Understanding nursing personnel's health while working in end-of-life care-A hermeneutical study.

AIM: This study aimed to explore nursing personnel's health while working in end-of-life care. INTRODUCTION: End-of-life care is challenging both for nursing personnel and for the healthcare organisation, as retaining nursing staff is difficult. Although end-of-life care involves the risk of burnout, it also encompasses protective factors that can lead to personal and professional development and satisfaction, and that can enable personnel to encounter their own inner selves. In order to focus on the health of nursing personnel we chose the theory of caritative caring as our theoretical perspective. METHOD: A qualitative inductive research design with a hermeneutical approach was chosen to explore nursing personnel's health while working in end-of-life care. Two assistant nurses and six registered nurses with experience in end-of-life care at a palliative care unit participated. The study was approved by a Regional Ethical Review Board. RESULTS: The results are presented on three levels: rational, structural and existential. In the rational level, fellowship and togetherness with colleagues, as well as being able to distinguish between private life and work were important for nursing personnel's strategies for maintaining their health. At the structural level, social togetherness, sharing emotions and being involved in each other's emotions were important for nursing personnel's health. The existential level showed that the nursing personnel's own existential situation was affected when their inner self was emotionally affected by the patients' suffering. The awareness of suffering, life and death made the nursing personnel feel inner security, both as nursing professionals and as human beings. CONCLUSION: A common perspective based on a theory of caritative care may be helpful for retaining nursing personnel. While the study highlights nursing personnel's health while working in an end-of-life care context, the results may also be applicable to nursing professionals' health in other contexts.

The Caring Mission - Nursing Personnel's Inner Driving Force in End-of-Life Care.

Constantly facing human suffering and impending death can generate anxiety and insecurity in nursing personnel in end-of-life care. The aim of the study is to reveal nursing personnel's inner driving force in end-of-life care. A phenomenological hermeneutical method was used to search for meaning in the narrative data collected in this study. The structural analysis resulted in four themes: The appeal in the patient's vulnerability, The appeal in the patient's joy, Facing one's own existence in vulnerability, and Being at home with colleagues. Both vulnerability and joy motivated nursing personnel in caring. The care was often emotionally engaging and oscillated between grief and joy, which required a great deal from the nursing personnel both as professionals and fellow human beings. At the same time the emotionally engaging constituted an inner driving force, which gave them courage to do the best for the patients at the end of life.

Use and exchange of knowledge in the introduction of hospital-based home rehabilitation after a stroke: barriers and facilitators in change management.

BACKGROUND: The purpose of the study was to contribute to research and practice on how the use and exchange of knowledge can facilitate change in health care, specifically methods supporting managers. The study also aimed to investigate barriers related to governance principles that may affect organizational ability to improve quality of care. To achieve the purpose, the study followed a project of hospital-based home rehabilitation after a stroke at a hospital in Norrbotten County, Sweden. METHODS: Seven individual interviews were performed to obtain information from the project members and the managers involved in the project. A group interview with the team and their immediate manager were conducted after the project ended. A thematic analysis was performed to identify and present patterns that formed the results of the study. RESULTS: The study shows how knowledge was identified, gathered, used, and disseminated in the project. The analysis pointed out how knowledge played an important role from two perspectives: in evidence-based practice in rehabilitation work and for change management. Knowledge exchange and learning across organizational boundaries increased the pace, efficiency, and effectiveness, but collaboration on knowledge, in the sense of joint activities based on a common purpose, only took place within the rehabilitation work. Furthermore, there were indications that governance principles, such as the distribution of financial responsibility and the requirements for official recommendations, influenced the pace of change. CONCLUSIONS: It was shown that the exchange of knowledge and collaboration can facilitate change in health care, but that communication needs to be planned and prioritised. Readiness for change was the basis for the success of the project and for ensuring commitment among those involved. There is also a need for the management to understand how governance principles may affect the efficiency of change work.

Older persons and relatives' experience of coordinated care planning via a video meeting.

Aim: The study aimed to describe coordinated care planning via a video meeting from the perspective of older persons and their relatives. Design: A qualitative inductive research design was used to describe older persons and relatives' experience of care planning via video meeting. Methods: Eight unstructured interviews were conducted. Purposive sampling resulted in a sample of four older persons and four relatives. The material was analysed by qualitative content analysis. Results: The theme being excluded illustrates how the older persons and their relatives experienced care planning via a video meeting as lack of a personal relationship, meaninglessness and lack of participation. The older persons and their relatives had a feeling of being excluded and in an unfamiliar situation. Lack of information about the meeting's structure and content impaired their ability to prepare for it beforehand, which led to uncertainty.

