<p>Diss. (sammanfattning) Umeå : Umeå universitet, 2002</p> / digitalisering@umu

The overall purpose of this thesis is two-fold; to illuminate the meaning of living with ‘impurity’ in terms of malodorous exuding ulcers, and the meaning of caring for people with ‘impure’ bodies in institutions and in people’s homes. The thesis comprises four papers based on studies using qualitative methods. To illuminate nursing care as narrated by 27 retired care providers in northern Sweden, seven audio recorded group dialogues were performed (I). The transcribed group dialogues were analysed using a hermeneutic approach. The findings formulated as cleanliness, order and clear conscience point to purity. By cleaning patients and their surroundings repeatedly, by preserving order in various ways and by keeping a clear conscience, nurses committed to preserving purity. This study opened up for questions concerning the meaning of ‘impurity’ and‘purity’ in nursing today leading to papers II-IV. Learning about ‘purity’ is possible through studying ‘impurity’. Audio recorded narrative interviews were performed to illuminate the meaning of living with malodorous exuding ulcers (II) and the meaning of caring for people with malodorous exuding ulcers (III). A phenomenological-hermeneutic method was used to analyse the nine transcribed interviews with patients (II) and 10 transcribed interviews with nurses (III). The comprehensive understanding of living with malodorous exuding ulcers (II) was formulated as being trapped in a debilitating process that slowly strikes one down. There is a longing for wholeness and purity. When finding consolation, i.e., encountering genuineness and feeling loved, regarded and respected as fully human despite ulcers, patients feel purified. The comprehensive understanding of caring for people with malodorous exuding ulcers (III) was formulated as being exposed to, and overwhelmed by suffering that is invading. One runs the risk of experiencing desolation when one cannot make the ulcers and malodour disappear and fails to protect patients from additional suffering. To illuminate nurses’ reflections on obstacles and possibilities providing care as desired by people with malodorous ulcers (IV), six nurses from a previous study (III) were interviewed. An illustration with findings from paper II was shown and participants were asked to reflect on obstacles and possibilities providing the care desired by patients. The 12 audio recorded transcribed interviews were analysed using qualitative content analyses. The interpretations were presented as one theme ‘striving to do ‘good’ and be good’. The sub-themes related to the obstacles were ‘experiencing clinical competence constraints’, ‘experiencing organisational constraints’, ‘experiencing ineffective communication’, ‘fearing failure’ and ‘experiencing powerlessness’. The sub themes related to possibilities were ‘spreading knowledge on ulcer treatments’, ‘considering wholeness’ and ‘creating clear channels of communication’. The meaning of living with ‘impurity’ in terms of malodorous exuding ulcers, and the meaning of caring for people with ‘impure’ bodies in institutions and in patients’ homes is interpreted as striving for purity. Patients experience impurity when feeling dirty, losing hope, and not being respected and regarded as fully human. Nurses experience impurity when failing to shield patients’ vulnerability and their own defencelessness, and when facing obstacles preventing them from providing good care and being good nurses. Both patients and nurses may experience purity through consolation. For nurses, mediating consolation presupposes being consoled by being recognised for their challenging work, being respected and included in multiprofessional teams supported by the health care organisation and the leaders. Then patients can become consoled, and feel restored and fully human again despite their contaminated body.

