Chemotherapy-induced Emesis: Experienced Burden in Life, and Significance of Treatment Expectations and Communication in Chemotherapy Care.

OBJECTIVE: Because antiemetics have become more effective and integrative therapies such as acupuncture are used in combination with antiemetics, people receiving chemotherapy for cancer today might expect less emesis than in the past. It is not previously described if and how people receiving modern antiemetics during chemotherapy experience emesis. The objective of this study was to describe experiences regarding emesis among persons undergoing emetogenic chemotherapy, and how it affects their quality of life, daily life and work. A further aim was to describe views on the significance of treatment expectations and communication with healthcare personnel while undergoing chemotherapy for cancer. METHOD: Fifteen participants (median age 62 years, n = 1 man and n = 14 women, with breast (n = 13) or colorectal (n = 2) cancer) undergoing adjuvant or neo-adjuvant highly or moderately emetogenic chemotherapy were interviewed individually. The data were then analyzed using inductive thematic analysis. RESULTS: Three themes described the participants' experiences: "Your whole life is affected, or continues as usual," covering descriptions of emesis limiting some participants' everyday lives, while others experienced no emesis at all or had found ways to manage it. Overall, participants described satisfaction with their antiemetic treatment. "Experiences and expectations more important than information", that is, the participants reported wanting all the information they could get about possible adverse effects of treatment, although they believed previous experiences were more important than information in creating expectations about treatment outcomes. The participants reported that being seen as a unique person was of utmost importance: "Meet me as I am." This creates trust in healthcare personnel and a feeling of safety and security in the situation. CONCLUSIONS: These findings underline the importance of person-centered care and support in creating positive treatment expectations. Future research is called for regarding the potential antiemetic effects of positive communication regarding strengthening positive treatment expectations during emetogenic chemotherapy.

Staff structural empowerment-Observations of first-line managers and interviews with managers and staff.

AIM: The aim was to study how first-line managers act to make structural empowerment accessible for nursing staff and furthermore to relate these observations to the manager's and their nursing staff's descriptions regarding the staff's access to empowering structures. BACKGROUND: Staff access to empowering structures has been linked to positive workplace outcomes. Managers play an important role in providing the conditions for structural empowerment. METHOD: Five first-line managers were observed for two workdays. Managers and staff (n = 13) were thereafter interviewed. Field notes and interviews were analysed using directed content analysis. RESULTS: The managers displayed intentional actions that could enable their staff access to empowering structures. Managers and staff described the importance of staff's access to empowering structures. CONCLUSION: Staff who perceive to have access to structural empowerment have managers who are present and available. Unanimity among managers and staff existed in regard to the importance of staff having access to structural empowerment. The managers work continually and intentionally, doing many things at the same time, to provide the staff access to empowering structures. IMPLICATIONS FOR NURSING MANAGEMENT: The study shows the importance of promoting managers' awareness of staff's access to structural empowerment and maximizing managers' presence and availability to their staff.

Impact of clinical ethics support on daily practice-First-line managers' experiences in the Euro-MCD project.

AIM: To explore first-line managers' experiences of what Moral Case Deliberation has meant for daily practice, to describe perceptions of context influence and responsibility to manage ethically difficult situations. BACKGROUND: In order to find measures to evaluate Moral Case Deliberation, the European Moral Case Deliberation Outcome instrument was developed and is now in the stage of revision. For this, there is a need of several perspectives, one of them being the managerial bird-eye perspective. METHOD: Eleven first-line managers at workplaces, participating in the European Moral Case Deliberation Outcome instrument project, were interviewed and thematic analysis was applied. RESULTS: Managers' experiences were interpreted as enhanced ethical climate: a closer-knit and more emotionally mature team, morally strengthened individuals, as well as ethics leaving its marks on everyday work and morally grounded actions. Despite organizational barriers, they felt inspired to continue ethics work. CONCLUSION AND IMPLICATIONS: This study confirmed, but also added ethical climate aspects, such as morally grounded actions. Furthermore, adding ethical climate as a construct in the European Moral Case Deliberation Outcome instrument should be considered. First-line managers need clear directives from their managers that ethics work needs to be prioritized for the good of both the staff and the patients.

Relationships between structural and psychological empowerment, mediated by person-centred processes and thriving for nursing home staff.