Ideas of caring in nursing practice.

In nursing practice, awareness of ethical inner values and a common understanding of nursing and caring are needed. It is therefore important to highlight ideas of caring in nursing practice. The aim of this paper was to illuminate nursing, caring and ethical inner values in caring and caring in nursing practice. By being attentive, open, respectful and treating the patient as a person, nurses can enhance both their own and the patient's sense of personal meaning in the caring relationship. Nurses can use self-reflection to create an awareness of nursing, caring and ethical inner values in caring.

"The challenge of joining all the pieces together" - Nurses' experience of palliative care for older people with advanced dementia living in residential aged care units.

AIMS AND OBJECTIVES: To describe nurses' experiences of palliative care for older people with advanced dementia living in residential aged care units. BACKGROUND: Dementia is a global health problem and the number of older people with dementia who need palliative care is increasing. Previous research has revealed that care for older people with dementia in the final stage of life is usually complex. However, little is known about how nurses experience palliative care for older people with advanced dementia living in residential aged care units. METHOD: Nine individual, semi-structured face-to-face interviews with nurses working in residential aged care units for older people with advanced dementia in palliative care in Western Sweden were analysed using qualitative inductive content analysis. The COREQ checklist was followed. RESULTS: The nurses considered that palliative care for older people with advanced dementia is a complex and challenging form of care. In particular, they identified three challenges that must be met: developing specialised knowledge and skills, developing teamwork as a working method and creating a caring relationship. CONCLUSIONS: The results of our analysis indicate that if nurses are aware of and understand that the challenges are essential for "joining all the pieces together," the palliative care for older people with advanced dementia may become a positive experience for nurses and may increase their sense of satisfaction and security in their professional role. RELEVANCE TO CLINICAL PRACTICE: For the palliative care to be successful, the nurses need to "join all the pieces together," that is succeed in developing specialised knowledge and skills, developing teamwork as a working method and creating a caring relationship to establish a person-centred care with the older person with advanced dementia and with his or her relatives.

Organizing for sustainable inter-organizational collaboration in health care processes.

Integrating health care services has proven to be important from both the patient and organizational perspectives. This study explores what defines a perceived well-functioning collaboration in the inter-organizational process of providing assistive devices in Sweden. Two focus groups comprising participants with profound knowledge of collaboration were performed, and data were analyzed in five steps, resulting in a data structure. Results yield the identification of three interacting processes: coordinating efforts to patient needs, ensuring evidence-based practice, and planning for efficient use of resources. These processes affected one another, and, therefore, would likely not have been effectively managed separately. The study contributes to theories of process management and organization by specifically focusing on how to analyze and improve sustainable collaboration in health care processes at both the management and professional levels. Theoretical frameworks that show different ways of organizing collaboration, as well as the concepts of action nets and boundary objects, can support both analysis and planning of collaboration. The intention would be to develop integration in inter-organizational health care processes, resulting in more person-centered care.

Nursing students' attitudes toward care of dying patients: A pre- and post-palliative course study.

BACKGROUND: Many nursing students are not prepared to encounter death and care for patients who are at the end of life as newly educated nurses. The Frommelt Attitude Toward Care of Dying Scale (FATCOD) has been used to assess nursing students' attitudes during their education and changes have been noted. OBJECTIVE: To examine nursing students' attitudes towards care of dying patients before and after a course in palliative care. DESIGN: A descriptive study with a pre and post design. SETTINGS & PARTICIPANTS: Nursing students (n = 73) enrolled in a mandatory palliative course in the nursing programme at a Swedish university. METHODS: Data were collected before and after a palliative care course using FATCOD and qualitative open-ended questions. Data from FATCOD were analysed using descriptive and analytical statistics. The open-ended questions were analysed with qualitative content analysis. RESULTS: The students' mean scores showed a statistically significant change toward a more positive attitude toward care of dying. Students with the lowest pre-course scores showed the highest mean change. The qualitative analysis showed that the students had gained additional knowledge, deepened understanding, and increased feelings of security through the course. CONCLUSIONS: A course in palliative care could help to change nursing students' attitudes towards care of patients who are dying and their relatives, in a positive direction. A course in palliative care is suggested to be mandatory in nursing education, and in addition to theoretical lectures include learning activities such as reflection in small groups, simulation training and taking care of the dead body.

Follow-up visits to older patients after a hospital stay: nurses' perspectives.

