Changes in patterns of knowing the patient: the case of British district nurses

'It's like trying to ice a cake that's not been baked': a qualitative exploration of the contextual factors associated with implementing an evidence-based information intervention for family carers at the end of life

Aim:

To explore the introduction of an evidence-based information intervention – the ‘Caring for Someone with Cancer’ booklet – within home care and end-of-life care, to inform future implementation and practice development within this setting.

Background:

Family carers’ contribution is crucial to enable care and death of people at home. The ‘Caring for Someone with Cancer’ booklet received positive responses from family carers and District Nurses and is an evidence-based intervention designed to support carers to deliver basic nursing tasks. Further feasibility work was required to establish how it should be implemented. Little is known about how to successfully translate interventions into practice, particularly within home care settings and end-of-life care.

Methods:

Implementation of the ‘Caring for Someone with Cancer’ booklet, utilising a qualitative case study approach, in four home care sites. Semi-structured interviews, informed by Normalization Process Theory (NPT), were undertaken at implementation sites in May 2016–June 2017. Participants were generalist and specialist nurses, managers, and Healthcare Assistants (HCAs). A framework approach to analysis was adopted.

Findings:

Forty-five members of staff participated. Failed implementation was associated with organisational-level characteristics and conditions, including workforce composition and predictability of processes. Unstable work environments meant home care providers focused on short-term rather than long-term goals, precluding practice development. Staff’s perceptions of the time available to engage with and implement the intervention inhibited adoption, as many participants were “just getting through the day”. Implementation was successful in sites with explicit management support, including proactive implementation attempts by managers, which legitimatised the change process, and if all staff groups were engaged. To encourage uptake of evidence-based interventions in home care settings, practitioners should be given opportunities to critically reflect upon taken-for-granted practices. Future implementation should focus on work pertaining to the NPT construct ‘Collective Action’, including how staff interact and build confidence in new practices.

Expert Nurses' Perceptions of the Relevance of Carper's Patterns of Knowing to Junior Nurses

This study explored with expert nurses in the UK how nursing wisdom can be developed in new and junior nurses. Carper's patterns of knowing and Benner's novice-to-expert continuum formed the theoretical framework. Employing a constructionist research methodology with participant engagement in co-construction of findings, data were collected via 2 separate cycles comprising 4 consecutive sessions followed by a nationally advertised miniconference. Empirical, ethical, personal, and esthetic knowing was considered evident in junior nurses. Junior nurses in the UK seem to lack a previously unrecognized domain of organizational knowing without which they cannot overcome hegemonic barriers to the successful development of nursing praxis.

A poststructural rethinking of the ethics of technology in relation to the provision of palliative home care by district nurses

Technology and its interfaces with nursing care, patients and carers, and the home are many and varied. To date, healthcare services research has generally focussed on pragmatic issues such access to and the optimization of technology, while philosophical inquiry has tended to focus on the ethics of how technology makes the home more hospital like. However, the ethical implications of the ways in which technology shapes the subjectivities of patients and carers have not been explored. In order to explore this, poststructural theory, in particular the work of Butler, Foucault, and Deleuze, is used to theorize the relationship between subjectivity and materiality as ethically mandated on producing rather than precluding the development of subjectivities in novel ways. This theoretical understanding is then utilized through a process of 'plugged in' as described by Jackson and Massie that aims to link empirical data, research, and philosophical inquiry. Through this process, it is suggested that power, which the empirical data demonstrate, is frequently exercised through medical discourses and restricts patients' and carers' ability to shape the material environment of the home as a place to live and be cared for in palliative stages of illness. Alternative discourses are suggested both from the empirical data as well as other research, which may offer patients and carers the possibility of reclaiming power over the home and their subjectivities. Finally, the dichotomy between the home and hospital, mediated via technology, is posited as being problematic. It is argued the dichotomy is false and should be moved away from in order to allow an ethical embrace of technology in palliative care.

Nursing Care Aesthetic in Iran: A Phenomenological Study

Background:

Despite the emphasis of contemporary nursing theories on the belief that nursing is a science and an art in care, published studies show that only the nursing science has developed. Many experts believe that by recognizing and perceiving this concept, the clinical field can develop aesthetic knowledge in nursing and education of students.

