Nurses' experience with relatives of patients receiving end-of-life care in nursing homes and at home: A questionnaire-based cross-sectional study.

AIM: The aim of this study was to explore any differences between nurses working in nursing home and home-based care in their experiences regarding relatives' ability to accept the imminence of death and relatives' ability to reach agreement when deciding on behalf of patients unable to consent. DESIGN: An electronic questionnaire-based cross-sectional study. METHOD: An electronically distributed survey to 884 nurses in long-term care in Norway in May 2014. A total of 399 nurses responded (45%), of which 197 worked in nursing homes and 202 in home-based care. RESULTS: Nurses in home-based care, more often than their colleagues in nursing homes, experienced that relatives had difficulties in accepting that patients were dying. Nurses who often felt insecure about whether life extension was in consistency with patients' wishes and nurses who talked most about life-prolonging medical treatment in communication with relatives more often experienced that relatives being reluctant to accept a poor prognosis and disagreements between relatives in their role as proxy decision makers for the patient.

Contested discourses and culture sensitivity: Norwegian nursing students' experience of clinical placement in Nicaragua.

Aim: The purpose of this study was to gain understanding of Norwegian students' practical experience of "culture sensitivity." Design: Using focus-group interviews and individual written assignments, we draw on a Foucauldian-inspired approach to analyse nursing students' narratives about their clinical placement in Nicaragua. Method: Seven third-year bachelor nursing students enrolled in a clinical placement programme on the Caribbean coast in Nicaragua and participated in focus-group interviews. Interviews were conducted prior to their departure to Nicaragua and after their return to Norway. Other sources of data included learning objectives for clinical placement, written individual assignments with students' reflections about their experiences and achievement of learning objectives. Results: Students expressed gradually increased awareness about the nursing discourses and power relations shaping clinical encounters throughout their learning trajectory in clinical placement. They became more aware of the politics of nursing practices through their experiences of clashes between different nursing discourses.

The significance of communities of practice: Norwegian nursing students' experience of clinical placement in Bangladesh.

AIM: The purpose of this study was to gain understanding of Norwegian students' experience of learning in clinical placement in Bangladesh without formal one-to-one supervision, by a personal mentor in the ward. DESIGN: Using focus group interviews with bachelor nursing students we explored the significance of 'communities of practice' in nursing practicum abroad, socialization and knowledge transfer. METHOD: Seven third year bachelor nursing students enrolled in a clinical placement programme in Bangladesh participated in focus group interviews prior to their departure to Bangladesh, during their stay in Bangladesh and after their return to Norway. RESULTS: The Students' marginality and 'peripheral participation' triggered insight and reflection. The challenging but advantageous position of the peripheral students was heightened further due to the lack of one-to-one supervision in the clinic. Their previous experience with problem based learning and group learning was an asset that made them more resilient and helped them to cope.

Relatives' participation at the time of death: standardisation in pre and post-mortem care in a palliative medical unit.

PURPOSE: The aim of this study was to illuminate the development of standardisation of relatives' participation at the time of death in the Palliative Medical Unit and to explore if the implementation of standardisation brought palliative care more in line with its ideology. METHODS: A registration form was developed and utilized by the Palliative Medical Unit nurse in charge of the patient and family to register to what extent relatives participated at the time of death. The study consists of two data sets named evaluation 1 and 2. Evaluation 1 includes data collected during the period 01.11.1995-31.12.1999, representing 73% of all deaths (N = 244). Evaluation 2 includes data collected during the period 01.01.2003-31.12.2009, representing 71% of all deaths (N = 400). The data was analysed in SPSS, covering primarily the frequency of participation and correlation between evaluation 1 and evaluation 2. RESULTS: Relatives are more often present at the moment of death, while nurses are less present at this moment. Additionally, Palliative Medical Unit nurses use more time to inform and discuss relatives' participation in pre and post-mortem care, as well as making agreements with relatives after death occurs. CONCLUSION: Important premises for successful standardisation are fostering Palliative Medical Unit nurses' knowledge about various aspects of pre and post-mortem care through regular evaluation and an educational programme providing staff with necessary time, awareness and skills. In addition nurses also require sufficient amount of time in the clinic.

Cremation in Norway: regulation, changes and challenges.

In this article, I explore the development of modern cremation and cremation events in Norway. I focus on the multiple ontologies of cremation events and the relationships between the living mourners and the dead during the gradual transformation of the social person within Christian, secular as well as Hindu traditions in Norway. Within Christian tradition, this is a linear process that I intentionally contrast with the predominantly cyclical process within the Hindu tradition. I illustrate how various cosmological, eschatological, soteriological, economical, environmental, as well as socio-political factors regulate and shape the form and content of cremation events and disposal in Norway.