Older patients with multimorbidity and extensive healthcare needs are at risk of frequent readmission to hospital after discharge. With a Swedish report entitled 'Follow-up 48-72' as its basis, the present study aimed to describe nurses' experiences of follow-up visits to older patients with multimorbidity 48 to 72 hours after discharge from hospital. Semi-structured interviews were conducted with 10 nurses experienced with such home visits to older patients, and the material was analysed by qualitative content analysis. The results indicate that such visits by nurses can relieve patient anxiety, as patients are often unsure of the next steps, in terms of medication and care. According to the nurses, these visits created trust in the nurse-patient relationship and ensured patient safety. Follow-up visits soon after discharge from hospital should become a part of routine nursing, especially for older people with multimorbidity.

Reflecting on one's own death: The existential questions that nurses face during end-of-life care.

OBJECTIVE: When registered nurses care for patients at the end of life, they are often confronted with different issues related to suffering, dying, and death whether working in hospital or community care. Serious existential questions that challenge nurses' identities as human beings can arise as a result of these situations. The aim of our study was to describe and gain a deeper understanding of nurses' existential questions when caring for dying patients. METHOD: Focus-group interviews with registered nurses who shared similar experiences and backgrounds about experiences in end-of-life care were employed to gain a deeper understanding about this sensitive subject. Focus-group interviews were performed in hospice care, in community care, and in a palliative care unit in western Sweden. A qualitative hermeneutic approach was employed to interpret the data. RESULTS: Nurses' existential questions balanced between responsibility and guilt in relation to their patients, between fear and courage in relation to being professional caregivers and fellow human beings, and between hope and despair in relation to the other's and their own death. SIGNIFICANCE OF RESULTS: Nurses in end-of-life care experience various emotions from patients related to things physical, spatial, and temporal. When nurses encounter these emotions as expressing a patient's suffering, they lead to challenges of balancing between different feelings in relation to patients, as both professional caregivers and fellow human beings. Nurses can experience growth both professionally and as human beings when caring for patients at the end of life.

External mirroring of inner chaos: blogging as experienced by the relatives of people with cancer.

BACKGROUND: Relatives of a person suffering from cancer risk being affected both physically and psychologically. Blogging has become increasingly popular as a forum for communicating experiences, but few studies have focused on what blogging about a relative's cancer journey means to the author. AIM: To illuminate relatives' experiences of blogging when a family member is in the end-of-life phase of cancer. METHOD: Telephone interviews were conducted with 12 people about their experiences of blogging during and after their family member's illness. The data was analysed using qualitative content analysis. FINDINGS: Blogging facilitated everyday life, introduced the relatives to new friends with similar experiences, helped them in their grief process, and helped them to preserve memories. The negative aspects were being misunderstood and publicly criticised as well as the feeling of providing readers with 'reality show' entertainment. CONCLUSION: Blogging was seen as a complement to professional care that contributed to the prevention of ill health.

Community nurses' experiences of ethical problems in end-of-life care in the patient's own home.

AIM: To gain a deeper understanding of community nurses' experiences of ethical problems in end-of-life care in the patient's own home. METHOD: Ten female nurses from five different communities with experience of end-of-life care were interviewed. A hermeneutic approach inspired by Gadamer was used to analyse the qualitative data from the interviews. FINDINGS: In the first step of interpretation, two themes emerged: Uncomfortable feelings and Lack of cooperation and in the second step, one theme Lack of security emerged. Finally, the overall interpretation revealed the theme Feelings of loss of control in end-of-life care in the patient's own home. CONCLUSION: The nurses exhibited commitment and a desire to do good when caring for patients in the end-of-life phase, even if they sometimes experienced feelings of lack of control. This implies that, when confronted with care-related issues, they have the power to both act and react. This study aimed to increase understanding of ethical problems that arise in end-of-life care in the patient's own home and revealed the need to take the patients', relatives' and nurses' perspectives on health and suffering into consideration to ensure good end-of-life home care.

Community nurses' experiences of ethical dilemmas in palliative care: a Swedish study.

AIM: The aim of this study was to highlight community nurses' experiences of ethical dilemmas in palliative care. BACKGROUND: There are many studies on palliative care but research on how community nurses experience ethical dilemmas in palliative home care is lacking. The ethical dilemmas to which these nurses are exposed seriously challenge their ethical competence. METHOD: Seven community nurses described their experiences of ethical dilemmas in palliative home care. The data was analysed by means of qualitative content analysis. FINDINGS: The core themes that emerged were: powerlessness, frustration, and concern in relation to ethical dilemmas in palliative care. The nurses were motivated and felt responsibility for their patients' end of life, and their relatives, and took their duties seriously. They wanted to satisfy all parties; the patient, the relatives and other palliative care professionals. CONCLUSION: The study confirms the need for knowledge about how community nurses experience dilemmas in ethical decision-making. They have the freedom to act and the willingness to make decisions, but they lack competence and knowledge about how their colleagues' experience and deal with such issues.

