The Lived Experience of Critically-Ill Muslim Patients in Isolation.

PURPOSE: This study explored critically ill Muslim patients' experiences and perceptions related to confinement to isolation rooms. METHODS: The descriptive-interpretive lens of phenomenology was employed to explore and illuminate the isolation experience of critically ill Muslim patients). Semi-structured, face-to-face, audiotaped interviews were conducted . Colaizzi's method of data analysis, in combination with an interpretive analysis supported by van Manen's "lifeworld constituents" were used. RESULTS: Data analysis revealed four themes: Feeling isolated and imprisoned; losing basic patients' rights; feeling rejected by healthcare providers; and accepting isolation and its adversity. Findings were illuminated by applying van Manen's lifeworld constituents: spatiality, temporality, relationality and corporeality. The patients described the overwhelming impact of isolation on their physical, emotional, social and spiritual health. CONCLUSIONS: This study provides healthcare providers with an in-depth understanding of critically ill patients' physical, psychological and spiritual needs. Although the unique needs of Muslim patients are highlighted, it is evident that patients' suffering in isolation is universal. Healthcare providers are encouraged to consider creative measures to support and help patients cope with the adversity of isolation.

Student Perceptions of Classic and Game-Based Online Student Response Systems.

BACKGROUND: Online student response systems (OSRSs), driven by the Internet and cell phone technology, provide a free, easily accessible method to increase student engagement, facilitate active learning, and provide learners and teachers with instant feedback about learning progress. PURPOSE: This article describes undergraduate nursing students' use of 2 OSRSs and their perceptions of the impact of the tools on class participation and engagement. METHODS: Students used their own mobile phones or computers to access 2 types of OSRSs: a classic and a game-based OSRS. RESULTS: Students indicated that both systems increased participation and engagement. The game-based OSRS was favored over the classic OSRS. The potential for use of the game-based OSRS for assessing rapid-answer fact-based knowledge and the classic OSRS for assessing more complex learning tasks is discussed. CONCLUSION: Nurse educators are encouraged to consider integrating online response system technology into their classroom teaching.

An ethnographic-feminist study of Jordanian women's experiences of domestic violence and process of resolution.

We interviewed 12 Jordanian women who had experienced domestic violence (DV) and were receiving assistance at the Jordanian Women's Union (JWU). Our aim was to explore the history and factors supporting attainment of freedom from DV. Narratives revealed themes of DV toward girls; forced marriage; physical, psychological, or sexual abuse before and during marriage; and escalation and enduring DV. Escaping from DV required family and JWU support. In the context of a strongly patriarchal, religious society, we observed a process of resolution by shifting cultural values and themes of empowerment, with an undercurrent of suffering blamed on inequalities in the legal process.

Think globally, act locally: understanding sexual harassment from a cross-cultural perspective.

OBJECTIVES: Sexual harassment in medical education has been studied in the Americas, Europe and Asia; however, little is known about sexual harassment in Middle Eastern cultures. Our initial aim was to describe the sexual harassment of female doctors-in-training by male patients and their relatives in Turkey. During our analysis of data, we expanded our objectives to include the formulation of a framework that can provide a theoretical background to enhance medical educators' understanding of sexual harassment across cultures. METHODS: Questionnaires were provided to female resident doctors. Respondents were asked about their experiences of sexual harassment, about their reactions and about any precautionary measures they had used. Descriptive statistics were generated using SPSS software. Qualitative data were analysed using content analysis. RESULTS: Forty-nine (51.0%) of 96 distributed questionnaires were completed. Thirty-three (67.3%) participants stated that they had been sexually harassed by a patient or patient's relative at some point in their career. 'Gazing at the doctor in a lewd manner', selected by 25 (51.0%) participants, was the most common form of harassment. The methods of coping selected by the highest numbers of respondents involved seeking the discharge of the patient (24.2%), avoiding contact with the patient or relatives (24.2%) and showing rejection (21.2%). Participants' comments about the prevention of sexual harassment revealed a deep sense of need for protection. The interface between quantitative and qualitative findings and a review of the literature supported the development of a value-based, cross-cultural conceptual framework linking the valuing of hierarchy and conservatism with the occurrence of sexual harassment. CONCLUSIONS: We relate our findings to issues of patriarchy, power and socio-cultural influences that impact both the perpetrator and the target of sexual harassment. Medical educators are responsible for the control and prevention of sexual harassment of students. The globalisation of medical education requires that medical educators use a multi-cultural approach which considers socio-cultural influences and the diversity of female and male students' actions and perceptions of sexual harassment.

