Invisibility, Moral Knowledge and Nursing Work in the Writings of Joan Liaschenko and Patricia Rodney

Measuring invisible nursing interventions: Development and validation of Perception of Invisible Nursing Care-Hospitalisation questionnaire (PINC-H) in cancer patients

Visible nursing work is usually associated with formal work and physician-delegated tasks which are protocolised and usually well documented. Nevertheless, nurses carry out many actions and display specific attitudes and behaviours which, despite contributing to the well-being, recovery of patients and satisfaction with the attention received, are not as visible. Previous studies have been conducted in order to define 'invisible nursing interventions', but no quantitative instruments focused on measuring invisible nursing interventions have been found in the literature.

PURPOSE

To test the psychometric properties of the Perception of Invisible Nursing Care-Hospitalisation (PINC-H) questionnaire.

METHODS

Cross-sectional survey design. A self-administered questionnaire was completed by 381 participants recruited consecutively after discharge from a Spanish hospital. Data were collected from 2012 to 2020.

RESULTS

Three factors were identified from exploratory factor analysis, namely 'Caring for the person', 'Caring for the environment and the family' and 'Caring presence'. Criterion Validity Coefficient was highly significant (p < 0.001) with values ranging between 0.63 and 0.71. Cronbach's alpha was 0.96. Test-retest reliability was estimated in a subsample of 187 participants; in all the items, correlation coefficients were highly significant (p < 0.001) and within range (0.532-0.811) with a mean value of 0.680. Also, correlations between each dimension and the complete questionnaire indicated good temporal stability between measurements.

CONCLUSIONS

The instrument had satisfactory validity and reliability. PINC-H can contribute to highlight nursing interventions and behaviours which are often unseen and, thus, less valued. We argue that PINC-H will also be useful to evaluate the quality of invisible nursing care to oncology inpatients.

Between the patient and the next of kin in end-of-life care: A critical study based on feminist theory

BACKGROUND:

For the experience of end-of-life care to be 'good' many ethical challenges in various relationships have to be resolved. In this article, we focus on challenges in the nurse-next of kin relationship. Little is known about difficulties in this relationship, when the next of kin are seen as separate from the patient.

RESEARCH PROBLEM:

From the perspective of nurses: What are the ethical challenges in relation to next of kin in end-of-life care?

RESEARCH DESIGN:

A critical qualitative approach was used, based on four focus group interviews.

PARTICIPANTS:

A total of 22 registered nurses enrolled on an Oncology nursing specialisation programme with experience from end-of-life care from various practice areas participated.

ETHICAL CONSIDERATIONS:

The study was approved by the Norwegian Social Science Data Service, Bergen, Norway, project number 41109, and signed informed consent obtained from the participants before the focus groups began.

FINDINGS AND DISCUSSION:

Two descriptive themes emerged from the inductive analysis: 'A feeling of mistrust, control and rejection' and 'Being between hope and denial of next of kin and the desire of the patient to die when the time is up'. Deductive reinterpretation of data (in the light of moral distress from a Feminist ethics perspective) has made visible the constraints that certain relations with next of kin in end-of-life care lay upon the nurses' moral identity, the relationship and their responsibility. We discuss how these constraints have political and societal dimensions, as well as personal and relational ones.

CONCLUSION:

There is complex moral distress related to the nurse-next of kin relationship which calls for ethical reflections regarding these relationships within end-of-life care.

Compassion and Responsibility in Surgical Care

Ten nurses at a university hospital in Norway were interviewed as part of a comprehensive investigation into the narratives of nurses and physicians about being in ethically difficult situations in surgical units. The transcribed interview texts were subjected to a phenomenological-hermeneutic interpretation. The main theme in the narratives was being close to and moved by the suffering of patients and relatives. The nurses' responsibility for patients and relatives was expressed as a commitment to act, and they needed to ask themselves whether their responsibility had been fulfilled, that nothing had been left undone, overlooked or neglected, before they could leave the unit. When there was confirmation by the patients, relatives, colleagues and themselves that the needs of patients and relatives had been attended to in a morally and professionally satisfying manner, this increased the nurses' confidence and satisfaction in their work, and their strength to live with the burden of being in ethically difficult situations.

