyer-Olkin (KMO) test, exploratory and confirmatory factor analysis, one-way ANOVA and independent samples t test. The reliability was tested by Cronbach's alpha coefficient. Qualitative data were analysed using thematic analysis.

RESULTS

The KMO test for sampling adequacy was 0.90. All, but two, items were related to the same factor. Cronbach's alpha coefficient for the Tool was 0.91. Students found the Tool easy to use, and they gained new insights by completing it. However, students felt that some questions were repetitive and took time to complete.

CONCLUSIONS

The Tool has construct and discriminant validity, and high internal consistency (is reliable). In addition, students found the Tool useful, especially in early stages of education.

RELEVANCE TO CLINICAL PRACTICE

The Tool affords student nurses and midwives the opportunity to self-evaluate their knowledge, skills and attitudes about spirituality and spiritual care. The Tool offers students, educators and preceptors in clinical practice a tangible way of discussing and evaluating spiritual care competency.

Development of a spiritual care education matrix: Factors facilitating/hindering improvement of spiritual care competency in student nurses and midwives

Spiritual care is a fundamental aspect of caring and compassionate nursing/midwifery practice. However, nurses/midwives consistently report feeling unprepared to provide spiritual care for various reasons. A key reason appears to be the lack of structured spiritual care education in undergraduate nursing/midwifery curricula. Between 2016 and 2019, the three-year, European EPICC project ('Enhancing nurses' and midwives' competence in Providing spiritual care through Innovative education and 'Compassionate Care') sought to address gaps in nursing/midwifery competence in spiritual care. A key project output, and the focus of this paper, is the EPICC Gold Standard Matrix for Spiritual Care Education ('EPICC Matrix'), which depicts the complex array of factors hindering/facilitating the development of nursing/midwifery spiritual care competency. The EPICC project followed two major studies that identified factors contributing to nursing/midwifery spiritual care competency development. This evidence, along with the mixed methods focus of the EPICC project to enable co-projection of its outputs informed the development of the EPICC Matrix. The EPICC Matrix was considered to represent 'the cultural, social and political environment in which spiritual care competency develops' in student nurses/midwives. The EPICC Matrix illustrates spiritual care educational considerations during the process of selecting suitable nursing/midwifery students; through the specific aspects of the teaching and learning environment, the student as a person, and the clinical environment in which spiritual care competency develops; and finally, how the student is assessed as competent in providing spiritual care. Recent research supports the use of the EPICC Matrix in undergraduate nursing/midwifery curricula and strengthens the case for support of the other EPICC project outputs, including: the EPICC Spiritual Care Education Standard, EPICC Adoption Toolkit, and the continuation of the EPICC Network. Further testing of the EPICC Matrix to determine its relevance in different cultural/professional contexts within and outside of Europe would be welcomed.

Educational interventions and strategies for spiritual care in nursing and healthcare students and staff: A scoping review

AIMS AND OBJECTIVES

To map existing evidence about educational interventions or strategies in nursing and allied healthcare concerning students' and staffs' spiritual care provision.

BACKGROUND

Spiritual care is an important part of whole person care, but healthcare staff lack competence and awareness of spiritual issues in practice. To rectify this, it is important to identify what educational approaches are most helpful in supporting them to provide spiritual care.

DESIGN

A scoping review using the PRISMA-ScR checklist.

METHOD

Searches in the databases CINAHL, MEDLINE, ATLA and ERIC were conducted for papers spanning January 2009-May 2020. Search terms were related to spirituality, spiritual care, education and clinical teaching. Appraisal tools were used.

RESULTS

From the 2128 potentially relevant papers, 36 were included. The studies were from 15 different countries and involved nurses, physicians and other health-related professions, and both quantitative, qualitative and mixed methods were used. The results are presented in three themes: Understanding of spirituality, Strategies in educational settings, and Strategies in practice settings. The review points to great diversity in the content, lengths and setting of the educational interventions or strategies.

