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Intensivpasientens gåtefulle kunnskap: om erfart kunnskap og kunnskapsformidling i enintensivkonteks
Nordic Council of Ministers, Nordic School of Public Health NHV.
2011 (Norwegian)Doctoral thesis, comprehensive summary (Other academic)Alternative title
The enigmatic knowledge of intensive care patients experience and interpretation based knowledge in intensive care tutoring (English)
Abstract [no]

Bakgrunn og hensikt: For mennesker som blir akutt/kritisk syk blir livet oftest endret på kort tid fra å værevelfungerende i hverdagen til innleggelse i intensivavdeling hvor selveste livet kan stå på spill. Tradisjonelt settblir intensivpasienter tatt vare på gjennom medisinsk kunnskap og et naturvitenskapelig kunnskapsparadigme. Åvære akutt/kritisk syk innebærer å få spesielle opplevelser og erfaringer som går ut over hverdagserfaringene, oghvordan disse erfaringene trer fram i situasjonen. Denne kunnskapen pasientene bærer i seg er ikke bareindividuell og privat kunnskap, den representerer også en form for viten som trenger å forskes fram og løftes inni det offentlige rom både folkehelsevitenskapelig og sykepleievitenskaplig, nettopp fordi den omhandler viktigeforutsetninger for at pasientene skal bli sett og møtt også eksistensielt. Denne kunnskapen representerer en annenontologi og epistemologi enn den naturvitenskapelige kunnskapen og representerer derfor et annetkunnskapsperspektiv, også når det gjelder kunnskapsformidlingen i en klinisk veiledningssammenheng. Avhandlingens overordnede mål er å øke forståelsen av det å være alvorlig syk og hvordan kunnskap ut fraerfaringer har betydning i kunnskapsformidling i en intensivkontekst.

Data og metoder: Avhandlingen har en kvalitativ tilnærming. I delstudie I ble det gjort en review avartikler for å se på stress relatert til kropp, rom og relasjon. I delstudie II ble det gjennomført intervju medtidligere intensivpasienter om opplevelsen av kropp, kraft og bevegelse under kritisk sykdom. I delstudie III bletidligere intensivpasienter intervjuet angående deres opplevelse av kroppsnærværet til pårørende under kritisksykdom. I delstudie IV ble det gjort observasjoner med påfølgende intervjuer av intensivsykepleiere om deresformidling av erfart og fortolket kunnskap i en klinisk veiledningssituasjon. I alle fire delstudiene benyttes detfenomenologisk-hermeneutiske analyser.

Funn: I delstudie I kommer det fram at pasientene opplever stress knyttet til kropp, rom og relasjon.Kroppen påvirkes gjennom søvnavbrudd, smerter, angst og pasientene mister kontrollen over kropp og situasjon.Stress knyttet til rom framkommer gjennom at rommet blir et speil av situasjonen ved at den både representererlivet, men også redselen for døden. Gjennom det horisontale leie opplever pasientene at situasjonen utgjør enform for makt og de selv settes i avmakt. Relasjonelt stress framkommer oftest knyttet til sammenhenger hvordet utføres observasjoner, stell og behandling. Travelhet og organisering i avdelingen påvirker det relasjonellesamværet i form av stress. I delstudie II opplever intensivpasientene at kropp kraft og bevegelse trer fram bådegjennom ”tapet” av kroppen, hvordan de handterer situasjonen og hvordan de gjenerobrer kropp, kraft ogbevegelse. De opplever kraftløshet og bevegelsesbergrensninger. Dette innvirker på avhengigheten til andre ogskaper konflikter til pårørende. Pasientene handterer det kroppslige tapet gjennom mobilisering av familiengjennom å involvere dem. Samtidig blir de selvbeskyttende og utestenger familiesammenhengene. Kampen forlivet håndterer de gjennom galgenhumoren og skriket om hjelp som siste nødrop. Gjenerobringen av kroppen erknyttet til små framskritt, gjennom personalets motivasjon og gjennom drømmen om å utrette noe i livet. Idelstudie III opplever pasientene konflikt mellom nærheten og distanse til pårørende. De kjenner seg utestengt,samtidig som de bekreftes med gaver. Pasientene opplever det konfliktfylt når de sammenligner pårørendesreaksjoner og egen situasjon. De er redd at fellesskapet med pårørende skal opphøre, samtidig må de begrensesamværet. Å ikke kunne kommunisere med pårørende i kroppsnærværet oppleves motsetningsfullt. I delstudieIV formidler sykepleierne kunnskap til intensivstudentene gjennom meningsskapende kunnskapsbevegelser. Deformidler inntrykk fra situasjonen for å skape oversikt, de formidler kunnskap om fenomenene som framtrer ogde formidler hvordan de kan hjelpe kroppens egne prosesser. De vurderer og formidler også pasienteneskroppslige uttrykk og hvordan disse kan forstås og imøtekommes. Sykepleierne er også opptatt å formidlekunnskap for at studentene skal utvikle og få egne erfaringer i kroppen.

