Balancing between a Person-Centred and a Common Staff Approach: Nursing Staff's Experiences of Good Nursing Practice for Patients Who Self-Harm.

The aim of this study was to describe nursing staff's experiences of good nursing practice in psychiatric in-patient care for patients with self-harming behavior. The participants were nine nurses and eight nursing assistants working in two in-patient wards in general psychiatry. Four focus group discussions were held and subjected to qualitative content analysis. The findings showed that good nursing practice balanced a person-centred approach with a common staff approach, allowing people who self-harm and staff to share responsibility for structuring everyday life, keeping to the plan, communicating decisions, and finding individual opportunities for relief. Reflective discussions among the staff concerning prejudice, emotional stress, lack of resources, and shortcomings in care planning could also prevent a stigmatizing culture and organizational deficiencies, which would be beneficial for both the people who self-harm and the staff.

Abstraction and interpretation during the qualitative content analysis process.

Qualitative content analysis and other 'standardised' methods are sometimes considered to be technical tools used for basic, superficial, and simple sorting of text, and their results lack depth, scientific rigour, and evidence. To strengthen the trustworthiness of qualitative content analyses, we focus on abstraction and interpretation during the analytic process. To our knowledge, descriptions of these concepts are sparse; this paper therefore aims to elaborate on and exemplify the distinction and relation between abstraction and interpretation during the different phases of the process of qualitative content analysis. We address the relations between abstraction and interpretation when selecting, condensing, and coding meaning units and creating categories and themes on various levels. The examples used are based on our experiences of teaching and supervising students at various levels. We also highlight the phases of de-contextualisation and re-contextualisation in describing the analytic process. We argue that qualitative content analysis can be both descriptive and interpretative. When the data allow interpretations of the latent content, qualitative content analysis reveals both depth and meaning in participants' utterances.

Patients' experiences of isolation in psychiatric inpatient care: Insights from a meta-ethnographic study.

Historically, people with mental ill-health have been isolated from society. Although mental health care has moved from closed to more open forms of care, in many societies care is still provided in locked wards, and people with mental ill-health are sometimes secluded from their fellow patients, families, friends, and visitors. The aim of this study was to illuminate patients' experiences of isolation in psychiatric inpatient care. A systematic review of qualitative research was conducted, and the key findings were subjected to meta-ethnographic synthesis. The findings were twofold: 'being admitted to prison' and 'having access to shelter'. The experience of isolated care as prison-like symbolizes patients' longing for freedom and feeling restricted and limited by rules, stripped of rights, abandoned, controlled, powerless, and unsupported. In contrast, the experience of isolation as shelter symbolizes safety and the opportunity to regain control over one's own situation. A stigmatizing public view holds that people with mental ill-health are dangerous and unpredictable and, therefore, unsafe to themselves and others. Being placed in isolation because these fears contribute to self-stigma among patients. Promoting a sheltered experience in which isolation is used with respect for patients and the reasons are made explicit may encourage recovery. A shift in emphasis in ward culture from observation to engagement is needed to reduce blame, shift patient experiences from prison to shelter, and to support autonomy as a therapeutic intervention.

Understanding the incomprehensible - patients' and spouses' experiences of comprehensibility before, at and after diagnosis of amyotrophic lateral sclerosis.

BACKGROUND: Previous studies have examined manageability and meaningfulness in amyotrophic lateral sclerosis (ALS), but there is a lack of studies examining the comprehensibility of ALS among patients and their spouses. AIM: This qualitative retrospective study aimed to illuminate patients' and spouses' experiences of comprehensibility in ALS from a long-term perspective, when symptoms appeared before diagnosis, and when the diagnosis was given and in life after diagnosis. METHODS: Individual semi-structured interviews with 14 patients and 13 spouses were performed. The transcribed interviews were subjected to qualitative content analysis. FINDINGS: Through the whole disease process, patients and spouses feared the unknown regardless of whether they comprehended the disease or not. They described that they before diagnosis felt uncertainty. It was problematic to comprehend what was wrong and what the deterioration implied. At the diagnosis, they described feelings of losing their foothold. Long-term after diagnosis, they still lived in fear and looked for reasons why they were afflicted. CONCLUSIONS: Findings of similar experiences in comprehensibility between patients and spouses strengthen the importance of support and information to both parties. Since they hovered between comprehensibility and incomprehensibility during the whole disease process, it is important that their questions, fears and worries are met, from the first visit at hospital and through the whole process. Multiprofessional teams, such as ALS teams and palliative teams can from a holistic perspective increase the possibility of meeting their needs in their unique situation.

