The Changing Face of Psychiatric Nursing –Care or Control?

This report has been written as part of the project “Toward improved quality – developing nurse’s continuing vocational training in hospitals and inpatient units”. Its overall goal is to ensure high quality, ethically appropriate and therapeutically effective interventions to enable nurses to manage distressed and disturbed patients in European psychiatric hospitals and inpatient units. In this large-scale, multinational projects there are all together six European countries involved: Finland, Ireland, England, Portugal, Italy and Lithuania. The project work plan were during autumn 2006 and spring 2007. The content of this publication was produced in the first stage of the project aiming to collect the preliminary source material for the project. The literature review was carried out in the project stage, providing the groundwork for the next steps for the project. This project aims to develop an interactive multinational portal with training material. Therefore, it is important to share an understanding of basic information, psychiatric nurse’s continuing vocational education, laws and ethical codes and patient restriction used in mental health care. In this publication, the purpose of the material produced here is to understand nurses’ educational need related to vocational continuing education and to be used in further project stages as an empirical data collection. The data were collected as a preliminary source material for latter phases where nurse’s perceptions of the current practice, nurse’s attitudes to mental illness, prevalence of use of seclusion room and existing and desired vocational training provision will be collected in six different European countries. The following organisations are involved in this project: University of Turku, Dublin City University, St. Vincent Hospital, National Council for the Professional Development of Nursing and Midwifery, University of Padova, Klaipeda College - Health Faculty, Klaipeda Psychiatric Hospital, Escola Superior de Enfermagem de Lisboa, Centro Hospitalar Psiquiátrico de Lisboa, Omnia Vocational Institution the Espoo Region, Kellokoski psychiatric hospital, Hyvinkää hospital area, Pirkanmaa Hospital District, Kingston University & St. George’s Medical School and South West London & St. George’s Mental Health NHS Trust. A wide variety of different countries, organisations and individuals in this project give us a strong confidence that theoretical, practical, ethical and political issues around the topic of interest will be taken account during this project lifetime. We are aware the content of this book will be partially outdated almost as soon as it has been published. We still hope that this publication will encourage nurses and different professions working in mental health care field to have a basic understanding of similarities and differences between different European countries related in mental health care. We also hope that this publication will inspirate and motivate nurses in maintaining and developing the quality of psychiatric care in Europe.

Reflective Learning in Higher Education: A Comparative Analysis

A descriptive, exploratory study is presented based on a questionnaire regarding the following aspects of reflective learning: a) self-knowledge, b) relating experience to knowledge, c) self-reflection, and d) self-regulation of the learning processes. The questionnaire was completed by students studying four different degree courses (social education, environmental sciences, nursing, and psychology). Specifically, the objectives of a self-reported reflective learning questionnaire are: i) to determine students’ appraisal of reflective learning methodology with regard to their reflective learning processes, ii) to obtain evidence of the main difficulties encountered by students in integrating reflective learning methodologies into their reflective learning processes, and iii) to collect students’ perceptions regarding the main contributions of the reflective learning processes they have experienced

Supporting older people’s independent living at home through social and health care collaboration