CONCLUSIONS

Courses in spiritual care should be implemented in curricula in both undergraduate and postgraduate education, and several studies suggest it should be mandatory. Courses should also be available for healthcare staff to raise awareness and to encourage the integration of spiritual care into their everyday practice. There is a need for greater consensus about how spirituality and spiritual care are described in healthcare settings.

RELEVANCE TO CLINICAL PRACTICE

Spiritual care must be included both in monodisciplinary and multidisciplinary educational settings. The main result of spiritual care courses is in building awareness of spiritual issues and self-awareness. To ensure the provision of spiritual care for patients in healthcare practices, continuing and multidisciplinary education is recommended.

Mental Health Staff Perspectives on Spiritual Care Competencies in Norway: A Pilot Study

Spirituality and spiritual care have long been kept separate from patient care in mental health, primarily because it has been associated with psycho-pathology. Nursing has provided limited spiritual care competency training for staff in mental health due to fears that psychoses may be activated or exacerbated if religion and spirituality are addressed. However, spirituality is broader than simply religion, including more existential issues such as providing non-judgmental presence, attentive listening, respect, and kindness (International Council of Nursing [ICN], 2012). Unfortunately, healthcare personnel working in mental health institutions are not well prepared to address spiritual concerns or resources of their patients (Cone and Giske, 2018). Therefore, a mixed-method pilot study was conducted using a self-assessment survey tool to examine spiritual care competencies of mental health staff in Norway and to understand the perspectives of mental health staff in the Scandinavian context (Stockman, 2018). Five questions and comments related to survey items provided rich qualitative data. While only a small pilot with 24 participants, this study revealed a need for spiritual care educational materials targeted specifically for those who work in mental health, materials that address the approach of improving attitudes, enhancing skills, and increasing knowledge related to spirituality and spiritual care of patients.

Consequences of the Covid-19 virus on individuals receiving homecare services in Norway. A qualitative study of nursing students' reflective notes

Background

Reflective notes in nursing education can facilitate students’ understanding of how individuals in need of home healthcare services experience unfamiliar situations, such as a pandemic. The aim of this study is to describe the consequences of the COVID-19 virus for individuals receiving homecare services through the eyes of nursing students.

Methods

This is a qualitative descriptive study using content analysis to examine reflection notes from 17 nursing students in their last year of academic studies while undertaking home healthcare service training.

Results

Our study shows students’ reflections on the consequences of the COVID-19 virus on individuals needing home healthcare services and their families. The analysis reveals three categories that described the effect of the virus according to students’ reflections: i) how social life became restricted and only includes the closest family members and home healthcare staff (declining social circle), ii) how family members take on more responsibility to care for the individual and the pronounced impact of this on the day-to-day lives of the individual’s next of kin (expanding responsibility of care), and iii) actions and reactions related to preventing the spread of the virus (dealing with the invisible threat).

Conclusions

Students’ reflection notes show that COVID-19 had major consequences, not only on the individuals receiving home healthcare services, but also on their relatives and on home healthcare staff.

Nursing Students Explore Meaningful Activities for Nursing Home Residents: Enlivening the Residents by Cultivating Their Spark of Life

International research focuses on person-centered care, quality of life, and quality of care for people living in long-term care facilities, and that it can be challenging to improve the quality of life for residents with dementia. The aim of this study was to explore ways of developing appropriate person-centered activities for nursing home residents based on what would be meaningful for them. A qualitative explorative design was chosen. Twelve students each year over a three-year period participated in the study (altogether 36). Each student tailored joyful and meaningful activities for two nursing home residents and wrote eight reflection journals each (altogether 284). Additional data came from eight focus group interviews with the students. Data were analyzed using qualitative content analysis. The main theme was “Enlivening the residents by cultivating their spark of life”. Two main categories were identified: (1) “Journeying to meaningful and enlivening (enjoyable) activities”, and (2) “Expressions of enlivening”, It is possible to tailor meaningful and enlivening activities together with the individual person with dementia. Involvement and engagement are necessary to understand the verbal and nonverbal expressions and communicate with the individual resident.

