Interprofessional negotiations in biopsychosocial pain rehabilitation: a need for silent bargains.

Communicating effectively, including the ability to negotiate, has been claimed to be key competencies in interprofessional practice. However, these day-to-day contributions to interprofessional teamwork are not yet sufficiently understood. The aim of this article is to explore the day-to-day interprofessional negotiations in biopsychosocial pain rehabilitation. A qualitative design with an ethnographic approach was applied to the overall study. Participant observation of interprofessional encounters and clinical encounters in a pain rehabilitation ward was undertaken in 2016 for a period of 19 weeks. Intermittent interviews with 12 professionals were conducted. Data were analyzed in an abductive process using thematic analysis. We present the results as two themes: 1) Silent conflicting interests in the office, and 2) Silent dissatisfaction with meetings. The study showed that the team members had opportunities to negotiate in interprofessional offices and meetings, while they perceived insufficient time for discussion, and their individual work being interrupted by each other in the offices. They did not discuss their dissatisfaction, but silently bargained on how to spend time together. Professionals can contribute to teamwork through silent bargains that can promote a low level of conflict and thereby preserve a good workflow.

Diminishing pain stigma: patient perceptions of encounters with interprofessional teams in biopsychosocial pain rehabilitation.

PURPOSE: To explore how patients in biopsychosocial pain rehabilitation perceive encounters with interprofessional teams. The focus of this article is to explore how interactions can perpetuate or diminish chronic pain stigma. MATERIAL AND METHODS: An ethnographic approach was applied to the study. Participant observation of interprofessional encounters and clinical encounters in a pain rehabilitation ward was undertaken in 2016 (19 weeks). Interviews with 12 professionals and seven patients were conducted. Data were analysed in an abductive process using thematic analysis. RESULTS: The patients perceived their encounters with interprofessional teams as supportive, with implications for pain stigma. This is presented as two themes: (1) being seen as credible, involving patients being believed in and a concept of being overactive at the expense of their own health, and (2) being helped to see their situation in a new light, which involves enthusiasm about changing and challenging views in a process with professionals who were supportive and united across professions. CONCLUSION: Interprofessional biopsychosocial pain rehabilitation may be an intervention that can diminish internalised stigma in patients suffering from chronic pain. The study contributes to increased understanding of patient perceptions of positive encounters with professionals during a learning process in rehabilitation and of the imbued influence on power relations. This appears to be fundamental to diminishing pain stigma, as the occurrence of stigma is dependent on differences in power.KEY MESSAGESInterprofessional biopsychosocial pain rehabilitation can be an intervention for diminishing internalised pain stigma in patients.Knowledge on how encounters with professionals induce personal learning processes among people with chronic pain.

A vulnerable journey towards professional empathy and moral courage.

Background: Empathy and moral courage are important virtues in nursing and nursing ethics. Hence, it is of great importance that nursing students and nurses develop their ability to empathize and their willingness to demonstrate moral courage. Research aim: The aim of this article is to explore third-year undergraduate nursing students' perceptions and experiences in developing empathy and moral courage. Research design: This study employed a longitudinal qualitative design based on individual interviews. Participants and research context: Seven undergraduate nursing students were interviewed during or immediately following their final clinical placement. Ethical considerations: The Norwegian Social Science Data Services (NSD) approved the study. Participants were informed that their participation was voluntary and were assured confidentiality. They were informed that they could withdraw from the study at any time, without providing reasons. Findings: Affective empathy seemed to be strong among third-year undergraduate nursing students. However, they tried to handle the situations in a 'professional' way, and to balance their emotions. At the same time, they expressed how difficult it can be to show moral courage when confronted with poor patient care. In addition, they spoke about a lack of role models during clinical practice and supervision. Conclusions: Undergraduate nursing students are in a vulnerable position throughout their journey to become professional and to develop empathy and moral courage. The professional socialisation and forming of professional empathy and moral courage among nursing students, may be seen as a complex interaction of formal and hidden curriculum, where role models play an important role. We argue that the main theme 'Vulnerable students - a journey towards professional empathy and moral courage' may cover the longitudinal project as a whole. This vulnerability is something both teachers and supervisors should be aware of when following up with students in their clinical placements.

Learning practical nursing skills in simulation centers - A narrative review.

