How nurses can ensure the sounds patients hear have a positive rather than negative effect upon recovery and quality of life.

A number of studies imply that control of a patient's auditory environment can generate an improvement in recovery and quality of life. The evidence suggests nurses have the ability to control their patients' auditory environment and in so doing can reduce factors which contribute to physical and psychological instability. Through communication nurses are able to humanise treatment, deter ignorance and cement personal relationships of mutual trust between patients and their families. Reference to nursing unconscious patients in Intensive Therapy Units (ITU) indicates how nurses can relate theory to practice and ensure a positive rather than negative experience of recovery by regulating and influencing the sounds patients hear.     

Institutional Courage: An Antidote to Institutional Betrayal and Broken Trust

An emerging area of interest is how institutional betrayal among nurses might lead to issues of nurse well-being, such as burnout and turnover. In this phenomenon, the organization, whether by explicit actions or the abstract ethos of the work environment, can become a contributing factor to psychological well-being. Within health care, the systemization and corporatization of medical services has contributed to a more institutional identity. Institutional actions that defy the expectation for safety and violate relationships between individual and institution are termed institutional betrayal. In any case or among any population of nurses, the key element of institutional betrayal is a violation of trust. If trust is lacking and the relationship with the organization is broken, then the person would feel a psychological weight or some sort of strain on their ethos that wears on their resilience. For nurses, this fractured relationship then makes patient care feel more like work than caring, which then cascades to burnout. In a system depleted of institutional trust, nurses might feel useless and wasted in the churn of the “system,” so they become depersonalized and bitter. Building back institutional trust becomes a pivotal way to counteract the trauma of betrayal. Rebuilding trust takes acts of courage. It is not easy for an organization or institution to admit it harmed people, and likely even more difficult as public relations and brand image become critical factors in health care business practices. But to admit these faults and take bold action is an act of institutional courage, one that can help heal the wounds experienced by nurses and larger society.     

Impersonal trust and professional authority: exploring the dynamics

AIM: The aim of the study was to explore the relationship between impersonal trust, governmentality and professional activity through an analysis of professional discourse. BACKGROUND: This study emerged from an earlier paper that described a four-dimensional model based on Luhmann's definition of trust as "reducing complexity and managing expectations". Linking trust with the Foucauldian notion of governmentality develops this further. Governmentality raises the question of how professional authority is constituted through the practice of nurses and other health and welfare professionals. METHOD: Discourse analysis was used to explore the text from two genres--academic literature and interview material (n = 17)--in the context of community residential services for people with learning disabilities. Findings. The study provided evidence to support claims that trust is produced through impersonal systems. Trust is contested in a dynamic process where there are gains and losses. Professionals in organisations actively promote trust, often through systems of distrust. The study also built on the four-dimensional model of impersonal trust--trust, mistrust, abuse and hope--and re-conceptualized the trust-hope dimension. CONCLUSION: There are theoretical links between governmentality and trust. Similarly, in order to understand trust nurses need to understand the dynamic nature of the systems in which they operate. The proposition that trust could frustrate hope adds an element of controversy to the discussion of hope in the nursing literature.     

Perioperative Nurses' Encounter with Value Conflicts

The aim of the study was to gain a better insight into perioperative nurses' experience in a value conflict that has arisen in the perioperative caring environment and how they deal with it. In order to obtain as full and objective a picture as possible the critical incident technique was chosen. Perioperative nurses were asked to write down stories about value conflicts which they have experienced in the perioperative caring environment. When interpreting the textual content of the stories the aim has been to understand the meaning of nurses' experiences and how the nurses act in a value conflict situation. A value conflict is something that nurses have become part of against their own will. They are prevented from giving the good care they want to give, they are in conflict with themselves and have a bad conscience, and they feel guilt and shame for not having prevented the value conflict. The nurse who is involved in a value conflict aims, for the sake of the patient, to be a professional caring nurse. The nurse chooses to be the patient's neighbour, the one who suffers along with the patient and represents the patient's cry for help.     

