Silence, shame and abuse in health care: theoretical development on basis of an intervention project among staff

Nursing students' experience of moral distress in clinical settings: A phenomenological study

AIM

To explore nursing students' moral distress (MD) experiences in clinical settings.

DESIGN

An interpretative phenomenological analysis (IPA) design was employed.

METHODS

Purposive sampling was used. In-depth semi-structured face-to-face interviews were conducted from December 2020 to June 2021 with nursing students who were taking the internship course in clinical settings. Data analysis was conducted following Dickman et al.'s (1989) method.

RESULTS

Ten nursing students participated in this study. Three main themes were identified, including (1) negative learning environments, (2) internal disgust and (3) threats to professional identity.

CONCLUSION

Findings showed that value conflict, lack of knowledge of ethical standards and its application, and unprofessional approaches result in negative environmental learning perceptions from the nursing students. Therefore, due to being unable to change the situation, they start to feel guilt and shame and, as a result, decide to escape the problem instead of managing it. These feelings lead to internal disgust. This issue indicates the importance of improving the knowledge and perception of these situations. Thus, nursing students must be prepared for the real world, where their ideals are constantly challenged. MDs were experienced as threats to dignity, inequality, distrust, and change of mentality towards nursing, characterised as threats to professional identity. It is suggested to inquire about the process of nursing students' resiliency in morally disturbing situations to deduce the suitable approach for clinical education.

Harm reduction strategies in acute care for people who use alcohol and/or drugs: A scoping review

BACKGROUND

People who use alcohol and/or drugs (PWUAD) are at higher risk of infectious disease, experiencing stigma, and recurrent hospitalization. Further, they have a higher likelihood of death once hospitalized when compared to people who do not use drugs and/or alcohol. The use of harm reduction strategies within acute care settings has shown promise in alleviating some of the harms experienced by PWUAD. This review aimed to identify and synthesize evidence related to the implementation of harm reduction strategies in acute care settings.

METHODS

A scoping review investigating harm reduction strategies implemented in acute care settings for PWUAD was conducted. A search strategy developed by a JBI-trained specialist was used to search five databases (Medline, Embase, CINAHL, PsychInfo and Scopus). Screening of titles, abstracts and full texts, and data extraction was done in duplicate by two independent reviewers. Discrepancies were resolved by consensus or with a third reviewer. Results were reported narratively and in tables. Both patients and healthcare decision makers contributing to the development of the protocol, article screening, synthesis and feedback of results, and the identification of gaps in the literature.

FINDINGS

The database search identified 14,580 titles, with 59 studies included in this review. A variety of intervention modalities including pharmacological, decision support, safer consumption, early overdose detection and turning a blind eye were identified. Reported outcome measures related to safer use, managed use, and conditions of use. Reported barriers and enablers to implementation related to system and organizational factors, patient-provider communication, and patient and provider perspectives.

CONCLUSION

This review outlines the types of alcohol and/or drug harm reduction strategies, which have been evaluated and/or implemented in acute care settings, the type of outcome measures used in these evaluations and summarizes key barriers and enablers to implementation. This review has the potential to serve as a resource for future harm reduction evaluation and implementation efforts in the context of acute care settings.

The continuum of violence against women: Gynecological violence within the Medical Model in Chile

OBJECTIVE

This study aims to investigate the presence of gynecological violence within the health system in Chile, quantify the magnitude of this problem, define its general contours, and shed light on a phenomenon that has long been silenced. Additionally, we are interested in detecting differences between public and private health services, as well as exploring the role played by variables such as sexual orientation, ethnicity, age, and educational level in contributing to the prevalence of gynecological violence.

METHODS

This study employed a cross-sectional and not probabilistic sampling approach. It included a sample of 1503 women from all regions of Chile, who were of legal age and who had attended gynecological services. A questionnaire was applied between January 2021 and April 2022 using the online platform SurveyMonkey®. Data were collected through the second national survey on obstetric and gynecological violence (GinObs 2021). The study adheres to activist research methodologies and was conducted in collaboration with activists and academic researchers.