Rapid insulin-dependent endocytosis of the insulin receptor by caveolae in primary adipocytes.

BACKGROUND: The insulin receptor is localized in caveolae and is dependent on caveolae or cholesterol for signaling in adipocytes. When stimulated with insulin, the receptor is internalized. METHODOLOGY/PRINCIPAL FINDINGS: We examined primary rat adipocytes by subcellular fractionation to examine if the insulin receptor was internalized in a caveolae-mediated process. Insulin induced a rapid, t(1/2)<3 min, endocytosis of the insulin receptor in parallel with receptor tyrosine autophosphorylation. Concomitantly, caveolin-1 was phosphorylated at tyrosine(14) and endocytosed. Vanadate increased the phosphorylation of caveolin-1 without affecting insulin receptor phosphorylation or endocytosis. Immunocapture of endosomal vesicles with antibodies against the insulin receptor co-captured caveolin-1 and immunocapture with antibodies against tyrosine(14)-phosphorylated caveolin-1 co-captured the insulin receptor, demonstrating that the insulin receptor was endocytosed together with tyrosine(14)-phosphorylated caveolin-1. By immunogold electron microscopy the insulin receptor and caveolin-1 were colocalized in endosome vesicles that resembled caveosomes. Clathrin was not endocytosed with the insulin receptor and the inhibitor of clathrin-coated pit-mediated endocytosis, chlorpromazine, did not inhibit internalization of the insulin receptor, while transferrin receptor internalization was inhibited. CONCLUSION: It is concluded that in response to insulin stimulation the autophosphorylated insulin receptor in primary adipocytes is rapidly endocytosed in a caveolae-mediated process, involving tyrosine phosphorylation of caveolin-1.

Expression of a mutant IRS inhibits metabolic and mitogenic signalling of insulin in human adipocytes.

Adipose tissue is a primary target of insulin, but knowledge about insulin signalling in human adipocytes is limited. We developed an electroporation technique for transfection of primary human adipocytes with a transfection efficiency of 15% +/- 5 (mean +/- S.D.). Human adipocytes were co-transfected with a mutant of IRS-3 (all four potential PI3-kinase binding motifs mutated: IRS-3F4) and HA-tagged protein kinase B (HA-PKB/Akt). HA-PKB/Akt was immunoprecipitated from cell lysates with anti-HA antibodies, resolved with SDS-PAGE, and immunoblotted with phospho-specific antibodies. We found that IRS-3F4 blocked insulin stimulation of HA-PKB/Akt phosphorylation and in further analyses also translocation of recombinant HA-tagged glucose transporter to the plasma membrane. IRS-3F4 also blocked insulin-induced activation of the transcription factor Elk-1. Our results demonstrate the critical importance of IRS for metabolic as well as mitogenic signalling by insulin. This method for transfection of primary human adipocytes will be useful for studying insulin signalling in human adipocytes with molecular biological techniques.

Colocalization of insulin receptor and insulin receptor substrate-1 to caveolae in primary human adipocytes. Cholesterol depletion blocks insulin signalling for metabolic and mitogenic control.

Caveolae are plasma membrane invaginations with several functions, one of which appears to be to organize receptor mediated signalling. Here we report that in primary human subcutaneous adipocytes the insulin receptor was localized to caveolae by electron microscopy/immunogold detection and by isolating caveolae from plasma membranes. Part of insulin receptor substrate 1 (IRS1), the immediate downstream signal mediator, was colocalized with the insulin receptor in the plasma membrane and caveolae, as demonstrated by immunofluorescence microscopy, immunogold electron microscopy, and immunogold electron microscopy of transfected recombinant HA-IRS1. In contrast, rat epididymal adipocytes lacked IRS1 at the plasma membrane. Depletion of cholesterol from the cells using beta-cyclodextrin blocked insulin stimulation of glucose uptake, insulin inhibition of perilipin phosphorylation in response to isoproterenol, and insulin stimulation of protein kinase B and Map-kinases extracellular signal-related kinase (ERK)1/2 phosphorylation. Insulin-stimulated phosphorylation of the insulin receptor and IRS1 was not affected, indicating that caveolae integrity is required downstream of IRS1. In conclusion we show that insulin receptor and IRS1 are both caveolar proteins and that caveolae are required for both metabolic and mitogenic control in human adipocytes. Our results establish caveolae as foci of insulin action and stress the importance of examining human cells in addition to animal cells and cell lines.

