HØST 2008, NR. 3 PUBLIKASJON NR. 89 VOLUME/ÅRGANG 28

Transcription

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
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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
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:
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
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: outi.kanste@oulu.fi
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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
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
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
11
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.
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.
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
Ann-Catrin.Blomberg@kau.se
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 Ann-Catrin.Blomberg@kau.se
Acknowledgement
We would like to thank professor Barbro Arvidsson, Gjøvik university
college, Norway, for valuable comments concerning the phenomenographic method.
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13
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
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
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).
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
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,
margareta.lindgren@imv.liu.se, inger.s.andersson@bredband.net
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18
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Oxford.
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
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
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
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, marit.storli@hist.no
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– årsrapport 2003; 2005.
3. Hjort PF. Uheldige hendelser i helsetjenesten – en lære-, tenke- og faktabok. Oslo: Gyldendal akademisk; 2007.
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Rygge J. Oslo: Ad Notam Gyldendal; 1997.
MARIT STORLI
23
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?
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
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,
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.
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. anitta.juntunen@kajak.fi
Merja Nikkonen, Assistant Professor, Department of Nursing Science,
University of Kuopio, P.O. Box 1627, FIN –70211 Kuopio
merja.nikkonen@uku.fi
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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
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
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
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.
hilde.smith-strom@betanien.no
Ingun Thornes, RN, Department of Dermatology, Haukeland
University Hospital, Bergen, Norway
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patients with venous ulcers. York: RCN Institute, 1998.
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and stockings for venous leg ulcers. Cochrane Database of Systematic
Reviews 2000;(2):CD0002665.
18. Charles H. Venous leg ulcer pain and its characteristics. Journal of Tissue
Viability 2002;12:154–158.
19. Hofman D, Ryan TJ, Arnold F, Cherry GW, Lindholm C, Bjellerup M. Pain
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26. Dawes M, Summerskill W, Glasziou P, Catabellotta A, Marin J, Hopayian
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33
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.
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
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
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 karin.sundin@nurs.umu.se
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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
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. sonia.bentling@mdh.se
Åke Lennander, Fil.kand. universitetsadjunkt, koordinator Nordmannätverket. Mälardalens högskola, Akademin för hälsa, vård och välfärd SE Box 325, 63105 Eskilstuna. ake.lennander@mdh.se
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
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?
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
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?
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?
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?
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. siv.nordhagen@hig.no
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.
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.
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. Bente.Norbye@hitos.no
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
agneta.pagels@karolinska.se
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
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).
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
Finn.Nortvedt@su.hio.no
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
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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

HØST 2008, NR. 3 PUBLIKASJON NR. 89 VOLUME/ÅRGANG 28

Transcription

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