Background: Practical skills are complex procedures integrating communication and caring, as well as technical and manual aspects. Simulation at a simulation/skills center offers a wide range of learning activities and aims to imitate patient situations. Objectives: To investigate the international research literature on practical skills learning in simulation/skills centers in nursing education. Research questions: 1. What are the range and type of practical skills studied? 2. What learning activities are focused on in the studies included in the review? 3. What are the learning outcomes and how are they assessed? Design: Narrative review. Methods: We searched electronically and included studies from Medline Ovid, CINAHL, Eric, Embase, Academic Search Premiere, and Cochrane. Unique indexing terms and search strategies were developed for each database. The criteria for inclusion were bachelor nursing students as the study population and practical nursing skills learning in simulation/skills centers. We used Rayyan QCRIt for the initial screening and the Mixed Method Appraisal Tool for quality assessment. We used a narrative approach to synthesize the diverse range of studies. Findings: One hundred and twenty-one studies from 26 countries published between January 2013 and March 2022 were included. The amount of quantitative research was overwhelming (n = 108). A total of 50 different practical skills were represented. The studies focused on which learning modalities resulted in the best learning outcomes. Only 8.5% (n = 7) of the included studies concerned students' learning processes. Skill performance (n = 101), knowledge (n = 57), confidence (n = 34), and satisfaction (n = 32) were the main learning outcomes measured. Discussion: The quality assessment indicated that 10 of the studies achieved 100% on the mixed method appraisal tool criteria. In many of the studies with quasi-experimental and randomized controlled trial designs, the intervention group received some form of educational treatment while the control group received no treatment. The choice of no treatment for the control group in pedagogical research seems to disregard the inherent purpose and effect of teaching and learning. Conclusion: Heterogeneity in the use of learning modalities and measuring instruments precludes the possibility of building on other research. Technical skills were the preferred choice of skill, while skills that involved a fair measure of communication and collaboration were only sparingly studied. Students' learning processes were barely touched on in the included studies. More focus should be placed on this area in further research, since the choice of learning modalities may affect the students' learning processes in significant ways.

Challenges in the assessment of nursing students in clinical placements: Exploring perceptions among nurse mentors.

AIM: The aim was to explore how nurse mentors experience the assessment of nursing students in clinical placements at hospitals and in municipal health care. DESIGN: The study is qualitative with an explorative and descriptive design. METHODS: Based on an interview guide, we conducted 19 individual qualitative interviews and four focus group interviews with nurse mentors from various levels and fields of nursing education at a Norwegian university. RESULTS: Feedback in and on action was an integrated part of the formative assessment. In the summative assessment, where the university lecturer also participates, the nurse mentors perceived their role as passive. A disturbing finding was that divergent views on the student's competence sometimes occurred in these situations, thus challenging the credibility of the student assessment. Perceptions of nursing values and concerns embedded in nursing practice as collective criteria appear to have an impact on the mentors' assessment of the nursing students.

The puzzle of therapeutic emplotment: creating a shared clinical plot through interprofessional interaction in biopsychosocial pain rehabilitation.

Interprofessional collaboration is increasingly encouraged and studied. However, there remains a need to broaden the understanding of professionals' contributions through their day-to-day interactions to minimize the impact of professional boundaries that evoke gaps in patient care. Drawing upon narrative theory emphasizing therapeutic emplotment, this ethnographic study explores how professionals contribute to interprofessional collaboration through social interactions during teamwork. Data collection was undertaken in a biopsychosocial pain rehabilitation ward in a hospital in Norway in 2016, and included participant observation of the ward-based work of two teams, and interviews with professionals from six professions (12) and patients (7). Formal and informal interprofessional interactions and patient encounters were observed. The study found that through interactions, the professionals' shared their understandings across all professions about the successfulness of their own work and of what outsider professionals were doing incorrectly when addressing patients from a biomedical approach. Imbued in these interactions were the pieces of an implicit shared clinical plot for their patients' journeys through rehabilitation and life afterwards. We argue that creating the shared clinical plot enhances conciliation across professions and interpersonal motivation to carry out the work. A struggle between perspectives in interprofessional collaboration should not be prematurely interpreted as an obstruction to collaboration, since the struggle can imbue essential narrative work. This extends the theoretical study of therapeutic emplotment as a central motivational process in interprofessional collaboration in teams.

Undergraduate nursing students' ability to empathize: A qualitative study.