Person-centred care has been shown to have positive outcomes for patients and for staff. However, the complexity of the link between structural conditions, work in a person-centred manner and outcomes for staff is insufficiently described. We tested the relationship between structural empowerment and psychological empowerment, as mediated by nursing home staff members' self-ratings of working in a person-centred manner, the person-centred climate and thriving. Questionnaires were distributed to staff working in 12 nursing homes in Sweden. A serial mediation model was tested. The results showed that higher access to structural empowerment was related to higher psychological empowerment mediated by staff working in a more person-centred manner, improved person-centred climate, and improved staff ratings of thriving. These results point to the importance of strengthening the preconditions for staff to work in a person-centred manner and nursing home managers play an important role in this.

Research methods in nursing students' Bachelor's theses in Sweden: A descriptive study.

BACKGROUND: During the nursing programme in Sweden, students complete an independent project that allows them to receive both a professional qualification as a nurse and a Bachelor's degree. This project gives students the opportunity to develop and apply skills such as critical thinking, problem-solving and decision-making, thus preparing them for their future work. However, only a few, small-scale studies have analysed the independent project to gain more insight into how nursing students carry out this task. OBJECTIVES: The aim of the present study was to describe the methods, including ethical considerations and assessment of data quality, applied in nursing students' independent Bachelor's degree projects in a Swedish context. DESIGN: A descriptive study with a quantitative approach. METHODS: A total of 490 independent projects were analysed using descriptive statistics. RESULTS: Literature reviews were the predominant project form. References were often used to support the analysis method. They were not, however, always relevant to the method. This was also true of ethical considerations. When a qualitative approach was used, and data collected through interviews, the participants were typically professionals. In qualitative projects involving analysis of biographies/autobiographies or blogs participants were either persons with a disease or next of kin of a person with a disease. CONCLUSIONS: Although most of the projects were literature reviews, it seemed unclear to the nursing students how the data should be analysed as well as what ethical issues should be raised in relation to the method. Consequently, further research and guidance are needed. In Sweden, independent projects are not considered research and are therefore not required to undergo ethics vetting. However, it is important that they be designed so as to avoid possible research ethics problems. Asking persons about their health, which occurred in some of the empirical projects, may therefore be considered questionable.

It's not all about moral reasoning: Understanding the content of Moral Case Deliberation.

BACKGROUND: Moral Case Deliberation is one form of clinical ethics support described as a facilitator-led collective moral reasoning by healthcare professionals on a concrete moral question connected to their practice. Evaluation research is needed, but, as human interaction is difficult to standardise, there is a need to capture the content beyond moral reasoning. This allows for a better understanding of Moral Case Deliberation, which may contribute to further development of valid outcome criteria and stimulate the normative discussion of what Moral Case Deliberation should contain. OBJECTIVE: To explore and compare the content beyond moral reasoning in the dialogue in Moral Case Deliberation at Swedish workplaces. METHODS: A mixed-methods approach was applied for analysing audio-recordings of 70 periodic Moral Case Deliberation meetings at 10 Swedish workplaces. Moral Case Deliberation facilitators and various healthcare professions participated, with registered nurses comprising the majority. Ethical considerations: No objection to the study was made by an Ethical Review Board. After oral and written information was provided, consent to be recorded was assumed by virtue of participation. FINDINGS: Other than 'moral reasoning' (median (md): 45% of the spoken time), the Moral Case Deliberations consisted of 'reflections on the psychosocial work environment' to a varying extent (md: 29%). Additional content comprised 'assumptions about the patient's psychosocial situation' (md: 6%), 'facts about the patient's situation' (md: 5%), 'concrete problem-solving' (md: 6%) and 'process' (md: 3%). CONCLUSION: The findings suggest that a restorative function of staff's wellbeing in Moral Case Deliberation is needed, as this might contribute to good patient care. This supports outcome criteria of improved emotional support, which may include relief of moral distress. However, facilitators need a strategy for how to proceed from the participants' own emotional needs and to develop the use of their emotional knowing to focus on the ethically difficult patient situation.

An intervention targeting fundamental values among caregivers at residential facilities: effects of a cluster-randomized controlled trial on residents' self-reported empowerment, person-centered climate and life satisfaction.