Tässä tutkimuksessa tarkasteltiin ikäihmisten kotona asumista sosiaali- ja terveydenhuollon yhteistyön näkökulmasta. Tutkimuksen tarkoituksena oli lisätä ymmärrystä iäkkäiden kotihoidon asiakkaiden voimavaroista arjesta selviytymisen näkökulmasta, ja tutkia miten asiakkaiden hoito sosiaali- ja terveydenhuollon yhteistyönä toteutuu. Tutkimus oli poikkileikkaustutkimus, jossa sovellettiin kuvailevaa ja vertailevaa tutkimusasetelmaa. Tutkimusaineisto kerättiin yhden länsisuomalaisen kunnan kotihoidon asiakkailta (≥65 v.) ja heitä hoitavilta ammattihenkilöiltä. Kotihoidon 21 iäkästä asiakasta kuvasivat omia voimavarojaan arjesta selviytymisen näkökulmasta sekä kokemuksiaan hoidon toteutumisesta ammattihenkilöiden yhteistyönä. Aineisto kerättiin avoimella haastattelulla ja analysoitiin sisällön analyysillä. Lisäksi 25 kotihoidon ammattihenkilöä: 13 kotipalvelun työntekijää, 11 kotisairaanhoitajaa ja lääkäri kuvasivat kokemuksiaan iäkkään asiakkaan hoidon toteutumisesta ammattihenkilöiden yhteistyönä. Aineisto kerättiin fokusryhmähaastattelulla ja analysoitiin sisällön analyysillä. Näiden tulosten sekä aikaisemman kirjallisuuden perusteella laadittiin strukturoitu kyselylomake, jolla analysoitiin ja vertailtiin asiakkaiden ja ammattihenkilöiden näkemyksiä siitä, miten asiakkaiden hoito sosiaali- ja terveydenhuollon yhteistyönä toteutui. Esitestausten jälkeen kyselylomake lähetettiin 200 kotihoidon asiakkaalle ja 570 heitä hoitavalle kotihoidon työntekijälle: 485 kotipalvelun työntekijälle, 81 kotisairaanhoitajalle ja 4 lääkärille. Kyselyyn vastasi 120 asiakasta (60 %) ja 370 ammattihenkilöä (65 %). Ryhmien välisten erojen tarkastelussa käytettiin ristiintaulukointia, Pearsonin khin neliötestiä ja Fisherin tarkan todennäköisyyden testiä. Iäkkäiden asiakkaiden kuvauksissa voimavarat muodostuivat elämänhallinnan tunteesta ja toimintatahdon säilymisestä. Asiakkaat ammensivat arkeen voimaa harrastuksista ja sosiaalisesta verkostosta, mutta ulkopuolisten asettamat elämisen ehdot, terveydentilan heikkeneminen sekä yksinäisyys asettivat ikäihmisen ja hänen voimavaransa suurten haasteiden eteen. Tulokset osoittivat, että ammattihenkilöiden toiminta oli osittain ristiriidassa ikäihmisten omien odotusten kanssa, eikä se kaikilta osin tukenut asiakkaiden omia voimavaroja. Ammattihenkilöt tekivät hoitoon liittyviä päätöksiä ja toimintoja asiakkaiden puolesta, vaikka asiakkaille itselleen oli tärkeää elämänhallinnan tunne ja toimintatahdon säilyminen. Asiakkaiden voimavarojen tukemista moniammatillisena yhteistyönä vaikeuttivat ammattihenkilöiden vaikeus tunnistaa asiakkaiden omia voimavaroja sekä niitä uhkaavia tekijöitä, tiedon kulun ongelmat, tavoitteeton ja epäyhtenäinen tapa toimia sekä ammattihenkilöiden vastakkain asettuvat näkemyserot ja toimintatavat. Asiakkaiden ja ammattihenkilöiden näkemykset toteutetusta hoidosta erosivat toisistaan tilastollisesti merkitsevästi (p<0.05). Asiakkaat arvioivat sekä itsenäiseen toimintaan tukemisen että fyysisen, psyykkisen ja sosiaalisen tuen toteutuneen työntekijöitä huonommin. Yhteistyön kehittämishaasteita kotihoidossa ovat asiakkaan oman elämänsä asiantuntijuuden vahvistaminen, toimintakulttuurin muuttaminen asiakaslähtöiseksi tavoitteelliseksi toiminnaksi, ammattihenkilöiden roolien ja vastuun selkiyttäminen sekä tiedon kulun menetelmien kehittäminen. Tutkimus vahvistaa gerontologisen hoitotieteen tietoperustaa ja tuottaa uutta tietoa, jota voidaan soveltaa sosiaali- ja terveysalan koulutuksessa ja johtamisessa

From "being to the self" to "become to be": on development of autonomy construction in nursing students

Objective: To understand nursing student's self-consciousness and his/her autonomy in the discipline of fundamentals of professional care in the context of a liberating pedagogical proposal. Methodology. This qualitative, case-based research in the model of Ludke and André involved 14 students participating in the discipline. Data were collected by non-participatory observation and analysis of documents. Field observation was conducted from March to July 2010 and data were collected according to the proposal of Minayo: pre-analysis, exploration of material and treatment of results. Results. We constructed two thematic units of analysis: from "being to the self" and exercise of "become to be". Conclusion. When nursing students feel more liberty, they have the opportunity to substitute the scary prospect of learning something new material to something that motivates their curiosity and leads them to become more autonomous.

