MESSAGE FOR INSTRUCTIONS
QualitativeResearch article analysis
Name: ____SAMPLE QUALITATIVE ANALYSIS_______________ Date: ___________
APA Reference:___ Adams, K. W., & Tolich, D. (2011). Blood transfusion: The patient’s experience. American Journal of Nursing, 111(9), 24-30. https://doi.10.1097/01.NAJ.0000656328.23963.82 ____________________________________________________
This analysis is on a qualitative research article. Choose ONE of the qualitative research articles provided in Workshop Two. Do not write a narrative paper. Use the worksheet to complete this assignment. Use your own words to paraphrase information from the article. You can use direct quotes, but use them sparingly. Cite all paraphrases and direct quotes; each box must be cited. Use the grading rubric for guidelines on how to answer each of the questions on the worksheet. When you have completed the assignment, save a copy for yourself and submit a copy to the 2.3 Dropbox by the end of the workshop.
Problem Statement
&
Purpose Statement
Problem Statement: According to the authors, the problem is that little research had been conducted about the patient’s perspective of the treatment and they sought to fill that gap in nursing knowledge. Purpose Statement: The research purpose was to identify both patients’ understanding blood transfusions, and also whether they experienced discomfort in the process of the blood transfusion. (Adams & Tolich, 2011) Comment by Stormer, Mari: Both the problem stimulating the study and the purpose of the study must be indicated. What was the problem, and why was the study being conducted?
Assessment of Literature Reviewed
(Background information)
Although no U.S. results were located through the literature review, two Australian studies, both from 1999 were reviewed. Also reviewed was a study examining the differences between physicians’ and laypersons’ ideas regarding the risks of various medical procedures, including blood transfusions. In all, 12 journal articles were reviewed, only three of which were published within the past five years. Of the other ten references, seven were texts related to various concepts of research, as opposed to the topic. (Adams & Tolich, 2011) Comment by Stormer, Mari: The assessment of literature reviewed is an assessment of the background information the authors provide on the general topic. You will briefly summarize the literature reviewed and assess the quality and quantity of sources used. This assessment will involve examining both the reference list and the article’s literature review. (How many sources were used? How many peer-reviewed articles? How many were published within five years of when this article was published? What were the topics covered?)
Research Question(s) written as a question
(The findings answer the research question)
The research question was “how do patients perceive blood transfusion?” (Adams & Tolich, 2011, p. 24). Comment by Stormer, Mari [2]: This must be written out as a question. The recurring themes of the study will answer this question. The research question is directly related to the purpose of the study.
Research Design
(Phenomenological, Ethnographic, Descriptive, Exploratory, Grounded Theory)
Research design was a qualitative, descriptive inquiry (Adams & Tolich, 2011) Comment by Stormer, Mari [2]: This is the research method used to conduct the study.
Sample, Setting,
&
Sampling Method
Sample: Twenty-one patients who had received a blood transfusion. Comment by Stormer, Mari: The sample is a description of the participants who were selected for the study, plus the number of participants.
The setting is where the study took place.
Sampling method is how the participants are selected. The sampling method will be either probability (random) or nonprobability (nonrandom). The subtype under whichever one it is must also be indicated. The most likely nonprobability sampling method for qualitative research is convenience or purposive. Convenience is who is available, and purposive is picking out certain people the author wants to participate.
Setting: an Ohio hospital.
Sampling Method: A nonprobability, convenience sampling method was used in this study. (Adams & Tolich, 2011)
Data Collection
&
Data Analysis
Data Collection: The method of data collection was open-ended interviews with a semi-structured format. A list of 35 questions asked of all subjects was included in the article. The interviews were tape recorded and observed by a research assistant. Comment by Stormer, Mari: Data collection for qualitative research is usually interviews, open-ended surveys, or focus groups. Provide a brief summary of the steps used to collect the data. Data analysis should describe how the themes were determined. A technique called content analysis will be used to extract the data. There are a few different types. Describe the one used in the research article. Sometimes it is done entirely manually, and sometimes a software program is also used.
Data Analysis: Transcripts of interviews were analyzed by coding them into themes. The secondary investigator and research assistant later contributed their interpretations regarding the coding. (Adams & Tolich, 2011)
Ethical & Legal Issues (Informed Consent, Anonymity, Confidentiality, Institutional Review Board)
The authors stated that prior to the interviews they discussed their own potential biases and used bracketing to maintain objectivity. Approval was obtained from the hospital’s IRB before beginning the study. Informed consent was collected prior to reviewing the charts and interviewing the patients. To assure confidentiality, the study data was identified by blood product vials, rather than patient names. Patient names were stored in password-protected computers in a locked office. (Adams & Tolich, 2011) Comment by Stormer, Mari: IRB approval from a facility and/or university is required. A plan to get informed consent is required in order to get IRB approval. Confidentiality should be maintained. If the study was funded by an organization, that should be mentioned.
Limitations
The subjective nature of qualitative research is a limitation in and of itself. Study limitations included small size, one location, a fairly homogenous sample of mostly elderly white women, and no medically unstable patients. Also, the patients were relying upon their memories of a situation in which they were anemic. Comment by Stormer, Mari: Limitations are issues that limit the findings from being generalized to other settings. The authors should mention them, but you can also assess that. Small sample size, nonprobability sampling, a single setting, homogenous sample, and the subjectivity of qualitative research are common limitations.
(Adams & Tolich, 2011)
Common Themes
Upon completion of data analysis, the authors found five distinct themes: paternalism, decision making, patients’ knowledge, blood safety and administration, and the nurse’s role. Paternalism referred to the patients’ viewing their physicians as being knowledgeable and having their best interest in mind. Their decision making followed the physician’s recommendations. Regarding patients’ knowledge, the patients seemed to have not felt as if they’d been adequately informed prior to the transfusions. Regarding blood safety and administration, most patients wondered if the procedure were safe. The nurse’s role was considered to be educative, comforting, and attentive. (Adams & Tolich, 2011) Comment by Stormer, Mari: Common themes are the answers to the research question. For qualitative research, that would be the identified themes. The exact wording of the themes should be indicated, along with a very brief explanation of each theme.
Implications for Nursing Practice
The authors imply that patients seem to need more information before, during, and after a transfusion. They advocated examining and revising transfusion practices, along with related patient education. Nursing students should also be taught the importance of examining a procedure from a patient’s perspective, as well as to provide patient education whenever possible. (Adams & Tolich, 2011) Comment by Stormer, Mari: Implications are how the authors suggest applying the findings to nursing
Recommendations for Further Research
Adams and Tolich recommended surveying nurses for their knowledge deficits regarding blood transfusions. They also suggested studying the reasons patients cite for receiving transfusions, and correlating those to their perceived experiences. Another possibility is that studies conducted in varied cultures could be useful. Duplicating the basics of the study to other procedures would also provide valuable information regarding determining patients’ knowledge and perceptions about procedures. A larger study in a more ethnically diverse population in more than one setting could offer greater external validity. (Adams & Tolich, 2011) Comment by Stormer, Mari: Recommendations are additional studies the authors recommend be done. Sometimes the authors don’t make recommendations, and you would acknowledge that, and then give your own suggestions.
QualitativeResearch article analysis
Name: _________________________________ Date: ______________________
APA Reference:_______________________________________________________
This analysis is on a qualitative research article. Choose ONE of the qualitative research articles provided in Workshop Two. Do not write a narrative paper. Use the worksheet to complete this assignment. Use your own words to paraphrase information from the article. You can use direct quotes, but use them sparingly. Cite all paraphrases and direct quotes; each box must be cited. Use the grading rubric for guidelines on how to answer each of the questions on the worksheet. When you have completed the assignment, save a copy for yourself and submit a copy to the 2.3 Dropbox by the end of the workshop.
Problem Statement
&
Purpose Statement
Assessment of Literature Reviewed
(Background information)
Research Question(s) written as a question
(The findings answer the research question)
Research Design
(Phenomenological, Ethnographic, Descriptive, Exploratory, Grounded Theory)
Sample, Setting,
&
Sampling Method
Data Collection
&
Data Analysis
Ethical & Legal Issues (Informed Consent, Anonymity, Confidentiality, Institutional Review Board)
Limitations
Common Themes
Implications for Nursing Practice
Recommendations for Further Research
In
t
ensive and Critical Care Nursing (2016) 33, 21—29
Availa
b
le online at www.sciencedirect.com
ScienceDirect
j o u r n a l
h
o m e p a g e : w w w . e l s e v i e r . c o m / i c c n
Nurses’ involvement in end-of-life care of
patients after a do not resuscitate decision
on general medical units in Saudi Arabia
Ibrahim K. Abu-Ghori a, Mustafa M.E.