Methodological challenges in qualitative content analysis: A discussion paper.

This discussion paper is aimed to map content analysis in the qualitative paradigm and explore common methodological challenges. We discuss phenomenological descriptions of manifest content and hermeneutical interpretations of latent content. We demonstrate inductive, deductive, and abductive approaches to qualitative content analysis, and elaborate on the level of abstraction and degree of interpretation used in constructing categories, descriptive themes, and themes of meaning. With increased abstraction and interpretation comes an increased challenge to demonstrate the credibility and authenticity of the analysis. A key issue is to show the logic in how categories and themes are abstracted, interpreted, and connected to the aim and to each other. Qualitative content analysis is an autonomous method and can be used at varying levels of abstraction and interpretation.

Patients' expectations and experiences of epilepsy surgery--A population-based long-term qualitative study.

OBJECTIVE: The aim of this prospective and population-based longitudinal study was to explore patients' expectations before surgery and their experiences both short and long term after epilepsy surgery. METHODS: A national sample of adult patients answered open-ended questions preoperatively, 2 years after surgery and at a cross-sectional long-term follow-up (mean 13 years, standard deviation [SD] 1.85). The answers were analyzed by qualitative content analysis. RESULTS: Eighty patients participated in the study. Before surgery, patients experienced a belief in a "normal" life; they hoped for reduction of seizures and medication, a richer social life, and more self-confidence. However, they also experienced anxiety of the unknown. They were afraid of the operation, of continued seizures, and of complications. At both postoperative follow-ups patients experienced increased independence. They had symptom reduction, felt relief from worries and fears, and felt that they had a new life. However, some patients experienced that the operation had changed their life to the worse due to both psychological and neurologic adverse effects, regardless of whether they had obtained seizure freedom or improvement. SIGNIFICANCE: Positive experiences of epilepsy surgery dominated, both in the short and long term. However, attention must be paid to negative expectations before and negative experiences after surgery in order to provide individual support and information. This should increase the possibility for patients to have realistic hopes before surgery and to find coping strategies in the new life situation after surgery.

Quality of interactions influences everyday life in psychiatric inpatient care--patients' perspectives.

Everyday life consists of daily activities that are taken for granted. It forms the foundation for human efforts and contains elements of both comfort and boredom. Because everyday life escapes no one, life in a psychiatric ward will become ordinary while staying there. This study aims to explore everyday life in psychiatric inpatient care based on patients' experiences. We individually interviewed 16 participants with experiences of psychiatric inpatient care and analysed the data in accordance with the methods of grounded theory. Data collection and analysis continued in parallel in accordance with the method. Our results showed that everyday life is linked to the core category quality of interactions influences everyday life, and three constructed categories-staff makes the difference, looking for shelter in a stigmatizing environment, and facing a confusing care content-were related to the core category. Our results highlight the importance of ordinary relationships between staff and patients in psychiatric inpatient care. These results can be used to develop nursing interventions to improve psychiatric inpatient care and might also be used as a basis for reflective dialogues among staff.

Struggling to find meaning in life among spouses of people with ALS.