The development of a consensus-based spiritual care education standard for undergraduate nursing and midwifery students: An educational mixed methods study

AIMS

The aim of this study was to develop a consensus-based Spiritual Care Education Standard for undergraduate N/M students to use in undergraduate programmes.

DESIGN

Mixed methods were used consisting of qualitative and quantitative methods based on the principles of Delphi research.

METHODS

The sample consisted of a total of 58 (N = 58) participants from 21 European countries. Data collection was conducted from June 2017 - February 2019 and took place in facilitated iterative action learning cycles and online surveys. Data were analysed by descriptive statistics and qualitative analysis. Consensus was stated by >90% agreement.

RESULTS

The process resulted in an EPICC Spiritual Care Education Standard consisting of the following four spiritual care competences: Intrapersonal spirituality, Interpersonal spirituality, Spiritual care: assessment and planning, Spiritual care: intervention and evaluation. For every competence, learning outcomes were described in knowledge, skills and attitudes.

CONCLUSION

This Standard guides N/M spiritual care education, student assessment and research. It can be the starting point for discussing spiritual care competences in other healthcare professions. Follow-up research should focus on implementation of the standard and on assessment of students' spiritual competence.

IMPACT

The Standard guides curriculum and programme development. The Standard guides students in performing their learning process. The Standard provides a frame of reference for policy making and follow-up research.

Hospitalized Patients' Perspectives on Spiritual Assessment: A Mixed Methods Study

BACKGROUND

Research shows that spirituality is important, but patients report that nurses rarely address spiritual issues, and research from the patient viewpoint is limited.

AIM

The research objective was to gain knowledge about hospitalized patients' perspectives on spiritual assessment by nurses.

METHOD

This is a mixed methods exploratory study reporting on quantitative/qualitative aspects of the patient perspective. Norwegian nurses in an acute care hospital distributed a 21-item spiritual assessment survey to patients they felt would not be burdened by completing it. Patients' demographic data were not identifiable, survey packets were returned anonymously via hospital mail by 157 hospitalized patients. Each survey item and several variables on the demographic sheet had space for comments. Quantitative analysis used SPSS 21, qualitative data were thematically analyzed.

FINDINGS

Statistically significant correlations were found with all survey items. Hospitalized people reported high comfort with spiritual assessment by nurses. Qualitative findings revealed that patients had differing views on if, when, and how nurses should ask spiritual questions of them.

CONCLUSIONS

It is important to identify patients' perspectives in order to provide patient-centered holistic care. Understanding patient views will enlighten nurses and may promote spiritual care and improve patient health outcomes.

Talking about spiritual matters: First year nursing students' experiences of an assignment on spiritual conversations

BACKGROUND

Spiritual care is part of holistic nursing. However, nurses have reported that their education does not sufficiently prepare them for spiritual care in practice. Few studies have reported students' perspectives on how they acquire skills and knowledge in spiritual care.

AIM

The aim of the study was to explore how first year nursing students experienced a compulsory assignment that asked them to carry out a conversation with someone about spiritual aspects of nursing care and to reflect about it in relation to nursing.

DESIGN

The study was a qualitative content analysis of students' reflective logs.

METHODS

This research analysed the reflective logs of 385 (76%) first year nursing students from one religious and one secular university in Norway. The logs were written in response to an assignment based on Stoll's assessment guide, which asked them to carry out a conversation about spiritual aspects of nursing care.

RESULTS

Analysis yielded three main categories that characterised students' experience of this assignment: meeting oneself, beyond one's comfort zone and discovering the other.

CONCLUSIONS

Students brought few skills and little experience in spiritual care into their education, and they felt that spiritual care conversations were personal and outside of their comfort zone. It is challenging for nursing education to equip nursing students with the competence in spiritual care necessary to meet the standard set out by the International Council of Nursing.