B
odrick b, Rafat Hussain c,
G. Hussein Rassool d,∗
a Acute Medical Unit, Ministry of National Guard Health Affairs, King Abdul-Aziz Medical City, Riyadh,
Saudi Arabia
b King Saud bin Abdulaziz University for Health Sciences, Riyadh, Saudi Arabia
c University of New England, Armidale, New South
W
ales, Australia
d Faculty of Psychology, Islamic Online University, The Gambia
Received 11 March 2015; received in revised form 13 October 2015; accepted 14 October 2015
KEYWORD
S
Do-not-resuscitate;
End-of-life care;
Nurses’ involvement;
Nurses’ lived
experience;
Reflective journaling
technique
Summary
Objectives: To describe the essence of the nurses’ lived experience and explore the meaning
of their involvement in end-of-life care after a do-not-resuscitate decision has been made.
Research methodology/design: The research design embraced qualitative, exploratory and
descriptive approaches utilising aspects of phenomenology. Purposive sampling of twenty-six
registered nurses was used. Data was collected using the reflective journaling technique and
were analysed using an integrated approach. Field notes were also used as a mean to enrich
the description of the findings contextually.
Setting: Medical units in Saudi Arabia.
Results: Three main themes emerged: exhausted medical treatment, continuity of nursing
care and cultural considerations in nursing care. Related sub-themes were also identified as
an extension to the description of the main themes.
Conclusion: The findings affirm that nurses working on medical units continue to maintain a
constant level of care for patients and families after the do-not-resuscitate decision. Nurses
found that caring for dying patients was a rewarding and worthwhile experience, albeit a chal-
lenging and demanding one. The findings suggest that improvement in end-of-life care would
be best achieved by collaborativ
members.
© 2015 Elsevier Ltd. All rights re
∗ Corresponding author at: Sidi Bou Said, Avenue Bengali 3, Morcelleme
E-mail addresses: ghorii@ngha.med.sa (I.K. Abu-Ghori), BodrickM@
N
husseinrassool@gmail.com (G.H. Rassool).
http://dx.doi.org/10.1016/j.iccn.2015.10.00
2
0964-3397/© 2015 Elsevier Ltd. All rights reserved.
e and interdisciplinary practices amongst the health care team
served.
nt Raffray, Les Guibies, Pailles, Mauritius. Tel.: +230 2861734.
GHA.MED.SA (M.M.E. Bodrick), rhussain@une.edu.au (R. Hussain),
dx.doi.org/10.1016/j.iccn.2015.10.002
http://www.sciencedirect.com/science/journal/09643397
www.elsevier.com/iccn
http://crossmark.crossref.org/dialog/?doi=10.1016/j.iccn.2015.10.002&domain=pdf
mailto:ghorii@ngha.med.sa
mailto:BodrickM@NGHA.MED.S
A
mailto:rhussain@une.edu.au
mailto:husseinrassool@gmail.com
dx.doi.org/10.1016/j.iccn.2015.10.002
22
I.K. Abu-Ghori et al.
Implications for Clinical Practice
• The findings should be used to strengthen the specific areas of interaction and cooperation between nurses and
healthcare team members in the end-of-life care of patients who have a ‘do-not-resuscitate’ code on medical units.
• The educational preparation of nurse on the Islamic perspective of death and its related rituals.
• The need for research to examine the role of nurses in addressing the spiritual and religious needs of dying Muslim
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patients and their families.
ntroduction
atients who suffer from chronic illnesses are admitted to
edical units to receive medical treatment and nursing
are. In spite of the medical units’ primary emphasis on
reatment and recovery from chronicity, many patients die
uring the course of admission to these units. The ‘do not
ttempt cardiopulmonary resuscitation’ (DNACPR) decision
s initiated at a point when the curative treatment has been
xhausted. A range of ‘end-of-life’ (EOL) care options is
herefore provided on these units to such patients when
eath is imminent. In recent years, the need to improve
OL care has received growing recognition in the literature
Bolmsjo, 2008; London and Lundstedt, 2007). Many authors
ave highlighted that limited research attention has been
iven to date on issues of EOL care on medical units despite
he fact that such units are frequently the site of patient
eaths when curative medical treatment plans have failed
o sustain life (Borbasi et al., 2005; Rogers and Addington-
all, 2005; Thompson et al., 2006). Concurrently, there is
aucity of research studies from Saudi Arabia on EOL care
egarding hospitalised patients after a DNACPR decision has
een made.
EOL care relates to dying patients and is often used
nterchangeably with terms such as palliative, terminal and
omfort care (McCann et al., 2007). Comprehensive and
uality EOL care not only involves provision of compassion-
te care for dying patients, but also helping their families
o cope with the imminence of death of their loved ones
Allen, 2008). The cultural and spiritual needs of patients
nd families at the EOL are considered nowadays as essen-
ial determinants in providing quality EOL care, particularly
n the acute hospital setting (Thomas et al., 2008). The most
requently cited concern by patients at the EOL is that their
ultural and spiritual needs are barely addressed in hos-
itals and that there is a need to enhance the awareness
nd knowledge of healthcare providers in these influential
omains (Brown et al., 2006).
Nurses’ recognition of daily Muslim rituals at EOL care
nd the subsequent delivery of respectful EOL nursing care
o patient and family, is regarded as essential in the Saudi
rabian context (Al-Shahri and Al-Khenaizan, 2005). Ross
2001) argues that nurses’ understanding of Muslim tradi-
ional practices related to death would ensure provision of
ulturally congruent EOL nursing care.
ackground
urses are the frontline caregivers for patients in the final
hase of EOL on medical units. The literature depicts that
lthough providing care for dying patients and their families
t
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t
E
n medical units is an essential component of nursing care,
urses have experienced difficulties in meeting the unique
eeds of these patients and their families, particularly
fter the DNACPR decision has been made (Coombs et al.,
012; Long-Sutehall et al., 2001). Although there are
everal nursing studies that have investigated patient and
amily experiences of EOL care, these have been conducted
ainly on intensive care units (Badger, 2005; Heland, 2006;
cGrath and Holewa, 2006). A review of literature on
OL care has revealed that there is a limited literature
xamining the role of nurses in EOL care on medical units
Hopkinson et al., 2003; Graham et al., 2005; Thompson
t al., 2006; Wallerstedt and Andershed, 2007).
Nurses perform a pivotal role in helping dying patients on
edical units attain freedom from pain and other distressing
ymptoms. This unique experience therefore allows nurses
o influence enormously the last moments of a person’s life
nd the indelible memory of the death of a loved one for
amily members (Smeltzer et al., 2010). The provision of
OL care, nevertheless, can be one of the most demanding
nd stressful experiences for nurses in their daily practice
Weigel et al., 2007). Thompson et al. (2006) confirm the
oint that there is a range of nursing issues which require
onsideration, such as recognition in EOL care, provision
f an EOL care plan and nursing support to family mem-
ers. Furthermore, nurses must deal with their own personal
oral, cultural and emotional responses alongside the dying
rocess of the patient (Thompson et al., 2006).
Hopkinson et al. (2003), on the basis of a phenomenologi-
al study of nurses’ experience of EOL care on medical units,
eported that providing care for dying patients and their
amilies tended to cause frustration and feeling of unease
or nurses. The nurses were unable to answer questions from
atients, which resulted in them subsequently, developing a
ense of psychological isolation from other healthcare team
embers. Clinical uncertainty and frequent deterioration
f these patients, however, can be difficult and unpre-
ictable and quiet often create additional pressures and
hallenges for healthcare professionals, specifically when
eciding if patients have reached the terminal phase of their
ife (Barnett, 2006; Bristowe et al., 2015).
Wallerstedt and Andershed (2007) study of nurses’ expe-
ience in caring for terminally ill patients in hospital
ettings, reported the expressions of dissatisfaction from
urses, owing to perceptions of inadequate cooperation
rom the other members of the healthcare team during the
nal phase of a patient’s life. Using data from nurses’ reflec-
ions of participation in EOL care, Graham et al. (2005) also
eport that nurses often develop a sense of failure when
hey are unable to achieve the predetermined goals at the
OL. The research studies outlined above emphasised the
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that are applicable to qualitative methodologies, namely:
credibility (truth value), transferability (applicability),
Nurses’ involvement in end-of-life care of patients after a do not
importance of nurses building a therapeutic relationship
with patients and families, the establishment of efficacious
and solid communication and interpersonal interactions and
support for nurses in providing quality EOL care.
