Lack of care in nursing: is character the missing ingredient?

Experience of midwives in providing care to labouring women in varied healthcare settings: A qualitative study

BACKGROUND

Midwives are essential to timely, effective, family-centred care. In South Africa, patients have often expressed dissatisfaction with the quality of midwifery care. Negative interpersonal relationships with caregivers, lack of information, neglect and abandonment were consistent complaints. Less is known about how midwives experience providing care.

AIM

This research explored and described the experiences of midwives in providing care to labouring women in varied healthcare settings.

SETTING

Midwives practicing in the Gauteng province, South Africa, in one of three settings: private hospitals, public hospitals or independent maternity hospital.

METHODS

A convenience sample of midwives (N = 10) were interviewed. An exploratory and descriptive design, with individual semi-structured interviews conducted, asked a primary question: 'How is it for you to be a midwife in South Africa?' Transcribed interviews were analysed using thematic coding.

RESULTS

Five themes were found: proud to be a midwife, regulations and independent function, resource availability, work burden and image of the midwife.

CONCLUSION

Midwives struggle within systems that fail to allow independent functioning, disallowing a voice in making decisions and creating change. Regardless of practice setting, midwives expressed frustration with policies that prevented utilisation consistent with scope of practice, as well as an inability to practice the midwifery model of care. Those in public settings expressed concern with restricted resource appropriation. Similarly, there is clear need to upscale midwifery education and to establish care competencies to be met in providing clinical services.

CONTRIBUTION

This research provides evidence of the midwifery experience with implications for needed health policy change.

The delivery of compassionate nursing care in a tick-box culture: Qualitative perspectives from a realist evaluation of intentional rounding

Background

Compassion is integral to professional nursing practice worldwide and a fundamental value in healthcare. Following serious care failures at a healthcare provider in the United Kingdom, a government commissioned report (the Francis Report) made several recommendations for strengthening compassion in nursing care and consequently ‘intentional rounding’ was incorporated into nursing practice in the United Kingdom. Intentional rounding is a structured process implemented primarily in the United Kingdom, North America and Australia, whereby nurses conduct 1–2 hourly checks on every patient using a standardised protocol and documentation.

Objectives

To examine the role of intentional rounding in the delivery of compassionate nursing care in England from multiple perspectives.

Methods

This paper reports qualitative findings from one phase of a realist evaluation of intentional rounding which used a mixed-methods approach. Individual, semi-structured interviews were undertaken with 33 nursing staff, 17 senior nurse managers, 34 patients and 28 family carers from three geographically spread case study hospital sites in England. Interviews elicited detailed reflections on the contexts, mechanisms and outcomes of intentional rounding and how it impacted the interviewee and those around them.

Results

This study found little evidence that intentional rounding ensures the comfort, safety or dignity of patients or increases the delivery of compassionate care. The systematised approach of intentional rounding emphasises transactional care delivery in the utilisation of prescribed methods of recording or tick boxes rather than relational, individualised patient care. It has the potential to reduce the scope of nursing care to a minimum standard, leading to a focus on the fundamentals as well as the prevention of adverse events. Its documentation is primarily valued by nursing staff as a means of protecting themselves through written proof or ‘evidence’ of care delivered, rather than as a means of increasing compassionate care.

Conclusions

This large-scale, theoretically-driven study of intentional rounding – the first of its kind – demonstrates that intentional rounding prioritises data collection through tick boxes or a prescriptive and structured recording of care. Thus, intentional rounding neither improves the delivery of compassionate nursing care nor addresses the policy imperative it was intended to target. This study raises questions about the role, contribution and outcomes from intentional rounding and suggests a need for a wider, international debate within the nursing profession about its future use. If an intervention to increase compassionate nursing care is required, it may be better to start afresh, rather than attempting to adapt the system currently implemented.

Relationships Between Positive and Negative Attributes of Self-Compassion and Perceived Caring Efficacy Among Psychiatric-Mental Health Nurses

The purpose of this correlational quantitative study was to examine the relationships between work-related demographic variables, self-compassion, and perceived caring efficacy among psychiatric-mental health nurses (PMHNs), as measured using the Self-Compassion Scale and Caring Efficacy Scale. Participants were RNs actively working in psychiatric-mental health settings in the United States who are currently members of the American Psychiatric Nurses Association. Results suggest PMHNs with high levels of positive attributes of self-compassion had higher perceived levels of caring efficacy and those with high levels of negative attributes of self-compassion had lower perceived levels of caring efficacy. No statistically significant relationships were found between demographic variables, such as years of work experience, nurse:patient ratio, and perceived level of caring efficacy. The knowledge of the association between attributes of self-compassion and perceived caring efficacy can provide nurses with improved awareness of the need to be compassionate to the self and its relationship to effectiveness of care provided, potentially leading to positive health outcomes in clients. [Journal of Psychosocial Nursing and Mental Health Services, 58(2), 32-40.].

