Background As more people are living longer, they become frail and are affected by multi-morbidity, resulting in increased demands from the ambulance service. Being vulnerable, older patients may have reduced decision-making capacity, despite still wanting to be involved in decision-making about their care. Their needs may be complex and difficult to assess, and do not always correspond with ambulance assessment protocols. When needing an ambulance, older patients encounter ambulance clinicians who are under high workloads and primarily consider themselves as emergency (...) medical care providers. This situates them in the struggle between differing expectations, and ethical conflicts may arise. To resolve these, providing ethical care, focussing on interpersonal relationships and using ethical competence is needed. However, it is not known whether ambulance clinicians possess the ethical competence required to provide ethical care. Thus, the aim of this study was to deductively explore their ethical competence when caring for older patients with reduced decision-making ability. Methods A qualitative deductive and exploratory design was used to analyse dyadic interviews with ambulance clinicians. A literature review, defining ethical competence as comprising ethical sensitivity, ethical knowledge, ethical reflection, ethical decision-making, ethical action and ethical behaviour, was used as a structured categorization matrix for the analysis. Results Ambulance clinicians possess ethical competence in terms of their ethical knowledge, highlighting the need for establishing an interpersonal relationship with the older patients. To establish this, they use ethical sensitivity to interpret the patients’ needs. Doing this, they are aware of their ethical behaviour, signifying how they must act respectfully and provide the necessary time for listening and interacting. Conclusions Ambulance clinicians fail to see their gut feeling as a professional ethical competence, which might hinder them from reacting to unethical ways of working. Further, they lack ethical reflection regarding the benefits and disadvantages of paternalism, which reduces their ability to perform ethical decision-making. Moreover, their ethical knowledge is hampered by an ageist approach to older patients, which also has consequences for their ethical action. Finally, ambulance clinicians show deficiencies regarding their ethical reflections, as they reflect merely on their own actions, rather than on their values. (shrink)

Background: Confidentiality lies at the core of medical ethics and is the cornerstone for developing and keeping a trusting relationship between nurses and patients. In the wake of the HIV epidemic, there has been a heightened focus on confidentiality in healthcare contexts. Nurses’ follow-up of HIV-positive women and their susceptible HIV-exposed children has proved to be challenging in this regard, but the ethical dilemmas concerning confidentiality that emerge in the process of ensuring HIV-free survival of the third party – the (...) child – have attracted limited attention. Objective: The study explores challenges of confidentiality linked to a third party in nurse–patient relationships in a rural Tanzanian HIV/AIDS context. Study context: The study was carried out in rural and semi-urban settings of Tanzania where the population is largely agro-pastoral, the formal educational level is low and poverty is rife. The HIV prevalence of 1.5% is low compared to the national prevalence of 5.1%. Methods: Data were collected during 9 months of ethnographic fieldwork and consisted of participant observation in clinical settings and during home visits combined with in-depth interviews. The main categories of informants were nurses employed in prevention of mother-to-child transmission of HIV programmes and HIV-positive women enrolled in these programmes. Ethical considerations: Based on information about the study aims, all informants consented to participate. Ethical approval was granted by ethics review boards in Tanzania and Norway. Findings and discussion: The material indicates a delicate balance between the nurses’ attempt to secure the HIV-free survival of the babies and the mothers’ desire to preserve confidentiality. Profound confidentiality-related dilemmas emerged in actual practice, and indications of a lack of thorough consideration of the implication of a patient’s restricted disclosure came to light during follow-up of the HIV-positive women and the third party – the child who is at risk of HIV infection through mother’s milk. World Health Organization’s substantial focus on infant survival (Millennium Development Goal-4) and the strong calls for disclosure among the HIV-positive are reflected on in the discussion. (shrink)