Submitted by Filipe dos Santos (fsantos@pucsp.br) on 2016-10-18T17:02:04Z No. of bitstreams: 1 Felipe Suster Gomes Fonseca.pdf: 2325451 bytes, checksum: 5412fd2999ab01c4990f65d7eb8b2f7a (MD5) / Made available in DSpace on 2016-10-18T17:02:04Z (GMT). No. of bitstreams: 1 Felipe Suster Gomes Fonseca.pdf: 2325451 bytes, checksum: 5412fd2999ab01c4990f65d7eb8b2f7a (MD5) Previous issue date: 2016-08-25 / Coordenação de Aperfeiçoamento de Pessoal de Nível Superior / To seek the phenomenological hermeneutic experience and interpret the conditions of clinical psychology in its own phenomenal happening; this is the core of this work. To proceed with this claim, we will take the phenomenological and hermeneutical philosophy trying to occupy their own places. Heidegger is the greatest exponent of this way of thinking, that's why we will reserve more attention to the thinker from the Black Forest, as he could contribute to the pursuit of our fundamental experience, but always in conjunction with two important influences (Dilthey and Husserl). Thus, we can’t equivocate on to characterize this work as a heideggerian proposal. We'll present essays that tried to penetrate the nerve of thinking that is inculcated in the fundamental experience of his own phenomenology- hermeneutics, reducing spaces interpreting own corresponding authors of this philosophical school. For this, we will not focus on a conceptual appropriation in view of applicability of such a philosophy. Our contribution to the psychological clinic will take place in the thinking of the sense of being of our theoretical life in his historical happening, keeping the manifest phenomenological field as interpretative possibility of our horizon of meaning / Buscar a experiência fenomenológico-hermenêutica para se interpretar as condições da clínica psicológica em seu próprio acontecimento fenomênico; este é o núcleo do presente trabalho. Para prosseguirmos com tal pretensão, iremos tomar a filosofia fenomenológica e hermenêutica procurando habitar suas moradas reflexivas. Sendo Heidegger o grande expoente deste caminho do pensar, abriremos maior espaço ao que o pensador da Floresta Negra tem a contribuir com a busca da nossa experiência fundamental, porém, sempre em articulação com duas de suas maiores influências (Dilthey e Husserl). Sendo assim, não podemos nos equivocar em caracterizar este trabalho como uma proposta heideggeriana. Apresentaremos ensaios que tentarão penetrar no centro nevrálgico da meditação incutida na experiência fundamental da própria fenomenologia-hermenêutica, encurtando espaços e interpretando os próprios autores correspondentes desta escola filosófica. Para isto, não iremos focar em uma apropriação conceitual em vista de uma aplicabilidade de tal filosofia. Nossa contribuição à clínica psicológica se dará no pensamento do sentido de ser de nossa vida teórica em seu acontecimento histórico, tendo o próprio campo fenomenológico manifesto como possibilidade interpretativa de nosso horizonte de sentido

The thesis comprises four papers. The overall aim was to illuminate meanings of becoming and being burnt out respectively not becoming or being burnt out. The papers deal with two groups of healthcare personnel, one group on sick leave due to medically assessed burnout (n=20) and one group who showed no indications of burnout (n=20) from the same workplaces at psychiatric (n=7) and elderly (n=7) care units. A further aim was to describe personality traits and to elucidate perceptions of conscience (PCQ), stress of conscience (SCQ), moral sensitivity (MSQ-R), social support (SocIS) and resilience (RS) among the people in these two groups. Papers I and II are based on the text of narrative interviews interpreted using a phenomenological-hermeneutic method. Papers III and IV are based on data, pertaining to the same participants as in Papers I and II, derived from the following questionnaires; Cattell’s Sixteen Personality Factors Questionnaire (16PF) (III), ‘Perception of Conscience’ (PCQ), ‘Stress of Conscience’ (SCQ), ‘Moral Sensitivity Revised’ (MSQ-R), ‘Social Interactions Scale’ (SocIS) and ‘Resilience Scale’ (RS) (IV). Conventional statistical methods and Partial Least Square Regression (PLSR) were used to analyse the data (III, IV). In Paper I the aim was to illuminate meanings of becoming and being burnt out as narrated by healthcare personnel. The results show that meanings of becoming and being burnt out is to be torn between what one wants to manage and what one can actually manage. It is as if one’s ideals become more like demands for, regardless of the circumstances, one must be and show that one is capable and independent. It also means being dissatisfied with oneself for not living up to one’s own ideals as well as being disappointed in other people for not providing the confirmation one strives for. Feelings that one is a victim of circumstances emerge. Becoming and being burnt out leads to a futile struggle to live up to one’s ideals and when failing to unite one’s ideal picture with one’s reality one finally reaches an overwhelming feebleness. In Paper II the aim was to illuminate meanings of not becoming or being burnt out at workplaces where others developed burnout, as narrated by healthcare personnel. The results show that meanings of not becoming or being burnt out are to be rooted in an outlook on life which perceives its many-sidedness of prosperity, adversity, strength and weakness in oneself and others. An openness towards the circumstances of life emerges. Being able to judge the possibilities