The implications of Kristeva's notion of the abject in understanding the significance of therapeutic knowledge and practice in mental health nursing

Mental health nursing knowledge is largely excluded in certain key clinical guideline groups despite nursing practice being so important to service users. This exclusion may be because mental health nurses work close to what cannot be spoken of easily, or at all--the abject. Good mental health nursing practice depends on the individual person of the mental health nurse rather than any knowledge frameworks. Education should focus on relational aspects of practice to develop this and to define the core identity of mental health nursing as a therapy. This paper discusses therapeutic knowledge and practice in mental health nursing through Kristeva's notion of the abject as that which is the other side of language, closely linked to the feminine space of the chora. The chora is a provisional, stable space, associated with the mother's body, where the first possibility of signification can take place. Mental health nursing is a therapeutic practice that draws on knowledge that is practical, tacit, empirical, embodied and intuitive, as well as knowledge that is regarded here as beyond the tacit; the latter indicating an encounter with the abject. Mental health nursing as a practice potentially places an extraordinary ethical onus on the individual nurse in his/her relations with patients and indicates that it is the person of the nurse who is therapeutic rather than any knowledge framework, with major implications for education and professional identity. The presence of mental health nursing practice at the heart of the mental health care system, while effectively being ignored as a treatment by the National Institute for Health and Care Excellence, embodies a critique of the currently dominant evidence-based paradigm.

The power of relationships: exploring how Public Health Nurses support mothers and families during postpartum home visits

Postpartum home visiting by Public Health Nurses (PHNs) has been used by many health departments across Canada as a way of supporting new mothers and their families. Although positive health outcomes are linked with support from PHNs, little is known about how this occurs during the home visit. The purpose of this research was to explore how home visiting programs for mothers and babies were organized, delivered, and experienced through the everyday practices of PHNs, mothers, and managers in Nova Scotia, Canada. Feminist poststructuralism was used to guide the research and semi-structured face-to-face interviews were conducted with 16 PHNs, 16 mothers, and 4 managers. Participants described how relationships were an essential part of supporting mothers and families. These findings also challenge dominant health discourses and stereotypes that are often associated with mothering and the practice of PHNs with families.

Values in nursing students and professionals

Background:

Many studies have explored personal values in nursing, but none has assessed whether the predictions made by the theory of intergenerational value change are true for the different generations of nursing professionals and students. This theory predicts a shift in those personal values held by younger generations towards ones focussed on self-expression.

Research question:

The purpose of the study was to identify intergenerational differences in personal values among nursing professionals and nursing students and to determine whether generational value profiles fit the predictions made by the theory.

Research design:

An exploratory comparative design with a cross-sectional survey method was used.

Participants and research context:

Participants were recruited from four public hospitals and 10 Primary Care Centres in medium-size cities in Spain. A sample of 589 nurses and 2295 nursing students participated in the study. An open survey method was used to collect data that were classified grouping reported values into categories following a method of value lexicon construction and analysed by contingency tables with Pearson’s χ2 and standardized residuals.

Ethical considerations:

Approval to conduct the study was obtained from the Deans of the nursing schools and the Directors of Nursing of the institutions. Anonymity was guaranteed, participation was voluntary and participants were informed of the purpose of the study.

Findings:

The results can be synthesized in two age-related trends in the reporting of values among three groups of participants. First, among younger nurses and students, some nursing core values (e.g. ethical and professional) decreased in importance, while other values centred on social relationships and personal well-being increased.

Discussion and Conclusion:

This study shows intergenerational change in personal values among both nursing students and young nursing professionals. Findings suggest the need to pay more attention to value training and professional socialization during the schooling period.

Nursing's role in courage development in patients facing complications of diabetes

The purpose of this study was to explore the experience of nurses in relation to courage development in patients with disabling complications of diabetes. The phenomenon of courage has been explored in philosophy, theology, literature, and other fields of inquiry rooted in the humanities. Nursing inquiry has not often been directed toward an exploration of courage, although coping, compassion, caring, and other experiences integral to the nurse-patient relationship have been examined. The holistic view of the cascading effect of complications on the individual patient is often overlooked. This qualitative study used phenomenological inquiry and included face-to-face interviews of nurses to explore their experience in assisting patients in the development of courage. The experience of courage is investigated as it relates to a specific group of patients who have complications of diabetes. Four categories representing the unique opportunities for courage development by nurses were generated. These categories included education, advocacy, relationship building, and humanization. Each category described nursing intentions and actions and taken together formed an essential structure of courage development. Conclusions indicated that nurses recognize and are able to describe their role in courage development. Implications for improved health through deliberate caring nursing interventions, aimed at courage development, are presented.

Effectiveness of psychiatric mental health nurses: can we save the core of the profession in an economically constrained world?

Mental and behavioral disorders are common, affecting more than 25% of all people at some time during their lives. Mental disorders and their burden on society have increased dramatically. This scenario can be an opportunity for psychiatric/mental health (P/MH) nurses. Some literature shows gratifying experiences of care delivered by P/MH nurses, but that can also be a threat if, in a world with an economic dominance such as ours, we are not able to clarify our identity and effectiveness. One implication of this is that we need to identify the contribution of nursing to patient outcomes through nurses' independent, dependent, and interdependent roles. The authors stressed the importance of improving our accountability and fighting against invisibility to policy makers to prioritize the nurse-client relationship and identify our effectiveness. Based on some literature, the authors argue that clinical nurse specialists are in a better position than nurse practitioners to produce nursing-sensitive outcomes.