OBJECTIVE: The aim of this study was to illuminate experiences of finding meaning in life among spouses of people with amyotrophic lateral sclerosis. METHOD: Thirteen interviews were analyzed with qualitative content analysis. RESULTS: The spouses were struggling for meaning at the end of a dark tunnel. They felt limited and isolated in their proximity to death. They lived imprisoned lives, felt lonely, considered life to be unfair and incomplete, and mourned the loss of their future. However, they found meaning despite the proximity of death through cherishing their own lives, fellowship, accepting the present, and believing in meaning after the partner's death. SIGNIFICANCE OF RESULTS: Meaning in life strengthened spouses' well-being and ability to find pleasure in a difficult situation. It also strengthened their will to live after the partner's death. Limitations and isolations were strong predictors of what could impair their well-being and the possibility of finding meaning after the partner's death. Spouses need individual support throughout the disease process and after the partner's death, to give them the strength to find meaning in life and prioritize what is important for them. Paying attention to what might prevent them from finding meaning could make it easier to help them in their situation. Providing joint support to the patient and spouse might also help them to see each other's situation, come together, and help each other.

Personnel's Experiences of Phlebotomy Practices after Participating in an Educational Intervention Programme.

Background. Blood specimen collection is a common procedure in health care, and the results from specimen analysis have essential influence on clinical decisions. Errors in phlebotomy may lead to repeated sampling and delay in diagnosis and may jeopardise patient safety. This study aimed to describe the experiences of, and reflections on, phlebotomy practices of phlebotomy personnel working in primary health care after participating in an educational intervention programme (EIP). Methods. Thirty phlebotomists from ten primary health care centres participated. Their experiences were investigated through face-to-face interviews. Findings were analysed using qualitative content analysis. Results. The participants perceived the EIP as having opened up opportunities to reflect on safety. The EIP had made them aware of risks in relation to identification procedures, distractions from the environment, lack of knowledge, and transfer of information. The EIP also resulted in improvements in clinical practice, such as a standardised way of working and increased accuracy. Some said that the training had reassured them to continue working as usual, while others continued as usual regardless of incorrect procedure. Conclusions. The findings show that EIP can stimulate reflections on phlebotomy practices in larger study groups. Increased knowledge of phlebotomy practices improves the opportunities to revise and maximise the quality and content of future EIPs. Educators and safety managers should reflect on and pay particular attention to the identification procedure, distractions from the environment, and transfer of information, when developing and implementing EIPs. The focus of phlebotomy training should not solely be on improving adherence to practice guidelines.

Family caregivers' experiences of relinquishing the care of a person with dementia to a nursing home: insights from a meta-ethnographic study.

Many people with dementia are cared for in their homes by family caregivers. As the dementia progresses, admission of the family member to a nursing home becomes inevitable. The aim of this meta-ethnographic study was to describe caregivers' experiences of relinquishing the care of a family member with dementia to a nursing home. A systematic literature search of PubMed, Cinahl and PsychInfo, between the years 1992 and 2012, was performed, and 10 qualitative articles, based on 180 family caregivers' experiences, were included. The family caregivers' described their experiences as a process that went from being responsible for the decision, through living with the decision, adjusting to a new caring role and having changed relationships. They felt unprepared and lonely with these changes. They experienced loss, guilt and shame, but also feelings of relief. Their roles in the nursing home environment were to make sure that the individual needs of the person with dementia were respected and to monitor the quality of care. They wished to maintain their relationship with the person with dementia and to establish meaningful relationships with caring staff. The process of relinquishing care is similar to a crisis process, which starts with a turning point, followed by a coping face and finally the outcome of the process. The adaption to the new situation can be facilitated if the family caregivers are recognised as partners in the care of the person with dementia. The family caregivers' unique knowledge of their relatives' previous life story should be acknowledged in both care planning and daily care. Welcoming family caregivers to regular meetings with staff can contribute to increase the feeling of partnership. Offering staff clinical supervision could be one way of preparing them to deal with the emotional strain reported by family caregivers.

Interaction between diabetes specialist nurses and patients during group sessions about self-management in type 2 diabetes.