of influencing things, as well as being able to let go of injustice and look after oneself with a clear conscience are revealed as meanings of not becoming and being burnt out. In Paper III the aim was to describe personality traits among burnt out and non-burnt out healthcare personnel from the same workplaces. The results show, that the people in the burnt out group had lower scores regarding emotional stability and higher scores regarding anxiety than the people in the non-burnt out group but the results also showed a wide variation of personality traits within the groups. The most important indicators for belonging to the burnt out group were openness to changes and anxiety, and for belonging to the non-burnt out group, emotional stability, liveliness, privateness and tension. In Paper IV the aims were to elucidate perceptions of conscience, stress of conscience, moral sensitivity, social support and resilience among burnt out and non-burnt out healthcare personnel from the same workplaces. The results show that higher levels of stress of conscience and moral sensitivity, a perception of conscience as a burden, having to deaden one’s conscience in order to keep working in healthcare and perceiving a lack of support from those around them characterize the burnt out group. Those in the non-burnt out group are characterised by lower levels of stress of conscience, an out-look on life with a forbearing attitude, a perception of conscience as an asset, an ability to deal with one’s conscience in a constructive way and a perception of receiving support from those around them. The comprehensive understanding from the four papers (I-IV) is discussed in light of a theoretical framework derived from Emmy van Deurzens thoughts about the four life worlds: the natural world (the physical world), the public world (the social world), the private world (the psychological world) and the ideal world (the spiritual world). The result can be summarized in terms of the human condition in life and demonstrates the essential importance of reconciling the vita activa (the active life of labor, work and action), the vita contemplativa (thinking, willing and judging) and not least the vita regenerativa (rest and recovery) in order to avoid being burned out. / Samvetsstress i vården

The aim of this thesis was to investigate what an intervention comprising systematic discussion groups meant in the context of conflicts and cooperation between social care staff and nursing staff, over a period of 7–15 months. The intervention was carried out in four experimental dwellings in special types of housing for elderly and disabled people and in comparison with four similar reference dwellings. Results are based on 27 interviews prior to the intervention and 29 after. The interviewees were managers, registered nurses, enrolled nurses and care assistants and concerned their experiences regarding problematic situations that occurred in their everyday work. The questionnaires (before n=84 and after intervention n=93) used were: sense of coherence, job-satisfaction and burnout and were aimed at investigating staff experiences of working climate and the influence of the intervention. The issues were investigated both before and after the intervention. Observations were used to determine whether they could provide further knowledge about the intervention and thus extend our understanding of the marginal differences in the complementary studies. The phenomenological hermeneutic interpretation of the narratives in the interviews shows that the intervention was important to the experiences of being in problematic situations. The results before the intervention and in reference dwellings are equivalent and elucidate staff members' struggle to retain their self-esteem and to be confirmed by their colleagues. The experimental dwellings narratives show a change from rejecting to confirming communication among colleagues. Moreover, subtle changes are present which point to an emotional closeness where attempts have been made to understand colleagues' perspective and reactions where the residents are the central concern in the narratives. An analysis of the content of the interviews after intervention shows equivalent changes in experimental dwellings and reference dwellings. The analysis shows that the staff's view of problematic situations had been softened and that they viewed their colleagues as less of a hindrances. There were no mentions made of the previously indicated conflicts between social and nursing staff. The results also show that staff members are not afraid to stand by their own ideas of how they should act in various situations. The staff experience of the working climate was positive both before and after the intervention and no significant differences could be seen. What stands out from the observation study is that the groups have different cultures and thus different prerequisites for the intervention. In two of four groups the intervention seemed to give rise to positive meanings regarding the staffs´ understanding of each other, necessary for their successful cooperation, but when the groups are in the ”basic assumption phase” other additional strategies are probably also needed. The marginal differences shown in the other complementary studies can be understood in terms of two of the four groups not perceiving the intervention to any large extent. When the internal group processes are of great importance it is essential to pay attention to culture of the staff groups before the intervention is implemented.

