Being burdened and balancing boundaries: a qualitative study of nurses' experiences caring for patients who self-harm.

Although nurses encounter self-harm patients in various settings, self-harm has seldom been addressed in psychiatric nursing research. The research question was: 'What are nurses' descriptions of experiences of caring for psychiatric patients who self-harm?' The data were comprised of text based on narrative interviews with six nurses employed in a psychiatric hospital in Sweden. By using qualitative content analysis, two themes and seven sub-themes were constructed. The theme 'Being burdened with feelings' involved the sub-themes: 'Fearing for the patient's life-threatening actions', 'Feeling overwhelmed by frustration' and 'Feeling abandoned by co-workers and management'. The theme 'Balancing professional boundaries' involved the sub-themes: 'Maintaining professional boundaries between self and patient', 'Managing personal feelings', 'Feeling confirmed by co-workers' and 'Imagining better ways of care'. Of significance are the nurses' feelings of fear, frustration and abandonment creating the sense of being burdened. This study points to the importance of releasing these burdens, not only for the sake of the nurses, but to improve the care of the patients. The importance of increased knowledge, support and supervision for professionals working with people who self-harm, not only in psychiatric care, needs to be addressed in research, education and development of practice.

Psychiatric nurses' response to suicidal psychiatric inpatients: struggling with self and sufferer.

Research on nurses' responses to suicidal patients is sparse. The purpose of this secondary analysis of qualitative data from interviews with 19 nurses employed in Norway was to describe nurses' responses to suicidal psychiatric inpatients. Thematic analyses revealed four themes: 'struggling with discernment of self and sufferer'; 'reconciling inner dialogue'; 'opening up while envisioning self from sufferer'; and 'revisioning the meaning of life revealed over time'. The main theme was 'struggling with self and sufferer'. While these findings reveal existential issues and self reflections of psychiatric nurses' struggle with the suffering of suicidal patients, they also contribute to a methodological debate. Further research is needed to examine nurses' responses to suicidal patients in various settings and to develop secondary analysis of qualitative data.

Struggling for hopefulness: a qualitative study of Swedish women who self-harm.

There has been an increase in the number of Swedish psychiatric patients who self-harm, yet self-harm is seldom described in published research. The aim of this study was to describe how people who self-harm experience received care and their desired care. Nine participants, all Swedish women who had been treated for inpatient or outpatient psychiatric care, narrated their experiences of care for self-harm. Using qualitative content analysis, two themes were formulated: 'Expecting to be confirmed while being confirmed fosters hopefulness'; and, 'Expecting to be confirmed while not being confirmed stifles hopefulness'. Each of these themes emerged from five subthemes that clustered around positive and negative aspects of being seen-not being seen, being valued-being stigmatized, being connected-disconnected, being believed-doubted, and being understood-not being understood. Of significance is for nurses to view persons who self-harm as human beings and to grasp the importance of being confirmed by staff that can foster hopefulness in persons who self-harm, yet realize the possibility of the paradoxical nature of hopefulness and being confirmed.

Being met--a passageway to hope for relatives of patients at risk of committing suicide: a phenomenological hermeneutic study.

Fifteen Norwegian relatives narrated their experiences of "being met" by mental health care personnel regarding the care of their adult family member who had seriously thought about or attempted suicide. The narrative interviews were audiotaped, transcribed into text, and then interpreted using a phenomenological hermeneutic method. The results of the interpretation revealed that the context of being met was characterized by "being helpless and powerless." The six themes that were constructed describing being met were: Being-seen as a human being; participating in an I-Thou relationship; trusting personnel, treatment, and care; feeling trusted by personnel; being consoled; and entering into hope. The experience of being met in the midst of the care of a relative in crisis created possibilities for hope. Being met, in this context, is a passageway to hope.

A study of decision making among U.S. psychiatric nurses.