Trust and distrust between patient and doctor

To trust someone is to have expectations of their behaviour; distrust often involves disappointed expectations. But healthy trust and distrust require a good understanding of which expectations are reasonable, and which are not. In this paper, I discuss the limits of trustworthiness by drawing on recent studies of trust in the context of defensive medicine, biobanking and cardiopulmonary resuscitation decisions.     

Tinkering and tailoring individual consultations: how practice nurses try to make cardiovascular risk communication meaningful

Aims and objectives. To explore the perspectives of practice nurses in their role of communicating cardiovascular risk to patients. Background. Nurses in primary care have for some time been engaged in cardiovascular risk discussions with patients. With the recent introduction of the NHS Health Checks, the focus on this work is set to increase. Design. Qualitative using a framework approach. Methods. Two focus groups and 16 semi-structured interviews were conducted with nurses purposively sampled from those working in primary care. Results. The nurses' accounts revealed the need to develop a relationship of trust and establish a level of relevance with each individual patient whilst discussing cardiovascular risk. Potential aspects of these discussions were as follows: working within a highly structured data-collecting task; time constraints and consideration of the individual's context. We used the idea of tailoring to describe how nurses navigate and constantly modify and pitch their approach for each patient they see in response to these constraints. Conclusion. We suggest that in order for risk to be made meaningful to patients, practice nurses recognise the need for such information to be embedded in the more reciprocal dynamics of nurse-patient consultations. From their perspective, success is often as much about not saying something, or saying it in a particular way, as saying anything accurately or consistently. Relevance to clinical practice. For practice nurses to be instrumental in the successful delivery of health prevention policy initiatives such as the NHS Health Checks, it is important to acknowledge their views and perspectives in undertaking this work. This study suggests that the nurses recognised the need for further skills and a refinement of approach for those health professionals involved.     

Unrelieved pain: an ethical and epistemological analysis of distrust in patients.

Unrelieved pain is a serious clinical problem that has received little attention in bioethics. This paper contends that unrelieved pain is the result of distrust in patients that reveals both an ethical and epistemological failure on behalf of nurses and physicians. The analysis is conceptually framed in previous work on the articulation of trust in nursing. Specifically, an argument is made that clinicians do not trust patients' subjective experiences, distrust patients from marginalized and relatively less powerful groups, and resist entrusting themselves or becoming vulnerable to patients' pain and suffering. The authors discuss the need for awareness and critical examination of deeply entrenched societal beliefs and values that influence everyday decision-making in pain management.     

Adolescents with inflammatory bowel disease feel ambivalent towards their parents' concern for them

This is a grounded theory study to identify concepts for describing how adolescents with inflammatory bowel disease (IBD) respond to their parents' concern for them. Ten adolescent boys and seven girls were interviewed. In the analysis four main categories emerged: ambivalence, ability/inability, compliance/resistance and trust/distrust. We found ambivalence to be the most distinctive theme to appear in the way in which these young people described how they felt about their parents' response to their disease. The core category ambivalence was expressed as an oscillation between seeking close contact with one's parents or, sometimes, staving them off, one moment feeling anxiously dependent upon them or turning to them for protection and support and the next, trying to achieve a dialogue with them. The core category comprised three subcategories, ability/inability, compliance/resistance and trust/distrust. The clinical support for young individuals with IBD should include an awareness of the simultaneous existence of conflicting attitudes, reactions and emotions.     

Crises of trust

Extensive media coverage is warning of a crisis of trust that has emerged as a serious issue in our society. This article explores the meaning of "crisis," concepts of crisis management, mechanisms for building trust, and the underlying significance of trust and distrust. Evidence is adduced to testify to the erosion of trust and factors in our society that reflect the potential for crises of trust. Organizational decision makers, including hospital managers, are urged to identify and reflect upon weaknesses in their organizations in order that remedial action can be taken to preempt such crises.     