BACKGROUND: Empathy is of great importance in nursing, as it helps us to see and meet the needs of patients and hence to care for patients in an appropriate way. Therefore, it is of great importance that nursing students and nurses develop their ability to empathize. OBJECTIVE: The study aimed at gaining knowledge on what characterizes undergraduate nursing students' ability to empathize with patients during their first practice in a nursing home. In addition, the aim of the study was to investigate what nursing students think is important with regard to upholding their ability to empathize with patients in a professional way. RESEARCH DESIGN: This research has a phenomenological and hermeneutic design, based on qualitative interviews. Participants and research context: A total of 11 undergraduate nursing students participated in interviews during or right after their first practice in a nursing home. Ethical considerations: Norwegian Social Science Data Services approved the study. Participants were informed that their participation was voluntary. The participants were also assured confidentiality, and they were informed that they could withdraw from the study at any time, without providing any reasons. FINDINGS: What the findings show is that affective empathy is strong among undergraduate nursing students in their first practice. They think the emotions are important to be able to empathize, and they are afraid of becoming indifferent. At the same time, they are afraid that the feelings will hinder them from acting in a professional manner. DISCUSSION: The findings are discussed in light of previous theories on empathy, and especially perspectives on empathy, emotions, and morality. CONCLUSION: Affective empathy seems to be strong among nursing students, and this may be of great importance to be sensitive to patients' well-being. However, affective and cognitive empathy should be balanced if nurses will have to meet patients in a professional way.

Adolescents' experience of complex persistent pain.

BACKGROUND AND AIMS: Persistent (chronic) pain is a common phenomenon in adolescents. When young people are referred to a pain clinic, they usually have amplified pain signals, with pain syndromes of unconfirmed ethology, such as fibromyalgia and complex regional pain syndrome (CRPS). Pain is complex and seems to be related to a combination of illness, injury, psychological distress, and environmental factors. These young people are found to have higher levels of distress, anxiety, sleep disturbance, and lower mood than their peers and may be in danger of entering adulthood with mental and physical problems. In order to understand the complexity of persistent pain in adolescents, there seems to be a need for further qualitative research into their lived experiences. The aim of this study was to explore adolescents' experiences of complex persistent pain and its impact on everyday life. METHODS: The study has an exploratory design with individual in-depth interviews with six youths aged 12-19, recruited from a pain clinic at a main referral hospital in Norway. A narrative approach allowed the informants to give voice to their experiences concerning complex persistent pain. A hermeneutic analysis was used, where the research question was the basis for a reflective interpretation. RESULTS: Three main themes were identified: (1) a life with pain and unpleasant bodily expressions; (2) an altered emotional wellbeing; and (3) the struggle to keep up with everyday life. The pain was experienced as extremely strong, emerging from a minor injury or without any obvious causation, and not always being recognised by healthcare providers. The pain intensity increased as the suffering got worse, and the sensation was hard to describe with words. Parts of their body could change in appearance, and some described having pain-attacks or fainting. The feeling of anxiety was strongly connected to the pain. Despair and uncertainty contributed to physical disability, major sleep problems, school absence, and withdrawal from leisure activities. Their parents were supportive, but sometimes more emotionally affected than themselves. The adolescents described how they strived for normality and to not become an outsider. Being met with necessary facilitation from school was important, as well as keeping up with friends. These adolescents had all been treated by an interdisciplinary pain team, and stated that they had an optimistic view of the future, despite still having some symptoms. CONCLUSIONS: The study provides new insights into adolescents' own experiences of complex persistent pain occurring unexpectedly, developing dramatically over time, and influencing all parts of their everyday lives. The adolescents entered vicious cycles, with despair and decreased physical and social functioning, with the risk of isolation and role-loss. However, these young people seem to have a strong motivation to strive for normalcy. IMPLICATIONS: These findings may encourage healthcare providers to perceive adolescents' persistent pain through the lenses of a biopsychosocial approach. We suggest that further research into adolescents with persistent pain should include longitudinal studies of quality of life and gender perspectives.

Challenges in the nurse's role in rehabilitation contexts.