RESULTS

57.9% of the women participants reported having experienced violence. Such violence appears to occur most frequently in the public health system, although not exclusively, and the victims are often people who belong to native ethnic groups, who identify as of African descent, whose sexual orientation is lesbian, who are elderly, and who have a lower level of education.

CONCLUSION

Gynecological violence is an integral part of the continuum of violence against women and is consistently reported in both public and private health services. This form of violence has serious consequences for women's health and constitutes a significant public health problem.

Nurse Disrespect and Abuse Toward Laboring and Child-Birthing Women

BACKGROUND

Disrespect and abuse of laboring and child-birthing women in healthcare is a global problem that violates a woman's right to respectful care. The abuse can be life-threatening and jeopardizes their rights to health, bodily integrity, and freedom from discrimination. This study aimed to understand the factors influencing nurse and midwife disrespect and abuse of child-birthing women in healthcare settings.

METHODS

An exploratory, nonexperimental, cross-sectional design was used to identify correlates and predictors of disrespect and abuse of child-birthing women by nurses/midwives. Pearson product-moment correlation and hierarchical multiple regression analyses were used to explore the relationships between nurse intrapersonal, interpersonal (Nursing Incivility Scale), organizational/structural factors (Professional Practice Work Environment Inventory), and disrespect and abuse (Disrespect and Abuse Scale) toward women during labor and childbirth.An online electronic survey was used to collect data from an international nursing and midwifery population from May 2021 to September 2021. Data were collected from 231 nurses and midwives.

RESULTS

The standardized regression coefficients showed that gender, number of hours worked per week, and organizational/structural factors were all predictors of disrespect and abuse. Organizational/structural factors were the strongest predictor of disrespect and abuse, accounting for 20% of the variance in the regression model.

DISCUSSION

These findings support the patient abuse in healthcare model, where researchers hypothesized that nurse/midwife intrapersonal, interpersonal, and organizational/structural factors contribute to patient abuse in healthcare settings. Work environment, gender, and number of hours worked per week were significant predictors of disrespect and abuse. The results of this study support future research that addresses unhealthy work environments and develops policies to transform the values and norms of labor and delivery.

Does My Humor Touch You? Effect of Leader Self-Deprecating Humour on Employee Silence: The Mediating Role of Leader-Member Exchange

Purpose

Silence is a typical negative behaviour exhibited by employees when they are faced with tension and stress and is influenced by a number of factors. Leaders have an important influence on employees' emotions and behaviour, but the research is not yet clear enough. In this paper, we focus on the research frontier of self-deprecating humour of leaders, aiming to analyse its effect on employee silence and discuss the mechanism of the role of leader-member exchange (LMX) in it, based on social exchange theory.

Methods

We conducted a regression analysis and bootstrap test for mediating effects based on 2531 data from 151 financial institutions in mainland China. A simple random sampling was taken of the target population to ensure an unbiased sample. Using Harman's single-factor test to check the data for common method bias. Regression analysis and Bootstrap test were used to analyze the correlation between variables and mediating effect models.

Findings

(a) Leader self-deprecating humour significantly reduces employee silence and effectively improves the quality of LMX; (b) There is a significant negative relationship between LMX and employee silence; (c) LMX plays a mediating role in the process of self-deprecating humour influencing employee silence and this mediating effect is complete; (d) Affective exchange between leaders and employees appears to be an essential factor in reducing stress from leaders and reducing employee silence.

Originality/Value

We attempt to open the black box of the mechanism of action between leader self-deprecating humour and employee silence, enrich and expand the application of social exchange theory to negative employee behavior, and provide new theoretical knowledge and empirical evidence from developing countries.

Practical Implications

The results of the study indicated that self-deprecating humor of leaders can significantly inhibit employee silence through high levels of LMX. Moreover, the mediating role played by LMX was complete. Therefore, organizations should not only focus on the role of leadership humor, but also to achieve mutual respect and trust between leaders and subordinates, and an emotional exchange that goes beyond economic relationships.