Patient Seclusion and Restraint Practices in Psychiatric Hospitals - Towards Evidence Based Clinical Nursing

The overall goal of this study was to support evidence based clinical nursing regarding patient seclusion and restraint practices. This was done by ensuring professional competence through innovative learning methods. The data were collected in three phases between March 2007 and May 2009 on acute psychiatric wards. Firstly, psychiatric inpatients’ experiences and suggestions for seclusion and restraint practices were explored (n=30). Secondly, nursing and medical personnel’s perceptions of seclusion and restraint practices were explored (n=27). Thirdly, the impacts of a continuing vocational eLearning course on nurses’ professional competence was evaluated (n=158). Patients’ perspectives received insufficient attention during the seclusion and restraint process. Improvements and alternatives to seclusion and restraint as suggested by the patients focused on essential parts of clinical nursing, but were not extensively adopted. Also nursing and medical personnel thought that patients’ subjective perspective received little attention. Personnel proposed a number of alternatives to seclusion and restraint, and they expressed a need for education and support to adopt these in clinical nursing. Evaluation of impacts of eLearning course on nurses’ professional competence showed no statistical differences between an eLearning group and an education-as-usual group. This dissertation provides evidence based knowledge about the realization of seclusion and restraint practices and the impacts of eLearning course on nurses’ professional competence in psychiatric hospitals. In order to improve clinical nursing the patient perspective must be accentuated. To ensure personnel’s professional competence, there is a need for written clinical guidelines, education and support. Continuing vocational education should bring together written clinical guidelines, ethical and legal issues and the support for personnel. To achieve the ambitious goal of such integration, achievable and affordable educational programmes are required. This, in turn, yields a call for innovative learning methods.

Quality of Abdominal Surgical Nursing Care

The study evaluates the quality of abdominal surgical nursing care. The data were collected from patients (n=1208) having undergone abdominal surgical operations on their last day of hospitalization and nurses (n=218) working in the same wards. Three instruments originally created in Finland and adapted to the Lithuanian context were used: (1) Good Nursing Care Scale for patients and nurses (GNCS-P, GNCS-N), (2) Nurse Competence Scale (NCS), and (3) Nurse Empowerment Scale (NES). Patient and nurses’ perceptions of the quality of nursing care were evaluated. In addition, nurses’ perceptions of their competence and empowerment were evaluated. The patient and nurses' perceptions of the quality of abdominal surgical nursing care were positive, with more criticism in the nurses’ perceptions. Both patients and nurses gave the lowest evaluation to the quality in the progress of nursing care and the co-operation with significant others. The nurses gave the highest evaluation to the self-assessed level of their competence and the frequency of using competences in practice, with the highest assessment given to situation management and their role at work and the lowest to teaching-coaching and ensuring quality. The nurse perceptions of their empowerment were positive in the qualities and performance of an empowered nurse and empowerment promoting factors, with the highest evaluation in moral principles and sociability and the lowest evaluation in the future-orientedness and expertise. The empowerment-impeding factors were evaluated as negative. The perceptions of the quality of nursing care of both patients and nurses had significant correlations with patient and nurse satisfaction and nurse job independence. The nurse perceptions of their competence and empowerment correlated with their education, the type of the nurse license, completed courses of development of their knowledge and skills, nurse job independence, and nurse satisfaction. The nurse perceptions of the quality of nursing care had a positive correlation with their perceptions of competence and empowerment. Generally, the quality of nursing care was evaluated as high and had correlations with the patients' demographic and satisfaction factors and with the nurse demographic, work-related, and satisfaction factors. The study produced the knowledge that the quality in co-operation with significant others and the progress of nursing process, surgical nurse competence in teaching-coaching, and future-orientedness of surgical nurse empowerment need to be improved in order to develop the quality of abdominal surgical nursing care. The knowledge may be used to offer better services for abdominal surgical patients and increase their satisfaction with nursing care, as well as to increase nurses' satisfaction with work and independence at work. The study suggests implications for clinical practice and management, nursing education, and nursing research.