The purpose of this study was to describe psychiatric nurses' decision making and to test a Finnish instrument. A 56-item survey was mailed to 351 psychiatric nurses with a return rate of 48%. A varimax factor analysis showed 5 factors (intuitive, self-confidence, interpretive, collected information, and analytic processing) with alphas ranging from .71 to .85. Results indicate U.S. psychiatric nurses extensively use intuitive interpretive decision making and cultural bias needs to be considered when using a foreign instrument. Further research is needed to refine this instrument and describe psychiatric nurses' decision making.

Decision making of psychiatric nurses in Finland, Northern Ireland, and the United States.

The purpose of this study was to describe the decision-making process of 339 psychiatric nurses in Finland, Northern Ireland, and the United States and to discuss any differences observed among nurses in these countries. The instrument used in the study was a 56-item, Likert-type questionnaire tested in several previous studies that have confirmed its validity and reliability. Three different models of decision making were identified on the basis of factor analysis. Overall, it may be concluded that the decision-making process of psychiatric nurses is broadly based, but it varies between countries. Nurses from Northern Ireland used only analytical decision-making models; nurses from Finland made decisions strongly favored analytical decision-making models but also used some intuitive models; and American nurses used intuitive decision-making and analytical-processing models.

Technology-based nursing education: overview and call for further dialogue.

With the rapid growth of technology has come increasing reliance among health science disciplines to integrate technology into many courses. It is apparent that this reliance on technology in nursing education is increasing rapidly regardless of any guiding philosophy of education or pedagogy. The two-fold purpose of this article is to review the development of technology-based nursing education and to identify areas requiring further dialogue among nurse educators. It is becoming clear that nurse educators need to analyze values, communication, and social processes when deciding, judging, and assessing technological use within curricula. Nurse educators need to reflect on the tidal wave of change brought by technology and begin an earnest dialogue regarding its impact on the discipline.

Transforming desolation into consolation: the meaning of being in situations of ethical difficulty in intensive care.

The purpose of this phenomenological-hermeneutic study was to illuminate the meaning of being in ethically difficult care situations. The participants were 20 enrolled nurses employed in six intensive care units in Sweden. The results reveal a complex human process manifested in relation to one's inner self and the other person, which transforms desolation into consolation through becoming present to the suffering other when perceiving fragility rather than tragedy. The main point of significance here is for all health professionals to create an ethical work environment and strive for praxis that fosters 'at-homeness', which renders us free to transform desolation into consolation. Consolation is of significance in ethics because it makes us available and helps us to fulfil the demands of life, while desolation makes us unavailable to others.

From optimism to pessimism. A case study of a psychiatric patient.

This article focuses on the results of a single case study which illuminates an understanding of phases in nursing care for a patient in a psychiatric setting in Sweden. The focus of this study is a 50-year-old man who showed progressive deterioration from increased motor activity to oral, sexual, destructive and aggressive actions. Data collection using five methods occurred during a 21-month period. Results of the content analysis processes identified four distinct but non-discrete phases of the patient's complex condition. Medical and nursing care was categorized in three approaches: optimistic, strategic and resigned. The results raise the question of whether there is action that is without any meaning as an expression of the patient's wishes, thoughts and feelings. It seems clear that the patient in this study felt really angry and in despair. However, during moments of lucidity, he also indicated that he felt this was not an authentic expression of his 'real' self. His experience was that of a splintered world.

The meaning of caring for patients on a long-term psychiatric ward as narrated by formal care providers.

Seventeen care providers were interviewed about their caring experiences on a hospital psychiatric ward. The interviews focused on the meaning of their work, including the care they provide and the nature of the patient as a person. The study was guided by a phenomenological hermeneutic perspective inspired by Ricoeur (1976). The analysis focused on context and form. Three themes illuminate the meaning of care provided. These themes are as follows; being in the midst of human storage, moving towards a human care of relations, and struggling with 'the old' and 'the new'. Experiencing work as being in the midst of a human storage reflects the historical and human situation of warehousing psychiatric patients. The care providers are experiencing a shift in their view of the patient and the meaning of their work, towards a more human care of relations. For these care providers, there is a struggle between the past, the present and the future. This struggle between 'the old' and 'the new' conveys a struggle between doing as a nurse, which dominates the past, and relating, which is, or needs to be, the current and future focus in psychiatric care. The shift in view distinguished itself by the care providers viewing the patient as being vulnerable and having problems with relations. The results have been interpreted and discussed in the light of a previously published interview study with the patients, carried out at the same time on the same ward. Attending to ingrained attitudes of the past and their influence on new approaches to care is essential to understanding not only changes in ways of doing nursing tasks, but also ways of relating.