The cultural and religious differences between nurses
and patients present as a challenge and concern in the
care of EOL patients (Blais et al., 2006). There is a great
need for sensitivity in EOL care delivery in relation to both
cultural and religious beliefs of patients and families. In
a country like Saudi Arabia, these issues are of consider-
able significance, as the majority of patients are Muslims,
whereas care providers, particularly nurses, are expatriates
and predominantly non-Muslims. Within a hospital setting
with a large multinational and multicultural expatriate nurs-
ing workforce, nurses’ understanding of Islamic practices
and considerations surrounding a patient’s death, the dying
process and support for family members in coping with death
all need further investigation since there is limited literature
available on these issues (Touhy et al., 2005).
It was observed by the principal author that the multi-
national nurses appear to become more involved in EO
L
care. These expatriate nurses, who are largely non-Muslims
and non-Arabic speaking, have different religious, language
and cultural backgrounds from the patients, who are Mus-
lim, Arabic-speaking and live an Islamic way of life. Some
nurses had raised the point that, contrary to expectations,
the majority of physicians, who are Muslims and Arabic-
speaking, appear to become less involved in EOL care after
the DNACPR decision has been made. In the context of the
research setting, this paradox of increased involvement by
expatriate nurses after DNACPR and the lesser involvement
of other healthcare members, particularly local physicians,
is regarded as an unexplained phenomenon.
The study
Aim
The purpose of the study was to examine the nurses’ lived
experience and the meaning of their involvement in EOL care
after a DNACPR decision has been made on medical units in
Saudi Arabia?
Design
This is a qualitative, exploratory and descriptive investi-
gation that used related methods in a process of inquiry.
It utilised aspects of phenomenology to study nurses’
reflective accounts of their lived experience and discover
meanings in EOL care of DNACPR patients on medical units
(Richards and Morse, 2007; Streubert and Carpenter, 2010).
This methodology provides participants with an opportu-
nity for introspection, disclosure and feedback (Ruth-Sahd,
2003), which matched the aim of the study that focused on
the lived experiences of the nurses.
Setting
The study was conducted on eight medical units in a large
tertiary-level teaching hospital in Riyadh, Saudi Arabia. A
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scitate decision on general medical units in Saudi Arabia 23
urposive sample of twenty-six registered nurses (RNs) were
ecruited for participation. The intention was to recruit par-
icipants who had experienced the phenomenon and who
ould be able to articulate what it was like to have lived
hat experience. The eligibility of RNs invited to participate
as based on the following exclusion criteria: employed at
he hospital for less than on year on medical units; last expe-
ience in EOL care on medical units was more than two years
go; and had experienced any level of emotional distress
esulting from either a patient or a personal family mem-
er’s death and/or who had undergone counselling related
o EOL issues in nursing practice.
ata collection
ata were collected using a reflective journaling tech-
ique. This technique was chosen because of its congruence
ith the professional nursing practice context of the hos-
ital setting and that it invokes depth of self-reporting
y respondents (Taylor, 2006; Walker, 2006). The research
nstrument was based on Johns’ original model of struc-
ured reflection (1992) and informed by the modifications
iven by Johns (2004) and Quinn and Hughes (2007).
ractice for writing reflective journals was offered to the
tudy participants through training sessions using their
ost recent experiences related to non-EOL patient-care
Plack et al., 2005). In the present study, participants were
iven four to six weeks to complete their reflective jour-
al entries in a safe and private environment of their
hoice.
ata analysis
uring data collection, the first author kept field notes
o document his observations to contextualise and enrich
he description of the findings and to ensure idiosyncratic
escriptions or expressions heard or seen in the field had
een recorded meticulously (Patton, 2002). The transcripts
f the returned reflective journals were analysed using
n integrated approach that included Coffey and Atkinson
1996), Johns’ model of structured reflection (Johns, 2004)
nd Tesch (1990). The stepped approach (see Table 1 for
etails) resulted in an emergence of main themes and sub-
hemes. Concurrently, memos to the researcher were used
s a method of recording significant aspects of findings dur-
ng data analysis that added further depth and richness to
he context of the findings.
rustworthiness
o maintain scientific integrity throughout the study, Guba’s
pdated model of 1981, cited in Krefting (1991, 215)
as used. It includes four aspects of trustworthiness
ependability (consistency) and confirmability (neutrality).
able 2 presents these aspects, together with the strate-
ies used to ensure the rigour and trustworthiness of this
tudy.
24
Table 1 Modified data analysis process.
Steps Procedure
1. Read two to three reflective journals to obtain a
sense of the whole experience and make notes as
ideas occur relating to the coding process.
2. Select one section of the reflective journal and work
on it to arrange categories related to the underlying
meaning and experiences and continue making notes
and/or write memos to self as ideas occur related to
the context or phenomenon.
3. Select the next section in the reflective journal and
repeat step 2 above but move to interpretation and
linkages between segments of data. Continue to
make notes on interpretation and/or write memos to
self where aspects of data trigger thinking in relation
to field notes, contextual data and/or content of
other reflective journals.
4. After completion of four to five reflective journals,
the analysis as undertaken in steps 1, 2 and 3 should
be reviewed in combination with field notes and
memos that have been generated. The review
includes the coding process, naming of categories
and arrangements thereof, emerging interpretations
and any notes made.
5. The content is scrutinised to identify recurring
and/or similar topics. These are assessed critically to
identify depiction by words related to the essence of
meaning. This identification represents emergent
themes, which are then arranged into columns and
the data from the four or five reflective journals that
have been reviewed are arranged accordingly as the
themes and content of categories are matched.
6. Repeat step 1 to step 5 above until all the reflective
journals have been reviewed and analysed
accordingly.
7. Devise a system of labelling for each theme with a
symbol, as in coding and arrange the themes in
separate columns to include the reflective journal
code and related extract of narrative text.
8. Review the themes that do not conform to the
recurrent topics in the emergent themes. Assess
whether they are unique themes or redundant
themes and make notes on the related justification.
9. After completion of all reflective journals following
steps 6, 7 and 8 above, the themes in columns are
reviewed for further assessment as major themes
and their sub-themes, to portray the experiences of
the RN participants in EOL care after DNACPR.
10. The major themes and sub-themes are finalised
according to logical arrangement to reflect the
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essence of experience and meaning that has
emerged.
thical considerations
pproval for the study was granted by the University of New
ngland Human Research Ethics Committee and the Hospi-
al’s Research and Ethics Committee where the study was
arried out. Participation was voluntary and participants
t
I.K. Abu-Ghori et al.
ere assured of their right to withdraw at any stage without
reason. Written consent was obtained from all partici-
ants prior to participate in the study. The confidentiality
f data was assured by use of a specific numeric coding sys-
em for reflective journal returns, which was known only to
he researcher and the individual participant.
esults
list of the main themes and sub-themes that emerged
rom the data analysis is presented in Table 2 and described
n more detail in the relevant section below. Briefly, the
nalyses of data lead to the development of three main
hemes: ‘‘exhausted medical treatment’’; ‘‘continuity of
ursing care’’; and ‘‘cultural considerations in nursing
are’’. Within each of the three key themes, some distinct
ub-themes were also identified (see Table 3 for details).
xhausted medical treatment
he first major theme focused on exhausted medical treat-
ent. The thematic analysis also revealed the presence of
wo sub-themes embedded within the core theme: exclusion
f on nursing staff from DNACPR decision-making process;
nd varying physician involvement in patient care once a
NACPR decision has been made. According to the partici-
ants, exhausted medical treatment was an early indicator
o recognise a dying patient. This posed a challenge for
urses in managing patients on the medical units because
f the opposing views of some doctors and a general lack
f consensus on when the EOL stage had been reached. The
ollowing reflective journal excerpt illustrates this situation:
‘‘End of life means when a pt [patient] is so gravely ill
[and] that death is imminent and inevitable at any time.
At this time the [patient] is considered in the terminal
phase of a progressive, irreversible dying process. Having
a pt [patient] in a terminal phase, is not easy at all.’’ (RJ
16)
In such a situation, if the patient is approaching death
n the medical unit, then the nurses pay focused attention
o the importance of the patient’s right to die, providing
ignity and enabling accompanying family support. In the
ollowing exemplar, a participant described honouring the
atient’s dignity at death:
‘‘End-of-life care mean[s] to allow patient to die with
considering his dignity and avoid[s] any inappropriate
prolongation of dying.’’ (RJ 25)
A sense of exclusion from the DNACPR decision-making
rocess was expressed by the participants who showed self-
wareness regarding the cultural and religious differences
hat possibly influence the non-participation of nursing in
he DNACPR discussion. One participant raised the concern
hat the majority of nurses who are working in the hospi-
al are expatriates and non-Arabic speakers and as such are
xcluded from the DNACPR decision-making process, stating
hat:
‘‘As nurse[s] we play a very minimal role in decision-
making as a ‘No Code’ [DNACPR]. But nurses also can
Nurses’ involvement in end-of-life care of patients after a do not resuscitate decision on general medical units in Saudi Arabia 25
Table 2 Measures used to establish trustworthiness of the study.