Integrating spiritual care into nursing education and practice: Strategies utilizing Open Journey Theory

Throughout nursing, spirituality is a recognized domain of patient care, but nurses feel ill prepared by their nursing education to provide care that is spiritual in nature to patients and their families. Incorporating spiritual care into nursing curricula is challenging in light of the amount of topics for healthcare learning. Open Journey Theory is based on the merging of two grounded theories, one teaching and one learning theory, and is the suggested framework for integrating spirituality and spiritual care across all levels of nursing education. Specially chosen readings (books, articles), activities (role-plays, discussion groups), and assignments (journaling, writing papers, giving reports) can be integrated into already existing courses. By utilizing the three stages of preparing, connecting, and reflecting to frame student learning, nurse educators can introduce and build on spiritual concepts from the simple to the complex over the course of the entire nursing program.

Nursing and midwifery students' perceptions of spirituality, spiritual care, and spiritual care competency: A prospective, longitudinal, correlational European study

BACKGROUND

Nurses and midwives care for people at some of the most vulnerable moments of their lives, so it is essential that they have the skills to give care which is compassionate, dignified, holistic and person-centred. Holistic care includes spiritual care which is concerned with helping people whose beliefs, values and sense of meaning, purpose and connection is challenged by birth, illness or death. Spiritual care is expected of nurses/midwives but they feel least prepared for this part of their role. How nursing and midwifery students can be prepared for spiritual care is the focus of this study.

OBJECTIVES

1. To describe undergraduate nursing and midwifery student's perceptions of spirituality/spiritual care, their perceived competence in giving spiritual care and how these perceptions change over time. 2. To explore factors contributing to development of spiritual care competency.

METHODS

Prospective, longitudinal, multinational, correlational survey design. A convenience sample of 2193 undergraduate nursing and midwifery students (69% response rate, dropping to 33%) enrolled at 21 universities in eight countries completed questionnaires capturing demographic data (purpose designed questionnaire) and measuring perception of spirituality/spiritual care (SSCRS), spiritual care competency (SCCS), spiritual wellbeing (JAREL) and spiritual attitude and involvement (SAIL) on 4 occasions (start of course n = 2193, year 2 n = 1182, year 3 n = 736, end of course n = 595) between 2011 and 2015. Data were analysed using descriptive, bivariate and multivariate analyses as appropriate.

RESULTS

Perceived competency increased significantly over the course of students' study which they attributed to caring for patients, events in their own lives and teaching/discussion in university. Two factors were significantly correlated with perceived spiritual care competency: perception of spirituality/spiritual care, where a broad view was preferable, and personal spirituality, where high spiritual wellbeing (JAREL) and spiritual attitude and involvement (SAIL) scores were preferable.

CONCLUSIONS

We have provided the first international evidence that perceived spiritual care competence is developed in undergraduate nursing and midwifery students and that students' perceptions of spirituality and personal spirituality contribute to that development. Implications for teaching and learning and student selection are discussed. The study is limited by attrition which is common in longitudinal research.

Risking existence: The experience and handling of depression

AIMS AND OBJECTIVES

To gain insight into how people suffering from depression experience and manage life.

BACKGROUND

Depression is the leading cause of incapacitation and constitutes the second largest healthcare burden worldwide, causing considerable discomfort for depression sufferers and their significant others. Depression must be understood against the backdrop of a person's context as well as biological, psychological and social factors. While various studies have been conducted on the process of depression, only a few studies have examined its existential aspects.

DESIGN

A classical grounded theory methodology employing open and selective coding was used to identify the participants' main concern and the strategies they used to handle it.

METHOD

Data were collected in 2015-2016 during 18 in-depth interviews with people with current or former moderate depression. The data were analysed through constant comparisons until the grounded theory emerged.

RESULTS/FINDINGS

The main concern of the participants was Longing for belonging, and they handled their depression through a process named Risking existence. The process comprised four phases: (i) Ungraspable processing; (ii) Giving clues; (iii) Daring dependence; and (iv) Courage to be. The process of risking existence was accompanied from beginning to end by three essentials: to hope, to endure and shame.

CONCLUSION

Working in mental health care involves encountering the pain, suffering and despair that humans endure. This challenges nurses to go beyond the symptoms and to listen for their meaning to each individual person.