OBJECTIVE: The aim of this study was to explore the interaction between diabetes specialist nurses (DSNs) and patients with type 2 diabetes (T2D) during group sessions about self-management. METHODS: Ten DSNs and 44 patients were observed during group sessions about self-management, and thereafter the observations were analyzed using qualitative content analysis. RESULTS: The interaction was characterized by three themes: becoming empowered, approaching each other from different perspectives, and struggling for authority. The interaction was not a linear process, but rather a dynamic process with distinct episodes that characterized the content of the sessions. CONCLUSION: It is important to achieve an interaction that is patient-centered, where the DSN is aware of each patient's individual needs and avoids responding to patients in a normative way. A satisfying interaction may strengthen patients' self-management, and also may strengthen the DSNs in their professional performance. PRACTICE IMPLICATIONS: Authority struggles between patients and DSNs could be a prerequisite for patients to become autonomous and decisive in self-management. DSNs might benefit from an increased awareness about this issue, because they can better support patients if they do not perceive authority struggles as threats to their professional role.

Finding meaning despite anxiety over life and death in amyotrophic lateral sclerosis patients.

AIM AND OBJECTIVES: To illuminate how people with amyotrophic lateral sclerosis (ALS) create meaning despite the disease. BACKGROUND: Coping strategies for living with ALS have already been investigated. However, there is a lack of studies on how people with the disease find meaning and what helps and hinders this. DESIGN: A qualitative descriptive study. METHODS: Fourteen individual interviews were performed in Spring 2007. The interviews were analysed by qualitative content analysis. RESULTS: Two themes emerged to illuminate the complex life situation of the interviewees: experiences of anxiety over life and death and finding meaning despite the illness. It became clear that the uncertain journey towards death was more frightened than death itself. Despite the incurable disease, which brought feelings of life and death anxiety, physical loss, unfairness, guilt, shame and existential loneliness, they also found meaning in life, which strengthened their will to live. Meaning was found through their family and friends, the act of giving and receiving help, the feeling of having a life of their own and accepting the present. The perspective of life was transferred to a deeper view where material things and quarrels were no longer in focus. CONCLUSIONS: Despite the disease, the participants found meaning in life which strengthened their will to live. RELEVANCE TO CLINICAL PRACTICE: The balance between anxiety over life and death and finding meaning in life indicates the importance of support through the whole disease process. Both disease-specific problems and existential questions must be tackled. Nurses and other professionals need to be aware of the patients' existential qualms. There is a need to focus on what is important for the individual, and emphasis must be placed on where that person can find meaning.

Changes in sense of coherence in old age - a 5-year follow-up of the Umeå 85+ study.

OBJECTIVE: This study aims to describe the changes in sense of coherence (SOC) over time and relate these changes to negative life events among very old people. DESIGN: Prospective and longitudinal study. SUBJECTS: 190 old women and men participated, of whom 56 could be included in the 5-year follow-up. METHODS: The mean SOC score from the first and second data collection were compared using a paired sample t-test. The relationship between the index of negative life events and the changes on SOC score between the two data collections was investigate using linear regression. MAIN OUTCOME MEASURES: Antonovsky's SOC scale and an index of negative life events including severe physical and mental diseases, various losses as losses of spouses, cognitive and functional ability. RESULT: For the whole group of subjects (n = 56), the SOC scores was higher (70.1 vs. 73.7, p = 0.029) at the second point measure. The most common negative life events at follow-up were loss of independence in activities in daily living and decrease in cognitive function. A significant correlation between the index of negative life events and changes in SOC over 5 years was found (p = 0.025). The more negative life events, the more decrease in SOC. CONCLUSION: We concluded that there is a risk of decreased SOC and thereby quality of life when negative life events accumulate among very old people. Nursing interventions might play an important role for maintaining and perhaps strengthening SOC among old people exposed to negative life events.

Being flexible and tuning in: professional caregivers' reflections on management of violent behaviour in nursing homes.