Criteria Strategy Applicability
Credibility (truth
value)
Prolonged
engagement
The researcher was working as a full-time clinical nurse manager on
an acute medical unit at the hospital. Trust and rapport with the
participants was established through multiple information and
training sessions that lasted about three months during data
collection.
Field notes Field notes were kept by the researcher during data collection that
added depth of context.
Transferability
(applicability)
Authority of
participants
The participants were selected by purposive sampling owing to their
lived experience in EOL care after DNACPR on medical units.
Thick description The design of the reflective journal instrument with an open-ended
question on each page and twenty (20) lines for expanded
expressiveness contributes to rich and vivid descriptiveness. This
provided Sufficient descriptive data on the context, the research
methodology and the researcher’s epistemological stance.
Dependability
(consistency)
Reflective journal
training sessions
The reflective journal training sessions were conducted with
participants prior to completion of their reflective journal entries.
The established use of reflective practice and journaling by
registered nurses at the hospital contributed to participants adapting
easily to the reflective journal instrument for data collection.
Confirmability
(neutrality)
Authority of the
researcher and
ongoing site
co-supervisor
The research was supervised by an experienced qualitative
researcher (co-supervisor) with expertise in reflective journaling and
qualitative methodology who was available at the research site.
Reflexivity Field notes were used to preserve recorded information. Weekly
sessions were held with the research site co-supervisor at which
topics and field notes concerning data collection were discussed
extensively and where appropriate bracketing was used to retain
objectives curiosity in the research process.
Memos The memos were used during data analysis to identify and document
the researcher’s own biases or perspectives, which preserved the
authenticity of data collected.
Table 3 Emergent main themes and sub-themes in the study.
Main-themes Sub-themes
1. Exhausted medical
treatment
1A. Nursing excluded from DNACPR decision-making
1B. Varying physician involvement after the DNACPR decision
2. Continuity of nursing care 2A. C
ompassionate and comfort nursing care
2B. Focused comprehensive nursing care
2C. N
urses coordinating care contributions
3. Cultural considerations in 3A. Recognition of Islamic aspects in nursing care
B. In
n
E
p
o
c
w
nursing care 3
contribute factors like nutrition, family support, psycho-
logical and physical condition, emotional condition of the
patient when they discuss about ‘No Code’. But here in
the hospital, no doctor will ask the nurse’s opinion before
taking a decision. May [be] [because] lot of western and
foreign nurses [are] working in this country, and language
is a barrier.’’ (RJ 03)
It is a noteworthy observation that the above participant,
despite acknowledging the status of nurses as ‘foreign’, has
b
tegrating Islamic aspects into education on EOL nursing care
evertheless outlined that nurses could still be involved in
OL care in ‘nutrition, family support, . . .’ related to the
hysical and emotional needs of the patient. The nurses
bserved that physicians and other member of the health-
are team were seemingly not interested in being present
ith the patient’s family when death occurred. The example
elow illustrates this view:
‘‘It is [a] very rare happen[ing] that the physician is
present at [the] patient[’s] bedside upon [at] the moment
2
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e
v
c
C
T
a
a
c
t
t
n
b
d
p
p
w
p
p
t
t
c
i
u
a
‘
C
T
a
t
f
m
t
p
e
c
t
w
w
i
s
e
c
N
N
a
a
e
m
p
h
6
of death of [the] DNACPR patient. They [physicians] are
hesitant to provide emotional support for the family. . . .
It [is] very seldom that the physician or any multidis-
ciplinary team [members] are present [at] the time or
moment of death of any DNACPR patient.’’ (RJ 01)
In the opinion of the respondents, the withdrawal of
hysicians from active involvement with patients occurs
ither because of reduced need for active medical inter-
ention or because patients who are DNACPR are possibly
onsidered as a low physician priority.
ontinuity of nursing care
he present study found that medical nurses render care in
n ongoing manner so that patients’ and families’ needs are
cknowledged, irrespective of the patients’ resuscitation
ode status. The following empirical evidence confirmed
hat nursing care is given on a continuum before and after
he DNACPR decision:
‘‘The patients will be taken care of; support will be given
to the family. For us [nurses] the end-of-life does not
mean the end-of-care . . . My care was not different after
the decision has been made.’’ (RJ 07)
Most participants acknowledged that the provision of
ursing care for patients at the EOL after DNACPR should
e based on the patient’s needs, rather than the medical
iagnosis or the disease itself. This perspective in nursing
ractice is epitomised in the following exemplar, in which a
articipant explained how EOL nursing care on medical units
as provided on the basis of patients’ needs, rather than the
atient diagnosis or resuscitation code status:
‘‘We really try our best to provide them with excellent
care and give them their remaining dignity and quality of
life. In our unit, on nursing side we care [for] patients not
base[d] on their code status, but providing equal right[s]
as a patient.’’ (RJ 14)
In the following excerpt from the reflective journal, a
articipant summed up the perceived understanding of con-
inuity of nursing care in EOL, using various related terms
hat illustrated the extent of the caring philosophy. It vividly
aptured and encapsulated the full sense of the meaning
n the term ‘continuity of nursing care’. The participant
sed philosophically appropriate terms to convey the caring
ttitude in EOL care such as ‘tender’, ‘loving’, ‘patiently’,
devotedly’, ‘relieve him’, ‘very fragile’ and ‘best care’.
‘‘End-of-life care is a tender, loving, comprehensive and
full of sympathy kind of care rendered to a very termi-
nally ill and dying patient . . . So the nurse will have to
patiently and devotedly turn him frequently, feed him
as prescribed, give medications to relieve him from pain
and discomfort. Wash him tenderly because the skin is
already very fragile . . . We want the best care for them
before they die.’’ (RJ 13)
ompassionate and comfort nursing care
he expressions ‘empathy’, ‘tender care’, ‘comfort care’
nd ‘compassionate care’ were used by the participants
i
d
i
t
I.K. Abu-Ghori et al.
o describe the ‘compassionate and comfort nursing care’
or patients and families after a DNACPR decision has been
ade. The following excerpt demonstrates how a par-
icipant, despite the deep level of understanding of the
atient’s pain at EOL, was able to control the extent of
motional involvement with the patient. Although it was a
hallenge to remain calm and not to show concern openly,
he participant was aware by reflective disclosure that this
as an important contribution to caring for patients who
ere dying:
‘‘However during his last admission I know it would be
the last time though I prayed that he will still get well. I
know this was the same prayer his parents had. I always
try to provide the best care I can for my patients . . . as I
gave my last nursing care [a] few days before he passed
away, my heart was in pain too. I still wanted to save him
or to prolong his life if I could, [.] [The] the day before
he died, every time I entered the room, he was reaching
out to me as he wanted to be held or carried out of bed.’’
(RJ 06)
In EOL care situations, the nurse-patient relationship is
ntimate in nature and involves the provision of compas-
ionate and comfort nursing care. The following reflective
xemplar shows that compassionate nursing care was the
ornerstone in provision of EOL care:
‘‘The most important [aspect] is — we are giving the
most compassionate specialized care for the living. It
is base[d] on comprehensive understanding of patient
suffering and focuses on providing effective pain and
symptoms management to seriously ill patients while
inquiring [ensuring] quality of life. Providing appropriate
end-of-life care became a primary concern of each and
every one of us [as nurses].’’ (RJ 21)
urses coordinating care contributions
ursing staff use coordination as a skill to marshal avail-
ble hospital resources effectively in response to patients’
nd families’ needs in EOL care. The following empirical
vidence from the reflective journals explicates the commit-
ent of a participant to coordinate EOL care for the dying
atient:
‘‘Another role [for nurses in EOL care] is being the bridge
between the doctor and family or patient, because some
of them [patients or families] just consented [to DNACPR]
without really understanding what is it. As a nurse [I] just
tell the doctors to give some explanation to the fam-
ily. For other team members, respiratory therapist for
example using a nebulisation if patient is desaturating.
For [the] dietician [I] can suggest diet of the patient.
[Physicians] should visit patient from time to time, daily
won’t [would not] hurt because if not it makes family
more anxious.’’ (RJ 10)
There is also the revelation that other members of the
ealthcare team were reluctant to intervene in situations
nvolving patients in EOL care after DNACPR. The respon-
ent indicated a level of disappointment with experiences
n which some team members appeared to ‘de-prioritise’
he care of EOL patients after DNACPR.
resu
D
T
c
a
f
D
f
D
s
n
o
d
d
i
e
D
r
i
l
a
n
a
a
a
c
i
h
f
c
t
e
o
t
b
i
p
c
s
S
t
a
T
e
f
i
o
c
p
D
fi
w
c
(
c
Nurses’ involvement in end-of-life care of patients after a do not
‘‘Sad to say some members of the health team its [are]
not fully active doing their responsibilities. I think they
are considering, when working [with] this kind of patient
[that] there’s [there is] no use or benefit on [of] it. That’s
why when they will visit this kind of patient [,] they will
not stay longer [than] even five minutes.’’ (RJ 21)
This profile draws attention to the different prioritisation
applied in approaches to care between nurses and other
healthcare team members. This variation in approach reaf-
firms the role of nurses in coordinating care contributions
by assuming an EOL advocacy and leadership role to ensure
continuity of care for patient and family.
