The experience of younger adults and their next of kin following a myocardial infarction and registered nurses' conceptions of caring in a coronary care context

Sammanfattning: Despite the fact that caring has been regarded as the core of nursing for decades, our knowledge about caring is still mainly on a philosophical level. The problem with these philosophical descriptions is that they do not serve as explicit guides for today's nurses, particularly in the light of the considerable changes that have taken place in the healthcare sector. One of the aims of this thesis was therefore to describe registered nurses' conceptions of caring. Another aim was to extend, and understand the nurses' descriptions by analysing their views of caring through a hierarchical outcome space (findings from Paper III), and in relation to a patient case reflecting the meaning of the experience after a myocardial infarction (findings from Paper I). Even if there is a growing knowledge base within healthcare, with a firm focus on medicine and technology, knowledge about the patients' and their next of kin' experiences is sparse by comparison. Such knowledge is needed to understand what to be prioritised in the development of nursing interventions directed at younger people and their next of kin after a myocardial infarction. A further aim of this thesis was to elucidate the meaning of the experience of younger people and their next of kin following a myocardial infarction. This thesis is based on a naturalistic inquiry. For Paper I, the sample consisted of younger people (55 years and younger) who had suffered a myocardial infarction (n = 17). For Paper II, the sample comprised their next of kin (n = 13). Data was collected by means of narrative interviews and the analysis was conducted by the phenomenological-hermeneutic method (Papers I-II). In Papers III and IV, the sample consisted of registered nurses (n = 21). The data for Paper III was collected by means of interviews and the analysis of the transcribed texts was inspired by phenomenography. In Paper IV, a stimulated recall interview technique was used. The transcribed texts were analysed in two distinct phases inspired by the descriptions of deductive and inductive content analysis. The findings in Paper I reflected how the experience of younger people after a myocardial infarction could be interpreted as an everyday fight to redress the balance in life. In Paper II, the experience of being a midlife next of kin of a relative who had suffered a myocardial infarction could be interpreted as standing alone when life took an unexpected turn. In Paper III, the findings mirrored four qualitatively different ways of understanding caring from the nurses' perspective but with a hierarchical relationship: Caring as person-centredness, Caring as safeguarding the patient's best interests, Caring as nursing interventions and Caring as contextually intertwined. The most comprehensive feature of their collective understanding of caring was their acknowledgment of the person behind the patient, i.e. person-centredness. In Paper IV the findings from the first phase, the deductive analysis reflected the main content of how nurses could understand caring, the hierarchical outcome space from Paper III, but the analysis indicated that the hierarchical outcome space broke up i.e. flipped. The findings from the second phase, the inductive analysis showed that the nurses' views of caring fell into four generic categories; Person-centredness 'lurking' in the shadows, Limited 'potential' for safeguarding the patient's best interests, Counselling as virtually the 'only' nursing intervention and Caring preceded by the 'almighty' context. The findings from both phases of content analysis were interpreted to offer extended understandings and perspectives of how the nurses' could understand caring. The findings indicated that there is a need to reform the overall contextual conditions surrounding caring. Such reformation should facilitate caring signified by safe clinical judgements, nurses standing by their patients, care based on the individual patient and deliverance and development of relevant nursing interventions. Nurses' conception of caring as person-centredness seems to be a prerequisite for practising caring in a person-centred fashion, however, this needs to be cultivated on a daily basis. This approach could innovate care and cardiac rehabilitation. Therefore there must be a greater awareness in the in-hospital care that caring is contextually intertwined. Managers as well as leaders need to investigate how the context is organised and structured to provide contextual improvements. In order to ensure that the essentials of caring are met at all times, nurses need to plan and deliver caring in a structured and systematic way. Using nursing models for care including the nursing process can facilitate this. Using systematic structures in caring, as the nursing process, will supply nurse with relevant problem-solving models and simultaneously support them to work in a person-centred way, where the patients' objective and subjective symptoms and experiences are taken into account in caring.