Høst 2008, Nr. 3 Publikasjon Nr. 89 Volume/årgang 28

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SYKEPLEIERNES SAMARBEID I NORDEN SSN vård I NORDEN NORDIC JOURNAL OF NURSING RESEARCH 3. 2008 HØST 2008, NR. 3 PUBLIKASJON NR. 89 VOLUME/ÅRGANG 28 Redaksjonelt Ansvarlig redaktør Artikler Guðrún Kristjánsdóttir, PhD Vård i Nordens vitenskapelige artikler refereebedømmes. Vitenskapelige artikler skal ikke overskride 5.000 ord inkludert abstract, referanser, figurer og tabeller. Andre artikler/short papers som pilotstudier, metodeartikler og artikler om evidensbasert sykepleie o.l. skal ikke overskride 2.500 ord alt inklusive. Redaksjonskomité Lise Hounsgaard, Danmark PhD Lisbeth Fagerström, Finland, PhD Erla Kolbrún Svavarsdóttir, Island PhD Ida Torunn Bjørk, Norge Dr. polit Ole Söderhamn, Sverige PhD Vård i Norden Vård i Norden er et nordisk tidskrift som utgis av Sykepleiernes Samarbeid i Norden (SSN). Mål Vård i Norden formidler et bredt spekter av sykepleievitenskap og utvikling for å høyne standarden på sykepleien. Målgruppe Vård i Norden tilbyr sykepleiere fra de nordiske land å publisere vitenskapelige artikler og andre typer artikler på dansk, norsk, svensk og engelsk. Vård i Nordens målgruppe er både forskere og sykepleiere i klinisk praksis så vel som lærere og studenter i sykepleierutdanning på alle nivå. Komplett manuskriptveiledning finnes på Vård i Nordens hjemmeside www.vardinorden.org Refereegruppen består av 215 medlemmer fra de nordiske land. Refereegruppens sammensetning er under konstant vurdering for å sikre at den til enhver tid representerer den nødvendige og ønskede kompetanse. Refereeprosessen er dobbelt blind. Hver artikkel bedømmes av minst 2 av de personer som inngår i refereegruppen. Alle artikler indekseres og skal ha engelsk abstrakt og nøkkelord. Andre artikler, som har forskningsinteresse og relevans i forhold til sykepleiefagets utvikling, bedømmes bare av Vård i Nordens redaksjonskomité og redaktør. Innhold Vård i Norden publiserer i første rekke artikler som omhandler klinisk sykepleie/omvårdnad, sykepleiepraksis og utdanning. Andre typer artikler kan være pilotstudier, metodeartikler og artikler om evidensbasert sykepleie/vård. Også forfattere med annen bakgrunn er velkomne til å sende inn artikler for publisering dersom artiklene bidrar til kunnskapsutvikling innen sykepleie/omvårdnad. 2 VÅRD I NORDEN 3/2008. PUBL. NO. 89 VOL. 28 Redaksjon Vård i Norden Postboks 456 Sentrum Besøksadresse: Tollbugt. 22 0104 Oslo, Norge Telefon +47 22 04 33 04 +47 22 41 08 29 Marit Helgerud Telefax +47 22 04 32 80 e-mail: marit.helgerud@ sykepleierforbundet.no Alle artikler skal innsendes til redaksjonen elektronisk Vård i Nordens hjemmeside www.vardinorden.org www.vardinorden.no Abonnementskontor Vård i Norden Postboks 456 Sentrum NO-0104 Oslo, Norge vård I NORDEN Nordic Journal of Nursing Research Tlf.: +47 22 04 33 04 mail: medlemstjenester @sykepleierforbundet.no Birgitte K. Nyberg Faks: +47 22 04 31 10 Vård i Norden utkommer 4 ganger årlig. Abonnement Abonnementskategorier og abonnementspriser for 2008: Universitetsbibliotek kr. 5.000 Høgskolebibliotek kr. 2.500 Sykehusbibliotek/ Sykehus kr. 1.000 Enkeltabonnent online & papir kr. 300 Enkeltabonnement skal tegnes gjennom hjemmesiden For å få tilgang til Vård i Norden online brukes f.o.m. 2006 bare abonnementsnummer. Enkeltabonnement bare online kr. 150 Indeksering Studenter ASSIA, CINAHL/EBSCO, Swemed+, ArtikelSök 50% rabatt De tre første kategorier innebærer registrering av IP-adresser. Opplag Abonnement tegnes via hjemmesiden eller byrå. Layout Konti for innbetaling av abonnementsavgift: Danmark: BG Bank 9541-0007499841 Finland: SAMPO 800019-70732641 Norge: Den norske Bank/postgiro 7877.08.56808 Sverige: PostGirot 47 88 87-3 1.600 eksemplarer Allservice AS, N-4017 Stavanger Trykk Bryne Stavanger Offset ISSN: 0107-4083 Fotografisk, mekanisk eller annen form for gjengivelse eller mangfoldiggjørelse av dette tidsskrift eller deler av dette er ikke tillatt ifølge gjeldende lov om opphavsrett Redaksjonen avsluttet 15.09.08 Redaksjonelt 3 Editorial: Whom shall we serve? – Nursing care for building healthier nations Guðrún Kristjánsdóttir, redaktør Dear reader of Vård i Norden! Nursing is central to modern health care and requires a commited and appreciated profession applying its special knowledge and skills. The present issue of Vård i Norden (VIN) – The Nordic Journal of Nursing Research addresses several urgent issues concerning the fundamentals of the nursing profession. The quality of care, and patient safety are addressed in three papers (Andersson & Lindgren, p. 14; Storli, p. 19; Smith-Strøm & Thornes, p. 29). Professional role and role aquisition, and the importance of leadership for role performance and professionalism are the focus of the first two papers (Kansten, p. 4; Blegeberg, Blomberg, & Hedin, p. 9). Other papers address educational issues and issues of patient nurse interactions. All these issues are on the abstract call agenda of ICN’s 24th Quadrennial Congress: Building healthier nations, in Durban, South Africa at the end of June of 2009 (www.icn.ch/congress2009). The universal focus of nursing addressed in the present papers of our journal, and reflected in the conference agenda of ICN, shows the embedded public servant philosopy of the nursing profession. In the advocacy for the public good the authors of the present VIN papers wonder how the profession can do better in its role commitements and performance as well as educational standards, not to mention ensuring and promoting quality in health care delivery. In the face of organizational turmoil in health care systems and institutions one is paused by the shallow voice of the nursing profession in the Nordic Countries in advocating client rights to quality health care in terms of effectiveness, relevance, access, and equity, e.g. in relation to public debates about the ramification of privatization of care, and the recent battles for higher salaries. As health care is increasingly subjected to the laws of the market, the health professions will increasingly be serving the goals of managers and company owners, unless confidently clinging on to their committment to serving the public. Our journal challenges researchers to confront these changes with quality research to provide evidence for future development of health delivery systems serving individual and public health needs according to the mission of the nursing profession. Dr. Gudrún Kristjánsdóttir, Editor REDAKTØR GUDRÚN KRISTJÁNSDÓTTIR Sykepleievitenskap . Omvårdnadsforskning . Nursing Science The association between leadership behaviour and burnout among nursing personnel in health care Outi Kanste, PhD, RN, Researcher ABSTRACT The aim of the study was to explore the association between leadership behaviour and burnout among nursing personnel in health care. Surveys were sent to a random sample of 900 nurses and nurse managers in various health care organizations around Finland. Of these, 660 nurses responded (73%), 627 of whom were accepted for the final analysis. Leadership behaviour was measured with Multifactor Leadership Questionnaire (MLQ) and burnout with Maslach Burnout Inventory-Human Services Survey (MBI-HSS). Correlations and one-way ANOVA were used for statistical analysis. Nursing leadership is both positively and negatively associated with burnout among nursing personnel. Idealized influence, inspirational motivation, intellectual stimulation, individualized consideration and contingent reward were positively associated with personal accomplishment and negatively with emotional exhaustion and depersonalization. Active management-by-exception behaviour of the nurse manager may increase personal accomplishment. Passive management-by-exception and laissez-faire leadership were positively related to emotional exhaustion and depersonalization, while the connection to personal accomplishment was negative. Active and future-oriented transformational leadership and rewarding subordinates seem to protect from burnout. On the other hand, passive leadership behaviour is an exposing factor for burnout among nursing personnel. The findings can be used in leadership education in the area of health care and to promote work well-being. KEY WORDS: burnout, nursing leadership, nursing personnel Introduction 4 Nursing leadership is a central success factor in health care organizations when aiming for strategic goals of health care, because the field of health care is labour-intensive and based on powerful know-how. It is not insignificant how nurse supervisors lead their subordinates and how nurses feel about their work and behave with clients or patients. Leadership contributes to nearly everything that happens in the organizations. The multifactor leadership theory (1, 2) is perhaps the most widely used comprehensive theory of leadership that encompasses a range of leader behaviours. It represents nine leadership dimensions composed of five transformational leadership dimensions (attributed and behavioural idealized influence, inspirational motivation, intellectual stimulation and individualized consideration), three transactional leadership dimensions (contingent reward, active and passive management-byexception), and one nontransactional laissez-faire leadership dimension. Nursing profession is at a high risk for burnout, because nursing is typically stressful and emotionally demanding work. Nurses are repeatedly confronted with people’s needs, problems and suffering (3). The concept of burnout was introduced in the 1970s as a description of adverse reactions to work in human services. Perhaps the best-known multidimensional definition presents burnout as a syndrome of emotional exhaustion, depersonalization and reduced personal accomplishment. Emotional exhaustion is the key aspect of the syndrome, referring to feelings of being emotionally overextended and depleted of one’s emotional resources. Depersonalization involves negative, cynical, overly detached and impersonal attitudes and feelings towards other people. Finally, reduced personal accomplishment refers to a decline of feelings of competence and successful achievement in one’s work as well as to a tendency to evaluate oneself negatively, particularly regarding one’s work with other people (4, 5). Leadership and burnout have been mainly examined as separate elements, and not enough attention has been paid to the relationship between these phenomena. Only few studies have systematically addressed this question (6, 7). Furthermore, in earlier burnout research leader behaviour has been considered rather narrowly, such as social support, and not from the viewpoint of comprehensive and multidimensional VÅRD I NORDEN 3/2008. PUBL. NO. 89 VOL. 28 NO. 3 PP 4–8 theory of leadership. Prior research has underestimated leadership as a factor in the development of subordinate burnout, partly because of inadequate conceptualization and measurement of both the leadership and burnout concepts (6). In addition, the focus of empirical nursing leadership research has been in the United States, which is why comparable results are needed from other countries and cultures. The work environments associated with low levels of nurse burnout are those in which nurses have good support and feedback, job clarity, autonomy and low levels of complexity in their work, with managers with a social leadership style that covers the relational aspect of work, such as well-being and job satisfaction (8). Several studies have shown that sufficient social support from the supervisor protects nurses from burnout (3, 8). Supervisor consideration and initiating structure have been shown to be related to subordinate burnout. High consideration generally protects from burnout, but results concerning initiating structure are inconsistent (9–12). Transformational leadership and the quality of clinical supervision have shown to be related to low emotional exhaustion and depersonalization among staff in community mental health agencies (13). Stordeur et al. (7) found in their study among hospital nursing staff that stress from the physical and social environment, role ambiguity, and active-management-by-exception were associated with increased levels of emotional exhaustion, whereas transformational leadership and contingent reward did not influence emotional exhaustion. On the other hand, transformational leadership has been found to be negatively associated with staff burnout in mental health service teams, whereas passive management-by-exception and laissez-faire leadership were related to high burnout levels (14). Leithwood et al. (6) found that transformational leadership practices had a significant ameliorating effect on teacher burnout by enhancing teachers’ sense of personal accomplishment. Contingent reward may also ameliorate a reduced sense of personal accomplishment, whereas the effects of holding high performance expectations may exacerbate the sense of emotional exhaustion. Seltzer et al. (15) reported in a study among students that burnout is inversely related to transformational leadership facets and contingent reward. A team organization structure, charisma of the leader, intellectual stimulation, individualized consideration, rewarding and a clan culture are antecedents to a favourable work environment that leads to job satisfaction and less burnout (16). In summary, the analysis of previous studies showed that leadership has been considered rather traditionally as a two-dimensional construct composed of consideration and initiating structure (9–12). Some studies have failed to distinguish between the different subscales of multidimensional leadership (6, 15, 16). Burnout has also been measured as a unidimensional phenomenon (6, 9, 10, 11, 15), or only the emotional exhaustion subscale of burnout has been considered (7, 16). In some studies data have been collected from only one organization (7, 10), which puts the generalizability of the results in question. The purpose of this study was to investigate the association between leadership behaviour and burnout among nursing personnel from the multidimensional perspective of both leadership and burnout. The study was conducted form the viewpoint of nursing personnel working in different health care organizations. Methods Data collection Data were collected by a nationwide postal survey in two stages in 2001–2002. The study population consisted of nurses, public health nurses and head nurses who were in the register of the Finnish Nurses Association (FNA). The sample was gathered by using stratified random sampling. The study population was divided into four subgroups: (1) university, central and district hospitals, (2) health centres, (3) psychiatric hospitals and (4) private hospitals. These four subgroups were selected because most nurses work in these types of health care organizations. In addition, head nurses were included as a separate subgroup regardless of the type of organization they were working in. The purpose of the stratification was to obtain a greater degree of sample representativeness and to be able to include respondents from various types of health care organizations (Table I) (17). At the first stage of data collection, questionnaires were sent to 250 nurses drawn from the membership register by means of systematic sampling. 150 respondents were chosen from subgroup 1 and 100 from subgroup 2, because about half of the members of the FNA worked in subgroup 1 and about one fourth in subgroup 2. The aim of the first data round of collection was to evaluate the applicability of the membership register for research purposes, the adequacy of sampling and the internal consistencies of the instruments (pre-testing). The purpose of this evaluation was to ensure that the register and sampling made it possible to obtain a representative and nationwide random sample of nurses and nurse managers around Finland. At the second stage, questionnaires were sent to 550 nurses. Of them, 200 were chosen from subgroup 1, 150 from subgroup 2, 100 from subgroup 3 and 100 from subgroup 4. In addition, questionnaires were sent to 100 head nurses. Within the subgroups, systematic sampling was used. The data obtained at these two stages were combined as final data, because the first stage proved that the membership register was applicable for research purposes and the sampling was adequate, the internal consistencies of both the MLQ and the MBI-HSS subscales (Table II) were satisfactory (Cronbach’s alpha > 0.70), and no major changes were made to the instruments on the grounds of the pre-test. Only a few items had to be slightly modified. Questionnaires with pre-paid return envelopes were mailed to the respondents’ home addresses. In the first survey, the response rate was 54%. One repeat questionnaire was sent to the non-respondents three weeks after the first and second data collection stages. This increased the response rate to 73%. Overall, 660 questionnaires were returned: 187 after the first and 473 after the second data collection stage. Thirty-three were excluded from the final analysis because of missing values or the fact that the respondents did not work in the field of nursing. After the exclusion of these questionnaires, the sample consisted of 627 respondents. Measures Leadership behaviour was measured with the current version of the Multifactor Leadership Questionnaire (MLQ, form 5X-rater, Copy- right© 1995 by Bernard Bass and Bruce Avolio), which is one of the most widely used instruments to measure the Multifactor Leadership Theory (18–20). MLQ is a self-report measure that includes 78 items (Table II). The items have been designed to measure nine dimensions of leadership: attributed idealized influence, behavioural idealized influence, inspirational motivation, intellectual stimulation, individualized consideration (representing transformational leadership), contingent reward, active and passive management-by-exception (representing transactional leadership) and laissez-faire leadership (2, 18). Both nurses and head nurses evaluated the behaviour of their own immediate supervisor. A 5-point response scale ranging from 1 (not at all) to 5 (frequently, if not always) was used. The Maslach Burnout Inventory-Human Services Survey (MBIHSS, Copyright© 1981 by Christina Maslach and Susan E. Jackson) was used to assess burnout (5). The MBI-HSS has been shown to be the most valid and reliable multi-dimensional instrument for measuring burnout in human service work (21, 22). The MBI-HSS is a selfreport measure that includes 22 items (Table II). These items have been designed to measure the three subscales of burnout: emotional exhaustion, depersonalization and personal accomplishment. The Table I. Respondents’ background factors (n = 627) Background factor Work task Nurse Specially trained nurse Public health nurse or other title in nursing Nurse manager (e.g. head nurse) Gender Female Male Age 1) < 30 years 30–39 years 40–49 years ≥ 50 years Work experience in health care 2) < 5 years 5–20 years > 20 years Employment situation Permanent staff Temporary staff Temporarily out of nursing 3) Working hours Daytime work Two-shift work Three-shift work or night work Organization University hospital Central hospital District hospital Health centre or other municipal organization Psychiatric hospital or organization Private hospital or organization Work unit Inpatient ward Community health care Outpatient clinic Intensive care or operative unit Psychiatric unit f % 360 85 63 119 57 14 10 19 592 35 94 6 54 140 256 170 9 23 41 27 75 289 256 12 47 41 522 81 24 83 13 4 230 109 283 37 18 45 138 109 58 186 72 63 22 17 9 30 12 10 293 97 54 83 97 47 15 9 14 15 Note. 1) mean age 43.7 years (standard deviation 9 years, range 23–60), 2) mean work experience in health care 17.8 years (standard deviation 10 years, range 1–38), 3) maternity, parental, sick leave or unemployed. OUTI KANSTE 5 Sykepleievitenskap . Omvårdnadsforskning . Nursing Science Table II. Cronbach’s alpha coefficients and correlations among leadership dimensions and burnout subscales (n = 627) alpha items II (A) II (A) 0.88 8 1 II (B) IM IS IC CR MBEA MBEP II (B) 0.90 10 .81 1 IM 0.92 10 .83 .86 IS 0.91 10 .76 .82 .86 1 IC 0.94 9 .81 .78 .85 .80 CR 0.91 9 .81 .79 .85 .80 .87 1 MBEA 0.80 9 -.03 .09 -.03 .01 -.12 -.03 1 MBEP 0.78 5 -.62 -.55 -.62 -.55 -.64 -.57 .29 1 LF 0.90 8 -.69 -.68 -.72 -.66 -.72 -.65 .16 .80 LF EXH DEP PA 1 1 1 EXH 0.88 9 -.12 -.12 -.17 -.14 -.21 -.17 -.01 .22 .19 1 DEP 0.79 5 -.08 -.16 -.16 -.14 -.16 -.17 -.10 .15 .12 .48 1 PA 0.81 8 .08 .14 .12 .08 .07 .07 .19 -.10 -.09 -.05 -.24 1 Note. II (A) = Idealized influence (attributed), II (B) = Idealized influence (behaviour), IM = Inspirational motivation, IS = Intellectual stimulation, IC = Individualized consideration, CR = Contingent reward, MBEA = Active management-by-exception, MBEP = Passive managementby-exception, LF = Laissez-faire leadership, EXH = Emotional exhaustion, DEP = Depersonalization, PA = Personal accomplishment Correlations (Pearson product moment correlation coefficient) below 0.08 are non-significant (p > 0.05), those between 0.08 and 0.11 are significant at the p-value of < 0.05, those between 0.12 and 0.14 are significant at the p-value of < 0.01, whereas those equal to, or above 0.15 are significant at the p-value of < 0.001 response scale was a 7-point Likert scale indicating the frequency of experiencing each symptom (1 = never, 7 = every day). The terms patients/clients were substituted for recipients, which had been used in the original version of the MBI-HSS. The Finnish version of the MLQ and the MBI-HSS was developed based on a translation-backtranslation procedure. The original English versions were translated into Finnish and then backtranslated blindly into English by a Finnish translator. After that, the Finnish translator checked the equivalence of the two English versions of the instruments. The items of the Finnish instruments were formulated with the same contents as the items in the original ones, taking into account the cultural features of the Finnish health care system. The internal consistencies of both the leadership and burnout subscales were satisfactory, since Cronbach’s alpha met the generally acceptable minimum of 0.70 suggested by Nunnally (23) (Table II). Background information was collected using a 26-item researcher-developed instrument. Ethical considerations Before data collection, the Finnish Nurses Association gave permission to use information on its membership register. The questionnaire was accompanied by a covering letter that explained the purpose of the study, emphasized voluntary participation and guaranteed absolute confidentiality. The respondents were given an opportunity to contact the researcher by telephone or email if they had questions about the study. 6 Data analyses The data were analysed with statistical methods with the SPSS 11.0 (24). Descriptive statistics were used to summarize the background factors of the respondents (Table I). Sum variables were formed from the leadership and burnout variables by counting up the values of variables and dividing the sum by the number of variables (Table II). On the basis of the graphic representations (histogram and boxplot), it can be concluded that the sum variables were reasonably well described by a normal distribution. Distributions of the variables were symmetrical, so parametric methods could be used (17). Pearson product moment correlation coefficient was used to investigate the correlations between leadership dimensions and burnout subscales. The means of leadership dimensions were classified into three categories based on the incidence of leadership behaviour as follows: VÅRD I NORDEN 3/2008. PUBL. NO. 89 VOL. 28 NO. 3 PP 4–8 1.00–2.49 = extremely seldom, 2.50–3.49 = once in a while and 3.50–5.00 = often. The statistical significance of the differences between the groups in the mean values of burnout subscales was tested with one-way analysis of variance (one-way ANOVA). The post hoc multiple comparisons were examined with Scheffe’s test. P-values less than 0.05 were interpreted as being statistically significant. Findings More than half of the participants of the study were nurses, and most of them were women. Most of the respondents were permanent staff. Nearly half of them were in irregular three-shift work or night work. One third of the respondents worked in health centres or other municipal organizations and one fifth in university hospitals. Nearly half of the participants worked in inpatient wards in different medical specialities. The background factors of the respondents are shown in Table I. Transformational nursing leadership (comprising attributed and behavioural idealized influence, inspirational motivation, intellectual stimulation and individualized consideration) and contingent reward were positively associated with personal accomplishment and negatively associated with emotional exhaustion and depersonalization among nursing personnel. Passive management-by-exception and laissez-faire leadership were positively related to emotional exhaustion and depersonalization, whereas the connection to personal accomplishment was negative. Active management-by-exception of the nursing personnel was negatively related to depersonalization, whereas no connection with emotional exhaustion was found. Quite a surprising finding was that active management-by-exception was rather strongly associated with personal accomplishment (Table II). Similar results were found in one-way ANOVA, where the means of burnout subscales were examined according to all nine leadership dimensions. Emotional exhaustion among nursing personnel was minor when transformational leadership dimensions and contingent reward appeared often in the nurse manager’s leadership behaviour, as opposed to if these leadership behaviours appeared once in a while or extremely seldom. Regarding active management-by-exception the differences between groups were not statistically significant in one-way ANOVA. However, emotional exhaustion was stronger when the nurse manager often expressed passive management-byexception and laissez-faire leadership as compared to when these lea- dership behaviours appeared once in a while or extremely seldom (Table III). Depersonalization among nursing personnel was minor when behavioural idealized influence, inspirational motivation, intellectual stimulation, individualized consideration and contingent reward appeared often in the nurse manager’s leadership behaviour compared to situations where these leadership behaviours appeared once in a while or extremely seldom. Regarding attributed idealized influence and active management-by-exception the differences were not statistically significant in the group comparisons. On the other hand, depersonali- Table III. The means of burnout subscales according to leadership dimensions in one-way ANOVA (n = 627) zation among nursing staff was stronger when the nurse manager expressed often passive management-by-exception and laissez-faire leadership as opposed to when these leadership behaviours appeared extremely seldom (Table III). Personal accomplishment among nursing staff was stronger when behavioural idealized influence, inspirational motivation, intellectual stimulation, contingent reward and active management-by-exception appeared often in the nurse manager’s leadership behaviour than if these leadership behaviours appeared once in a while or extremely seldom. The differences were not statistically significant in the group comparisons regarding attributed idealized influence, individualized consideration, passive management-by-exception and laissez-faire leadership behaviours (Table III). Discussion Leadership dimensions Idealized influence (attributed) extremely seldom once in a while often Idealized influence (behaviour) extremely seldom once in a while often Inspirational motivation extremely seldom once in a while often Intellectual stimulation extremely seldom once in a while often Individualized consideration extremely seldom once in a while often Contingent reward extremely seldom once in a while often Active management-by-exception extremely seldom once in a while often Passive management-by-exception extremely seldom once in a while often Laissez-faire leadership extremely seldom once in a while often In total EXH mean p-value DEP mean p-value PA mean p-value 3.12 3.00 2.75 0.003 1.93 1.75 1.83 ns. 6.15 6.15 6.24 ns. 2.95 3.11 2.81 0.005 1.95 1.94 1.68 < 0.001 6.03 6.19 6.22 0.045 3.09 3.14 2.76 < 0.001 2.00 1.90 1.71 < 0.001 6.05 6.11 6.27 0.040 3.06 3.09 2.64 < 0.001 1.95 1.89 1.61 < 0.001 6.20 6.05 6.35 < 0.001 3.29 2.92 2.81 < 0.001 1.96 1.86 1.72 0.002 6.24 6.09 6.22 ns. 3.11 3.00 2.76 0.004 1.91 1.96 1.59 < 0.001 6.18 6.09 6.28 0.015 2.86 3.02 2.89 ns. 1.90 1.80 1.70 ns. 6.08 6.19 6.40 0.001 2.72 3.05 3.25 < 0.001 1.74 1.85 1.96 0.005 6.26 6.12 6.11 ns. 2.77 3.00 3.41 < 0.001 1.76 1.88 1.91 0.025 6.24 6.09 6.20 ns. 2.95 1.82 6.18 Note. EXH = Emotional exhaustion, DEP = Depersonalization, PA = Personal accomplishment, ns. p > 0.05 The results of this study suggest that transformational leadership behaviour comprising idealized influence, inspirational motivation, intellectual stimulation and individualized consideration as well as contingent reward were related to strong personal accomplishment and low emotional exhaustion and depersonalization among nursing personnel. Passive management-by-exception and laissez-faire leadership behaviour of the nurse managers were related to high emotional exhaustion and depersonalization as well as low personal accomplishment. Thus, the current findings are in line with previous studies (6, 7, 13–15) showing that nursing leadership has resonance for burnout among nursing personnel. Active management-by-exception of the manager was related to low depersonalization among nursing personnel. Quite a surprising finding was that active management-by-exception behaviour was rather strongly associated with personal accomplishment. Similar results have been found in studies concerning leadership from the traditional twodimensional point of view: both consideration and initiating structure have been found to be related to low burnout level (9–12). On the other hand, Stordeur et al. (7) have shown in their study that active management-by-exception among hospital nurses was significantly associated with increased levels of emotional exhaustion. Respectively, Seltzer et al. (15) have found that management-by-exception was positively associated with burnout in a sample of university students. Although active management-by-exception has been regarded as rather traditional leadership behaviour in multifactor leadership theory, according to the results of this study active monitoring of nurses’ work performance is still needed in health care organizations. This is important especially when supporting the feelings of personal accomplishment. Respectively, Garman et al. (25) have stated that an active management-byexception style may in fact be a distinct and necessary component of successful leadership in the area of health care, such as in mental health. The correlations between leadership behaviour and burnout subscales were rather low (range between -0.01 and 0.22), but the correlations were in line with previous studies (9–14). In addition, as Polit & Hungler (17) have stated, the correlations between variables of a psychosocial nature are typically in the 0.10 to 0.40 range. The results of this study indicate a significant, although modest, association between leadership behaviour and burnout among nursing personnel. In spite of the fact that the correlations were small, they do exist and are significant, and thus they highlight important implications for nursing practice. It seems that nurse managers play an important role in nurse burnout by the leadership behaviour they exhibit toward nursing personnel. The interventions aimed at preventing or reducing burnout may focus more than previously on the leadership behaviour of the nurse manager. This creates challenges for leadership education and training. It is recommended that nurse managers be trained to give their staff adequate feedback, social support, individualized consideration and encouragement to develop their know-how. As Kalimo et al. (26) have emphasized, the factors related to the social processes at work seem to be crucial to burnout. For instance, weaknesses in organizational climate and unrewarding work contribute to the development of burnout, which is also rooted in an individual’s lack of feeling of worth and competence. OUTI KANSTE 7 Sykepleievitenskap . Omvårdnadsforskning . Nursing Science However, the study is not without limitations. The findings are based on data from a cross-sectional study design which precludes any interpretation of potentially causal effects. A further limitation concerns the lack of objective measures of leadership behaviour and nurse burnout. Results are based on self-report measures that may lead to a social desirability response bias. This refers to the tendency of some participants to misrepresent their responses consistently by giving answers that are congruent with prevailing social norms (17). Nearly all the respondents and evaluated nurse managers were female. This arouses questions about the stability of the results in male populations. For this reason, making generalizations of the findings beyond this sample of nursing staff must be done with caution. However, based on their background information, the respondents represented well the study population. There was no statistically significant difference in participants’ mean ages (44 vs. 43 years) compared to another organizational study of members of the Finnish Nurses Association (27). The proportion of women was also nearly equal (94 vs. 98%). The central organization types were represented equally well in this study because the other study (27) found that about half of the nurses worked in university, central and district hospitals and one third in health centres or other municipal organizations. Despite these limitations, the results can be used in academic leadership education in the area of health care and leadership training in health care organizations, as well as to improve the quality of the world of work and to promote work well-being. Further research is needed to gather evidence of the effects of leadership on positive indicators of work well-being, such as empowerment and work engagement. Conclusions Nursing leadership is both positively and negatively associated with burnout among nursing personnel in health care. Active and futureoriented transformational leadership and rewarding subordinates seem to protect from burnout. These leadership behaviours protect from emotional exhaustion and depersonalization and increase personal accomplishment. Active management-by-exception behaviour of the nurse manager may increase personal accomplishment among nurses. On the other hand, passive leadership behaviour of the nurse manager, such as passive management-by-exception and laissez-faire leadership, are exposing factors for burnout, particularly emotional exhaustion and depersonalization, among nursing personnel. In today’s health care the qualities of a forward-looking transformational nurse manager are essential in successful nursing leadership, but traditional leadership behaviour such as rewarding and active monitoring of work performance is still needed. Acknowledgements This study was financially supported by a grant from the Emil Aaltonen foundation. Researcher will thank the Publisher, MIND GARDEN, Inc. for giving permission to use the Multifactor Leadership Questionnaire as well as Consulting Psychologists Press, Inc. for giving permission to use the Maslach Burnout Inventory (Human Services Survey). Accepted for publication 23.01.2007 Outi Kanste, PhD, RN, Researcher, Institute of Health Sciences, Department of Nursing and Health Administration, BOX 5300, 90014 University of Oulu, Finland. E-mail: [email protected] References 8 1. Bass BM. Leadership and performance beyond expectations. New York: Free Press, 1985. 2. Bass BM, Avolio BJ. Full range leadership development. Manual for the Multifactor Leadership Questionnaire. Redwood City: Mind Garden® Inc, 1997. VÅRD I NORDEN 3/2008. PUBL. NO. 89 VOL. 28 NO. 3 PP 4–8 3. Bakker AB, Killmer CH, Siegrist J, Schaufeli WB. Effort-reward imbalance and burnout among nurses. 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Transformational leadership: is it a source of more burnout and stress? Journal of Health and Human Resources Administration 1989; 12:174–185. 16. Schulz R, Greenley JR, Brown R. Organization, management, and client effects on staff burnout. Journal of Health and Social Behavior 1995; 36:333–345. 17. Polit DF, Hungler BP. Nursing Research: Principles and methods. Philadelphia: Lippincott, 1999. 18. Avolio BJ, Bass BM, Jung DI. MLQ – Multifactor Leadership Questionnaire. Technical Report. Redwood City: Mind Garden® Inc, 1995. 19. Den Hartog DN, Van Muijen JJ, Koopman PL. Transactional versus transformational leadership: an analysis of the MLQ. Journal of Occupational and Organizational Psychology 1997; 70:19–34. 20. Vandenberghe C, Stordeur S, D’hoore W. Transactional and transformational leadership in nursing: structural validity and substantive relationships. European Journal of Psychological Assessment 2002; 18:16–29. 21. Evans BK, Fischer DG. The nature of burnout: a study of the three-factor model of burnout in human service and non-human service samples. Journal of Occupational and Organizational Psychology 1993; 66:29–38. 22. Schaufeli WB, van Dierendonck D. The construct validity of two burnout measures. Journal of Organizational Behavior 1993; 14:631–647. 23. Nunnally JC. Psychometric theory. New York: McGraw-Hill Book Company, 1978. 24. SPSS® Inc. SPSS® Base 11.0 for Windows User’s Guide. Chicago: SPSS® Inc, 2001. 25. Garman AN, Davis-Lenane D, Corrigan PW. Factor structure of the transformational leadership model in human service teams. Journal of Organizational Behavior 2003; 24:803–812. 26. Kalimo R, Pahkin K, Mutanen P, Toppinen-Tanner S. Staying well or burning out at work: work characteristics and personal resources as long-term predictors. Work & Stress 2003; 17:109–122. 