The role of emotion regulation, coping, self-reflection and insight in staff interaction with patients with a diagnosis of personality disorder in forensic settings

WHAT IS KNOWN ON THE SUBJECT?: Interaction between staff and patients with a diagnosis of personality disorder in forensic settings is important for quality of care, but research is lacking on what determines this interaction. WHAT THE PAPER ADDS TO EXISTING KNOWLEDGE?: Insight, emotion-focused coping and emotion regulation of staff influence the interaction between staff and these patients. Staff who understand their own thoughts, feelings and behaviour better (more insight) needed less support, encouragement or back-up from their patients. Staff who cope by getting upset, blaming themselves or fantasizing about solutions (emotion-focused coping) on the contrary needed more support from their patients. Emotion regulation had an impact on the relation between coping and hostile staff behaviour. When staff get upset (emotion-focused coping) and try to think differently about the situation (reappraisal), this makes them behave in a more hostile manner towards their patients. When staff suppress their emotions and also distract themselves or engage in social activities (avoidance-focused coping), they behave in a less hostile manner towards their patients. WHAT ARE THE IMPLICATIONS FOR PRACTICE?: In order to provide compassionate care for their patients, staff ought to be trained in self-compassion. This may help them not to get upset, blame themselves or fantasize about solutions and to understand their own thoughts, feelings and behaviour better. As a result, staff may need less support, encouragement or back-up from their patients. Context is important: Staff ought to suppress their emotions when emotions run high, but only when they also care for themselves by distracting themselves or engaging in social activities. Facing and regulating their emotions by changing what they think about the situation (reappraisal) may be more appropriate once emotions have settled down. This may help staff to remain compassionate towards their patients in the long run and avoid burn-out or compassion fatigue due to ignoring their own needs and boundaries. ABSTRACT: Introduction Research is lacking on what determines interaction between staff and patients with a diagnosis of personality disorder in forensic settings. Aim To test whether coping, self-reflection, insight and emotion regulation are related to the behaviour of staff towards these patients, and to test the possible moderating and mediating effect of emotion regulation. Method Using a cross-sectional design, 76 direct care staff of a forensic clinic completed questionnaires on all variables. Relations were tested using simple linear regression, mediation and moderation analyses. Results Insight and emotion-focused coping of staff were related to seeking less and more support from patients, respectively. Emotion regulation by reappraisal combined with emotion-focused coping was associated with more hostile behaviour by staff, and suppression combined with avoidance-focused coping with less hostile behaviour. Conclusion Insight, emotion-focused coping and emotion regulation of staff influence the quality of care of patients with a diagnosis of personality disorder in forensic settings. Future research ought to include contextual factors. Implications for practice Enhancing self-compassion may improve insight and reduce emotion-focused coping. Context is important: Taking the needs of staff into account may involve suppressing emotions combined with avoidance in a highly emotional situation while facing and reappraising the situation when emotions are low.

Evaluating fundamentals of care: The development of a unit-level quality measurement and improvement programme

AIMS AND OBJECTIVES

The project aimed to develop a unit-level quality measurement and improvement programme using evidence-based fundamentals of care.

BACKGROUND

Feedback from patients, families, whānau, staff and audit data in 2014 indicated variability in the delivery of fundamental aspects of care such as monitoring, nutrition, pain management and environmental cleanliness at a New Zealand District Health Board.

DESIGN

A general inductive approach was used to explore the fundamentals of care and design a measurement and improvement programme, the Patient and Whānau Centred Care Standards (PWCCS), focused on fundamental care.

METHODS

Five phases were used to explore the evidence, and design and test a measurement and improvement framework.

RESULTS

Nine identified fundamental elements of care were used to define expected standards of care and develop and test a measurement and improvement framework. Four six-monthly peer reviews have been undertaken since June 2015. Charge Nurse Managers used results to identify quality improvements. Significant improvement was demonstrated overall, in six of the 27 units, in seven of the nine standards and three of the four measures. In all, 89% (n = 24) of units improved their overall result.

CONCLUSION

The PWCCS measurement and improvement framework make visible nursing fundamentals of care in line with continuous quality improvement to increase quality of care.

RELEVANCE TO CLINICAL PRACTICE

Delivering fundamentals of care is described by nurses as getting ?back to basics'. Patient and family feedback supports the centrality of fundamentals of care to their hospital experience. Implementing a unit-level fundamentals of care quality measurement and improvement programme clarifies expected standards of care, highlights the contribution of fundamentals of care to quality and provides a mechanism for ongoing improvements.