The silent demand in the diagnostic phase

Patients' experience of going through the diagnostic phase in hospital is apt to be overlooked by nurses and physicians; most of their inner preparative work for receiving the diagnosis is hidden because of the vulnerability of the situation. This paper discusses findings from a grounded theory study, of 18 in-depth interviews of 15 patients going through medical investigation at a gastric ward in a Norwegian university hospital. The interviews were conducted in 2002–2003. The generated 'Preparative Waiting Theory', which accounts for how patients in the diagnostic phase work to prepare themselves for receiving a diagnosis, is discussed in relation to the Danish theologian and philosopher Løgstrup's writings about the ethical demand and life utterances of trust, openness and the untouchable zone. The ethical demand from patients going through medical investigations is silent and radical, and thus challenging for nurses and physicians to judge how to best fulfil. Examples from the interviews are used to illustrate patients' vulnerability as they prepare to face the conclusion about their case. To the extent trust develops between patients and nurses/physicians, patients can reveal what is at stake in their lives without feeling exposed or embarrassed. Because of the power nurses and physicians have in the healthcare system, and because of laws, morals and conventions guiding practice, we have a professional responsibility to develop a culture that fosters the ability and willingness to take care of our patients.     

Caring with difficulty: Brazilian nurses' experiences of gynaecological surgery care

da Costa Vargens OM, Berterö CM. International Journal of Nursing Practice 2010; 16 : 159–165
Caring with difficulty: Brazilian nurses' experiences of gynaecological surgery care This study was made by a qualitative approach based on symbolic interactionism and grounded theory. The subject was defined as what mutilation means for nurses who take care of women submitted to gynaecological surgery. The aim was to identify the interaction relationship of nurses as female with the phenomenon of mutilation in gynaecological surgeries and how it affects their relationship with female patients in this situation. Data were obtained by interviews with 16 nurses who work in gynaecology units. The findings present two core categories: speaking as a professional and speaking as female. When they spoke as professional nurses they defined mutilation technically. As females they verbalized their conflict and difficulty in working with mutilation and redefined it as being the loss of something very important for themselves. We conclude that female nurses when confronting female surgery distances themselves behind the professional nurse and performs nursing care as a daily routine. It means that these nurses live a personal conflict that influences directly on how they supply care. They care for but do not care about, the ethos of biomedicine leads carers on to a technical path from which it is difficult to get off.     

Trust and managerialism: exploring discourses of care

AIM: This paper reports a study that explored the relationship between trust and managerialism through an analysis of professional discourse. BACKGROUND: Managerialism is a distinct set of discourses and practices related to managerial effectiveness, flexibility and consumer responsiveness that have come to characterize debates over the provision of health and welfare services across the developed world. At the same time, trust has attracted increasing academic and political interest. Managerial discourses are critical of healthcare professions and the way they operate. Professional opinions are challenged as representing the interests of professions rather than service users; as a consequence trust is contested. However, where practitioners are both professionals and managers, the boundaries between these discourses become blurred. Moreover, paradoxical development occurs where increasing autonomy for practitioners is accompanied by a strengthening of managerial controls over their activity. METHOD: Discourse analysis was used to explore the text from two genres, academic literature and interviews (n = 17), in the context of community residential services for people with learning disabilities. The study was conducted in 2001. FINDINGS: Two broad themes were identified, each with a number of sub-themes. The first focuses on the relationship between managerialism and trust located around the management of expectations. The second, 'the politics of care', explores the way professional and managerial discourse articulate to produce complementary and contradictory positions. CONCLUSION: The colonization of professional activity by managerial discourse has produced a context where professional activity is defined by a series of managerial imperatives; trust, which was once the product of intimate social activity is now shaped through techniques based on distrust such as audits and quality monitoring. Nevertheless, the persistence of tensions between trust and managerialism suggest an ongoing struggle for professional autonomy in the face of increasing managerial controls.     

Paediatric nurses, children and the development of trust

Nurses in paediatric settings work hard to develop trusting relationships with the children in their care. There are, however, barriers to these trusting relationships, because nurses are often involved in painful or frightening procedures for children, and sometimes parents may hamper the development of trust between nurse and child. Nurses use a range of strategies to try and gain confidence and co-operation from children, but recognize that at times it is necessary to simply restrain and carry on. In exploring the experiences of paediatric nurses, it became evident that the need to carry out painful procedures while trying to maintain relationships with children was taken for granted in this type of practice setting. What did not appear evident to the nurses was the dichotomy that they viewed trust as really important, but considered breaking trust to be essential.     