27. Markkanen P, Montin L. Organization study. Finnish Nurses Association, handouts 1/2002, Helsinki, 2002. Sykepleievitenskap . Omvårdnadsforskning . Nursing Science Nurses conceptions of the professional role of operation theatre and psychiatric nurses Birgitt Blegeberg, RN, MNSc – Ann-Catrin Blomberg RNT, MNSc – Birgitta Hedelin RNT, PhD, Professor ABSTRACT The shortage of specialist trained nurses in the operating theatre and psychiatric care is a problem in Swedish health care. There is a great need for recruitment since in both areas nurses have a high average age and few students register in these specialties at university. The reason for the low interest for these specialties is not clear. The purpose of the study was to investigate nurses’ and nurse students’ conceptions of the professional role of operating theatre and psychiatric care nurses. A qualitative approach with phenomenographic method was used. Twelve nurses and four nurse students were interviewed. Three categories of conceptions within each specialty emerged. Operating theatre nurses’ professional role was perceived as: Dependent assistant, Responsible monitor and Fragmented nurse. Psychiatric nurses’ professional role was perceived as: Empathetic agent, Conscious diplomat and Fragmented nurse. The informants had difficulties in understanding the professional role in both fields. One conclusion is that the theoretical and clinical training in basic nurse education play an important role for choosing specialist training as operating theatre nurse or psychiatric nurse. KEYWORDS: Nurse specialist training, Operating theatre nurse, Psychiatric nurse, Phenomenography Introduction In Sweden there is a shortage of specialist trained nurses in operation and psychiatric care. The average age of these practising nurses will in the near future lead to an extended need for specialist trained nurses. Furthermore, many of the places in the educational programme are vacant due to a low number of applicants (1, 2). The shortage of operating theatre nurses is also an international problem. The deficiency had as early as 1992 reached a critical level in Great Britain (3). Both in Great Britain and the United States there is a shortage of operating theatre nurses due to an ageing workforce. One problem is that the student nurses have no opportunities for clinical training at an operating theatre in the basic nursing programme (4, 5, 6). A field study on a voluntary basis lasting two or three days is not enough for the students to gain insight into pre-, intra-, and post-surgery care to increase their interest for the speciality (7, 8). Different kinds of measures have been implemented to change the situation, both for nursing students (4) and practising nurses (5, 6). The lack of operating theatre nurses means that the nurses do not have the possibility to carry out patient-related care (9). Operating theatre nurses have been an unnoticed group. Both patients and nursing colleges have only a limited appreciation of perioperative nurses’ contribution (10). The preconceived ideas are that the operating theatre nurse only assists the surgeon, has no contact with patients, and that the profession is considered as technical (9,10). The shortage of psychiatric nurses in Sweden is also problematic. During the last 10 years the tasks for special trained nurses have alternated related to organisational changes. Psychiatric nurses’ work field has increased from working in specialist care in hospitals to working in the community psychiatric services and in patients’ homes (1, 2). Major problems in recruitment is also an international problem (11, 12). Psychiatric nurses are providing care to service users of all age groups and in all settings as liason to obstectric and gynaecological practice (13), a behavioural health service to public school settings (14) and people on long-term sick-leave in primary health care (15). Nurses and nurse students have little and often incorrect knowledge about psychiatric care. The lack of or too short clinical training makes it difficult for them to get a true picture of the professional role (16). Rhodes and Bouic (17) argue that the student nurses before their clinical training often have a fear of mentally-ill patients, which makes it hard to grasp the professional role. Chang and Cheng (18) point out that nurse students have to get an understanding of psychiatric care as a whole, and especially of the professional role of the psychiatric nurse, in order to create an interest in the area. More administrative work, training and support to various levels of nurses has led to decreased possibilities for psychiatric nurses to exercise their special competence in caring for the patient (11, 19). The two nurse specialities have different approaches that underlie their actions and possess a body of knowledge that distinguishes them from each other and from the professional role of other nurses (cf. 1, 2). Based on this background it is of vital importance to gain a deeper understanding of nurses’ understanding of these specialities. The aim of this study was to investigate nurses’ and student nurses’ conceptions of the specialist nurses’ professional role in the operation theatre and psychiatric care. Method The study has a qualitative and explorative approach. A phenomenographic approach was chosen as we wanted to acquire qualitatively different conceptions of the phenomenon under study (c.f. 20, 21). The main purpose of the phenomenographic approach is to describe how phenomena or objects are conceived by humans. This means that the interest is directed towards experiences and meanings instead of explanations, connections or frequencies (22, 23). Differences in conceptions are based on the individuals’ different experiences related to phenomena in the world, and conceptions vary not only between individuals but also within the individual over time (20). Obtaining personal conceptions of phenomena are often made in an unconscious way. Phenomenography focuses on how a person conceives a phenomenon in the surrounding world, «the second-order perspective». How a phenomenon «really is» is called «the first-order perspective» (20, 21), but this is not the focus in this study. Informants The informants were registered nurses without specialist training and student nurses. In order to achieve as broad and varied description as possible the informants were chosen purposefully. Inclusion criteria were that the nurses had graduated six, four and two years before data BIRGITT BLEGEBERG, ANN-CATRIN BLOMBERG OG BIRGITTA HEDELIN 9 Sykepleievitenskap . Omvårdnadsforskning . Nursing Science gathering and the student nurses were in the last semester. From each group four informants were chosen. The student database in a university in western central Sweden was used to search for informants on the basis of age, sex and working in different districts in the council. An exclusion criterion was that no informant should be personally known to the researchers in advance. In total 16 informants, 13 women and three men, 21 to 49 years of age, were included in the study. Ethical considerations The participation of the nurses and student nurses was voluntary. The informants were told that they could withdraw from the study at any time and that their integrity would be respected. Quotes in the text are presented in such a way that the person’s identity is protected. During the period of work only the authors have had access to the material. The ethical principles for caring science in the Nordic countries (24) were followed. Data collection The informants were contacted by telephone and asked for consent to participate in the study. The aim of the study was explained to them and the time and place for the interviews was agreed upon. The data were collected by open interviews by two of the authors (ACB, BB). Each interview lasted 30 – 45 minutes and was based on the following questions: How do you conceive the professional role of the operating theatre nurse? How do you conceive the professional role of the psychiatric nurse? By using open questions we wanted to capture deeply-rooted conceptions instead of superficial opinions. We tried not to take anything for granted, but asked follow-up questions and made comments to make the informant tell more, explain and preferably also give examples (cf. 20, 21, 22). The first two authors made eight audio-taped interviews each. Before the data collection started, two pilot interviews were carried out to test the interview questions but these interviews were not included in the findings. The questions were found to be relevant and useful for the study. Data analyses In the data analysis the steps below were followed: 1. The interviews were typed out verbatim by the interviewers and the transcriptions were read through by all authors to establish an overall impression. 2. Statements related to how the informants conceived the specialist nurses’ professional roles were searched for. 3. Similarities and differences in the statements were colour- marked in the text and constituted preliminary conceptions. 4. The preliminary conceptions were taken out of their context and attention was focused on the statements per se. They were revised to be as qualitatively separate as possible. 5. Conceptions that showed qualitative similarities were labelled and summarised into a descriptive category. 6. Finally, the conceptions were grouped into six descriptive categories, three categories for each specialist nurse’s professional role, and in all 13 subcategories. Table 1: Descriptive categories and subcategories related to conceptions of the operating theatre nurses’ professional role. The operating theatre nurse’s professional role Dependent assistant • Standing passing tools • Fixed in space and time Responsible monitor • Being well prepared • Keeping things in place • Securing the operation area 10 Fragmented nurse • Giving incomplete care • Having no relation to patients VÅRD I NORDEN 3/2008. PUBL. NO. 89 VOL. 28 NO. 3 PP 9–13 Findings The operating theatre nurse was conceived as being a dependent assistant, a responsible monitor and a fragmented nurse. These three descriptive categories were built on seven subcategories which are described below and elucidated by quotations from the interviews (see table 1.) The operating theatre nurse Dependent assistant The dependent assistant was described as the doctor’s assistant, «tied to the operating table». The conception was based on two subcategories: standing passing tools and fixed in space and time. Standing passing tools The major function of the dependent assistant was to pass tools to the surgeon. The assistants were dependent on the doctor’s request and had few opportunities to influence their own work. Even though the work demanded high concentration it was seen as a dull routine work with lots of stereotyped tasks. Fixed in space and time The dependent assistant’s work was described as standing in the same place for hours without replacement. They had few opportunities to move or leave the operating table during the operation. Because of the locked position the work was seen as being physically demanding. Oh my God, it’s hard work standing still on the same spot during the operation, listening to what they [ the surgeons] say and giving them the things they want. I think it seems to be monotonous … one appendix or gall bladder is like any other … Responsible monitor The responsible monitor had a precise planning and overall hygienic responsibility during the operation which demanded a specific knowledge. The conception was based on three subcategories: being well prepared, keeping things in place and securing the operation area. Being well prepared The responsible monitor was described as an important link in the operating team. The monitor was a driving force in the operation and was prepared for every stage of the operation. This precise planning meant that the responsible monitor would always be a step ahead of the surgeon, giving the right instrument at the right moment. A clever operating theatre nurse knows beforehand what the surgeon wants… Keeping things in place The responsible monitor was seen as orderly and meticulous, keeping everything in order, counting and checking all instruments, cloths and other material before, during, and after the surgery. This function was seen as specific for the operating theatre nurse. … they have the responsibility for all tools to be in place before the operation wound is sutured, so that nothing is left inside the patient…. Securing the operation area The responsible monitor’s task was to guard that the established hygienic rules were followed before and during the surgery. This involved the whole environment in the operating theatre as well as the instruments and other equipment during the operation. It’s only the operating theatre nurse who has this knowledge, concerning how to prepare the instruments, and keep the tools in order and count them carefully; yes you must be accurate. It’s the operating theatre nurse’s work to keep everything in order. Fragmented nurse The fragmented nurse was perceived as having a limited view, participating in the patient’s care only in connection with the operation. The conception was based on two subcategories: giving incomplete care and having no relation to patients. Giving incomplete care The nurse’s contribution to the caring process was incomplete. The nurse was not participating in the whole care of the patient as they were only focusing on the operation. As they did not follow the patient after the operation they had no possibility to evaluate the care given. They can’t follow how the patients are getting along and their recovery…. To meet and talk with them and try to do little extra for the individual patient, that’s the best thing about being a nurse Having no relation to patients The fragmented nurse was considered not to have any relationship to the patient and could thus not get the full picture of the situation. The patient was seen as an object in the high-technology environment and was disregarded as an individual. The patients in the operation theatre had sort of no identity, they were only seen as a body where something should be done. … It’s in some way impersonal…. The psychiatric nurse The psychiatric nurse was conceived as being an empathetic agent, a conscious diplomat and a fragmented nurse. These three descriptive categories were built on six subcategories which are described below and elucidated by quotations from the interviews (see table 2.) Empathetic agent An empathetic agent needs to possess a profound perceptive ability, have a great deal of patience and be a good listener to support and plan together with the patient. The conception was based on two subcategories: being attentive, sensitive and patient, and being a professional intermediary. Being attentive, sensitive and patient An empathetic agent was there for the sake of the patient. The nurse had many professional conversations and follow-ups with the patients and had to be able to understand non-verbal communication. To work with patients with mental ill-health problems demanded more patience compared with other patients. Yes, …to have the patience to listen, or the ability to listen to diffe- Table 2: Descriptive categories and subcategories related to conceptions psychiatric nurses’ professional role. The psychiatric nurse’s professional role Empathetic agent • Being attentive, sensitive and patient • Being a professional intermediary Conscious diplomat • Having a balanced attitude • Being a committed observer Fragmented nurse • Focusing on the mental perspective • Having an obscure function rent signals, I think the patients may say one thing and mean another. The nurse must be able to catch what’s going on Being a professional intermediary The professional intermediary was conceived as independent. They were often alone in assesing the patients’ condition and planning together with the patient, and they informed the doctor about this. The nurse acted as a link and an intermediary between the patient and the doctor. I think they have an independent task. They visit the patients in their homes so it’s their responsibility to assess how the patients are feeling… Conscious diplomat A conscious diplomat had to be aware of the fact that many strong feelings were involved in the contact with mental-health patients. This influenced the nurse’s relationship to and attitude towards the patient. The conception was based on two subcategories: having a balanced attitude and being a committed observer. Having a balanced attitude It was perceived as important to be aware of how to express oneself, as well as how and when the «right» questions should be asked. The importance of keeping one’s distance to the patients and their problems was stressed. ...... it’s important to be able to be objective and to keep your distance, to keep work and private life apart, … you have to consider carefully what you say and do so it doesn’t come out wrong Being a committed observer It required commitment and time from the psychiatric nurse to observe the patients as a basis for planning nursing interventions. This was seen as a central aspect of the professional function. I think it’s different in the psychiatric care … you need to have more time …sort of approaching the patients in an indirect way to catch what the problem is, to observe in order to understand how to help… Fragmented nurse The fragmented nurse was expected to view the patient only from the mental perspective. The conception was based on two subcategories: focusing on the mental perspective and having an obscure function. Focusing on the mental perspective While focusing on the mental perspective, the knowledge of somatic conditions and technical skills was lost. Seeing only the patients’ mental-health needs and problems led to a limited view. … if I were to work within the psychiatric care my nursing skills wouldn’t be useful, I’m afraid I’d lose them after a while. Having an obscure function The nurses’ obscure function made it difficult to understand their actual role. The nurses did not make any visible interventions but were only present in the ward. No demands seemed to be made on the staff or the patients. The nurses’ function seemed unclear and unstructured. During working hours the nurses were often occupied with some needlework, looking at TV or playing card with the patients. However, whether these tasks were included in the patients’ treatment plan was not clear. It’s hard to understand why the staff are doing what they do, or maybe I should say, not doing much Discussion The purpose of the study was to investigate the nurses’ and student nurses’ conceptions of specialist trained nurses’ professional role in the operation theatre and psychiatric care. A phenomenographic approach was chosen to capture different perceptions of the professional role which can be significant factors for nurses for choosing or not BIRGITT BLEGEBERG, ANN-CATRIN BLOMBERG OG BIRGITTA HEDELIN 11 Sykepleievitenskap . Omvårdnadsforskning . Nursing Science 12 choosing these specialist training programmes. The selection of informants was wide in order to obtain a large variation of perceptions, which has helped to reach our aim with the study. The findings show that the informants regarded the professional role of specialist trained nurses in the operation theatre and psychiatric care as poles apart. The operating theatre nurse was perceived as a dependent doctor’s assistant during surgery while the psychiatric nurse was perceived as an independent mediator between the patient and the doctor. The operation theatre nurses are in their profession characterised as responsible, meticulous and orderly during the operation. The psychiatric nurses’ professional knowledge was vague and difficult to understand, and no specific interventions were described. Both specialties were described as fragmented, however in very different ways. The operation theatre nurses reduced the patient to a body and an operation wound while the psychiatric nurse reduced the patient to a mental being without bodily needs. One perception of the operating theatre nurse in this study, as well as in other studies (cf. 9) was that the nurse’s main task was only to pass instruments during surgery. In reality the nursing activities involve a complex blend of practical actions based on professional knowledge and experience (25). The operating theatre nurse’s work was also perceived as important in the surgery team, based on specific knowledge in the field, although is was dull, monotonous and physically demanding. The informants’ perceptions were based on impressions related to their clinical training and visits to surgery wards. According Sampson (4), Trice et al (5) and Beyea (6) the students form their opinions on the basis of what they have seen during their visit to an operating theatre. Lack of knowledge of the professional role hindered them in reflecting over what the operating theatre nurse actually does during operation. Bull and Fitzgerald (10) emphasised that it is difficult to get other people to understand what the operating theatre nurse actually does and what makes it different from other professions in healthcare. The operating theatre nurse’s lack of an overall view of the patient’s care was thought to be a deficiency in the professional role. The nurse was considered as only meeting sedated or sleeping patients together with other professions. From that point of view the informants in this study considered it as impossible to develop a caring relationship to the patient. However, these brief meetings during which the nurse has to convey confidence have been pointed out as a unique feature for the operating theatre nurse (9). Introducing the perioperative dialogue as a method would mean continuity in patient care and increase the operating theatre nurse’s opportunity to develop a caring relationship to the patient. The significance of the perioperative working model for the professional role is also emphasised by other authors (26, 27). In this study the professional role of the psychiatric nurse seemed to be harder to grasp than the operating theatre nurses’ professional role. Rhodes and Bouic (17) state that defective knowledge and short theoretical and clinical training make it difficult for the student to get a true picture of mental health care. This is fortified by the informants’ perceptions of the psychiatric nurses’ role in this study. Furthermore it became evident that the students during their clinical training were often left alone with the patients and were not guided by the tutoring nurse in their communication with the patients. This can have contributed to the difficulty in understanding the content of psychiatric nursing. The psychiatric nurse’s way of behaving, sensitivity and patience, and being there for the sake of the patient were regarded as distinctive traits in the psychiatric nurse’s relationship with the patients. An empathetic and diplomatic ability was considered to be important in the relationship with mentally ill persons. A holistic and humanistic approach in psychiatric nursing, as described by Paterzon and Zderad (29) and Peplau (30) among others, seemed to have influenced the informants’ understanding. However, some of them had experienced the opposite during their basic training. They felt that the patients’ suffering was only seen from a psychiatric point of view and instead of talking with the patients at the ward, the nurses were busy playing cards or looking at TV. These contradictory experiences and expectations made the professional role of the psychiatric nurse unclear and confusing. VÅRD I NORDEN 3/2008. PUBL. NO. 89 VOL. 28 NO. 3 PP 9–13 In a study by Blegeberg and Blomberg (31) the lack of knowledge is a significant factor for not choosing a specialist training in these fields. This can be caused by too short clinical training during the basic nursing programme. According to Durkin (12) and Melrose & Shapiro (32), the clinical nursing staff and the tutoring nurses’ attitudes and behaviour towards the patients sets the tone for the students’ experiences of clinical training in psychiatric care, which can be of crucial importance to a later choice of specialist training. Sampson (4) argues that the purpose of the clinical training at operation theatre is to remove preconceptions and achieve knowledge of the operating theatre nurse’s professional role. Public opinion and the mass media can also have had a negative influence on the informants’ conceptions on both nurse specialities in this study. Methodological reflections In this study we were interested in examining how nurses and nurse students conceived the specialist nurses’ professional role in the operation theatre and psychiatric care. A second order perspective (21, 23) was chosen, focusing on how a person conceives a phenomenon in real life. Validity in a phenomenographic study is dependent on to what extent the descriptive categories represent the conceptions of the informants and the research question (33). Reliability is dependent on the fact that a bystander is able to identify the descriptive categories in the data. The ability to communicate the results must be tested by an outside auditor (33). The task of the auditor is to check that the categories agree with the information given in the interviews and not with the researchers’ preconceptions. During the analysis all three authors were working together and scrutinised the data and the evolving system of categories. The category systems were also presented to active nurses, with and without these specialties. The nurses considered the categories to be relevant, applicable and of importance for the studied group (cf. 34). Implications for nursing education and clinical practice With regard to the large recruitment problems within the specialties operation theatre and psychiatric nursing, this study brings out factors that can be of vital importance for future recruitment of specialist trained nurses. Based on this study some recommendations can be made: – essential improvements must be made to inform the nursing students in basic theoretical and clinical training about salient features in different nursing specialty roles. – major improvements must be made to inform nurses about the operation theatre and psychiatric nurses’ professional roles. Accepted for publication 20.06.2008 Birgitt Blegeberg, Akershus university hospital, Stensby, NO-1478 Lörenskog Ann-Catrin Blomberg, Karlstads university, Faculty of Social and Life Sciences, Department of Nursing, SE-651 88 Karlstad [email protected] Birgitta Hedelin, Gjövik university college, Department of Nursing, NO – 2802 Gjövik and Karlstads university, Faculty of Social and Life Sciences, Department of Nursing, SE-651 88 Karlstad Correspondence: Ann-Catrin Blomberg, email [email protected] Acknowledgement We would like to thank professor Barbro Arvidsson, Gjøvik university college, Norway, for valuable comments concerning the phenomenographic method. References 1. Sveriges Kommuner och Landsting. Varför utbildas så få? Planeringsstöd Specialistsjuksköterskor inför «generationsskiftet». 2007a www.skl.se 2. Sveriges Kommuner och Landsting. Vilken utbildning och kompetens behövs? Tillgång på specialistsjuksköterskor. 2007b www.skl.se 3. Mehigan S. Future practitioner. 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Journal of Advanced Nursing 1999;30:1451–1458. 33. Alexandersson, M. Den fenomenografiska forskningsansatsens fokus. (The phenomenographic approache in focus.) In Starrin, B. and Svensson, P-G. (eds) Kvalitativ metod och vetenskapsteori. (Qualitative methods and theory of science). Lund: Studentlitteratur, 1994:111–136. 34. Sandelowski M. The problem of rigor in qualitative research. Advances in Nursing Science, 1986;8:27–37. BIRGITT BLEGEBERG, ANN-CATRIN BLOMBERG OG BIRGITTA HEDELIN 13 Sykepleievitenskap . Omvårdnadsforskning . Nursing Science The Karen instruments for measuring quality of nursing care. Item analysis Inger S. Andersson, RN, BNc, PhD, Associate Researcher – Margareta Lindgren, RN, PhD, Senior Lecturer ABSTRACT Aim: To determine the discriminative power of the Karen-patient and the Karen-personnel instruments for measuring quality of care, and to reduce the number of items. The aim was also to test the internal consistency. Background: Well tested instruments for measuring quality of care, including both the patient- and the personnel perspective, is needed in nursing care. A model was developed, called the KISAAL-system, from which the two instruments used in this study derived from. Methods: The instruments Karen-patient and Karen-personnel were examined for discriminative power using Likert’s method for analysis and Cronbach’s alpha coefficient for measuring internal consistency. Results: The item analyses resulted in a reduction of 39 items in the Karen-patient instrument and 27 items in the Karen-personnel instrument. Thus, thirty five items remained in both instruments, considered a manageable number. The internal consistency was 0.86 for Karen-patient and 0.88 for Karen- personnel. The remaining items correspond with the original instruments. Conclusion: After performing the analysis the remaining items in both instrument discriminated well and the reliability was good. The contents in both scales correspond with the original items and have been reduced to a suitable number to handle in clinical practice. The development of the instruments will continue testing the construct validity. KEY WORDS: Quality of care, the Karen instruments, instrument development, patient’s perspective, personnel’s perspective Introduction 14 The present study has its roots in the need to measure and evaluate quality of care, especially at a time when resources allocated to health and medical care is being limited. This is of concern for many groups in the society, but perhaps most of all for patients, hospital staff and politicians. There are, principally, two ways of developing an instrument: to construct a new one or to adopt one that already exists. This study is a part of a major project aimed to develop instruments for measuring quality of nursing care. As a concept, quality of care is complex and multidimensional. It can be seen from different perspectives: that of the patient/consumer, the organisation, the professional or the researcher. Quality as a concept is neutral, but the perception of quality is evaluative: good or bad quality (1). Quality of care has been given different meanings in the literature (2), although the definitions are many and different meanings are ascribed to the concept. The core of a quality definition is the balance of health benefits and risks (3). It is necessary to first specify what quality of care is in the context in which it should bee used and to define the concept before using it (4). The concept of care quality in this study is equivalent to that of Donabedian including effectiveness, access, equity and relevance (5, 6). The best known and most thoroughly tested instruments for measuring the quality of nursing care have been developed in the USA, e.g. the Rush Medicus Nursing Process Quality Monitoring Instrument (RMI-MSV) developed by Jelenik et. al. in 1975 (7). These instruments has been translated, modified and tested in several countries (8, 9). A Swedish version of the RMI-MSV instrument has been modified and tested by Götherström et. al. in 1994 (10). It is designed to measure process quality. Other instruments have been designed to measure structural quality, such as the Slater Nursing Competencies Rating Scale, developed by Wandelt & Slater in 1975, which measures nurses’ competence (11). A number of instruments have been developed to measure the quality of the result/the outcome of the care. Result or outcome from a patient perspective focuses on e.g. cure, restoration of function, (and/or relief) wellbeing, health, quality of life, patient satisfaction and patients safety (12, 13). One way of measuring outcome quality is to measure the fulfilment of goals and the goal for nursing is health (12). One example of such an instrument, developed by King is the «Goal Attainment Tool» (14). Instruments developed in the Scandinavian countries are the GNCS-P- (Good Nursing Care Scale for patients), the QPP- (Quality VÅRD I NORDEN 3/2008. PUBL. NO. 89 VOL. 28 NO. 3 PP 14–18 from Patients Perspective) and the PaPeR (Patients Perspective on Care and Rehabilitation) instrument. These instruments have a patient’s perspective of quality of care (15, 16, 17, 18). However, the instruments Karen-patient and Karen-personnel, developed by Andersson in 1995, provides the possibility of measuring and comparing the patients’ and the personnel’s opinion of the quality of the care given (1). Some of the instruments mentioned have an American view of nursing and quality of care, and with American culture as their point of departure. Given this, it is vital to develop instruments which are grounded in the conditions that affect health and nursing care in Sweden, i.e. instruments based on the view of the quality of care that is found among patients, hospital staff, those who are most involved in the quality of care (1). The development of a new instrument started in spite of already existing instruments, Andersson’s intention was that an instrument should have its roots in Swedish culture and from the environment in which it is to be used. It is of major importance that both patients and staff are able to express their opinions of the quality of care, and to be able to compare these opinions (1). The KISAAL – system, A model of quality of care In a study Andersson’s presented a system for measuring quality of care named the KISAAL-system. The system was based on thematic interviews with the three interest groups: patients, personnel and politicians. The questions in the interview guide concerned seven areas: the meaning of the concept quality of care, factors influencing the quality of care, important aspects of care, the meaning of health and quality of life, the goals of nursing care, quality of care related to selfcare and factors increasing the quality of care (1). The question areas chosen and the formulation of questions in the interview guide were inspired by Donabedian and Kitson (20, 19). The interviews were analysed inductively, using qualitative and quantitative content analyses and thereafter divided into six groups of which the Karen group measures the quality of nursing care. These six groups can be related to each other to facilitate a total assessment of the quality of nursing care and its management. The Karen group is the focus in the system and is described below (1). Development of the Karen group – content validation The content in the Karen group can be stated in brief. The main focus in the perception of quality of care was, firstly, the quality off the staff, emphasising their characteristics and skills. Secondly, quality in implementing care, involving care measures of an affective nature and the quality of patient – staff relationship. Thirdly the patient- related quality results, consisting of such changes in the patient’s health status, such as a cure or a change in health; cognitively oriented results like better knowledge about one’s condition; wellbeing as a result of care; satisfaction with the care and treatment provided, and with the staff. One hundred and thirty-four statements were formulated with the content in the Karen group as a base. This statement constitutes items and 58 of them were formulated from the patients’ point of view, 46 from the staff’s and 30 from both patients’ and staff’s point of view regarding their perception of the quality of care, expressed in the interviews study (1). The items were also formulated as negative and positive statements according to Likert (21) and divided into the StructureProcess-Outcome quality, the S-P-O triad, according to Donabedian (4, 22). A content validation took place to determinate the content relevance of items. It focuses on assessment of judgements systematically provided by experts (23). The 134 items were compiled in a questionnaire and a group of 193 nurses were asked to judge the relevance of each and every item to the quality of care. According to the model used a large number of items could be Table 1. Items included in the Karen-patient instrument, after performing discrimination discarded (1). The rest of the items were analysis and face validity further developed in this study. Item Formulation Similar Difference positive/negative content MH-ML > 1.00 Structure quality 3. The staff has the capability of vivid realisation 4. The staff shows no consideration 6. The staff shows no interest 7. The staff is calm, assured 9. The staff shows no commitment 10. The staff is nice, kind, happy, good 11. The art on the walls makes me depressed* 13. Here are so many staff categories* 14. There is orderliness on this ward* 16. Here are so many different staff members that take care of me 17. I have a nurse of my own that is responsible for my care 18. I have not got to know the staff 20. There is a positive atmosphere on this ward Process quality 23. Hear they are able to find out what’s wrong, to diagnose 24. I do not receive the help/care I need 25. I get to learn about my illness 26. I do not receive any information about my treatment 28. The staff is able to motivate, stimulate, encourage the patients 30. The staff makes the patients calm 32. The staff shows no tact or dignity 34. The staff treats me with respect 35. Here one receives an individual and personal treatment and is well taken care of 37. My care is planned together with the staff Outcome quality 52. I was quickly relieved from my suffering 53. I have not received the help I needed 55. Now I can go home and work with what I usually do 56. Now I can soon go home and take care Of my self 57. I have not received help to live with my illness 59. I have become healthier 61. I am not satisfied with my stay 63. I have been encouraged and can live with my illness 65. I feel that I have participated in, have been allowed to be a part of the decisions about my care/treatment 68. One sleeps well here 72. I am happy with the care/treatment 73. My expectations were not realised The study Pos Neg Neg Pos Neg Pos Neg Neg Pos x x x x x (x) x x 1.44 1.25 1.06 1.25 1.00 Neg 1.37 Pos Neg Pos 1.07 1.13 1.13 Pos Neg Pos x x Neg Neg Pos Neg Pos Pos Pos 1.13 1.06 1.50 1.32 x x x 1.13 1.19 1.06 1.06 1.07 1.81 Pos Neg 1.62 1.50 Pos 1.43 Pos Neg Pos Neg 1.18 1.50 1.37 1.38 Pos 1.19 Pos Pos Pos Neg 1.25 1.06 1.19 1.19 * items added after performing face validity (x) items no longer formulated similarly in the Karen-patient and Karen-personnel instruments Aim The aim of the study was to determine the discriminative power of the items in two instruments, Karen-patient and Karen-personnel and to reduce the number of items. A further aim was to test the internal consistency as a measure of reliability. Methods Participants A ward with patients treated for medical and surgical diseases was chosen. The study group comprised 64 patients who were discharged from a medicalsurgical ward and 42 personnel from the same ward. The inclusion criteria for the patients were: at least 18 years of age or older, and a hospital stay of at least 3 days. They were informed verbally and consecutively included by the clerk on the day of departure. Written information was added to the questionnaire, containing information about the study, the participation being voluntary. The patients were instructed to respond anonymously after departure to their homes. A total of 80 patients were asked if they wished to participate, of which 64 of them (80%) participated. The personnel were informed about the study in writing and at information meetings connected to the delivery of the questionnaire. The written information contained information about the aim of the study, the participation being voluntary, and telephone numbers of the researchers. Fifty members of staff were available for inclusion and 42 (84%) answered the questionnaire. Data collection This study was performed at a University Hospital and the data collection was completed in 1997. The items from the Karen group in the KISAAL system were put into two questionnaires; one aimed for patients and one for personnel. The items were graded on a 5-grade Likert scale. The respondents were asked to indicate their agreement with each staINGER S. ANDERSSON OG MARGARETA LINDGREN 15 Sykepleievitenskap . Omvårdnadsforskning . Nursing Science tement on the scale, from strongly agree to strongly disagree (21). Items were formulated as negative and positive statements according to Likert and divided into the S-P-O triad according to Donabedian (21, 4). Karen-patient The patient questionnaire comprised 74 items, of which 22 were related to structure quality, 29 to process quality and 23 related to outcome quality. Thirty eight items were positively formulated and 36 negatively. Karen-personnel The personnel questionnaire comprised 62 items, of which 24 were related to the structure quality, 12 to process quality and 26 related to outcome quality. Thirty-three items were positively formulated and 29 negatively. Twenty-three of the items, in both the patient and the personnel questionnaires, were similar regarding content. Data analysis Discrimination analysis of the two Karen-instruments was carried out in the following four steps by using Likert’s method. In the first step, the total sum of scores for all items, for each individual included, was calculated. In the second step, two extreme groups of respondents were selected, 25% of the individuals in each group. One group with the highest total score (H) and the other group with the lowest total score (L) were thus further analysed. In the third step the mean (M) for every item in the selected groups H and L was calculated, thus two mean values are obtained for each item, mean high (MH) and mean low (ML). The fourth step is to calculate the difference between MH and ML for each item. The difference between MH and ML is regarded as an expression of the discriminative power of each item (21). Cronbach’s Alpha Coefficient was used to measure the internal consistency of the Karen-patient and Karen-personnel questionnaire (24). The demographic data were analysed by mean values, standard deviation and range. Ethical consideration The study has been performed in accordance with the declaration of Helsinki and approved by the Research Ethics Committee of Faculty of Health Sciences, Linköping University, Sweden Results The study included 64 patients of whom 26 were men and 38 women. The mean age was 48.4 ± 16.9 years, with a range of 19 to 78. The mean length of hospitalisation was 12.5 ± 15.1 days, with a range of 3 to 83 days. Thirty-one of the patients had been treated on the same ward earlier. The number of participants in the personnel group was 42, of whom 3 were men and 38 were women. The personnel group consisted of 21 registered nurses and 21 nursing aids. The mean age was 41.9 ± 11.5, ranging was 25 to 63 years. Item analysis and discriminative power Karen-patient The high scoring group (HM) included 18 (25%) respondents and the low scoring group (LM) included 18 (25%) of the 64 patient respondents. After calculating MH-ML, 43 items with a mean difference < 1.00 were excluded and 31 items with a mean difference > 1.00 were retained in the new instrument. Approximately 30 items was considered to be a suitable number of items to be managed in the new instrument. For this reason, M > 1.00 was established (Table 1). 