Background:Many frail older persons who die in Swedish nursing homes need assisted bodily care. They must surrender their bodies to the authority of assistant nurses, which may affect their autonomy and dignity of identity. While assistant nurses claim to support older persons’ wishes, older persons claim they have to adapt to assistant nurses' routines. The provider–receiver incongruence revealed here warrants investigation.Aim:To describe the elements of assisted bodily care, as performed in a nursing home.Research design:Data were collected through thirty-nine observations of (...) assisted bodily care, analyzed with qualitative content analysis.Participants and research context:Seventeen older persons and twenty-two assistant nurses from a Swedish nursing home.Ethical considerations:The research was conducted in line with the Declaration of Helsinki, further approved by the regional ethics committee.Findings:Findings show that assisted bodily care consists of assistant nurses’ practical work, performed at a high tempo. Assistant nurses still attempt to adapt this work to the older persons’ wishes for self-determination, taking into account their day-to-day state of health. In spite of time pressure and occasional interruptions, there is room for consideration and affection in assisted bodily care.Discussion:Assistant nurses try to promote older persons’ dignity of identity, but sometimes fail, possibly due to lack of time. They nevertheless seem to know the older persons well enough to adapt the assisted bodily care according to their preferences and to support self-determination. This indicates that openness to older persons’ lifeworlds may be more important than the amount of time available.Conclusion:Nursing home contexts might benefit from adopting a person-centered palliative care perspective, highlighting the value of relationships and shared decision-making. If so, older persons and assisted nurses could agree on practices and goals in assisted bodily care beforehand. Such routines may be time-saving and beneficial to all. (shrink)

In the past decades, narrative practices have been developed, and care has been conceptualized as being narrative in nature. More recently, narrative care has been developing both as a practice and a field of study. It is necessary to make the theoretical foundations of narrative care visible to avoid the risk of narrowly defining narrative care as a matter of storytelling and listening. In this article, we develop an understanding of narrative care grounded in early feminist pragmatist philosophy, with a (...) focus on social and political activism and experience. Pragmatism holds the possibilities to open spaces for realities that are constantly in flux and for emergent situations that must be considered across time, diverse places and social contexts. With the aid of Vera’s stories about her relationship with Tammy, we demonstrate the importance of recognizing that realities are multiple, complex and uncertain. Furthermore, we discuss how the stronghold of formula stories and issues of power, positioning and inequities, restrict people’s possibilities to be, become and co-author their stories. We also argue that the playfulness, imagination and world travelling of narrative care are in line with early feminist pragmatism, which draws on a wide and diverse range of experiences. Jane Addams linked democracy to dialogue, joint experiences and social equality. This calls for the development of ethical frameworks grounded in care that are more specifically focused on relational ethics and a commitment to dialogical and relational democracy and the prioritization of community. (shrink)

Background: Worldwide, older persons lack access to palliative care. In Sweden, many older persons die in nursing homes where care is provided foremost by assistant nurses. Due to a lack of beds, admission is seldom granted until the older persons have complex care needs and are already in a palliative phase when they move in. Objective: To describe assistant nurses’ perspectives of providing care to older persons at the end of life in a nursing home. Research design: Data were collected (...) in semi-structured individual interviews and analyzed with inductive qualitative content analysis. Participants and research context: Seven assistant nurses from a nursing home in Sweden were randomly selected. Ethical consideration: The research was approved by the local ethics committee. Results: Three main categories emerged; “Death a natural part of life”; “The older person’s well-being”; and “Care in the moment of death”; and seven sub-categories. The assistant nurses described themselves as knowing the older persons well enough to provide good end-of-life care. This was achieved by making small-talk while providing daily care. Relying on experience-based knowledge, they strove to provide end-of-life care built upon respect and engagement with the ambition to strengthen older persons’ dignity, for example, by lowering the tempo of care at the end of life, in spite of organizational restrictions. Discussion: The assistant nurses offered attentive end-of-life care, focusing upon bodily care. The existential needs of the older persons were not foregrounded. Conclusion: To develop their work, and to promote an ethical foundation for such care, assistant nurses might need support and education to be able to offer a care more in line with the aims of palliative care. Furthermore, the organization of care needs to promote, not impede, the realization of this development. (shrink)