Seen as core: a Delphi consensus study of essential elements of mental health nursing care in Ireland

Continued ambiguity about the scope of mental health nursing is harmful to the discipline's identity and to patients' interests. Using a Delphi survey design, consensus was achieved on a set of 70 items representing core elements of mental health nursing among a sample of 150 mental health nurses working in Ireland. Items achieving consensus in Round 3 of the survey were composed of 28 clinical phenomena (framed as client problems), 18 direct and 12 indirect nursing interventions, and 12 nursing-sensitive outcomes of care. Mental health nurses accepted responsibility across a broad range of outcomes apart from those linked to physical care, the one domain of care rejected by participants. The findings portray mental health nursing as a psychosocial enterprise, encompassing both phenomenological and diagnosis-related elements.

Migrant Care Workers’ Relationships with Care Recipients, Colleagues and Employers

The literature on migrant care workers has tended to place little emphasis on the multiple relationships that migrant carers form with care recipients, employers/managers and work colleagues. This article makes a contribution to this emerging field, drawing on data from qualitative interviews carried out with 40 migrant care workers employed in the institutional and domiciliary care sectors in Dublin, Ireland. While the analysis revealed generally positive carer—care recipient relationships, significant racial and cultural tensions were evident within the vertical and especially the horizontal relationships in the care workplace. The article argues that these findings highlight the need for additional research on the relationships formed in the long-term care sector and further theorizing on the meaning and importance of the affective components of care work within increasingly commodified care markets.

Technologically-Mediated Nursing Care: the Impact on Moral Agency

Technology is pervasive and overwhelming in the intensive care setting. It has the power to inform and direct the nursing care of critically ill patients. Technology changes the moral and social dynamics within nurse—patient encounters. Nurses use technology as the main reference point to interpret and evaluate clinical patient outcomes. This shapes nurses’ understanding and the kind of care provided. Technology inserts itself between patients and nurses, thus distancing nurses from patients. This situates nurses into positions of power, granting them epistemic authority, which constrains them as moral agents. Technology serves to categorize and marginalize patients’ illness experience. In this article, moral agency is examined within the technologically-mediated context of the intensive care unit. Uncritical use of technology has a negative impact on patient care and nurses’ view of patients, thus limiting moral agency. Through examination of technology as it frames cardiac patients, it is demonstrated how technology changes the way nurses understand and conceptualize moral agency. This article offers a new perspective on the ethical discussion of technology and its impact on nurses’ moral agency. Employing reflective analysis using the technique of embodied reflection may help to ensure that patients remain at the centre of nurses’ moral practice. Embodied reflection invites nurses critically to examine how technology has reshaped conceptualization, understanding, and the underlying motivation governing nurses’ moral agency.

Ethical challenges in pain management post-surgery

This qualitative study describes ethical challenges faced by Iranian nurses in the process of pain management in surgical units. To address this issue, semistructured interviews were conducted with 26 nurses working in surgery units in three large university hospitals in Tehran. An analysis of the transcripts revealed three main categories: institutional limitations; nurses' proximity to and involvement with pain and suffering; and nurses' fallibility. Specific themes identified within the categories were: insufficient resources, medical hierarchy; difficulties with believing patients' complaints regarding pain and suffering; and experiencing the consequences of poor judgments. Our findings lead us to conclude that, as nurses are much closer to patients' pain and suffering than other health professionals, being aware of their ethical problems, and being able to reflect on them and discuss and learn from them, will reduce the burden of the ethical challenges faced. The findings will help nurses in other countries to devise suitable ways to reduce the ethical burdens they bear in their daily practice.

Engaging with a new reality: experiences of overseas minority ethnic nurses in the NHS

AIM AND OBJECTIVE

The purpose of this study was to explore, describe and develop a greater understanding of the experiences of overseas black and minority ethnic nurses in the National Health Service (NHS) in the south of England.

BACKGROUND

For the past five decades, the NHS has been recruiting overseas black and minority ethnic nurses from several former British colonies to alleviate the manpower shortages. More recently there has been a shortage of nurses in the labour force and as a result the NHS has once again recruited overseas nurses. Despite this recruitment drive there are limited studies outlining how overseas black and minority nurses have fared in the NHS.

METHODS

This qualitative phenomenological study used four purposeful focus groups and all participants involved were interviewed at a place convenient for them. These all non-white participants originated from Asia, Africa and the Caribbean. Each focus group contained six participants with an overall total of 24 participants involved in the study.