16 Karen-personnel The high (HM) scoring group consisted of 11 (25%) and the low scoring group of 11 (25%) of the 42 personnel respondents. After calculating MH-ML, 30 items with a mean difference < 1.00 were excluded and 32 items with a mean difference > 1.00 were retained in the new instrument. Approximately 30 items were considered to be a suitable number of items to be managed in the new instrument. For this reason M > 1.00 was established (Table 2). VÅRD I NORDEN 3/2008. PUBL. NO. 89 VOL. 28 NO. 3 PP 14–18 Face validity and Cronbach’s alpha Karen-patient Four items, with a mean difference < 1.0 were added after performing face validity, these four items were: No. 3 The staff has the capability of vivid realisation No. 11 The art on the walls makes me depressed No. 13 Here is so many categories of staff No. 14 There is orderliness on this ward In total, the Karen-patient instrument contains thirty-five items, of which, 12 items are similar to items included in the Karen-personnel instrument (Table 1). Karen-personnel After performing face validity, one item with a mean difference > 1.00 was excluded namely, number 15, (the art on the walls makes me depressed). Four items with a mean difference < 1.00 were added. These four items were: No. 4 The staff shows no consideration No. 6 The staff shows no interest No. 35 Are they able to find out what’s wrong, to diagnose? No. 39 The patients receive an individual treatment In total the Karen-personnel instrument contains thirty-five items of which 12 items are similar to items included in the Karen-patient instrument (Table 2). After reducing the number of items to 35 the Cronbach’s Alpha coefficient was 0.86 for the Karen-patient instrument and 0.88 for the Karen-personnel instrument. Discussion Instruments measuring quality of care, to be used in Sweden; should have its roots in Swedish culture and from the environment in which it is to be used. It is also of major importance that patients and care personnel, are able to give their views of the quality of care. Studies including all these categories make it possible to compare their opinions of quality. The instruments Karen-patient and Karen-personnel are new and developed for measuring quality of care. These instruments have been developed despite already existing instruments but the development has been performed with a different starting-point. At first, thematic interviews have been performed with patients and personnel. Then, the items included in the instruments have been generated from the statements in the interviews. It is also possible to make correlations between Structure- Process- and Outcome quality since the Donabedian S-P-O- triad constitutes the theoretical frame-work for the construction of the items included in the instruments. The opinion about the quality of care can be measured among patients and personnel and also be compared. Finally, the instruments are designed to measure quality of care and will point out the need for specific improvement in the quality of care. The grading system used in Karen-patient and Karen-personnel instruments is a 5-grade Likert-scale. The items included were formulated as statements according to Likert’s agreement scale, and the respondent’s answers agree or disagree in relation to the items. Half of the items are formulated positively and half of the items in a negative way, Likert motivates this as follows, «To avoid any space error to any tendency to a stereo typed response» (21 s 46). In addition, positively and negatively formulated items remained so the instrument is still to be looked upon as a Likert-scale. The content in remaining items correspond with the 74 items in the original scale, namely; the quality off the staff, emphasising their characteristics and skills, quality in implementing care, involving care measures of an affective nature and the quality of patient-staff relationship, the patient-related quality results, consisting of such changes in the patient’s health status such as a cure or a change in health; cognitively oriented results like better knowledge about one’s condition; wellbeing as a result of care, satisfaction with the care and treatment provided, and with the staff. Karen-patient can be compared with the QPP–instrument (17) and the GNCS-P (15, 16), which were developed at about the same time as the Karen-instruments. The comparison can also be made with a new instrument, the PePeR-instrument, developed specific for elderly patients (18). When comparing these instruments there are both similarities and differences. All four instruments have a theoretical model as base and the items formulated are inspired by interviews with patients. The items were designed to cover categories in theoretical models but are expressed differently in the instruments. To measure the quality of care, but actually measure patient satisfaction, and only from a patient perspective is insufficient. Patient’s satisfaction is one indicator in the complicated concept of care quality, and may depend on other factors, such as the patient’s expectations and experiences. The personnel’s opinion is not exami- ned as in the Karen-instruments and can not, therefore, be compared with that of the patients. In the Karen-personnel instrument, almost half of the items have been excluded. The remaining items in Structure quality concern the personal’s skills and characteristics. Items of psychosocial nature are also remaining. In Process-quality, remaining items are about affective care, psychosocial relations and influence. Items in Outcome quality were formulated from the personnel’s perspective and are about work satisfaction. In other words you can say that work satisfaction is a result of the personnel’s feeling of being satisfied with the patients and the care they are able to give to the patients. The content in the items in the Karen-patient instrument still correspond with the original instrument. Thus, the instrument can be used to measure quality of care. As in the Karen-patient instrument items formulated both positively and negatively remain, so the instrument still is to be Table 2. Items included in the Karen-personnel instrument after performing looked upon as a Likert-scale. The discrimination analysis and Face validity. remaining items in the two Karen instruments make it possible to compare perItem Formulation Similar Difference sonnel and patient opinions about strucpositive/negative content MH-ML > 1.00 ture and process-quality. However, no Structure quality similar items in the instruments related At this ward: to outcome quality remain, thus it is not possible to make comparisons related to 1. The staff is clever and skilful Pos (x) 1.36 outcome quality. The aspects of care that 4. The staff shows no consideration Neg x patients consider representing quality of 6. The staff shows no interest * Neg x care often differs from the aspects high7. The staff is not committed Neg x 1.36 lighted by professionals (25, 26). 9. The staff is calm, assured Pos x 1.36 The internal consistency was tested 10. The staff is nice, kind, happy, good Pos x 1.10 by using Cronbach’s alpha coefficient 13. We never learn anything new Neg 1.09 and resulted in 0.86 for the Karen-pati15. The art on the walls makes me depressed ** Neg (x) 1.90 ent- and 0.88 for Karen-personal instru17. There are so many staff categories Neg x 1.27 ment. The results are good since the 18. Their orderliness Pos x 1.10 Cronbach’s alpha coefficient should be 19. No one is responsible (it seems like) Neg 1.46 above 0.70 but probably not higher than 20. Every one performs the tasks routinely 0.90 (27). Since the scales were Likert without seeing the general picture Neg 1.70 scales, his method for analysis was 21. The staff collaborates Pos 1.93 used for testing the scales’ discrimina23. The patients get to know the staff Pos 1.19 tive power. Likert’s method was also 24. There is a positive atmosphere Pos x 1.60 considered to be favorable for the 25. All are able to talk to each other Pos 2.36 reduction of the number of items. 26. There is no enviousness Pos 2.00 27. We do not listen to each other Neg 2.00 28. We do not consider each other Neg 1.45 Conclusion 29. We cannot talk about the problem Neg 1.36 In conclusion, it can be stated that the 30. We all get on well together Pos 1.36 remaining items in both the Karen-pati32. There have been many economic savings ent and the Karen-personnel instrument that have affected the patients Neg 1.28 discriminated well after using Likerts Process quality analysis method. The reliability, i.e. the 35. Are they able to find out what’s wrong, to diagnose* Pos x internal consistency is good. Though 36. The staff is not able to motivate, stimulate, excluding a considerable number of encourage the patients Neg 1.01 items, the content in the items corres38. The staff makes the patients feel calm Pos x 1.19 ponds with the original items. The 39. The patients receive an individual treatment* Pos x items in both the Karen-patient and the 40. One gets no personal contact with the patients Neg 1.27 Karen-personnel instruments have been 43. The patient is involved in the treatment Pos x 1.82 reduced to a suitable number to handle 45. The patient has no say Neg 1.64 in clinical practice when examining Outcome quality care quality. The development of the 48. The work gives me satisfaction Pos 1.30 instruments will continue in a study to 49. I feel no work fellowship Neg 1.46 further testing the construct validity. 52. I do not feel secure in my work Neg 1.00 53. The work gives me a lot as a human being Pos 1.20 54. The work develops me as a human being Pos 1.19 Acknowledgements 56. I do not have the strength for the nursing task Neg 2.09 57. I feel harmony in the work Pos 1.00 The authors gratefully appreciate * items added after performing Face Validity ** item excluded after performing Face Validity (x) no longer similar formulated in The Karen-Patient and the Karen-personnel instrument grants from Linköping University and The Medical Research Council of Southeast Sweden no F96-461. INGER S. ANDERSSON OG MARGARETA LINDGREN 17 Sykepleievitenskap . Omvårdnadsforskning . Nursing Science Accepted for publication 13.02.2007 Inger S. Andersson RN, BNc, PhD. Associate Researcher & Margareta Lindgren RN, PhD. Senior Lecturer. Address for correspondence: Department of Medicine and Health, Division of Nursing Science, Faculty of Health Sciences, Linköpings Universitet, SE-581 85 Linköping, Sweden. Phone: +46 13 22 17 85, Fax: +46 13 12 32 85, [email protected], [email protected] References 18 1. Andersson I S. Utveckling av metoder för mätning av vårdkvalitet – med inriktning mot omvårdnad. (Developing Methods for Measuring Quality of Care – With Particular Emphasis on Nursing). Medical Dissertations 1995, 464, Department of Caring Science, Linköping University, Sweden (In Swedish). 2. Donabedian A. Evaluating the quality of medical care. Milbank Mem Fund Q 1966; 44:166–206. 3. Donabedian A. The quality of medical care: a concept in search of definition. Journal of Family Practice 1979; 9: 277–84. 4. Donabedian A. The quality of care: How can it be assessed? JAMA 1988;60: 1743–8. 5. Donabedian A. Exploration of Quality Assessment and Monitoring. 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A technique for measurement of attitudes (Dissertation). 1932 Faculty of Philosophy, Columbia University, New York. 22. Donabedian A. Some issues in evaluating the quality of nursing care. American journal of Public Health 1969; 59: 1833–36 23. Lynn M. Determination and quantification of content validity. Nursing Research 1986; 35: 382–385. 24. Cronbach L.J. Coefficient alpha and the internal structure of tests. Psychometrica 1951;3: 297–334. 25. Williams S.A. Quality and care: Patents’ perception. Journal of Nursing Care Quality 1998;12: 18–25. 26. von Essen L. and Sjödén P-O. The importance of nurse caring behaviors as perceived by Swedish hospital patients and nursing staff. International Journal of Nursing Studies 1991; 28: 267 – 81. 27. Streiner D, and Norman G. Health measurement scales. A practical guide to their development and use. 1995, 2nd ed. Oxford University Press. Oxford. Sykepleievitenskap . Omvårdnadsforskning . Nursing Science Feilmedisinering i sykehus – organisasjonskulturens påvirkning Marit Storli, Høgskolelektor/cand.polit MEDICAL ERRORS IN HOSPITAL – THE INFLUENCE OF ORGANIZATIONAL CULTURE ABSTRACT The belief that medical errors can be avoided by using sanction and punishment implements a neglect of the importance of developing safety systems. The culture within the health services will be of vital importance if the successful prevention of medical errors is to be achieved. This work based on four focus groups including 22 nurses from emergency wards in a hospital has given information how the organizational culture will affect the occurrence and reporting of medication errors. Individual perspective and personal responsibility is well incorporated and deeply rooted in the nursing culture, while understanding of the importance of systems and routines for patient safety in general may be improved. The understanding of incident reports as a preventive measure was underdeveloped. Self-reproach was a general response by the nurses if they had contributed to a medication error. Criticism of the system is more adequate than criticism of individuals since self-reproach only create defensiveness and blaming. Incident reporting systems should be free from negative consequences for those who report. The health services would be improved by developing security systems and changing the culture from blame to safety. KEY WORDS: Focus groups, Medication errors and nursing culture, Reporting as teaching aid. Bakgrunn og tidligere forskning I Norge er det stipulert at uheldige hendelser i helsevesenet fører til 2000 dødsfall og 15 000 skader i året (1). Et høyt antall uønskede hendelser er knyttet til legemiddelhåndtering (2, 3). Undersøkelser fra Norge og Sverige indikerer at legemiddelfeil forekommer hos 5 – 10 % av alle innleggelser i sykehus. Resultatene samsvarer med tilsvarende undersøkelser fra USA (4). Uheldige hendelser omfatter alle prosesser som har eller kunne fått et uønsket forløp eller gir et uønsket resultat for pasienten, uavhengig av om noe eller noen kan klandres for det (3). Dagens avanserte og kompliserte helsetjeneste har enorme terapeutiske muligheter, mens økt bruk av legemidler som injiseres direkte i blodbanen har et stort skadepotensial. Dersom en sykepleier administrerer feil legemiddel skjer en feilmedisinering. Hjort er en av pionerene innenfor arbeidet med uheldige hendelser i Norge. Han hevder det trengs en ny kultur for å håndtere og lære av uheldige hendelser i helsetjenesten. Det er et potensial for at ca. halvparten av hendelsene kan forebygges. Organisasjonskultur og underliggende praksis er viktige arbeidsområder for å bedre pasientsikkerheten da kulturen er avgjørende for hva helsepersonell gjør og hvordan de gjør det. En åpen kultur hvor medlemmene erkjenner at ingen organisasjon og ikke noe menneske er ufeilbarlig er av stor betydning (1, 3). Schein betrakter organisasjonskultur som et lært resultat av erfaringer i en gruppe eller sosial enhet og som felles oppfatninger av verden rundt. Kulturen har en stabiliserende og forutsigbar virkning, og medfører at organisasjonsmedlemmene vil beholde den selv om den er uhensiktsmessig og ikke oppfyller sentrale målsettinger. Hvordan lederen evner å påvirke kulturen i positiv retning er av avgjørende betydning (5). Busch betrakter den vestlige kulturen som en skyldkultur; mens det tidligere var kirken som var den skyldpåleggende instans, er det nå helsevesenet (6). En studie i sykehjem viste at ved å bedre kommunikasjonen og medarbeidernes deltakelse i beslutningsprosesser kan ledere øke den enkeltes ansvarsfølelse og evne til utvikle sikkerhetskultur i stedet for en skyldkultur (7). Reason skriver at alle handlinger i helsetjenesten springer ut av et system og en kultur og kan ikke sees isolert. Menneskelig feilbarlighet kan bli moderert, men kan aldri bli fjernet (8). Årsakene til uheldige hendelser er sammensatte og finnes som oftest i systemet. Eksempel på systemfeil kan være tidspress, ufull- stendig bemanning og kompetanse, dårlige rutiner og dårlig arbeidsmiljø (1). Walker (9) fant i en studie at redsel for sanksjoner og skadeomfang på pasient påvirket hvorvidt hendelsene ble rapportert. Sexton m.fl. (10) sammenlignet innvirkning av stress og tretthet hos helsepersonell i intensivbehandling og i luftfart. Mens piloter innrømmet og tok hensyn til at stress påvirker sikkerhet, innrømmet helsepersonell i liten grad at stress var et problem. En studie av nyutdannede sykepleiere i en norsk sykehusavdeling viste at læringsmiljøet manglet refleksjon og en åpen kritisk dialog. Det å stille spørsmål var mer til bryderi enn til gjensidig inspirasjon. Majoriteten oppfattet læring som et individuelt ansvar (11). Hensikt og problemstilling Allerede i 1992 påpekte Helsedirektoratet at bevisst bruk av erfaringer fra feil og uheldige hendelser kan bedre kvaliteten i helsevesenet (12). Forbedringsarbeid setter krav til organisasjonskulturen og bør kjennetegnes ved åpenhet, refleksjon og læring (13). Sykepleierne koordinerer mangfoldet av kontakter mellom pasient og behandlerteam. De har en sentral rolle i arbeidet med å oppdage og forebygge feil (14). Ledelsen vil kunne påvirke hvor trygt det er å rapportere og gi kulturelle normer for når det er tillatt å varsle. Gjennom å støtte varslerne (whistleblowers) bidrar ledelsen til å skape en sikkerhetskultur hvor det er naturlig å rapportere om feil (15). I forbindelse med min hovedfagsoppgave i helsevitenskap ble det foretatt en omfattende datainnsamling i 2002/2003 om ulike rammefaktorer som påvirker feilmedisinering hos sykepleiere. Sykehuset hvor undersøkelsen ble gjennomført utmerket seg ved lav avviksrapportering (16, 17). Organisasjonskulturelle faktorer kan ha betydning for rapportering og hvorvidt sykepleiere får mulighet til å lære av feilhandlinger. Denne artikkelen tar utgangspunkt i deler av datamaterialet fra undersøkelsen og har følgende problemstilling: Hvilke organisasjonskulturelle faktorer påvirker forekomsten av feilmedisinering og rapportering av disse i sykehus? Ut fra dette ble følgende forskningsspørsmål utformet: • Hva særpreger rutinebruk, kommunikasjon og samhandling ved legemiddelutdeling? • Hvilke reaksjoner er forbundet med å gjøre feil? • Hva er viktig for å unngå feilmedisinering? MARIT STORLI 19 Sykepleievitenskap . Omvårdnadsforskning . Nursing Science Metode Fokusgruppeintervju ble valgt som metode. Denne tilnærmingen er godt egnet for å lære om erfaringer og synspunkter i et miljø der mange mennesker samhandler, og kan derfor gi en god indikasjon på hvordan sykepleiere i sykehus oppfatter feilmedisineringsproblemet (18). Etiske vurderinger og tilgang til feltet Et motsetningsforhold kan oppstå i forbindelse med å forske på kvalitet i helsevesenet. På den ene siden står hensynet til å ivareta konfidensialitet og opprettholde tillit til intervjupersonene, mens det på den andre siden bør opplyses om kvalitetsbrist/risiko for pasientsikkerhet. Andre forskeres mulighet til å gjennomgå mine metoder og funn (reliabilitet og overførbarhet) innebærer at en må angi utvelgelse av informanter, noe som igjen kan svekke kravet til konfidensialitet (18, 19). Aktuelt sykehus ble kontaktet og det ble innhentet tillatelse til å gjennomføre intervjuene både fra ledelse og hovedtillitsvalgt. Informasjonsbrev med forespørsel om å delta i en diskusjonsgruppe og orientering om frivillig informert samtykke ble utsendt til utvalgte deltakere. Alle som deltok i undersøkelsen underskrev samtykkeerklæring. Datamaterialet ble oppbevart i låst skap. Avdelinger og informanter ble anonymisert, og jeg var spesielt oppmerksom på tekstbiter som kunne bidra til å henge ut avdelinger/poster. Medhjelpere som bidro i forbindelse med innsamling, transkripsjon eller bearbeiding av data underskrev taushetserklæring. Det ble det viktig å rekruttere deltakere som hadde relevante opplysninger om emnet. Avdelingene ble valgt strategisk med tanke på risiko for feilmedisinering og stort forbruk av høypotente legemidler, høyt tempo og mottak av øyeblikklig hjelp. Deltakerne fra de utvalgte postene ble valgt tilfeldig (20). På forhånd måtte antall fokusgrupper avtales for at de ansatte skulle få gjøre dette i arbeidstiden. Fire fokusgruppeintervju med åtte deltakere i hver ble planlagt gjennomført ut i fra anbefalinger fra metodelitteraturen (18, 21) og av hensyn til begrensede ressurser i prosjektet. Sykdom og travelhet i avdelingene medførte noe frafall, så følgende fokusintervju ble gjennomført: 20 Intervjuene ble tatt opp på lydbånd og transkribert så å si ordrett. Kommentarer til interaksjonen i gruppene ble skrevet i parentes. Hvert gruppeintervju varte fra 75 til 95 minutter og utgjorde fra 29 til 37 sider i utskrift. Transkripsjonene ble tilpasset skriftspråk i presentasjon av funn, og informantene ble kodet med fiktive navn. Dataanalyse Klassifisering av transkripsjonene i tematiske tekstbiter skjedde relativt åpent for å finne fram til de tema som ble oftest omtalt (meningsfortetning). Et mønster dannet seg i løpet av de 2–3 første gruppene, og den fjerde bekreftet mønsteret. I tillegg til at jeg selv klassifiserte intervjuene, klassifiserte to personer uavhengig av hverandre to intervju hver. Deretter ble tekstbitene organisert i hovedkategorier og underkategorier (18, 19). Kategoriseringen ble gjort med sideblikk til forskningsspørsmålene og intervjuguiden slik at kun valide data ble behandlet videre. Begrepet organisasjonskultur har vært utslagsgivende for hvilke hovedkategorier og underkategorier som behandles her (1, 5): Rutinebruk • formelle og uformelle sikkerhetstiltak Relasjoner • tverrfaglig samarbeid • lederstil Fortolkning • erkjennelse av rutiner og prosedyrer som sikkerhetstiltak • vektlegging av individuelle ferdigheter • reaksjoner og opplevelser ved feilmedisinering Presentasjon av funn Tilfeldige sikkerhetsrutiner mest brukt Dobbeltkontroll var den mest brukte sikkerhetsruinen for å forbygge feil, men det fantes sykepleiere som mente dette var sløsing med tid. Ved en avdeling resulterte misnøye fra hjelpepleierne i at de sluttet med dobbeltkontroll fordi dette tok for mye av sykepleiernes tid. Det var vanlig at intraGruppe 1 Gruppe 2 Gruppe 3 Gruppe 4 venøs medisin ble dobbeltsjekket, mens det 4 deltakere 7 deltakere 5 deltakere 6 deltakere Post var mindre kontroll med tabletter: Ortopedisk avd. 2 ulike sengeposter 1 2 Lise: Vi skjerper oss veldig når det er intravenøs medisin. Marginen er Kirurgisk avd. 3 ulike sengeposter 1 1 1 1 ganske liten, vi dobbeltsjekker Hjertemedisinsk avdeling, 3 ulike sengeposter 3 1 2 bestandig, mens på tabletter og Barneklinikk, 2 ulike sengeposter 1 2 1 «sup» er vi ikke så nøye på dobbeltAnestesi/intensiv/kuvøse (høyrisikoavdelinger) 2 1 1 1 sjekkinga. Hanna: Man har litt mindre respekt for når man gir tabletter da de ikke taes like Ansienniteten hos deltakerne varierte fra 1 1⁄2 til 37 1⁄2 år. Halvparten av fort opp i kroppen og får mindre kondeltakerne hadde ansiennitet mellom 2 1⁄2 og 4 1⁄2 år. sekvenser. Med utgangspunkt i forskningsspørsmålene ble det utarbeidet en intervjuguide, men ble bare delvis brukt fordi gruppediskusjonene fløt Eva fortalte om en ubehaglig episode hvor hun gav tilbakemelding til lett og produserte rikelig med data som var relevant for problemstilen kollega om en stikkpille som var satt i vagina i stedet for rektum. lingen (18, 19, 21). Kollegaen reagerte med å bli sint og sluttet å snakke med henne. Eva Relevante spørsmål for denne artikkelen var følgende: mente det hadde vært lettere å si fra dersom feilen hadde blitt oppda– Hvordan fungerer samarbeidet med legene i forbindelse med legeget som følge av sjekkrutiner. middelutdeling? Det fantes prosedyrer om utdeling av legemidler i sykehusets kvali– Hva skal til for at prosedyrer og rapporteringsrutiner brukes tetssystem. Disse ble lite brukt på grunn av utilgjengelighet og mangaktivt? elfull oppdatering. Olga innrømmet at hun «aldri hadde sett i de pro– Hva slags tilbakemeldinger fra kolleger og ledelse kan forventes sedyrebøkene om legemiddelhåndtering». Ingen av sykepleierne eller om dere gjør feil? andre som de kjente hadde blitt spurt om å være delaktig i utfor– Hva ville dere vært redd for dersom dere gjorde feil ved legemidmingen av prosedyrene. delutdeling? Sengepostene brukte å utarbeide egne spesialtilpassede prosedyrer, – Hva er viktig for at feil og avvik skal være et vanlig tema på posplansjer eller instruksjonslapper som var hengt opp på vaktrommet ten? eller på medisinskapet. Det var tilfeldig at de ble laget, og hvordan de ble laget. Sykepleierne fant dem hensiktsmessig og brukte dem hypJeg ledet selv fokusgruppeintervjuene og hadde i tilegg med en medpig, men de var bare unntaksvis godkjent og kunne betegnes som prohjelper. sedyrer. I en gruppe ble det fortalt at de brukte å pakke inn intravenøsVÅRD I NORDEN 3/2008. PUBL. NO. 89 VOL. 28 NO. 3 PP 19–23 slanger for å unngå forvekslinger hos pasienter som samtidig fikk sondeernæring. Hanna hadde følgende kommentar til slike former for tiltak: Ja vi er så fantastisk oppfinnsom som sykepleiere, vi lager egne løsninger, klipper av ender på slanger slik at de passer inn i hverandre. Er det tomt for noe, finner vi en midlertidig løsning siden det er sånt lavbudsjett på utstyr. Legen har ansvar og sykepleieren tar ansvar Selv om sykepleierne er en underordnet yrkesgruppe i forhold til legene ved legemiddel- håndtering, utførte de oppgavene med høy grad av autonomi og tok også ansvar for den delegerte oppgaven, noe denne diskusjonen viser: Gro: Dersom du tror at pasienten har behov for noe han har brukt hjemme, og foreslår det for legen, får du gehør og sjelden avslag. Åse: Men da ser en hvor mye ansvar sykepleieren har fått. Gro: Ja, du begir deg inn på et område du ikke har noe med. Anne: Men du samler deg jo erfaring. Vi har et ansvar overfor doktoren, ettersom vi gir pasientene det som han sier. Han må få tilbakemelding hvis det ikke går som forventa. Vi forsømmer vår rolle og pasienten kan komme til å lide hvis vi ikke tar tak i problemet. Vi ser andre ting enn doktoren som er innom få minutter i løpet av dagen Det var ikke uvanlig at sykepleierne fikk et spørsmål tilbake når de etterlyste foreskriving av et legemiddel: «Hva mener du da, hva bruker dere å gjøre her?» Noen leger overlot til sykepleierne å informere pasienten om at de var satt på nye legemidler. Utrykk som «vi må passe på legene», «vi må minne dem på ellers glemmer de» gikk igjen i diskusjonene, og skapte et visst inntrykk av en moderlig holdning ovenfor legene. Sykepleierne prøvde å bry legene minst mulig. Ved behov for medisinering om natta ble tilkalling av legene forsøkt unngått. I stedet prøvde sykepleierne å ordne opp på egen hånd for som Åse sa «– blir de tilkalt kan de bli litt småsure, men det går fort over». Uerfarne sykepleiere syntes det var vanskelig å be legen selv sette ukjente medisiner og opplevde å måtte takle mange situasjoner svært selvstendig. Lydighetsnormen var sterk og medførte at de hadde problemer med å sette grenser for egen kompetanse: Anna: En problemstilling når det gjelder feilmedisinering er at du blir bedt om å gjøre ting som du egentlig ikke er kompetent til. Åsa: I forbindelse med en akuttsituasjon hvor jeg ikke hadde mulighet til å slå opp, fikk jeg beskjed om å gi et preparat jeg ikke hadde vært borti. Det var mye, jeg trakk opp syv ampuller, den hestedosen på en bitte liten baby. Jeg visste ikke om det var lite eller mye? Måtte bare stå der og gi da. Da følte jeg at dette ikke var noe artig. Hovedinntrykket var likevel at det eksisterte et positivt samarbeid mellom lege og sykepleier. Legene overlot mye ansvar for standard legemiddelbehandling til sykepleierne og hadde ikke problemer med å anerkjenne sykepleiernes kliniske kompetanse. Lederstil som neglisjerer risiko? Hovedinntrykket var at økonomi fikk mye oppmerksomhet fra ledelsen, mens lite risikotenking ble synliggjort. Særlig gjaldt dette innkjøp av legemidler og tilhørende utstyr. Informasjon om nye legemidler kom i form rundskriv. Sykepleierne innordnet seg det som ble bestemt, selv om beslutningene gav dem mange frustrasjoner i hverdagen i form av økt risiko for forvekslinger og feilmedisinering. På en avdeling hadde sykepleierne «mast i mange år» om å få medisinrom. Til tross for at det representerte brudd på forskrifter i arbeidsmiljøloven om håndtering av antimikrobielle midler, ble det ikke prioritert fra ledelsen. Ved håndtering av feil ble det fortalt eksempler på mindre heldige tilbakemeldinger fra ledere. Tilbakemelding på feil eller episoder med alvorlig feilmedisinering ble gitt i plenum. Meningen var ikke å henge ut, men det ble svært tøft for de som fikk slike beskjeder i andres påhør. Det ble uttrykt misnøye vedrørende oppfølging av alvorlige feil siden de sjelden resulterte i permanente tiltak. Sykepleiene gav gjennomgående inntrykk av å ha liten tro på at de kunne påvirke beslutninger i sin egen organisasjon. Avviksrapportering oppfattes ikke som forbedringsverktøy Fokusgruppeintervjuene bar preg av sykepleiere med lite kjennskap til avviksmeldesystemet. Rita fra sengepost uttalte at hun: «– aldri har vært opp i situasjonen og skrevet avviksmeldinger selv, og jeg vet heller ikke om noen som har gjort det, så den prosedyren vet jeg ikke noe om» Det fremkom ingen opplysninger om opplæring eller oppfordring til å skrive avvik med unntak av høyrisikoavdelingene. Følgende diskusjon illustrerer dette: Bitte: Jeg tror ikke jeg har vært med på noe avviksmeldingsskriving på grunn av feilmedisinering, så jeg vet ikke. Olga: Jeg mener det vart gjort hos oss for ei stund siden, men jeg husker verken hva det var eller – Hanna: (fra høyrisikoavdeling) Jeg har jo skrevet et par, de gangene jeg har gjort det, har jeg gått til ledelsen og sagt ifra om hendelsen, og de har fortalt hvordan jeg skal gjøre det, og så fått tilbakemelding etterpå. Vi har gjennomgang av alt – hvordan og hva som skal meldes fra ledelsen sin side. Og hvor viktig det er å bruke det. Bitte: Jeg har ikke sett et sånt skjema heller jeg. I flere diskusjoner om avviksrutiner ble ordet «tror» brukt når de gjorde rede for hvordan rutinen fungerte eller hensikten med rutinen. Følgende uttalelser tyder på liten forståelse for at hensikten med avviksrapportering var å forbedre et system fremfor å henge ut syndebukker: «det gir jo dårlig statistikk og viser hvilke sykehus som er verst» og «kanskje det gir god statistikk å ha lite feilmedisineringer på sin avdeling?» Det ble uttrykt behov for innføring i avviksmeldeskjemaene. Bitte utrykte det klarest: «vi må få vite at vi har noe som heter avviksskjema». De som hadde brukt skjemaene viste ikke hvor de ble av. Mindre alvorlige avvik ble ikke rapportert med begrunnelse om at det ble for mye papirarbeid og for tidkrevende. Medisin som ikke ble gitt til riktig tid var ingen opplagt form for avvik. Individuelt ansvar vektlegges fremfor systemtenking Deltagerne la vekt på det individuelle ansvaret som hver enkelt sykepleier hadde i forbindelse med utdeling av legemidler. Streng arbeidsmoral ble synliggjort hvor de gav utrykk for at ved feilhandlinger «– måtte en til enhver tid være parat til å påta seg skyld». Sykepleierne gav uttrykk for store krav til seg selv i arbeidet med legemidler. Utrykk som «vi må bli flinkere», «ydmykhet i forhold til oppgaven», «du skal ikke bli kjepphøy, men ha ærefrykt for det du driver med» var uttrykk som ble brukt til å beskrive viktige personlige egenskaper. Det var viktig å ha evne til å be om hjelp, tørre å dumme seg ut ved å stille banale spørsmål og takle negative tilbakemeldinger eller korreksjon. Etter nærmere refleksjon ble deltagerne i en gruppe enig om at en flink sykepleier var den som sa ifra når hun hadde gjort en feil. Ble det fortalt eksempel på episoder med feilmedisinering, så dukket skyldspørsmålet opp. Da en gruppe diskuterte en feilmedisineringsepisode med alvorlig skade, konkluderte gruppen med delt skyld mellom lege og sykepleier som henholdsvis hadde ordinert og delt ut medisinen. Feilmedisinering – kilde til selvbebreidelse? Samtaler om ubehaget som fulgte med feilmedisinering skapte høyt engasjement. En grovopptelling på transkripsjonen viser at det var denne underkategorien som informantene gav mest informasjon om. 14 av de 22 sykepleierne gav fyldige beskrivelser om ubehaget som fulgte med å gjøre feil og om selvbebreidelse som reaksjonsmønster. Her gjengis utdrag av noen typiske eksempler: MARIT STORLI 21 Sykepleievitenskap . Omvårdnadsforskning . Nursing Science Jeg hadde blitt fryktelig skuffa over meg selv. Selv om du kan skylde på dårlig tid og mye annet, er det i bunn og grunn du selv som har gjort feilen og har ansvaret for at feilen ikke har skulle blitt gjort. (Gro) Er redd for å bli sett ned på, at de skal tenke at du ikke er en flink sykepleier for alle vil jo gjerne være flink. (Sara) Det er et nederlag å gjøre feil, det er å krype til korset. Jeg dummet meg ut en gang – da jeg satte igjen medisinbegeret på nattbordet og så var det feil nattbord. (Petra) Informantene gav generelt utrykk for at de kunne forvente støtte fra sine kolleger om de gjorde feil. Det eksisterte «uformelle terapigrupper» hvor de sammen med nære kollegaer fikk ventilert og lettet sin bør. Det fantes alltid noen som ikke gav støtte, og det var ikke i alle situasjoner at de ubetinget gav støtte til kollegaer som hadde gjort feil, for noen basiskunnskaper måtte en kunne forvente. Å gi ekte støtte var betinget av at en senere kunne stole på vedkommendes kompetanse. Diskusjon Metodiske betraktninger Kostnader med å arrangere fokusgrupper er små sammenlignet med hva en får igjen av nyttig informasjon. Individuelle intervju av tilsvarende utvalg ville gitt bedre mulighet til å gå i dybden, men blitt mer ressurskrevende. Formålet med studien var å bidra til større sikkerhet og forbedret kvalitet i sykehus. Jeg ønsket å unngå handlingsvalg som kunne medføre at sykehuset, avdelinger eller personer ble uthengt, gikk i forsvar og dermed bremset en utvikling mot større åpenhet omkring feil og uheldige hendelser. Deltagerne syntes problemstillingene var relevante og at deltagelse i en slik gruppe økte bevisstheten om feilmedisinering. Med tanke på de sensitive områder som ble diskutert og at deltakerne var ukjent for hverandre, var åpenheten likevel stor. Sykepleierne beskrev en virkelighet som langt fra var ideell, fortalte om egne reaksjoner på feilmedisinering og om episoder hvor de selv hadde delt ut feil medisin. Fokusgruppeintervju gir de andre deltagerne tilgang til de samme opplysningene som forskeren. Deltagerne forpliktet seg til å holde opplysninger i gruppen. Likevel prøvde jeg å være oppmerksom på om noen fortalte om personlige eller intime erfaringer som de senere kunne komme til å angre på. Informanter ble valgt fra et stort sykehus som utmerket seg med lav avviksrapportering. Deltakerne ble tilfeldig valgt fra strategisk utvalgte avdelinger. Funnene beskriver kulturelle faktorer som bl.a. påvirker avviksrapportering i et sykehus som utmerker seg med lav rapportering. Studien gir ikke tilstrekkelig grunnlag for å si at funnene gjelder generelt for sykehus, men generaliserbarheten i denne studien styrkes av at funnene samsvarer med internasjonale studier som viser at lav avviksrapportering er et kulturelt fenomen hvor bl.a. sanksjoner og manglende systemperspektiv er med å forhindre rapportering (1, 7, 8, 9,10). Metodens egnethet til å skaffe gyldige opplysninger om kulturelle faktorer vil i stor grad avhenge av hvorvidt deltakere tør si det de mener. Gruppepress og mangel på åpen atmosfære er eksempler på uheldige faktorer som påvirker troverdigheten av resultatene. Generelt var diskusjonene preget av spontanitet, livlig prat og en uformell atmosfære, og det kom fram virkelighetsbeskrivelser et godt stykke unna idealene. Opptelling av antall uttalelser fra informantene viste at alle sykepleierne deltok i diskusjonene. Selv om gruppestørrelsene ble mindre enn planlagt, var mønsteret rimelig entydig i alle grupper. Det er ingen grunn til å anta at funnene er særtrekk for kun disse utvalgte sykepleierne, da lignende funn er gjort i internasjonale studier (4, 8, 9, 10, 14). Bruk av eksterne personer til klassifisering var en hjelp til å unngå forutinntatthet som følge av lang yrkeserfaring i forskningsfeltet og dermed styrke troverdigheten på undersøkelsen (19). 22 Hva særpreger rutinebruk, kommunikasjon og samhandling ved legemiddelutdeling? Avviksmeldesystemet fungerer dårlig og viser at dette ikke oppfattes VÅRD I NORDEN 3/2008. PUBL. NO. 89 VOL. 28 NO. 3 PP 19–23 som et forbedringsverktøy. Hofseth & Lippestads studie (22) viste at rapportering økte ved bedre opplæring i systemets hensikt og virkemåte. Eksemplet med avklipte slanger viste at provisoriske tiltak ble brukt i beste mening for å ivareta pasientene. Opplæring i risiko, sikkerhetstenking og avviksmeldesystemer kan styrkes både i grunnutdanning og ved internopplæring på sykehuset. Bruk av anonyme melderutiner som behandles internt vil kunne være et godt grep (23). Positive erfaringer med systemet øker forståelsen for at feilmedisinering ikke kun er et individuelt problem som den enkelte selv må ta hele ansvaret for. Sykepleierne opplever i liten grad kommunikasjon med legene som et spenningsfelt. Hofseth & Lippestads studie (22) konkluderte også med nært samarbeid og god informasjonsflyt mellom lege og sykepleier. Uerfarne sykepleiere hadde problemer med å sette grenser for egen kompetanse. En hierarkisk organisasjonsstruktur gjør det vanskelig for sykepleierne å komme med kritiske tilbakemeldinger til legene. Studien «Munnkurv» tyder på at det eksisterer en sterk lydighetsnorm blant sykepleiere, og at kulturen på enkelte arbeidsplasser skaper dårlige vilkår for å ta opp kritikkverdige forhold (24). Resultater fra en norsk studie viser at både sykepleiestudenter, klinikere og lærere trenger å bli trent i kontinuerlig kvalitetsforbedring (25). På samtlige avdelinger og spesielt på sengepostene, ble sykepleiernes ressurser, erfaring og engasjement i liten grad utnyttet til å redusere risikoen ved legemiddelbehandling. Ledelsens bidrag til å skape en sikkerhetskultur i tråd med anbefalinger fra Firth-Cozens var lite synlig (15). Ingen eksempler ble nevnt hvor ledelsen var oppmerksom på kulturelle forhold som påvirket pasientsikkerheten i negativ retning. Bjørk (10) hadde lignende funn i sin studie. På individnivå kan ledelsen fungere som støttespillere ved å flytte fokus fra straff over på læring. Sykepleiernes medvirkning og påvirkning i legemiddelbehandling synes ikke helt å stå i forhold til det ansvaret de påtar seg. Hvilke reaksjoner er forbundet med å gjøre feil? Ufarliggjøring med hensyn på sanksjoner, systematiske tilbakemeldinger og konkrete forbedringstiltak ved rapportering av feilmedisinering vil bekjempe underrapportering. Sykehuset hvor deltakerne jobbet utmerker seg ved lav avviksrapportering. Reaksjoner i form av sterk selvbebreidelse ved feilmedisinering kan ha sammenheng med en kulturnorm med liten aksept for feil eller at feilhandlinger er tabubelagt. Feilmedisinering vil da bryte med sterke normer for god yrkesetikk og føre til at sykepleieren i verste fall reagerer med selvforakt dersom pasienten blir skadet. Verken helsetjenesten eller sykepleieren er tjent med eller lærer noe av at den som skader pasienten graver seg ned i selvmedlidenhet eller selvopptatthet (3, 26). Avgjørende for at det skal skje læring er at sykepleieren bevarer en positiv selvoppfatning på tross av det har skjedd en uheldig hendelse. Ved de aller fleste uheldige hendelser er det liten grunn til kritikk av enkeltpersoner (1). Gjennom å sørge for faglig og menneskelig støtte, kan sykehuset gjøre det beste ut av en vanskelig situasjon for pasient, pårørende og helsepersonell. Hva er viktig for å unngå feilmedisinering? Det individuelle ansvaret hos hver enkelt sykepleier vektlegges høyt. Ledelsens utfordring med tanke på å forbygge feilmedisinering er å få sykepleierne til i mindre grad å individualisere ansvaret og rette kravene innover mot seg selv (5, 7). I stedet bør sykepleiernes moralske og personlige ansvar i sterkere grad dreie seg om å varsle systemet om uheldige konsekvenser. Sykepleierne er avhengig av at avdelingslederne tar med seg deres innspill lenger opp i systemet. I en kultur hvor det er sparsomt med diskusjon om faglige spørsmål blir det liten mulighet til å lære av feilhandlinger gjennom melding av uheldige hendelser. Konklusjon Fokusgruppeintervju produserte rikelig med data som kunne avdekke organisasjonskulturelle faktorer som har betydning for feilmedisinering og rapportering. Feil og uheldige hendelser utnyttes fortsatt i liten grad som læringsmiddel og organisasjonskulturen synes å være beheftet med gamle tankemåter i sykepleie knyttet til høyt individansvar og vektlegging av personlige egenskaper som ydmykhet. Sykepleiernes engasjement og positive vilje utnyttes i liten grad systemmatisk til å unngå feilmedisinering. Ledelsen må ha forståelse for at feil gjøres og leve med de feil som er begått, men ikke at de gjentas. For å ivareta pasientsikkerheten bør sykehus legge større vekt på systematisk opplæring i sikkerhetsrutiner og påvirke endring fra en skyldkultur til en sikkerhetskultur. Forfatteren ønsker å takke sykepleierne som deltok i fokusgruppene og førsteamanuensis John-Arne Skolbekken for kommentarer og inspirasjon. Takk til Norsk Sykepleierforbund for forskningsstipend i forbindelse med datainnsamling og takk til Avdeling for Sykepleie for forskningstid. 