Being a "Warrior" to Care for the New Family: A Meta-ethnography of Nurses' Perspectives on Municipal Postnatal Healthcare.

Care in the postnatal period is a goal for all families with a newborn baby, and support from nurses might prevent long-term health problems and contribute to a positive postnatal experience. This meta-ethnography aims to integrate and synthesize qualitative studies that illuminate and describe nurses' perspectives on municipal postnatal health care in high-income countries. Systematic literature searches for qualitative studies were conducted and 13 articles were included. The analysis followed the seven phases of Noblit and Hare. Being a "warrior" to care for the new family was identified as an overarching metaphor accompanied by three main themes: Stretching human boundaries, Stretching system boundaries, and Stretching knowledge boundaries. The overarching metaphor offers a deeper understanding of the nurses as "warriors" who despite tight timeframes and heavy workloads are stretching toward a caring relationship with the families. Being a warrior continuously pushing system boundaries puts the nurses in risk of being overstretched, balancing between their ideals and the reality. As more knowledge and clearer policies and procedures regarding the inclusion of fathers and LGBTQ parents in municipal postnatal healthcare are needed, more focus placed on the father or non-birthing parent, different cultural traditions and family constellations in practice and education is suggested.

Opening Pandora's box: A meta-ethnography about alcohol use in pregnancy from midwives' and other healthcare providers' perspectives.

INTRODUCTION: Alcohol consumption has increased in recent years, including among women of childbearing age. A woman's alcohol intake during pregnancy is linked to complications and injuries in the newborn, and the risk of the child being harmed by the mother's alcohol use increases in proportion to the amount of alcohol she consumes. This meta-ethnography aims to explore midwives' and other healthcare providers' experiences of screening pregnant women for alcohol use in pregnancy and counselling them on the subject. METHODS: A systematic literature search in CINAHL, Maternity & Infant Care, MEDLINE, and Scopus was conducted in August 2021 and updated in January 2023. The CASP checklist was used to assess the included articles and meta-ethnography was used to synthesize the data. RESULTS: Fourteen qualitative studies were included. In the synthesis, we use the metaphor of Pandora's box to deepen our understanding of the topic. We found that some healthcare providers tiptoe around the box, not wanting to face the consequences and responsibilities of asking women about their alcohol use. Others refuse or are reluctant to open the box because they lack knowledge about screening and counselling. Some eventually open the box, understanding the importance of establishing a trusting relationship to address alcohol use and seeing the need for knowledge and screening tools. CONCLUSIONS: Healthcare education has the important task of ensuring that healthcare personnel have sufficient evidence-based knowledge about alcohol use in pregnancy. In the future, a health-promoting, tailored approach offering women in pre-pregnancy and early pregnancy sufficient evidence-based information should be implemented.

LGBTQ+ Persons' Experiences of Parenthood in the Context of Maternal and Child Health Care: A Meta-ethnography.

This study aims to integrate and synthesize knowledge of lesbian, gay, bisexual, transgender and queer (LGBTQ+) persons' experiences of parenthood in the context of maternal and child health care. For nurses to provide optimal care for LGBTQ+ parents, we need to derive knowledge from their perspectives. An interpretive meta-synthesis approach, meta-ethnography, was chosen for this study. A lines-of-argument synthesis based on four themes was developed: (1) Entering the world of LGBTQ+ parenthood; (2) The emotional journey in LGBTQ+ parenthood; (3) Struggling with the system as a LGBTQ+ parent and (4) A need to expand the knowledge horizon of LGBTQ+ parenthood. The overarching metaphor, "To be recognised as parents, unique and good enough, like everybody else," reflects how recognition and inclusion may support LGBTQ+ persons in their parenthood and broaden the understanding of parenthood. Knowledge of the LGBTQ+ family needs to be given greater attention in maternity and child health care settings, and in education and health policies.

The Metamorphosis. The impact of a young family member's problematic substance use on family life: a meta-ethnography.