The association between bathing and weaning trial duration.

OBJECTIVE: To describe patterns of bath care for patients who are weaning from prolonged mechanical ventilation (PMV) and to explore the association between bathing and weaning trial duration. METHODS: Descriptive correlational study. Clinical records from 439 weaning trial days for 30 patients who required PMV were abstracted for bathing occurrences during weaning trials, within 1 hour before a trial, and nocturnally. RESULTS: Most baths occurred during weaning trials (30.8%) or at night (35.3%), and less frequently (16%) within 1 hour before a trial. No significant effects were found on trial duration for nocturnal bathing or bathing within 1 hour before a trial. By using random coefficient modeling, weaning duration was shown to be longer when bathing occurred during a weaning trial (P < .05), even when controlling for age, severity of illness, and days on bedrest. CONCLUSION: Bathing occurred during approximately one third of PMV weaning trials. Baths during PMV weaning trials were associated with longer weaning trial duration.

Wash and wean: bathing patients undergoing weaning trials during prolonged mechanical ventilation.

BACKGROUND: Bathing is a fundamental nursing care activity performed for or with the self-assistance of critically ill patients. Few studies address caregiver or patient-family perspectives about bathing activity during weaning from prolonged mechanical ventilation (PMV). OBJECTIVE: To describe practices and beliefs about bathing patients during weaning from PMV. METHODS: Secondary analysis of qualitative data (observational field notes, interviews, and clinical record review) from a larger ethnographic study involving 30 patients weaning from PMV and the clinicians who cared for them using basic qualitative description. RESULTS: Bathing, hygiene, and personal care were highly valued and equated with "good" nursing care by families and nurses. Nurses and respiratory therapists reported "working around" bath time and promoted conducting weaning trials before or after bathing. Patients were nevertheless bathed during weaning trials despite clinicians' expressed concerns for energy conservation. Clinicians recognized individual patient response to bathing during PMV weaning trials. CONCLUSION: Bathing is a central care activity for patients on PMV and a component of daily work processes in the intensive care unit. Bathing requires assessment of patient condition and activity tolerance and nurse-respiratory therapist negotiation and accommodation with respect to the initiation or continuation of PMV weaning trials during bathing. Further study is needed to validate the impact (or lack of impact) of various timing strategies for bathing patients who are on PMV.

Experiences of self-monitoring: successes and struggles during treatment for weight loss.

We interviewed 15 individuals who completed a behavioral weight loss treatment study with the aim of exploring participants' reflections on their feelings, attitudes, and behaviors while using a paper diary to self-monitor their diet. Constant comparative and matrix analysis procedures were used to analyze interview data; the qualitative results were then interfaced with descriptive numerical data on individuals' adherence to self-monitoring and weight loss. Three categories of self-monitoring experience were identified: (a) well-disciplined-those who had high adherence to self-monitoring, high weight loss, and a "can do" positive approach, (b) missing the connection-those who had moderate adherence, moderate- to low weight loss, and an "it's an assignment" approach, without integrating self-monitoring into everyday life, and (c) diminished support-those who had poor adherence, poor weight control, and were adversely affected by coexisting negative factors. Given the variations in how individuals integrated the process of self-monitoring, we need to consider individualizing self-monitoring strategies to improve adherence.

Transitioning to end-of-life care in the intensive care unit: a case of unifying divergent desires.

Traditionally, the intensive care unit (ICU) has focused on reversal of life-threatening illness. Patients with incurable cancer admitted to the ICU present unique challenges for clinicians when these patients transition to end-of-life (EOL) care. A dimensional analysis of a single case study from a larger 30-case ethnographic study was used to explore the cancer patient's transition to EOL care in the ICU. Family members and clinicians had different expectations of care, which resulted in divergent treatment goals and desires for the patient, a 62-year-old woman with presumed pneumonia and underlying terminal glioblastoma multiforme. The attending physician and palliative care consultant unified family members' and clinicians' divergent goals and desires through a mediating process of probing the family about the patient's wishes. This process unified those involved and brought them to a place of acceptance. This case illustrates the turning point and rationale for the shift to EOL care in the ICU and the important role that communication plays in the transition. Understanding individual and family processes and family members' need for time to adjust to the transition to EOL is an essential element of practice within ICUs that increasingly manage terminally ill cancer patients.