When Gödel developed his functional interpretation, also known as the Dialectica interpretation, his aim was to prove consistency of first order arithmetic by reducing it to a quantifier-free theory with finite types. Like other functional interpretations Gödel’s Dialectica interpretation gives rise to category theoretic constructions that serve both as new models for logic and semantics and as tools for analysing and understanding various aspects of the Dialectica interpretation itself. Gödel’s Dialectica interpretation gives rise to the Dialectica categories , in: Contemp. (...) Math., vol. 92, Amer. Math. Soc., Providence, RI, 1989, pp. 47–62] and J.M.E. Hyland in [J.M.E. Hyland, Proof theory in the abstract, Ann. Pure Appl. Logic 114 43–78, Commemorative Symposium Dedicated to Anne S. Troelstra ]). These categories are symmetric monoidal closed and have finite products and weak coproducts, but they are not Cartesian closed in general. We give an analysis of how to obtain weakly Cartesian closed and Cartesian closed Dialectica categories, and we also reflect on what the analysis might tell us about the Dialectica interpretation. (shrink)

Drawing upon the literature on action research and case-study research, this paper discusses similarities and differences between these two forms of research practice. The paper also highlights some of the criticisms and challenges action researchers face. It suggests ways in which action researchers may enhance the discussability of action research by: (a) increasing the transparency of their research processes, (b) declaring the intellectual frameworks brought into action research projects, (c) discussing transferability of findings, and (d) defining accumulation of results. This (...) may require an extension to scientific discourse. In particular, the paper suggests that action researchers could change the ways in which action research results are reported to increase their reach among a wider audience. (shrink)

For us, narrative care is grounded in pragmatist philosophy and focused on experience. Narrative care is not merely about acknowledging or listening to people's experiences, but draws attention to practical consequences. We conceptualize care itself as an intrinsically narrative endeavour. In this article, we build on Lugones' understanding of playfulness, particularly to her call to remain attentive to a sense of uncertainty, and an openness to surprise. Playfulness cultivates a generative sense of curiosity that relies on a close attentiveness not (...) only to the other, but to who we each are within relational spaces. Generative curiosity is only possible if we remain playful as we engage and think with experiences and if we remain responsive to the other. Through playfulness, we resist dominant narratives and hold open relational spaces that create opportunities of retelling and reliving our experiences. Drawing on our work alongside older adults, as well as people who work in long‐term care, we show the possibilities of playfulness in the co‐composition of stories across time. By intentionally integrating playfulness, narrative care can be seen as an intervention, as well as a human activity, across diverse social contexts, places and times. (shrink)

This article takes its point of departure in a research project studying the psychosocial problems of living with HIV. The project was intended to participate in changing practices dealing with these problems. It became a project including many differently situated and intersecting personal and generalized perspectives. The article researches the development of the HIV project as a contribution to discussions related to Participatory Action Research and Practice Research. In mainstream approaches methodological indications are often presented as rules to follow in (...) order to ensure the quality of the obtained knowledge. But situated historical and societal processes are involved in the effectuation of the HIV project, like they are in any other project. Researching the project heightens the awareness of the necessity of reflecting on situated and historical issues of power and marginalization and on the positions of the researcher in a given field of research. Methodological flexibility may also be necessary in order to encompass different perspectives. Such reflections and strategies are necessary precisely to ensure the development of knowledge and practice alike. (shrink)

We describe our clinical experience in treating patients with Tourette syndrome and other tic disorders using infra-low frequency neurofeedback, often in conjunction with cognitive behavior therapy. Following a narrative description of our approach, we present outcome data for 100 successive cases. Many of the children and adolescents that we have treated since 2005 did not derive sufficient benefit from standard treatment for Tourette syndrome and other tic disorders. In our clinical experience, based on extensive before- and after- testing and symptom (...) tracking, this patient group derived significant additive benefit from complementary neurofeedback treatment. The majority of trainees attained a higher level of functioning and were able to live up to their potential in a way they were not able to prior to neurofeedback treatment. (shrink)