Nurses' narratives about using coercion in psychiatric care.

To illuminate nurses' experience of using coercion against psychiatric patients, a phenomenological hermeneutic study was conducted with seven registered nurses and seven enrolled mental nurses. The findings revealed that these nurses desired to be seen by themselves, their co-workers and patients as doing good, being good and providing good care but they experienced the use of coercion as not good. This conflict made it difficult for these nurses to question the use of coercion and consider alternative solutions. The theory of change by Watzlawick et al. (1974) served as a theoretical framework for the interpretation of all interviews regarded as one text. In order to explore alternatives to the use of coercion in psychiatric care, nurses need assistance to step outside the traditional way of regarding coercion in psychiatric care and seek to create new solutions.

Dignity in situations of ethical difficulty in intensive care.

In intensive care, situations of ethical difficulty are common. For the purpose of illuminating the meaning of being in ethically difficult situations, 20 registered nurses (RNs) employed in six intensive care units in Sweden narrated episodes of ethical difficulty. From a phenomenological hermeneutic perspective, the core theme of 'dignity' was identified in 85 stories. Stories with the concept of dignity reveal a threefold meaning; transforming disrespect into respect for the inviolable value of the human being; transforming ugly situations into beautiful ones; transforming discord of death into togetherness. Stories without the concept of dignity were oriented toward skills and physical care without reflection on actions and a 'taken-for-granted attitude' that good will prevail. Comparing and contrasting stories with and without dignity revealed the demands of dignity: attentiveness, awareness, personal responsibility, engagement, fraternity and active defence of dignity. In light of the philosophies of Weil, Marcel and Ricoeur, the demands of dignity correspond to qualities generated when struggling for respecting the dignity of human beings. This study reveals that dignity begets dignity, which opens the RNs to the ethical dimension. This, in turn, counteracts the risk of dehumanizing care in technocratic environments.

Meeting tragedy: interviews about situations of ethical difficulty in intensive care.

For the purpose of illuminating the meaning of being in ethically difficult situations, eight enrolled nurses, 12 registered nurses and 10 physicians (n = 30) working in intensive care units in Sweden were asked to narrate care episodes of ethical difficulty. A phenomenological-hermeneutical analysis of the 30 narratives about nine care episodes disclosed that all stories concerned meeting tragedy, which evoked a spirit of compassion that pointed to values. The 'intention of compassion' aimed at respecting these ethical values. Respecting ethical values meant being consoled, which generated confidence in life that helped the person to embrace tragedy. When values were not respected, ethical problems emerged. Communication of values facilitated realisation, while unconscious values were indirectly communicated through emotions. Such communication meant risking vulnerability and meeting oneself. Meeting self and one's vulnerability demanded abilities of being consoled, i.e. in this study giving consolation, providing realistic treatment and being faithful in one's profession. A prerequisite for expressing personal standpoints and cooperating in the struggles of respecting ethical values was holding each other in great respect. When meeting tragedy, the spirit of compassion pointed to ethical problems, to the possibilities of solving the problems, and to the fulfilment of vision through converting feelings of despair into action energy.

Two views on accreditation. How to prepare for an NLN self study.

Preparing for NLN accreditation need not be an arduous and time-consuming task that is merely survived. The self study can be an ongoing and integral process of review and evaluation instead of a flurry of activity surrounding the months prior to an onsite visit. When the criteria serve as ongoing program standards, a program is more easily and readily prepared for the NLN accreditation process.