Objectives:

The purpose of this study was to explain clients and nurses perspective of nursing care aesthetics.

Patients and Methods:

Using an interpretive phenomenology, 12 clients and 14 nurses were interviewed. Participants in this study were purposefully selected and their experiences were analyzed using Van Manen’s hermeneutic phenomenological framework.

Results:

Emerged themes were as follows: subjective description, overt spirituality, opening desperate impasse, sense of unity, continue to shine, and painful pass and pleasing. According the participants experiences, nursing care aesthetics includes subjective description of spiritual and desirable caring behaviors combined with sense of unity and sympathy between the nurse and the patients, which leads to opening in desperate impasse with creating the feeling of satisfaction and peace in the patient. It is a shining of clinical capabilities and an action beyond what should be combined with a decorating care that leads to a pleasant ending against the pain and suffering of the others for the nurse.

Conclusions:

Many caring behaviors associate with aesthetic experience for both patients and nurses and despite two different views, findings of this study showed that these experiences were similar in most cases. The aesthetics of nursing care was defined as what reflects the holistic nature of nursing with an emphasis on spirituality and skill. Results of this study are effective in identification of the values existed in nurse caring behaviors and developing of profession by instruction, implementation, and evaluation them.

Patient safety risks associated with telecare: a systematic review and narrative synthesis of the literature

Background

Patient safety risk in the homecare context and patient safety risk related to telecare are both emerging research areas. Patient safety issues associated with the use of telecare in homecare services are therefore not clearly understood. It is unclear what the patient safety risks are, how patient safety issues have been investigated, and what research is still needed to provide a comprehensive picture of risks, challenges and potential harm to patients due to the implementation and use of telecare services in the home. Furthermore, it is unclear how training for telecare users has addressed patient safety issues. A systematic review of the literature was conducted to identify patient safety risks associated with telecare use in homecare services and to investigate whether and how these patient safety risks have been addressed in telecare training.

Methods

Six electronic databases were searched in addition to hand searches of key items, reference tracking and citation tracking. Strict inclusion and exclusion criteria were set. All included items were assessed according to set quality criteria and subjected to a narrative synthesis to organise and synthesize the findings. A human factors systems framework of patient safety was used to frame and analyse the results.

Results

22 items were included in the review. 11 types of patient safety risks associated with telecare use in homecare services emerged. These are in the main related to the nature of homecare tasks and practices, and person-centred characteristics and capabilities, and to a lesser extent, problems with the technology and devices, organisational issues, and environmental factors. Training initiatives related to safe telecare use are not described in the literature.

Conclusions

There is a need to better identify and describe patient safety risks related to telecare services to improve understandings of how to avoid and minimize potential harm to patients. This process can be aided by reframing known telecare implementation challenges and user experiences of telecare with the help of a human factors systems approach to patient safety.

Information needed to support knowing the patient

"Knowing the patient" is an essential element of nursing practice. Despite a key finding in prior studies, few scholars have directly inquired about the meaning of knowing the patient with nurses. We aimed to describe the meaning of knowing the patient and investigate how nurses obtain the information needed to support knowing the patient. A descriptive qualitative study was conducted with 12 nurses caring for pediatric patients on intensive care units. Nurses described knowing the patient as knowing clinical and personal information for individualized care. Verbal, paper-based, and electronic information sources were used to gather information needed to know the patient. The use of a paper-based supportive tool was the most valuable information source for nurses to know their patients. Future studies must further investigate the use of these paper-based tools and offer electronic solutions to support nurses in knowing their patients.

‘Busyness’ and the preclusion of quality palliative district nursing care

Ethical care is beginning to be recognised as care that accounts for the views of those at the receiving end of care. However, in the context of palliative and supportive district nursing care, the patients’ and their carers’ views are seldom heard. This qualitative research study explores these views. Data were collected through semi-structured interviews with 26 patients with palliative and supportive care needs receiving district nursing care, and 13 of their carers. Participants were recruited via community nurses and hospices between September 2010 and October 2011. Post-structural discourse analysis is used to examine how discourses operate on a moral level. One discourse, ‘busyness’, is argued to preclude a moral form of nursing care. The discourse of friendship is presented to contrast this. Discussion explores Gallagher’s ‘slow ethics’ and challenges the currently accepted ways of measuring to improve quality of care concluding that quality cannot be measured.