Competence in intensive and critical care nursing - development of a basic assessment scale for graduating nursing students

Intensive and critical care nursing is a speciality in its own right and with its own nature within the nursing profession. This speciality poses its own demands for nursing competencies. Intensive and critical care nursing is focused on severely ill patients and their significant others. The patients are comprehensively cared for, constantly monitored and their vital functions are sustained artificially. The main goal is to win time to cure the cause of the patient’s situation or illness. The purpose of this empirical study was i) to describe and define competence and competence requirements in intensive and critical care nursing, ii) to develop a basic measurement scale for competence assessment in intensive and critical care nursing for graduating nursing students, and iii) to describe and evaluate graduating nursing students’ basic competence in intensive and critical care nursing by seeking the reference basis of self-evaluated basic competence in intensive and critical care nursing from ICU nurses. However, the main focus of this study was on the outcomes of nursing education in this nursing speciality. The study was carried out in different phases: basic exploration of competence (phase 1 and 2), instrumentation of competence (phase 3) and evaluation of competence (phase 4). Phase 1 (n=130) evaluated graduating nursing students’ basic biological and physiological knowledge and skills for working in intensive and critical care with Basic Knowledge Assessment Tool version 5 (BKAT-5, Toth 2012). Phase 2 focused on defining competence in intensive and critical care nursing with the help of literature review (n=45 empirical studies) as well as competence requirements in intensive and critical care nursing with the help of experts (n=45 experts) in a Delphi study. In phase 3 the scale Intensive and Critical Care Nursing Competence Scale (ICCN-CS) was developed and tested twice (pilot test 1: n=18 students and n=12 nurses; pilot test 2: n=56 students and n=54 nurses). Finally, in phase 4, graduating nursing students’ competence was evaluated with ICCN-CS and BKAT version 7 (Toth 2012). In order to develop a valid assessment scale of competence for graduating nursing students and to evaluate and establish the competence of graduating nursing students, empirical data were retrieved at the same time from both graduating nursing students (n=139) and ICU nurses (n=431). Competence can be divided into clinical and general professional competence. It can be defined as a specific knowledge base, skill base, attitude and value base and experience base of nursing and the personal base of an intensive and critical care nurse. Personal base was excluded in this self-evaluation based scale. The ICCN-CS-1 consists of 144 items (6 sum variables). Finally, it became evident that the experience base of competence is not a suitable sum variable in holistic intensive and critical care competence scale for graduating nursing students because of their minor experience in this special nursing area. ICCN-CS-1 is a reliable and tolerably valid scale for use among graduating nursing students and ICU nurses Among students, basic competence of intensive and critical care nursing was self-rated as good by 69%, as excellent by 25% and as moderate by 6%. However, graduating nursing students’ basic biological and physiological knowledge and skills for working in intensive and critical care were poor. The students rated their clinical and professional competence as good, and their knowledge base and skill base as moderate. They gave slightly higher ratings for their knowledge base than skill base. Differences in basic competence emerged between graduating nursing students and ICU nurses. The students’ self-ratings of both their basic competence and clinical and professional competence were significantly lower than the nurses’ ratings. The students’ self-ratings of their knowledge and skill base were also statistically significantly lower than nurses’ ratings. However, both groups reported the same attitude and value base, which was excellent. The strongest factor explaining students’ conception of their competence was their experience of autonomy in nursing. Conclusions: Competence in intensive and critical care nursing is a multidimensional concept. Basic competence in intensive and critical care nursing can be measured with self-evaluation based scale but alongside should be used an objective evaluation method. Graduating nursing students’ basic competence in intensive and critical care nursing is good but their knowledge and skill base are moderate. Especially the biological and physiological knowledge base is poor. Therefore in future in intensive and critical care nursing education should be focused on both strengthening students’ biological and physiological knowledge base and on strengthening their overall skill base. Practical implications are presented for nursing education, practice and administration. In future, research should focus on education methods and contents, mentoring of clinical practice and orientation programmes as well as further development of the scale.