AIMS AND OBJECTIVES: This qualitative, descriptive study aimed to illuminate professional caregivers' reflections on managing residents' violent behaviour in nursing homes. BACKGROUND: Violence towards caregivers in the care of older people is a challenge attracting increasing attention in nursing research. However, studies that focus on the approaches caregivers in nursing homes resort to and how they manage everyday care situations involving threats and violent situations are relatively few. METHODS: The study was based on 41 interviews in which the caregivers reflected on their own courses of action in violent situations. The interviews were subjected to qualitative content analysis. RESULTS: This study showed that caregivers were flexible and in tune with the resident by averting and defusing threatening and violent situations. The caregivers tried to give care in line with the residents' condition, control their own spontaneous reactions and interpret the residents' reactions as communicative signs indicating how they should interact with the resident in the situation. As a last resort, when previous approaches had been unsuccessful, the caregivers took a firm stand, confronted the resident and the violent behaviour more directly, but with respect and with the residents' best interests in mind. CONCLUSIONS: These findings illuminate how caregivers successfully can manage threatening and violent behavior in nursing homes by being flexible and tuning in with the resident but also by taking a firm stand with the residents' best interests in mind. To be flexible and in tune with residents, it is important to know the residents' personal histories. This may mean involving stakeholders, such as family members and friends, in the care of residents with violent behaviour. IMPLICATIONS FOR PRACTICE: We believe that it is important to involve stakeholders in the care of threatening and violent residents in nursing homes as it is important to get information on the residents' personal history. However, there are risks when interpreting residents' behaviour in light of their personal histories as relatives experiences may be subjective and the information may give the caregivers preconceived ideas about the resident.

Talking via the child: discursively created interaction between parents and health care professionals in a pediatric oncology ward.

The aim of this study was to describe discursively constructed interactions between parents and health care professionals (HCPs) in a pediatric oncology ward. Field notes from 70 focused participant observations and 16 informal interviews with 25 HCPs interacting with 25 parents of children with cancer were analyzed using discursive psychology. Six dominant interpretative repertoires (flexible parts of discourses used in everyday interaction) were found. Repertoires used by the HCPs were child, parent, or family oriented, mirroring the primary focus of the interaction. Parents used a spokesperson repertoire to use their own expertise to talk on behalf of the child; an observer repertoire, in which they kept in the background and interfered only when needed; or a family member repertoire to position themselves on a level equal to the ill child. The results are discussed in relation to philosophies influencing pediatric nursing, such as family-centered nursing and child-centered nursing.

Factors that facilitate and hinder the manageability of living with amyotrophic lateral sclerosis in both patients and next of kin.

AIM AND OBJECTIVES: This study aims to illuminate factors that facilitate and hinder the manageability of living with amyotrophic lateral sclerosis in patients and next of kin. Fourteen patients and 13 next of kin were interviewed. BACKGROUND: The whole family becomes affected when a person gets the disease. Therefore, it is important to identify strategies for managing the life situation among both patients and their next of kin. DESIGN: A qualitative descriptive study. METHOD: This study based on individual interviews was performed in spring 2007. The interviews were subjected to qualitative content analysis. RESULTS: The results indicate constant fluctuation between opportunities and limitations in individual ability - of patients and family members - to manage the life situation. Both patients and next of kin devised strategies to manage their situations through acceptance, living in the present and perceiving real presence and support from family, friends and authorities. Dysfunctional relationships with family members, friends, or authorities reduced the manageability of the situation. Furthermore, patients experienced difficulties managing their situations when forced into passivity and increased dependence. Next of kin experienced decreased ability to manage because of burden, lack of own time and feelings of being controlled. CONCLUSION: The fluctuations in manageability and the similarities and differences between the pairs, indicate the importance of support, both for the individual and the family. RELEVANCE TO CLINICAL PRACTICE: Fluctuations in manageability and similarities and differences between approaches to managing the situation suggest a need for input from caregivers, for the whole family. Family members need support and time for their own needs and also the opportunity to increase their awareness and understanding of the needs of other family members. This study may give health personnel insight into how to help families devise strategies to manage a complex life situation.

Experiences of abdominal massage for constipation.