BACKGROUND: In Sweden the national fundamental values for care of older people state that care should ensure that they can live in dignity and with a sense of well-being. Our hypothesis was that a caregiver intervention targeting the national fundamental values would improve perceived empowerment, person-centered climate and life satisfaction among older people living in residential facilities. METHODS: The study was a cluster-randomized controlled trial with a pre- and one post-test design, conducted in 27 units (17 study units) at 12 residential facilities for older people in five municipalities in central Sweden. The units in each municipality were randomly assigned to intervention or control group. The caregiver intervention was carried out using an interpretative approach with eight guided face-to-face seminars, where self-reflection and dialogue were used. Data were collected using questionnaires. The number of residents was 43 (78 %) in the intervention group and 37 (71 %) in the control group. The Chi-square test and Mann-Whitney U-tests were performed to detect differences between groups and Wilcoxon signed rank tests to explore differences in change over time within groups. Furthermore, generalized estimating equation (GEE) models were used to study effects of the intervention controlling for clustering effects. RESULTS: Primary outcome measures were empowerment, person-centered climate and life satisfaction. In the intervention group, improvements at follow-up were found in residents' self-reported empowerment (n = 42; p = 0.001, Median difference 4.0, 95 % CI 1.5;6.0), person-centered climate (n = 42; p ≤0.001, Median difference 8.0, 95 % CI 4.5;11.4) and life satisfaction regarding the factor quality of everyday activities (n = 40; p = 0.033, Median difference 9.7, 95 % CI 1.0;21.9) while disempowerment decreased (n = 43; p = 0.018, Median difference -1.3, 95 % CI -2.0;0.0). In the control group person-centered climate decreased (n = 37; p = 0.002, Median difference -8.5, 95 % CI -13.6;-3.0) and quality of everyday activities (n = 36; p = 0.012, Median difference -11.6, 95 % CI-21.7;-3.4). Change over time between groups was significant for empowerment (p = 0.001, Median difference 6.0, 95 % CI 3.0;9.0), disempowerment (p = 0.006, Median difference -2.0, 95 % CI -4.0;-1.0) and person-centered climate (p ≤ 0.001, Median difference 16.0, 95 % CI 9.7;23.0) and for life satisfaction regarding the factor quality of everyday activities (p = 0.002, Median difference 22.1, 95 % CI 8.2;37.4). Results of GEE confirmed earlier results; revealed interaction effects for empowerment (parameter estimate -5.0, 95 % CI -8.3;-1.8), person-centered climate (parameter estimate -16.7, 95 % CI -22.4;-10.9) and life satisfaction regarding the factor quality of everyday activities (parameter estimate -25.9, 95 % CI -40.3;-11.5). CONCLUSION: When the Swedish national fundamental values were put into practice increases in empowerment, person-centered climate and quality of everyday activities were found among older people with intact cognitive ability living in residential facilities. Limitations to consider are the differences between the two groups at baseline, drop-outs and that neither the data collector nor the outcome assessors were blinded to group assignment of participants. TRIAL REGISTRATION: The study was registered in ISRCTN92658034 in January 2013.

Aims and theoretical frameworks in nursing students' Bachelor's theses in Sweden: A descriptive study.

BACKGROUND: Nursing students' independent projects in Sweden not only provide an opportunity to receive a professional qualification as a nurse but also gain a Bachelor's degree in nursing. The aim of these projects is to demonstrate knowledge and understanding within the major field of the education. OBJECTIVES: This study aimed to describe and analyze the topics as well as theoretical frameworks and concepts in nursing students' independent projects, which lead to a Bachelor's degree, in a Swedish context. DESIGN: A total of 491 independent projects, written by nursing students in Sweden, were included in the study. METHODS: Topics together with theoretical frameworks and concepts in the projects were identified. Similar topics and theoretical frameworks and concepts, respectively, were grouped into subcategories, and similar subcategories were then merged into a main category. The number of entries in each category was counted for descriptive statistics in order to allow for the demonstration of magnitude. RESULTS: The most common topics concerned experiences and managing when having an illness, experiences of care and of being a caregiver, and healthcare staff's care and knowledge. The nursing theories/models that were most often used were Eriksson's Theory of Caritative Caring, Travelbee's Human-to-Human Relationship Model, and Orem's Self-care Theory. Among the non-nursing theories/models, perspectives and concepts lifeworld, ethical values and principles, existential concepts and quality of life/health-related quality of life, were most often used by these students. CONCLUSION: There may be some difficulty in finding a topic for the project that is relevant for both a professional qualification as a nurse, as well as for achieving the requirements of a Bachelor's degree in nursing. The study indicates that there is a need to widen the student's understanding of different nursing theories/perspectives/models/concepts during nursing education so that students are familiar with a broad range of these when conducting their independent project.

Ethics rounds: An appreciated form of ethics support.