Evaluation of an e-learning course: coercion practices in psychiatric nursing

The goal of the study was to evaluate an e-learning course entitled “Nursing interventions to manage distressed and disturbed patients” and intended for psychiatric nurses, using Kirkpatrick’s evaluation model. The aim was to describe nurses’ reactions, learning, behaviour change and impacts resulting from this e-learning course. This dissertation comprises four papers, and the data were collected 2008-2012 from three different sources; electronic databases, an e-learning platform and psychiatric hospitals. First, a systematic literature review was conducted to understand the effectiveness of e-learning. Second, an RCT study was implemented to investigate the impact of the e-learning course on nurses’ job-satisfaction, knowledge and attitudes (N=158). Third, to complete the picture of nurses views of the e-learning course related to knowledge transfer, the nurses’ perspective was studied (N=33). Lastly, the effects of the e-learning course from nursing managers’ perspective in psychiatric hospital organisations were studied (N=28). The systematic review showed that although the nurses were satisfied with the e-learning, no effects were found in the RCT study of nurses’ job satisfaction. The RCT study showed no effects on nurses’ learning related to knowledge increase, but there was change in attitudes. The managers described the changes in the nurses’ knowledge and attitudes. Among the nurses behaviour changed with knowledge transfer from the e-learning course to practice and they pointed out development issues related to their work. The final impacts of the e-learning course revealed advantages and disadvantages of the e-learning course and its implications for nurses’ work. This dissertation provides new insight into nurses’ reactions, learning, behaviour change and impacts resulting from an e-learning course in their continuing education. In order to improve nurses’ continuing education systematic evaluation is needed, for which Kirkpatrick’s evaluation model is a useful tool.

Nurse Competence of Graduating Nursing Students

The competence of graduating nursing students is an important issue in health care as it is related to professional standards, patient safety and the quality of nursing care. Many changes in health care lead to increased demand with respect to nurses’ competence as well the number of nurses. The purpose of this empirical study was to i) describe the nurse competence areas of nursing students in Europe, ii) evaluate the nurse competence of graduating nursing students, iii) identify factors related to the nurse competence, and to iv) assess the congruence between graduating nursing students’ self-assessments and their mentors’ assessments of students’ nurse competence. The study was carried out in two phases: descriptive phase and evaluation phase. The descriptive phase focused on describing the nurse competence areas of nursing students in Europe with the help of a literature review (n=10 empirical studies and n=4 additional documents). Thematic analysis was used as the analysis method. In the evaluation phase, the nurse competence with particular focus on nursing skills of graduating nursing students (n=154) was assessed. In addition, factors related to the nurse competence were examined. Also, the congruence between graduating nursing students’ self-assessments and their mentors’ assessments of students’ nurse competence was evaluated by comparing graduating nursing students’ self-assessments with the assessments by their mentors (n=42) in the final clinical placement in four university hospitals. Descriptive statistics and inferential statistics were used to analyse the data. Based on the results, the nurse competence of nursing students in Europe consists of nine main competence areas: (1) professional/ethical values and practice, (2) nursing skills and interventions, (3) communication and interpersonal skills, (4) knowledge and cognitive ability, (5) assessment and improving quality in nursing, (6) professional development, (7) leadership, management and teamwork, (8) teaching and supervision, and (9) research utilization. Graduating nursing students self-assessed their nurse competence as good. However, when graduating nursing students’ nurse competence was assessed by their mentors, the results were poorer. Readiness for practice based on nurse education, pedagogical atmosphere on the ward, supervisory relationship between student and mentor and being in paid work in health care at the moment of the study were the most significant factors related to the nurse competence. Conclusions: Nurse competence can be evaluated with a scale based on self-assessment, but other evaluation methods could be used alongside to ensure that nurse competence can be completed and evaluated critically. Practical implications are presented for nurse education and nursing practice. In future, longitudinal research is needed in order to understand the development of nurse competence during nurse education and the transition process from a nursing student to a professional nurse.