AIM AND OBJECTIVE: To shed light on how nurses perceive particular challenges that they experience in encounters with patients in rehabilitation wards. BACKGROUND: Rehabilitation is a tailor-made process that allows someone with impairment to live well. Many rehabilitation institutions embrace strong beliefs in patient participation as well as awareness of and listening to the needs and wishes of patients. To our knowledge, few studies have investigated the challenges encountered by nurses from patients in rehabilitation contexts and how these challenges might influence their roles as nurses. DESIGN AND METHODS: This study has a qualitative design that is based on three focus group interviews with nurses working in three rehabilitation wards. A convenience sample of 15 nurses, five from each ward, was recruited to participate in focus group interviews. The participants worked in wards for patients suffering mainly from stroke and head injuries. The analysis is inspired by hermeneutic principles to explore the participants' challenges in their role in rehabilitation contexts. RESULTS: Data analyses identified three main themes surrounding the challenges experienced by nurses: (1) Adjusting patients' and next of kin's expectations, (2) Tailoring support and information, (3) Recognising patients' knowledge. CONCLUSION: Our results from the three rehabilitation wards indicate that nurses display various educative strategies. There is, however, a need for further empirical work into how knowledgeable patients and next of kin create new challenges with implications for the nurse's role within rehabilitation contexts. RELEVANCE TO CLINICAL PRACTICE: The study highlights the educative aspects of the nurse's role in relation to patients and next of kin on rehabilitation wards as significant contributors to recovery processes.

User involvement and experiential knowledge in interprofessional rehabilitation: a grounded theory study.

BACKGROUND: User involvement is increasingly important in developing relevant health care services. The aim of this study was to contribute to a deeper understanding of user involvement and patients' experiential knowledge as recognized and incorporated into clinical practice by rehabilitation professionals. METHODS: A qualitative design using a grounded theory approach was applied. Data were collected by observations of the interprofessional meetings at two rehabilitation units treating patients with traumatic brain injury and multiple trauma and by individual semi-structured interviews with rehabilitation professionals. RESULTS: The professionals recognized and incorporated user involvement into clinical practice as formal or authentic. Formal user involvement was sometimes considered pro forma. Incorporating patient' experiential knowledge was considered a part of authentic user involvement. Possible gaps between the patients' experiential knowledge and professional expertise were recognized. Challenges included dealing with 'artifacts', sources of information external to the patients' own experiences, and addressing the patients' possibly reduced insight due to trauma. CONCLUSION: Patients' experiential knowledge was recognized as an essential component of the professionals' knowledge base. The professionals considered user involvement and patients' experiential knowledge as part of their clinical practice. Implementation of user involvement and contribution of patients' experiential knowledge could be improved by understanding the issues raised in practice, such as possible negative consequences of user involvement in form of burdening or disempowering the patients. A better understanding of the characteristics and measures of user involvement is necessary in order to be able to offer its full benefits for both the patients and the professionals.

Understanding everyday life of morbidly obese adults-habits and body image.

BACKGROUND: Morbid obesity is a progressive, chronic condition associated with failed attempts at change and repeated relapses. AIM: There seems to be little previous research into the understanding of the everyday life of morbidly obese adults. We wanted to gain more knowledge about characteristics of eating habits and body image as well as motivational forces for change. METHODS: A qualitative approach was chosen in order to gain insight into how morbidly obese adults experience everyday life. Qualitative interviews are well suited to provide insight into themes from the interviewee's life story from the subjects' own perspectives. To gain insight into such processes, a narrative approach that allowed the informants to give voice to their ways of doing, thinking and feeling in daily life, was adopted. The informants comprised seven women and four men aged of 26-56 years, recruited from a population of obese individuals who had participated in a weight reduction course. A hermeneutic approach was used where the research question was the basis for a reflective interpretation. RESULTS: The following meaning-units were identified: to be perceived as overweight; and to see oneself as overweight. Ingrained habits: the struggle between knowing and doing; acting without knowing; and eating is soothing. CONCLUSIONS: Seeing oneself as an obese person is a gradual process that implied experiencing oneself as different from significant others, such as (slim) siblings and friends. To experience a gap between knowing and doing concerning food habits in everyday life indicates that informants value they have a choice. This is an important insight to consider when framing interventions to support this vulnerable group.

Personal factors associated with health-related quality of life in persons with morbid obesity on treatment waiting lists in Norway.