Konklusjon: Gjennom fire delstudier løfter avhandlingen fram kunnskap som står i klar kontrast til dennaturvitenskapelige kunnskapen. Pasientene utsettes for store opplevelsesmessige belastninger i situasjonen somakutt/kritisk syke som setter de i en avmaktssituasjon ved at sykepleierne ikke fanger opp og handterer kroppensegen kunnskap i situasjonen. Pasientene befinner seg ofte i en eksistensiell situasjon som er preget avmarginalitet og eksistensiell væren. Pasientene viser at de har forutsetninger for å mestre situasjonen, menhjelpes lite til slik mestring. Intensivsykepleierne formidler ulikt faglig innhold til studentene for å skapeerfaringer og forståelse i situasjonen. Erfaringskunnskapen fra intensivkonteksten må derfor sees som et viktigkunnskapssupplement til folkehelsearbeidet.

Abstract [en]

Background and purpose: Acute/critically ill patients have had their life-conditions severely altered from awell-functioning everyday situation to a situation in which they struggle to survive. Traditionally the knowledgeparadigmfrom natural sciences together with medical expertise constitutes the framework for treatment. To beacute/critically ill involves experiences and events and phenomena typical to the situation. The patients’embodied knowledge is not limited to the personal and private sphere, it refers to highly relevant preconditionsfor visibility and reception, also on an existential level; it represents knowledge which needs to be researchedand discussed openly within the public health and nursing sciences. This knowledge represents a differentontology and epistemology from the natural sciences and thus a different perspective, also with regards toclinical tutoring. The dissertation’s primary target is to increase the knowledge about how critical illness isexperienced and how experience based knowledge is significant to teaching in an intensive care context.

Data and methods: The dissertation is based on qualitative methods. Sub-study I includes reviews ofarticles on stress in a perspective of body, space and relationship. Sub-study II contains interviews with formerICU patients relating to their experience of body, strength and movement during critical illness. Sub-study III isbased on former ICU patients’ experience of the physical presence of their significant others during criticalillness. Sub-study IV contains observations and interviews of ICU nurses on how they teach experience basedand interpretation based knowledge in clinical tutoring. Phenomenological-hermeneutic analysis method isapplied to all four sub-studies.

Findings: Sub-study I describes how patients experience stress in a perspective of body, space andrelation. The body is influenced by sleep deprivation, pain and anxiety. Patients experience loss of control withtheir bodies as well as with the situation. The room mirrors the situation patients are in, creating stress by itsrepresentation of life as well as fear of dying. The patient’s horizontal position reflects disproportionate powerinducing a sense of disempowerment. Relational stress situations usually appear in contexts involvingobservation, care or treatment. The organizational structure and activity on the ward affects stress levels. In substudyII the ICU patients experience how power and movement is affected by a sense of loss of body, how theymanage to respond to the situation and how they eventually reclaim the body, power and movement. Theyexperience disempowerment and limitations to movement. This causes dependency and creates conflicts withtheir significant others, especially with regards to proximity and distance. The patients address their loss of bodyby drawing on resources from their significant others, yet refrain from allowing themselves involvement infamily matters. The struggle for survival is characterised by gallows humour and the cry for help as their finalcry. Reclaiming the body happens stepwise with the aid of staff combined with a need to achieve. Sub-study IIIdescribes problems related to proximity to, and distance from, the significant others. A sense of exclusion iscontradicted by being showered with gifts. It is unsettling for patients to have their situation compared to theirsignificant others’. They fear the loss of community with loved ones, yet they need to limit visits fromsignificant others. The lack of ability to communicate when others are physically present is unsettling. Sub-studyIV describes how ICU nurses tutor students in practise by demonstrating knowledge in meaningful actions. Theyconvey their impressions of situations to provide an overview, convey knowledge of observable phenomena, andteach skills to assist the body’s own processes. They also assess and evaluate physical expressions in the patientand how these can be read and addressed. Nurses are also concerned with conveying embodied knowledge totheir students.

Conclusion: In four sub-studies this dissertation highlights a form of knowledge which clearly contraststhat of the natural sciences. During acute critical illness patients experience severe stress and disempowermentcaused by a lack of response and action from nurses who are unable to interpret the body’s own knowledge inthe situation. Patients are often facing life and death questions characterised by marginality and existentiality.Patients demonstrate ability to cope with the situation, but are rarely assisted with coping. Intensive care nursesdisseminate a variety of professional skills and knowledge to their students in order to provide comprehensionand understanding of situations. Experience based knowledge from an intensive care context thus becomes asignificant supplementary factor in the public health perspective