A framework to develop a clinical learning culture in health facilities: ideas from the literature

HENDERSON A., BRIGGS J., SCHOONBEEK S., & PATERSON K. (2011) A framework to develop a clinical learning culture in health facilities: ideas from the literature. International Nursing Review 58 , 196–202 Background: Internationally, there is an increase in demand to educate nurses within the clinical practice environment. Clinical practice settings that encourage teaching and learning during episodes of care delivery can be powerful in educating both the existing nursing workforce and nursing students. Aim: This paper presents a framework, informed by the literature, that identifies the key factors that are needed to encourage the interactions fundamental to learning in clinical practice. Key concepts: Learning occurs when nurses demonstrate good practice, share their knowledge through conversations and discussions, and also provide feedback to learners, such as students and novices. These types of interactions occur when positive leadership practices encourage trust and openness between staff; when the management team provides sessions for staff to learn how to interact with learners, and also when partnerships provide support and guidance around learning in the workplace. Application of concepts: This framework presents how the concepts of leadership, management and partnership interact to create and sustain learning environments. The feedback from proposed measurement tools can provide valuable information about the positive and negative aspects of these concepts in the clinical learning environment. Analysis of the subscales can assist in identifying appropriate recommended strategies outlined in the framework to guide nurses in improving the recognized deficits in the relationship between the concepts. Conclusion: Leadership, management and partnerships are pivotal for the creation and maintenance of positive learning environments. Diagnostic measurement tools can provide specific information about weaknesses across these areas. This knowledge can guide future initiatives.     

Aspects of the working life of women in the nursing profession in South Africa: survey results

This article reports on a survey done among nurses registered with the South African Nursing Council. The survey was carried out in the last quarter of 2003. The purpose of the survey was to investigate aspects of the working life of women in the nursing profession in South Africa and to make recommendations on how their working environment could be improved. The important findings were that pay-related issues dominate as the main problem at work. Improving pay scales and being paid according to extra experience, responsibilities and qualifications could improve the nurses' working environment. Furthermore, training opportunities, medical insurance and equal opportunities should be addressed as a matter of urgency. In general, respondents had a positive attitude towards their job, which leaves the impression that nurses still regard their jobs as something they do for the sake of a service to the community and not only for the money they earn.     

Differences in moral judgment between nursing students and qualified nurses

This longitudinal study examined how nursing students' moral judgment changes after they become qualified nurses working in a hospital environment. The sample used was a group of 80 nursing students attending a university in Suwon, Korea, between 2001 and 2003. By using a Korean version of the Judgment About Nursing Decisions questionnaire, an instrument used in nursing care research, moral judgment scores based on Ketefian's six nursing dilemmas were determined. The results were as follows: (1) the qualified nurses had significantly higher idealistic moral judgment scores than the nursing students; (2) the qualified nurses showed significantly higher realistic moral judgment scores than the nursing students; and (3) when comparing idealistic and realistic moral judgment scores, both the qualified nurses and the nursing students had higher scores for idealistic moral judgment. Further study is recommended to examine changes in moral judgment.     

The development of theory in British nursing: current position and future prospects

This paper is concerned with the development of theory in the discipline of nursing as it is practised in Great Britain. It stems from dissatisfaction with the generally uncritical adoption by British nurses of models of nursing which have been developed to explain and enhance North American practice. After the introductory paragraph, four roles for nursing theory are proposed. These are: to define nursing by describing nursing phenomena; to form a realistic basis for curriculum design; to provide tools for the professional practice of nursing; and to provide a nursing language. It is then argued that although British nurses have recognized the need for an adequate theoretical basis for practice, their response has been rather uncritical adoption of American models of nursing. As a basis for practice, it is argued that American models generally fail to meet the needs described above, and therefore fail to have impact on clinical work. Structural and philosophical reasons for this failure are identified. Following a brief discussion of the inductive and deductive approaches to the development of theory, the paper closes with the argument that British nurses should be concerned with the development of new theory which, if grounded in the reality of practice, would be likely to be both useful and realistic.     