PURPOSE: This meta-ethnography seeks to provide insight into the impact that a young family member's problematic substance use has on family life. BACKGROUND: Problematic substance use (PSU) usually emerges in adolescence or young adulthood. Living with a family member with PSU is highly stressful. An understanding is needed of families' experiences and their needs for adapted help and support, hence we have explored the impact of a young family member's PSU on family life. METHODS: Systematic literature searches for qualitative research that explores the impact of PSU on family life and family relationships were conducted and the seven stages of meta-ethnography were used. RESULTS: Fifteen articles were included. The Metamorphosis was established as an overarching metaphor. Five main themes accompany this metaphor: stranger in the family; injuring chaos; no trust any more; family lock-up; and helpless societies. CONCLUSION: The Metamorphosis reflects the all-embracing change experienced by families. Family members have felt powerless and helpless; often they wish to stay involved but do not know how. PSU at a young age can develop into lifelong chronic health challenges. Family-oriented help must be readily available in this phase as parents and siblings become deeply involved. Family involvement is seldom incorporated into routine treatment practices; such incorporation is therefore needed.

Multicultural doula care from the perspectives of immigrant women in Norway: A qualitative study.

OBJECTIVES: The aim of the study was to illuminate immigrant women's experiences of multicultural doula care as part of the 'Vulnerable, pregnant and new in Norway - Safe during childbirth with a multicultural doula' project. METHODS: The qualitative design was based on Braun & Clarke's thematic analysis. Semi-structured interviews were held, assisted by an interpreter, with seven immigrant women from three different countries. RESULTS: The overarching theme illuminated a significant caring relationship between the immigrant women and their multicultural doula. The relationship was important for the women's positive childbirth experience. Furthermore, four themes emerged as follows: feeling alone and scared; needing to be looked after; not knowing the language; and giving birth in a new and unfamiliar culture. The results revealed that the women felt safeguarded by the multicultural doula. They felt cared for and understood when the doulas acted as guides, knowing the culture and language, in collaboration with the midwife in maternal care. CONCLUSIONS: Multicultural doulas can contribute to optimizing the quality of care provided to immigrant women during pregnancy and childbirth, with focus on an equal quality of care for all women. The findings can raise awareness of cultural competence in midwifery practice. More research is needed to develop new models that incorporate multicultural doulas into healthcare policies.

Parents' experiences with public health nursing during the postnatal period: A reflective lifeworld research study.

AIM: To describe mothers' and fathers' experiences with public health nursing and child and family health centre services in the postnatal period, both as a couple and as individuals. METHOD: A phenomenological reflective lifeworld research approach with a descriptive design was chosen. A purposive sample of 10 mothers and 10 fathers were interviewed twice, 1-2 and 6-8 weeks postpartum, using joint and individual interviews. By focusing on being open and flexible, the data were analyzed to elucidate a meaningful structure of the phenomenon. RESULTS: The findings revealed that parents' experiences with public health nurse (PHN) and Child and Family Health Centre (CFHC) services in the postnatal period are characterised by a longing to be seen and confirmed both as unique individuals and as a family by the PHN. Although an increased need for both lay and professional care is prominent during the postnatal period, the parents drew a varied picture of their experiences demonstrating that the CFHC services are focussing almost exclusively on mother and child. CONCLUSION: A public health nurse can contribute to strengthen parenthood and promote the family's health when the focus is on the new baby. Being cared for while learning to care for the baby is pivotal in a phase that involves both joy and vulnerability. This study adds knowledge concerning the importance of both parents being seen and confirmed by the PHN as unique individuals and a family unit in the postnatal period.

A meta-ethnography of language challenges in midwifery care.

INTRODUCTION: The aim was to synthesize qualitative studies that shed light on immigrant women's own experiences regarding language challenges during pregnancy, birth and the postpartum period in a new country. Wikberg's theory of intercultural caring was chosen as the theoretical perspective. METHODS: This meta-ethnography was conducted in accordance with Noblit and Hare, an interpretative qualitative review approach in seven phases, based on inclusion and exclusion criteria, and a systematic and manual search yielding a total of 1253 articles. Seven articles were included after a quality appraisal using the CASP instrument, and the process is shown in a PRISMA chart. The 142 women from the studies represented 42 different nationalities and were residents in 6 different host countries. RESULTS: A synthesis model illuminates the immigrant women's experiences of language challenges. 'To comprehend and to be understood as a unique person' emerged as the overarching theme, based on the three analogous themes: 'a desire to be met with respectful understanding', 'ethical and accurate interpreting', and 'caring midwives and new relationships'. The fourth opposite theme, 'violations and feelings of inferiority' describes the immigrant women's experiences when the language challenges remained. CONCLUSIONS: Midwives should be aware of language challenges in pregnancy, birth and postpartum care to minimize the risk of violations and unnecessary suffering related to care. The synthesis model can serve as a guide for respectful understanding, ethical and accurate interpreting, and caring, in accordance with Wikberg's dimensions of intercultural caring: universality, context, culture, and the needs and wishes of the immigrant women.