The overall aim of the study is to understand and describe the phenomenon ‘atmosphere in care settings’ as experienced by patients, significant others and health care staff. The study consists of four papers, each of which illuminates various aspects of the phenomenon. Data consisted of observations and interviews with patients, significant others and staff (n=126) within a hospice, a geriatric, a medical and an oncology setting, and community care settings for older people. Narrative analysis, grounded theory, and phenomenological hermeneutics were used in a triangular fashion to analyse the data. The findings illuminate the phenomenon ‘atmosphere in care settings’ as being constituted by two interacting and interwoven dimensions: the physical environment and people’s doing and being in the environment. The physical environment is the first dimension, and five aspects were illuminated, namely the physical environment as a symbol; as containing symbols; as influencing interaction; as facilitating a shift of focus from oneself to the environment, and; as containing scents and sounds influencing experiences of at-homeness or alienation. People’s doing and being in the environment is the other dimension, and five aspects were illuminated, namely the experience (or absence of experience) of a welcoming; of seeing and being seen; of a willingness to serve; of a calm pace; and of safety. It was understood that people’s doing and being influences experiences of the physical environment and that the physical environment influences experiences of people’s doing and being. The comprehensive understanding illuminated that the phenomenon is not merely subtle qualities of the place for care, but an active part of care. Both the physical environment and peoples doing and being conveys messages of caring and uncaring. The atmosphere of a care setting can at best support experiences of at-homeness in relation to oneself, others and the surrounding world.

Avhandlingens övergripande syfte är att tolka och beskriva innebörder av stöd, utifrån att vara förälder till barn med funktionsnedsättning och att vara professionella stödjare. Datainsamling har skett i form av berättande intervjuer med 39 föräldrar (23 mödrar och 16 fäder) och 9 professionella (7 kvinnor, 2 män) från olika verksamheter. Samtliga intervjuer har analyserats med hjälp av fenomenologisk hermeneutisk metod. Innebörder av att vara förälder till barn med funktionsnedsättning (studie I) har tolkats som en medvetenhet om viktiga värden i livet. Barnet har ett inneboende värde som en unik person och föräldrarna strävar efter att göra sitt bästa för barnet. Denna strävan innebär att konfrontera oro, osäkerhet och rädsla i vården av barnet och andra personers nedvärdering av barnet. I föräldrarnas strävan att tillmötesgå barnets olika behov, ingår också att anpassa egna behov efter barnets. Den fördjupade förståelsen av studiens resultat är, att det handlar om en strävan att möjliggöra för barnet att leva ett gott liv. Innebörder av att få stöd av professionella (studie II) har tolkats som att föräldrar och barn blir bekräftade som värdefulla personer och att föräldrarna uppnår trygghet och kompetens i föräldraskapet och får ett hopp för barnets framtid. Erfarenheter av att inte få stöd, medför en kamp mot de professionella, för att kräva det stöd som föräldrarna anser att de och barnet behöver. Innebörder av att vara professionell stödjare (studie III), består av att ha personlig filosofi, som är integrerat i sättet att vara och handla som stödjare. Det innebär att vara trygg i hoppet om att det alltid går att göra något för att hjälpa, genom att söka unika lösningar i den aktuella situationen. Tillit till föräldrar som partners och att få deras tillit, samt att möjliggöra för föräldrarna att uppnå kompetens och trygghet i vården av sina barn är andra innebörder. Detta har tolkats som en frihet från att vara bunden av byråkrati och prestige och en möjlighet att vara äkta, följa sin filosofi och att vara i samklang med barn och föräldrar. Innebörder av informellt stöd (studie IV) har tolkats som en livsberikande gemenskap, där barnet, innefattas i kärleksfulla relationer med närstående och har en naturlig plats i samhället. Att som föräldrar kunna dela glädje, oro och sorg med andra personer och att få möjlighet att uppleva lättnad och spontanitet i det dagliga livet, är andra innebörder av informellt stöd. Helhetsförståelsen av de fyra studierna är, att stöd av professionella i sin tur är ett stöd i föräldrars etiska förpliktelse i deras strävan att möjliggöra för barnet att leva ett gott liv. Informellt stöd betyder att föräldrar och barn är inneslutna i trofasta och berikande relationer med andra. / The overarching aim of this thesis is to interpret and describe the meanings of support for parents from the context of being a parent of a child with disability. The data collection is based on narrative interviews with 39 parents (23 mothers and 16 