Patient Abuse in Healthcare: A Theoretical Synthesis

Patient abuse in healthcare is an emerging phenomenon in need of explanation and further analysis. Preventing abusive incidents in healthcare requires identifying structural imbalances that make mistreatment of vulnerable individuals possible. A theory synthesis of the vicious violence triangle and the socioecological model provides a framework to investigate factors that influence nurses' abusive behavior toward patients in hospitals. Concepts include direct violence, structural violence, cultural violence, and intrapersonal, interpersonal, and organizational factors. The patient abuse in healthcare theory supports empowerment and transformation of nursing and nursing science and offers a blueprint for research that promotes health equity.

Development and psychometric properties of the hospitalized elder abuse questionnaire (HEAQ): a mixed methods study

BACKGROUND

Older patients are more vulnerable and prone to abuse and neglect in hospitals and acute care settings. The present study aimed to develop and assess the psychometric properties of a questionnaire for screening abuse in hospitalized older adults.

METHODS

This study was conducted from October 2017 to September 2019 using the exploratory sequential mixed-methods research design. The participants were selected among those admitted to various wards of six teaching hospitals affiliated with Shiraz University of Medical Sciences, Shiraz, Iran. In the qualitative phase of the study, using the inductive content analysis method, the concept of abuse in hospitalized older adults was extracted through individual in-depth semi-structured interviews with 16 older patients and 11 family caregivers. Based on qualitative findings and a review of existing literature, an initial version of the questionnaire was developed. In the quantitative phase of the study, the psychometric properties (face, content, construct, and convergent validity; internal consistency and stability) of the questionnaire were examined.

RESULTS

Based on qualitative findings and literature review, a pool of 154 candidate items was defined. These items were reduced to 37 after initial refinement, qualitative and quantitative face and content validity, and item analysis. The outcome of principal component analysis further reduced the number of items to 27, which were grouped into 5 components, namely "Shortcomings in management and care facility", "Neglect of professional commitments", "Physical and psychological abuse", "Protracted treatment process", and "Invasion of privacy". The explained variance of these 5 components was 50.09% of the overall variability of the questionnaire. The convergent validity of the questionnaire was acceptable (P < 0.00, r = - 0.44). Cronbach's alpha coefficient and intraclass correlation coefficient for the entire questionnaire were 0.89 and 0.92, respectively; indicating high reliability and stability of the questionnaire.

CONCLUSION

The hospitalized elder abuse questionnaire (HEAQ) has acceptable psychometric properties. It is recommended to use HEAQ to screen for suspected cases of abuse of hospitalized older adults.

Counteracting Abuse in Health Care: Evaluating a One-Year Drama Intervention with Staff in Sweden

In Northern European countries 13–28% of female patients seeking gynecological health care have reported abuse by health care staff (AHC). We conducted workshops with health care staff using the improvised role-play method Forum Play (FP), based on techniques developed by Boal. The study explores to what extent the intervention increased the staff’s awareness of AHC and their ability to take action against it. A total of 16 half-day FP workshops were conducted with staff from a Swedish women’s clinic over one year. Self-reported questionnaires were distributed to all staff before, during, and after the intervention. Primary outcome measures were the number of reported occasions of AHC and FP participants’ ability to act in AHC-situations. We found an increase in the participants’ self-reported ability to act in AHC-related situations. However, no change could be observed in the number of reported occasions of AHC between baseline and one year after the intervention. Health care staff’s participation in workshops using improvised role-play can increase staff’s perceived ability to take action in AHC situations. The voluntary nature of the intervention may have attracted those who were already aware of the topic, and likely explains the unchanged awareness of AHC.

Re-negotiating agency - patients using comics to reflect upon acting in situations of abuse in health care

Background

There is a growing body of international research that displays the prevalence and character of abuse in health care. Even though most of these studies are conducted from a patient perspective little is known about how patients conceptualize their agency in relation to such situations. This study aimed to explore how patients reason about their potential to act in abusive situations.