BACKGROUND: Ethics rounds are one way to support healthcare personnel in handling ethically difficult situations. A previous study in the present project showed that ethics rounds did not result in significant changes in perceptions of how ethical issues were handled, that is, in the ethical climate. However, there was anecdotal evidence that the ethics rounds were viewed as a positive experience and that they stimulated ethical reflection. AIM: The aim of this study was to gain a deeper understanding of how the ethics rounds were experienced and why the intervention in the form of ethics rounds did not succeed in improving the ethical climate for the staff. RESEARCH DESIGN: An exploratory and descriptive design with a qualitative approach was adopted, using individual interviews. PARTICIPANTS AND RESEARCH CONTEXT: A total of 11 healthcare personnel, working in two different psychiatry outpatient clinics and with experience of participating in ethics rounds, were interviewed. ETHICAL CONSIDERATIONS: The study was based on informed consent and was approved by one of the Swedish Regional Ethical Review Boards. FINDINGS: The participants were generally positive about the ethics rounds. They had experienced changes by participating in the ethics rounds in the form of being able to see things from different perspectives as well as by gaining insight into ethical issues. However, these changes had not affected daily work. DISCUSSION: A crucial question is whether or not increased reflection ability among the participants is a good enough outcome of ethics rounds and whether this result could have been measured in patient-related outcomes. Ethics rounds might foster cooperation among the staff and this, in turn, could influence patient care. CONCLUSION: By listening to others during ethics rounds, a person can learn to see things from a new angle. Participation in ethics rounds can also lead to better insight concerning ethical issues.

Ethics rounds do not improve the handling of ethical issues by psychiatric staff.

BACKGROUND: One way to support healthcare staff in handling ethically difficult situations is through ethics rounds that consist of discussions based on clinical cases and are moderated by an ethicist. Previous research indicates that the handling of ethically difficult situations in the workplace might have changed after ethics rounds. This, in turn, would mean that the "ethical climate", i.e. perceptions of how ethical issues are handled, would have changed. AIM: To investigate whether ethics rounds could improve the ethical climate perceived by staff working in psychiatry outpatient clinics. METHODS: In this quasi-experimental study, six inter-professional ethics rounds led by a philosopher/ethicist were conducted at two psychiatry outpatient clinics. Changes in ethical climate were measured at these clinics as well as at two control clinics at baseline and after the intervention period using the instrument Hospital Ethical Climate Survey. RESULTS: Within-groups comparisons of median sum scores of ethical climate showed that no statistically significant differences were found in the intervention group before or after the intervention period. The median sum scores for ethical climate were significantly higher, both at baseline and after the intervention period (P ≤ 0.001; P = 0.046), in the intervention group. CONCLUSIONS: Ethics rounds in psychiatric outpatient clinics did not result in significant changes in ethical climate. Outcomes of ethics rounds might, to a higher degree, be directed towards patient-related outcomes rather than towards the staff's working environment, as the questions brought up for discussion during the ethics rounds concerned patient-related issues.

What actions promote a positive ethical climate? A critical incident study of nurses' perceptions.

Few qualitative studies explore the phenomenon of positive ethical climate and what actions are perceived as promoting it. Therefore, the aim of this study was to explore and describe actions that acute care ward nurses perceive as promoting a positive ethical climate. The critical incident technique was used. Interviews were conducted with 20 nurses at wards where the ethical climate was considered positive, according to a previous study. Meeting the needs of patients and next of kin in a considerate way, as well as receiving and giving support and information within the work group, promoted a positive ethical climate. Likewise, working as a team with a standard for behaviour within the work group promoted a positive ethical climate. Future research should investigate other conditions that might also promote a positive ethical climate.

Moral distress and ethical climate in a Swedish nursing context: perceptions and instrument usability.

AIMS AND OBJECTIVES: The aim was fivefold: to describe Swedish nurses' perceptions of moral distress and determine whether there were differences in perceptions depending on demographic characteristics and to describe the usability of the Moral Distress Scale in a Swedish context. Further, the aim was to describe Swedish nurses' perceptions of ethical climate and the relationship between moral distress and ethical climate. BACKGROUND: Moral distress has been studied for more than two decades and the Moral Distress Scale is the most widely used instrument for measuring it. Moral distress has mainly been studied in relation to nurses' characteristics, but increasing attention has been paid to contextual aspects, such as ethical climate, that could be associated with moral distress. DESIGN: Descriptive, with a quantitative approach. METHODS: The study used two questionnaires: the Moral Distress Scale and the Hospital Ethical Climate Survey. The study was carried out at two hospitals in Sweden and included 249 nurses. RESULTS: Both level and frequency of moral distress were low, however level of moral distress was high in situations when the patient was not given safe and proper care. Generally, the frequency of moral distress was lower than the level. Of the situations on the Moral Distress Scale, 13 of the 32 were considered irrelevant by 10-50% of the participants. The more positive the ethical climate was perceived to be, the less frequently morally distressing situations were reported. CONCLUSIONS: Since a positive ethical climate was associated with less frequent occurrences of moral distress, it should be investigated what contributes to a positive ethical climate. To be used in a Swedish context, the Moral Distress Scale needs further revision. RELEVANCE TO CLINICAL PRACTICE: Open dialogues at wards are encouraged regarding what practices contribute to a positive ethical climate.