20. Patton MQ. Qualitative research evaluation methods. 3. edition. California: Thousand Oaks: Sage Publications; 2002. 21. Morgan DL, Schannell AU. Planning focus groups. California: Thousand Oaks: Sage Publications; 1998. 22. Hofseth C, Lippestad, J-W. Legers og sykepleieres håndtering av uheldige hendelser i sykehus. Oslo: SINTEF Unimed helsetjenesteforskning. Rapport nr. STF78 H023501; 2002. 23. Leape LL. Patient safety. Reporting of Adverse Events. N Engl J Med. 2002; 347, (20): 1633 – 1638. 24. Hetle A. Munnkurv og varsling. En studie av ytringsfrihetens vilkår blant sykepleiere. Oslo: Arbeidsforskningsinstituttet; 2005. 25. Kyrkjebø JM. Å lære å forbedre kvaliteten på utøvelse av sykepleie i sykepleierutdanningen. Norsk tidsskrift for sykepleieforskning, 2006; 8:3, 3 – 1. 26. Lønning P. Ubehag, skam, skyldbevissthet, anger. Nordisk tidsskrift for palliativ medisin. Omsorg 1/2003; 2003. Godkjent for publisering 21.04.2008 Marit Storli, Høgskolelektor/cand.polit Høgskolen I Sør-Trøndelag, Avdeling for sykepleie, NO – 7004 Trondheim, [email protected] Referanser 1. Hjort PF. Uheldige hendelser i helsetjenesten. Oslo: Sosial og helsedirektoratet; 2004. 2. Statens helsetilsyn. Rapport fra helsetilsynet 5/2005. Oslo: Meldesentralen – årsrapport 2003; 2005. 3. Hjort PF. Uheldige hendelser i helsetjenesten – en lære-, tenke- og faktabok. Oslo: Gyldendal akademisk; 2007. 4. GRUK. Sikrere legemiddelhåndtering i pleie- og omsorgstjenester. Skien: Stiftelsen GRUK; 2003. 5. Schein EH. Organisasjonskultur og ledelse; er kulturendring mulig? Oslo: Mecuri media forlag; 1987. 6. Busch CJ. Skyld og skyldfølelse. Nordisk tidsskrift for palliativ medisin. Omsorg 1/2003; 2003. 7. Scott-Cawiezell J, Vogelmeister A, McKenny C, Rantz M, Hicks L, Zellmer D. Moving from a culture of blame to a culture of safety in nursing home setting. Nursing Forum, volume 41. 2006. July–September. No.3. 8. Reason JT. Understanding adverse events, the human factor. I Vincent C. Clinical risk management. Enhancing patient safety. 2. utgave. London: BMJ Publishing Group; 2001. 9. Walker SB. Nurses` view on reporting medication incidents. International Journal of Nursing Practice. 1998.Vol. 4(2): 97 – 102. 10. Sexton BJ, Thomas EJ, Helmreich RL. Errors, stress, and teamwork in medicine and aviation: cross sectional surveys. BMJ 2000; 320: 745-749. 11. Bjørk IT. Sykehusavdeling – et miljø for læring? Vård i Norden 4/2001. Vol.21 No. 4PP4–9. 12. Piene H. Kvalitetssikring basert på meldinger om skader, uhell og klager i helsetjenesten: En utredning med forslag til oppfølging ved kvalitetsutvalg i institusjoner og kommuner. Oslo: Helsedirektoratets utredningsserie; 492. 1992. 13. Sosial og helsedirektoratet. – Og bedre skal det bli! Nasjonal strategi for kvalitetsforbedring i Sosial- og helsetjenesten 2005–2015 (IS-1162). Oslo: 2005. 14. Baker H, Napthine R. Nurses & medication: A literature review. Australia: Australian Nursing Federation – Publications unit; 1994. 15. Firth-Cozens J. Teams, culture and managing risk. I Vincent C: Clinical risk management. Enhancing patient safety. 2. utgave. London: BMJ Publishing Group; 2001. 16. Storli M. Feilmedisinering. En studie av strukturelle og relasjonelle rammer rundt utdeling av legemidler på sykehus. Hovedfagsoppgave i helsevitenskap. Trondheim: ISH, NTNU; 2004. 17. Statens helsetilsyn. Elle-melde-deg fortelle. Oslo: Årsrapport 1999 fra Meldesentralen; 1999. 18. Halkier B. Fokusgrupper. Roskilde Universitetforlag: Samfundslitteratur; 2002. 19. Kvale S. Det kvalitative forskningsintervju. Oversatt av Anderssen TM og Rygge J. Oslo: Ad Notam Gyldendal; 1997. MARIT STORLI 23 Sykepleievitenskap . Omvårdnadsforskning . Nursing Science Family support as a care resource among the Bena in the Tanzanian village of Ilembula Anitta Juntunen, RN, PhD – Merja Nikkonen, RN, MEd, PhD ABSTRACT This article aims to analyse family support as a care resource from a cultural perspective. The purpose of the study was to reflect on the cultural factors defining family support as a care resource among the Bena in the Tanzanian village of Ilembula. The data was collected through interviews, participant observation and personal working diaries. Sixty-one villagers were interviewed. The data was analysed using the inductive qualitative content analysis method. The findings show that the culturally defined characteristics of family support among the Bena in the village of Ilembula were maintaining integrity, moral responsibility, role division, and being present; while the main actions taken by families to support their ill relatives were succour and comfort. The characteristics and activities of family support reflected the worldview of the Bena, their family-centred values, cultural beliefs and the lack of a social security system in Ilembula. The study proved that family support is a meaningful part of care, reflecting the Bena’s world view and their cultural values beside their socio-cultural conditions. The results can be exploited in the practice and teaching of transcultural nursing. KEY WORDS: family support, care resource, social support, family care provision, Bena Introduction 24 It is widely accepted in nursing literature that the family context is important to health and in the treatment of illness. (1, 2, 3.) The role of the family is discussed to clarify the concept of social support in nursing care. Finfgeld-Connett (3) defines social support as an advocative interpersonal process characterized by a reciprocal exchange of information. The characteristics of social support are emotional, instrumental as well as informational support and appraisal. Antecedents of emotional and instrumental support include a perceived need plus a social network and climate that are conducive to the exchange of social support. (3, 4.) Thus, social support is context specific. A positive relationship between social support and health is prevalent in existing literature. Social support produces selfconfidence, health maintenance behaviours, self-care behaviour, effective coping behaviours, a perceived sense of control, a sense of stability, recognition of self-worth, and decreased anxiety and depression. (4, 5, 6, 7, 8.) Social support is context specific, which indicates that it varies among ethnic groups. This, in turn indicates the need for the culturally sensitive provision of care, presenting the challenge for nurses to consider family support as a care resource. The field of research on family care-provision extends back to early studies carried out during the 1950s and 1960s on the family unit in general. Studies dating from the 1980s and early 1990s focused on specific care-giving activities, roles and responsibilities while current studies emphasize understanding the processes and impacts of caregiving across different physical and mental conditions and ethnically diverse populations. (9.) Burchard (10) has suggested that family nursing has the potential to form a new care paradigm. This study is a part of a research project describing professional and lay care among the Bena in the Ilembula village in Tanzania. (11.) This study focuses upon the culturally defined family support among adults suffering from various symptoms of illnesses common in Ilembula. Infections such as malaria, pneumonia, intestinal infections, HIV, and tuberculosis were the most common illnesses among the adult Ilembulians. The research questions were: 1) how do adult villagers describe family support as a care resource, and 2) what significant cultural beliefs are there in family support? VÅRD I NORDEN 3/2008. PUBL. NO. 89 VOL. 28 NO. 3 PP 24–28 The Ethnographic research approach This study applied the ethnographic research approach in order to find new cultural knowledge concerning family support among the Bena in Ilembula. It also provided information from the Bena themselves in their own cultural context and the opportunity to gain knowledge of the villagers’ way of life and day to day activities. There is no explicit definition of ethnography. (12).Usually it is viewed as a research approach based on field work with participatory observations and open interviews. (13). Van Maanen (14) refers to ethnography as the study of the culture a given group of people more or less share and sees it as both a method of study, and a result of such study. The first concerns the collection of data in a specified culture, and the latter refers to the construction of an ethnographic report. Aamodt (15) views ethnography as an endeavour to learn what knowledge people use to interpret experience and mould their behaviour within the context of their culturally constituted environment. The researcher him/herself is the most sensitive and important instrument in this type of study and this is why his/her interpersonal skills are critically important when in the field. Thus, ethnographic texts do not mirror other cultures but are the products of intercultural communication. (14, 15, 16, 17.) Ilembula as the context of the fieldwork Transcultural nursing scholars emphasise the context of the phenomenon studied. The cultural context consists of information on factors such as values, social structure, way of life, and the economical and ecological factors, of a society. (13.) Ilembula village is located in the Iringa region 700 km south-west of Dar Es Salaam and its population is estimated to be over 5000 people. The village lies at an altitude of 1400 meters, and the climate is dry, since annual rainfall is 600–800 mm. The majority of the inhabitants are Bena, one of the 120 Bantu speaking tribes living in Tanzania. The villagers earn their living by cultivating maize and keeping domestic animals and the majority of them do not have a regular income. The Ilembula Lutheran Hospital was established in 1950 by Swedish missionary doctors. The concept of family has a much wider meaning in Africa than in Europe. In the traditional society the family includes children, parents, grandparents, uncles, aunts, brothers and sisters, who may have their own children, and other immediate relatives. A human being is viewed as a member of a family, which includes both the living and the livingdead ancestors. The household in Africa is what European societies call family. A typical household in Ilembula consists of a husband, a wife and 5–6 children. There are many single-head households, run by a woman who is either divorced or single and lives with her children or whose husband is working outside Ilembula. Polygamist families also exist; the wives usually live separately in their own houses. The Bena belong to patrilineal societies. (11.) Selection of informants The main concern in ethnographic research is to obtain a representative sample by virtue of the informants’ experience, roles, sex, status, and age. (14.) The informants were selected from different groups of people in order to gain in-depth data (Table 1). General informants provided common information about the phenomenon studied, they were interviewed 1–2 times, while the key informants were persons known to have a deep knowledge and experience in the domain of the study and they were interviewed 2–5 times. (18) The majority of informants were middle-aged or elderly. Data collection and analysis The data was collected within 51⁄2 months in 1997. The data collection methods, open-ended interviews and participatory observation, are typical of qualitative ethnographic research. (12.) The Swahili language skills of the researcher were not sufficient for the scientific work and research assistants, one male and three females, were needed. The research assistants arranged the interviews and translated the researcher’s questions to Swahili or Bena and the interviewee’s answers to English. During the interviews, it turned out to be important that the researcher understood spoken Swahili satisfactorily, because the research assistants did not always translate the information she (the researcher) considered valuable. Since the interviews were recorded, she was able to check the validity of the translations with an assistant and the key informants who had knowledge of English. The interviews were carried out in peoples’ homes, work places, traditional healers’ «surgeries» and hospital wards at the times suggested by the interviewees. The interviews lasted for 1–11⁄2 hours and were recorded with the permission of the informants. During the interviews the researcher made notes and observations on gestures, surroundings, contexts and her feelings and reactions. The researcher’s role in participatory observation was mainly to be an observer. When attending traditional healers at work, the researcher observed co-operation between the client and his/her relatives, and in the hospital wards she observed relatives as care providers. The data was processed using inductive qualitative content analysis. (13.) Analysis was initiated during fieldwork after writing up the recorded interviews and observations (table 2). Firstly, the raw data was reduced by identifying the actions, expressions and beliefs related to support performed by a family. Secondly, the actions and expressions were clustered to define the characteristics of family support. Thirdly, the actions, expressions and beliefs related to family support were categorised and studied according to the cultural context of the Bena in Ilembula. Fourthly, the major themes and research findings were abstracted and discussed with two key informants in order to confirm validity. Results On the basis of the data analysis, four concepts defining the characteristics of family support were: maintaining integrity within the extended family, moral responsibility, role division, and being present. Maintaining integrity Family support was based on the aim to maintain integrity within the extended family. Maintaining integrity meant togetherness, actions taken to share hardship caused by the illness, and to guarantee the support of the extended family during difficult times. In times of trouble, togetherness, a feeling of unity was essential in extended families – the closer the relationship, the more important it was to maintain unity between family members. The Ilembulians pointed out in the interviews that illnesses, with the exception of minor health ailments, were not a private matter. The extended family became involved if home remedies did not improve the patient’s condition, as one informant described: If something severe happens to me, my wife goes to my family, and if something happens to her, I go to her father or brothers or a sister. These families come together and decide what to do together. Coming together meant negotiations concerning how the capable family members would share the hardships caused by the treatment of the illness. The major problems encountered were arranging transport to a hospital, finding money for treatment, nursing the patient, and taking care of the patient’s children, household and domestic animals. In order to get information about the causes of the illness and the treatment required, members of the extended family accompanied the patient to a traditional healer and/or a medical doctor in a hospital. The more relatives present, the better the doctor’s or healer’s prescriptions were understood. Ensuring the support of the extended family in times of trouble was important. Members of the extended family visited the patient regularly, whether s/he was at home or in hospital, to say ‘pole’ (a consolation) and to find out about his/her progress. They had two reasons for doing so: first, to ensure support from the extended family in the future, when they might have problems themselves, secondly, to prove that they did not cause the illness by means of witchcraft, as a female informant explained: If I don’t go to see a patient, it means… from where did he get it (the illness)? Moral responsibility Taking care of a patient is the moral responsibility of the family. Anxiety, steps taken to ensure recovery, fear of being criticized by the community and punished by ancestors define moral responsibility in the Ilembulian context. Moral responsibility was best expressed in the attitude known as kuhangaika ‘being anxious’. The family became anxious if the patient did not show signs of improvement and found all the available specialists and remedies they could afford. This often meant consulting Table 1. Occupation, number and sex of informants one healer after another besides hospitals and private Occupation of informants General Key Number of Sex clinics, buying medicines and, depending on the informants informants all informants Female Male cause of the illness found by a healer, performing Villagers rituals among the extended family. One informant – farmers 13 3 16 15 1 explained: Maybe if we only rely on this one, we – traditional healers 7 3 10 3 7 won’t get good drugs. Then we meet somebody on the – trained hospital staff 5 2 7 6 1 road who says «Maybe it would have been better if – village administrators 4 1 5 0 5 you had seen that healer». So, we go there. – teachers 3 2 5 1 4 The families wanted to ensure the recovery of a – village health workers 2 1 3 1 2 patient by meeting his/her wishes. The informants – traditional birth attendants 3 0 3 3 0 said that an ill person was never left alone even if the relative taking care of him/her became exhausted. If Relatives of patients 10 2 12 7 5 the patient was in bed at home, somebody, e.g. a child Total 47 14 61 36 25 was constantly nearby to hear the patient’s wishes. In hospital, the relatives taking care of the patient ANITTA JUNTUNEN OG MERJA NIKKONEN 25 Sykepleievitenskap . Omvårdnadsforskning . Nursing Science explained the relationship between their caring actions and the patient’s condition, as one informant explained: if a patient is assisted in all that s/he needs there is hope s/he will recover soon. This relationship appeared in different situations, as when a mother explained that her child had fever in the afternoon because she delayed bathing him. The informants shared the opinion that they could not rely on nurses, because the nurses were busy with drug administration and other procedures. The relatives stayed in the hospital for as long as 2–3 months, if the patient’s condition required such a long period of hospital treatment. They were very careful to cater to the needs and wishes of elderly family members because by doing so they believed they would be blessed by the living-dead ancestors after the death of such elderly relatives. Fear of being criticized by the community and punished by ancestors motivated family members to care for their patients, as one informant said: It might happen that he (a patient) wants to go to the toilet and he falls down, because he has nobody to help him. That would not be good for us as his relatives. The moral responsibility to care was stressed by informants who had noticed that some relatives, e.g. daughtersin-law, were not willing to take care of their mothers-in-law. The informants believed that such persons would be punished for their selfishness later: If you don’t respect your elders, you may become sick or loose your work or property after they die. – From a cultural perspective, moral responsibility is based on a sense of close-knit unity within the family. 26 a wife or a grown-up son provided it and the extended family paid the costs. A child was taken care of by any of the grown-up relatives, including fathers. The position of the firstborn son became significant when one of the parents fell ill. He was expected to arrange everything required to ensure good care, either alone or with another parent. The main duty of the head of the family was to pay expenses or to find money to cover the costs. – The role division in caring was based on the beliefs related to a culture bound syndrome known as baridi (emotional coldness). It was defined as the outcome of disrespect or of the neglect of close family members, and it reflected the worldview and cultural values of the Bena. Being Present Being present meant staying constantly near to the patient, as described by an informant: There must be somebody to stay near, together, to comfort and help the patient. Succour, which here refers to assistance given by relatives at times of need, was an important element of being present. Being present began with greetings, the expression of pole and asking about the patient’s condition. It included giving time, sitting together and eating or drinking tea together, or remaining silent but physically close to the patient. The person taking care of a patient, either alone or with one or two other family members, fed and bathed the patient when necessary, washed the linen, changed clothes and slept near him. The relative who was present also assisted nurses by keeping an eye on the intravenous fluid infusions, urinary catheter, feeding via nasogastric tubes, collecting samples, transporting the patient to the x-ray department and monitoring his/her general condition, especially after an operation. The relative acted as a mediator: s/he informed physicians and nurses about the history of the patient’s illness and transferred their orders to the patient. However, it was considered even more important to keep the rest of the family informed of the patient’s progress and the prescriptions given by health professionals. Other reasons for being present were the possibility that a patient might die without anybody hearing his/her last words. This was very important if the person had property: If the one dying is a father and has some wealth, relatives will be interested in hearing instructions concerning how to share the wealth. Besides property, the relatives were interested in whether the patient had been involved in witchcraft or had made other serious mistakes that could have caused for example, litego (a curse) and wanted to confess it, as an informant explained: They hide the shame from the family till the end when they say for example: «I am dying because I slept with the wife of Mr X». Litego was a verbal curse initiated during a symbolic ritual performed by the person against whom the wrong was committed, or a witch. It was Role Division Role division was characteristic of family support, and it was emphasised by the Ilembulians in the interviews and observed on hospital wards. Role division meant sharing care provision on the basis of sex, age and status in the family. After taking home-made, traditional medicines as first aid such as local herbs from a tree or plant known since childhood, or chemical drugs bought from a pharmacy, the patient turned to his/her grandparents, who knew the herbs traditionally used in the family. When the patient had severe symptoms or was suffering from chronic ailments, the head of the household, e.g. a father, informed the head of the extended family. After this process the patient could be sent to hospital or the family might decide to consult a traditional healer, or both. If the patient needed the attention of a medical doctor, such a decision would always require permission from the head of the family, who was the oldest man in the extended family. Hospital treatment was considered expensive and a part of the costs had to be paid immediately, which was often impossible for those without savings. In the sudden onset of a child’s illness, a mother could consult a traditional healer without asking her husband or any other family member for permission, since the Table 2. Moral responsibility as a characteristic for family support healers’ fees were flexible and payable in terms of work, material, food or money. Statements Actions and Cultural beliefs Characteristic of When a patient was unable to attend to his/ expressions of family explaining family family support her daily needs, members of the extended family support support were expected to assist him/her according to Maybe if we rely just searching for the best kuhangaika = their age and sex, as an informant nursing on this one, we won’t possible treatment for attitude of being her daughter explained: Anybody can come and get good drugs. a patient without anxious take care of the patient, as long as s/he belongs saving efforts to the same family and is permitted to stay close to him. To be close to a patient If the patient is bedside care ensure recovery meant maintaining hygiene, taking care of assisted in all what interaction between moral responsibility secretions, feeding, changing position, and s/he needs there is caring actions and changing and washing the linen. It was not then hope s/he will recover patient’s condition possible to avoid seeing the patient’s genitals, soon. which was forbidden to everyone forepart from If you do not respect bedside care, time fear of being criticized spouses, adult children of the same gender as your elders, you will giving, verbal and by the community and the patient, and sisters and brothers. If a get problems after they physical support punished by ancestors woman required bedside care, a husband, a have died. grown-up daughter and any grown-up female It would not be good relative could nurse her in hospital or at home, for us as his relatives. or sometimes at a traditional healer’s. When a male person needed bedside care, a male relative, VÅRD I NORDEN 3/2008. PUBL. NO. 89 VOL. 28 NO. 3 PP 24–28 believed that the words said during the ritual had the power to destroy the life of the guilty person and his/her family members. Discussion Criteria for Validity Lincoln and Cuba (19) have defined the following criteria to evaluate qualitative ethnographic research: credibility, confirmability, meaning in context, recurrent pattering, saturation and transferability. The questions of validity in ethnographic research involve the researcher, the quality and analysis of the data and the research report. Credibility, the truth of the informants, was established by recurrent field contacts. The informants’ explanations and interpretations in the Swahili language were translated into English by a native Bena and both were recorded. The data was confirmed by systematically going through the field notes and tape recordings and by careful data analysis. The final findings were shared and examined by two key informants. Meaning in context refers to the gaining of meaning in the natural environment. Experience, some knowledge of the Bena and Swahili languages and prior knowledge enabled the researcher to enter the community and establish contact with the villagers quickly, enabling an opportunity to understand contextual meanings during a relatively short period of field work. Recurrent pattering refers to repeated experiences, events, instances or ways of doing things. In order to meet this criterion, the researcher interviewed and observed different people in different situations and environments. Saturation was established in spite of the language problem and the relatively short time used for collecting data. Transferability, the ability to generalise the findings within other contexts, is no longer relevant since the data was collected a long time ago. Ethical Questions and Human Problems Related to the Fieldwork The ethnographic research approach raises many ethical issues for consideration in relation to data gathering and reporting. The points considered important in this study were the relationship between the researcher and the informants, profits for the informants, maintaining objectivity and neutrality, and cultural fears. During fieldwork, the researcher considered mutual respect to be a crucial issue. Informants were told the purpose of the study and they were aware of their right to refuse to participate in the research (20). The research assistants were advised not to coerce or manipulate the informants and to keep the information gained confidential. The question of financial rewards for the informants turned out to be a sensitive issue, since some villagers refused indirectly – which was considered polite in the Bena community – to give interviews, because they would not gain financially. One of the challenges the researcher faced was how to maintain objectivity and neutrality. At the beginning, the researcher’s understanding of cultural meanings was very limited. Later, as she came closer to the informants’ world, the researcher recognized her own ethnocentrism and criticized the concept ‘going native’. The researcher worked at the limits of her tolerance and found herself criticizing Bena practices while on the other hand, critically questioning Western values and way of life. Cultural fears arose when the researcher was warned about visiting traditional healers by European missionaries «who give you spirits causing a mental sickness». Findings The characteristics of family support: maintaining integrity, moral responsibility, role division and being present, reflected a worldview that included family-centred values, cultural beliefs and the lack of a social security system among the Bena in Ilembula. The family played a central role in caring for and supervising ill relatives in hospital and in acting as mediators between the health care personnel, patient and the rest of the family. The impact of family support was crucial to the wellbeing of the patient, since the role of the nurses was to implement doctor’s prescriptions and administrate medication. The findings of this study raise the question of co-operation between professional nurses and family care givers. Families living with a relative who is chronically ill live between hope and despair, suffering and possibility (21), which was obvious in Ilembula where the families were even the main care resource of seriously ill, dying AIDS patients. However, they received very little encouragement from the nurses because traditionally it was not acceptable to become too involved in another family’s situation within their culture. On the other hand, accepting family as a care resource could have been interpreted by nurses as a lack of respect for their status and expertise as a trained professional. Problems arose if the patient did not have any relatives to take care of her/him, emphasising the significance of the family as a form of social security system. A patient without family carers depended on the care and support provided by nurses, which was often technical in nature. (11.) The traditional family structure is breaking down in Tanzania, also in rural villages like Ilembula. This will create challenges for nursing resources, since families perform a remarkable amount of everyday care. On the other hand, FinfgeldConnett (3) simultaneously advises nurses to encourage patients to use and enhance personal support networks; she says that nurses should reconsider investigating social support as a nursing intervention because of its non-professional nature. Doane et al (22) propose that the provision of competent, ethical, and culturally safe nursing care could be enhanced by a relational point of view. This means understanding the family as a relational experience and nursing and culture as relational processes, and conceptualizing difference as a basis for connection providing foundations for a more effective way of working through differences. In this study, the family support observed focused on patients with infections or long-term physical illnesses related to HIV. Mental health ailments were a taboo in the village and the family support of mentally ill patients must also be examined. It would also be interesting to study how family support is genderrelated. The findings showed that there were not differences between the sexes but the age of the patient was significant – the older the patient the more carefully s/he was cared for. The findings are limited due to the age of the data. However, there are no previous transcultural studies on family support as a care resource in an African context. The findings proved that family support among the Bena in Ilembula is based on worldview and cul-tural values, which change much more slowly than socio-cultural conditions. Thus the results can be used in transcultural nursing practice and teaching. Accepted for publication 04.02.2008 Corresponding author: Anitta Juntunen, Principal Lecturer, Department of Social Services, Health and Sports, Kajaani University of Applied Sciences, P.O. Box 52, FIN – 87101 Kajaani. [email protected] Merja Nikkonen, Assistant Professor, Department of Nursing Science, University of Kuopio, P.O. Box 1627, FIN –70211 Kuopio [email protected] References 1. Friedemann ML, Åstedt-Kurki P & Paavilainen E. Development of a family assessment instrument for transcultural use. Journal of Transcultural Nursing 2003; 14(2): 90–99. 2. Schumacher KL, Beidler SM, Beeber AS & Gambino P. A transactional model of cancer family care giving skill. Advances in Nursing Science 2006; 29(3): 271–286. 3. Finfgeld-Connett D. Clarification of Social Support. Journal of Nursing Scholarship 2005; 37(1): 4–9. 4. Langford C.P.H., Bowsher J, Maloney J.P. & Lillis P.P. Social support: a conceptual analysis. Journal of Advanced Nursing 1997; 25(1): 95–100. 5. Given B.A., Given C.W. & Kozachik S. Family support in advanced cancer. A Cancer Journal for Clinicians 2001; 51(4): 213–231. 6. Waters C.M. Professional nursing support for culturally diverse family members of critically ill adults. Research in Nursing & Health 1999; 22(2): 107–117. 7. Maly R.C., Umezawa Y., Leake B. & Silliman R.A.. Mental health outcoANITTA JUNTUNEN OG MERJA NIKKONEN 27 Sykepleievitenskap . Omvårdnadsforskning . Nursing Science mes in older women with breast cancer: Impact of perceived family support and adjustment. Psycho-Oncology 2005; 14(7): 535–545. 8. 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Laadulliset tutkimusmenetelmät hoitotieteessä. 2. uudistettu painos. WS Bookwell Oy, Juva, 44–80; 2003. 14. Van Maanen J. An End of Innocence Ethnography of Ethnography. In: Van Maanen J (ed.) Representation in Ethnography, 1–35. Sage Publications Inc. Thousand Oaks, California;1995. 28 VÅRD I NORDEN 3/2008. PUBL. NO. 89 VOL. 28 NO. 3 PP 24–28 15. Aamodt A.M. Ethnography and epistemology: Generating Nursing Knowledge. In: Morse J.M. (ed.) Qualitative Nursing Research: A Contemporary Dialogue, 27–40. Aspen Publishers, Inc. Rockville, Maryland;1989. 16. Wellin C. & Fine G. A. Ethnography as work: career socialization, settings and problems. In: Atkinson P, Coffey A, Delamont S, Lofland J & Lofland L. (eds.) Handbook of ethnography. SAGE Publications, London 323–339; 2001. 17. Tedlock B. The observation of participation and the emergence of public ethnography. In: Denzin N.K. & Lincoln Y.S. (eds.) Qualitative Research. SAGE Publications, 467–481; 2005. 18. Roper J. & Shapira J. Ethnography in nursing research. SAGE Publications, California; 2000. 19. Lincoln Y.S. & Cuba E.G. Naturalistic Inquiry. Sage Publication, Beverly Hills; 1985. 20. Gregory T.B. Discussion in Ethics. In: Guba E.G. (ed.) The Paradigm Dialog, 158–164. Sage Publications, USA.;1990. 21. Chesla C.A. Nursing Science and Chronic Illness: Articulating Suffering and Possibility in Family Life. Journal of Family Nursing 2005; 11(4): 371–387. 