RELEVANCE TO CLINICAL PRACTICE

The grounded theory of risking existence provides a model by which nurses can orient themselves when working with people who are depressed. Each phase describes different strategies that patients use that can help the nurse recognise what is going on, thus enabling him or her to understand and guide his or her patients.

Factors contributing to student nurses'/midwives' perceived competency in spiritual care

BACKGROUND

The spiritual part of life is important to health, well-being and quality of life. Spiritual care is expected of nurses/midwives, but it is not clear how students can achieve competency in spiritual care at point of registration as required by regulatory bodies.

AIM

To explore factors contributing to undergraduate nurses'/midwives' perceived competency in giving spiritual care.

DESIGN

A pilot cross-sectional, multinational, correlational survey design.

METHOD

Questionnaires were completed by 86% (n=531) of a convenience sample of 618 undergraduate nurses/midwives from six universities in four countries in 2010. Bivariate and multivariate analyses were performed.

RESULTS

Differences between groups were small. Two factors were significantly related to perceived spiritual care competency: perception of spirituality/spiritual care and student's personal spirituality. Students reporting higher perceived competency viewed spirituality/spiritual care broadly, not just in religious terms. This association between perceived competency and perception of spirituality is a new finding not previously reported. Further results reinforce findings in the literature that own spirituality was a strong predictor of perceived ability to provide spiritual care, as students reporting higher perceived competency engaged in spiritual activities, were from secular universities and had previous healthcare experience. They were also religious, practised their faith/belief and scored highly on spiritual well-being and spiritual attitude/involvement.

CONCLUSIONS

The challenge for nurse/midwifery educators is how they might enhance spiritual care competency in students who are not religious and how they might encourage students who hold a narrow view of spirituality/spiritual care to broaden their perspective to include the full range of spiritual concerns that patients/clients may encounter. Statistical models created predicted factors contributing to spiritual care competency to some extent but the picture is complex requiring further investigation involving a bigger and more diverse longitudinal sample.

Discerning the healing path--how nurses assist patient spirituality in diverse health care settings

AIMS AND OBJECTIVES

To examine nurses' experiences in spiritual care in diverse clinical settings, preferably not palliative care.

BACKGROUND

Spirituality is part of holistic nursing care. The concept of spiritual literacy is introduced as the nurse's ability to read the spiritual signs of the human experience.

DESIGN

Classical grounded theory methodology with open and selective coding was used to identify the participants' main concern and the strategies they used to resolve it, and to develop a substantive grounded theory.

METHOD

Data were collected in 2008 and 2014 during eight focus group interviews with a total of 22 nurses recruited from a master's programme, postgraduate programmes and a local hospital. Data were analysed through constant comparison until the grounded theory emerged.

RESULTS

The participants' main concern was how to assist the patient to alleviation. The participants resolved this by Discerning the healing path, which comprises three stages: Tuning in on spirituality, Uncovering deep concerns and Facilitating the healing process. These three stages are accompanied all the way by the participants' Willingness to overcome own comfort zone and Building a trusting relationship.

CONCLUSION

Spirituality is of relevance for all areas of nursing care, not just dying patients or those in palliative care. Spirituality relates to the deep and important things in life and affects how patients face health issues. Nurses attend to spirituality in patients because the pain of the soul touches them and the calmness of spiritual peace amazes them.

RELEVANCE TO CLINICAL PRACTICE

The professional culture in the health care team socialises nurses into the workplace, and leaders need to pay close attention to how they can foster openness to spiritual matters. The personal and professional maturity of the nurse is fundamental to his or her willingness and ability to overcome own comfort zone.

Når mor ikke vil spise – Etiske dilemmaer i møte med underernærte mennesker med demens i sykehjem

Aim

This article explores the ethical dilemmas nurses in nursing homes experience when caring for malnourished patents with dementia. The background for the study is the increasing number of patients with dementia in nursing homes in Norway, and the growing awareness of malnutrition amongst these patients.

Method

The study has a qualitative, descriptive design. Data came from four focus group interviews with 15 nurses working with patients with dementia from six different nursing homes. The transcribed interviews were analysed and five ethical dilemmas were identified.