"Suffering as a Lifelong Companion: A Phenomenological-Hermeneutic Study of Men Living With Severe Psychiatric Illness"Lidelse som livslang følgesvenn: En fenomenologisk-hermeneutisk studie av menn som lever med alvorlig psykiatrisk sykdom.

Accumulation of suffering in later life due to severe psychiatric illness has received surprisingly little interest in nursing research. Suffering in daily living seems to be more demanding for men, a phenomenon still debated in the literature. This phenomenological-hermeneutic study aims at describing and interpreting the perspectives of adult men and their experiences of suffering in daily living with severe psychiatric illness, diagnosed as schizophrenia. Data were collected in dialogical conversations with four men aged between 20 and 40 years, living alone in northern Norway. The themes created from the structural understanding illuminate the participants' suffering as simultaneously struggling against the grasp of the illness and for reshaping the future. The theoretical interpretation unfolds the multidimensionality of their suffering and the need for confirmation of the suffering and reconciliation with the losses from illness, thus making reorientation to the future possible.

Relationships influencing caring in first-line nursing leadership: A visual hermeneutic study.

AIM: To explore and interpret relationships that influence caring in nursing leadership, in the context of Nordic municipal health care, from first-line nurse managers' perspectives. DESIGN AND METHOD: We chose a visual hermeneutic design. A three-stage interpretation process outlined by Drew and Guillemin, based on Rose, was used to analyse drawings and the following reflective dialogue from three focus groups, with a purposive sample of 11 first-line nurse managers. The study was conducted from February to May 2018. RESULTS: The findings demonstrated that first-line nurse managers struggled to balance their vision with administrative demands. Caring for patients implied caring for staff; however, they often felt as if they were drowning in contradictory demands. First-line nurse management could be a lonely position, where the first-line nurse managers longed for belonging based on increased self-awareness of their position within an organisation. Superiors' support enabled first-line nurse managers' in their primary aim of caring for patients. CONCLUSION: First-line nurse managers showed deep roots to their identities as nurses. Caring for patients included caring for staff and was their main concern, despite demanding reforms and demographic changes affecting leadership. Superiors' support was important for FLNMs' self-confidence and independence in leadership, so the first-line nurse managers can enact their vision of the best possible patient care. This study adds knowledge of the significance of caring in nursing leadership and the caritative leadership theory. IMPACT: In order to recognise FLNMs as vulnerable human beings and provide individual confirmation and support, a caring organisational culture is needed. FLNMs need knowledge based on caring and nursing sciences, administration and participation in formal leadership networks. These findings can serve as a foundation for developing educational programmes for nurse leaders at several organisational levels.

Unravelling the grief of involuntary pregnancy loss: A meta-ethnography of midwives' and nurses' emotional experiences.

BACKGROUND: Parents who experience involuntary pregnancy loss encounter nurses and midwives when requiring care. But the environment in which this attention is provided turns it into a stressful and challenging event that favours the concealment of emotions. Literature supports the development of compassion in nurses and midwives who tend to parents who experience pregnancy losses. AIM: To synthesise the emotional experiences of midwives and nurses when caring for parents who have suffered an involuntary pregnancy loss. METHOD: This is a synthesis of qualitative studies following Noblit and Hare's interpretive meta-ethnography. Eleven studies met the research objective and inclusion criteria. RESULTS: An overarching metaphor, 'Unravelling the grief of loss', accompanied by four major themes provided interpretive explanations to the experiences of midwives and nurses in caring for involuntary pregnancy losses: 'Pulling the thread' - looking for the meaning of loss; 'Yarn entanglement degree' - determinants for grief expression; 'Detangling tools' - focusing on the loss; and 'Fraying the thread' - moving away from the loss. DISCUSSION: The provision of whole care to these parents requires midwifery and nursing training and continued education. Furthermore, the organisational culture should prioritise the health and well-being of midwives and nurses. CONCLUSION: Midwives and nurses encounter the parents' loss in care and personally in various ways and give meaning to the loss conditioned by personal and professional determinants. They unravel the grief of loss by looking for the meaning, expressing their grief, focusing and moving away from the loss.

"Human Flourishing with Dignity": A Meta-Ethnography of the Meaning of Gardens for Elderly in Nursing Homes and Residential Care Settings.