Clinicians' evaluation and management of mental health, substance abuse, and chronic pain conditions in the intensive care unit.

OBJECTIVE: The purpose of this study was to describe clinicians' evaluation and management of co-existing mental health, substance abuse (MHSA), and chronic pain (CP) conditions in patients with prolonged critical illness. Little is known about the evaluation and management of these conditions in the intensive care unit, and practice guidelines do not address management in the context of critical illness, optimal sedation/analgesia, or ventilator weaning. DESIGN: Longitudinal qualitative description. SETTING: Intensive care unit of an urban academic medical center. PATIENTS: Total of 12 patients with co-existing MHSA or CP conditions who were weaning from mechanical ventilation. INTERVENTIONS: Intensive care unit clinicians, patients, and family members were formally interviewed and directly observed in the critical care setting for 56 consecutive weeks. MEASUREMENTS AND MAIN RESULTS: Transcribed interviews, field notes, and clinical records, representing >400 documents, were reviewed and coded using constant comparative analysis to identify the facilitators, barriers, contextual factors, and consequences associated with the evaluation and management of MHSA and CP conditions. Numeric clinical data supplemented and clarified thematic findings. Facilitators of MHSA and CP evaluation and management included family as history keepers, the use of subspecialty consultations, and anticipated alcohol withdrawal. Barriers included limited history taking and assessment of MHSA and CP conditions and the use of cognitive shortcuts. Consequences included nonintegration of MHSA and CP medications and diagnoses, episodic pharmacologic responses to psychobehavioral symptoms, and clinician-patient interpersonal tension. Contextual factors involved ambiguous psychobehavioral symptomatology, patients' critical illness and inability to speak, and competing clinical goals. CONCLUSIONS: The explicit evaluation and management of MHSA and CP conditions was highly variable and inconsistent across cases. Findings suggest that MHSA and CP conditions require monitoring and management similar to that required for other chronic conditions. Multidisciplinary, individual-level, and system-level responses are warranted to address the complex interplay of barriers, consequences, and context.

Patient involvement in health-related decisions during prolonged critical illness.

We describe patterns of communication of patients involved in health-related decision making during prolonged mechanical ventilation (PMV). Data were collected using observation, interview, and record review. Twelve of 30 patients participated in decisions about initiating, withdrawing, and withholding life-sustaining treatment, surgery, artificial feeding, financial/legal issues, discharge care, and daily care procedures. Patient involvement was largely validation or confirmation of what clinicians and families had already decided. Patients' participation was enlisted by clinicians and family members even when the patients did not exhibit full decisional capacity. Patient involvement in health-related decisions during prolonged critical illness is a shared and negotiated process that requires continued empirical study and ethical analysis.

Family presence and surveillance during weaning from prolonged mechanical ventilation.

OBJECTIVES: The research was designed to describe the care and communication processes during weaning from long-term mechanical ventilation (LTMV). A portion of those findings, specifically, how family members interact with the patient and respond to the ventilator and associated intensive care unit bedside equipment during LTMV weaning, are reported here. METHODS: Ethnography was conducted in a medical intensive care unit (MICU) and step-down MICU following 30 adults who were being weaned from LTMV (>4 days). Data collection involved field observations conducted from November 2001 to July 2003; interviews with patients, family members, and MICU clinicians; and clinical record review. RESULTS: Family members were present at the patients' bedside during 46% of weaning trials and interacted with patients through touch, talking, and surveillance. Families' bedside surveillance activities were interpretive of numeric monitor displays and laboratory values, protective of patient safety and comfort, and often focused exclusively on weaning. Interpretive language and surveillance were learned from and imitative of clinician behaviors. Clinicians characterized the family's presence as helpful, a hindrance, or having no effect on the weaning process. Quantitative analysis using random coefficient modeling examining the effect of family presence on length of weaning trials showed significantly longer daily weaning trials when families were present (P < .0001). CONCLUSION: Critical care clinicians influence families' acquisition of interpretive surveillance skills at the bedside of patients who are being weaned from LTMV. This study provides a potentially useful conceptual framework of family behaviors with long-term critically ill patients that could enhance the dialogue about family-centered care and guide future research on family presence in the intensive care unit.

Event analysis techniques.