Findings

The ethical dilemmas were: ‘Guilty conscience or abuse against patient’, ‘To take account of patient or relatives’, ‘Professional judgment or national guidelines’, ‘Busy times lead to weight loss for patients’ and ‘Reflection with colleagues or professional uncertainty’.

Conclusion

By understanding and articulating ethical dilemmas nurses experience in caring for undernourished patients with dementia, these challenges can be better dealt with. By reflecting upon the various forms of pressure nurses face in every day practice, they can be better prepared to act for the benefit of malnourished patients with dementia.

How undergraduate nursing students learn to care for patients spiritually in clinical studies--a review of literature

AIM

To gain knowledge about what is known about how undergraduate nursing students learn to care for patients spiritually in their clinical studies.

BACKGROUND

Spirituality is related to meaning, hope and comfort and spiritual care is part of nurses' responsibility. Clinical studies are vital for students to integrate knowledge, clinical reasoning and formation. However, nurses are important in role modelling.

METHOD

A literature search was undertaken using international databases from 1980 to 2012. Articles were thoroughly evaluated and 10 papers reviewed for this article.

RESULTS

Four main areas emerged as essential for learning spiritual care in clinical studies: (1) the importance of learning in real-life situations with repeated exposure to patients in diverse placements; (2) use of pedagogical methods that assist students to understand, work with and reflect on patients' spirituality; (3) to be aware of and overcome conditions prohibiting spiritual care learning; and (4) to see spiritual care learning in connection with how students are prepared and how they are followed up after clinical studies.

CONCLUSION

Clinical studies are fundamental to students' learning of spiritual care in nursing.

IMPLICATIONS FOR NURSING MANAGEMENT

Nurse leaders play a key role in keeping holistic care a nursing focus and creating a good learning environment.

Opening up to learning spiritual care of patients: a grounded theory study of nursing students

AIM

To determine undergraduate nursing students' perspectives on spiritual care and how they learn to assess and provide spiritual care to patients.

BACKGROUND

Nursing is concerned with holistic care. Systematic teaching and supervision of students to prepare them to assist patients spiritually is a growing focus. However, there is limited consensus about the competences students need to develop and little is written related to students learning processes.

DESIGN

Grounded theory was used to identify students' main concern and develop a substantive grounded theory.

METHOD

Data collected during semi-structured interviews at three Norwegian University Colleges in eight focus groups with 42 undergraduate nursing students were analysed through constant comparison of transcribed interviews until categories were saturated.

RESULTS

The participants' main concern was 'How to create a professional relationship with patients and maintain rapport when spiritual concerns were recognised'. Participants resolved this by 'Opening up to learning spiritual care'. This basic social process has three iterative phases that develop as a spiral throughout the nursing programme: 'Preparing for connection', 'Connecting with and supporting patients' and 'Reflecting on experiences'.

CONCLUSION

Nurses need a wide range of competences to fulfil the nursing focus on holistic patient care. Nursing education should prepare students to recognise and act on spiritual cues. A trusting relationship and respectful and sensitive communication assist students to discover what is important to patients. An educational focus on spiritual and existential themes throughout the nursing programme will assist students to integrate theoretical learning into clinical practice.

RELEVANCE TO CLINICAL PRACTICE

Study participants reported seeing few role models in clinical settings. Making spiritual assessment and interventions more visible and explicit would facilitate student learning in clinical practice. Evaluative discussions in clinical settings that include spiritual concerns will enhance holistic care.

Being in suspense: women's experiences awaiting breast cancer surgery

AIM

This article is a report of a qualitative study of women's experiences after having received a breast cancer diagnosis and awaiting primary surgery.

BACKGROUND

Breast cancer is experienced as an important stressor and a major challenge. How women appraise the diagnosis affects their postsurgery adaptation. Although studies have documented the presurgery period as stressful, in-depth understanding of women's experiences while awaiting surgery studied during this stressful period is still needed.