The aim of this qualitative study was to gain an understanding of the meaning that community psychiatric nurses impart to their everyday interactions with patients in depot neuroleptic treatment situations. Nine experienced community psychiatric nurses were interviewed using semistructured, open-ended questions. Data analysis was by the phenomenological descriptive method according to Giorgi. Four themes were identified, highlighting aspects of the moral meaning of treating patients with depot neuroleptics: (1) ‘benevolent justification’ occurs when nurses perceive that the patient’s welfare is at (...) stake; (2) ‘inability to advocate the patients’ best interest’ occurs when nurses feel they are at a disadvantage; (3) ‘accommodative interactions’ occur when nurses are able to respond to a patient’s expressed needs; and (4) ‘acceptable advocacy’ occurs when physicians are sensitive to nurses’ suggestions on patients’ treatment. The findings indicate that treatment care planning involving both patients and nurses is essential to enhance patients’ autonomy, which is a precondition for satisfactory interactions. This phenomenological study describes the meaning that nurses give to administering depot neuroleptic injections to patients in the context of community psychiatric clinics. The phenomenon of concern was identified as the moral aspect in the interactions with individual patients in the treatment situation. (shrink)

Compassion is often understood as central to nursing and as important to ensure quality nursing and healthcare. In recent years, there has been a focus on strategies in nursing education to ensure compassionate nurses. However, it is not always clear how the concept of compassion is understood. Theoretical conceptualisations that lie behind various understandings of compassion have consequences for how we approach compassion in nursing education. We present some ways in which compassion is often understood, their philosophical underpinnings and the (...) consequences these understandings can have for nursing education. We argue that it is useful for nursing education to understand compassion as a cognitive emotion and discuss how such an understanding can inform educational approaches to compassion. (shrink)

Background: Nurses and student nurses in Malawi often encounter challenges in taking a moral course of action. Several studies have demonstrated a need for increased awareness of ethical issues in the nursing education. Objective: To explore the challenges experienced by nurse teachers in Malawi in their efforts to enhance students’ moral competence in clinical practice. Research design: A qualitative hermeneutic approach was employed to interpret the teachers’ experiences. Participants and research context: Individual interviews (N = 8) and a focus group (...) interview with teachers (N = 9) from different nursing colleges were conducted. Ethical considerations: Ethical approval was granted and all participants signed their informed consent. Findings: Two overall themes emerged: (1) authoritarian learning climate, with three subthemes: (a) fear of making critical comments about clinical practice, (b) fear of disclosing mistakes and lack of knowledge and (c) lack of a culture of critical discussion and reflection that promotes moral competence; and (2) discrepancy between expectations on learning outcome from nursing college and the learning opportunities in practice comprising three subthemes: (a) gap between the theory taught in class and learning opportunities in clinical practice, (b) lack of good role models and (c) lack of resources. Discussion: Our findings indicated that showing respect was a central objective when the students were assessed in practice. A number of previous studies have enlightened the need for critical reflection in nursing education. Few studies have linked this to challenges experienced by teachers for development of moral competence in practice. This is one of the first such studies done in an African setting. Conclusion: There is a clear relationship between the two themes. A less authoritarian learning climate may enhance critical reflection and discussion between students, teachers and nurses. This can narrow the gap between the theory taught in college and what is demonstrated in clinical practice. Moral competence must be enhanced in order to ensure patients’ rights and safety. (shrink)

Background: A limited number of studies have shown that patient advocacy can be influenced by both facilitators and barriers which can encourage and discourage nurses to act as patient advocates. Objective: This study’s aim was to describe Swedish nurses’ perceptions of influencers on patient advocacy. Research design and context: Interviews with 18 registered nurses from different Swedish clinical contexts were analysed using the phenomenographic method. Ethical considerations: Ethical revisions were made in accordance with national legislation and guidelines by committees for (...) research ethics at Karlstad University. Findings: Three levels of hierarchically related influencers on patient advocacy were found in the descriptive categories. The fundamental influencer, the nurse’s character traits, was described in the perceptions that advocacy is influenced by nurse’s having a moral compass, having control over the care situation, being protective and feeling secure as a nurse. The second most vital influencer, the nurse’s bond with the patient, was expressed in the perceptions of knowing the patient and feeling empathy for the patient. The third level of influencers, the organisational conditions, was described in the perceptions that the organisational structures and organisational culture influence patient advocacy. Discussion: The results correspond with findings from earlier research but add an understanding that influencers on patient advocacy exist at three hierarchically related levels. Conclusion: The nurse’s character traits are the fundamental influencer to patient advocacy, but in order to be comfortable and secure when advocating for patients, nurses also need to be familiar with both the patient and the situation. A supposition could be that all influencers interact, which needs to be further addressed in future studies. (shrink)