Principles of Servant-Leadership in Community Health Nursing

This article discusses the outcomes of a secondary analysis of ethnographic research data, focusing specifically on management issues and behaviors which can help the reader to visualize evidence-based examples of servant-leadership, a transformational leadership model that seeks to empower members of an organization to act as both servants and leaders within a work environment of mutual respect, trust, and collaboration. Participants included nurses, supervisors, administrators, and others observed and interviewed in the agency and nurses accompanied on home visits. Analysis revealed leadership behaviors and issues which are clarified through example(s) and sorted into three thematic categories: respect and valuing of one as a unique individual, affirmation of professional judgment and fair treatment regarding workload, and collaboration with supervisors and administrators in a spirit of willingness. A servant-leadership model can support personal and professional growth, empowering nurses to play a leadership role and thereby increasing nurse collaboration, satisfaction, and retention.

District nurses' attitudes toward patient consent: the case of mechanical ventilation on amyotrophic lateral sclerosis patients: results from a French national survey

PURPOSE

In France, a recent law emphasizes patient rights and prohibits unwanted therapies in end-of-life care. As end-of-life home care is increasing, we aimed to assess French district nurses' attitudes toward terminally ill patients' autonomy.

MATERIALS AND METHODS

We used data from a nationwide telephone survey conducted in 2005 among a random sample of French district nurses (n = 602). Nurses' attitudes were assessed with a clinical case describing a patient (randomly defined as a male or a female aged 50 years) having amyotrophic lateral sclerosis (ALS) who urgently needs mechanical ventilation. Nurses were asked whether patient consent was necessary before performing intubation/tracheotomy, and the analysis took into account various covariates, including nurses' religiosity, nurses' attitudes toward living wills, and patient sex.

RESULTS

Overall, 44% of nurses considered that an ALS patient with respiratory failure should always be intubated (53% for a female patient, 40% for a male patient, P < .01), and after intubation, 27% upheld tracheotomy without considering patient consent as a necessary prerequisite (39% among male nurses, 30% among female nurses, P < .05). Poor communication with terminal patients and hostility toward living will were also predictive of willingness to perform both mechanical ventilation and tracheotomy without patient consent.

CONCLUSIONS

A significant part of French district nurses may have a disturbing propensity to support intubation and tracheotomy with insufficient attention paid to the patient's will. Further research should investigate potential causal factors (such as increased workload) as well as sex-related attitudes in nurse-patient relationship.

Patient falls: acute care nurses' experiences

AIM

To describe the findings from a qualitative study exploring acute care nurses' experiences with patient falls.

BACKGROUND

Patient falls continue to be a problem in acute care settings for nurses at the point of care. Despite the growing body of knowledge related to risk factors and interventions for fall prevention, minimal attention has been given to nurses' perspectives of patient falls.

DESIGN

A qualitative descriptive design was used.

METHOD

Focus group discussions were conducted with nurses working on a cross-section of inpatient acute care settings. Audio-taped sessions were transcribed and analysed thematically.

RESULTS

Nurses described their experience of falls as 'knowing the patient as safe', an ongoing affirmation that the patient was free from harm. In this focused, narrowly defined and highly specific knowing, nurses employed the key strategies of assessment, monitoring and communicating. Variable conditions influenced whether these strategies were effective in giving nurses the knowledge they needed to keep the patient safe. When strategies failed to provide nurses with knowledge of their patients as safe and patients fell, this created considerable stress for nurses and prompted them to use a range of coping strategies.

CONCLUSION

Knowing the patient as safe has the potential to resolve the tension between patient safety and independence. The critical, often taken for granted, activities used by nurses in this knowing must be expanded to include the meaning falls have for patients and attend to factors beyond nurses control such as environmental redesign and staffing.

RELEVANCE TO CLINICAL PRACTICE

Nurses play an important role in fall prevention through knowing the patient as safe but must be supported through the use of a multi-faceted approach extending from the individual nurse to the institutional level.