METHOD

Twenty-one women with newly diagnosed breast cancer were interviewed individually the day before surgery at a Norwegian university hospital, between February 2006 and February 2007. Interviews were analysed using the qualitative meaning condensation method.

FINDINGS

Feeling healthy, but having to adapt to disease, waiting, uncertainty, having to tell and existential awareness were themes identified. Having to wait was experienced as frightening, painful, long and difficult - but also necessary. Some expressed apprehension because they could not do anything about their situation. Others emphasized that it was good to have some time between diagnosis and surgery to become personally prepared and spend time with loved ones. Informing others about the diagnosis was a great burden for most of them. Social networks could both give and crave support.

CONCLUSION

Healthcare professionals need to be sensitive to the individual experiences of women awaiting breast cancer surgery to give support to ease their situation. Setting the date for surgery will alleviate anxiety. Follow-up studies about the potential impact of presurgery experiences on later experiences of living with breast cancer and intervention studies are needed.

Patterns of 'balancing between hope and despair' in the diagnostic phase: a grounded theory study of patients on a gastroenterology ward

AIM

The aim of the study was to learn how patients going through the diagnostic phase experienced and handled their situation.

BACKGROUND

Many studies report about the stressful diagnostic phase; however, none has presented a conceptual theory where the concepts are sufficiently related to each other. The Theory of Preparative Waiting has previously been published as a descriptive grounded theory and describes the experience of a group of gastroenterology patients going through the diagnostic phase.

METHOD

A classical grounded theory design was used, with data derived from 18 in-depth interviews with 15 patients in a gastroenterology ward at a Norwegian University Hospital. Interviews were conducted during 2002-2003.

FINDINGS

Participants' main concern was found to be how they could prepare themselves for the concluding interview and life after diagnosis. The theoretical code of 'balancing' had four patterns; controlling pain, rational awaiting, denial, and accepting. These patterns of 'balancing' guided how participants used the categories of 'Preparative Waiting Theory''seeking and giving information', 'interpreting clues', 'handling existential threats' and 'seeking respite'. Patterns were strategies, so one person could use more than one pattern.

CONCLUSION

The diagnostic phase was a difficult time for the participants and the 'Preparative Waiting Theory' can assist nurses in assessing how patients prepare themselves differently for getting a diagnosis. All patients would find it helpful to be followed up by a designated contact person at the ward; however, patients using mostly the patterns of controlling pain and denial would benefit most from such support.

'Preparative waiting' and coping theory with patients going through gastric diagnosis

AIM

This paper reports a study of how hospitalized patients with gastro-intestinal problems going through diagnostic workups experience and handle the situation. It presents a theory of 'preparative waiting' and discusses it in relation to Lazarus' theory of appraisal, stress and coping.

BACKGROUND

The pre-diagnostic phase is reported to be the most stressful time of the illness for patients, but there is little research on this with patients in gastric units. According to Lazarus, appraisal and coping are concurrent, and stress must be understood as both an intra- and an inter-personal process.

METHOD

A grounded theory design was chosen to conduct and analyse 18 in-depth interviews with 15 patients in a gastric unit at a Norwegian university hospital. The data were collected in 2002-2003.

FINDINGS

Participants' main concern was found to be how to prepare themselves for the results of the investigation and for life afterwards. The substantive grounded theory of 'Preparative waiting' presented here explains how they acted to do so. To be in the diagnostic phase meant to be in a process of continuously attempting to make sense of one's situation. Participants could judge their case to be harmful, a threat, a challenge, a benefit, or combinations of these. Their searches for realistic interpretation were balanced with searches for hopeful signs. This, together with lowering and rising of awareness, prevented them from despair. The process of understanding and handling the situation was concurrent, and was influenced by their relationships with family, friends, fellow patients, healthcare personnel and God.

CONCLUSION

To the degree that patients trusted that nurses understood and were sensitive to the complex processes of appraising and coping, they became patients' key support persons. By providing adjusted information, coordinating care and examinations, respecting privacy, and inquiring about existential concerns, nurses could promote patients' ability to prepare for receiving the diagnosis and life after.