This study aims to identify and synthesize qualitative research regarding residents' experiences of gardens while living in nursing homes and residential care facilities. To provide an optimal nursing environment inspired by nature, we need to derive knowledge from the residents' perspective. An interpretive meta-synthesis approach, a meta-ethnography, was chosen for this study. Altogether, six articles representing three continents and comprising 124 participants were included. The six articles that fulfilled the inclusion criteria were analyzed and synthesized according to Noblit & Hare's seven phases of meta-ethnography and the recent eMERGe guidelines. Four themes were identified: (1) The garden-a place to feel a connection with life, (2) the garden-a place to sense and find comfort, (3) the garden-a place to feel healthy and alive, and (4) the garden-a place to relate past and present. An overarching metaphor, "human flourishing with dignity," offers a deeper understanding of the meaning of the garden for older people in nursing homes and residential care. This meta-ethnography provides a reflective, systematic, data-driven synthesis based on literature spanning ten years. Rather than simply relying on retelling, the narration of experiences according to the primary researcher's descriptions and interpretations results in new knowledge. The significance of gardens for older people's health and well-being needs to be given greater attention and space in nursing practice, education, and health policies.

Contemplating Help-Seeking in Perinatal Psychological Distress-A Meta-Ethnography.

Perinatal psychological distress (PPD) may cause delays in help-seeking in the perinatal period, which is crucial for families with small children. Help-seeking theories focus on rational processes of behavior wherein 'help-seeking' is viewed as a decision-making process, in which action is preceded by recognizing a problem. We identified the phase prior to actual help-seeking actions as a life situation and a phenomenon through which to gain a deeper understanding from women's own perspectives. The aim of this study was to integrate and synthesize knowledge of women's experiences of contemplating seeking help for PPD. We chose interpretative meta-ethnography by Noblit and Hare (1988) and implemented eMERGe guidelines in reporting. The search was performed systematically, and the 14 included studies were evaluated with Critical Appraisal Skills Programme checklist (CASP). We identified seven themes and a metaphor in a lines-of-argument synthesis, showing that contemplating help-seeking is a multidimensional phenomenon. We did not observe a straightforward and linear process (as previous research suggests) but instead a complex process of contemplating help-seeking. A clinical implication is that service providers should work with outreach and develop their tools to connect with mothers with PPD. Another suggestion is to improve training in mental health literacy prior to or during pregnancy.

Going blindly into the women's world: a reflective lifeworld research study of fathers' expectations of and experiences with municipal postnatal healthcare services.

Purpose: The aim of this study is to describe new fathers' expectations of and experiences with municipal postnatal healthcare services.Methods: A phenomenological reflective lifeworld research (RLR) approach has been used. Ten fathers were interviewed about their expectations of and experiences with municipal postnatal healthcare services, and the data were analysed to elucidate a meaning structure for the phenomenon.Results: The essential meaning of the phenomenon of fathers' expectations of and experiences with municipal postnatal health care described as going blindly into the women's world. The essential meaning is further explicated through its four constituents: not knowing what to ask for, feeling excluded, seeking safety for the family and longing for care.Conclusions: Entering the postnatal period with sparse knowledge about the child and family healthcare services available is difficult for the fathers who do not know what to ask for and what to expect. The fathers' feel excluded by the public health nurse, and the postnatal health care is seen as a mother-baby-public health nurse triad. The feeling of exclusion and inequality might be avoided if public health nurses focused both on mothers' and fathers' individual follow-up needs in the postnatal period and on seeing the newborn baby and the parents as a family unit.

Primary healthcare midwives' experiences of caring for parents who have suffered an involuntary pregnancy loss: a phenomenological hermeneutic study.

OBJECTIVE: To illuminate the experiences of primary healthcare midwives who care for parents who have suffered an involuntary pregnancy loss. DESIGN: The phenomenological hermeneutic approach developed by Lindseth and Norberg was used to carry out narrative interviews. SETTING AND PARTICIPANTS: A purposive sample of 11 public primary healthcare midwives from a municipality in northern Spain, was selected. The participants' ages ranged between 26 and 62 years, and they were all women. FINDINGS: Four main themes were identified: (1) handling adversity, (2) finding a motive to get involved, (3) providing care from the rear, and (4) avoiding emotional connections with the parents. For the midwives, caring for parents who had suffered an involuntary pregnancy loss meant leaving their own comfort zone and handling adversity. They described acting in different ways such as going beyond task-focused care, following their intuition or avoiding encounters with the parents. CONCLUSIONS: More knowledge and preparation in terms of communication skills and bereavement is crucial for midwives in order to meet the needs of parents who have suffered an involuntary pregnancy loss. A caring organizational culture and supportive leadership will facilitate care continuity between specialized and primary healthcare and promote the welfare of midwives.