Technology and its effect on knowing the patient: a clinical issue analysis

Nurses want to know the patients for whom they are providing care. Historically, hospital stays were longer, and nurses felt that they had the time to get to know the patient. During the past 2 decades, nursing research has found that "knowing the patient" is important to nurses and patients; however, nurses do not believe that they have the time to get to know the patient. The world in which we live and in which healthcare is delivered has changed. The emergence of technology has driven a significant amount of the change. Technology has the potential to help nurses "know the patient." The purpose of this article was to outline the importance of knowing the patient and describe how investment in technology can support this important concept. A clinical issue analysis framework was used to develop this manuscript. The main conclusions from the analysis include as follows: knowing the patient is central to quality patient care, time to get to know patients is increasingly difficult, and technology can provide a clinical patient portrait potentially enabling nurses to have time to get to know the patient as a person, resulting in improved patient and nurse satisfaction.

Maintaining the continuity of care in community children's nursing caseloads in a service for children with life-limiting, life-threatening or chronic health conditions: a qualitative analysis

AIMS AND OBJECTIVES

To explore the factors that influence community children's nurses' (CCNs') perceptions of their workload. To identify ways that CCNs develop and maintain continuity of care and carer.

BACKGROUND

The notion of continuity of care/carer has been central to nursing development for the last 30 years. In the literature, community nursing is used to illustrate the concepts of responsibility relationships and continuity of care/carer. However, an assumption is made that the case allocation method is assumed to be the norm in community nursing. The recent UK literature indicates that the case allocation method is not necessarily working in community nursing. It suggests that there may be continuity of care via teams of community nurses and health care assistants, but not necessarily continuity of carer. This seems to reinforce the notion that ideas about the nature of nursing work, the relationship between nurse and client and the mode of care are constructed, contextual and not self-evident. Little has been written about this regarding CCN work.

DESIGN

Collaborative action research design using qualitative methods.

METHODS

In depth interviews with six CCNs drawn from a NHS funded, PCT hosted CCN service in the West of England; documentary analysis of caseload data; thematic analysis of analytical memos and field-notes.

RESULTS

The analysis of the CCNs' interviews identified the mechanisms and strategies they used for managing their work, meeting clients' needs while ensuring that continuity of care and carer was maintained. From their responses to questions, the responsibility relationship and autonomy characteristics of their role were perceived to be a good thing. However, they acknowledged that working in such a way is stressful and provided examples from their everyday working lives. They emphasised the role of support from colleagues as an important way of maintaining and sustaining the responsibility relationships inherent in their work pattern.

CONCLUSIONS

The findings from this study seem to support the notions prevalent in the literature that ideas about the nature of nursing work, the relationship between nurse and client and the mode of care are socially constructed and automatically given. The group of CCNs in this project actively manage their caseloads to maintain the continuity of care and carer in a particular model of service delivery.

RELEVANCE TO CLINICAL PRACTICE

This project provides some illustrations of the way continuity of care may be achieved at the informational, management and relational levels of practice. The typology of continuity of care allows the discrete areas of CCN work to be highlighted and explored, providing insights on an area of practice that is under-reported. The study provides a basis for future research to examine the different configurations of CCN services for the same client group or services for different clients, e.g. diabetes care, so that service providers may configure provision to meet children's and their family's needs.

The (un)-certainties of district nurses in the context of cultural diversity

AIM

This paper is a report of part of a study exploring district nurses' understanding and practices in relation to discrimination and inequalities issues.

BACKGROUND

Clients from minority ethnic groups continue to experience inequalities in health status and care provision. District nurses work with a wide range of clients, yet research has demonstrated inequities in service provision to clients from minority ethnic groups due to organizational, professional and personal constraints.

METHODS

A qualitative methodology was used to explore district nurses' understanding of discrimination and equalities issues in the context of their work. Semi-structured interviews were undertaken during 2003 with 18 district nurses employed in two primary care organizations in England providing healthcare services to a large and culturally diverse population.

FINDINGS

District nurses' accounts were marked by uncertainty, suggesting that many lacked confidence when discussing issues of ethnicity and cultural difference. There were marked differences in the extent to which they appeared to recognize or engage with clients' experiences of discrimination or inequalities, or to recognize inequitable service provision to clients from minority ethnic groups. Key issues were a lack of provision of district nursing services to some clients, and failures to meet clients' language and communication needs, and although reflecting organizational constraints, such continuing inequities were largely unquestioned.

CONCLUSION

There is a need for further educational and practice developments to enable district nurses to provide more equitable care to clients from culturally diverse communities, ensuring that the key professional discourse of individual care and advocacy are fully realized in their work with all clients.