AIM: This study aims to illuminate participants' experiences of receiving abdominal massage for constipation. BACKGROUND: Abdominal massage has been found to decrease the severity of constipation and abdominal pain, but little is known about how patients experience receiving abdominal massage. DESIGN: The present study is a qualitative descriptive study, based on individual interviews. METHOD: Nine adults receiving abdominal massage for constipation were invited to participate. Semi-structured interviews were conducted in Sweden between 2005-2007. The interviews were transcribed and subjected to qualitative content analysis. RESULTS: Four themes were formulated: 'being on one's guard', 'becoming embraced by safe hands', 'being touched physically and emotionally' and 'feeling vulnerable'. The participants reported that they were on guard, i.e. they were sceptical about whether or not abdominal massage was effective and suitable. However, as the massage sessions continued, they found the massage pleasant and began to feel embraced and in safe hands. They described how the abdominal massage made them feel as 'being touched physically and emotionally' and their bowel habits were improved. Along with the improvements, their agony was gone and they felt relieved. However, they considered their new condition fragile and they felt vulnerable to relapse. CONCLUSIONS: Abdominal massage was experienced as pleasurable, and after treatment, the participants felt more comfortable with their bowel function. Participants described abdominal massage as affecting the whole person. RELEVANCE TO CLINICAL PRACTICE: Abdominal massage has been shown to be an effective intervention for constipation. A crucial aspect is that nurses need to be sensitive and respect the intimacy associated with the abdomen.

Physically violent behaviour in dementia care: Characteristics of residents and management of violent situations.

OBJECTIVE: Physically violent behaviour (PVB) is common among residents with dementia and often complicates nursing care. This study aims to explore types of caring situations, resident characteristics related to PVB and professional caregivers' management of PVB. METHODS: The study included 40 group homes for 309 residents with dementia. Data was gathered by means of structured interviews, the Multi-Dimensional Dementia Assessment Scale and the Geriatric Rating Scale. RESULTS: Ninety-eight of the residents (31.7%) were assessed as showing PVB during the preceding week. Three factors were independently associated with PVB: male gender, antipsychotic treatment and decline in orientation. Violent residents were more likely to have impaired speech, difficulties understanding verbal communication and prescribed analgesics and antipsychotics than were non-violent residents. PVB occurred mainly in intimate helping situations and was managed by symptom-oriented approaches, such as distraction, medication and isolation. The working team also held frequent discussions about the residents with PVB. CONCLUSION: This study shows that PVB is frequently displayed among residents in group homes for persons with dementia and the caregivers mainly manage PVB in a symptom-oriented way. To enhance the quality of care for patients with dementia, there is a need for interventions that aim to understand and manage the residents' physical violent behaviour.

Parental experiences of information within pediatric oncology.

Parents of children with cancer use information to create knowledge about their child's disease. Information can help parents reduce chaos and create a feeling of control, but there are often obstacles to its acquisition, which has been described as similar to learning a new language. The purpose of this study was to describe parents' experiences of acquiring and using information to create knowledge about their child's cancer during the course of the illness. The authors used qualitative content analysis on data from focus groups and individual interviews with 14 parents of children with cancer. Two themes were constructed: (a) feeling acknowledged as a person of significance included feeling safe and secure in spite of uncertainty, having one's hopes supported, and getting relief from other families' experiences; (b) feeling like an unwelcome guest included feeling abandoned at important milestones, feeling forced to nag for information, and feeling burdened by the obligation to inform others. Parents may need extra attention at important milestones such as treatment cessation, with information meetings grounded in the parents' own needs.

Professional caregivers' perceptions of providing information to parents of children with cancer.

Information has been described as a critical part of the care for parents of children with cancer, but not much is known about how caregivers makes decisions about informing parents. This study aims to illuminate professional caregivers' perceptions of providing information to parents of children with cancer. Twenty caregivers at a Swedish pediatric oncology ward participated in four focus group interviews. The interviews were transcribed verbatim and subjected to qualitative content analysis. Two themes were found: Matching the amount of information to the parents' needs concerned situations where the amount of information provided according to the caregivers' assessment is deemed too small, appropriate, or too large. Navigating through a vague structure dealt with a disrupted setting, unclear responsibilities within the team, difficult timing, unintelligible information, and underused tools for communication. Implications for intervention development are discussed.