Cultural considerations in nursing care
The medical nurses acknowledge the Islamic and cultural
aspects pertaining to the way of life in Saudi Arabia and that
it must be taken into account during nursing interventions in
EOL care. The extract that follows reveals how one partici-
pant acknowledged the importance of cultural and religious
practices, yet expressed concerns about the safety of the
patient in relation to the medical care equipment.
‘‘When death is imminent, the family expects that the
patient be dealt with differently e.g. [for example]
[blessed] olive oil be applied all over the whole body.
If the patient is on tube feeding, ordinary bottled water
should not be used to flush the feed, instead ‘‘Zam-Zam’’
[obtained from the water well in the Holy Mosque in Saudi
Arabia]. And again, the dying patient’s bed is positioned
to face Mecca [the Muslim holy city in Saudi Arabia]. This
[at] times creates a little bit of concern for the nursing
staff as this position might be pulling the patient away
from the necessary [medical] equipment i.e. oxygen and
/or suction apparatus. Yes, nurses have to show respect
for the culture and religion especially during this critical
time.’’ (RJ 05)
The importance of respecting the patients’ and families’
beliefs, knowing the unique needs and responses of dying
patients and families and trying to show respect for them is
confirmed and characterised by the reflection on experience
of one of the participants:
‘‘I have observed here that the family tries to use dif-
ferent cultural and traditional way of treating the sick
member of the family. They use prayers, . . ., putting oil
to the whole body, applying herbal medicine…, apply-
ing henna [herbal medicine] over the pt’s [patient’s]
head. And for me, as a nurse, I respect what these peo-
ple believe as long as it would not compromise the pt’s
[patient’s] deteriorating condition and safety. I under-
stood that it is not only the pt [patient] who suffers the
pain from the disease but also the pain that’s in the heart
of the family as they watch / see the near death of their
loved ones. All I can offer is to give my support both to
the pt. [patient] and his family.’’ (RJ 16)
The depth of respect shown in the above excerpt further
portrays the extent to which non-Muslim nurses demonstrate
respect for Muslim traditional practices, even when they
encounter them as new experiences.
r
t
l
o
u
scitate decision on general medical units in Saudi Arabia 27
iscussion
he lived experience of nurses in this study illuminates spe-
ific areas of interaction and cooperation between nurses
nd healthcare team members that could be the focus
or improvement in the EOL care of patients who have a
NACPR code on medical units. In this study, a range of
eelings were revealed by nurses regarding their role in the
NACPR decision-making process: feelings of acceptance,
atisfaction, emotional stress, powerlessness, unprepared-
ess, dissatisfaction, frustration and anger. These emotions
ccurred as a consequence of their exclusion from DNACPR
ecisions. Several studies have reported that nurses in their
aily practice may hold a range of views regarding their
nvolvement in the EOL decision-making process (Calvin
t al., 2007). However, the involvement of nurses in the
NACPR decision-making process in the final stage of EOL
emains debatable.
A noteworthy consideration with regard to continu-
ty of nursing care is that nurses took the initiative to
ead other healthcare members in responding appropri-
tely to patients’ and families’ needs at the EOL. The
urses observed how, without team work and support, their
bility to coordinate effective care for DNACPR patients
nd their families was a challenge. The strategies associ-
ted with coordinating patient care for EOL after DNACPR
ode appeared to be driven by the nurses’ belief in the
mportance of their role as patient advocates. This is per-
aps because nurses spend more time with patients and
amilies in EOL care after DNACPR than any other health-
are members. The withdrawal of physicians may indicate
heir awkward feelings regarding death and dying, which is
videnced by their avoidance of family near the moment
f death. This could also be due to their lack of educa-
ion on principles of EOL care. The findings of a study
y Gibbins et al. (2011) on newly qualified physicians
n the United Kingdom showed that the newly qualified
hysicians felt unprepared to provide appropriate EOL
are. The implication is that caring for patients in EOL
hould be part of the undergraduate medical curriculum in
audi Arabia.
The findings of the present study showed nurses’ ambi-
ions to provide quality EOL care to DNACPR patients
nd their families. This is reinforced by the findings from
hompson et al. (2006) who found that nurses make great
fforts to provide quality care for dying patients and their
amilies despite their workload. Lack of sufficient time ded-
cated to dying patients, owing to the increased acuity of
ther patients or the complexity of tasks and clinical pro-
edures on medical units, is an added challenge to the
rovision of continuity of nursing care at the EOL after
NACPR. Beckstrand et al. (2006) found that a lack of suf-
cient time to care for dying patients and their families
as a significant concern for nurses in the context of a
omplex acute hospital setting. Wallerstedt and Andershed
2007) concluded that if nurses were to provide quality EOL
are, then they needed sufficient time to allow them to
espond promptly to the evolving needs of EOL patients and
heir families. The implication of this study is that staffing
evels should be reviewed to meet the increased demands
f patients and families who require EOL care on medical
nits.
2
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8
The findings of the present study highlight the need for
ollaborative service development that is congruent with
he International Council of Nurses (ICN) document on col-
aborative practice in the twenty-first century (Schober
nd McKay, 2004). The authors emphasise that collabo-
ative service development denotes the contemporary need
f modern times for interdisciplinary action in approaches
o improving healthcare delivery. They assert that col-
aborative service development is best positioned by an
ntegrated approach where healthcare providers are consid-
red equal in their roles and functions. In relation to this, the
nterdisciplinary approach is grounded by common health
oals, shared decision-making and ‘nourished by a climate
f mutual respect, trust and support’ (Schober and McKay,
004:8).
Nurses in this study appeared to realise that meeting
he cultural and religio-spiritual needs of dying patients and
heir family members was as important as providing qual-
ty physical nursing care. Although several research studies
ave discussed nurses’ role in providing spiritual care for
ying patients and their families, they are based on the
udeo-Christian traditions and values (McCann et al., 2007;
assool, 2000). In direct contrast, there has been scant
ttention in the literature about nurses’ involvement in the
piritual care of dying Muslim patients, particularly those in
conservative Muslim community. Thus, the findings of this
tudy have the potential to provide researchers with evi-
ence of the need for additional research to examine the
ole of nurses in addressing the spiritual and religious needs
f dying Muslim patients and their families.
imitations
he qualitative study was limited in approach because it
ocused only on experiences within the context of one
ospital in Saudi Arabia and limited in its transferability.
espite this limitation, the knowledge of the meanings and
ssences identified in the nurses’ lived experience provide
n understanding of the experience of multinational nurses
ith similar backgrounds. Another limitation is that this
tudy relied on each participant’s recall of the lived expe-
ience in EOL care after DNACPR. The narratives included
n the reflective journals cover a period of two years on
edical units in the hospital. Therefore, the accuracy of
ecall may have been distorted as a result of the pass-
ng of time, whereby previous experiences in EOL care
ay have been diffused with other DNACPR experiences
o answer the reflective journal questions. It should be
tated, however, that it was apparent that the experience
f participants was both vividly recalled and thoroughly
escribed.
onclusion
he findings of the study confirm that nurses working on
edical units showed compassion towards DNACPR patients
nd their families. The essence of their lived experience is
aving the ability to identify with the suffering of patients
nd families and their willingness to help and to provide
elief and support at this time. Nurses found caring for dying
atients to be a rewarding and worthwhile experience,
B
I.K. Abu-Ghori et al.
lbeit a challenging and demanding one. The findings
uggest that improvement in EOL care would be best
chieved by collaborative and interdisciplinary practices
mongst the health care team members. Further research
imed at understanding the perspectives of various team
embers, in particular physicians would enhance our
nderstanding of provision of appropriate level of support
nd optimal teamwork required to manage the phenomenon
f EOL care after DNACPR on medical units in Saudi Arabia.
thical statement
pproval for the study was granted by the University of New
ngland Human Research Ethics Committee and the Hospi-
al’s Research and Ethics Committee where the study was
arried out. Participation was voluntary and participants
ere assured of their right to withdraw at any stage without
reason. Written consent was obtained from all partici-
ants prior to participate in the study. The confidentiality
f data was assured by use of a specific numeric coding sys-
em for reflective journal returns, which was known only to
he researcher and the individual participant
onflict of interest statement
o conflict of interest has been declared by the authors.
unding
his research received no specific grant from any funding
gency in the public, commercial, or not-for-profit sectors.
cknowledgments
his research was conducted as part of the requirements for
he degree of Master of Nursing (Honours) at the University
f New England, Australia. We would like to thank the gen-
ral medical unit nurses who participated in the study for
heir valuable contribution.