fathers) and nine professionals (seven women and two men) from various areas in the health care system and local authority. A phenomenological hermeneutic method guided the text analyses. The meanings of being a parent of a child affected by disability (study I) have been interpreted as awareness about important values in life. The child has an intrinsic value as a unique person and the parents are striving to do their best for their child. This striving means confronting worries, unsafeness and fear in the care of the child and confronting other persons’ devaluation of the child. Adjusting the parents’ own needs to those of the child and orchestrating the child’s various needs are other meanings. The deepened understanding of the result of the study is that the parents are striving to enable the child a good life. Being supported by professionals (study II) means experiences of the child and oneself as being confirmed as valuable persons. Moreover, it enables parents to gain confidence and competence in their parenthood and hope for the child’s future. Experiences of lack of support give rise to a struggle against the professionals, aimed at getting the support the parents regard as necessary for their own and their child’s needs. The meanings of being a supporter (study III) were interpreted as being and acting according to a personal philosophy, which is integrated in the professional task, and believing that it is always possible to help by searching for unique solutions in the current situation. Trusting the parents as partners and enabling the parents to gain competence and confidence in the care of their children are further meanings. The deepened understanding of being a professional supporter is to be in tune with one’s philosophy and the child’s and parents’ needs. The meanings of informal support (study IV) were interpreted as experiences of being involved in true relationships with other persons. This enables the child and the parents to be in a life enriching togetherness. The interpreted whole of the studies is that being a parent of a child affected by disability means to strive for the fulfilment of the ethical obligation to enable the child to have a good life. To be supported by professionals means receiving help to fulfil the ethical obligation. Being a professional supporter means to be and act in accordance to the unique child and parent and the present situation. Informal support means to be involved in a natural human togetherness.

Personal knowledge was disclosed amongst a group of experienced registered nurses in relation to feeding severely ill patients with cancer and dementia (I,II,III), communicating with severely demented patients (IV,V), and receiving group supervision (VI). Principled ethics did not seem an adequate model for describing the ethical reasoning of experienced RNs. For the twenty RNs working in oncological care the question of whether or not to accept active euthanasia was the most urgent. The twenty RNs working in dementia care emphasized the difficulty they had in understanding the meaning of communicative cues in severely demented patients. Both groups of nurses saw themselves as advocates for their patients and seemed to reason mainly in accordance with the Golden Rule. Through a phenomenological hermeneutic analysis of video recordings of two RNs' interaction with each of four severely demented patients, it was possible to interpret the patients' vague and unclear communicative cues. But observations based on an assessment of facial muscle movements showed that it was very difficult (the FACS). Group supervision based on a narrative framework was carried out in order to support nurses working in dementia care. Interviews with the fifteen RNs showed that they experienced recognition and reassurance of worth, an increased repertoire of actions, gained new perspectives, an increased awareness of their professional role, and interdependence. It is proposed that the care of severely ill patients can be improved by the use of a narrative approach both as regards understanding patients and encouraging RNs to develop their clinical knowledge through reflecting on their own and their coworkers' narrations about care. / <p>Diss. (sammanfattning) Umeå : Umeå universitet, 1993, härtill 6 uppsatser.</p> / digitalisering@umu