Event analysis (EA), a qualitative research technique adapted from the fields of anthropology and sociology, can be used to describe and explain social interactions and behaviors associated with complicated clinical situations. Event analysis is useful in limiting the focus of data collection in complex settings and in obtaining and managing multiple perspectives about an event of interest while situating the event within appropriate social and environmental contexts. This article reviews contemporary uses of EA in clinical nursing research, describes the modification and application of EA techniques to common methods of data gathering (observation, interview, and document review) in clinical settings, and presents recommendations for conducting EA in clinical settings by using exemplars from a current study.

Striving for normalcy: symptoms and the threat of rejection after lung transplantation.

The purpose of this paper is to describe the psychosocial process of the symptom experience associated with the threat of organ rejection after lung transplantation. A grounded theory approach, including theoretical sampling and constant comparative analyses, was used in a sample of 14 lung transplant recipients who varied in age, gender, underlying lung disease, experience with rejection, and time since transplantation. 'Striving for normalcy' was the core process linking each of the four stages of the symptom experience and interpretation: naïveté, vulnerability, discovery, and insight. Each stage was marked by an initiating event, a predictable symptom response, and a dialectic (an internal struggle between recipients' personal perceptions of the situation and the juxtaposed understandings of the situation that they gleaned from transplant clinicians). Each stage was also labeled with a descriptor of the aspect of striving for normalcy that accounted for the variation in the symptom responses that recipients exhibited, the dialectics they faced, and the exemplars for each stage of the process. During the stage of naïveté, recipients were elated at improvements after transplantation, and often denied or delayed reporting symptoms. Once they experienced a rejection episode they entered the stage of vulnerability and became more vigilant about symptoms. The discovery stage was marked by the realization that rejection lacked characteristic symptoms; therefore, it was important to recognize any changes from their baseline condition. Recipients who achieved the insight stage realized that until they gave up some independence in exchange for interdependence, extended periods of normalcy eluded them, and embraced a reciprocal relationship with the transplant team. Knowledge that recipients' experience evolves over time from furtive hope during the stage of naïveté to qualified hope during the insight stage, directs us to intervene using stage-specific interventions to promote better symptom recognition and reporting.

Using conceptual triangulation to develop an integrated model of the symptom experience of acute rejection after lung transplantation.

The aim of this study was to develop a comprehensive model of the symptom experience associated with the development of acute rejection after lung transplantation by integrating the findings from a theory-testing quantitative study that explored the physiologic aspects and a theory-generating qualitative study that explored the interpretive aspects. Findings from the multimethod studies were integrated using conceptual triangulation methods described by Foster (Adv Nurs Sci. 1997;20:1-12). The integrated model will guide the development of interventions to promote effective patterns of symptom recognition and reporting of acute rejection.

Homeless persons' decisions to accept or reject public health disease-detection services.

The purpose of this study was to describe the factors that homeless persons report as influencing their decisions to utilize or reject a public health disease-detection program. Although there is copious literature on homelessness, few studies report the real-life perspectives of homeless persons toward health or health promotion. A convenience sample of 55 sheltered and street-dwelling homeless persons, who either resided in or were visiting seven shelters in a large northeastern U.S. city, were interviewed. The interview questions focused on the bases for decisions to accept or reject tuberculosis screening. The in-depth semistructured audio-taped interviews were transcribed, coded, and categorized using Ethnograph software. Interviews were analyzed using the constant comparative content analysis methods. The findings describe homeless persons' reasons for accepting or rejecting a tuberculosis-detection service, the prominent role of shelter personnel in recruitment for health-related interventions, and the confidentiality needs of women with children. This information can assist community health practitioners in designing and advertising health-promotion and disease-detection programming.

The contextual nature of decision making near the end of life: hospice patients' perspectives.

Mr. C. was diagnosed with lung cancer seven months ago. The cancer then spread to his brain. He was fully aware that the physicians were treating his symptoms, not the disease, however, discussions regarding the goals of treatment did not occur. He continued the treatment regimen of chemotherapy and radiation therapy. While at home one evening, he fell and fractured his femur. His mobility and independence were at once greatly compromised. While recovering in the hospital, he made the decision to opt out of curative treatment. He stated, "I want to go home, play with my cat, smoke cigarettes, and be with my friends when they can visit." What are the processes by which adults with life-threatening conditions make decisions about their care? What is the context of these decisions? The purpose of this study was to describe the process of decision making for adults with a terminal illness.