Methods

Qualitative interviews were conducted with thirteen patients in Sweden. Central in the interviews were three comics, inspired by Boal’s Forum Theatre and part of an earlier online intervention study in which the informants had participated. Each comic showed a situation in which a patient feels abused, and on the opposite side were suggestions for how the patient could act in response. Informants were asked to reflect about situations of abuse and in specific upon the comics. We used the methodology of constructivist grounded theory throughout the study, including the analysis.

Results

It appeared that the informants constantly re-negotiated their and other patients’ agency in relation to the specifics of the event, patients’ and staff’s responsibilities, and the patients’ needs and values. This process questions views of agency as fixed and self-evident, and can be understood as part of changing discourses about patients’ social role and possibilities to organize their care. Using a feminist theory of power we expected the informants to elicit instances of resistance to domination, which is central to the comics. While doing that, the informants also hinted at parallel stories of empowerment and less visible forms of agency in spite of domination.

Conclusion

The current analysis showed different ways in which the informants constantly re-negotiated their agency in potentially abusive situations. Not only did the informants engage in reflections about immediate responses to these untoward situations, they also engaged in thoughts about strategies that could protect them and counteract abuse in health care over the long-term. This opens up for future research into ways patients organize their care and identify threats and barriers to the care they need, which could be valuable knowledge for care quality improvement.

Understanding and preventing situations of abuse in health care - Navigation work in a Swedish palliative care setting

In their everyday work, health professionals find themselves in situations that they perceive to be abusive to patients. Such situations can trigger feelings of shame and guilt, making efforts to address the problem among colleagues a challenge. This article analyzes how health professionals conceptualize abusive situations, and how they develop collective learning and explore preventive strategies. It is based on an interactive research collaboration with a hospice and palliative care clinic in Sweden during 2016-2017. The empirical material consists of group discussions and participant observations collected during interactive drama workshops for all clinic staff. Based on three types of challenges in the material, identified through thematic analysis, we establish the concept of navigation work to show how health professionals prevent or find ways out of challenging and potentially abusive situations. First, the navigation of care landscapes shows how staff navigate the different territories of the home and the ward, reflecting how spatial settings construct the scope of care and what professionals consider to be potentially abusive situations. Second, the negotiation of collective navigations addresses the professionals' shared efforts to protect patients through the use of physical and relational boundaries, or mediating disrupted relationships. Third, the navigation of tensions in care highlights professionals' strategies in the confined action space between coercing and neglecting patients who oppose necessary care procedures. Theoretically, the concept of navigation work draws upon work on care in practice, and sheds light on the particular kind of work care professionals do, and reflect on doing, in order to navigate the challenges of potentially abusive situations. By providing a perspective and shared vocabulary, the concept may also elicit ways in which this work can be verbalized, shared, and developed in clinical practice.

Living with painful endometriosis - A struggle for coherence. A qualitative study

OBJECTIVES

The study sought to examine women's experience of painful endometriosis including long-term aspects, social consequences, impact of treatment and development of own coping strategies.

STUDY DESIGN

This qualitative study was based on 16 individual interviews analyzed according to grounded theory. The thirteen women (age 24-48) were recruited at a pain clinic in Stockholm, Sweden.

RESULTS

A theory illustrating women's experience of living with painful endometriosis was developed with three categories and one core category. Bidirectional interactions between the categories and with the core category were found. Endometriosis influenced the women's sensations, feelings and reactions, creating a sense of difference from other women (category: Woman with painful endometriosis). The condition led to either helpful or harmful encounters with health care and significant others (category: Dependence). It also had overall physical, social and existential consequences (category: A ruined life). To cope, the women had to struggle for coherence by searching for understanding, coping and meaning (core category: Living with painful endometriosis).

CONCLUSIONS

Living with severe painful endometriosis signified a struggle for coherence. The women needed to deal with feelings of difference, dependence and a ruined life and thus struggled for understanding, coping and meaning. Health-care providers should promote the struggle for coherence by explaining the feeling of difference, minimizing dependence and supporting the process of disease-related grief.