Swedish and Chinese nurses' conceptions of ethical problems: a comparative study.

AIM: To investigate Swedish and Chinese nurses' conceptions of ethical problems and workplace stress and ascertain whether there are differences between the nurses in the two countries and between types of clinics. BACKGROUND: Nursing can be regarded as an ethical practice and ethical problems are one type of problems nurses have to deal with. DESIGN: The research design was comparative and quantitative. METHODS: A questionnaire was used. The study was carried out at one hospital in China and two hospitals in Sweden. One hundred and thirty-six Chinese nurses and 137 Swedish nurses participated. RESULTS: There was a statistical difference between nurses working in the different countries regarding commonest stated ethical problem. The Swedish nurses indicated a greater number of ethical problems than the Chinese nurses. The latter felt irritated, dissatisfied or sad at work or after work more often than the Swedish nurses. Forty-one per cent of the nurses in both countries thought there was a modest or rather big difference between the current and the desired quality of nursing. CONCLUSIONS: The findings were partially the same in the two countries and this underlines the importance of looking at ethical problems from an organisational perspective. RELEVANCE TO CLINICAL PRACTICE: The findings also show the need for a reduction of nurses' workload as well as the importance of assuring that nurses have the knowledge they need to carry out their work. The communication between nurses and other members of the health-care team, patients and relatives also needs to be improved.

A cross-cultural comparison of nurses' ethical concerns.

The aim of this study was to compare Swedish and Chinese nurses' experiences of ethical dilemmas and workplace distress in order to deepen understanding of the challenges neuroscience nurses encounter in different cultures. Qualitative interviews from two previously performed empirical studies in Sweden and China were the basis of this comparative study. Four common content areas were identified in both studies: ethical dilemmas, workplace distress, quality of nursing and managing distress. The themes formulated within each content area were compared and synthesized into novel constellations by means of aggregated concept analysis. Despite wide differences in the two health care systems, the nurse participants had similar experiences with regard to work stress and a demanding work situation. They were struggling with similar ethical dilemmas, which concerned seriously ill patients and the possibilities of providing good care. This indicates the importance of providing nurses with the tools to influence their own work situation and thereby reducing their work-related stress.

Workplace distress and ethical dilemmas in neuroscience nursing.

This study concerns Swedish nurses' experiences of workplace stress and the occurrence of ethical dilemmas in a neurological setting. Qualitative interviews were conducted with 21 nurses. The interview results were subjected to qualitative latent content analysis and sorted into 4 content areas: workplace distress, ethical dilemmas, managing distress and ethical dilemmas, and quality of nursing. Common workplace stressors were high workload and lack of influence. These were perceived to have negative consequences for the quality of nursing. Ethical dilemmas mainly concerned decision making on initiation or withdrawal of treatment, which was experienced as a troublesome situation where conflicts could arise. The nurses managed the distress and ethical dilemmas by accepting and adjusting to the situation and seeking support from colleagues. They also endeavored to gain new strength in their private lives.

Nurses' conceptions of decision making concerning life-sustaining treatment.

The aim of this study was to describe nurses' conceptions of decision making with regard to life-sustaining treatment for dialysis patients. Semistructured interviews were conducted with 13 nurses caring for such patients at three hospitals. The interview material was subjected to qualitative content analysis. The nurses saw decision making as being characterized by uncertainty and by lack of communication and collaboration among all concerned. They described different ways of handling decision making, as well as insufficiency of physician-nurse collaboration, lack of confidence in physicians, hindrances to patient participation, and ambivalence about the role of patients' next of kin. Future research should test models for facilitating communication and decision making so that decisions will emerge from collaboration of all concerned. Nurses' role in decision making also needs to be discussed.