Place, publisher, year, edition, pages
2011. , 111 p.
Series
NHV Reports and Doctor of Public Health-Theses, ISSN 0283-1961 ; NHV Report 2011:3
Keyword [en]
Public health science, nursing science, phenomenological-hermeneutics, qualitative methods, stress, strengths, movement, significant others, experienced based knowledge, health promotion
Keyword [no]
Folkehelsevitenskap, sykepleievitenskap, fenomenologisk-hermeneutikk, kvalitativ metodikk, stress, kraft og bevegelse, pårørende, erfart og formidlet kunnskap, helsepromosjon.
National Category
Medical and Health Sciences
Identifiers
URN: urn:nbn:se:norden:org:diva-3726ISBN: 978-91-86739-10-2 (print)OAI: oai:DiVA.org:norden-3726DiVA: diva2:786401
Public defence
2011-05-16, Nordic School of Public Health NHV, Göteborg, Sweden, 13:00 (Norwegian)
Opponent
Supervisors
Available from: 2015-02-09 Created: 2015-02-05 Last updated: 2015-02-09Bibliographically approved
List of papers
1. Living the situation stress-experiences among intensive care patients.
Open this publication in new window or tab >>Living the situation stress-experiences among intensive care patients.
2007 (English)In: Intensive & Critical Care Nursing, ISSN 0964-3397, E-ISSN 1532-4036, Vol. 23, no 3, 124-31 p.Article in journal (Refereed) Published
Abstract [en]

The study is about the types of stress that patients in intensive care units experience. Ten reviewed articles selected from Cinahl and Pubmed between 1994 and 2003 constitute the data. The paper is a literature review, and the data is analysed from the phenomenological-hermeneutical point of view. Stress related to the body, room and relationships is discussed. Experiences of stress that are related to the body include bodily stress reactions, deprivation of control, emotions related to technical equipment, procedures and loss of meaning. Stress related to the room highlights the environment and the situation in which the patient finds him/herself. The ethical relations of professionals and separation of patients from their significant others constitute stress related to relationships.

Keyword
Hermeneutic; Intensive care nursing; Phenomenology; Stress; Experience
National Category
Medical and Health Sciences
Identifiers
urn:nbn:se:norden:org:diva-3724 (URN)10.1016/j.iccn.2006.09.002 (DOI)17088063 (PubMedID)
Available from: 2015-02-05 Created: 2015-02-05 Last updated: 2015-02-09Bibliographically approved
2. The bodily presence of significant others: Intensive care patients' experiences in a situation of critical illness.
Open this publication in new window or tab >>The bodily presence of significant others: Intensive care patients' experiences in a situation of critical illness.
2010 (English)In: International Journal of Qualitative Studies on Health and Well-being, ISSN 1748-2623, E-ISSN 1748-2631, Vol. 5, no 4Article in journal (Refereed) Published
Abstract [en]

This study is about intensive care patients and the bodily presence of significant others. The aim of the study is to inquire and understand the patients experience of the body in relation to their significant others during critical illness. Open, unstructured, in-depth interviews with six former intensive care patients provide the data for the study. The phenomenological-hermeneutical analysis points to a theme among ICU patients' experience of conflict between proximity and distance during the bodily presence of their relations. Patients experience different and conflicting forms of responses to the presence of their significant others. Patients experience significant positive confirmation but also negation through this presence. In the ICU situation, the reactions of significant others appear difficult to deal with, yet the physical presence is significant for establishing a sense of affinity. Patients seek to take some responsibility for themselves as well as for their relatives, and are met with a whole spectrum of reactions. Intensive care patients experience the need to be actively, physically present, which often creates sharp opposition between their personal needs and the needs of their significant others for active participation.

Keyword
Phenomenology, hermeneutics, intensive care patients, critical illness, significant others
National Category
Medical and Health Sciences
Identifiers
urn:nbn:se:norden:org:diva-3725 (URN)10.3402/qhw.v5i4.5120 (DOI)21063475 (PubMedID)
Available from: 2015-02-05 Created: 2015-02-05 Last updated: 2015-02-09Bibliographically approved
3. Body, strength and movement*intensive care patients’ experienceof body
Open this publication in new window or tab >>Body, strength and movement*intensive care patients’ experienceof body
2008 (English)In: International Journal of Qualitative Studies on Health and Well-being, ISSN 1748-2623, E-ISSN 1748-2631, Vol. 3, 77-88 p.Article in journal (Refereed) Published
Abstract [en]

This study is about intensive care patients’ experience of strength, body and movement during critical illness in an intensivecare unit. The aim of the study is to inquire and understand the ways the body and its experience appear when thephenomena of strength and movement are altered. The data were collected through in-depth interviews with seven patientsand analysed from a phenomenological-hermeneutical point of view. The findings showed a body that refuses to cooperateand is often marginally able to cope with the situation at all. It showed relational bonding between the patients and healthpersonnel and/or significant others where the patients were overlooked and at the same time dependent on the same persons.They were waving between life and death through dimension of existence, which is contrasted to earlier experiences. Theyshowed feeling responsible for the family through a role in to reduce their fears. At the same time, they are in a continuousstruggle for life in which they balance between vague hope and a situation so challenging that the only thing left is grimhumour. They showed progressing and expectations where the slightest changes in the situation in a positive direction createa hope in them.

Keyword
Phenomenology, hermeneutics, body, strength, movement, intensive care patients
National Category
Medical and Health Sciences
Identifiers
urn:nbn:se:norden:org:diva-3723 (URN)
Available from: 2015-02-05 Created: 2015-02-05 Last updated: 2015-02-09Bibliographically approved

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