22. Doane G.H. & Varcoe C. The «Hard Spots» of Family Nursing. Journal of Family Nursing, 2006;12(1): 7–21. Sykepleievitenskap . Omvårdnadsforskning . Nursing Science Patient safety regarding leg ulcer treatment in primary health care Hilde Smith-Strøm, Senior Lecturer, MSc, RN – Ingun Thornes, RN ABSTRACT Aims. The aims of this study were to survey how nurses collaborated with a hospital department of dermatology and how they treated chronic leg ulcers and to survey the nurses’ knowledge of leg ulcer treatment. Background. Patients with leg ulcers do not necessarily receive treatment based on best evidence. Improving wound treatment among patients with leg ulcers requires surveying areas in which the treatment can be improved. Methods. A descriptive study was used. The subjects were all registered nurses (N=158) who treated leg ulcers in primary health care in one Municipality in Norway. Data were collected using a standardized questionnaire. Findings. Not all patients had been diagnosed before the treatment started. Mainly nurses (57%) prescribed treatment when no diagnosis had been made. Nurses changed the treatment without consulting the department of dermatology. Compression and pain treatment were not standard procedure for all patients. Not all patients had continuity of provider in treatment. The main sources of the nurses’ knowledge were their own experiences and those of colleagues. Conclusion. The treatment of leg ulcer did not comply with international guidelines, and this can threaten patients’ safety. The nurses perceived their knowledge of wound treatment to be insufficient. KEY WORDS: leg ulcer treatment, district nurses, primary health care, patient safety, evidence-based practice Introduction During recent years, awareness has increased of the serious widespread quality problems in health care, including rising costs, difficult access and wide variation in safety and quality (1). Treating patients with leg ulcers is a challenge to health professionals, because venous leg ulcer is a chronic disease that often takes years to heal, recurrence rates are high and it is a major cause of morbidity, pain and health care costs (2,3). Improving patients’ safety and avoiding adverse events in wound treatment requires basing the quality of care on treatments of known efficacy, interprofessional collaboration and knowledge about wound treatments. Using treatments with known efficacy improves healing rates and the quality of life and reduces the cost of care (4,5). Studies (2–4) show that patients do not necessarily receive treatment based on best evidence. Studies focusing on nurses’ knowledge of leg ulcer treatment found that most district nurses believed that their knowledge of wound treatment was insufficient, and they felt uncertain about the treatment. The uncertainty included wound treatment, assessment, diagnosis and selection of dressing. The main sources of the nurses’ knowledge were their own nursing practice and their education (6,7). In another study (3), only half the patients received a diagnosis before treatment started. Not all patients were treated with compression; 15% of the patients had pain, but only 17% received some form of pain treatment. Ulcers were measured regularly for 11% of the patients. The mean number of nurses providing leg ulcer care to each patient was 19 (3). Ribu et al. (8) found very similar results. In addition, the treatments were poorly documented. Lack of exact diagnosis, compression therapy and pain treatment reduce patient safety and can lead to adverse events. However, in primary health care, patients are frequently referred to the care of nurses without the physician first determining the underlying cause of the leg ulcer or with insufficient support from general practitioners (9). The care of these patients is reported to occupy at least 25% of the working time of district nurses and takes up substantial health care resources (9,10). Increasing the training and knowledge of wound treatment and using treatments with known efficacy can reduce the cost and time spent on wound treatment (9,10). Research (9–11) has documented that nurses and physicians must collaborate closely to improve wound treatment. A study evaluating the implementation of a nurse-led service found that practical guidelines and enhanced cooperation with family physicians and specialists produced better healing rates and improved efficiency (4). Moffatt & Franks (5) found that reorganizing leg ulcer service, including steering groups, resulted in improved professional practice, better patient outcome and more efficient use of resources. Few studies of wound treatment and care have been performed in Norway, which creates difficulty in evaluating the quality of leg ulcer care. The aims of this study therefore surveyed how district nurses collaborated with a department of dermatology and how they treated chronic leg ulcer and surveyed the district nurses’ knowledge of leg ulcer treatment as a basis for developing best practices. Methods Population and design The total population of registered nurses in primary health care in nine districts in one Municipality in Norway in 2003 who treated leg ulcers was 158 (according to the Municipality health service). A census survey was designed for this population, and all registered nurses were asked to participate. No exclusion criteria were used. All nine districts in the municipality participated. We used a descriptive design, because the main purpose was to illuminate the district nurses’ treatment and knowledge of patients with leg ulcers. Data collection We used a questionnaire to collect data. It was pilot-tested on 20 district nurses in three municipalities in Norway. In the pilot study, the senior nurses delivered the questionnaires to the district nurses. Before we started to collect data in the main study, we held a meeting with all senior nurses from the districts to inform them about the study, the results of the pilot study and the procedure for data collection. In the main study, the procedure for data collection was changed to a personal meeting with the district nurses to increase the response rate in the districts. However, in three of the nine districts a personal meeting was not possible, and the senior nurses delivered the questionnaire to the participants. We sent reminders after 3 weeks to the senior nurses in these districts. Instruments The questionnaire was divided into three parts. In parts 1 and 2, we constructed questions on how chronic leg ulcers were treated in primary health care based on discussion with three district nurses and one dermatological nurse, a literature review, field research and the HILDE SMITH-STRØM OG INGUN THORNES 29 Sykepleievitenskap . Omvårdnadsforskning . Nursing Science researcher’s own experience from primary health care. The questionnaire had both closed and open questions. A Likert scale (1–5) was used for closed questions. The questionnaire in part 1 (11 items) included questions about whether a dermatologist had assessed the leg ulcer before treatment started, who ordered the treatment when no diagnosis had been made, waiting time before consulting a dermatologist and whether the nurses changed the treatment without consulting a dermatologist. In part 2 the questionnaire (10 items) included questions about whether the nurses were satisfied with the telephone consultation, the follow-up for wound impairment and the clinical procedures, whether compression, pain treatment and measurement of the leg ulcers were common procedures in treatment, how documentation was carried out and who treated the leg ulcers. Some of the questions left space for in-depth comments. Part 3 had four questions about the nurses’ knowledge; the nurses’ confidence in wound treatment, their knowledge of wound treatment, the sources of this knowledge and the nurses’ opinions on the most important factor in wound treatment. All four questions had space for in-depth comments. The questionnaire in part 3 had previously been used in a population of nurses in a city in Norway (6,7). have a dermatologist assess the ulcer to determine the underlying cause before treatment started, was not standard procedure. The nurses changed the treatment without consulting the dermatologist. Compression and pain treatment were not standard procedure for all patients. Not all patients had continuity of provider in treatment. Most nurses believed that they had insufficient knowledge about wound treatment. The main sources of knowledge of the nurses were their own and their colleagues’ experiences and not from evidence-based knowledge. The results are further presented as text, tables and excerpts from the statements of the nurses. Validity and reliability The content validity is the degree to which the items in an instrument adequately represent the universe of content (12). This was supported by the literature review on leg ulcer care, data gathered from the field and the researchers’ own experience in primary health care. To establish face validity, which is whether the tool appears to measure the concept intended (12), input was gained from experts in the field of leg ulcer care from both primary health care and a hospital department of dermatology and from nursing research. The construct validity is the degree to which an instrument measures the construct being investigated (12). This seemed to be satisfactory, because collaboration, knowledge and leg ulcer treatment and care are well-known concepts to the nurses. The nurses’ replies indicated good understanding of the questionnaire. The pilot study tested all parts of the questionnaire. This pilot test had three main foci: whether the questionnaire was clear and easy to complete, whether questions needed to be added or removed and whether the data collection was going to be effective. We determined that the questionnaire was clear and easy to complete and made no important changes for the main study. In the main study, all the questions were answered properly, which indicates that the reliability was reasonably good. One factor that could reduce the reliability is that only the researchers analyzed the data. Waiting time for the first dermatological consultation Figure 1 shows that the nurses said that 3 weeks elapsed on average before the first consultation at the department of dermatology. Data analysis A descriptive and interpretative data analysis was carried out. We summarized the quantitative data and presented them as frequencies, means, percentages and standard deviations and analyzed them using the statistics program NSD-stat. Data from the open-ended questions were transcribed verbatim, read and categorized according to what emerges from the data (13). The nurses’ qualitative statements are presented as excerpts of the comments and are italicized. Nurses also changed the treatment without consulting the department of dermatology. Of 98 nurses, 10% did this often, 46% sometimes and 44% never. The qualitative data from nurses (n=49) who reported that they changed the procedure without consulting a dermatologist showed different reasons for doing this: long time before access (n = 11), they trusted their own knowledge (n = 10), treatment prescribed by the dermatologist was the worst treatment (n = 12), improved wound healing (n = 9), insufficient communication between the department of dermatology and the district nurses (n = 4), the treatment ordered by the department of dermatology was too expensive (n = 2) and the nurse was not capable of following the prescribed procedures (n = 1). Approval The management of the Department of Health and Social Care of the Municipality, the senior nurses in all nine municipal districts and the Norwegian Social Science Data Services approved the study. A letter about the study was sent to all nurses in primary health care, assuring them of anonymity and confidentiality and informing them that participation was voluntary. No written consent was required, because completing the questionnaire was voluntary. Results 30 Ninety-nine district nurses (63%) completed the questionnaire. The response rates were lower in the districts where the senior nurses delivered the questionnaire. Overall, the findings showed that offering to VÅRD I NORDEN 3/2008. PUBL. NO. 89 VOL. 28 NO. 3 PP 29–33 Who assessed the cause and prescribed the treatment? Not all patients had an assessment by a dermatologist to determine the underlying cause of the ulcer before treatment started in the municipal health service. Of 99 nurses, only 22% reported that the patients always had a diagnosis before treatment, 45% often, 32% sometimes and 1% never. Of 74 nurses, 57% mainly decided the treatment when there was no underlying diagnosis, 43% reported that the general practitioner ordered the treatment, and a common statement from the general practitioner was «treat the leg ulcer as you normally do». Figure I: Waiting time for the first dermatological consultation, (%), (n=91) 70 59 60 Mean: 3,1 SD (0,68) % of nurses 50 40 28 30 20 11 10 1 1 0 1 w eeks 2 w eeks 3-4 w eeks > 2 months > 3 months Clinical procedures, telephone consultation and follow-up from the department of dermatology when the patient is registered in the system The nurses were asked whether they were satisfied with the clinical procedures they received from the department of dermatology. Of 99 nurses, 96% were satisfied and 4% were not. Table I shows that the district nurses were mostly satisfied with the contact with the department of dermatology for patients registered in the system. 31 Discussion Table I. Contact between the department of dermatology and district nurses for patients registered in the system, (%), (n=99) Questions Telephone consulting Very good Good Moderate Poor Very poor Mean (SD) 16% 41% 27% 15% 1% 2.44 (0.97) Offering a new consultation for wound impairment 5% 34% 41% 15% 5% 2.82 (0.93) Follow-up by the department of dermatology for wound impairment 17% 57% 24% 2% 2.11 (0.7) Methodological considerations The sample comprised all the district nurses in one Municipality in Norway. The reply rate was 63%, which indicated that the results are considered reliable and can be generalized. The response rate was lower among nurses in districts in which the senior nurses delivered the questionnaire. The reasons for this include not receiving the questionnaire, not being motivated to fill in the questionnaire or the senior nurse having a negative attitude. Collaboration between the department of dermatology and primary care nurses Successful treatment in wound care requires close collaboration between nurses and specialist physiciOrganization of leg ulcer care in the municipal health service ans to improve wound treatment (3,5,11). In this study, nurses reporThe 99 nurses were asked whether giving compression to patients with ted good collaboration with the department of dermatology on folloinsufficient venous flow was standard procedure, and 32% reported wing up wound impairment, telephone consultations and clinical proalways, 53% often, 17% sometimes and 1% never. Eighteen percent cedures. Nurses were least satisfied with the ability of the department always gave drugs to patients with leg ulcers, 52% often and 30% someof dermatology to offer new consultations for wound impairment. times. Only 5% of the nurses reported that they always measured the This could be why not all nurses followed the recommendations from surface area of the wound, 13% often, 57% sometimes and 25% never. the department of dermatology. Nurses reported that they changed trePersonnel other than registered nurses often treat wounds. Fifty-nine atment without consulting the physicians. One main reason was that percent of the nurses often delegated the wound treatment to auxiliary getting access to the department of dermatology took a long time. nurses, 33% sometimes, 2% always and 6% never. The three main However, such decisions should be made in cooperation with the spereasons for this were: few nurses in the system, auxiliary nurses had sufcialist, because wound impairment can have several different causes ficient knowledge about wound treatment and performing wound treat(14,15). Leg ulcer treatment is multidisciplinary, and nurses operating ment in connection with other nursing tasks was practical. Of the 99 alone cannot implement best practices (3). Not assessing the right caunurses, 14% always used a primary nursing care model, 41% often, 33% ses for changing treatment can lead to inappropriate treatment and sometimes and 12% never. The nurses used several different documenadverse events (15). Establishing an ambulant team of specialist nurtation systems, such as evaluation reports (41%), electronic documentases in wound care from both primary health care and the department tion (24%), wound records (20%) and care plans (15%). of dermatology that is responsible for following up patients with wounds in primary health care will probably reduce these problems Nurses’ evaluation of their knowledge of leg ulcer treatment and increase patient safety. The team will improve continuity, docuOf 94 nurses, 65% said they did not have enough knowledge about mentation and the quality of treatment offered. Another important wound treatment of leg ulcer. These nurses wanted more knowledge alternative is frequent seminars on wound treatment for primary nurabout new methods and treatment of leg ulcers and new documented ses arranged by the department of dermatology. This will improve the products and dressings in the treatment of leg ulcers. Most nurses knowledge of the primary nurses on wound treatment. In addition, it (62%) sometimes felt uncertain in a wound treatment situation, 26% will also provide an opportunity for contact between the department of seldom, 8% often and 4% never. The qualitative data showed that they dermatology and the nurses in primary health care. were most uncertain in three main categories: whether the procedure Nurses also reported that not all patients had a diagnosis before the was the right treatment, when the procedure should be changed and treatment started, and nurses mainly ordered the treatment in such how often to change dressings. cases. This applies in other studies (2,3,8) and seriously threatens patient safety, because the underlying cause of ulcer must be determined Most important sources of nurses’ knowledge of leg ulcer and appropriate treatment choices made before treatment starts (14). treatment The long waiting time before patients get access to the department of The nurses could respond to more than one source of knowledge about dermatology was probably the main reason the patients had not been leg ulcer (Table 2). diagnosed before treatment started. In this study, most patients had to The main sources of the nurses’ knowledge were their own and collewait 3–8 weeks before being assessed by a dermatologist. This may agues’ experiences and courses in leg ulcer treatment. Books, journals lead to a difficult position, because the district nurses have to start treand guidance from the hospital department of dermatology seemed to be atment before diagnosis, which is not necessarily based on safe and the least important sources of the nurses’ knowledge. sound services. Treatment of leg ulcers is complicated, and clinical assessment of leg ulcers is difficult without training (15). In accordance with international guidelines, Table II. Most important sources of nurses’ knowledge of leg ulcer treatment comprehensive assessment is essential to determine the underlying cause and a dermatologist must pern** % form this (14). Clinical guidelines based on best eviFrom own experience 78 24 dence are reported to be a key vehicle for promoting Journals and books 47 14 evidence-based practice and should be a standard procedure in treating patients with leg ulcers (4). Colleagues 68 20 Studies in a community health service have also Brochures from pharmaceutical companies 24 7 showed that organized wound treatment based on Guidance from hospital department of dermatology 55 16 evidence-based service, including clear aims, collaCourses in leg ulcer treatment* 62 19 boration between professional groups, clinical gui* Hospital department of dermatology. ** Nurses could respond to more than one source of knowledge about leg ulcer. delines and clear leadership, had managed to improve healing rates, reduced the average number of care visits and provided care to more patients HILDE SMITH-STRØM OG INGUN THORNES Sykepleievitenskap . Omvårdnadsforskning . Nursing Science without raising the cost (4,5). These principles are reported to improve the quality of care and can improve patient outcomes and cost-effectiveness (16). Methods of treating chronic leg ulcer in primary health care Even though compression, pain treatment and measurement of the leg ulcer surface area are essential in healing venous leg ulcers, this was not a common procedure among all nurses. Despite the strong evidence for the use of compression for venous leg ulcers (17), only 32% of the nurses reported that they always used compression therapy. Pain treatment is essential for patients with venous leg ulcers, but pain is often considered a sign of arterial disease or infection and has received little attention in the wound-healing literature. Misinterpreting pain can lead to poor management, and compression therapy may therefore be withheld (18,19). Regular measurement of the leg ulcer surface area is a reliable index for healing and is recommended in wound treatment (14,20), but only 5% of the nurses reported that they always did this. The absence of clear pain treatment, compression therapy and measurement may reflect the lack of knowledge and skills and lead to delayed healing and/or deterioration of the ulcer and increased cost (14). Other studies (3,8,20) also report these tendencies. The shortage of nurses in health care seemed to be the main reason why nurses delegated wound treatment to auxiliary nurses. This is similar to other studies (3,10,21). To change this, nurses must document to their supervisors how delegating wound treatment to the group of health care workers that has the least professional competence can affect the quality of care. Physicians and nurses should share responsibility for managing leg ulcer care, with assistance from auxiliary nurses to increase the quality of wound treatment based on best available evidence (2,11). Nevertheless, it is very positive that primary health care largely uses the primary nurse model. For patients, this means that they have one nurse (or at least very few) with whom they interact, more continuity in wound treatment, improved documentation and greater potential for active participation by the patient in care. Studies in which the primary nurse model has not been implemented showed a lack of continuity in assessing wounds, treating them, follow-up and documentation (22). This reduced the quality of the treatment offered to patients and increased costs. Nurses used different documentation systems. Only 20% of the nurses used a standardized wound record, although this form of documentation is recommended (23). Using a standardized wound record instead of continual evaluation reports improves the opportunities to assess the effect of treatment methods and procedures over a specific period of time and thereby assures high-quality treatment. Standardized wound records also provide a better basis for comparing current treatment with other types of intervention and can lead to new knowledge and new types of intervention with the aim of improving the quality of health outcomes. Primary health care should therefore increasingly attempt to use documentation systems that include good indicators for measuring the results of interventions. 32 The districts nurses’ knowledge of leg ulcer treatment More than half the nurses reported that they had insufficient knowledge about wound treatment. The main sources for updating knowledge were their experience and that of colleagues. These are still the most common sources for decision-making in clinical practice among nurses and similar groups and may undermine best practice in wound treatment (6,7,24,25). However, personal experiences and those of colleagues are important in wound treatment but not sufficient and must be seen in connection with the best available evidence (25,26). Research-based evidence on wound treatment is increasing rapidly, and nurses need to be updated with the latest evidence to provide optimal care for patients with leg ulcers. Research-based evidence demonstrates how treatment and care affect health outcomes and thus helps to assure quality in nursing practice. Such knowledge will become even more important in the future as a result of national standards for quality assurance, such as those in Norway (27), and because patients increasingly know more about current methods of treatment and their rights. Wound treatment delivered by people who are ignorant of avaiVÅRD I NORDEN 3/2008. PUBL. NO. 89 VOL. 28 NO. 3 PP 29–33 lable research evidence will miss important opportunities to benefit patients and may cause significant harm and threat to the safety of patients (1). This study indicated that not all district nurses used best evidence to secure good care. Nurses have a central role in leg ulcer care. Their expertise must be allowed to grow by continual education and the stimulation needed for their important job. One way to improve the knowledge of nurses in wound treatment would be to educate them in the different steps in evidence-based practice: formulating an answerable question, searching and critically appraising the evidence, implementing and evaluating the outcome (25,26). Nurses who work and understand the principle of evidence-based practice and have a critical attitude towards the evidence and their own practice will probably increase patient safety. A study (6) found that nurses mentioned a high level of knowledge as an important factor in wound treatment. Most nurses also reported that they felt uncertain about wound treatment, especially whether the procedure was the appropriate treatment, when the procedure should be changed and how often to change dressing. Uncertainty may effect the wound healing and may threaten patients’ well-being and prolong the healing period. This indicates that nurses need to be better educated in wound treatment. Closer collaboration between specialized clinics and primary health care is also recommended to reduce this uncertainty. Improving clinical practice also requires that nurses use clinical guidelines for the treatment of wounds: user-friendly statements that bring together the best external evidence and other knowledge necessary for making decisions about wound treatment. This should be required for all patients with leg ulcers (14). Conclusion and implications The treatment of leg ulcers in this study did not meet international guidelines, which can seriously threaten patient safety. Improving access to departments of dermatology may improve wound care treatment. The nurses’ lack of knowledge and skills must be taken seriously. The way they identified best practices was not in accordance with evidence-based practice. Further research is needed to investigate in depth the reasons for this and how to improve nursing knowledge to achieve safe health care based on best practices and high-quality care. Acknowledgement We acknowledge Jane Mikkelsen Kyrkjebø, Associate Professor, Department of Health and Social Sciences, Bergen University College for important advice in finishing the article. Accepted for publication 22.01. 2008 Hilde Smith-Strøm, Betanien Diaconal University College, Vestlundveien 19, NO–5145 Fyllingsdalen. [email protected] Ingun Thornes, RN, Department of Dermatology, Haukeland University Hospital, Bergen, Norway References 1. Detmer DE. Addressing the crisis in US health care: moving beyond denial. Quality and Safety in Health Care 2003;12:1–2. 2. Lindholm C, Bergensen D, Lindhagen A. Chronic wounds and nursing care. Journal of Wound Care 1999;8:5–10. 3. Lorimer KR, Harrison MB, Graham ID, Friedberg E, Davies B. Venous leg ulcer care: how evidence-based is nursing practice? Journal of Wound Care 2003;30:132–142. 4. Harrison MB, Graham ID, Lorimer K, Friedberg E, Pierscianowski T, Brandys T. Leg-ulcer care in the community, before and after implementation of an evidence-based service. Canadian Medical Association Journal 2005;172:1447–1452. 5. Moffatt CJ, Franks PJ. Epidemiology and health services research. Implementation of a leg ulcer strategy. British Journal of Dermatology 2004;151:857–867. 6. Haram R, Ribu E, Rustøen T. 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Dawes M, Summerskill W, Glasziou P, Catabellotta A, Marin J, Hopayian K, Porzsolt F, Burls A, Osborne J. Sicily Statement on Evidence-based Practice. Medical Education 2005;5:1–7. 27. …And it’s going to get better! National Strategy for Quality Improvement in Health and Social Services (2005–2015). For leaders and providers. Oslo: Directorate for Health and Social Affairs, 2005 (IS-1162 E; http://www.shdir.no/publlikkasjoner/handlingsplaner/_and_it_s_going_to_ get_better_32297, accessed February 20, 2008). 33 HILDE SMITH-STRØM OG INGUN THORNES Sykepleievitenskap . Omvårdnadsforskning . Nursing Science Personers upplevelse av att leva med kronisk hjärtsvikt – Systematisk litteraturstudie Ann-Sofi Barremo, Leg. sjuksk., Magister i omvårdnad – Elisabeth Bruce, Leg. sjuksk., Magister i omvårdnad – Monica Salander, Leg, sjuksk. Universitetsadjunkt – Karin Sundin, Leg, sjuksk., Med. doktor, Universitetslektor PERSONS’ EXPERIENCES OF LIVING WITH CONGESTIVE HEART FAILURE – A SYSTEMATIC LITERATURE REVIEW ABSTRACT Background: Heart failure is a clinical syndrome where the heart is no longer able to maintain adequate blood circulation to the tissue. Many suffer from symptoms difficult to handle such as dyspnoea, fatigue, and physical weakness. Aim: The purpose of the study was to investigate peoples’ experiences of living with congestive heart failure. Method: A systematic literature review was used. Relevant articles were found in the Medline and Cinahl databases. The articles were examined, classified and critically appraised. Twenty articles were included. A qualitative content analysis was used to organize the results. Results: The results are described in three main categories: losses, protecting independences and readjustment. The category ‘losses’ details physical, emotional and social changes that people experience as losses caused by the debilitating symptoms of heart failure. The category ‘protecting independences’ shows the different ways in which people try to keep control over their lives. The category ‘readjustment’ presents how people try to seek a new ‘wholeness’ in life after the changes heart failure have caused by using acceptance, adaptation and finding new meanings. Conclusion: Living with congestive heart failure can be experienced as a synopsis of the «suffering human being» on a continuum, a time axle; from falling ill to seeking a new meaning in life. KEYWORDS: heart failure, experience, literature review, qualitative content analysis, suffering. 34 Bakgrund Metod Antal personer som insjuknar i hjärtsvikt ökar i västvärlden (1, 2). Hjärtsvikt är en kronisk sjukdom med sviktande hjärtmuskelfunktion som kroppen försöker kompensera. Dessa kompensationsmekanismer får till slut motsatt effekt vilket leder till svåra konsekvenser (3). Hjärtsviktens svårighetsgrad delas in i fyra klasser enligt New York Heart Association, NYHA I- IV, från nedsatt hjärtfunktion utan några symtom till symtom redan i vila (4). Symtom som personer med kronisk hjärtsvikt vanligtvis drabbas av är uttalad andnöd (5), hosta, ökade urinmängder (6), ödem (3), illamående, aptitlöshet (7), försämrad sömn, trötthet (7–9), depressiva symtom (10–11), samt nedsatt fysisk funktion (12–17). Att drabbas av kronisk sjukdom kan leda till en känsla av sårbarhet, vilsenhet och ensamhet (18). Kroppen kommer i fokus på ett annat sätt än den gjorde utan sjukdom. Det som tidigare var känt och tryggt med kroppen har blivit alltmer okontrollerbart (19). Vid insjuknande i hjärtsvikt finns ofta svårigheter att självständigt klara av det dagliga livet och att medverka i det sociala livet på samma sätt som förr (20). Hjärtsvikten orsakar trötthet som upplevs som brist på fysisk energi. Det leder ofta till bristande överensstämmelse mellan individens kapacitet och intentioner (21). Att leva med svår kronisk hjärtsvikt innebär att inte veta vad som väntar imorgon, eftersom symtomen är komplexa, mångfacetterade och oförutsägbara. Sjukdomsförloppet kan upplevas som en «berg och dalbana», en pendling mellan försämring och förbättring (22–23). De flesta studier beträffande personer med hjärtsvikt skildras utifrån symtom och upplevelser som i huvudsak blivit beskrivna av andra än personen med hjärtsvikt (24). Det är önskvärt med en ökad kunskap och förståelse beträffande hur personer med hjärtsvikt upplever sin situation. Därför var syftet med denna litteraturstudie att utforska personers egna upplevelser av att leva med kronisk hjärtsvikt. Litteratursökning En systematisk litteratursökning som utgick från syftet genomfördes (25). Inklusionskriterier var män och kvinnor över 45 år med hjärtsvikt klassificerad I-IV enligt NYHA kriterierna (4), kvalitativa och kvantitativa artiklar skrivna på engelska. Exklusionskriterier var översiktsartiklar, studier beträffande personer med demens och barn, samt artiklar publicerade före 1995. Litteratursökning gjordes via databaserna Cinahl och Medline/PubMed. VÅRD I NORDEN 3/2008. PUBL. NO. 89 VOL. 28 NO. 3 PP 34–38 Urval Artiklarna valdes ut om de innehöll en etisk reflektion (26–27), om studiernas giltighet och pålitlighet diskuterades, om deras titlar, abstrakt eller nyckelord svarade mot studies syfte. Av de utvalda artiklarna hittades sju relevanta artiklar i Cinahl och sexton artiklar i Medline/Pubmed, varav tre var dubbletter. Procedur De tjugo utvalda artiklarnas vetenskapliga kvalitet granskades med hjälp av kvalitetsgranskningsprotokoll för kvalitativa studier (n=17), kvalitetsgranskningsprotokoll för kvantitativa studier (n=2), samt en artikel granskades med båda kvalitetsgranskningsprotokollen (28). Analys En kvalitativ innehållsanalys genomfördes på de 20 utvalda artiklarnas resultat. Syftet var att organisera, skapa struktur och finna mening i det insamlade materialet (26). Artiklarna lästes först i sin helhet för att få en första förståelse. Därefter lästes artiklarnas resultat igen ett flertal gånger för att finna en djupare förståelse. De meningsenheter som svarade mot syftet plockades ut. Meningsenheter med liknande betydelse fördes ihop och tolkades tillsammans för att abstraheras till underkategorier. Därefter sorterades alla underka- tegorier med samma betydelser ihop och huvudkategori konstruerades. Resultat Huvudresultatet indelades i tre kategorier: Förluster; Värna oberoendet; och Nyorientering. Resultatet presenteras med huvudkategorier som överrubriker och underkategorier som underrubriker. Förluster Upplevelser av fysiska förluster Ett flertal av de svårigheter som personer med kronisk hjärtsvikt upplevde orsakades av fysiska förluster som ledde till inskränkningar i det dagliga livet. Symtom såsom andnöd, trötthet och nedsatt energi (29–32) var påtagliga. Förlust av aktiviteter pga. muskelsvaghet (30, 33–37), svårigheter att ligga ned, ett ökat sömnbehov samt nedsatt alkoholtolerans (33) påverkade vardagen. Likaså törst, torr mun, nedsatt aptit tillsammans med tröttheten medförde ett försämrat förhållande till mat (38). Försämringar upplevdes även i det sexuella intresset och förmågan p.g.a. de fysiska symtomen (31, 37) och/eller orsakad av läkemedel (33). Andnöden och den svullna ödematösa kroppen kunde upplevas som att drunkna (34, 39) speciellt på morgonen (31, 34). «When you can’t breathe and you wonder what the hell, what do you mean I can’t breathe?...And the feeling is…like being under water» (34, s. 35) Nedsatt energi (35) och störd nattsömn pga. hosta och/eller urindrivande medicinering orsakade ökat sömnbehov dagtid (40). De fysiska symtomen ledde även till kognitiva konsekvenser såsom koncentrationssvårigheter och nedsatt intellektuell förmåga (33, 40). Detta upplevdes orsaka förlust av den kontroll de tidigare haft (32). Emotionella uttryck för förluster Att insjukna i kronisk hjärtsvikt innebar stora förändringar i livet, som kunde upplevas chockartat (31). I det tidiga skedet av hjärtsvikt orsakade de fysiska symtomen ofta upplevelser av ångest, nervositet, rädsla (33) samt nedstämdhet (34). Dessa känslor förändrades ofta när personen levt med hjärtsvikt en tid. Personer med hjärtsvikt beskrev att de i början av sjukdomsprocessen upplevde irritation, bitterhet och tomhetskänslor i samband med funderingar på varför de insjuknat samt på grund av omgivningens reaktioner. De uttryckte att de levde med mycket ilska och att svagheten som tillståndet orsakat irriterade dem. De upplevde personlighetsförändringar som bidrog till rädsla inför det dagliga livet och inför döden vilket var något helt nytt och skrämmande (31). De upplevde leda, frustration, depression, skuld, otålighet men även avundsjuka på friska personer (34). De upplevde sig även otrygga och misstänksamma i relationen till andra och till vårdpersonal, något som de tidigare inte haft problem med (29). Att inte ha fullständig kontroll över sjukdomstillståndet innebar oro inför döden, vardagliga bestyr och ekonomin (32, 41). Känslomässig kontroll ansågs svårare att uppnå än anpassning till det dagliga livets krav. Känslor av att vara arg, mindre lycklig och att ständigt kämpa mot sin rädsla upplevdes (32). Det var lättare att acceptera fysiska smärtor än svårigheter att orka med det psykiska, såsom att hålla skenet uppe inför sig själv och andra (36). En kamp utspelades mellan att försöka förstå tillståndet och hantera läkemedlen och symtomen orsakade av hjärtsvikten (39). Det fanns även en besvikelse över bristande information (33, 36, 42–43) som orsakade oro inför den ovissa framtiden. Känslor som hopplöshet, självförebråelser och otillfredsställelse i livet (41), förlust av hopp om framtiden, rädsla och oro över att inte kunna ta hand om sig själv längre och bli en börda för andra var påtaglig (29, 31–32, 35–36, 41). De hade varken känt sig lugna eller trygga av att vistas på sjukhus. Anledningen var att de upplevt smärtsamma procedurer, förlorad kontroll och nära döden upplevelser, vilket även bidrog till att de väntade länge med att åter uppsöka vård vid symtomförsämring (34). Ytterligare en anledning var att vårdpersonalen hade makten att bestämma över vårdvalet. Att vara beroendet av vårdpersonalen skapade en känsla av otrygghet och en del patienter upplevde att de kände sig mindre värda och att personalen inte beaktade deras behov. Samtidigt framhölls även att de upplevde det tryggt att bli bekräftad och igenkänd under vårdtiden (44). Upplevelser av sociala förluster Eftersom både den fysiska och mentala kapaciteten ofta var nedsatt upplevde personer med kronisk hjärtsvikt att de inte klarade av att upprätthålla tidigare socialt liv (33). Upplevelse av social isolering kunde uppstå på grund av de begränsningar som uppkommit genom minskad social aktivitet, restriktioner gällande vätska, diet, rökning och alkohol i det dagliga livet. Detta kunde upplevas betungande (31, 33–34, 41, 45). Vissa skämdes för att de inte mådde bra och att de inte gick att lita på när det gällde att delta i olika sociala aktiviteter. Exempelvis saknades glädjen över att äta på restaurang eftersom det inte upplevdes som tidigare. Även förmågan att vara sexuellt aktiv upplevdes förlorad. De upplevde att de inte längre kunde kräva av sin partner att stanna kvar hos dem och därigenom tvinga partnern att leva i celibat (33). Känslan av ensamhet upplevdes större då inte några anhöriga fanns i närheten (36). «The kids have their own lives».«…other people got a life. You can’t depend on them. You know, you take away their life because you can’t do anything» (31, s. 13) Värna oberoendet Strategier som hjälp för att hantera det dagliga livet En strävan att försöka hitta sätt som underlättade vardagen fanns. När andnöden var som värst skapade personer med hjärtsvikt kontroll över den genom att vara lugn samt genom olika egenvårdsåtgärder. De upplevde ett behov av att klara sig själva och anpassade sig därför till det nya tillståndet genom att utveckla nya metoder, rutiner och/eller strategier för att öka sitt oberoende (29, 38–40). De kunde välja bort praktiska göromål såsom städning för att i övrigt själva klara av det dagliga livet (32) eller att de valde bort fritidsaktiviteter för att istället klara av att vara yrkesarbetande (43). De försökte anpassa sig till sitt nya liv genom att bibehålla sitt lugn, tänka positivt, inte oroa sig och vara tacksamma för att de levde och de uppskattade de gånger de kunde ta sig ut i sociala sammanhang. Erfarenheten av sjukdomen hade gjort dem medvetna om sina begränsningar. De upplevde att läkemedlen hjälpte dem trots bieffekter (33). Trots trötthet och orkeslöshet tvingade de sig själva att genomföra aktiviteter när de i förväg bestämt sig för det (40). Att få bibehålla oberoendet och kontrollen gav en känsla av värdighet, självaktning och respekt (30). Upplevelse av stöd som hjälp för att själva hantera det dagliga livet Personer med hjärtsvikt upplevde ofta ett behov av praktiskt stöd från sin omgivning för att själva klara vardagen (32, 35, 41). Ett behov av psykosocialt stöd såsom relationen till familj och vänner upplevdes även betydelsefullt för att bibehålla hoppet, framtidstron (41, 45), lugnet och en bättre hantering av sömnsituationen (40). Att de hade någon att vända sig till gjorde att de kände sig tryggare (36). Även närheten till ett husdjur kunde vara av betydelse (32). «When you’re in the company of others, you have a tendency to forget about yourself’, I think having friends that care about you is the best medicine in the world.» (32, s. 446) Det fanns även ett upplevt behov av stöd från sjukvården för att själva klara av livet med hjärtsvikt. Det var stöd från de vårdgivare som personerna kände förtroende för och kunde samtala med (29, 32, 41) och som bidrog med tröst (39). De uppskattade även stöd från vårdpersonal för att kunna klara av sjukdomen i hemmet (30). De har även beskrivit att andlighet kunde ge dem hopp och stöd i hanteringen av sjukdomen (32, 39, 45). Hjärtsvikten upplevdes inte få sätta stopp för livet, de ansåg att de ville fortsätta leva med hjälp av Gud och råd från vårdpersonalen (43). Stöd i form av kommunikationshjälpmedel, att skriva brev, skicka e-mail och kunna samtala i telefonen (32, 41) upplevdes positivt av ANN-SOFI BARREMO, ELISABETH BRUCE, MONICA SALANDER OG KARIN SUNDIN 35 Sykepleievitenskap . Omvårdnadsforskning . Nursing Science vissa, liksom tekniska hjälpmedel såsom att bära en Med-eMonitor som bland annat påminde dem om när mediciner skulle tas, om diet och träning (46). Upplevelse av information som hjälp att hantera det dagliga livet Att erhålla information om hjärtsvikten (47) kunde inge hopp om framtiden. Att få vetskap om orsaken till att de drabbats, konsekvenser av hjärtsvikten samt hur de bäst skulle leva (42), till vem de kunde vända sig vid förändringar av tillståndet (31, 42, 47) samt information om prognosen upplevdes betydelsefullt. För att försöka skapa kontroll informerade de sig (45). Äldre personer med hjärtsvikt upplevde att de litade på sitt eget omdöme, vilket gjorde att de själva ansåg att de kände när de behövde skaffa sig mer information om sitt tillstånd (29). Behovet av förbättrad information upplevdes önskvärt framförallt hos personer som av en händelse fått diagnosen hjärtsvikt (47). Att få information om signaler och symtom ansågs viktigast. Därefter kom information om medicinering, prognos, riskfaktorer, generell information, diet, aktivitet och slutligen psykologiska faktorer (48). Vissa personer föredrog skriven information och andra muntlig information (34). Några upplevde att de fick kunskap genom att själva läsa foldrar de fått, vilket ingav stolthet (41). De önskade att informationen skulle vara objektiv och lätt att förstå men framförallt ge svar på de frågor de själva ställt samt att informationen förmedlades utan stress (42). Valet att inte vilja ha information Behov av att erhålla information upplevdes inte av alla samt kunde vara beroende av hur länge de levt med hjärtsvikt. Vissa upplevde att de fått tillräckligt med information redan. De uttryckte en rädsla för att informationen skulle skapa ångest och att hoppet om framtiden kunde försvinna om de fick information om prognosen. Personerna medgav också att de var medvetna om att de kommit till det stadiet i livet när döden närmade sig vilket gjorde att de inte upplevde ett behov av information om prognosen, eftersom det ändå inte förändrade något. Andra skäl till att inte vilja motta information var att de inte skulle vara kapabla att förstå informationen om hjärtsvikten och den medicinska behandlingen (42). Orsaken kunde även vara ointresse, förnekelse av hjärtsvikten eller att de överlämnade allt till vårdpersonalen (47). Nyorientering Existentiella funderingar Det faktum att livet snart var över hanterades på olika sätt. Bearbetningen genomfördes av vissa på ett filosofiskt plan, medan andra organiserade sina affärer och satte upp mål för det som de ville hinna uträtta innan livet var slut (30). Hur det hanterades var mer relaterat till åldern än till hjärtsvikten (42). Upplevelsen av att ha haft ett bra liv kunde i vissa fall befrämja en känsla av lugn och känslan av att vara mer redo att dö (44). Efter att ha levt med hjärtsvikt en längre tid uttryckte vissa personer att de blivit öppnare i sin andlighet och att de utforskade den mer än tidigare (32). Om en religiös tro fanns i grunden kunde en känsla av frid (45) och lugn infinna sig och de upplevde då minskad rädsla för döden (33). Hjärtsvikten upplevdes ibland bidra till att den andliga tron förstärktes, att det var Gud som bestämde och att de därmed lade sitt liv i Guds händer (32). Vissa upplevde också att hjärtsvikten varnade om tillståndet och dess konsekvenser och såg därför hjärtsvikten som en gåva. Hos andra fanns tvivel på Gud och känslor av att de inte förstod meningen med varför de insjuknat (39). 