Nursing Inquiry最新文献

Recent discourse emphasizes the need to integrate social and structural determinants of health-such as poverty, violence, houselessness, and discrimination-into mental health care service design and delivery. This study investigates how psychiatric-mental health nurse practitioners (PMHNPs) navigate the conflicting demands of an efficiently organized clinic and the realities of patients experiencing chronic mental illness along with structural adversity. Using an institutional ethnographic approach, this research focused on the everyday work practices of nine PMHNPs in outpatient community mental health clinics in a major American city. The findings revealed disjunctures within two powerful discourses related to patient access to care that circulate in mental health settings: (1) "every door is an open door," and (2) "meeting people where they are." PMHNPs believe in the values promoted by the rhetoric while also being required to work outside institutional structures to meet real patient needs. By illustrating how the institutional coordination expected to improve health systems overlooks PMHNPs' expert knowledge, we highlight how addressing the "structural determinants of health" in clinical care for people with serious mental illnesses remains an ideological aspiration. We call for a reevaluation of mental health care practices and systemic transformation through the informed, ground-level interventions of PMHNPs.

This study explored the social determinants of chronic pain management among people who use drugs, focusing on the ethical notions shaping care-giving and the social contexts in which they operate. It draws on qualitative data from interviews with people who were currently using drugs and had chronic pain, recruited in Uyo, Nigeria. Narratives show how pain-related disability adversely impacted participants' livelihoods by hampering their ability to perform daily tasks. They also show how care-giving, informed by the ethical duty of care in nursing/healthcare professions and traditions of informal care, shaped the experience and meanings of chronic pain and helped participants overcome barriers to healthcare. Care-giving was situationally undermined by the ethics of justice where chronic pain was seen as retribution for moral deviance and participants were deemed undeserving of care. The study contributes to the literature on chronic pain management among people who use drugs by showing how stigma undermines professional and informal care ethics through reframing chronic pain as retribution and care as something to be earned, rather than an ethical duty. It concludes by reflecting on the implications for nursing and healthcare practice and calling for interventions to tackle stigma and improve pain management for these persons.

This study examines the sociolegal construction of the family, its impact on informal caregiving, and the implications for family nursing. Nurses were among the first healthcare workers to recognize the family as a crucial site of growth, development, and recovery from illness. Despite widespread endorsement of family-centered principles, actual practice often falls short of ideals, and there is limited empirical evidence supporting the effectiveness of family-based interventions. Through analysis of historical, legal, and sociological sources, this study argues that nursing has not reckoned with the family's transformation from a public entity into a private repository of dependency care. The findings suggest that family nursing would benefit from greater attention to the legal, gendered, and economic dimensions of the family.

Nurses practicing in forensic mental health hospital settings work with patients involved in the criminal justice system who are also diagnosed with psychiatric illnesses. Nurses work towards collaborative and therapeutic relationships with patients with an eventual goal of recovery and successful discharge to the community. Though the majority of patients in these settings in Canada are diagnosed with psychotic disorders, a smaller proportion may be diagnosed with antisocial personality disorder (ASPD), a patient population often described as 'difficult' or even 'untreatable' by nurses. In this paper, we offer a critical examination of forensic mental health nursing practice with this patient population, based upon a qualitative study, using discourse analysis methodology of nursing practices in a Canadian high security forensic hospital setting. Nurse participants described those challenges faced and strategies employed when working with patients diagnosed with ASPD, and who had been found not criminally responsible on account of mental disorder (NCRMD). Michel Foucault's poststructuralist concept of disciplinary power provides the theoretical lens in which both patient behaviours deemed 'difficult' and nursing practices are interrogated. Our findings indicate that the secure forensic mental health hospital environment represents a highly disciplinary space, wherein constant observation of patients occurs, and attempts are made to 'normalize' behaviours deemed abnormal. Patients diagnosed with ASPD regularly violate hospital rules and behavioural expectations, leading to frustration amongst nursing staff. Tensions existed in proposed strategies for working with these patients between strict adherence to unit rules and the disciplinary order, and a willingness to loosen these rules in attempts to improve nurse-patient relationships. The nursing implications of these opposing strategies are critically examined, with proposals for practices that exist both within and outside the disciplinary order are offered.

This systematic review aims to develop a conceptual framework to identify nursing-sensitive indicators for preventing and managing pressure ulcers. The first step involves defining evidence-based indicators critical to effective prevention and management. The second step examines the relationships influencing the management of these indicators, using insights derived from scientific research findings. This review is guided by a conceptual framework rooted in Structural State Theory and uses a methodological approach. A total of 956 articles were identified through a search of original references from Medline/PubMed, Scopus, Cochrane Library, and CINAHL, covering the period from 2012 to 2023. A systematic review of 29 studies identified 241 relationships between dependent and independent variables. A theoretical conceptual framework highlighted nursing-sensitive indicators (independent variables) related to patients, nurses, pressure injury/ulcer management, organizational structure, and their association with pressure injury/ulcer outcomes (dependent variables). The analysis showed that patient-focused studies had the highest frequency of relationships. This review highlights the complexity of managing pressure injuries/ulcers and the essential role of nursing care practices and interventions in shaping outcomes. The findings highlight the need for specialized wound care nurses and further research on nursing interventions, urging hospitals to invest in structural changes and nurse education.