Lipids and glycosphingolipids in caveolae and surrounding plasma membrane of primary rat adipocytes.

We have made a comprehensive and quantitative analysis of the lipid composition of caveolae from primary rat fat cells and compared the composition of plasma membrane inside and outside caveolae. We isolated caveolae from purified plasma membranes using ultrasonication in carbonate buffer to disrupt the membrane, or extraction with nonionic detergent, followed by density gradient ultracentrifugation. The carbonate-isolated caveolae fraction was further immunopurified using caveolin antibodies. Carbonate-isolated caveolae were enriched in cholesterol and sphingomyelin, and the concentration was three- and twofold higher, respectively, in caveolae compared to the surrounding plasma membrane. The concentration of glycerophospholipids was similar suggesting that glycerophospholipids constitute a constant core throughout the plasma membrane. The composition of detergent-insoluble fractions of the plasma membrane was very variable between preparations, but strongly enriched in sphingomyelin and depleted of glycerophospholipids compared to carbonate-isolated caveolae; indicating that detergent extraction is not a suitable technique for caveolae preparation. An average adipocyte caveola contained about 22 x 10(3) molecules of cholesterol, 7.5 x 10(3) of sphingomyelin and 23 x 10(3) of glycerophospholipid. The glycosphingolipid GD3 was highly enriched in caveolae, whereas GM3, GM1 and GD1a were present inside as well as outside the caveolae membrane. GD1b, GT1b, GM2, GQ1b, sulfatide and lactosylceramide sulfate were not detected in caveolae.

Cell surface orifices of caveolae and localization of caveolin to the necks of caveolae in adipocytes.

Caveolae are noncoated invaginations of the plasma membrane that form in the presence of the protein caveolin. Caveolae are found in most cells, but are especially abundant in adipocytes. By high-resolution electron microscopy of plasma membrane sheets the detailed structure of individual caveolae of primary rat adipocytes was examined. Caveolin-1 and -2 binding was restricted to the membrane proximal region, such as the ducts or necks attaching the caveolar bulb to the membrane. This was confirmed by transfection with myc-tagged caveolin-1 and -2. Essentially the same results were obtained with human fibroblasts. Hence caveolin does not form the caveolar bulb in these cells, but rather the neck and may thus act to retain the caveolar constituents, indicating how caveolin participates in the formation of caveolae. Caveolae, randomly distributed over the plasma membrane, were very heterogeneous, varying in size between 25 and 150 nm. There was about one million caveolae in an adipocyte, which increased the surface area of the plasma membrane by 50%. Half of the caveolae, those larger than 50 nm, had access to the outside of the cell via ducts and 20-nm orifices at the cell surface. The rest of the caveolae, those smaller than 50 nm, were not open to the cell exterior. Cholesterol depletion destroyed both caveolae and the cell surface orifices.

Insulin induces translocation of glucose transporter GLUT4 to plasma membrane caveolae in adipocytes.

Insulin-stimulated glucose uptake in muscle and adipose tissue is the result of translocation of insulin-regulated glucose transporters (GLUT4) from intracellular vesicles to the plasma membrane. Here we report that GLUT4 in the plasma membrane of 3T3-L1 adipocytes were located predominantly in caveolae invaginations: by immunogold electron microscopy of plasma membranes, 88% of GLUT4 were localized to caveolae structures and this distribution within the plasma membrane was not affected by insulin. By immunofluorescence microscopy, a major part of GLUT 4 was colocalized with caveolin. The total amount of GLUT4 in the plasma membrane increased 2.2-fold in response to insulin as determined by immunogold electron or immunofluorescence microscopy. GLUT4 were enriched in caveolae fractions isolated without detergents from plasma membranes of rat adipocytes. In these fractions, GLUT4 were largely confined to caveolin-containing membranes of the caveolae preparation isolated from insulin-stimulated cells, determined by electron microscopy. Insulin increased the amount of GLUT4 2.7-fold in this caveolae fraction. Caveolae were purified further by immunoisolation with antibodies against caveolin. The amount of GLUT4 increased to the same extent in the immunopurified caveolae as in the cruder caveolae fractions from insulin-stimulated cells. We conclude that insulin induces translocation of GLUT4 to caveolae.