Becoming a caring nurse : the heart of the matter in nurse education

This thesis in caring science didactics is based on a thinking, where the fundamental basis for the didactic is science-based, i.e. it does not emanate from the nursing profession but brings forward a didactic that grows out of caring science and its core substance and ethos. This view on didactics arises from the caritative theory developed by Eriksson. The overall aim of the study is to clarify the meaning and essence of understanding, as well as to explore and deepen the understanding of student nurses' processes of understanding and becoming with the intention of developing a theory model for caring didactics. The overarching research questions are: What is the essence of understanding (of caring science knowledge)? What are the possibilities and importance of understanding in the appropriation of caring science? What characterizes and impels the process of becoming? The thesis consists of four sub studies and a summary section. The overall methodological approach is hermeneutic involving quantitative as well as qualitative methods. The data for the study has been collected through a longitudinal research project that followed student nurses at three universities during their entire education. The empirical sub studies form the basis for the interpreted knowledge that is formulated in the new understanding. This new understanding have, through additional theory-charging with the theory fragments from Gadamer, generated the heuristic synthesis which is illustrated in the theory model. The findings shows that understanding can be described as something unlimited, as an endless movement, which can be illustrated as a lying eighth, a lemniscate. The lemiscate of understanding is characterized by seeing, knowing and becoming and consists of seven differently named phases; the acquired horizon of understanding, the encounter of horizons, the dialogue of horizons, the fusion of horizons, application, reflection and shaping a new horizon of understanding. Bildung (formation), is the ultimate imprint of the endless spiral movement of understanding. Ethos and arête constitute the hubs around which the lemniscate of understanding circles. These include the spirit and driving force that the student carries within. The caring culture encloses the lemniscate of understanding. The caring culture provides the life space of understanding and the prevailing basic values are evinced in the culture.

Collective learning within nursing clinical groups /

This qualitative study examined collective learning within nursing clinical groups. Specifically, it explored the influence of the individual on the group and the impact of the group on the individual. The study was organized using the concepts from Debbie Kilgore's theory of collective learning (1999). The sample consisted of 1 8 second-year university nursing students and 3 clinical instructors. Data were collected via individual interviews with each participant and researcher's observations during a group conference. The interviews were tape-recorded, transcribed, and analyzed using key concepts from Kilgore's framework. Several interesting findings emerged. Overall, it appeared that individual components and group components contributed to the quality and quantity of collective learning that occurred in the groups. Individually, each person's past group experiences, personality, culture, and gender influenced how that individual acted in the group, their roles, and how much influence they had over group decisions. Moreover, the situation which seemed to cause the greatest sense of helplessness and loss of control was when one of their group members was breaking a norm. They were unable to deal with such situations constructively. Also, the amount of sense of worthiness (respect) and sense of agency (control) the member felt within the group had an impact on the person's role in group decisions. Finally, it seemed that students felt more connected with their peers within the clinical setting when they were close with them on a personal and social level. With respect to the group elements, it seemed that the instructors' values and way of being were instrumental in shaping the group's identity. In group 2, there were clear examples of group consciousness and the students' need to go along with the majority viewpoint, even when it was contrary to their own beliefs. Finally, the common goal of passing clinical and dealing with the fears of being in the clinical setting brought solidarity among the group members, and there seemed to be a high level of positive interdependence among them. From the discussion and analysis of the findings, recommendations were given on how to improve the learning within clinical groups.

Registered nurses' perceptions of factors impacting on their continuing education /

This qualitative study examined the effects of hospital restructuring on a group of nurses at a community hospital. Eleven nurses were asked questions in order to gain insight into their experience in this situation. Ten of these participants were female, and one was male. The intent was to gather information about how restructuring has affected their lives, including, their motivational factors and barriers to participation in continuing education, and their descriptions of their workplace environment. Audiotaped interviews were conducted on two occasions to obtain this data. Emergent themes included the nurses' comments about continuing education, motivational factors, barriers that included geography and time, reactions of co-workers, restructuring, the College of Nurses' Quality Assurance Program including peer feedback, and performance appraisals. The literature review compares the barriers and motivational factors to the previous research findings. Thus, this study gave voice to the experience of this group of nurses, working in a healthcare setting that is involved in restructuring. This information is important to the healthcare system, since many areas are involved in restructuring. The whole process, if it is to be successful, depends on the frontline workers, namely the nurses. Thus, if there is anything to be learned from this group of people, that could be used to improve this progression, everyone would benefit from this information, were it to be implemented. Everyone is a stakeholder in the quality of healthcare in our province. The frontline workers are the ones that hold the vantage point to be able to provide suggestions for the changes needed to successful. These nurses are not just motivated by work issues however, and educating them and motivating them will also improve the care provided through increased knowledge and enhanced self-esteem.