36 Acceptans och anpassning Trots den sorg och de förluster som hjärtsvikten orsakat kunde personer med kronisk hjärtsvikt uppleva att de måste inse allvaret i sjukdomen och acceptera att livet hängde på en skör tråd (38, 41) för att kunna gå vidare med sina liv (32, 39–40). Vissa försökte leva som om inget hänt, men när de ställdes inför viktiga val och beslut hade de hjärtsvikten i sina tankar (31). Fysiska symtom som trötthet, orkeslöshet och andningssvårigheter kunde ses som en naturlig del, de hade blivit mer medvetna om sina resurser som glädje och humor och försökte ta tillvara på dagen (44). När de hade insett att de måste leva VÅRD I NORDEN 3/2008. PUBL. NO. 89 VOL. 28 NO. 3 PP 34–38 med sin sjukdom och att de inte kunde påverka förloppet försökte de sträva efter så bra livskvalitet som möjligt (43). Förmågan att anpassa sig till en ny livsstil genom att utnyttja de resurser som de hade kvar och vila när det behövdes, gjorde det mer möjligt att acceptera de begränsningar som hjärtsvikten orsakade (29, 31–33, 35). Att erfara ny glädje i livet Personer med hjärtsvikt som kommit till insikt om sitt tillstånd och förlikat sig med detta kunde uppleva en ny glädje i livet. De försökte njuta av livet och göra saker som de visste att de i framtiden kommer att vara oförmögna att klara av. Trots svåra orosmoment fanns ett hopp om framtiden (31). Förmågan att fortfarande kunna vara en aning fysiskt aktiv kunde skapa en känsla av glädje hos dessa personer (33). De ansåg att små negativa saker inte fick störa, varje dag sågs istället som en välsignelse. Genom att hjälpa andra, ha sin Gudstro, utöva sin hobby och/eller fritidsaktiviteter fann de trots sjukdomen en mening och tillfredställelse i sina liv (39, 45). Resultatdiskussion Att insjukna i hjärtsvikt medför förluster som påverkar det dagliga livet. Denna litteraturstudie visar att i sjukdomsprocessens början fokuserar ofta personen med hjärtsvikt på de fysiska förlusterna som hjärtsvikten medför och därmed finns en risk att hanteringen av det emotionella och sociala lidandet hindras. Detta överensstämmer med Erikssons teori om lidande (49). Den oro som hjärtsvikten ofta orsakar kan vara tung att ensam hantera. Studier har visat att för att orka gå vidare behöver en sjuk och lidande person bekräftelse av en annan person (50–51). Denna bekräftelse kan förmedla tröst (52–55) och ge personen ökad kraft och möjlighet att genomlida och bearbeta sin förändrade livssituation, vilket enligt Younger (56) kan leda till utveckling. Om förståelse, bekräftelse och tröst däremot uteblir så kan det leda till ett onödigt ytterligare lidande som kan hindra bearbetningen av det existentiella lidandet (51, 57). Ekman et al. (29) visade i sin studie av personer med hjärtsvikt att upplevelsen av trygghet i situationen bland annat påverkas av relationen till vårdpersonalen. Denna litteraturstudie visar att när personer levt med hjärtsvikt en tid och börjat inse konsekvenserna av sjukdomen kan en pendling mellan hopp och hopplöshet infinna sig. Personerna kan då, i överensstämmelse med lidandeteorier (50), försöka att integrera den nya verkligheten på ett så funktionellt sätt som möjligt samt försöka värna oberoendet och ha en önskan om att vara delaktiga (51, 58). De kan då använda olika strategier och metoder för att försöka behålla kontrollen och själva klara av att hantera vardagen så att de inte utgör en belastning för andra. I linje med kristeorin (59) försöker de finna en nyorientering i tillvaron. Denna litteraturstudie visar att de flesta studier som fokuserar på upplevelsen hos personer med hjärtsvikt har innehåll som behandlat behovet av att värna oberoendet. Detta kan tolkas som att personer med hjärtsvikt har en drivkraft som styrs av ett inneboende hopp om en nyordnad framtid. Detta gör det enligt Morse och Penrod (60) möjligt att kämpa vidare och att inte ge upp. Det kan även, i överensstämmelse med Strandberg, Åström och Norbergs (61) studie, tolkas som att stävan efter att klara sig själv även styrs av den egna oron och rädslan över det kroniska tillstånd de befinner sig i och att de inte vill vara beroende. Att få vara i hoppet och sträva efter ett meningsfullt liv är påtagligt i litteraturstudien. Detta har även Benzein, Norberg och Saveman (62) funnit i sin studie när de studerade hoppets betydelse för personer med cancer. Den nyorientering som personer med hjärtsvikt kan uppleva kan utifrån Frankls teori om strävan efter meningsfullt liv (63) förstås som att personerna med hjärtsvikt uppnått försoning i sitt tillstånd. Resultatet i denna litteraturstudie visar hur personerna genom att anpassa sig till det nya tillståndet och sin nya identitet lyckats gå vidare med sina liv. Det kan förstås som att nya möjligheter och intressen fått ersätta det som gått förlorat och den självbild som rubbats har återuppbyggts (56, 60, 64). När personen med hjärtsvikt genomlidit förändringar och funnit sätt att hantera den nya tillvaron, så kan enligt Morse och Pendron (60) en förlikning ha skett med den nya tillvaron även känslomässigt. Insikten om att inte kunna ta livet för givet kan ha gjort att de upptäckt de små tingens värde. För att stå ut med förändringar i den förändrade livssituationen så görs försök att se glädjen i det lilla (45) Slutsats Litteraturstudiens resultat visar på att personer med hjärtsvikt upplever ett behov av att mötas med förståelse för sitt försämrade hälsotillstånd och sin nya livssituation som är fylld av förluster. De behöver stöd med praktiska angelägenheter och med bearbetning mot nyorientering i livet. Samtidigt har de ett stort behov av att uppleva självständighet. Det är av betydelse att vårdpersonalen inser och beaktar dessa till synes motsatta behov. Metoddiskussion Litteraturstudien utgick från en fokuserad problemformulering samt syfte. Frågor formulerades utifrån detta och användes som utgångspunkt för en planlagd systematisk sökning av vetenskapliga artiklar i databaser för att på bästa sätt besvara frågorna. Anpassade kvalitetsgranskningsmallar (28) användes, av författarna oberoende av varandra för att minska subjektiviteten, när de funna vetenskapliga artiklarna värderades systematiskt och kritiskt beträffande kvalitet, pålitlighet och giltighet (25). Resultaten av granskningarna jämfördes och sammanfördes därefter. De i litteraturstudien använda artiklarna hade god kvalitet vilket innebar att studierna hade genomförts utifrån redig problemformulering, det hade använts en relevant och giltig metod och det fanns en tydlig metodbeskrivning och resultatredovisning. Vidare användes i vår litteraturstudie formulerade frågor för att öka giltigheten, när svaren plockades ut från artiklarnas resultat. Svaren på frågorna från alla artiklar sammanfördes därefter till en text. Även upplevelser redovisade i artiklar genomförda med kvantitativ metod ingick i analysen (65). Därefter bearbetades texten med en kvalitativ innehållsanalys för att nå en djupare förståelse av upplevelser av att leva med kronisk hjärtsvikt. Akseptert for publisering 14.05.2008 2Ann-Sofi Barremo, leg. Sjuksköterska, Magister i omvårdnad (RN, MSc), 2Elisabeth Bruce, leg. Sjuksköterska, Magister i omvårdnad (RN, MSc), 1Monica Salander, leg, Sjuksköterska, Universitetsadjunkt (RN, Junior lecturer), 1Karin Sundin, leg, Sjuksköterska, Medicine doktor, Universitetslektor (RNT, MSc, PhD, Assistant Professor) 1 Umeå Universitet, Institutionen för Omvårdnad, Campus Örnsköldsvik (Umeå University, Department of Nursing, Campus Örnsköldsvik) 2 Västernorrlands läns landsting, Örnsköldsvik (Västernorrland County Council) Adress för korrespondens: Karin Sundin, Umeå Universitet, campus Örnsköldsvik, Box 843, SE – 891 18 Örnsköldsvik [email protected] Referenser 1. McMurray JJ, Stewart S. Epidemiology, aetiology, and prognosis of heart failure. Heart 2000; 83: 596–602. 2. Schenk-Gustafsson K. 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Sense of ‘understanding and being understood’ in the care of patients with communication difficulties, Umeå University Medical Dissertations. New Series No 699-ISBN 91-7191-933-3, Department of Nursing, Umeå University, Umeå, Sweden 2001. 58. Eldh AC, Ekman I, Ehnfors M. Conditions for patient participation and non-participation in health care. Nursing Ethics 2006; 13: 503–514. 59. Cullberg J. Kriser och utveckling. WS Bookwell, Finland 2001. 60. Morse JM, Penrod J. Linking concepts of enduring, uncertainty, suffering, and hope. Image: Journal of Nursing Scholarship 1999; 31: 145–150. 61. Strandberg G, Åström G, Norberg A. Struggling to be/shown oneself valuable and worthy to get care. One aspect of the meaning of being dependent on care – a study of one patient, his wife and two of his professional nurses. Scandinavian Journal of Caring Sciences 2002; 16: 43–51. 62. Benzein E, Norberg A, Saveman BI. The meaning of the lived experience of hope in patients with cancer in palliative home care. Palliative Medicine 2001; 15: 117–126. 63. Frankl VE. Man’s search for meaning: an introduction to logotherapy. Pocket Books, London 1984. 64. Jaarsma T, Halfen R, Tan F, Huijer Abu-Saad H, Dracup K, Diederiks J. Self-care and quality of life in patients with advanced heart failure: The effect of a supportive educational intervention. Heart & Lung 2000; 29: 319–330. 65. Sandelowski M. Combining qualitative and quantitative sampling, data collection, and analysis techniques in mixed-method studies. Research in Nursing and Health 2000; 23, 246–255. Short papers Synligt, osynligt och synliggjort 10 år i ett Nordiskt nätverk av sjuksköterskeutbildningar Sonia Bentling & Åke Lennander VISIBLE, INVISIBLE AND VISIBILIZED. TEN YEARS IN A NORDIC NETWORK IN NURSING EDUCATION ABSTRACT The multicultural society has impacts on the nursing profession and multicultural aspects of education have impacts on international cooperation. Material from 10 years in a Nordic network with higher education institutions within nursing was analysed in order to develop cooperation, mobility, curriculum and research. Methods of benchmarking were used in analysing political documents, memorandum, descriptions of the departments, course programs and reports from teachers and students. The results indicated that the process from planning to realization was unclear, ambitions were higher than outcomes; experiences of mobility were mostly described in terms of personal experiences, enriching and useful, but relations to political goals or institutional strategies were invisible. Effects on academic subjects or competence were not reported, nor were they asked for. Weeklong courses with more participants were successful. However the research method implied new insights in the results; experiences became visible effects beyond an individual level exists, but they had to be named and asked for. KEYWORDS: Internationalisation; networking in nursing education; benchmarking. Internationalisering och internationalisering på hemma plan (IaH) Internationalisering skall bidra till att skapa medborgare med kulturell kompetens och medvetenhet, som kan fungera i mångkulturella samhällen. Det mångkulturella samhället ger konsekvenser för sjuksköterskeprofessionen och mångkultur i utbildning ger konsekvenser för internationell samverkan. Mobilitet har vanligen angetts som mått på internationalisering, detta inte är tillräckligt. För att målen med internationalisering skall uppnås, måste effekterna ge avtryck i den dagliga verksamheten och knytas till hela institutionens arbete. Om inte, kan utlandsstudierna misslyckas i sitt uppdrag, mobiliteten reduceras till turism, med risk för att stereotypa bilder av värdlandet behålls. Internationalisering är en viktig hörnsten i högskolans arbete. Värdet av att utveckla en allmän kulturell kompetens är globalt förankrat. Idéerna kommer bland annat från UNESCO och WHO. Internationalisering och mobilitet förväntas ge positiva effekter på den akademiska utbildningen i allmänhet, på kulturell medvetenhet, internationell förståelse och även på världsfreden. Ett argument är att studenterna skall bli goda medborgare inte bara i sitt land utan i världen och kunna fungera internationellt och interkulturellt, många kommer att arbeta i andra länder men alla kommer att leva i multikulturella samhällen (1, 2, 3, 4). Enligt Nordiska ministerrådet finns en positiv attityd till nordisk samverkan men det är skillnad mellan attityder och verksamhet. Bolognaprocessen och en ökad europeisk samverkan genererar frågor om det finns en unik nordisk modell; exempel på «den bästa praktiken»; modeller för samverkan samt hur Norden kan bli synligt på den internationella arenan. Ministerrådet menar vidare att Norden inte är en homogen region, länderna är olika och studentmobiliteten är ojämnt fördelad, men nordisk samverkan är också exempel på en metod för att implementera Bolognaidéerna. Genom nätverk och samarbete kan Norden profilera sig som ett föregångsland för samverkan. Samarbetet fungerar väl, men kräver att man tar hänsyn till olikheterna, tydliggör strategier och att beskriva och jämföra nätverk kan ge uppslag till utvidgning och utveckling. (5). Student- och lärarmobilitet har varit den viktigaste vägen till internationalisering. Denna internationalisering genom import (6) innebär emellertid att det är svårt att veta om en kurs i ett annat land utvecklat internationella eller interkulturella erfarenheter. Den enskilda individen har troligen fått nya erfarenheter men även läroplaner och undervisningsstrategier måste organiseras så att de ger möjligheter till kri- tisk reflektion och utveckling. Trots omfattande insatser i utbytesprogram har mobilitet endast omfatta ca 10 % av studentpopulationen. De övriga 90 % berörs i liten eller ingen grad av utbytesverksamheten. Begreppet «Internationalisation at Home» (IaH) används för att beskriva aspekter som inkluderar institutioner, läroplaner, utbildningsideologier, kunskapsbegrepp och kulturella variationer på hemmaplan (7). All högre utbildning sker i en relativt likvärdig kultur, men föreställningar om undervisning, ämnesområde och nyckelbegrepp varierar, de bestäms av institutionernas ideologi men även av enskilda lärare. Internationalisering av läroplaner kan ha olika fokus som; kursinnehåll och utbildningsmetoder; förmedla globala perspektiv; förbereda för en internationell arbetsmarknad eller en total omstrukturering. «Filling the pot, or lighting the fire», är exempel på två poler mellan vilka många utbildningsinstitutioner befinner sig. Ideologierna ger helt olika pedagogiska metoder. Kunskapsbegrepp och utbildningskultur måste belysas, problematiseras och diskuteras (8, 9 ). Sjuksköterskeutbildningarna har länge arbetat med att utveckla och definiera ett nytt vetenskapligt ämne och högskolans ideologi, baserad på vetenskap och kritisk granskning har ersatt en utbildning som tidigare fokuserat praktisk handling. Utvecklingen är inte unik för Norden, den är globalt förankrad. Fältet omfattar en tolkning av människan, hälsan, vårdandet och den professionella uppgiften, men ämnesbeskrivningar, utbildningsinnehåll och professionella krav varierar. (10, 11). Vård (care) och bot (cure), liksom upplevelse av hälsa och sjukdom är kulturellt inlärt, relaterat till det omgivande samhällets värderingar och offentliga system. (12, 13). Patienten / vårdtagaren beskrivs med begrepp som: helhetssyn, individuella behov, livskvalitet och lidande, sjuksköterskan med krav på delaktighet, kommunikation och empati. Kulturkompetens blir en aspekt av den professionella kompetensen. Internationell samverkan kan bidra till utvecklingen av såväl individer som den gemensamma kunskapen men globalisering och internationalisering ställer även krav på att utveckla metoder om lärandet (14, 15, 16, 17). Politiska styrdokument anger att nordisk gemenskap och gemensamma värderingar är basen för att hålla ihop, profilera och ge tyngd åt samarbetet. «Samsyn» indikerar att samarbetet är enkelt, eftersom vi är lika. Problemet är att vi inte är lika. Variationer finns bland medborgarna och i utbildningsinstitutionerna. Det nordiska kulturbegreppet, professionella åtaganden, ämnesområdet och utbildningsideologier behöver belysas i internationellt samarbete. En pedagogisk konfeSONIA BENTLING OG ÅKE LENNANDER 39 Short papers rens i ett nordiskt nätverk, hade temat att öka kunskaperna om utbildningarna genom att belysa områden med potential för utveckling. Inför konferensen lämnade varje högskola material om formalia och eventuell pedagogisk eller vårdvetenskaplig profil. Då materialet diskuterades framträdde oklarheter och varierande tolkningar av begrepp, utbildningsnivåer och krav. Vidare illustrerades många av de svårigheter som följer med internationellt samarbete; man förstår inte allt på samma sätt på grund av olika språk, kulturer och traditioner. Ämnesområdet, professionella krav och strategier för att uppnå målen för akademisk sjuksköterskeutbildning och internationalisering behövde belysas. Syftet med föreliggande studie var att få underlag till en kritisk granskning och vidareutveckling av nätverksarbetet. Metod Planering och genomförande av studien utgick från «Benchmarking» (18, 19, 20, 21). Metoden innebär att undersöka aktiviteter för att belysa vad som pågår. Deltagarna beslutar vad som skall undersökas. Metoden är dels en strategi för att få människor att tänka utanför sina vanliga ramar, en inlärningsmetod där deltagarna identifierar och jämför aktiviteter för att finna styrkor och svagheter och slutligen en samverkans process. En projektgrupp av fem personer med ansvar för internationalisering vid tre av de ingående skolorna samt en projektledare genomförde arbetet. Det första förslaget till arbetsrubrik var: «Samma problem nu som då?» Syftet var att rikta tankarna mot vad man gjort. Under de första månadernas arbete formulerades en ny rubrik: «Fortfarande en osynlig verksamhet?» som ett resultat av de svårigheter som uppstod då material för analysen söktes och efterfrågades. Utifrån dessa frågor genomfördes datainsamling och analys. Datainsamlingen avser tiden från nätverkets start 1995 till 2003/2004. Materialet bestod av politiska styrdokument, dokument från nätverksmöten, officiella beskrivningar av institutionerna samt rapporter från lärare och studenter. I dokumentanalyser illustrerades formella regelverk, beslutsvägar och genomförda aktiviteter. Student- och lärarerfarenheter från rapporter och intervjuer tolkades i enlighet med kvalitativ forskningsansats. Resultat Nordmannätverket Nordiska ministerrådet är samordnade instans med representanter från regeringarna i fem länder; Danmark, Finland, Island, Norge och Sverige, och tre självstyrande områden; Grönland, Färöarna och Åland. Ett organ för forskning, utbildning och informationsteknologi HÖGUT, har som främsta uppgift att främja nordiskt samarbete genom att genomföra, följa upp och utveckla utvecklings- och samarbete för lärare och studenter (NORDPLUS-programmet) men även att frågan om internationalisering på hemmaplan aktualiseras. HÖGUT:s ambitioner förverkligas genom bidrag till nätverk. Nätverket Nordman består av åtta sjuksköterskeutbildningar; två i Danmark, en i Finland, en i Norge, tre i Sverige en på Åland. Nätverkets arbete planeras vid årliga nätverksmöten då ansökningar, tilldelning, mobilitet, kurser, avtal, mål och utvidgning diskuteras. Från år 1995 till och med 2004 genomfördes 13 nätverksmöten. 40 Utbildningsinstitutioner och mobilitet De ingående skolorna visade på stora variationer. Tre var rena sjuksköterskeutbildningar, de andra institutioner inom universitet/högskolor. Sjuksköterskeutbildningarna hade från 48 och 320 studenter vid de minsta skolorna till 1000 vid de största. Lärarantalet varierar på liknande sätt. Det är emellertid oklart hur många lärare som faktiskt fanns i programmen eftersom redovisningarna varierade, liksom benämningarna på akademiska examina och lärartjänster. Processen av «planering, beviljande och utfall» var otydlig; varken lärare eller studenter hade rest ut i den omfattning som man planerat och ansökt om medel för. Mellan nätverkets höga ambitioner och planering och det faktiska utfallet uppenbarades ett stort gap. Orsaken kunde spåras i svårigheterna att locka lärare och studenter till utlandsvistelser, samt att det saknades medvetna strategier. En annan var avsaknaden av riktlinjer för redovisning, att koordinatorns roll och institutionsledningarnas inblandning varit oklar. Ingen hade efterfrågat en systematisk VÅRD I NORDEN 3/2008. PUBL. NO. 89 VOL. 28 NO. 3 PP 39–41 redovisning. Nätverkskoordinatorn redovisade använda medel till Nordplus och rapporterade muntligt till övriga deltagare. Det blev en form av personlig kunskap hos koordinatorn och personer i nätverket. I beskrivningarna av institutionerna fanns en fråga om eventuell profil. Frågan hade tre syften. Det första var att sjuksköterskestudenter möter både ett annat universitet och människor i en annan vårdkontext, det andra gällde akademiseringsprocess och det tredje var att profiler kunde ge uppslag till gemensamma kurser, forskningsprojekt och «IaH». Några exempel redovisades; en skola arbetade med reflektion som inlärningsmetod, en annan med etik, livsåskådning och PBL, en tredje profilerade hälsobegreppet. Lärarmobiliteten motsvarade cirka 10 utbyten per år. Lärarna deltog i undervisning och gjorde studiebesök efter individuella önskemål vanligen under en vecka. Många utbyten beskrevs som personligt berikande, men det var oklart om eller hur de påverkat arbetet, kunskaperna eller institutionen. 10–25 studenter per år genomförde sina utlandsstudier som klinisk praktik under fyra till tolv veckor. Norska studenter reste helst till Danmark, Åland och till Stockholm, svenskar valde hela nätverket, åländska valde en skola i Sverige, samt Danmark och Norge, danska studenter valde Norge och Stockholm, finska studenter valde Stockholmsskolor och Danmark. Erfarenheter av utbyten Sex studentrapporter och sex lärarrapporter, från samtliga skolor har granskats med fokus på kulturella och kunskapsmässiga erfarenheter. Det fanns tydliga skillnader mellan lärarnas och studenternas beskrivningar. Lärarna hade ofta en speciell fråga som de ville diskutera eller ta del av värdskolans erfarenheter av exempelvis distansutbildning eller akademiseringen. Flera uttryckte att det varit intressant och värdefullt att ta del av kollegornas erfarenheter, att det inte var formellt meriterande samt att det medförde en hel del extra arbete. Det blev ofta en kamp mellan personliga intressen och institutionernas krav på arbetsinsatser. Några exempel på pedagogiskt samarbete redovisades men den internationaliserig på hemmaplan, som skall främjas av utbytesverksamhet, hade inte påverkats av nätverkets aktiviteter. Studenterna var vagare i sina förväntningar men tydligare i sina slutsatser. Kulturella erfarenheter, som bidragit till egen utveckling, var behållningen. Eventuella språksvårigheter var övergående. Osäkerheten inför att komma till ett nytt land överbryggdes med hjälp av faddrar, gemensamt boende och att delta i kurser. Det kunskapsmässiga utbytet var svårt att skilja från den inre utveckling som de flesta kommenterade, som att «det varit berikande för själen; blivit mera öppen och fri i mötet med andra; man växer med utmaningen; mera självständig; bättre på att möta människor med olika bakgrunder». Alla beskrev skillnader mellan ländernas hälso- och sjukvård, att det professionella fältet varierade men inte om eller hur man hanterat dessa skillnader eller om det påverkat den egna kunskapen. Rutinerna för att rapportera varierade, liksom innehållet. Mobiliteten beskrevs vanligen som «turism», givetvis berikande för individen, men relationen till övergripande mål eller pedagogiska strategier var osynlig. Vid presentationen av rapporten i samband med en ny pedagogisk konferens 2005 framfördes emellertid från lärare som deltagit i mobilitet att det har stor inverkan på den personliga utvecklingen trots att detta inte framgått av det analyserade materialet. Områden som distansutbildning och klinisk handledning har utvecklats genom nätverkssamarbetet. Studenterna påpekade att lärare som varit i andra länder relaterar till detta och berikar därmed undervisningen. Internationellt utbyte ger alltså avtryck i den enskilde lärarens vardag och det kommer även de studenter tillgodo som träffar läraren ifråga, men detta syns inte i de analyserade beskrivningarna; det kan med andra ord beskrivas som en form av tyst kunskap i lärarens arbete, och som befintliga men osynliga effekter på hemmaplan. Intensivkurser och pedagogiska konferenser Två intensivkurser och en pedagogisk konferens genomfördes åren 1995–2004. Kurserna omfattade en vecka (internat) med föreläsningar, seminariet och diskussioner. I de första kurserna, «Handledning och vägledning under klinisk praktik», deltog 15 lärare och 19 studenter, i «Klinisk handledning – ett samband mellan teori och praktik i sjukskö- terskeutbildning» deltog 13 lärare och 24 studenter. Utvärderingarna visade att kulturella erfarenheterna fick stor plats, att det varit berikande men inte på vilket sätt. Enkelt boende, studenter och lärare tillsammans, nära kontakter gav gemenskapen och tankeutbyte, den problematiska handledarrollen, «att agera som den goda modern eller som trädgårdsmästaren» illustrerade olika pedagogiska metoder som gav avtryck i handledningsarbete. I den första pedagogiska konferensen med temat «Ökad förståelse för de olika utbildningarna och vidareutveckling av nätverkssamarbetet», deltog 21 lärare. Utifrån ett kulturkomparativt perspektiv fokuserades idé och verklighet, möjligheter och hinder, samt metoder för att förstå sig själv och andra. Även här poängterades att en inspirerande miljön gav tid till eftertanke och kreativ samvaro. Sammanfattning av resultaten Nätverkets ambitioner har varit högre än utfallet, mobiliteten har ökat något och erfarenheter beskrivs vanligen som en individuell upplevelse, tämligen fri i förhållande till strategier, kunskapsutveckling eller IaH. Effekter av utlandsvistelser fanns, men de efterfrågades sällan och syntes inte i utvärderingarna. Reflektion och att dela erfarenheter med andra var avgörande för att nå optimal effekt. Veckolånga kurser gav störst utdelning som språngbräda för fortsatt utveckling. Efter hand som rapporten (22) blev tillgänglig uppenbarades även exempel på erfarenheter som kan föras till området «tyst kunskap». Analyser och slutsatser provocerade tankarna så att man kunde sätta ord på erfarenheter som inte nämnts vid intervjuerna. Slutsatser Syftet med studien var att bidra till utveckling av Nordmannätverket. Internationaliseringen skall främja kulturell kompetens, satsningen på internationalisering har inte givit önskade resultat även om Nordplus verksamhet varit framgångsrik. Internationaliseringsprocessens kan beskrivas i fyra steg (23). Det första är student- och lärarmobilitet, det andra samverkan i läroplaner och forskning, det tredje IaH och det fjärde att saluföra resultat. Nordmannätverket är på väg mot steg två. Metoden «benchmarking» har bidragit till en fördjupning av arbetet på flera plan: till kunskapsutveckling hos dem som genomfört studien, lämnat data och delgivits resultaten samt till belysning av dolda aspekter. Internationell samverkan kräver förberedelse och uppföljning, det professionella fältet och ämnesområdet behöver problematiseras, reflektion över erfarenheter bör delas med andra, utbytesstudenter skall involveras i utbildningarna, samverkan bör beakta institutionernas profiler och pedagogiska ideologier om internationaliseringen skall få önskade effekter. Resultaten sammanfattas under rubrikerna: osynligt, synligt och synliggjort. «Det osynliga» refererar till politiska skrivningar om nordisk identitet, mångkulturellt samhälle, professionellt ämnesområde, samt pedagogiska ideologier. Detta finns i styrdokument och forskning men framträder inte i det analyserade materialet. «Det synliga» illustrerar nätverkets ambitioner som varit högre än utfallet, att mobiliteten ökat något, att personliga erfarenheter varit berikande och utvecklande samt att veckolånga kurser givit goda resultat. «Det synliggjorda» innebär att i datainsamling och tolkningsarbete synliggjordes rutiner, eller brist på rutiner i planering, genomförande och rapportering, samt att lärares undervisning påverkas och studenter kommer i åtnjutande av andras internationella erfarenheter, men det förblir på en personlig nivå om inte någon frågar efter det. Frågor om och i så fall varför någon institution är särskilt attraktiv; om mobiliteten uttrycker en medveten strategi; hur ämnesområdet och det professionella fältet varierar eller om det mångkulturella samhället/studentgruppen, utnyttjas kan ställas men inte besvaras efter denna studie. Sonia Bentling Docent, Fil. dr. universitetslektor, Mälardalens högskola, Akademin för hälsa, vård och välfärd, SE – Box 883 72123 Västerås. [email protected] Åke Lennander, Fil.kand. universitetsadjunkt, koordinator Nordmannätverket. Mälardalens högskola, Akademin för hälsa, vård och välfärd SE Box 325, 63105 Eskilstuna. [email protected] 41 Referenser 1. Brewer, E. (2004). From Student Mobility to Internationalisation at Home. Paper presented at the conference on «New Directions in International Education: Building Context, Connections and Knowledge. Beloit College, October 29–30 2004. www.beloit.edu/oie/conference/Brewer 2. Leask, B. (2001). Internationalisation: Changing contexts and their implications for teaching, learning and assessment. In L. Richardsson and J. Lindstone (Eds) Flexible Learning for a Flexibel Society, 389–401. www.aset.org.av/confs./aset_hersa2000 proc/leaskl-51k. 3. Nordiska Nordiska ministerrådet (2002). Nordisk samarbeid innen högre utdanning Handlinsplan 2002–2004. Styrningsgruppen for Nordisk samarbeid innen högre utdanning. HÖGUT. 4. Teekens, H. (2005). Internationalization at Home a background paper. Rotterdam, the Netherlands: International conference 9–10 May 2005. www.nuffic.nl/pdf/network 5. Maassen, P. & Uppström, T. M. (2005). Rethinking Nordic Cooperation in Higher Education. Internationalization of Higher Education Institutions in Northern Europe in the Light of Bologna. Copenhagen: Nordic Council of Ministers. TemaNord 2005:520. 6. Caruna,V. & Hanstock, J. (2003). Internationalising the Curriculum: From Policy to Practice. Paper presented at Salford University: Education in a Changing Environment 17–18 September 2003. www.edu.salford.ac.uk/ her/pro. 7. Crowther, P., Joris, M., Otten, M., Nilsson, B., Teekens, H. & Wächter, B. (2002). Internationalisation at Home. A position Paper. Amsterdam: European Association for International Education (EAIE). 8. Bentling, S. (1992). I idéernas värld. En analys av omvårdnad som vetenskap och grund för en professionell utbildning. Uppsala Studies in Education 45. Stockholm: Almqvist & Wiksell. 9. Ho, E., Bulman -Fleming, B. & Mitchell, B. (2003). Course Internationalization: Engaging Students As Learning Resources. University of Waterloo, Ontario: Canadian Bureau for International Education, 2003 Annual Conference. 10. Matilainen, D. & Eriksson, K. (red.) (2004). Vårdvetenskapens didaktik. Caritativ didaktik i vårdandets tjänst. Åbo Akademi, Institutionen för vårdvetenskap Vårdforskning 9/2004. 11. Bentling, S. (1995). Sjuksköterskeprofessionen. Vetenskapliga idéer och kunskapsutveckling. Falköping: Liber utbildning. 12. Andrews, M. & Boyle, J. (1995). Transcultural Concepts in Nursing Care. Philadelphia: J.B. Lippincott Company. 13. Spector, R (2000). Cultural Diversity in Health &Illness. New Jersey: Prentic Hall. 14. Lee, N. J. (1997). Learning from abroad: Benefits for nursing. Journal of Nursing Management, 5. 359 –365. 15. Merill, E. B. (1998). Culturally Diverse Students Enrolled in Nursing: Barriers Influencing Success. Journal of Cultural Diversity. Vol.5. No. 2, 58–66. 16. Woods Byrne, M. & Falk, K.(996). Philosophical Distanciation. An evaluation strategy for International Faculty Exchange in Health Sciences. Nursing Leadership Forum. 2 (4). Winter, 132–139. 17. Omeri, A., Malcolm, P., Ahren, M. &Wellington, B.(2003). Meeting the challenges of cultural diversity in the academic setting. NURSE. EDUC. PRACT. 2003 Mar; 3(1): 5–22. 18. Adatia Sandström, S. (2003) BIHUNE Benchmarking Internationalisation at Home (IaH) in Undergraduate Nursing Education in Europe. Final report. Socrates programme «General activities of observation and Analysis». Action 6.1. Växjö Universitet. 19. Daniels, N., Bryant, J., Castano, R. A., Danetes, O. G., Kahn, K. S. & Pannarunothai, S. (2000). Benchmarking of fairness for health care reform: a policy tool for developing countries. Bulletin of the world Health Organisation, 2000, 78 (6). 20. Jackson, N. & Lund, H. (2000). Benchmarking for Higher Education. Oxford: Society for Research into Higher Education & Open University Press. 21. Virtanen, A. & Mertano, S. (Ed) (1999). Learning by comparing. The Benchmarking of Administration at the Univeristy of Helsinki. Helsinki: Publications of Higher Education Evaluation Council 12: 1999 22. Bentling, S. & Lennander, Å. (2005). Idé, ambition och verklighet. Beskrivning och kritisk granskning av Nordmannätverket 1995– 2004. Nordmannätverket & Mälardalens högskola. Institutionen för vård- och folkhälsovetenskap http://www.mdh.se/polopoly_fs/1.10333!kritisk_gransking_ nordman_10_ar.pdf 23. Söderqvist, M. (2001). The internationalisation and strategic planning of higher-education institutions : an analysis of Finnish EPS strategies. Helsinki: Helsingin kauppakorkeakoulu ISSN 0356-889X SONIA BENTLING OG ÅKE LENNANDER Short papers Veiledningsmodell for sykepleierstudenter i sykehjem – en evalueringsstudie Siv Sønsteby Nordhagen Sykepleier, Høgskolelærer – Ragna Ingeborg Engelien, Sykepleier, Høgskolelærer – Inger Signe Johansson, Professor GUIDANCE MODEL FOR STUDENT NURSES AT NURSING HOMES – AN EVALUATION STUDY ABSTRACT The development project began in 2001 at a college in Eastern Norway. The aim was to concretize and structure the guidance of student nurses in their first and third years of bachelor degree study by operationalizing and implementing relevant learning situations at nursing homes in a guidance model. The model was evaluated in order to determine whether the application of the model had clarified and improved the nursing home as a trainee site for student nurses. Students in their first year respectively third year of study (n=41 vs n=14), and fifty-five instructor nurses participated in the evaluation after the trainee period. A questionnaire was distributed to the participants which focused on the impact of the guidance model. The results indicate that the guidance model increases consciousness and appears to motivate students and instructor nurses in the first year to a higher degree than is the case with participants in their third year. The comments confirm that through the guidance model, students quickly discover the focus of learning at nursing homes. The students expressed wishes that the guidance model be used to a larger extent in situations in which student, teacher and instructor nurse together are reflecting over clinical situations. KEY WORDS: evaluation study, guidance model, nursing home Bakgrunn 42 Rammeplanen for sykepleieutdanningen – og retningslinjene fra departementet – krever samarbeidsavtaler og ansvarsfordeling mellom høgskole og praksisfelt om veiledning av studenter (1,2). Det formelle ansvaret for praksisopplæringen har utdanningene, mens gjennomføringen «styres» av praksisfeltet. Dermed er det legitimt for praksis å si at utdanningen ikke er god nok. Karseth (3) mener dette underkjenner helsefeltets opplæringsansvar. Flere mener det er praksisfeltet som sitter med nøkkelen til å bestemme hvordan praksis skal organisere(4). Det har vært – og er – en viss ulikhet i fokus mellom profesjonsutdanningene og yrkesfeltet, ikke minst etter at utdanningene ble selvstendige institusjoner (3,5,6). Studentene trenger et strukturert læringsmiljø, som synliggjør læringsmålene for studentene (7,8). Læring av erfaring i praksis står og faller på muligheten til å observere, tolke, vurdere og reflektere (9,10). Det framkommer i flere studier at studentenes utvikling av gode læringsstrategier er tett forbundet med deres oppfattelse av læringskonteksten. Det er derfor viktig å kreve innsats og engasjement fra studentenes side fra første dag (11,12). Læring i den fagpraktiserende verden er en krevende og kompleks prosess. Det krever tillit og utholdenhet. Dette bør ha som konsekvens at praksisstudier konsentreres om de læringsaktiviteter som ikke kan realiseres i skolen (13,14,15). I sykehjem har kompleksiteten i forhold til sykepleiehandlinger blitt betydelig større de senere år, flere eldre multisyke pleies i sykehjem på grunn av omorganiseringer i helsevesenet. Dette gir læresituasjoner i forhold til helhetstenkning, fagutvikling, ledelse, og en god læringsarena for grunnleggende pleie og omsorg (16,17). Det er en utfordring på mange av praksisplassene å sette den kritiske tenkningen i system og å dokumentere kunnskapen. Dette er i samsvar med internasjonale studier (9,18). Et utviklingsprosjekt startet i 2001 ved en Høgskole på Østlandet i Norge. Målsettingen var å konkretisere og strukturere veiledningen av studenter i første – og tredje studieår gjennom opprasjonalisering og implementering av læresituasjoner ved sykehjem. For å utvikle en veiledningsmodell for læresituasjoner ble fokusgruppe benyttet. Fokusgruppa besto av en sykepleier fra hvert av de VÅRD I NORDEN 3/2008. PUBL. NO. 89 VOL. 28 NO. 3 PP 42–45 fire sykehjemmene i prosjektet, samt prosjektansvarlige (Engelien, Nordhagen). Strukturen og den teoretiske forankringen for veiledningsmodellen og implementeringen av denne utgår fra prinsipper for aksjonsforskning (19,20), samt Reason & Herson’s fire faser (21): Forberedelse –, orientering –, implementering – og evalueringsfase. I forberedelsesfasen foregikk kunnskapsdialogen i fokusgruppa. Dette la grunnlag for felles forståelse i prosjektet med følgende målsetting for veiledningsmodellen: – Kvalitetssikre praksisstudier i sykehjem. – Identifisere, konkretisere og dokumentere læresituasjoner i sykehjem. – Studentene anvender aktuelle læresituasjoner. – Bidra til fagutvikling og refleksjon i høgskolen i samarbeid med praksisfelt. De sykehjem som deltok i utviklingen av veiledningsmodellen identifiserte og beskrev sykepleiehandlinger som ble sammenfattet og systematiserte til læresituasjoner. Ved å systematisere etter sykehjemmenes krav til kvalitet på pleie, ble dette også en opprasjonalisering av kvalitetsforskriften til anvendelse i sykehjemmene (17). Kvalitetskravene samsvarer med målsetningen i studentenes fagplan og pasientenes grunnleggende behov. Veiledningsmodellen fokuserer på 110 læresituasjoner som gir studentene mulighet til å dokumentere progresjon innen fire nivåer av delaktighet, forankret i en teoretisk referanseramme fra Simpson og Moxnes (22,23). 1) observere 2) assistere 3) planlegge/ gjøre 4) reflektere skriftlig. Veiledningsmodellens utvikling og implementering redegjøres for i to rapporter (24,25). Figur 1 viser eksempel på et av de fjorten kvalitets kriteriene i veiledningsmodellen, samt hvordan kriteriet opprasjonaliseres i læresituasjoner. Denne opprasjonaliseringen av kriteriet personlig hygiene anvendes i før – og etter veiledning. Evalueringen av den anvendte veiledningsmodellen ble gjennomført i skoleåret 2002/2003. Informasjonen om veiledningsmodellen ble gitt faglig ledelse ved høgskolen og sykehjemmene, disse godkjente evalueringen. Hensikten med evalueringen var å få svar på om anvendelsen av veiledningsmodellen hadde tydeliggjort og bedret sykehjemmet som læringsarena. 43 Figur 1 Operasjonaliserte læresituasjoner i forhold til et kriterium i veiledningsmodellen KRITERIET: (TOALETT) FÅ IVARETA PERSONLIG HYGIENE OG NATURLIGE FUNKSJONER Læresituasjoner: Dette forutsetter at vi som pleiere har data som gir mulighet for individuell hjelp: Progresjonsnivåer Observere Assistere Planlegge/ lede Reflektert skriftlig Stell av pasient i seng Stell av pasient ved vasken / eller på sengekanten med fat Utføre dusj/karbad Fotstell /neglestell Barbering Hudpleie Sengeredning av tom seng Sengeredning med pasient i seng Forebygge eliminasjonsproblemer. Planlegger toalettbesøk eller bleieskift regelmessig Hjelpe pasienten med bleieskift / smøring av huden Utføre engangskatetrisering Legge inn permanent kateter Stell av permanent kateter Hjelpemidler i forhold til eliminasjon Dokumentasjon av eliminasjon Metode rene er systematisert ut fra likheter og ulikheter i svarene på spørsmålene fra informantgruppene. Informantene Etter avsluttet praksisperiode i første – og tredje studieår, deltok 41 Funn: første års – og 14 tredje års studenter, samt 55 praksisveiledere i evaResultatet av evalueringen presenteres i tabell 1. Den viser svarfrelueringen av veiledningsmodellen. Praksisveilederne er sykepleiere kvens og bortfall på spørreskjemaets spørsmål. Deretter presenteres eller hjelpepleiere ansatt ved de avdelingene der studentene praktikommentarer til respektive spørsmål. serte. Samtlige studenter med respektive praksisveiledere ved Tabell 1: Evaluering av veiledningsmodell. de fire sykehjemmene deltok. I et følgebrev til informantene redeSpørsmål i spørreskjemaet Ja: Nei: Ubesvart gjorde vi for hensikten, anonyantall (%) antall(%) antall(%) mitet og frivillighet. 1. Har struktureringen vært til hjelp for å 1.års studenter 27 (100%) tydeliggjøre sykehjemmets mål og 3.års studenter 9 (82 %) 2 (18 %) Datainnsamling læresituasjoner? Praksisveiledere 19 (90%) 0 2 (10%) For evalueringen av veilednings2. Har strukturering av læresituasjonene 1.