Too frightened to care? Accounts by district nurses working with clients who misuse substances

Drug misusers have complex health and social care needs, and experience considerable difficulties in accessing the assessment, care and treatment that they require. Despite the development of specialist services in many parts of the UK, substance misuse is often marginalised within mainstream general healthcare, and many practitioners are unprepared for the challenges of working with this client group. The present paper reports findings from a qualitative study that aimed to explore district nurses' understandings and practices in relation to discrimination and inequalities issues. The research took place during 2003 in two city-based primary care trusts in the North of England. Semistructured interviews were undertaken with 18 'G' grade district nurses. The authors present findings that highlight some of the challenges and tensions district nurses encounter when providing care to clients who misuse substances. The discourses of 'prejudice' and 'risk' were intertwined throughout the data, and served to shape service provision for clients who misuse substances. This was reflected in the district nurses' accounts of their own practice and that of other services, suggesting that these clients receive suboptimal care. The discourse of 'risk' was also used by district nurses to construct themselves as 'vulnerable', and this helped to explain some of their own practices of care provision. Many participants acknowledged their limited knowledge and experience of working with this client group. There is an urgent need for district nurses and other health professionals to develop their practice with these clients, who may present as both vulnerable and dangerous, in order to ensure that care is provided equitably and safely.

Nurses’ responses to expert patients: The rhetoric and reality of self-management in long-term conditions: A grounded theory study

BACKGROUND

Against the backdrop in the western world of increasing prevalence of chronic disease, active and informed patients and a policy emphasis on self-management, this English study explored health professionals' responses to expert patients.

OBJECTIVES

To:

DESIGN

A grounded theory approach was utilised with two concurrent data strands.

SETTING

A relatively affluent English county including community, primary and secondary care settings.

PARTICIPANTS

Via purposeful and theoretical sampling 100 health professionals (nurses, doctors, physiotherapists) and 100 adults affected by chronic disease participated.

METHODS

Focus groups, interviews and observation.

RESULTS

Nurses were found to be most anxious about expert patients when compared to other professionals, which appeared to be linked with a lack of professional confidence and unfounded fears regarding litigation. However, nurse specialists often provided a negative case for this. As a whole, nurses were most able to meet the emotional needs of patients, but apart from nurse specialists did not articulate this as a skill.

CONCLUSION

Apart from nurse specialists the majority of nurses appeared limited in appropriately facilitating self-management. It is suggested that this is linked to an ongoing nursing culture of patient as passive, an over-emphasis on empirical knowledge and a feeling of vulnerability on the nurses' part towards expert patients. The findings also indicate a rhetoric rather than reality of autonomous nursing roles within the chronic disease management agenda.

A follow-up study of professionals’ perspectives on the development of family health nursing in Scotland: A questionnaire survey

BACKGROUND

In 1998 the World Health Organisation Europe introduced the Family Health Nurse concept. The envisaged role of this community-based nurse was seen as multi-faceted and included helping individuals, families and communities to cope with illness and improve their health. During 2000-2002 Scotland led enactment of the concept through education and practice, and the first research study evaluating its operation and impact in remote and rural areas was published in 2003.

OBJECTIVE

This study's purpose was to follow up health care professionals' perspectives on the development of family health nursing in remote and rural areas of Scotland since 2002.

METHODS

The main research method used was questionnaire survey of all the established family health nurses in these areas and all other health and social care professionals with whom they had regular work-related contact. Where novel contexts or practice patterns emerged, further investigation was undertaken through telephone interviews.

FINDINGS

Twenty-three family health nurses (88%) and 88 of their colleagues (52%) returned questionnaires. Eight family health nurses were interviewed. The dominant theme within the findings was the gradual, positive development of a role which tended to maintain established community nursing service provision, yet also supplement this with a limited expansion of family health services and public health activities. The flexibility and wide scope of the FHN role in terms of providing generalist community health nursing services was clearly evident. However, capacity to engage with whole families was found to vary widely in practice.

CONCLUSIONS

Within remote and rural Scotland family health nursing is gradually consolidating and developing, but its particular aspiration to engage with whole families is often difficult to enact and is not a priority within mainstream UK primary care policy, planning or provision.