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- Nurses’ involvement in end-of-life care of patients after a do not resuscitate decision on general medical units in Saudi …
Introduction
Background
The study
Aim
Design
Setting
Data collection
Data analysis
Trustworthiness
Ethical considerations
Results
Exhausted medical treatment
Continuity of nursing care
Compassionate and comfort nursing care
Nurses coordinating care contributions
Cultural considerations in nursing care
Discussion
Limitations
Conclusion
Ethical statement
Conflict of interest statement
Funding
Acknowledgments
References
P
eripheral venous catheters (PVCs) are the most
common invasive device inserted in hospitals
internationally. Up to 60% of all patients undergoing
treatment in a tertiary hospital will have at least
one PVC during their hospital admission (New et
al, 2014; Alexandrou et al, 2015). Previous studies have found
that insertion of these devices is associated with a range of
negative outcomes, from mild discomfort to extreme pain or
anxiety (Halter et al, 2000; Wright, 2011). However, patients’
experiences of PVC insertion are under-investigated.
Experiences of peripheral IV insertion
in hospital: a qualitative study
Emily Larsen, Samantha Keogh, Nicole Marsh, Claire Rickard
ABSTRACT
Adult medical and surgical patients admitted to tertiary hospitals regularly
have peripheral venous catheters (PVCs) inserted for their treatment.
Anecdotally, patients report varying levels of pain and anxiety during
the insertion procedure; however, lived experiences of patients are not
well documented in the literature. The aim of this study was to gain
an understanding of patients’ experiences of PVC insertion. Some 10
participants were purposively sampled for semi-structured interviews, from
the medical and surgical wards at a tertiary hospital in Queensland, Australia.
Four key themes developed from the interview data: communication between
the patient and the inserter; technique of device insertion; competence of the
inserter; and location of the device. These themes informed practical ways
that nurses might improve the patient experience, including: consultation with
patients regarding device insertion preferences; siting the PVC in locations
other than the antecubital fossa and hand; ensuring experienced and
confident inserters are available to insert PVCs.
Key words: ■ Patients’ experience ■ Qualitative study ■ Catheterisation,
peripheral ■ Nursing, medical-surgical
Emily Larsen, Senior Research Assistant, Alliance for Vascular
Access Teaching and Research (AVATAR), Menzies Health Institute
Queensland (MHIQ), Griffith University, Nathan Campus, Brisbane,
Australia
Samantha Keogh, Professor, School of Nursing and Midwifery,
Queensland University of Technology, Brisbane, Australia
Nicole Marsh, Research Fellow in Vascular Access, Menzies
Health Institute Queensland (MHIQ), Griffith University, Australia
Claire Rickard, Professor, School of Nursing and Midwifery,
Griffith University, Australia
Accepted for publication: October 2017
Background
PVCs are inserted by medical or nursing staff (Alexandrou et
al, 2015) and are typically placed in the upper arm, lower arm,
hand or foot, using various size needles (measured by gauges)
(O’Grady et al, 2011). Catheter size and location for insertion
depend on patient characteristics (e.g. previous medical/
treatment history, comorbidities), infusion/treatment needs,
and patient preferences (Sansivero, 2010; Gorski et al, 2016).
Insertion may not always be successful, and escalation to a more
experienced clinician is sometimes necessary.
Patient risk factors for problematic insertion, such as advancing
age (Gabriel, 2012) and obesity (Sebbane et al, 2013), have increased
over time. Older people also have reduced suitable vasculature for
PVC placement, and often require multiple insertion attempts
(Maiocco and Coole, 2012). Further, unsuccessful PVC insertions
have increased the use of peripherally inserted central catheters
(PICCs) and other central venous access devices (CVADs), which
have higher morbidity, mortality and costs (Chopra et al, 2013).
One of the few papers to report the patient experience of
PVC insertion was published in 2015 by Robinson-Reilly and
colleagues (Robinson-Reilly et al, 2016). This qualitative study
of patients’ experiences of PVC insertion used semi-structured
interviews with patients in two rural oncology outpatient
units within a hermeneutic-phenomenology methodology
(Robinson-Reilly et al, 2016). The authors found that patients
discussed their negative experiences with others, accepted the
insertion as ‘a necessary evil’ and often recalled statements by
inserting health professionals about the quality of their veins.
This provided useful information; however, it was limited to a
rural oncology cohort and might not be widely applicable to
the hospital inpatient medical and surgical population.
Methods
Design
This study used a qualitative design to explore the patient’s
experience and develop an understanding of the physical
and emotional impact this may have on them during their
hospital stay. Semi-structured interviews were conducted using
a phenomenological-hermeneutic approach and Gadamer’s
Critical Hermeneutic Process was used to inform the research
methods (Gadamer, 1975; Fleming et al, 2003).
Setting and participants
A convenience sample of 10 participants from the medical and
surgical wards at the Royal Brisbane and Women’s Hospital
S18 British Journal of Nursing, 2017, (IV Therapy Supplement) Vol 26, No 19
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Table 1. Demographic data of survey participants
Study ID Admission type Gender Age (in years) Number of PVCs this
admission prior to interview
LOS prior
to interview
1 Surgical (orthopaedic) Male 62 6 8 days
2 Surgical (gastrointestinal) Male 79 2 5 days
3 Surgical (gastrointestinal) Female 51 1 2 days
4 Medical (general) Female 53 1 10 days
5 Medical (endocrine) Female 57 1 2 days
6 Surgical (gastrointestinal) Male 24 2 14 days
7 Medical (gastrointestinal) Male 61 2 4 days
8 Surgical (orthopaedic) Female 62 2 3 days
9 Surgical (urology) Male 67 1 2 days
10 Surgical (orthopaedic) Female 44 4 8 days
LOS: Length of stay; PVC: Peripheral venous catheter
in Queensland, Australia were recruited between May and
September 2015. Adult patients who had undergone a PVC
insertion were eligible for inclusion. Patients were excluded
if they were non-English speaking, confused, or undergoing
late-stage palliative treatment. The recruitment number was
determined by the point of saturation of themes and concepts.
Initially, the nurse overseeing the patient’s care for that day
was consulted to assess the suitability of approaching potentially
eligible patients. Patients who agreed to be approached were
visited by the researcher, who explained the purpose and nature
of the study. A participant information and consent form was
provided, and the participant was given ample opportunity
to ask questions and clarify their understanding of the study.
Of the 10 interviewed participants, 3 were from a medical
unit and 7 were from a surgical unit. There were an equal
number of men and women, aged from 24 to 79 years. Further
demographic data of the participants is shown in Table 1.
Data generation
After the patient had consented, a mutually suitable time
for the interview was established. Participants were given
the opportunity to choose the location for the interview—
at the bedside, or in a private room on their ward. All 10
participants opted to have the interview conducted at the
bedside. Those in shared rooms had their curtains drawn for
privacy and participants in single rooms were asked if they
would like the door completely shut. The digital audio-
recording device was in plain view at all times (not concealed)
and the participant was advised when it was turned on/off.
Consenting participants were asked an initial question ‘What
has been your experience of IV insertion?’, with following
questions developing as a result of participant responses and
conversation, such as ‘and what did you feel?’ and ‘how did this
experience compare to your previous device?’ The duration
of interviews was 5-26 minutes.
Data analysis
The point of saturation of themes was determined by two
processes. First, following each interview, the researcher reviewed
the recording and identified key findings. Second, at the point
that the interviewer believed theme saturation had been
achieved (n=8), the transcribed interviews were analysed in
more detail and an additional two interviews were conducted.
At the completion of these interviews, theme saturation was
met. Interviews were transcribed verbatim by an independent
party. Transcripts were initially reviewed for a preliminary
understanding of the findings, followed by a sentence-by-
sentence review approach. Initial themes were derived from the
process and verified by co-researchers. Participating individuals,
who had opted to do so, were provided with a letter summary
of the findings and were given a pre-paid envelope and contact
details to respond if they felt the findings did not reflect their
experience. There were no responses returned.
Ethical considerations
This study was conducted in accordance with the National
Statement on Ethical Conduct in Human Research and received
Human Research Ethics Committee approval by the Royal
Brisbane and Women’s Hospital (HREC/14/QRBW/518)
and Griffith University (NRS/46/14/HREC).