With the growing complexity of hospital care, patient safety has become even more critical. This study explores the development and exchange of situation awareness of clinical hospital ward nurses engaged in interdisciplinary and distributed teamwork. A focused ethnographic study was conducted and involved shadowing 10 hospital ward nurses, semi-structured interviews, group reflections and patient record screenings. In-depth analysis of three representative clinical cases using state-space diagrams and a critical decision method was performed. The results show that development and exchange of situational awareness is often not reciprocal, timely or complete, with insufficient information available before decisions are made, which can compromise patient safety. Factors in communication, coordination and learning climate were identified as influential. We argue that the complexity of nurses' work in which sensitivity, alertness and control over key nodes in the healthcare network is required to achieve assimilation and accommodation in situational awareness among involved healthcare professionals. Although challenging, we see opportunities to improve situational awareness transactions through nurses' leadership behaviour. Analysing interdisciplinary and distributed collaboration from the perspective of an information network provides insight into improving situational awareness transactions, the key role nurses play in them, and further promoting patient safety.

While understanding of what nurses do is most commonly framed as using clinical decision-making in completing a range of tasks to meet the care needs of patients, other perspectives show nurses as experiential carers and/or utilising a body of professional knowledge to do this. Taking data from an ethnographic study framed in Bourdieu's theory of practice, this paper aims to extend understanding of how nurses in acute care accomplish nursing-in-practice by utilising reconnaissance, a conceptualisation of nursing practice knowledges, as a vocabulary to further analyse these data. In this new way of thinking about what nurses do, nursing-as-it-happens is shown to be not about nurses making decisions as such, but about how nurses use contextualised knowledge to activate practices that respond to what needs to be done for patient care in the context of each practice situation. Focusing attention on what nurses accomplish in their daily practices-of-work reveals nurse agency as working with and for the patient. This enables recognition of how nurses working with multiple patients on a shift can make adjustments to their practices in light of unfolding situations and, when necessary, bring each of those patients as persons to the centre of their practice.

The digitalisation of healthcare is transforming nursing practice, presenting unique opportunities and challenges that demand more than technical competence from nursing professionals. Despite the growing integration of digital tools, nursing remains in the 'foothills of digital transformation', with significant gaps in the critical and theoretical frameworks required to navigate this shift effectively. This article explores how Paulo Freire's critical pedagogy may address these gaps by fostering critical digital skills in nursing students. Drawing on Freire's concepts of problem-posing education, conscientization, dialogue and praxis, the article proposes a pedagogical model that encourages students to critically examine the socio-political and ethical implications of digital tools within their practice. By aligning Freirean principles with contemporary nursing challenges, the article argues for a shift away from solely competency-based frameworks toward educational approaches that promote reflective, dialogical, and ethically informed engagement with technology. The limitations of Freirean pedagogy, including its difficulty in evidencing direct outcomes, are discussed alongside its potential to cultivate a philosophically engaged nursing workforce capable of navigating the complexities of a digital healthcare environment and its associated impact on the profession. This approach underscores the importance of preserving nursing's core ethical and relational values while embracing the transformative potential of digital technologies.

The 1991 film The Silence of the Lambs tracks the fictional pursuit of an American serial killer by a Federal Bureau of Investigation trainee, via the assistance of another incarcerated serial killer. It features psychologically disturbing themes, such as corpses, the mutilation of skin and monstrous persons. Incidentally, these are all themes regularly encountered by nurses in their day-to-day practices, including forensic mental health nurses. Despite regular encounters with these themes and phenomena, nurses continue to find them disturbing and troubling, but, at the same time, clinically fascinating. This paper will mobilize Kristeva's poststructuralist, psychoanalytic concept of abjection to relate the encounters in The Silence of the Lambs to those of nurses, to reconceptualize feelings of both disgust and fascination and to consider how vulnerability may benefit nursing practice. Of particular relevance are the breakdown of skin encountered in nursing practice, encounters with corpses and work with forensic patients considered monstrous. The film provides opportunity for nurses to conceptualize abjection in their own practice and to consider how a reconceptualization of boundaries and vulnerability may prove productive.

Shared governance in hospitals promotes the inclusion of nurses' expertise, knowledge and skills in organisational processes, and nurses increasingly fulfil positions in organisational hierarchies. However, incorporating nursing expertise in strategic governance structures might be complicated, as these structures are primarily linked to managerial and biomedical expertise. Drawing on a Foucauldian perspective on knowledge and power, intertwined and embedded in everyday (inter)actions, we study how newly appointed directors of nursing challenge these dominant 'modes of knowing'. By focusing on a (Dutch) healthcare organisation, a large academic medical centre, we gained insight into how the history of director of nursing roles relates to how nursing expertise is valued. We gathered qualitative data (from multiple sources) to get close to the daily practices of these directors. In this way, we were able to highlight three tactics that enable directors to relate to new 'knowledge-power knots': (1) positioning, by creating more unity; (2) profiling, by showing significance and (3) powering, by being alert and intervening. With these tactics, the directors of nursing try to embed themselves and their expertise in hospital governance. This study contributes to an everyday understanding of power and the tactics that directors of nursing employ as an ongoing practice. This provides practical starting points for embedding nursing in governance and decision-making.