Registered nurses' and nurse assistants' lived experience of troubled conscience in their work in elderly care--a phenomenological hermeneutic study.

BACKGROUND: In elderly care registered nurses (RNs) and nurse assistants (NAs) face ethical challenges which may trouble their conscience. OBJECTIVE: This study aimed to illuminate meanings of RNs' and NAs' lived experience of troubled conscience in their work in municipal residential elderly care. DESIGN: Interviews with six RNs and six NAs were interpreted separately using a phenomenological hermeneutic method. SETTINGS: Data was collected in 2005 among RNs and NAs working in special types of housings for the elderly in a municipality in Sweden. PARTICIPANTS: The RNs and NAs were selected for participation had previously participated in a questionnaire study and their ratings in the questionnaire study constituted the selection criteria for the interview study. RESULTS: The RNs' lived experience of troubled conscience was formulated in two themes. The first theme is 'being trapped in powerlessness' which includes three sub-themes: being restrained by others' omission, being trapped in ethically demanding situations and failing to live up to others' expectations. The second theme is 'being inadequate' which includes two sub-themes: lacking courage to maintain one's opinion and feeling incompetent. The NAs' lived experience of troubled conscience was formulated in the two themes. The first is 'being hindered by pre-determined conditions' which includes two sub-themes: suffering from lack of focus in one's work and being restrained by the organisation. The second theme is 'being inadequate' which includes two sub-themes: lacking the courage to object and being negligent. CONCLUSIONS: The RNs' lived experience of troubled conscience were feelings of being trapped in a state of powerlessness, caught in a struggle between responsibility and authority and a sense of inadequacy fuelled by feelings of incompetence, a lack of courage and a fear of revealing themselves and endangering residents' well-being. The NAs' lived experience of troubled conscience was feelings of being hindered by pre-determined conditions, facing a fragmented work situation hovering between norms and rules and convictions of their conscience. To not endangering the atmosphere in the work-team they are submissive to the norms of their co-workers. They felt inadequate as they should be model care providers. The findings were interpreted in the light of Fromm's authoritarian and humanistic conscience.

Assessing informal caregivers' experiences: a qualitative and psychometric evaluation of the Caregiver Reaction Assessment Scale.

With the aim to evaluate the Swedish version of the Caregiver Reaction Assessment Scale (CRA), informal caregivers (n = 209) to individuals with a malignant disease, dementia or a physical impairment were recruited. The CRA was developed in the USA and is a self-rating questionnaire consisting of five subscales, measuring family members' reactions to the experience of caring for a relative with mental or physical illnesses. Data were analysed using psychometric and qualitative methods. Findings indicated good internal consistency, and a factor analysis confirmed the structure with five subscales; however, an overlap of items between the subscales was found. A content analysis of respondents' comments indicated that there were problems due to presuppositions inherent in the questions and with the meaning of words. Problems regarding inclusion/exclusion aspects in some concepts were also found. Two aspects of caregiver reactions were found to be missing or only partly covered: worrying and positive experiences. Results from this study suggest that the Swedish version is useful for assessment of caregiver reactions but needs further refinement.

The meaning of skilled care providers' relationships with stroke and aphasia patients.

Little is known about the reciprocal influence of communication difficulties on the care relationship. To illuminate care providers' lived experiences of relationships with stroke and aphasia patients, narrative interviews were conducted with providers particularly successful at communicating with patients. A phenomenological hermeneutic analysis of the narratives revealed three themes: Calling forth responsibility through fragility, restoring the patient's dignity, and being in a state of understanding. The analysis disclosed caring with regard to the patient's desire, which has its starting point in intersubjective relationship and interplay, in which nonverbal communication is essential--that is, open participation while meeting the patient as a presence. Thus, care providers prepare for deep fellowship, or communion, by being available. They described an equality with patients, interpreted as fraternity and reciprocity, that is a necessary element in presence as communion. The works of Marcel, Hegel, Stern, and Ricoeur provided the theoretical framework for the interpretation.

Composite interval mapping reveals a major locus influencing embryonic development rate in rainbow trout (Oncorhynchus mykiss).

Little is known about the genetics controlling the rate of embryonic development in salmonids, despite the fact that this trait plays an important role in the life history of wild and cultured stocks. We investigated the genetics of embryonic development rate by performing an analysis of quantitative trait loci (QTL) on two families of androgenetically derived doubled haploid rainbow trout produced from a hybrid of two clonal lines with divergent embryonic development rates. A total of 170 doubled haploid individuals were genotyped at 222 marker loci [219 amplified fragment length polymorphism (AFLP) markers, 2 microsatellites, and p53]. A genetic linkage analysis resulted in a map consisting of 27 linkage groups with 21 of the markers remaining unlinked at a minimum LOD of 3.0 and maximum theta of 0.40. Eight of these linkage groups were matched to published rainbow trout linkage groups. Composite interval mapping (CIM) revealed evidence for two QTL influencing time to hatch, and suggestive evidence for a third. These QTL accounted for a total of 24.6% of the variation in time to hatch. One of these QTL had a large effect on development rate, especially in one family of doubled haploids, in which it explained 25.6% of the variance in time to hatch. QTL influencing embryonic length and weight at the commencement of exogenous feeding were also identified. The QTL with the strongest effect on embryonic length (lenR13) mapped to the same position as the QTL with the strongest effect on time to hatch (tthR13), suggesting a single QTL may have a pleiotropic effect on both these traits. These results suggest that the use of clonal lines with a doubled haploid crossing design is an effective way of analyzing the genetic basis of complex traits in salmonids.

Communicating with people with stroke and aphasia: understanding through sensation without words.

To illuminate the phenomena of 'communicating with people with stroke and aphasia without words', 10 care providers particularly successful at communicating with stroke and aphasia patients who were working at a stroke rehabilitation ward narrated their experiences of communicating with such patients. A phenomenological hermeneutic approach, inspired by Ricoeur's philosophy, was used in the analysis. Two main themes were found: facilitating openness and being in wordless communication. The care providers sensed the feelings of the patients and experienced similar feelings themselves, thus, the communication is guided by the shared feelings between the care provider and the patient, i.e. communion. For this 'communication through sensation' to take place, the following factors were found to be necessary: creative closeness in combination with protective distance; striving for satisfaction and against exhaustion and desperation; meeting the patient halfway to gain understanding; exhibiting attention and accessibility to the patient; and trust and confidence for both care providers and patients. The findings were interpreted and discussed in the light of works by Levinas, Lögstrup and Stern.

Suffering from care as expressed in the narratives of former patients in somatic wards.

To illuminate patients' experiences of suffering from care, ten former patients in somatic wards narrated a desirable care episode (n = 39) and an undesirable care episode (n = 51). The interviews were analysed using a phenomenological hermeneutic method inspired by Ricoeur's philosophy. Four themes were found: having a good rest, suffering through, searching for autonomy and being cared for by attentive and committed staff. The findings were interpreted in light of Eriksson's description of suffering, which describes three kinds of suffering: 'suffering of life', 'suffering of illness' and 'suffering of caring'. Although not mentioned explicitly, it was evident that cases of suffering from care were indicated in the patients' narratives. The themes were related to the patients' states of health, their experience of the care situation and their descriptions of themselves, and could be understood as related to the acts of the 'drama of suffering' described by Eriksson. The study highlights the need for the patient to find a co-actor in the drama of suffering in order to prevent suffering from care, i.e. prevent hindrance to the patient in her/his struggle against the 'suffering of illness' and the 'suffering of life'. The patients must be seen as the directors of their own dramas of suffering.