Results
The understanding gained from the interviews revealed elements
of patient satisfaction, as well as fear and mistrust of clinicians
who inserted and cared for their PVCs. While some patients
wanted to be involved in problem-solving and decision-making
processes, others were satisfied to hand all responsibility to
the clinician. Participants shared feelings of wanting the most
comfortable health care experience possible. For some, this
relied on open communication during the device insertion. For
others, it was the feeling of a sound sleep without interruption
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by their PVC or infusion machine. Four themes were derived
from the data.
Theme 1: communication between the patient and
the PVC inserter
Communication between the patient and the inserter was
highlighted as a key factor in the PVC insertion procedure.
Deficits in this communication process were a particularly
common finding, emerging from 6 of the 10 interviews. Some
patients reflected that, although they expressed concerns or
offered advice to the clinician inserting the PVC, their opinions
were met with refusal and/or mistrust.
The most emotive and frustrating element of the PVC
insertion experience, as reported by 4 of the 10 patients, was
an inability to influence the manner in which the procedure
was carried out. It related to communication in the preparation,
insertion and securement stages of the PVC placement process:
‘They don’t listen when you tell them you’ve
got no veins, and they just keeping probing and
prodding all over.’
Interview 4
Patients who were unhappy with the insertion procedure
often felt they did not have the ability to impact upon the
insertion location of the device.
‘I never thought you could actually say, “Oh,
can I have it here or there?”.’
Interview 8
Notwithstanding this, while most patients felt disempowered,
they nonetheless had a threshold of tolerance and could be
assertive when necessary. One patient stated that, despite
feeling her opinion was not valued, there were certain limits
she adamantly enforced:
‘They always keep on asking to go to my feet
and I won’t let them … No way in the world is
anybody sticking any things like that in my feet.’
Interview 4
In that same interview, it emerged that the PVC had been
dressed with a product to which the patient was allergic. Though
the patient had advised the clinician, the staff member had still
insisted on checking the patient’s medical chart prior to the
dressing being removed and replaced. That concept of mistrust
and disbelief from the treating clinician was mirrored with
another patient who had experienced similar situations:
‘It’s when you get someone that’s, um, not met
you before or hasn’t worked with you, ah, they
just don’t believe you.’
Interview 7
Separate from the process of PVC insertion, dressing and
securement, several patients felt that communication prior
to insertion was an important—but often lacking—aspect of
the procedure. Participants commented on the quality of the
warning given prior to device insertion, both positive and
negative. While most participants were told what the procedure
would feel like, some felt they were ill-prepared:
‘So when they—when you say—it’s just a little
scratch and then there’s massive pain, not a
good thing. Because you’re expecting a little pin
prick and it hurts like crazy.’
Interview 10
A number of patients with chronic illness and regular re-
admissions had experienced multiple PVC insertions. These
patients had become experts in the knowledge of their own
vasculature. Despite this, clinicians were not always receptive
to this advice:
‘You’re the one that knows your body and I
know my body back—back to front. But they
just don’t take any notice and that’s what
they’ve got to learn to do.’
Interview 4
‘And others, they’re almost arrogant with the
way they, they just ignore what you say and
“I know better than you” sort of thing … the
reason I told them that was to save all that
drama.’
Interview 7
It was clear in some cases that the patients had been told
they had poor vasculature by the inserting clinician. In other
cases, it seemed others had formed that conclusion themselves.
‘Because I’ve got no veins. I haven’t had veins
at all, um, not even as a kid … but no, when I
come in, they don’t take notice and they just jab
wherever they feel like it.’
Interview 4
‘Finding a vein to use is a problem too for me,
not everyone’s like that.’
Interview 7
In one interview, the patient acknowledged the inserter ‘had
to say something’ when they were experiencing difficulties.
‘They just said the veins aren’t good enough or
whatever, yeah … Only when they can’t—they’re
having trouble, yeah … Got to say something, aye?’
Interview 5
Theme 2: technique of device insertion
The quality and severity of pain varied among participants. The
discomfort was amplified with multiple attempts for insertion—
this emerged within 6 of the 10 interviews. Patients, while
acknowledging the need for the device, were disappointed if a
device was not inserted on the first attempt. Multiple insertion
attempts were linked with a change in the quality of the pain
from a sting to an ache, as well as an increase in pain severity.
‘When they just keep going in and in all the
time and moving it around, that’s the part that
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hurts the most … but they don’t take notice of
that, it’s not their arm.’
Interview 4
‘That was really, really sore, because she kept
poking at the same place and I was sort of
imagining it poking through the vein again and
that, and she just kept, push, push, pushing.’
Interview 8
Patients also had preferences related to speed of the insertion
process. Five patients felt that a slower, careful insertion would
decrease pain intensity and reduce the risk of vein damage. This
view was predominantly held by patients receiving ongoing
treatment over a number of hospital admissions.
‘They don’t go in slowly, they actually just get
there and go bang and that kills, it really does. It
hurts like crazy. If they do it slowly and properly
like that, people won’t complain.’
Interview 4
‘Maybe they need to take a little more time to
make sure they’ve got the—the vein tapped out
correctly.’
Interview 1
In contrast, three patients indicated positive experiences
associated with faster insertions, although this was typically
expressed by those who had experienced a ‘first attempt’
successfully inserted PVC.
‘He could just go straight through with it, it’s
done in seconds.’
Interview 3
‘You know, you—you’d just as soon have it fixed
and done—done once and not fooling around
with it, yeah.’
Interview 2
Theme 3: competence of the inserter
In 6 of the 10 interviews, patients associated better PVC
insertion experiences with those they perceived to be more
confident or experienced clinicians.
‘She clearly knew what she was doing. You could
tell by the body language.’
Interview 9
In contrast, less experienced inserters were linked to poorer
patient experiences.
‘Well, I was a bit—bit nervous when this new
nurse, first time she’s ever done it’.
Interview 2
Participant 9 went so far as to explain the qualities she
associated with confidence:
‘A person who in my mind is competent has
minimal movement, the movement is very
focused and the concentration is very intense
and the speed at which the procedure is
delivered is very rapid.’
Interview 9
Confidence and success of insertion were often linked with
professionals who inserted PVCs regularly as part of their day-
to-day practice.
‘Every time I’ve had it put in in the ER with one
of the nurses, it’s—you never really feel it. They’re
quick. They do ’em all—you know, so many
of them a day. Um, generally, if it’s a doctor or
someone, they tend to hurt a bit more and fidget
more to find a vein I guess, once they’re in.’
Interview 6
Participants were typically aware of the inserter’s profession
and indicated either relief or dismay based on this knowledge.
While some participants felt secure with a doctor inserting the
device, others preferred nurse inserters. This was usually related
to previous experiences and prior perceptions of the health
professionals’ training, expertise and confidence.
‘I felt a bit more secure with the doctor doing it
naturally.’
Interview 2
‘Oh, the doctors are useless … the doctors
are—I don’t think they want to do it and it’s
always better to get a nurse, because some
nurses do a lot, a lot of them. You know, doctor
doesn’t do very many of them anyway.’
Interview 7
Theme 4: location of the device
Despite the study interview questions relating only to the
insertion procedure, 8 of the 10 patients frequently referred
to PVC experiences occurring after the insertion procedure. It
emerged that these patients were constantly aware of the device
placement and found it had an ongoing negative impact on
their daily activities and sleeping habits. Patients with devices
inserted in either the antecubital fossa or in the hand reported
that they could not bend their arms, or had to be vigilant to
avoid the risk of the device or its tubing ‘catching’ on their
surroundings. In some cases, patients reported intermittent or
continuous pain at the PVC insertion site.
One of the primary concerns that emerged from the
interviews was the impact that device blockage had upon
activities of daily living. Some 3 of the 10 patients reported
losing significant sleep time due to blocked devices and the
subsequent alarming of infusion machines.
‘I swear it knows when I’m rolling over to go
to sleep, that’s why I’m so buggered [sic] in the
day, because I can’t keep my eyes open.’
Interview 3 (PVC location: antecubital fossa)
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‘I would, I would, I would ask them if they
could try and not do it right in the crook of my
arm, because as I say it’s—it’s—it’s—it’s ah, so
inconvenient. Because I’m—I’m a light sleeper
and um, you know you—I move and then the
thing goes off and then you’re awake and I find it
hard to get back to sleep and, you know et cetera.’
Interview 2 (PVC location: antecubital fossa)
Three patients interviewed stated they felt pain from the
PVC insertion site for the entire time while the device was
in place. In some cases, the pain reported after insertion was
worse than the insertion procedure.
‘It was in there for a little bit, it hurt the whole
time it was in there though.’
Interview 10 (PVC location: hand)
‘When they put it in the wrong place, that’s a—
that’s an ache and it really, really hurts, and it
builds.’