In general, patient participation is regarded as being informed and partaking in decision making regarding one’s care and treatment. This interpretation is common in legislation throughout the Western world and corresponding documents guiding health care professionals, as well as in scientific studies. Even though this understanding of the word participation can be traced to a growing emphasis on individuals’ autonomy in society and to certain dictionary defi nitions, there are other ways of understanding participation from a semantic point of view, and no trace of patients’ descriptions of what it is to participate can be found in these definitions. Hence, the aim of this dissertation was to understand patients’ experience of the phenomenon of patient participation. An additional aim was to understand patients’ experience of non-participation and to describe the conditions for patient participation and non-participation, in order to understand the prerequisites for patient participation. The dissertation comprises four papers. The philosophical ideas of Ricoeur provided a basis for the studies: how communication can present ways to understand and explain experiences of phenomena through phenomenological hermeneutics. The first and second studies involved a group of patients living with chronic heart failure. For the fi rst study, 10 patients were interviewed, with a narrative approach, about their experience of participation and non-participation, as defi ned by the participants. For the second study, 11 visits by three patients at a nurse-led outpatient clinic were observed, and consecutive interviews were performed with the patients and the nurses, investigating what they experience as patient participation and non-participation. A triangulation of data was performed to analyse the occurrence of the phenomena in the observed visits. For paper 3 and 4, a questionnaire was developed and distributed among a diverse group of people who had recent experience of being patients. The questionnaire comprised respondent’s description of what patient participation is, using items based on findings in Study 1, along with open-ended questions for additional aspects and general issues regarding situations in which the respondent had experienced patient participation and/or non-participation. The findings show additional aspects to patient participation: patient participation is being provided with information and knowledge in order for one to comprehend one’s body, disease, and treatment and to be able to take self-care actions based on the context and one’s values. Participation was also found to include providing the information and knowledge one has about the experience of illness and symptoms and of one’s situation. Participation occurs when being listened to and being recognised as an individual and a partner in the health care team. Non-participation, on the other hand, occurs when one is regarded as a symptom, a problem to be solved. To avoid non-participation, the information provided needs to be based on the individual’s need and with recognition of the patient’s knowledge and context. In conclusion, patient participation needs to be reconsidered in health care regulations and in clinical settings: patients’ defi nitions of participation, found to be close to the dictionaries’ description of sharing, should be recognised and opportunities provided for sharing knowledge and experience in two-way-communication.

Psychotherapeutic practice often involves the telling and retelling of a client’s stories of life in collaborative, meaning-making dialogue with a counsellor. This study demonstrates and explores the dynamics of counsellor contribution to this narrative co-construction, particularly the ways in which the counsellor’s inner conversations, reflexivity and interpretive style may emerge in practice and have an influence on the client’s understanding, re-evaluation and cohering of his or her own story. The multi-voiced, multi-layered intersubjective space and time in which this kind of narrative collaboration takes place is a difficult area to access for study but one whose potential impact on the client should make it the focus of respectful, ethical monitoring and careful reflective practice. Using phenomenological theories of reader-response and dialogical play, my research sets up an analogy between the way a reader might reflexively interact with life story episodes in a written text and the ways a counsellor might listen to and interpret a client’s stories of life over the course of a counselling contract. My project uses a comprehensive and episode-rich story of a life, the iconic ‘womb to tomb’ story of Jacob in the book of Genesis. My own hearer/reader response to the story gives rise to the creation of a set of imaginary dialogues between two interlocutors, Jacob as an elderly client reviewing his life story and myself as counsellor, listening to his stories of life. This methodology is used as a means to access an in vivo lived experience, as it might unfold in practice, of my counsellor contribution to Jacob’s story and the interplay of voices and standpoints which characterise it. Attention is drawn to the inchoate, but deeply human, intersubjective aspects of narrative co-construction as a process and the value of this form of reflective practice to surface actual praxis experience for analysis. Insights surfaced by this reader-response methodology point to the significant extent to which the hermeneutical standpoints and dialogical voices of a counsellor are actively involved and implicated in narrative co-construction.