From Midwife-Dominated to Midwifery-Led Antenatal Care: A Meta-Ethnography.

Provision of antenatal care includes risk identification, prevention and management of pregnancy-related diseases, but also health education, health promotion, support and guidance to smooth the transition to parenthood. To ensure good perinatal health, high-quality, free and easily accessed antenatal care is essential. The aim of this study was to identify, integrate and synthesize knowledge of midwives' experiences of providing antenatal care, attending to clients' individual needs whilst facing multiple challenges. We conducted a meta-ethnography, which is a seven-step grounded, comparative and interpretative methodology for qualitative evidence synthesis. A lines-of-argument synthesis based on two metaphors was developed, based on refutational themes emerging from an analogous translation of findings in the included 14 papers. The model reflects midwives' wished-for transition from a midwife-dominated caring model toward a midwifery-led model of antenatal care. Structural, societal and personal challenges seemingly influenced midwives' provision of antenatal care. However, it emerged that midwives had the willingness to change rigid systems that maintain routine care. The midwifery-led model of care should be firmly based in midwifery science and evidence-based antenatal care that emphasize reflective practices and listening to each woman and her family. The change from traditional models of antenatal care towards increased use of digitalization no longer seems to be a choice, but a necessity given the ongoing 2020 pandemic.

First-Line Nurse Managers' Challenges at the Crossroads of Norwegian Health Care Reforms.

Norwegian municipal health care has large public service offerings, funded by tax revenues; however, the current Norwegian welfare model is not perceived as sustainable and future-oriented. First-line nurse managers in Norwegian municipal health care are challenged by changes due to major political and government-initiated reforms requiring expanded utilization of home nursing. The aim of this theoretical study was to describe challenges the first-line nurse managers in a Nordic welfare country have encountered on the basis of government-initiated reforms and to describe strategies to maintain their responsibilities in nursing care. First-line nurse managers' competence, clinical presence, and support from superiors were identified as prerequisites to maintain sight of the patients in leadership when reforms are implemented. The strategies first-line nurse managers in Norwegian municipal health care use to implement multiple reforms, regulations, and new acts require solid competencies in nursing, leadership, and administration. Competence in nursing enables focus on the patient while leading the staff. Supports from superiors and formal leadership networks are described as prerequisites for managing the challenges posed by change and to persist in leadership positions.

Involuntary Pregnancy Loss and Nursing Care: A Meta-Ethnography.

Healthcare professionals find the care of parents following an involuntary pregnancy loss stressful and challenging. They also feel unprepared to support bereaved parents. The challenging nature of this support may have a personal impact on health professionals and the care provided to parents. The aim of this meta-ethnography is to synthesise nurses' and midwives' experiences of caring for parents following an involuntary pregnancy loss. A meta-ethnography of ten studies from five countries was carried out. GRADE CERQual was assessed to show the degree of confidence in the review findings. An overarching metaphor, caring in darkness, accompanied by five major themes provided interpretive explanations about the experiences of nurses and midwives in caring for involuntary pregnancy losses: (1) Forces that turn off the light, (2) strength to go into darkness, (3) avoiding stumbling, (4) groping in darkness, and (5) wounded after dealing with darkness. Nursing staff dealt with organizational difficulties, which encouraged task-focused care and avoidance of encounters and emotional connection with parents. However, nurses and midwives might go beyond in their care when they had competencies, support, and a strong value base, despite the personal cost involved.

"Navigation to prioritizing the patient" - first-line nurse managers' experiences of participating in a quality improvement collaborative.