Background Healthcare services are increasingly being shifted to home settings for patients nearing end-of-life. Consequently, the burden on family caregivers is significant. Their vulnerable situation remains poorly understood and there is little information available regarding their experiences of dignity. Aim This study seeks to understand the experiences of family caregivers related to dignity and loss of dignity, aiming to provide a deeper insight into their situation when caring for a home-dwelling family member nearing end-of-life. Research design and participants This exploratory (...) study consists of a second analysis combining data from two primary studies, including 24 family caregivers of a family member nearing end-of-life, and is founded upon Gadamer’s philosophical hermeneutics. Ethical considerations Approval was obtained from the Norwegian Agency for Shared Services in Education and Research and was based on voluntary participation, informed consent, and confidentiality. Results The following three main themes were identified: Having a meaningful existence within the living environment, being seen and valued as a family caregiver in relation with others and suffering in a space of loneliness. These contextual, relational, and existential perspectives were found to be closely interrelated. Conclusion and final considerations The dignity of family caregivers was closely tied to being seen as unique individuals, not merely caregivers, thereby requiring healthcare professionals (HCPs) to understand their personal needs. This study highlights the emotional distress and loneliness family caregivers feel in their dual role within the healthcare system, thereby calling for HCPs to adopt an attitude of gentleness and recognition to impart dignity-preserving care in homecare practices. (shrink)

Background It is a common ethical challenge for ambulance clinicians to care for patients with impaired decision-making capacities while assessing and determining the degree of decision-making ability and considering ethical values. Ambulance clinicians’ ethical competence seems to be increasingly important in coping with such varied ethical dilemmas. Ethics rounds is a model designed to promote the development of ethical competence among clinicians. While standard in other contexts, to the best of our knowledge, it has not been applied within the ambulance (...) service context. Thus, the aim of this study was to describe ambulance clinicians’ experiences of participating in ethics rounds. Methods This was a qualitative descriptive study, evaluating an intervention. Data were collected through sixteen interviews with ambulance clinicians who had participated in an intervention involving ethics rounds. The analysis was performed by use of content analysis. Results Two themes describe the participants’ experiences: (1) Reflecting freely within a given framework, and (2) Being surprised by new insights. The following categories form the basis of the themes; 1a) Gentle guidance by the facilitator, 1b) A comprehensible structure, 2a) New awareness in the face of ethical problems, and 2b) Shared learning through dialogue. Conclusion Incorporating structured ethics rounds seems to create a continuous development in ethical competence that may improve the quality of care in the ambulance service. Structured guidance and facilitated group reflections offer ambulance clinicians opportunities for both personal and professional development. An important prerequisite for the development of ethical competence is a well-educated facilitator. Consequently, this type of ethics rounds may be considered a useful pedagogical model for the development of ethical competence in the ambulance service. (shrink)

Person‐specific evidence was developed as a grounded theory by analyzing 20 selected case descriptions from interventions using the guided self‐determination method with people with various long‐term health conditions. It explains the mechanisms of mobilizing relational capacity by including person‐specific evidence in shared decision‐making. Person‐specific self‐insight was the first step, achieved as individuals completed reflection sheets enabling them to clarify their personal values and identify actions or omissions related to self‐management challenges. This step paved the way for sharing these insights and (...) challenges in a relationship with a supportive health professional, who could then rely on person‐specific evidence instead of assumptions or a narrow disease perspective for shared decision‐making. Trust in the evidence encouraged the supportive health professional to transfer it to the interdisciplinary team. Person‐specific evidence then enhanced the ability of team members to apply general evidence in a meaningful way. The increased openness achieved by individuals through these steps enabled them to eventually share their new self‐insights in daily life with other people, decreasing loneliness they experienced in self‐management. Relational capacity, the core of the theory, is mobilized in both people with long‐term health conditions and healthcare professionals. Further research on person‐specific evidence and relational capacity in healthcare is recommended. (shrink)