PURPOSE: To explore relationships of socio-demographic variables, health behaviours, environmental characteristics and personal factors, with physical and mental health variables in persons with morbid obesity, and to compare their health-related quality of life (HRQoL) scores with scores from the general population. METHODS: A cross-sectional correlation study design was used. Data were collected by self-reported questionnaire from adult patients within the first 2 days of commencement of a mandatory educational course. Of 185 course attendees, 142 (76.8%) volunteered to participate in the study. Valid responses on all items were recorded for 128 participants. HRQoL was measured with the Short Form 12v2 from which physical (PCS) and mental component summary (MCS) scores were computed. Other standardized instruments measured regular physical activity, social support, self-esteem, sense of coherence, self-efficacy and coping style. RESULTS: Respondents scored lower on all the HRQoL sub-domains compared with norms. Linear regression analyses showed that personal factors that included self-esteem, self-efficacy, sense of coherence and coping style explained 3.6% of the variance in PCS scores and 41.6% in MCS scores. CONCLUSION: Personal factors such as self-esteem, sense of coherence and a high approaching coping style are strongly related to mental health in obese persons.

Developing supervision skills through peer learning partnership.

Oslo University College, Faculty of Nursing places undergraduate students in peer learning partnerships: 3rd year students as tutors, and 1st year students as tutees during practical skill learning. A study was designed to investigate this peer learning project. One of the research questions in particular on the role of the tutors: How do 3rd year nursing students carry out their role as supervisors for 1st year students in the skills laboratory? The study had an exploratory design. Qualitative data was gathered by three members of a research team, using video recordings of the supervised sessions and focus group interviews with both 1st and 3rd year students. Data collection was repeated in 2006-2007-2008 in different groups of students. Four identified themes illustrate how the 3rd year students supervise during the performance of the procedures in the skills laboratory: Observe and guide, supportive attitude, identify with the patient, focus on theoretical knowledge. The results of this study indicate that apart from enhancing practical skill learning in 1st year students, the assignment in the skill laboratory also provided an arena for developing competence in supervision in third year students.

Cultivating authentic concern: exploring how Norwegian students learn this key nursing skill.

The importance of interpersonal and expressive qualities has long been recognized in nursing. Drawing on data from a qualitative study among nursing students in Norway, this article discusses how nursing students cultivate authentic concern with patients. Because the nursing role has become more ambiguous, it must be created and formed in a personal way. Nursing students need to learn how to use their subjectivity in a way that promotes caring and compassionate conduct.

Good work - how is it recognised by the nurse?

AIM: The aim of this paper is to shed light on how nurses describe situations that reflect achievement and provide confirmation that they have done good work. BACKGROUND: Nurses' recognition of good work does not seem to have been the object of direct investigation, but is indirectly reflected in studies focusing on nurses' perceptions on work environments and the multifaceted nature of nursing. However, acknowledging high-quality performance in professional nurses can facilitate nurses in maintaining and strengthening the goals and values of the profession. This in turn can help nurses shoulder the multifaceted responsibilities they have to patients and next of kin. DESIGN: This paper is part of the Professional Learning in a Changing Society project, Institute of Educational Research, University of Oslo, funded by the Research Council of Norway. The project involves four professional groups. This paper, however, focuses on a group of 10 nurses, nine of whom work in hospitals and one in an outpatient clinic. A qualitative approach was chosen to gain insight into how nurses, as well as the other professional groups in the project, engage in processes of knowledge production and quality assurance work. METHODS: Data presented in this paper derive from semi-structured in-depth interviews conducted during spring 2005 and focuses on the recognition of good work. RESULTS: The following themes were identified as essential in confirming that one did good work: securing fundamental needs of patients and next of kin; managing the flow of responsibilities; positive feedback. CONCLUSIONS. Good work seems to be related to specific situations and a sense of achievement by the respondents. RELEVANCE TO CLINICAL PRACTICE: Recognition of good work is not only rewarding and enjoyable; it may also serve as a source of consciousness raising for professional and ethical guidelines in the work place.

Emotional learning within the framework of nursing education.

Nursing requires a certain degree of emotional investment as well as the capacity to align one's emotions to the norms and values of the profession. The article is based on a qualitative study among nursing students in Norway. It discusses how peer learning in connection with sessions involving role-play may contribute to developing these qualities in future professionals. As researchers, we acquired access to a particular communication course for the third year nursing students at Oslo University College. The study combines two methodological approaches: observation and focus group interviews. The findings illustrate how students, by commenting on each others' experiences and performance, may be able to help each other to develop a richer repertoire in how to express themselves and to adapt their behavior to the needs of those being cared for.