Palliative care nurses' views on euthanasia

BACKGROUND: In debates on euthanasia legalization in Belgium, the voices of nurses were scarcely heard. Yet studies have shown that nurses are involved in the caring process surrounding euthanasia. Consequently, they are in a position to offer valuable ideas about this problem. For this reason, the views of these nurses are important because of their palliative expertise and their daily confrontation with dying patients. AIM: The aim of this paper is to report a study of the views of palliative care nurses about euthanasia. METHODS: A grounded theory approach was chosen, and interviews were carried out with a convenience sample of 12 palliative care nurses in Flanders (Belgium). The data were collected between December 2001 and April 2002. FINDINGS: The majority of the nurses were not a priori for or against euthanasia, and their views were largely dependent on the situation. What counted was the degree of suffering and available palliative options. Depending on the situation, we noted both resistance and acceptance towards euthanasia. The underlying arguments for resistance included respect for life and belief in the capabilities of palliative care; arguments underlying acceptance included the quality of life and respect for patient autonomy. The nurses commented that working in palliative care had a considerable influence on one's opinion about euthanasia. CONCLUSION: In light of the worldwide debate on euthanasia, it is essential to know how nurses, who are confronted with terminally ill patients every day, think about it. Knowledge of these views can also contribute to a realistic and qualified view on euthanasia itself. This can be enlightening to the personal views of caregivers working in a diverse range of care settings.     

Exploratory study of nursing in an operating department: preliminary findings on the role of the nurse

This study was exploratory and describes how nursing was viewed and practised by nurses who worked in an operating department. It also highlighted factors that might influence the role performance of operating department nurses. The research involved interviews with a sample of 6 nurses working in an operating department, observation of 32 hours of nursing work over 6 operating sessions, in addition to the analysis of various documents, including the nursing care plans of 22 patients. Data were triangulated and analysed by constant comparison. Findings indicated that nurses had difficulty in articulating exactly what it was that operating department nursing entailed, but rather viewed their role in terms of the functions they performed. Observations indicated that the nursing role was primarily orientated toward the physical rather than the psychological aspects of care-giving. Furthermore, it appeared that the medical profession, nursing philosophy/leadership and the characteristics of patients all influenced the manner in which nurses enacted their role. These findings suggest that further research into the role of the nurse within the operating department environment is warranted. Key factors from this study were developed into a framework suitable for guiding future study of the nursing role in this environment.     

Empathic processes during nurse–consumer conflict situations in psychiatric inpatient units: A qualitative study

Empathy is a central component of nurse–consumer relationships. In the present study, we investigated how empathy is developed and maintained when there is conflict between nurses and consumers, and the ways in which empathy can be used to achieve positive outcomes. Through semistructured interviews, mental health nurses (n = 13) and consumers in recovery (n = 7) reflected on a specific conflict situation where they had experienced empathy, as well as how empathy contributed more generally to working with nurses/consumers. Thematic analysis was used to analyse the data, utilizing a framework that conceptualizes empathy experiences as involving antecedents, processes, and outcomes. The central theme identified was ‘my role as a nurse – the role of my nurse’. Within this theme, nurses focussed on how their role in managing risk and safety determined empathy experienced towards consumers; consumers saw the importance of nurse empathy both in conflict situations and for their general hospitalization experience. Empathy involved nurses trying to understand the consumer's perspective and feeling for the consumer, and was perceived by consumers to involve nurses ‘being there’. Empathic relationships built on trust and rapport could withstand a conflict situation, with empathy a core component in consumer satisfaction regarding conflict resolution and care. Empathy allows the maintenance of therapeutic relationships during conflict, and influences the satisfaction of nurses and consumers, even in problematic situations. Nurse education and mentoring should focus on nurse self‐reflection and building empathy skills in managing conflict.