When not acting in ways that are recognised as physical self-defence, women are often – in psychology and in other dominant discourses – generalised as inherently passive during subjection to sexualised coercion (rape and attempted rape). Likewise, in the aftermaths, their (in)actions are frequently pathologised as ‘maladaptive coping strategies’. We present theoretically and empirically based arguments for an agency-oriented approach to women’s perspectives on sexualised coercion. Agency is understood as intentional, situated and strategic. Sexualised coercion is not generalised as a (...) single “traumatic” event, but conceptualised as life events. Meanings of coercion are embedded in social activities connected to discourses on ‘rape’ and ‘trauma’. Thus personal meanings of subjection are understood as developed in and through participation in trajectories across diverse contexts. Adopted in our study, this approach points to the great diversity of personal meanings of sexualised coercion. Moreover, it reveals intimate connections between situated, personal and dominant discursive meanings of coercion, and women’s strategies of (in)actions during and in the aftermaths of the events. Our analysis of participants’ perspectives also indicates an imperative need for reinterpreting concepts such as ‘victim’ and ‘passivity’. In a reinterpretation women, although subjected to sexualised coercion, emerge as subjects both during subjection and in the aftermaths. Furthermore their seemingly pathological behaviour may be re-conceptualised as person ally sense-making strategies of action in reflected attempts at (re)formulating and (re)organising their life strategies. (shrink)

This article explores the issue of girls’ concerns about sexual activity in a liberal Nordic context. Drawing on ethnographic fieldwork among young people in Denmark, the article identifies three types of concerns girls can have about sexual activity: social expectations, relational expectations and dignity. Whilst contemporary research has tended to focus on the influence different sexual morality discourses have in shaping different expectations and concerns about these, little attention seems to be paid to girls’ normative concerns about sex related to (...) well-being. This article sheds light on how these normative concerns are related to girls’ sense of dignity based on Andrew Sayer’s work on dignity and moral sentiments. Finally, the article argues that tension between sexual morality discourses and moral sentiments may be the source of resistance that girls practise with a new ‘fuckboy’ discourse. (shrink)

This book represents the views of one of the greatest mathematicians of the twentieth century on the analogies between computing machines and the living human brain.

Chapter Growing up Constructivist: Languages and Thoughtful People What is radical constructivism? It is an unconventional approach to the problems of ...

This article concerns a new constraint on the interaction of quantifier phrases and epistemic modals. It is argued that QPs cannot bind their traces across an epistemic modal, though it is shown that scoping mechanisms of a differentnature are permitted to cross epistemic modals. The nature and source of this constraint are investigated.

Moral behaviour, based on social norms, is commonly regarded as a hallmark of humans. Hitherto, humans are perceived to be the only species possessing social norms and to engage in moral behaviour. There is anecdotal evidence suggesting their presence in chimpanzees, but systematic studies are lacking. Here, we examine the evolution of human social norms and their underlying psychological mechanisms. For this, we distinguish between conventions, cultural social norms and universal social norms. We aim at exploring whether chimpanzees possess evolutionary (...) precursors of universal social norms seen in humans. Chimpanzees exhibit important preconditions for their presence and enforcement: tolerant societies, well-developed social-cognitive skills and empathetic competence. Here, we develop a theoretical framework for recognizing different functional levels of social norms and distinguish them from mere statistical behavioural regularities. Quasi social norms are found where animals behave functionally moral without having moral emotions. In proto social norms, moral emotions might be present but cannot be collectivized due to the absence of a uniquely human psychological trait, i.e. shared intentionality. Human social norms, whether they are universal or cultural, involve moral emotions and are collectivized. We will discuss behaviours in chimpanzees that represent potential evolutionary precursors of human universal social norms, with special focus on social interactions involving infants. We argue that chimpanzee infants occupy a special status within their communities and propose that tolerance towards them might represent a proto social norm. Finally, we discuss possible ways to test this theoretical framework. (shrink)

Synchronistic or psi phenomena are interpreted as entanglement correlations in a generalized quantum theory. From the principle that entanglement correlations cannot be used for transmitting information, we can deduce the decline effect, frequently observed in psi experiments, and we propose strategies for suppressing it and improving the visibility of psi effects. Some illustrative examples are discussed.

'The most thorough and scrupulous of contemporary students of induction' (the execrable Quinton 1993, p. 172).