Enacting death: contested practices in the organ donation clinic.

Based on the fieldwork at two Norwegian Intensive Care Units, we wish to discuss the sometimes inconsistent manner in which death is handled, determined and made real by nurses and other healthcare personnel in high-tech hospital situations. These discrepancies draw our attention towards different ways of attending to the dying and dead and views about appropriate or inappropriate codes of professional behaviour. As we will argue below, the analytical tools developed by Annemarie Mol are useful for sharpening our understanding of the enactment of multiple ontologies of death as they are enacted within the ICU. Annemarie Mol and John Law's notion of 'ontological politics' increases our awareness about the non-arbitrary way some but not other practices are considered self-evident whereas others are denigrated as muddled and illogical.

Negotiating leave-taking events in the palliative medicine unit.

In this article I explore the importance staff and relatives give to patients' social identity at the time of dying, death, and leave-taking in a palliative medical unit in Norway. I employ Timmermans' concept of death brokering and show how various patient identities are used to broker and negotiate the timing, content, and form of leave-taking events. In their end-of-life care, nurses strive to accommodate relatives and support them in their grief process. Making patient identities relevant illustrates the close relationships between maintenance of the integrity of the material body and maintenance of the integrity of the social person; this practice aligns biomedical and physical identities with biographical and personal identities. Maintenance of patients' social identity is not a uniform process. Throughout postmortem care, nurses and relatives oscillate between poles of nearness to and distance from the deceased, who paradoxically can be experienced as both socially alive and socially dead.

Enacting death in the intensive care unit: medical technology and the multiple ontologies of death.

This article explores various ways health personnel enact death in connection with mechanical ventilation treatment withdrawal in the intensive care unit (ICU) at Trondheim University Hospital. The main focus is on sedated terminal patients who undergo mechanical ventilator treatment withdrawal and relatives' presence at this time. Mol's (2002) praxiographic orientation of the actor-network approach is followed while exploring this medical practice. Utilizing this interdisciplinary science and technology studies approach this article describes what Timmermans and Berg (2003) have called ' technology-in-practice'. Thus the main focus of the analysis is on medical interventions, and enactments of death within medical practice. The article argues against a 'social essentialist' approach to medical technology, which views technology as a passive force empowered by social relations. It explores how various enactments of death are intrinsically linked with and shaped by the use of medical technology within clinical practice. A praxiographic inquiry into how death is enacted carefully takes notice of how medical practice and techniques make death audible, tangible, visible, knowable and real. Mol's praxiographic approach also enables a description of how the multiple enactments of death connect within end-of-life care through various forms of coordination. This article is based on interviews with 28 nurses and two physicians in a Norwegian intensive care unit.

Medical practice, procedure manuals and the standardisation of hospital death.

This paper examines how death is managed in a larger regional hospital within the Norwegian health-care. The central focus of my paper concerns variations in how healthcare personnel enact death and handle the dead patient. Over several decades, modern standardised hospital death has come under critique in the western world. Such critique has resulted in changes in the standardisation of hospital deaths within Norwegian health-care. In the wake of the hospice movement and with greater focus on palliative care, doors have gradually been opened and relatives of the deceased are now more often invited to participate. I explore how the medical practice around death along with the procedure manual of post-mortem care at Trondheim University Hospital has changed. I argue that in the late-modern context, standardisation of hospital death is a multidimensional affair, embedded in a far more comprehensive framework than the depersonalized medico-legal. In the late-modern Norwegian hospital, interdisciplinary negotiation and co-operation has allowed a number of different agendas to co-exist, without any ensuing loss of the medical power holder's authority to broker death. I follow Mol's notion of praxiographic orientation of the actor-network approach while exploring this medical practice.

Relatives' presence in connection with cardiopulmonary resuscitation and sudden death at the intensive care unit.

Within Norwegian intensive care units it is common to focus on the needs of the next of kin of patients undergoing end-of-life care. Offering emotional and practical support to relatives is regarded as assisting them in the initial stages of their grief process. It has also become usual to encourage relatives to be present at the time of death of close relatives. How can dignified end-of-life care coexist with the sometimes turbulent and dramatic character of intensive care in the highly technological environment of intensive care units? This paper describes a case study based on an incident that took place at the intensive care unit (ICU) of Trondheim University Hospital, Norway, in which the relatives of a newly deceased patient voiced unusually strong dissatisfaction with the way they were excluded in connection with cardiopulmonary resuscitation (CPR). The next of kin's criticism highlights an important paradox as well as a degree of inconsistency in lifesaving and end-of-life care at the ICU. I argue that an investigation of the multiple identities within medical practice can illuminate the potential for clashes between lifesaving and end-of-life care, as described and analysed in this paper.