RESULTS

Following thematic analysis, the findings revealed six themes such as, the devaluation process, concept of self-blame, discrimination/lack of equal opportunity, concept of invisibility, experiencing fear and benefits of being here. Several overseas nurses felt devalued and indicated that white UK nurses appeared to have placed little trust in them. They stated that both discrimination and lack of equal opportunity were present in the workplace and they also revealed that some white UK nurses were sometimes abusive. As a result they tolerated such behaviour for fear of being thrown out with their families. Despite such negative experiences participants indicated that the experiences gained whilst working in the NHS were useful.

CONCLUSIONS

There is a need for overseas nurses to be treated fairly and with respect particularly in the light of an acute labour shortage of nurses in the NHS. The findings suggest that overseas minority ethnic nurses' experiences have been mixed, with some positive as well as negative experiences, within a process that devalues them as workers.

RELEVANCE TO CLINICAL PRACTICE

This paper highlights a need for a re-evaluation of equal opportunity policies and proposes more diversity training so as to prepare nurses to cope with an increasingly complex and diverse workforce.

A model to describe the relationship between knowledge, skill, and judgment in nursing practice

This paper explores the relationship between knowledge, skill, and judgment and proposes a model to describe that relationship. Through illustration of the components and interrelationships within this model one can more clearly understand the nature of nursing work. Drawing on Benner's work on novice to expert, the model shows the interrelationship and the evolution of knowledge, skill, and judgment in a nurse's practice.

Nursing is different than medicine: ethical difficulties in the process of care in surgical units

AIM

This paper describes a study of the kinds of ethical difficulties nurses face in the process of care in surgical units.

BACKGROUND

Nurses face ethically difficult situations in trying to find the most appropriate actions to take for patients. Differences of opinion with doctors about the treatment and care of patients and conflicts between nurses' value systems and those in the organization where they are employed are described as sources of ethical difficulty. Nurses experience moral distress when institutional constraints restrict them from carrying out appropriate moral actions.

METHODS

Ten female nurses working in surgical units at one university hospital in Norway were interviewed as part of a comprehensive investigation into the narratives of nurses and doctors about being in ethically difficult situations. The transcribed interview texts were subjected to a phenomenological-hermeneutic interpretation. The study was conducted during 2004.

FINDINGS

The main ethically difficult care situations described by the nurses concerned being open and honest, trusting patients' complaints, and creating limits to their involvement. Differences in opinion with doctors about the treatments, the absence of doctors in the unit and limited interest in holistic treatment and care resulted in nurses not receiving the medical orders they needed. A heavy workload, lack of time and staffing problems resulted in difficult ethical prioritizations and reduced standards of care. Shared rooms and beds in the corridors made it difficult to preserve patients' rights to privacy and confidentiality.

CONCLUSION

Interventions and investments are needed to improve the work environment of nurses, especially modifying the job constraints of the work environment. The moral responsibility for upholding the quality of care in surgical services and hospital performance should be more equally distributed between nurses, doctors and hospital managers. Discussions and collaboration between and within healthcare disciplines and managers should be initiated to establish shared moral understanding of the standards of care in hospitals.

What should other healthcare professions learn from nursing ethics

This paper analyses the question what other healthcare professions should learn from nursing ethics, e.g. what should medical ethics learn from nursing ethics. I first analyse and reject all strong versions of the claim that nursing ethics is unique, because nursing is a unique practice. I then move to the question of whether the link between nursing ethics and nursing theory can be a model for other areas of healthcare ethics. I provide an analysis of the possibility of creating a theory of medicine and find that there cannot be a theory of medicine, and I argue briefly that this finding is also applicable to nursing. If there cannot be a theory of nursing, this entails that nursing ethics cannot be justifiably based on such a theory. In the final section, I then analyse the success of nursing ethics in resisting certain of the vices of Anglo-American analytic ethics, in particular the reductionism and individualism that characterizes much of healthcare ethics. I conclude that other healthcare ethics could usefully learn from this aspect of nursing ethics.

Self-sacrifice, self-transcendence and nurses' professional self

In this paper I elaborate a notion of nurses' professional self as one who is attracted towards intrinsic value. My previous work in 2003 has shown how nurses, who see intrinsic value in their work, experience self-affirmation when they believe that they have made a difference to that which they see to have value. The aim of this work is to reveal a further aspect of nurses' professional self. I argue that nurses' desire towards that which they see to have intrinsic value, is a necessary and self-transcending aspect of a nurses' professional self. I argue further that nurses' desire towards intrinsic value inevitably involves their vulnerability. Nurses who see intrinsic value are shown to be vulnerable to self-sacrifice in their inclination to work for the good of their patients, at the expense of themselves. Yet an ability to transcend their self in this way remains a necessary aspect of a nurse's professional self, which requires nurture and support through nurse education.