Examining the context of community nursing in Ireland and the impact of missed care

As populations rise and many global health policies point towards community care, it is important that health care delivery meets demand. In Ireland, a study was undertaken on the level and context of missed care in community nursing. The study used a survey to identify the quantity of, and reasons for, missed care; a reference group to develop possible health economic implications for missed care, and a small sample of semi-structured interviews to consider the macro-environment within which missed care occurred. This paper presents the findings of the health economics and qualitative data, and the study's implications for community nursing.

A critical analysis of the failure of nurses to raise concerns about poor patient care

The occurrence of poor patient care is emerging as one of the most significant, challenging, and critical issues confronting contemporary nursing and those responsible for the provision of health care more generally. Indeed, as a consequence of the increased recognition of the manner in which nurses can be implicated in the occurrence of poor patient care, there has been sustained critical debate that seeks to understand how such healthcare failings can occur and, in particular, why nurses seemingly fail to intervene, raise concerns, and effectively respond to prevent the occurrence and continuation of such poor patient care. In seeking to contribute to this critical discussion, and in contrast to those "situational explanations" that maintain that the failure to raise concerns is a consequence of the contextual factors and challenging conditions to which nurses can be subject in the clinical setting, this paper will provide a resolutely philosophical analysis of that failure. In particular, it will draw upon the work of Jean-Paul Sartre-the French philosopher generally regarded as one of the most influential thinkers of the twentieth century-in order to propose that his work can be productively recontextualized to provide a detailed, challenging, and provocative critical analysis of the occurrence and continuation of poor patient care and the role of individual nurse practitioners in such healthcare failings.

Curbing the urge to care: A Bourdieusian analysis of the effect of the caring disposition on nurse middle managers' clinical leadership in patient safety practices

BACKGROUND

Nurse managers play an important role in implementing patient safety practices in hospitals. However, the influence of their professional background on their clinical leadership behaviour remains unclear. Research has demonstrated that concepts of Bourdieu (dispositions of habitus, capital and field) help to describe this influence. It revealed various configurations of dispositions of the habitus in which a caring disposition plays a crucial role.

OBJECTIVES

We explore how the caring disposition of nurse middle managers' habitus influences their clinical leadership behaviour in patient safety practices.

DESIGN

Our paper reports the findings of a Bourdieusian, multi-site, ethnographic case study.

SETTINGS

Two Dutch and two American acute care, mid-sized, non-profit hospitals.

PARTICIPANTS

A total of 16 nurse middle managers of adult care units.

METHODS

Observations were made over 560h of shadowing nurse middle managers, semi-structured interviews and member check meetings with the participants.

RESULTS

We observed three distinct configurations of dispositions of the habitus which influenced the clinical leadership of nurse middle managers in patient safety practices; they all include a caring disposition: (1) a configuration with a dominant caring disposition that was helpful (via solving urgent matters) and hindering (via ad hoc and reactive actions, leading to quick fixes and 'compensatory modes'); (2) a configuration with an interaction of caring and collegial dispositions that led to an absence of clinical involvement and discouraged patient safety practices; and (3) a configuration with a dominant scientific disposition showing an investigative, non-judging, analytic stance, a focus on evidence-based practice that curbs the ad hoc repertoire of the caring disposition.

CONCLUSIONS

The dispositions of the nurse middle managers' habitus influenced their clinical leadership in patient safety practices. A dominance of the caring disposition, which meant 'always' answering calls for help and reactive and ad hoc reactions, did not support the clinical leadership role of nurse middle managers. By perceiving the team of staff nurses as pseudo-patients, patient safety practice was jeopardized because of erosion of the clinical disposition. The nurse middle managers' clinical leadership was enhanced by leadership behaviour based on the clinical and scientific dispositions that was manifested through an investigative, non-judging, analytic stance, a focus on evidence-based practice and a curbed caring disposition.

Exploring commitment, professional identity, and support for student nurses

Problems with the recruitment and retention of nurses globally mean that insight into the factors that might increase retention in qualified staff and students is crucial. Despite clear links between work commitment and retention, there is little research exploring commitment in student nurses and midwives. This paper reports the findings of a qualitative study designed to provide insight into commitment using semi-structured interviews conducted with nine pre-registration students and a qualitative survey completed by 171 pre-registration students. Thematic analysis of the data emphasised the impact of placement experiences on commitment via interpersonal relationships. Students typically emphasised their professional identity as the basis for commitment, although many participants also highlighted a lack of acceptance by qualified practitioners, which reduced it. There was evidence that suggested that practitioner workload may impact the student experience due to challenges in making sufficient time to provide support. Implications for retention strategies are discussed.