års studenter 17 (63%) 10(37%) modellen anvendtes et spørreskjema. vært en hjelp til faglig refleksjon i 3.års studenter 2 (18%) 9 (82%) Spørreskjemaet er utviklet veiledningen? Praksisveiledere 14 (67%) 2 (10%) 5 (23%) gjennom den didaktiske rela3. Har skriftliggjøring av læresituasjonene 1.års studenter 24 (89%) 3 (11%) sjonsmodell som referanseramme virket motiverende på deg? 3.års studenter 5 (45%) 6 (55%) (26), og omfattes av sju spørsmål Praksisveiledere 19 (90%) 1 (5 %) 1 (5 %) med fokus på innhold, struktur og 4. Mener du at avkryssingsrubrikkene 1) på 1.års studenter 26 (96%) 1 (4 %) anvendelse av læresituasjonene i læresituasjonene er hensiktsmessig for 3.års studenter 6 (55%) 4 (36%) 1 (9 %) praksisstudiet. Hver variabel har læring? Praksisveiledere 17 (81%) 4 (19%) svaralternativ ja/nei, samt plass 5. Var det hensiktsmessig å systematisere 1.års studenter 26 (96%) 1 (4%) for egne kommentarer på de respektive spørsmålene. Spørrelæresituasjonene på sykehjemmet ut fra 3.års studenter 9 (82%) 2 (18%) skjema ble besvart av 27 første kravene i kvalitetsforskriften? Praksisveiledere 19 (90%) 1 (5 %) 1 (5 %) års studenter (65 %), 11 tredje års 6. Har du bevisst brukt kvalitetsforskriften i 1.års studenter 25 (92%) 2 (8 %) studenter (80 %), og 21 praksisutøvelsen av sykepleiehandlinger for å 3.års studenter 9 (82%) 2 (18%) veiledere (40 %). dekke pasientens grunnleggende behov? Praksisveiledere 15 (71%) 5 (24%) 1 (5 %) Databearbeidingen av svarene i 7. Er det samsvar mellom de beskrevne 1.års studenter 23 (85%) 4 (15%) spørreskjema er gjennomført ved læresituasjonene og det du opplevde på 3.års studenter 8 (73%) 3 (27%) hjelp av deskriptiv statistikk, presykehjemmet? Praksisveiledere fikk ikke spørsmålet sentert i tabell, med prosent og frekvens fra de tre informantgruppene. De kvalitative kommenta- 1) Progresjonsnivåene: observere – assistere – planlegge/gjøre – reflektere skriftlig SIV SØNSTEBY NORDHAGEN, RAGNA INGEBORG ENGELIEN OG INGER SIGNE JOHANSSON Short papers Tabell 1 viser at veiledningsmodellen virker motiverende og forenkler læringsprosessen for første års studenter og praksisveilederne. Modellen tydeliggjør mangfoldet av læresituasjoner, og svarene viser at progresjonsnivåene er hensiktsmessig for læring. For tredje års studenter skaper veiledningsmodellen en oversikt over sykehjemmets mål og læresituasjoner, men er til mindre hjelp i faglig refleksjon og motivasjon enn for første årsstudentene. Majoriteten av de tre informantgruppene mener det er hensiktsmessig å systematisere læresituasjonene ut fra kvalitetsforskriften, og at dette gir en god oversikt. Evalueringen viser at sykepleiestudentene i første – og tredje studieår mener det er samsvar mellom læresituasjoner som er beskrevet i veiledningsmodellen og det de opplever i praksis på sykehjemmene. Kommentarer til spørreskjemaets spørsmål: Tydeliggjøring av sykehjemmets mål og læresituasjoner har betydning i forberedelse til praksisstudier på sykehjem og forenkler «bli kjent fasen» for begge student gruppene: «Veiledningsmodellen skaper refleksjonsgrunnlag og øker forståelsen.» (1.års student) «Flott å få de strukturerte læresituasjonene før praksis for å planlegge, og skrive individuell målsetting» (3.års student). Strukturering av læresituasjoner er ikke nok, studentene trenger tid sammen med praksisveilederne for å kunne reflektere faglig. Refleksjon er vanskelig uten veiledning mener første – og tredje års studenter. Det fremkommer av kommentarene at tredje års studenter har lettere for å få oversikt over læresituasjonene som finnes uten å benytte veiledningsmodellen. Skriftliggjøringen og opprasjonaliseringen letter veiledningen, og er bevisstgjørende i forhold til egen kompetanse. «Dette skaper motivasjon i veiledningen» (praksisveileder). Progresjonsnivåene «gir oversikt og får en til å tenke på hvor mye som er viktig innen pleie og omsorg» kommenterer første års studenter. De tredje års studenter som mener dokumentasjon av progresjon er negativt, kommenterer likevel dette kan være positivt for første års studenter. Praksisveilederne sier at struktureringen er et hjelpemiddel for å synliggjøre de læresituasjonene som finnes, og studentene har mulighet til å prioritere og dokumenterer egen deltakelse. Veilederne begrunner dette med at progresjonsnivåene er bevisstgjørende for studentenes nivå, og læringens mangfold i praksisperioden. Kvalitetsforskriften er av studentene benyttet i utøvelsen av sykepleiehandlinger for å dekke pasientenes grunnleggende behov. Det er spesielt i forbindelse med refleksjonsoppgaver av skriftlig karakter at tredje års studenter har benyttet kvalitetsforskriften. Praksisveilederne benyttet tidligere i liten grad kvalitetsforskriften i utøvelsen av sykepleiehandlinger. De som benyttet kvalitetsforskriften som en referanse i sitt arbeid var nyutdannede fra vår høgskole. Praksisveilederne kommenterer at synliggjøring av kvalitetsforskriften er et viktig bidrag for å bevisstgjøre alle om hva som ligger til grunn av lover og forskrifter for den pleien de utfører, og hvilke krav og rettigheter pasientene har. Kommentarer for forbedringer/endring av de strukturerte læresituasjonene: I hovedsak mener studentene at læresituasjonene bør brukes mer aktivt i veiledning og refleksjon av lærerne på høgskolen og praksisveilederne. Tredje års studenter kommenterte: «Det er behov for å videreutvikle veiledningsmodellen i forhold til læringsfokus i tredje studieår». Praksisveilederne kommenterer at de strukturerte læresituasjonene gjør det enklere for dem å vite hvilke krav / forventninger de skal ha til studenten, og studentene vet hva de kan lære. Enkelte praksisveileder mener konkretisering av læresituasjoner gir studentene en tidlig bevisstgjøring for utøvelsen av yrket. Ved å veilede studenter får praksisfeltet mulighet til å oppdatere seg faglig. Diskusjon 44 Artikkelen omfatter en evaluering av sykehjem som læringsarena. Evalueringen fokuserer på en veiledningsmodell utviklet for å synligVÅRD I NORDEN 3/2008. PUBL. NO. 89 VOL. 28 NO. 3 PP 42–45 gjøre læresituasjoner for sykepleiestudenter, og for å konkretisere veiledningsfokus for praksisveilederne på sykehjem. Diskusjon av funn: Grunnlaget for kunnskapsutvikling finnes i praksis, og anvendelse av teoretisk kunnskap i praksis er nødvendig for evaluering og videreutvikling av kunnskap (26 ). Resultatet viser at dokumentasjon og anvendelse av læresituasjoner i praksis kan utvikle studentenes praktiske kunnskap, og sykehjemmene blir bedre læringsarenaer. Studentene opplever gjennom læresituasjonene at de blir tatt i mot på en forberedt, strukturert og profesjonell måte. Dette hjelper studentene til å få en god start i forhold til krav og mål. Dette er i tråd med studier gjennomført på andre praksisarenaer (11,14). Veiledningsmodellen synliggjør det mangfold av læresituasjoner som finnes i sykehjem. Funnene viser at dette bidrar til mer motiverte og reflekterte studenter ved at de dokumenterer for seg selv og andre hvilke læresituasjoner de har utført, dette påpeker Halland i forhold til pedagogisk veiledning (27). Det er verdt å poengtere at studentene ikke har utviklet praktisk kunnskap ved å ha utført læresituasjonen, ferdighetstrening krever gjentakelse. Dette samsvarer med Fagermoen’s beskrivelse av en progressiv læringsprosess av manuelle ferdigheter (15). Det er første års studenter som har størst utbytte av veiledningsmodellen. Tredje års studenter har praksis erfaring som gjør konkretiseringen i forhold til grunnleggende behov mindre relevant. De er på et høyere faglig nivå, og får dermed helhetlig oversikt over sykehjemmets faglige utfordringer. Tredje års studenter har en bredere erfaring i pasientsituasjoner, et høyere faglig nivå, som de kan referere til. Eller som Benner sier om den kompetente praktiker: «Endelig, etter alle de anstrengelser, ser den kliniske verden ut til å være kommet under kontroll» (28, s.40). Gjennom praksis og refleksjon over denne skapes praktisk kunnskap. Sykepleieutdanningen er en profesjons utdanning. Den spesifikke kompetansen innebærer selvstendighet i beslutninger, etisk ansvarlighet og dyktighet i grunnleggende ferdigheter (15). Ved at sykehjemmene har konkretisert de læresituasjoner som representerer deres funksjons- og ansvarsområde er dette med på å bidra til at praksisstudiene har høynet kvalitet. Sykehjemmenes praksisveiledere har et eierforhold til veiledningsmodellen og veiledningen av studentene retter seg mot sykehjemmets aktuelle faglige utfordringer. Ut fra funnene ser veiledningsmodellen ut til å være et anvendbart verktøy i læringsprosessen, og gir en tidlig bevisstgjøring av krav og forventninger som ligger til grunn for utøvelse av yrket. Den gir også praksisveilederne en synliggjøring av nivå og forventninger til studentene fra høgskolens side. Dette samsvarer med Fagermoen om hva som skaper meningsfylt veiledning av sykepleiestudenter (15). Høgskolens bevisste bruk av kvalitetsforskriften i utdanningen viser at nyutdannede sykepleierne fra høgskolen bruker kvalitetsforskriften som referanseramme for sin praksis, og i veiledning av sykepleiestudenter. Studentene sier det er stort samsvar mellom praksisutøvelsen og de opprasjonalisert læresituasjoner på sykehjemmet. Dette viser validitet i forhold til de dokumenterte læresituasjonene. Dette synliggjør høy kvalitet på praksisplassene i sykehjem. Resultatene viser samlet sett at veiledningsmodellen er et viktig redskap i forhold til å nå studiets mål. Metodediskusjon av evalueringen Informantene i evalueringsstudiet var representative. Det er høy grad av troverdighet i resultatet fordi informantene har erfaring i anvendelsen av veiledningsmodellen. Spørreskjemaet ble utprøvd av kollegiet på Høgskolen før utsendelse. Allikevel kan vi se at for å øke gyldigheten på evalueringsstudiet savnes i etterkant spørsmålsstilling i forhold til anvendelses grad av veiledningsmodellen. Anvendelsesgrad kan påvirke svarene på de sju spørsmålsstillingene. Spørsmålsformuleringen i spørreskjemaets spørsmål fire er noe upresis. Progresjonsnivåer er et mer beskrivende og forklarende begrep enn «avkryssingsrubrikkene». Det var lærerne fra høgskolen tilknyttet de ulike sykehjemmene som distribuerte evalueringsskjemaene direkte til informantene. Det er usikkert om svarprosenten kunne vært endret om prosjektansvarlige hadde hatt ansvaret for dette. Praksisveiledernes svarprosent kan skyldes tidsaspektet i en hektisk hverdag, eller at ulike faggrupper var veiledere for sykepleiestudentene. Bortfallet kunne vært lavere om informantene hadde fått purring etter svarfrist. Oppsummering Veiledningsmodellen kan være et utgangspunkt for en senere studie om pasientens daglige grunnleggende behov tilfredsstilles, i henhold til kvalitetsforskriften. Utviklingsprosjektet har bidratt til å bevisstgjøre praksisveilederne og lærerne ved høgskolen de aktuelle faglige utfordringer studiestedene tilbyr. Dette viser at samarbeid, dialog og gjensidig respekt mellom vår høgskole og praksisfeltet kan kvalitetssikre læringsarenaen sykehjem. Det er gjennom forståelse for hverandres ståsted at de som hovedsakelig arbeider i praksis og de som hovedsakelig arbeider med teori, sammen kan utvikle kunnskap som kan bidra til å høyne kvaliteten på utøvelsen av faget. Siv Sønsteby Nordhagen Sykepleier, Høgskolelærer, Høgskolen i Gjøvik, Institutt for Sykepleiefag Gjøvik Ragna Ingeborg Engelien, Sykepleier, Høgskolelærer, Høgskolen i Gjøvik, Institutt for Sykepleiefag Gjøvik Inger Signe Johansson, Professor Høgskolen i Gjøvik, Institutt for Sykepleiefag Gjøvik, PhH Lektor i sykepleie, Avdelingen för omvårdnad, Karlstads Universitet, Karlstad, Sverige Korrespondanse: Siv Sønsteby Nordhagen, Instititt for Sykepleiefag, Høgskolen i Gjøvik, Postboks191. NO – 2802 Gjøvik. [email protected] 12. Holen, M. Pedersen, C., Rasmussen, Heidi N. Studiemiljø i praksis. Sygeplejersken 1998;8: 25–26. 13. Argyris, C., Schøn, D.A. Organizational Learning II: theory, method and practice. Addison – Wesley Publishing Company 1996. 14. Dæhlen, M., A. Havnes: Å studere eller gå på skole. Studiestrategier i profesjonsutdanningene. I: Aamodt, P.O., L.I. Terum (red.): Hvordan, hvor mye og hvorfor studerer studentene? Om læringsmiljø, jobbpreferanser og forståelse av kompetanse i profesjonsutdanningene. HiO-rapport 2003 nr. 8. 2003. 15. Fagermoen, M.S. Sykepleie i teori og praksis – et fagdidaktisk perspektiv. Universitetsforlaget, Oslo. 1993. 16. Stortingsmelding nr. 35,Velferd mot 2030. Helse-, og sosialdepartementet. 1994 – 95. 17. Rundskriv om: Kvalitet i pleie- og omsorgstjenestene. Sosial- og helsedepartementet. 1997. 18. Björkström, M. Den professionella sjuksköterskan – i relation till den akademiske sjuksköterskeutbildningen. Doktorsavhandling Karlstad University Studies 2005:57. 19. Hummelvoll, J.K. (red). Kunnskapsdannelse i praksis. Handlingsorientert forskningssamarbeid i akuttpsykiatrien. Universitetsforlaget, Oslo. 2003. 20. Lewin, K. Resolving Social Conflicts & Field Theory in Social Science.1997. 21. Reason, P., Heron, J. Research with people: The paradigm of cooperative experiential inquiry: Person Centered Review. 1986. 22. Bjølseth, H. Bruk av innlæringsmål I yrkesopplæringen. Universitetsforlaget. Oslo. 1993. 23. Moxnes, P. Læring og ressursutvikling i arbeidslivet. Institutt for sosialvitenskap. Oslo 1983. 24. Engelien, R.I., Nordhagen S.S. Teori i praksis – teori for praksis. Delrapport 10. Læresituasjoner i pleie og omsorgstjenesten i kommunen HIG – rapport nr.2, 2003. 25. Engelien, R.I., Nordhagen S.S. En re-analyse av metode i fagutviklingsprosjekt med aksjonsforskning som tilnærming. HIG – rapport nr.1, 2005. 26. Kirkevold, M. Vitenskap for praksis? Ad Notam Gyldendal, Oslo.1996. 27. Halland G. O. Læring gjennom stimulerende samspill. Veiledning, vurdering og ledelse. Fagbokforlaget. 2004. 28. Benner, P. Fra novise til ekspert: dyktighet og styrke i klinisk sykepleiepraksis. Tano, Oslo. 1995. Referanser 1. Rammeplan og forskrifter for 3- årig sykepleieutdanning. Kirke -, utdannings – og forskningsdepartementet, jan. 2000. 2. Strategi – og handlingsplan 2002 – 2005, Høgskolen i Gjøvik, 2002. 3. Karseth, B. Hva er gyldig kunnskap i sykepleierutdanningen. I Heggen, K, Christiansen, B., Karseth, B. (red.) Klinikk – akademia. Reformer, rammer og roller i sykepleierutdanningen. Universitetsforlaget, Oslo.2004: 103 – 119. 4. Mekki, T.E., Tollefsen,S. Utvikling av lærerplaner for praksis – et samarbeid mellom Haukeland sykehus og Høgskolen i Bergen. Rapport nr.9, Høgskolen i Bergen, 1999. 5. Furåker, C. Styring och visioner: sjuksköerskeutbildning i förändring. Avhandling Acta Universitatis Gothoburgensis. 2001. 6. Mogens, E. Lära i praktiken: en studie av sjuksköerskeutbildningens kliniska avsnitt. Doktorgradavhandling Stockholms universitet. 1994. 7. Bjørk, I.T., Bjerknes M.S. (red). Å lære i praksis. En veiviser for studentene, Universitetsforlaget, Oslo. 2003. 8. Rasmussen, K.D.. Næste gang bliver det bedre. Sygeplejersken 2000; 19: 41–44. 9. Ellström, P.E. Kompetans, utbildning och larande i arbetslivet: problem, begrepp och teoretiska perspektiv. Publica. Stockholm. 1992. 10. Lauvås, P., Handal,G. Veiledning og praktisk yrkesteori. Cappelen akademisk. Oslo. 1992. 11. Aamodt, P.O. Tidsbruk og studieinnsats. I: Aamodt, P.O., L.I. Terum. (red.): Hvordan, hvor mye og hvorfor studerer studentene? Om læringsmiljø, jobbpreferanser og forståelse av kompetanse i profesjonsutdanningene. HiO-rapport nr.8.2003. SIV SØNSTEBY NORDHAGEN, RAGNA INGEBORG ENGELIEN OG INGER SIGNE JOHANSSON 45 Short papers An educational model fitted for rural municipalities Bente Norbye, Høgskolelektor ABSTRACT Aim: The aim of the project was to develop a new model of education for implementing knowledge to nursing staff in a rural municipality. Background: The distance to the educational institution restricted nursing staff to attend courses at a University College. Due to the travelling cost and the requirements for replacements at work, a small rural municipality could only send one nursing staff at the time to relevant courses. Methods: Tromsoe University College agreed to do a project with the purpose to improve competence in a rural municipality. Bottom-up approach ensured that the nursing staff had an important role in deciding the structure and the content of the course. A mapping of competence required was completed. Findings: By combining lectures via video conferences, local workshops and local day seminars 22 nursing staff could attend a locally designed course. The course lasted 6 months and addressed the specific challenges linked to challenges identified in the mapping. The cost of the course was kept to a minimum due to no travel expenditure and no replacements required at work. Introduction Health personnel working in primary health care services are facing a challenge when it comes to keeping up with the increasing demands for competence. Patients in central hospitals are now admitted for a shorter period of time and will be in need of qualified nursing care for shorter or longer periods of time after discharged from the hospital. This article will focus on a project carried out in northern Norway in a rural municipality that had experienced drastic cutbacks in nursing staffing in community health care. The municipality is situated 3 hours driving distance from the nearest university town and had experienced an increasing need for upgrading of current skills and competence in the nursing staff. All health personnel shall conduct their work in accordance with the requirements to professional responsibility and diligent care that can be expected based on their qualifications, the nature of their work and the situation in general (1). At the same time the employer has the responsibility to see that necessary upgrading of skills is provided. This article will show how new knowledge was structured and implemented in the project that was run by Tromsoe University College, Faculty of health sciences. The article will focus on the process prior to the course starting and the model that was developed based on the experience from this process by using Lewin’s (2,3) three different phases of change as used in action research. It has been used as a methodology for change and has characteristics such as collaboration between researcher and practitioner. Action research was introduced to organisational studies and has frequently been used within the fields of education and by practitioners in different professions as a tool for better understanding and for improving professional practice. The changes that this project initiated were as a result of the identification of the need for increased competence, described by the nursing staff themselves, using a «bottom–up» approach which concerns the importance of a community owning the innovation (4). The educational phase 46 The administrative leader in the municipality took the initiative to establish a project team that should represent different levels of the community health care service; the head nurse, the trade union representative for the nurses and the trade union representative for the nurses’ assistants and the project leader from the university. With this representation in the team, different interests and different units were represented in the project. This was important because the project intended to address the staff’s need for increased competence as a whole. VÅRD I NORDEN 3/2008. PUBL. NO. 89 VOL. 28 NO. 3 PP 46–48 The first meeting with the project team aimed at identifying the issue for the project. The head nurse was concerned that the quality of nursing care would decline with less staff and wanted to focus on the competence level that would be demanded from every member of staff involved with the patient. The union representatives also stated that the staff reduction had made it more crucial for the nursing staff to have the required level of competence and that the staff often felt inadequate regarding the performance of their everyday work. At the outset, it was important for the project team to have a baseline to build on in order to form a strategy. Mapping the needs for future required competence would give the project team an indication as where to begin. An anonymous unstructured questionnaire was developed and distributed so that the employees were free to express in what field they needed to increase their personal level of competence. The participants were informed that the collected data would be used in deciding what themes for the course. The questionnaire was sent to 60 nursing staff with permanent employment. Collecting and analysing data The data from the questionnaires was collected by the head nurse and categorised into different subjects and fields of nursing using content analysis (5, 6). The themes were structured in a short and a long term perspective, – a long term perspective meaning up to three years ahead and the members of the project team made a priority list based on the findings from the questionnaire. The analysis was done according to the current need of the community health care sector and the chosen theme was caring for the demented person. Collaboration between the Tromsoe University College and the municipality To design a course tailed for this municipality, the university had to take these local requirements in consideration; • Numbers of participants: Due to practical reason there was put a limit to 20 participants • Locally based: That all activities should be based locally • Multi -disciplinary: The level of the course should meet the need for an multi-disciplinary group • Theme: The course should meet the demand of increasing competence in caring for the demented person • Duration: the course should last approximately 6 months • Time limit: The course should be finished before a new ward for the dementia patients was finished Selection of participants The intention was that all the participants should have time off to attend all the lectures, but the shift work was a challenge. The number of staff at work in the wards restricted how many could leave work at any one time, they had to be from different departments and have different levels of education in order to get the course multi-disciplinary. With participants from all departments it would also give enough staff increased ability to make a difference in the competence as a whole. The participants would get time off to attend the lectures but they had to use their spare time to attend the workshops. The head nurse had 22 staff from a multi- disciplinary group who were interested and got to attend the course. «Action» phase Development of a new course A tailored plan and timetable were presented where all local requirements were met. This included an opening day locally where the lecturers introduced the course and its content. In order to meet the requirements that all teaching activity should be held locally, video conferencing was chosen for the lectures. Both the university and the municipality had studios and the lecturers were experienced in the teaching methods required with the video conference. Preparations to the first video conference All participants were invited to one of the local studios prior to the lecture to go through important aspects in the video conference. Practical and pedagogical arrangements are important for the conference and none of the participants had attended a videoconference before. The lecturer was present in her studio on campus and the studios were connected in good time before the actual lecture started to establish a dialogue with the participants and to familiarise the course participants. It was important to start every lecture with an opening sequence where the participants could ask questions or comment on issues connected to the lecture, for example technological, pedagogical issues or the content of the course. The participants were also advised to take note of any questions, as there would be time for comments and questions at the end of every sequence. Workshops This course was planned to let the participants co-operate and share their previous experience and knowledge as they all had experience from working with dementia patients or patients with cognitive impairment. An important aspect of the course was to integrate new knowledge and to discuss this with other colleagues. The reflection process raises the levels of awareness and deepens insight into the situations and it will help the participants to integrate new knowledge and to understand different aspects of clinical practice better (7). The head nurse divided the participants into three different groups with seven and eight nursing staff in each group to be multi- disciplinary. One nurse in each group coordinated the work of the group and had the responsibility of being the contact person towards the university. To provide the necessary tools for the workshops the course participants were given a textbook developed for the course. Each workshop had a theme in connection with the previous lecture. Local preparations The preparation and planning highlighted the necessity of adjusting some of the daily routines in the different units due to the length of the course. The numbers of participants leaving work to attend the videoconferences could disturb the everyday running of the departments if this wasn’t taken care of in advance. The following adjustments were implemented; – The time of the patients’ main meal was moved forward 30 minutes. – Adjustments were made in the working schedules to maintain sufficient staffing. – Signed contracts were arranged with the staff. The course partici- pants got time off to attend the lectures and the workshops had to be arranged in their spare time. Local seminars Six video conferences were transmitted and eight workshops were completed over a period of six months. The final day of the course was planned as a one-day seminar locally in the rural municipality. Each group presented one chosen subject from their lecture and workshops and discussed their new knowledge and experience. The evaluation phase Evaluation of the course A written and an oral evaluation were completed at the end of the course. Of the 22 participants that started, 19 completed the course. The questionnaire was answered by 16 of those who completed. The video conferences were positively accepted. There had been some minor problems with the sound at the first lesson, but that was quickly overcome. The participants had the opportunity to ask questions and to offer comments but they thought it was difficult to come forward with the questions. Some of their statements were; «Great, an easy way of getting access to good lecturers», «its great to be able to attend this conference at a studio and you don’t have to travel». The workshops were organised by each group and it had been a challenge to find a suitable time for all to meet due to shift work and obligations outside working hours. However, the experiences of the use of workshops were positive. The participants found the discussions very useful and said it was stimulating to be together with staff from different departments and with staff with different educational backgrounds. Some of the comments were; «It has been good to share experiences», very interesting working with people with different backgrounds», «exciting, you learn from people with different opinions». The course lasted six months, from April to October. One recommendation would be to avoid long breaks such as summer holidays in between the lectures. The participants said it was difficult to get started again after the holidays due to the long break. The final date for the course was timed to coincide with the reopening of the ward for the demented patients but this hadn’t been important for the participants. For them it had been important to keep the lectures going every 14 days with the workshops in between. Discussion The combination of distance learning methods and workshops gave the participants a chance to discuss and reflect on the problems they didn’t have time to adress when they were at work. The combination of different methods of learning show that both the lectures and workshops helped the participants to focus on important issues regarding different aspects of caring for the dementia person. The important aspect was that being asked and to be prioritised to attend a specific course, gave an extra motivation for attending and completing the course with a theme they had requested. They could attend without having to do major changes in the everyday work or in their family situation. The workshops functioned well as a forum where they could discuss their previous experiences with their colleagues and reflect over the different themes both from recent knowledge and previous experiFig 1: Structure of the course with a combination of videoconferences, workshops and local seminars. BENTE NORBYE 47 Short papers ence (8). The employers could consider if the employees should get time off to attend these workshops within work time as for the video conferences. This could also be helped with smaller groups to make it easier to find a more suitable time to meet. The positive response to the workshops show that it would be worth looking into alternative ways of organising them. A course provided to a rural municipality where a high percentage of the nursing staff should be able to attend, demands close co-operation with a local project team prior to the course. Solving practical issues will be a critical factor regarding whether they can leave work to attend a lecture or not. The use of video conference as a long distant educational tool was a positive experience for the participants and it was important to use the existing infrastructure that was already available. There were no extra investments made in connection with the video conferences in this period, and the teaching methods were adjusted to the equipment that was already locally available. Small and Uttal (9) claim that because of the differences between the research that the academic faculty usually conduct, and the research and information needs of communities and practitioners, developing collaborative, productive relationships between community partners can often be challenging. For this project it was important to use an approach that fitted the nursing staff. The changes involved many complex issues and this was initiated by a bottom-up approach and included a reflective process within the project team. The participants had an important role in deciding the structure as well as the content of the course. An ongoing educational process where the nursing staff can decide the themes will give them an opportunity to meet the future demands of increased competence, where they feel it is most required. A mapping should be done on a regular basis, to evaluate the findings and also to give room for alterations. In this way there will be a continuous plan for increasing competence and also permit the universities to plan other new and relevant courses. The health personnel in this project had seen the need for increased competence, and due to close and well functioning co-operation the university was able to respond and design the course especially for the municipality. The employer has an important role in co-operation with the staff and with the project team and should be the link within the organisation regarding acceptance for such a course. A positive attitude from the employer in this municipality certainly helped in the process and contributed to the positive outcome of the course. The co-operation within the organisation gave the participants the possibility to attend the course, without any financial consequences to the individual or to the detriment of the quality of the work in the wards. For the educational institutions, it demands willingness to be both flexible and positive to demands for new courses that do not already exist. Conclusion 48 It has been possible to structure and implement knowledge to nursing staff in a rural municipality with the co-operation between the university and the municipality. This gave the nursing staff an opportunity to participate on a course locally based. This way Universities can cooperate and be an active partner in important development in community health care. It demands a close co-operation with the municipality and the co-operation can be the start of an ongoing educational process where the universities can be an active partner in contributing new knowledge in more varied ways to health personnel in rural areas. For this course the use of current technology combined with workshops and local day seminars were an important combination of different ways of learning. The lectures via video conferences could provide new knowledge and the participants could use the workshops to discuss issues in connection with the conference using their experiences from working situations. The different learning methods were dependent on and complemented each other together with the one-day seminars. This model can be used also in an inter- municipal co-operation and can help small municipalities getting access to further education and or continuously educating the staff locally. VÅRD I NORDEN 3/2008. PUBL. NO. 89 VOL. 28 NO. 3 PP 46–48 Kontaktadresse: Bente Norbye, Høgskolelektor, Høgskolen i Tromsø, Avdeling for Helsefag, NO – 9293 Tromsø. Tel + 47 77 66 06 01/Tel + 47 77 17 10 12. Fax + 47 77 66 06 12. [email protected] References 1. Norwegian Health Personnel Act 1999-07-02 nr.0064. NO. Oslo: Medlex Norwegian Health Information. 2. Lewin, K. Frontiers in group dynamics. Social planning and action research. Human relations. 1947; (1): 143–153. 3. Holter, I.M.& Schwartz-Barcott, D. Action Research. What is it? How has it been used and how can it be used in nursing. Journal of advanced nursing 1993; (18): 298–304. 4. Tones, K., Tilford, S & Robinson, Y. Health Education. Effectiveness and efficiency. London: Chapman & Hall; 1990. 5. Baxter, L.A. Content analysis. B. M. Montgomery & S. Duck Eds. Studying Interpersonal Interaction London: The Gilford Press 1991: 239–254. 6. Downe-Wambolt, B. Content Analysis. Method, Applications and Issues. Health care for Women International 1992; 13: 313–321. 7. Durgahee, Taleb. Reflective Practice. Nursing Ethics through story telling. Nursing Ethics 1997, (4):135–145. 8. Schön, D. Educating the reflective practitioner. San Fransisco & London: Yossey-Bass 1987. 9. Small, Stephen A & Uttal, Lynet. Action-Oriented Research. Strategies for Engaged Scholarship. Journal of Marriage and Family 2005 (67): 936–948. Short papers Patientdagbok vid kronisk sjukdom – utvärdering av ett verktyg i vård och egenvård Agneta Pagels, Leg. Sjuksköterska, Fil.Mag. Vårdpedagogik – Marie Wång, Leg. Sjuksköterska, Njursviktskoordinator – Annelie Magnusson, Chefssjuksköterska – Annika Eriksson, Chefssjuksköterska – Stefan Melander, Överläkare USING PATIENT DIARY IN CHRONIC ILLNESS CARE – EVALUATION OF A TOOL PROMOTING SELF-CARE ABSTRACT The Chronic Kidney Disease (CKD) Diary is a carefully adjusted patient education material used within renal care in Sweden. It is designed to promote the patient’s disease-related knowledge, involvement and self-care ability and to promote the cooperation between patient and nurse. This quality improvement study aimed at evaluating the benefit of the CKD Diary. Questionnaires were answered by patients with CKD and nurses within renal outpatient clinics. The results showed that the CKD Diary was to a great part used at home by the patients and their families. The patients as well as the nurses considered the CKD Diary as a useful tool to promote disease-related knowledge, involvement and self-care. Further the nurses found the CKD Diary helpful in promoting cooperation between patient and nurse and it was also adopted in group education sessions. It is recommended that a diary designed as the CKD Diary, i.e. well adjusted to the targeted patient group and with a structured introduction and follow-up could be an applicable tool to promote diseases-related knowledge, self-care, behavioural changes and collaboration in any chronic disease. KEYWORDS: care diary, patient education, self-care, chronic illness, chronic disease Bakgrund Vården av personer med kronisk njursvikt pågår vanligtvis under lång tid och bygger i stor utsträckning på patientens medverkan. Patientundervisning och patientens lärandeprocess har stor betydelse för dennes anpassning till sjukdomen och utgör en viktig del i behandlingen (1,2). Ett omvårdnadsmål är således att stödja patienten i att hantera sin hälsorelaterade situation, motivera och uppmuntra patienten till att uppnå högre grad av sjukdomsrelaterad kunskap, handlingsförmåga och självförtroende samt bättre kontroll över sin livssituation. Det förutsätter att vi som vårdgivare stödjer och uppmuntrar patientens delaktighet och egenvård. Delaktighet innebär att förstå och ha kunskap om sin hälsorelaterade situation och att kunna delta i planering och beslut i den egna vården. Patientens rätt till information om sin sjukdom och behandling och delaktighet i beslut om sin egen vård är fastställd i hälso- och sjukvårdslagen (3). Egenvård kan i detta sammanhang beskrivas som de aktiviteter som krävs för att optimalt kunna leva med en sjukdom i vardagen och egenvårdsförmåga som kunskaper, kompetens och aktiviteter relaterade till hälsa (4). Det specifika innehåll i egenvården som kan gälla för personer med avancerad kronisk njursvikt är att ha kontroll över medicinering, blodtryck, närings- och vätskeintag, fysisk aktivitet och vikt, liksom att vara observant på kroppssignaler och symtom (exempelvis andfåddhet, ödem, illamående, klåda, yrsel, infektionstecken). I en tidigare undersökning om njursjuka patienters upplevelse av vårdkvalitet framkom att man upplevde brister beträffande information, förmedling av sjukdomsrelaterad kunskap, helhetssyn och delaktighet i vårdbeslut (5). För den kroniskt sjuke är dessa områden viktiga för att förstå sin situation och klara av den egenvård som krävs. Vi såg att ett samlat patientundervisningsmaterial kunde bidra till att möta detta behov. Att ge information är ingenting nytt inom svensk hälso- och sjukvård, men vårdgivarens förhållningssätt vid mötet med patienten har på senare tid ifrågasatts och anses spela en avgörande roll för hur samtalet och undervisningen kommer att utfalla (1,6,7). Med andra ord har undervisningens struktur, upplägg och kommunikation stor betydelse för patientens delaktighet. Framtagande av «Dagbok för dig som har njursikt» År 2004 utgavs första upplagan av patientundervisningsmaterialet «Dagbok för dig som har njursikt» (fortsättningsvis benämnd Patientdagboken), som vänder sig till patienter med avancerad njursvikt (dvs. njurfunktion < 20 %). Den var resultatet av ett samarbete mellan de Njurmedicinska mottagningarna vid Linköpings och Karolinskas Universitetssjukhus. Till grund låg även gruppdiskussioner med sjuksköterskor verksamma inom njurmedicinsk vård samt utfallet av en fokusgrupp intervju, som genomfördes på Karolinska Universitetssjukhuset (Karolinska). I fokusgruppen deltog fem patienter med njursvikt varav två ännu inte påbörjat dialysbehandling, en hade hemodialysbehandling, en peritonealdialysbehandling och en person hade hem-hemodialys. De två sistnämnda skötte således sin dialysbehandling själva i hemmet. Öppningsfrågor i denna intervju var: «Vad bör en Patientdagbok innehålla och hur kan den användas?» Ur fokusgruppen framkom synpunkter på att Patientdagboken skulle vara sammanfattande och övergripande med skriftlig information samlad på ett ställe. Innehållet skulle bidra till ökad sjukdomsrelaterad kunskap, kroppskännedom och kontroll över hälsan. Dessutom framkom önskemål om att Patientdagboken skulle användas för uppföljning av sjukdomsutvecklingen, innehålla egenvårdsråd, ha utrymme för egna anteckningar, informera om olika behandlingsalternativ, hjälpa patienten att vara en välinformerad och jämbördig samarbetspartner i beslut rörande den egna vården samt utformas i A4-format med lösbladssystem, så att man lätt kan uppdatera och individanpassa materialet. Dessa synpunkter, idéer och önskemål sammanföll till stor del med författarnas egna. Syftet med Patientdagboken är att: – Öka patientens – och närståendes – kunskaper om njursvikt, symtom, olika hälsoaspekter och behandlingsalternativ – Underlätta egenvård och uppmuntra patienten till att vara aktiv och delaktig i sin vård. – Befrämja samarbetet mellan patient och vårdpersonal och underlätta uppföljning vid patientens mottagningsbesök. Patientdagbokens innehåll och design Patientdagboken utgörs av en pärm i A4 format med ett antal flikar och bygger på lösbladssystem. Grundmaterialet innehåller 70 sidor, AGNETA PAGELS, MARIE WÅNG, ANNELIE MAGNUSSON, ANNIKA ERIKSSON OG STEFAN MELANDER 49 Short papers men kan anpassas efter den enskilde individens informationsbehov genom att vartefter kompletteras med broschyrer, informationsblad etc. Undervisning kan med fördel utgå ifrån materialet, som följer patienten under vårdtiden, vilken vanligtvis pågår under flera år. Texten är avsiktligt kortfattad. Det finns ett framträdande utrymme för egna anteckningar, vilket uppmuntras och kan utgöra underlag för hälsosamtalen. Patienten kan själv notera och följa olika hälsoparametrar, som blodtrycksvärden, vikt, BMI, provsvar, läkemedel, kostordinationer, motionsprogram, träningsdagbok. Det finns även mallar och utrymme för att formulera mål för beteendeförändring, fördelar och nackdelar med befintlig och ändrad livsstil (s.k. motivationsbalans) samt att skriva reflektioner och tankar om hur man ser på sin sjukdom och livssituation. I övrigt handlar Patientdagboken om följande områden, som relaterar till kronisk njursjukdom: Njurarnas funktioner och sjukdomar, prover och provsvar, läkemedel, läkemedelseffekter, olika hälsoaspekter och symtom med specifika egenvårdstips, kost, fysisk aktivitet, behandlingsalternativ (olika dialysformer, transplantation), patientföreningen, ordlista, litteratur- och webbtips. Implementering och användning Patientdagboken har sedan 2004 genom ett läkemedelsföretag distribuerats till samtliga intresserade kliniker i Sverige, som arbetar med denna patientgrupp. Ett år efter att Patientdagboken färdigställts hade ca 1500 exemplar delats ut vid ca 40 mottagningar för njursviktiga i Sverige. Vid Karolinskas njurmedicinska mottagning hade efter ett år ca 70 patienter tilldelats Patientdagboken. Målgruppen var personer med avancerad njursvikt (ännu inte startat njurersättningsbehandling i form av dialys eller njurtransplantation) och med en etablerad läkarkontakt på mottagningen. Patientdagboken överlämnades i samband med sjuksköterskebesök. Sjuksköterskan introducerade och instruerade patienten om användningen. Patienten uppmuntrades att föra egna anteckningar och att ta med dagboken för uppföljning vid sina fortsatta besök på kliniken. Närstående uppmuntrades även att ta del av Patientdagboken. Att använda en för patientgruppen särskilt designad dagbok är en metod och ett interaktivt verktyg för att öka patientens kunskap om, kontroll över och delaktighet i sin sjukdom och behandling. Det finns tidigare och utvärderade erfarenheter av dagboksanvändning bl.a. inom cancervården (8-11). Sharp och medarbetare (8) fann att patienterna genom att använda en vårddagbok mådde bättre psykosocialt, att det uppstod färre missförstånd och att patienterna lättare tog till sig information. Således ville vi med detta projekt utvärdera nyttan och användningen av Patientdagboken. Syfte Syftet var att utvärdera det för patientgruppen speciellt framtagna patientundervisningsmaterialet «Dagbok för dig som har njursvikt» (Patientdagboken) (12). Material och metod Utvärderingen av Patientdagboken genomfördes ett år efter införandet genom frågeformulär, som skickades till respondenterna. Besvarade frågeformulär returnerades med svarskuvert. Frågeformulär Två frågeformulär med en blandning av slutna och öppna frågor konstruerades; Ett frågeformulär med 13 frågor, som vände sig till patienter med njursvikt samt ett frågeformulär med 15 frågor, som vände sig till sjuksköterskor verksamma vid njurmedicinska mottagningar i Sverige. 