BACKGROUND: First-line nurse managers are central to quality improvement work when changing work practices into better patient outcomes. Quality improvement collaboratives have been adopted widely to support quality management in healthcare services and shared learning. We have little knowledge of the first-line nurse managers' own perspectives concerning their need for support and knowledge in quality improvement work. Therefore, the aim of this study was to gain understanding of first line nurse managers' experiences in leading quality improvement work in their own organization when participating in a quality improvement collaborative. METHODS: An interpretive approach was chosen following Graneheim and Lundman's qualitative content analysis. Data was collected through three focus group interviews with first-line nurse managers representing different workplaces: the local hospital, a nursing home, and a homecare service in a rural area of Norway. RESULTS: "Navigation to prioritizing the patient" emerged as an overarching metaphor to describe the first-line nurse managers experiences of leading quality improvement work, based on three themes: 1) fellowship for critical thinking and prioritizing the patient; 2) mastering the processes in quality improvement work; and 3) the everyday reality of leadership as a complex context. CONCLUSIONS: A quality improvement collaborative encompassing knowledge transfer and reflection may create an important fellowship for health care leaders, encouraging and enabling quality improvement work in their own organization. It is crucial to invite all leaders from an organization to be able to share the experience and continue their collaboration with their staff in the organization. Continuity over time, following up elements of the quality improvement work at joint meetings, involvement by users, and self-development of and voluntary involvement in the quality improvement collaborative seem to be important for knowledge development in quality improvement. The supportive elements of the quality improvement collaborative fellowship were crucial to critical thinking and to the first-line nurse managers' own development and security in mastering the quality improvement work processes. They preferred prioritizing the patients in quality improvement work, despite haste and obstructive situations in an everyday context.

Safeguarding the patient in municipal healthcare-A hermeneutic focus group study of Nordic nursing leadership.

AIM: This study illuminates the meaning and purpose of clinical presence in nursing leadership in municipal home care from the first-line nurse manager's own perspective. BACKGROUND: Being a first-line nurse manager in the context of home care is demanding due to demographic changes and an ever-increasing number of elderly suffering from chronic diseases. Leading in this context entails leading from a distance because patients live and receive care in their homes. First-line nurse managers express the importance of clinical presence. However, there is a paucity of studies from home care of the meaning and purpose of presence. The theory of caritative leadership and the model of caring in nursing leadership served as the starting point for this study. METHODS: Hermeneutic abductive approach using a purposive sample of three semistructured focus group interviews with 11 first-line nurse managers in home care in three Nordic countries. RESULT: This study shows that first-line nurse managers described the meaning and purpose of their clinical presence in home care as safeguarding the patient by taking overall responsibility for care, securing the patients' voices, building and maintaining trustful relations, and securing a sensible economy. CONCLUSION: Our findings indicate that clinical presence serves the purpose of taking the overall responsibility for care and safeguarding the patient. Presence is perceived a necessity to verify staff providing the best possible care. First-line nurse managers acted metaphorically as a shield to protect patient care, which is the main concern in their leadership. The findings add new knowledge to the significance of caring in nursing leadership and the theory of caritative leadership. IMPLICATIONS FOR NURSING MANAGEMENT: First-line nurse managers need to be clinically present in order to safeguard the patient and to fulfil their threefold responsibilities for the patient, the staff and the economy. This study might also contribute to the political discussion concerning why nurses has to be first-line nurse managers and cannot be replaced by economists.

Gaming the system to care for patients: a focused ethnography in Norwegian public home care.

BACKGROUND: With its emphasis on cost-reduction and external management, New Public Management emerged as the dominant healthcare policy in many Western countries. The ability to provide comprehensive and customized patient-care is challenged by the formalized, task-oriented organization of home-care services. The aim of this study is to gain deeper understanding of how nurses and the patients they care for, relate to and deal with the organizational systems they are subjected to in Norwegian home care. METHODS: The focused ethnographic design is based on Roper and Shapira's framework. Data collection consisted of participant observation with field notes and semi-structured interviews with ten nurses and eight patients from six home care areas located in two Norwegian municipalities. RESULTS: Findings indicate cultural patterns regarding nurses' somewhat disobedient behaviors and manipulations of the organizational systems that they perceive to be based on economic as opposed to caring values. Rigid organization makes it difficult to deviate from predefined tasks and adapt nursing to patients changing needs, and manipulating the system creates some ability to tailor nursing care. The nurses' actions are founded on assumptions regarding what aspects of nursing are most important and essential to enhance patients' health and ensure wellbeing - individualized care, nurse-patient relationships and caring - which they perceive to be devalued by New Public Management organization. Findings show that patients share nurses' perceptions of what constitute high quality nursing, and they adjust their behavior to ease nurses' work, and avoid placing demands on nurses. Findings were categorized into three main areas: "Rigid organizational systems complicating nursing care at the expense of caring for patients", "Having the patient's health and wellbeing at heart" and "Compensating for a flawed system". CONCLUSIONS: Our findings indicate that, in many ways, the organizational system hampers provision of high-quality nursing, and that comprehensive care is provided in spite of - not because of - the system. The observed practices of nurses and patients are interpreted as ways of "gaming the system" for caring purposes, in order to ensure the best possible care for patients.