50 Urval Patientfrågeformuläret skickades till 60 patienter vid Njurmedicinska mottagningen, Karolinska. Patienterna hade vid frågetillfället haft Patientdagboken i minst tre månader och svarade anonymt. SjuksköVÅRD I NORDEN 3/2008. PUBL. NO. 89 VOL. 28 NO. 3 PP 49–52 terskeformuläret skickades till samtliga 40 mottagningar i Sverige, som vårdar patienter med avancerad njursvikt. Resultat Totalt 58 frågeformulär besvarades. Tjugosex (26) av 60 utskickade patientformulär – dvs. 43 % – besvarades. Patienternas ålder var mellan 21 och 84 år (M=65). Trettiotvå (32) av 40 utskickade sjuksköterskeformulär – dvs. 80 % – besvarades. Som kan utläsas av Tabell I använde sig de flesta respondenter av Patientdagboken och de flesta ansåg att dess omfattning var lagom och med ett innehåll som var tydligt och tillfyllest. Det var inte så vanligt att Patientdagboken togs med vid mottagningsbesöken och inte heller att patienten förde egna anteckningar. De flesta av patienterna ansåg att Patientdagboken underlättat förståelsen av sjukdomen och delaktighet i sin vård (Tabell II). En stor del av sjuksköterskorna ansåg att Patientdagboken bidragit till att befrämja patientens delaktighet, egenvård, lärande och sjukdomsrelaterade kunskaper (Tabell III). En majoritet av sjuksköterskorna ansåg också att Patientdagboken bidragit till att underlätta samarbetet med patienten (Tabell III). Patienter Tjugoen patienter (81 %) svarade att de använde Patientdagboken. De flesta använde den som lärobok, uppslagsbok och som samlingsplats för information även från annat håll. Kommentarer: «Jag läser den ofta och får svar på mina funderingar» «Läser för att få information om vad som rör njursvikt, fysisk aktivitet och kost» «Tittar ofta efter förklaring om läkemedel» «Att kunna få reda på hur min njursvikt påverkar min hälsa och hur jag skall uppnå god livskvalitet trots min sjukdom» Tabell I. Utvärderingsfrågor angående «Dagbok för dig som har njursvikt» Fråga Patienter (n=26) Sjuksköterskor (n=32) Använder du/mottagningen Patientdagboken? Mycket 7 (27 %) 12 (38 %) Ibland/lite 14 (54 %) 18 (56 %) Inte alls 5 (19 %) 2 (6 %) Tycker du Patientdagbokens omfattning är lagom? Ja 21 (81 %) 25 (78 %) För omfattande 2 (8 %) 3 (9 %) Ej svarat 3 (11 %) 4 (13 %) Saknas någon information? Ja 6 (23 %) 8 (25 %) Nej 14 (54 %) 18 (56 %) Ej svarat 6 (23 %) 6 (19%) Är informationen klar och tydlig? Ja 23 (88 %) 30 ( 94 %) Nej 2 (8 %) 0 Ej svarat 1 (4 %) 2 (6%) Använder anhöriga Patientdagboken? Ja 18 (69 %) 15 (47 %) Nej 8 (31 %) 12 (37,5 %) Vet ej 0 2 (6 %) Ej svarat 0 3 (9,5 %) För du/patienten egna anteckningar i Patientdagboken? Ja 9 (35 %) 13 (41 %) Nej 15 (57 %) 6 (18,5 %) Vet ej 0 7 (22 %) Ej svarat 2 (8 %) 6 (18,5 %) Patienterna ansåg att de hade mest nytta av kapitlen som handlade om njurarnas funktioner och sjukdomar, läkemedel, prover och provsvar samt hälsoaspekter, symtom och egenvård. De flesta (69 %) svarade att deras närstående läst eller tagit del av Patientdagboken. Kommentarer: «Den är bra när man behöver förklara något» «En hjälp för närstående att förstå sjukdomsförloppet» «Eftersom hela familjen blir inblandad är det helt nödvändigt. Välinformerade anhöriga oroar sig mindre» Det framhölls som positivt att kunna samla all information som rör sjukdomen på ett ställe, att ha en slags uppslagsbok där man kan söka information vid behov. Kommentarer: «Lätt att hitta…» «Som mångårig diabetiker är jag van vid att ta ansvar för min sjukdom. Då måste jag vara välinformerad, det gäller även vid njursjukdom. Här kan jag samla all information. Dagboken är definitivt ett stöd för mig» «Att den finns../…mycket praktisk och bra samtidigt som den är informativ i ett skede då man har svårt att komma ihåg allt man får veta av läkare och sjuksköterskor» sig ha mest nytta av kapitlen, som handlade om prover och provsvar, hälsoaspekter, symtom och egenvårdsråd, läkemedel, njurarnas funktioner och sjukdomar samt behandlingsalternativ. De skattade även kapitlet med utrymme för patienten att själv monitorera och föra egna anteckningar som värdefullt. Kommentarer från sjuksköterskorna: «Pärmen är uppskattad av patienterna» «Bra material som utgångspunkt för hälsodiskussion» «Underlättar för anhöriga att känna sig delaktiga» «Ordförklaringar bra» «Lättläst» «Bra med de markerade, återkommande boxarna med rubriken: «Vad kan jag göra själv?»» «Pärmen är för stor» «Gärna lite mer om kost» Diskussion Denna utvärdering brister i ett stort svarsbortfall från patientgruppen. Tyvärr skickades inte påminnelser, vilket hade gagnat svarsfrekvensen och utvärderingens trovärdighet. Trots detta tycker vi oss ha fått en fingervisning om Patientdagbokens betydelse för såväl patienter som närstående och vårdgivarorganisationen, vilket också bekräftas i vårt vardagliga arbete. Vi hade förväntat oss att fler patienter skulle föra egna anteckningar och ta med sig Patientdagboken vid sina mottagPå frågan om vad som upplevdes som mest negativt med Patientdagningsbesök. Behovet av detta kanske inte är så stort som vi trott, men boken angavs otillräcklig kostinformation och att formatet upplevdes det kan också finnas anledning att reflektera över hur vi som vårdpersom otympligt. sonal kan bli bättre på att uppmuntra patienterna till detta. Åsikter och Kommentarer: önskemål, som framkommit i utvärderingen har varit till hjälp när vi «Att bli påmind, en form av hatkärlek» reviderat materialet inför utgivningen av andra upplagan. «Att jag behöver den!» Patientdagbokens syfte var att öka patientens – och även närståen«För omfattande» des – kunskaper om njursvikt, symtom samt olika hälsoaspekter och behandlingsalternativ. Syftet var också att underlätta patientens egenPatienterna efterlyste mer information om bl.a. kost, sex och samlevvård och delaktighet, att befrämja samarbetet mellan patient och sjuknad samt fysiska och psykiska effekter av sjukdomen. sköterska samt underlätta uppföljning vid fortsatta mottagningsbesök. Utvärderingsresultaten antyder att dessa syften har infriats. Patientdagboken har utöver detta visat Tabell II. Patienternas erfarenheter av undervisningsmaterialet sig passa bra som undervisningsmaterial vid gruppun«Dagbok för dig som har njursvikt» dervisning samt till annan personal som vårdar den njurHar Patientdagboken underlättat: Ja Nej Ej svarat sjuke. Arbetet med att ta fram och därefter kliniskt … din förståelse om din njursjukdom? 22 (84 %) 3 (12 %) 1 (4 %) använda Patientdagboken har givit oss en ökad medvetenhet om pedagogik och dess betydelse i vården av kro… för dig att vara aktiv och delaktig i din vård? 22 (84 %) 3 (12 %) 1 (4 %) niskt sjuka. Vården vid kronisk njursvikt har alltmer kommit att fokusera på preventiva åtgärder. Det innebär bl.a. att eliminera eller minska riskfaktorer, som exempelvis rökning, inaktivitet, proteinuri, Sjuksköterskor/mottagningsenheter hypertoni, övervikt, bukfetma, höga blodfetter och malnutrition (13). Tolv (38 %) enheter använde sig av Patientdagboken i hög grad. Nitton Inte så sällan är riskfaktorerna livsstilsrelaterade och kräver således ett enheter (59 %) svarade att de använde materialet vid individuella patisamförstånd och en motiverad patient. Vi har sett att detta undervisentbesök och 14 (44 %) att materialet användes vid gruppundervisning. ningsmaterial väcker nyfikenhet och frågor även hos patienter, som Andra angivna användningssätt var vid sjuksköterskemottagning och befinner sig i en lindrigare sjukdomsfas. Vi ser här att ett hjälpmedel telefonrådgivning, till inneliggande patienter med akut njurinsufficiens som Patientdagboken kan vara användbart även i ett mer preventivt samt till patienter som tränades för självdialys. Materialet användes inriktat arbete. även till att ge patienten hemuppgifter inför uppföljande besök samt i Egenvården vid kronisk sjukdom går i stort ut på att ha så god konundervisningssyfte till nyanställd vårdpersonal och till annan vårdpertroll som möjligt över sin hälsa, livskvalitet och behandling. Det och sonal inom t.ex. primär- och hemsjukvården. Sjuksköterskorna ansåg den anpassning det innebär kan för många betyda livsstilsförändringar av större eller mindre grad. Patientundervisning och stödjande Tabell III. Sjuksköterskornas erfarenheter av undervisningsmaterialet samtal ställer höga krav på sjuksköterskan, «Dagbok för dig som har njursvikt» speciellt om man har som mål att åstadkomma Anser ni att Patientdagboken bidragit till en bestående beteendeförändring. En optimal att befrämja/underlätta: Ja Nej Vet ej Ej svarat patientundervisning fokuserar inte enbart på … patientens delaktighet och egenvård? 28 (87,5 %) 0 0 4 (12,5 %) sjukdom och sjukdomshantering utan ser även till helhet, livskvalitet och vardagsliv. Vi kan se … patientens lärande och att Patientdagboken erbjuder våra patienter sjukdomsrelaterade kunskaper? 26 (80 %) 0 3 (10 %) 3 (10 %) ökade möjligheter till information och uppfölj… samarbetet med patienten? 23 (71,5 %) 2 (6 %) 4 (12,5 %) 3 (10 %) ning, ökade möjligheter att ställa frågor, disku… patientens anpassning till sjukdomen? 19 (59,5 %) 0 9 (28 %) 4 (12,5 %) tera samt ökade förutsättningar till individan… patientens val av behandling? 11 (34 %) 4 (12,5%) 13 (41 %) 4 (12,5 %) passat lärande, coping, anpassning till sjukdomen och eventuell livsstilsförändring. AGNETA PAGELS, MARIE WÅNG, ANNELIE MAGNUSSON, ANNIKA ERIKSSON OG STEFAN MELANDER 51 Short papers Slutsatser Patientundervisningsmaterialet «Dagbok för dig som har njursvikt» visade sig vara ett mycket användbart och praktiskt verktyg fr.a. för patientens lärandeprocess, delaktighet och beteendeförändring, men även för att underlätta närståendes delaktighet. Sammanfattningsvis framkom av utvärderingen att Patientdagboken: – Används i hög grad i hemmet av såväl patienter som närstående – Lämpar sig väl vid gruppundervisning. – Bidrar till att befrämja delaktighet, egenvård, sjukdomsrelaterade kunskaper och samarbetet mellan patient och sjuksköterska. Rekommendationer Vi tror att det koncept som «Dagbok för dig som har njursvikt» representerar kan vara utmärkt att tillämpa vid många andra kroniska sjukdomstillstånd. Att skapa ett optimalt och till den aktuella sjukdomen välanpassat patientundervisningsmaterial kräver förutom tid och engagemang att författare/vårdgivare har en bred kunskap och erfarenhet. Ett genomtänkt användningsförfarande och en användarvänlig design borgar för framgång. Det är viktigt att i god tid fundera över finansiering och hur distribution av materialet ska gå till. Den eventuella möda man lägger ned på att skapa materialet vill vi dock påstå att man med råge får tillbaka i form av ett strukturerat, användarvänligt och patientanpassat undervisningsmaterial, som kan utgöra ett värdefullt verktyg i strävan att bedriva en vård, som uppmuntrar den kroniskt sjuke till ökad delaktighet och kontroll över sin hälsa. Tack till Roche AB, som bidragit till att detta vårdpedagogiska utvecklingsprojekt blev möjligt att genomföra. Agneta Pagels, Njurmedicinska kliniken, Karolinska Universitetssjukhuset, SE – 171 76 Stockholm. Tel: +46 851779835 [email protected] Marie Wång, Njurmedicinska kliniken, Karolinska Universitetssjukhuset, SE – 171 76 Stockholm Annelie Magnusson, Njurmedicinska kliniken, Karolinska Universitetssjukhuset, SE – 171 76 Stockholm Annika Eriksson, Njurmedicinska kliniken, Universitetssjukhuset i Linköping, SE – 581 85 Linköping Stefan Melander, Njurmedicinska kliniken, Universitetssjukhuset i Linköping, SE – 581 85 Linköping Referenser 52 1. Klang Söderkvist, B., (red.) (2001) Patientundervisning. Lund. Studentlitteratur. 2. Björvell, H., Engström, B. Kvalitetsindikatorer för patientundervisning. I Kvalitetsindikatorer inom omvårdnad (2001) Svensk Sjuksköterskeförening och Gothia. 3. Sahlin, J. (2006) Hälso- och sjukvårdslagen: med kommentarer. Stockholm. Norstedts 4. Orem, D. (1995) Nursing. Concepts of Practice. 5th Ed. Mosby Year Book Inc., St Louis, Missouri. 5. Picker Institute Europe. (2003) Through the Eyes of the Patient. Frågeformulär om patientens upplevelse av vårdkvalitet. Karolinska Sjukhuset, Njurmedicinska mottagningen. 6. Friberg, F (2003) Pedagogiska traditioner av betydelse för patientundervisning. I Andersson, E. (red.) Pedagogik inom vård och omsorg. Lund. Studentlitteratur. 7. Arborelius, E (1999) Varför gör dom inte som vi säger – Teori och praktik om att påverka människors levnadsvanor. Centrum för Barn och Ungdomars hälsa, Samhällsmedicin, Stockholms Läns Landsting. 8. Sharp, L., Laurell, G., Tiblom, Y., Andersson, A., Birksjö, R-M (2004) Care Diaries. A way of increasing head and neck cancer patient’s involvement in VÅRD I NORDEN 3/2008. PUBL. NO. 89 VOL. 28 NO. 3 PP 49–52 their own care and the communication between clinicians. Cancer Nursing,vol.27,No 2; 119–26 9. Lecouturier, J., Crack, L., Mannix, K., Hall, R., Bond, S (2002) Evaluation of a patient-held record for patients with cancer. European Journal of Cancer Care, 11, 114–21 10. Williams, JG, Cheung, W-Y, Chetwynd, N., Cohen, D., El-Sharkawi, S., Finlay, I., Lervy, B., Longo, M., Malinovzky, K (2001) Pragmatic randomised trial to evaluate the use of patient held records for the continuing care of patients with cancer. Quality in Health Care 10:159–65 11. van Wersch, A, de Boer, MF., van der Does, E, de Jong, P., Knegt, P., Meeuwis, CA., Stringer, P., Pruyn, JF. (1997) Continuity of information in cancer care: Evaluation of a logbook. Patient Educ Couns. Jul;31 (3):223–36 12. Melander, S., Pagels, A., Eriksson, A., Wång, M., Magnusson, A. (2005) Dagbok för dig som har njursvikt. Patientundervisningsmaterial. ISBN 91631-7992-X. Roche AB. 13. Nahas, ME., Bello AK. (2005) Chronic Kidney d: Disease: the Global Challenge. Lancet 2005 6;365:331–40 Short papers Kroppsfenomenologisk forskning – i grenselandet mellom empiri og filosofi 1 Finn Nortvedt, NR. Dr Philos THE PHENOMENOLOGICAL RESEARCH ON EMBODIMENT; SOME EMPIRICAL AND PHILOSOPHICAL CONSIDERATIONS. ABSTRACT The article elucidates fundamental issues about phenomenological research on subjectivity and embodiment. Two main problems are discussed. The first deals with the relationship between empirical and philosophical knowledge inside phenomenological and qualitative research itself. The main argument that is outlined is that because phenomenology originally and mainly is a philosophy and not an empirical science or method, the empirical research that implements phenomenology should be research with a profound and explicit theoretical foundation. In the analyses of empirical and subjective phenomena like pain, the research should try to implement a dynamic and dialectic relationship between philosophy and empirical knowledge. This dialectic relationship ought to be reflected throughout the whole research process, and especially in the analyses and presentation of the research results. The other and second issue raised in the article is on the relationship between phenomenology and other epistemologies. The article takes a pragmatic stand and argues that this relationship should be built on cooperation and that other epistemological traditions like the biomedical should be viewed as complementary and not opposite or contradictory to phenomenology. This is of crucial importance when it comes down to the question of understanding health science and implementing research on patient phenomena like pain and suffering etc. KEY WORDS: Philosophy, phenomenology, embodiment, qualitative research, pain. Kroppsfenomenologien er den posisjon innenfor fenomenologien som tematiserer hvordan vi som subjekter eksisterer og erfarer kroppslig i verden, i relasjon til kontekst og medmennesker. Denne artikkelen redegjør først for kroppsfenomenologiens grunnlag som er den filosofiske retningen som er blitt kalt fenomenologien. Deretter begrunnes noen hovedelementer i den kroppsfenomenologiske posisjonen med utgangspunkt i denne tradisjonens mest betydningsfulle tenker; den franske fenomenologen og filosofen Maurice Merleau-Ponty (1). Til slutt diskuteres hvordan en empirisk tilnærming som undersøker personlig og kroppslig erfaring med et filosofisk utgangspunkt kan bidra til helsefaglig forskning og kunnskapsutvikling. For å anskueliggjøre dette blir det gjort rede for et teoretisk fundament og grunnleggende antagelser i en doktoravhandling som studerte erfaringer med fantomsmerter etter komplett ryggmargskade og etter traumatiske amputasjoner (2). Fenomenologi og kroppsfenomenologi Fenomenologiens ambisjon i følge dens grunnlegger Edmund Husserl (1859–1938) og senere formulert av den tyske filosofen Martin Heidegger (1889–1976), var å studere fenomener slik de viser seg ved seg selv (3). Dette betyr et forsøk på å forstå verden og fenomenene gjennom å studere hvordan de framtrer for subjektet, for personen. Fenomenologien er deskriptiv og inneholder ikke som den biomedisinske kunnskapsforståelsen en kausal sansefysiologisk teori. Ambisjonen blir derfor å la erfaringene lede hen mot teoridannelsen. Det er dette som ligger implisitt i den opprinnelige fenomenologiens slagord «zu den sachen selbst »eller det å gå til saken selv (4). Dette er et perspektiv som også blir framhevet av den filosofen innenfor fenomenologien som er sentral i tilknytning til den kroppsfenomenologiske retningen, filosofen Maurice Merleau – Ponty (1908–1961). I sitt hovedverk Phenomenology of Perception er han opptatt av å formulere et helt nytt grunnlag for en persepsjonsfenomenologi og i et berømt forord til hovedverket utlegger han den fenomenologiske ambisjonen om å gå til saken selv som å vende tilbake til den verden eller virkelighet som eksisterer forut for all kunnskap, men 1 Denne artikkelen er en omarbeidet versjon av det oppgitte tema til min prøveforelesning til Dr. Philos. Det Medisinske Fakultet. UIO. 14.12.2006. «Kroppsfenomenologi og empirisk og filosofisk tilnærming – hvordan binde dem sammen i konkret forskning». som all kunnskap likevel omhandler. Merleau-Ponty poengterer også i det samme forordet at selv om fenomenologien er en filosofi som studerer essenser eller vesenstrekk så er det viktig at disse vesenstrekk enten de er knyttet til persepsjon eller bevissthet samtidig er bundet til en kontekst og en virkelighet, det vil si at de har en faktisitet (1). Sentrale begreper innenfor fenomenologien er dermed intensjonalitet og livsverden. Intensjonalitet handler nettopp om forholdet mellom bevissthet og verden og uttrykker at bevisstheten alltid er rettet mot noe; vår bevissthet er med andre ord gjenstandsrettet. Med smerte som eksempel så betyr det at når smerte viser seg som noe, så viser den seg samtidig som en kroppslig erfaring. Smerten er kroppslig, vi kjenner smerten og det gjør vi til og med selv om kroppsdelene som smertene lokaliseres til er tapt eller lammet (2). Men vår bevissthet er også intensjonal i den forstand at den samtidig er meningsfortolkende. Det innebærer at kroppen ikke lenger er å forstå som et passivt objekt for bevisstheten, men er selv fortolkende og meningsbærende (1). Intensjonalitet medfører at det som viser seg som noe (her smerte) viser seg for noen (for et kroppslig subjekt) og det viser seg i tillegg også i en sammenheng, i en kontekst. Den kroppslige erfaringen med smerte som eksempel, har dermed en meningsdimensjon som også er preget av personens livshistorie, hans tidligere erindringer, minner og opplevelse med smerte (2). Det er dette som gjør at enhver smerteopplevelse er unik og er preget av personens situasjonsoppfatning og tidligere erfaringer. Innenfor fenomenologien er subjektets verden også først og fremst å forstå som en livsverden; det vil si den verden som personen er intensjonalt rettet mot. Livsverden er verken en rent subjektiv eller objektiv verden, men det er en ambivalent verden, en mellomliggende verden som forstås ved at livet alltid er i verden, og at verden alltid er preget av den meningsfortolkning den tillegges av det enkelte subjekt. (5). Husserls opprinnelige fenomenologi er blitt kritisert for å være en ren bevissthetsfilosofi og for ikke å inkludere et subjekt med en bevissthet som er situert og kroppslig forankret (6). Senere Husserlforskning viser imidlertid at dette bildet av Husserls fenomenologi er mer nyansert, og at Husserl spesielt i sine senere arbeider opererer med en forståelse som innebærer at subjektet er kroppslig tilstede i verden. Denne kroppslighet framtrer ved at kroppen er plassert og lokalisert i en tid-rom dimensjon. Kroppen er vår bakgrunn i verden FINN NORTVEDT 53 Short papers som vi ikke trenger å lete etter. Den er dermed nullpunktet og det som perspektiverer subjektets orientering i verden (7). Husserl introduserte også en særskilt metode som han kalte epoche’. Epochen’ er blitt forstått å innebære at forskeren skulle sette i parentes eller tilside sin egen oppfatning om væren eller eksistens, for dermed å kunne komme fram til et sikrere fundament for all vitenskap som ikke hvilte på metafysiske antagelser (6). Den framtredende danske fenomenologen og Husserlforskeren Dan Zahavi påpeker imidlertid at formålet med epochen’ slett ikke er å sette tilside virkeligheten, men kun å suspendere eller nøytralisere en bestemt dogmatisk innstilling til denne, for dermed å kunne fokusere på det som viser seg, i denne sammenheng det fenomenologisk gitte (4–7). Den kroppsfenomenologiske retningen Maurice Merleau – Pontys tilnærming til fenomenologien var å studere persepsjonen og kroppens rolle i persepsjonen (1). Et sentralt begrep i hans filosofi er den levde kroppen. Begrepet levd innebærer at livet leves i og uttrykkes gjennom kroppen. Den levde kroppen er alltid og samtidig både objekt og subjekt, synlig og seende, berørt og berørende, sansende og sansbar (8). Kroppen overskrider skillet mellom materialisme og idealisme, mellom subjekt og objekt, og kroppen er selv bevissthet. Kroppen er heller ikke et filter mellom det materielle og det immaterielle. Den er ikke en ting blant andre ting, men er vår forankring i verden som subjekter. Med kroppen er vi plassert i en historisk og gitt verden og på den samme måten er den erfarte verden sanset i vår bevissthet gjennom den levde kroppen. Kroppen er det jeg ikke kan forlate, men er alltid nærværende, ikke som et perseptuelt objekt, men som meg selv. Merleau-Ponty (Ibid) viser gjennom sin kroppsfenomenologi også til et utvidet erfaringsbegrep. Vår erfaring av verden er ikke bare en erfaring av objekter, men kroppen har en stilltiende viten om førobjektive fenomener som for eksempel smerte. Vårt forhold til kroppen er som regel en pre -refleksiv (før-reflektert) oppmerksomhet som er så gjennomgripende at vi kun legger merke til den (kroppen) når vi frivillig og bevisst retter vår konsentrasjon mot den, som for eksempel ved å snu oss for å se vår egen kropp i speilet. Det kan også være at kroppen selv rykker oss ut av vår naturlige innstilling eller før–bevisste oppmerksomhet ved å plutselig markere seg i bevisstheten, og det er i grensesituasjoner som ved smerte, utmattelse eller sykdom at dette ofte skjer. Smerte kan som tidligere omtalt forstås som intensjonalitet på et slikt kroppslig og før-objektivt nivå som innebærer at all persepsjon og alle uttrykk er meningsbærende (9). Dette er noe av essensen i en fenomenologisk forståelse av smerte. Ved smerten vekkes vi på det kroppslige gjennom at oppmerksomheten rettes mot og forankres i forhold til den smertefulle kroppen eller kroppsdelen. Dermed er det også som legen og fenomenologen Drew Leder (10) framhever, at smerten virker splittende i forhold til subjektets relasjon til verden og det kroppslige. Smerte slår både utover og innover og kan føre til eksistensiell ensomhet og isolasjon fordi personens konsentrasjon hele tiden er rettet mot den smertefulle kroppen. Det er vesentlig å erkjenne at kroppslige erfaringer som smerte dermed har en eksistensiell dimensjon som må fortolkes og forstås for at pasientens plager kan avhjelpes og lindres. Kroppsfenomenologien har med dette også en hermeneutisk dimensjon, som blant annet formuleres av den svenske filosofen Svenaeus i sine arbeider om sykdomserfaringer og medisinsk fenomenologi (11). Det handler da om å fortolke for å forstå menneskelige erfaringer i sin kontekst, og det er for å følge Svenaeus (Ibid), nettopp når språket, kulturen og historien føres til sentrum av det fenomenologiske studiet at fenomenologien også blir hermeneutikk. 54 Kroppsfenomenologi og smerteforskning Mitt avhandlingsprosjekt var knyttet til å studere kroniske og vedvarende fantomsmerter som skyldtes traumatiske og kroppslige skader etter trafikk eller arbeidsulykker. Smertene var gjennomgående meget sterke og plagsomme, og de hadde en karakter som preget pasientenes forhold til det å leve i verden på en integrert måte og i samværet med andre (2). VÅRD I NORDEN 3/2008. PUBL. NO. 89 VOL. 28 NO. 3 PP 53–55 De dominerende teorier og den påfølgende forskningsinnsatsen innenfor smerte kan i hovedsak plasseres innenfor en forståelse hvor det fokuseres på hjerneprosesser og molekylærbiologiske mekanismer i det perifere nervesystemet og i ryggmargens bakhorn, og ikke smerte som den kroppslige erfaringen til et konkret subjekt (2). Studie av smerte bør imidlertid slik jeg ser det ikke atskilles fra at den erfares konkret og kroppslig. Det var som et teoretisk og empirisk bidrag til dette perspektivet at jeg i avhandlingen (Ibid) diskuterer og analyserer fantomsmerte i lys av personers erfaringer. Det er dermed ikke subjektivitet som sådan; som en abstrakt og filosofisk spekulasjon som her er sentralt, men hvordan subjektiviteten er konkret forankret innenfor en kroppslig horisont av mening og kontekst. De kroppslige erfaringene med smerte har da sin markør og forankring i den levde kroppen som en subjektiv kropp, men har likevel en forbindelse til en biologisk kropp; til kroppsinterne prosesser som er et resultat av nevrofysiologiske mekanismer. For å forstå og fortolke den subjektive og kroppslige smerteerfaringen bør forskeren derfor ha en forankring i basalkunnskap innenfor det biomedisinske kunnskapsområdet. Det innebærer samtidig en erkjennelse om at biologiske mekanismer og prosesser samtidig også har sitt nedslagsfelt i en erfart og levd kropp. Det var etter inspirasjon fra teoretiske perspektiver innenfor kroppsfenomenologien at jeg spesielt grep fatt i hvordan smerteerfaringene har et konkret kroppslig, språklig og relasjonelt uttrykk (2). Det var Merleau-Ponty’s fenomenologi som åpnet for mitt perspektiv på at disse erfaringene var vesentlige. Det var således den teoretiske inngangen fra kroppsfenomenologien som førte til at jeg så det jeg så i materialet og som gjorde at jeg tok tak i erfaringene knyttet til fantomsmertenes kroppslighet og språklige uttrykk, og til hvordan de preget personenes forhold til det å eksistere i verden og i relasjonen til sine nærmeste. Det er dermed ved den måten jeg bruker de teoretiske perspektivene fra kroppsfenomenologien at jeg får fram informantenes erfaringer på den måten jeg gjør. Jeg vil derfor hevde at et viktig utgangspunkt for å forstå sammenhengen mellom det filosofiske og det empiriske grunnlaget innenfor en kroppsfenomenologisk tilnærming, er at det teoretiske perspektivet både har en inngang og en utgang. Inngangen er forforståelsen og de teoretiske antagelsene som forskeren møter det empiriske materialet med. Utgangen er resultatet av de teoretiske refleksjonene i møtet med det empiriske materialet. Jeg vil i det neste avsnittet begrunne hvordan denne dialektikken i forholdet mellom empiri og teori kan komme til utrykk innenfor kvalitativ forskning. Empiri og filosofi innenfor kroppsfenomenologisk forskning Det er det filosofiske utgangspunktet som utgjør det teoretiske grunnlaget for å gå ut i verden og studere det empiriske, dvs de helt konkrete og levde erfaringene. Fenomenologien er som det er utlagt i det foregående primært en filosofi (4). Fenomenologien og kroppsfenomenologien er dermed ikke først og fremst en metode, men utgjør et epistemologisk utgangspunkt for å undersøke empiriske fenomener. Målet med en slik forskningstilnærming er å utforske datamaterialet videre i et produktivt samspill mellom teori og empiri. Denne type studier er dermed også teoretisk orienterte. Dette er et avgjørende poeng i forhold til det å gjøre det mulig å yte rettferd til det empiriske materialet innenfor en slik forskning. Uten et velfundert og godt utbygget teoriunderlag er det en fare for at studier som betegner seg selv som fenomenologiske kan ende ut i empirisme og at forskeren sitter igjen med store mengder datamateriale som aldri blir tilstrekkelig analysert eller teoretisk reflektert. Det er heller ikke antallet av informanter eller omfanget av det empiriske materialet som er avgjørende for en slik studies resultater og gyldighet, men det at informantene i utvalget er typiske representanter med særegne erfaringer knyttet til det fenomenet som skal undersøkes, og at dette materialet blir inngående teoretisk belyst og drøftet. Mange av de mest banebrytende funnene blant annet innenfor fag som nevrologi og nevrofysiologi har sitt utgangspunkt, ikke i store statistiske tallmateriale, men faktisk i studier av enkeltpersoner gjennom single-case undersøkelser. (12). Vitenskapshistorien, og spe- sielt den medisinske, men også innenfor psykologien har en rekke tilsvarende eksempler. Det er dermed ikke utvalgstørrelse eller datainnsamlingsmetode som avgjør forskningens implikasjoner og nytte for samfunn og praksis, men snarere de problemstillinger og hvilke områder den omfatter. Det dialektiske samspillet mellom teori og empiri innenfor en slik posisjon medfører også at forskerens perspektiv hele tiden utfordres og at hans forforståelse endres og utvikles. Det blir ideelt sett en kontinuerlig runddans mellom forforståelse, forskningsspørsmål og teoretisk tilnærming som hele tiden må reflekteres underveis i forskningen både under dataproduksjon og i selve den overlappende analysefasen. I nye situasjoner med nye informanter vil tidligere erfaringer ligge som et nødvendig og produktivt bakteppe for påfølgende intervju og observasjon. I den videre analysen av et slikt datamateriale er det også en utfordring at teori og empiri spiller sammen på et udogmatisk og produktivt vis uten at forskeren er låst til fenomenologien som en kunnskapsteorisk modell. Utgangspunktet for teoretisk analyse og fortolkning er det empiriske materialet, og tolkningene bør ideelt sett være veiledet og inspirert av, men ikke låst fast innenfor en spesifikk teori eller ontologi. Forskningens kunnskapsforankring og forskerens forforståelse – en sluttkommentar Kroppserfaringer knyttet til sykdom og lidelse er i ferd med å få et økende forskningsfokus blant helsearbeidere innenfor ulike disipliner. Det forskes i større grad ut fra kroppsfenomenologiske perspektiv og det er forskning som bør styrkes i framtiden. Det er viktig å konsolidere og videreutvikle denne forskningsinnsatsen innenfor flere felt, knyttet til fenomener som fatigue, intensivpleie og sederingsproblemtaikk, og også innenfor forskning knyttet til psykiatri og opplevelse av psykisk helse. Slik forskning er grunnlagsforskning innenfor helsefagene når det gjennom dybdestudier omkring kroppserfaringer utvikles ny kunnskap som kan skape en utvidet forståelse av det å leve med sykdom og lidelse. Bare gjennom en slik økt forståelse kan også sykepleie og andre helsefaglige intervensjoner utvikles og ha sin gyldighet. Det ligger imidlertid her utfordringer på flere plan som jeg avslutningsvis vil knytte noen kommentarer til. Før det første bør det tilstrebes et tettere samarbeid mellom ulike kunnskapsposisjoner når det gjelder fenomenologisk orientert og biomedisinsk forskning. Merleau – Ponty (1) benyttet selv flittig arbeider fra nevrofysiologien og gestaltpsykologien når han diskuterte og utviklet sin persepsjons og kroppsfenomenologi. Den måten han kombinerte ulike kunnskapsposisjoner for å utvikle sin persepsjonsfenomenologi kan og bør fortsatt inspirere kroppsfenomenologisk orientert forskning inn i vår tid. Utgangspunktet til den kroppsfenomenologiske helseforskningen har slik jeg har oppfattet det til nå, vært preget av en innretting som i stor grad har implisert et brudd med den biomedisinske posisjonen, hvor subjektet med sine kroppslige erfaringer samtidig i for stor grad er fraværende. Ved å utvikle og utforske empirisk materiale som tematiserer ulike former for kroppslig erfaring og i et samspill med andre teoretiske tilganger og kunnskapsposisjoner, kan dette bidra til å styrke utviklingen av interdisiplinære forskningssamarbeid som vil være både spennende, nødvendige og særs fruktbare. Mitt andre poeng er at helsefaglig forsking både i vid og konkret forstand handler om personer, om subjekter. Mennesket er ikke qua levende, død og subjektløs materie, men er kroppslig forankret innenfor en horisont av mening, av medmennesker og er preget av tidligere livserfaringer. Denne forståelseshorisonten innrammer også forskeren med sin forforståelse. Ingen forskning er forutsetningsløs, og dermed hører filosofiske og vitenskapsteoretiske antagelser og refleksjon hjemme innenfor enhver forskningsposisjon. En kroppsfenomenologisk forskning må ha sitt utgangspunkt i denne filosofiske retningens antagelser når den skal undersøke empiriske fenomener. Jeg vil imidlertid hevde at forholdet mellom empiri og filosofi er et forhold som må diskuteres og gjøres eksplisitt innenfor all forskning som dreier seg om mennesker i helse og sykdom. En viktig forutsetning for metodevalg som for eksempel valg av kvalitativ eller kvantitativ tilnærming er dermed ikke bare de forskningsspørsmål forskeren selv formulerer. Det dreier seg også om ontologiske forutsetninger, det vil si forskerens oppfatning av grunntemaer som knytter seg til spørsmål om syn på vitenskap, på hva sykdom er og hvordan den erfares. Forskerens innstilling til og i hvilken grad han problematiserer disse grunntemaene vil også forme hvordan han ønsker å undersøke det han vil undersøke. En slik etterlysning av klargjøring av forforståelse og redegjørelse for de grunnleggene teoretiske antagelsene som ligger til grunn for forskningen, må imidlertid ikke føre til dogmatisme og til nye former for bekjennelse og krav om rettroenhet. Jeg etterlyser først og fremst økt kunnskapspluralisme. Det er altfor ofte for tette skott mellom fag og forskningsmiljøer i dag. Det å kombinere perspektiv er slik jeg ser det vesentlig. Det er ingen kunnskapsdisiplin som sitter alene med svaret, heller ikke fenomenologien alene kan løse det som er vesentlige og kompliserte helseproblemer i vår tid, som for eksempel kronisk smerte. Det ligger dermed en primær moralsk utfordring og forpliktelse i forhold til samarbeid mellom ulike kunnskapstradisjoner for å utvikle nye og bedre metoder for behandling og lindring. Forskeren og forskningen må i et slikt perspektiv ha som sitt hovedmål om å tjene pasienten ved å utvide og bedre behandlingsmuligheter for mennesker som lider. Finn Nortvedt, Høgskolen i Oslo. Avdeling for Sykepleierutdanning. Stensberggt 27. PB 4. St Olavs Plass, NO – 0130 OSLO [email protected] Litteratur 1. Merleau-Ponty M. Phenomenology of Perception. Great. Britain: Routledge&Keegan Paul Ltd; 1960/2000 2. Nortvedt F. Innelukket i smerte og utestengt fra verden. En studie av fantomsmerte etter amputasjoner og etter tverrsnittslesjon hos ryggmargskadde. Avhandling til Dr. Philos. Det Medisinske Fakultet. Universitetet i Oslo. Oslo: Unipub; 2006 3. Moran D. Mooney. The Phenomenology Reader. London and New York; Routledge; 2002 4. Zahavi D. Fenomenology. Roskilde: Roskilde Universitetsforlag; 2003 5. Bengtsson J. Heggen K, Engelsrud G. Livsverdensfenomenologi och vårdforskning. Norsk Tidskrift for Sykepleieforskning. 2004; 6 (3); 3–6 6. Bengtsson J. Med livsverden som grund. Lund: Studentlitteratur; 1999 7. Zahavi D. Husserls fenomenologi. Stanford California: Stanford University Press; 2003 8. Engelsrud G. Hva er kropp? Oslo: Universitetsforlaget; 2006 9. Heggen K. Sykdom mellom prerefleksiv erfaring og diagnose: Bengtsson J. (red): Om livsverdensfenomenologi og helsefaglig forskning. Kristiansand: Høgskoleforlaget; 2006 10. Leder D. The absent body. Chicago and London: The University of Chicago Press; 1994 11. Svenaeus F. Sjukdomens mening. Stockholm: Natur och Kultur; 2003 12. Ramachandran V.S. Blakeslee S. Phantoms in the brain. New York: Quill; 2001 FINN NORTVEDT 55 Til Norge: B-blad i postabonnement Til øvrige Norden: Blad i postabonnement POSTADRESSE SSNs SEKRETARIAT VÅRD I NORDEN POSTBOKS 456 SENTRUM NO-0104 OSLO NORGE Innhold Redaksjonelt Editorial Sykepleievitenskap Omvårdnadsforskning Utvikling i sykepleien av Guðrún Kristjánsdóttir 3 Nursing Science and Research The association between leadership behaviour and burnout among nursing personnel in health care av Outi Kanste 4 Nurses conceptions of the professional role of operation theatre and psychiatric nurses av Birgitt Blegeberg, Ann-Catrin Blomberg og Birgitta Hedelin 9 The Karen instruments for measuring quality of nursing care. Item analysis av Inger S. Andersson og Margareta Lindgren 14 Feilmedisinering i sykehus – organisasjonskulturens påvirkning av Marit Storli 19 Family support as a care resource among the Bena in the Tanzanian village of Ilembula av Anitta Juntunen og Merja Nikkonen 24 Patient safety regarding leg ulcer treatment in primary health care av Hilde Smith-Strøm og Ingun Thornes 29 Personers upplevelse av att leva med kronisk hjärtsvikt – Systematisk litteraturstudie av Ann-Sofi Barremo, Elisabeth Bruce, Monica Salander og Karin Sundin 34 Short papers Synligt, osynligt och synliggjort 10 år i ett Nordiskt nätverk av sjuksköterskeutbildningar av Sonia Bentling og Åke Lennander Veiledningsmodell for sykepleierstudenter i sykehjem – en evalueringsstudie av Siv Sønsteby Nordhagen, Ragna Ingeborg Engelien og Inger Signe Johansson 39 An educational model fittet for rural municipalities av Bente Norbye 42 46 Patientdagbok vid kronisk sjukdom utvärdering av ett verktyg i vård och egenvård av Agneta Pagels, Marie Wång, Annelie Magnusson, Annika Eriksson og Stefan Melander 49 Kroppsfenomenologisk forskning – i grenselandet mellom empiri og filosofi av Finn Nortvedt 53 3. 2008 VOLUME/ÅRGANG 28