Interview 1 (PVC location: unidentified)
While some participants found that the device did not cause
them any inconvenience, others were constantly aware of the
device location.
‘But—I don’t know, at least—by having it there,
you’re aware of it more. If it’s further up the
arm, you tend to forget it’s there, whereas there
it’s a constant reminder. So you tend to be more
careful.’
Interview 9 (PVC location: hand)
‘Yeah, and that’s the worse place there, it really
is, and it always seems to get caught on things
too. You know, like your jackets or your pyjamas
or something, always pulling and that.’
Interview 8 (PVC location: forearm)
In summary, the findings of this study can be grouped into
four key themes of the patients’ lived experience of PVC
insertion and, to some extent, post-insertion experiences. These
are presented in Figure 1. The results indicated that patients
identified links between these themes. Location of the device
and technique of device insertion could, in many cases, have
been informed by better communication between the patient
and the inserter. Similarly, patients reported having better
experiences with competent, experienced inserters who inserted
the devices into the forearm veins, rather than other locations.
Discussion
The aim of the study was to explore the lived experience of
patients having a PVC inserted. This was met using qualitative
methodology, which allowed an exploration of this phenomenon
to create real understanding. While four themes emerged from
these findings, the overarching understanding gained was that
it is not the device itself that is of greatest concern to patients,
rather it is the inserter, specifically their communication
skills, competence and choice of insertion site. Patients need
to feel there is responsive and trusting communication with
the clinician; they want the inserter to have a technique that
reduces severity of pain/discomfort; they want to know that
the inserting clinician has adequate experience; and they need
the device inserted in a position where it will not be a burden.
Perhaps not surprisingly, there was a greater representation of
negative or neutral experiences than positive experiences. This
does not necessarily reflect that all PVC insertions are negative;
rather it may be that patients did not create as much meaning
from an experience if it was uneventful.
Communication and trust between the clinician and the
patient was found to be associated with the most significant and
negative patient experiences surrounding the PVC insertion
process. Patients preferred to be warned appropriately of what
to expect during insertion, even if they were told to expect
something negative. Some patients also felt that they could
have improved the insertion process if they had been listened
to by the inserting clinician, particularly in relation to the
location of the device. This was a key similarity identified with
the qualitative study by Robinson-Reilly et al (2016), which
explored PVC insertion experiences of patients in rural oncology
units. The theme ‘suggestions for improvement’ included a
recommendation for improved rapport between patient and
clinician (Robinson-Reilly et al, 2016). For clinicians to further
increase the role of the patient in PVC insertion, care and
maintenance, it is essential that the patient experience of PVC
insertion is first understood and valued.
In addition to not feeling included or their prior experience
being respected, patients felt ‘blamed’ for challenges with PVC
insertion and maintenance. This finding was also supported
by Robinson-Reilly et al (2016), who found that 13 of 15
interviewed participants had been told that they had ‘bad’ or
‘difficult’ veins. Ideally, if open and positive communication
is used, clinicians would trust patients’ advice about likely
procedural difficulty, and decide if their skill or confidence
is adequate. Regardless of the patient’s individual vasculature,
clinicians should be moving away from the fault placed on
patients (‘you have bad veins’) and look to solutions such as
referral/consultation with a more competent inserter. Most
patients agreed that regular practice was likely to lead to a better Figure 1. Correlations between themes
Patient
experience
Competence of
the inserter
Communication
between the patient
and the inserter
Location of
the device
Technique of
device insertion
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insertion experience. This belief is supported by Carr et al (2010)
who found that frequency of PVC insertion procedures directly
linked with confidence (Carr et al, 2010), which in turn is likely
to positively impact upon insertion success (Rippey et al, 2016).
Finally, participants with devices inserted in the antecubital
fossa or the hand reported a range of negative experiences
related to increased pain during insertion, and adverse impacts
upon sleep and other daily activities. Previous research has
found that PVCs inserted in the hand and antecubital fossa are
more likely to fail by both mechanical (e.g. dislodgement) and
occlusion/infiltration modes (Wallis et al, 2014). Considering
that patients also have poorer lived experiences related to these
sites, it is important that clinicians avoid these sites if possible.
Patient satisfaction is of increasing importance to healthcare
organisations. Positive patient experiences of PVC insertion
may improve the perception of care provision.
Limitations
This study was conducted using qualitative methodology,
which is valuable in developing understanding rather than
knowledge. While saturation of four key themes was gained
from the included participants, there may be other themes
yet to be explored which were not recounted by any of the
included patients, due to the included sample. It is therefore not
possible to generalise the findings of this study to all patients
receiving PVCs. The study was, however, conducted using a
robust qualitative methodology and does shed light on key issues
which clinicians may recognise in their own practice settings.
The onus lies on future researchers to conduct studies into how
professionals may understand and improve the phenomenon
of the lived experience of PVC insertion.
Conclusion
In summary, there is a clear need for improved communication,
insertion technique and device location choice during PVC
insertions. While the PVC insertion process is an invasive
procedure and therefore inherently inclined to cause pain, health
professionals must still endeavour to explore the most effective
techniques to minimise pain and discomfort for patients. BJN
Declaration of interest: none
Acknowledgements: the authors would like to acknowledge the
support of the participants and staff of the Royal Brisbane and
Women’s Hospital
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KEY POINTS
■ Patients want an experienced peripheral venous catheter (PVC) inserter
who listens to them
■ Communication failures and a perceived mistrust of patients’ own
knowledge result in frustration and increased discomfort from repeated
insertion attempts
■ Patients can clearly identify nurses/other clinicians who are confident and
competent PVC inserters
■ Forearm-inserted PVCs result in better patient experiences
CPD reflective questions
■ Should you incorporate patient preferences and decision-making when inserting a PVC?
■ Do you feel confident in the process of inserting PVCs and would this confidence be evident to your patients?
■ Do you know your hospital’s policy relating to escalation following repeated failed attempts at PVC insertion?
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ORIGINAL ARTICLE
Patient readmission for orthopaedic surgical site infection: an
hermeneutic phenomenological approach
Lilian Machado Torres, Ruth Natalia Teresa Turrini and Miriam Aparecida Barbosa Merighi
Aim and objective. To explore the individual experience of being readmitted for
surgical site infection resulting from orthopaedic surgery.
Background. Surgical site infection has been a cause of concern worldwide and con-
tributes to the greatest number of hospital readmission occurrences. Health profes-
sionals must understand the meaning of these readmissions for the individual, as an
understanding of these exclusive experiences improves the quality of surgical care.
Design. Qualitative research based on the existential phenomenology of Martin
Heidegger.
Method. Eleven individuals who were readmitted because of surgical site infec-
tion participated in the study. The testimonials were obtained over an 11-month
period in 2014–2015 based on the following leading question: What has it been
like for you to be readmitted because of orthopaedic surgical site infection? The
phenomenological analysis identified the sentiment units of the testimonials and
their interrelation, revealing the meanings.
Results. The revealed contents were fear and insecurity of the unknown, frustra-
tion, and the sense of time passing them by and being unable to live their lives.
The individuals felt neglected, and they experienced their social relationality as
impaired and sometimes approaching a breakdown. The patients connected with
God as an attempt to avoid complications and death.
Conclusion. We urge healthcare professionals to deepen their knowledge of the
dimensions of care by developing competencies that consider the subjectivity of
experiences of the health–disease process. When the only listening that takes place
is qualified listening, the professional’s attitudes compromise his or her ability to
provide true care, which transcends the knowledge of doing and reaches the
knowledge of doing with sensitivity.
Relevance to clinical practice. Nursing care requires an attitude that considers the
patient as more than a carrier of illness and should not be limited to what is
described and prescribed, although the latter cannot be excluded in an organisa-
tional point of view.
What does this paper contribute
to the wider global clinical
community?
• Professionals should develop com-
petencies for searching for what is
not shown in terms of patients’
experiences with the health–disease
process. Such competencies tran-
scend ‘knowing how to do’ to
achieve ‘knowing how to do with
sensitivity’.
• Permanent pedagogic and educa-
tion projects should contemplate
subjectivity, even in a transversal
fashion through other disciplines,
and depart from the biomedical
model that focuses solely on the
disease. Disciplines that include a
philosophical component in
healthcare training, especially a
Heideggerian approach, will help
to develop professionals with
empathy, that is, those who in
addition to looking and hearing
will be able to see and listen,
allowing patients to be themselves
in their singularity and plenitude.
• The need to conduct investigations
that highlight the perspectives of
the individual is emphasised. Such
an approach will contribute to a
better understanding of individual
needs and consequently improve
the quality of care.
Authors: Lilian Machado Torres, PhD, RN, Assistant Professor, Med-
ical Sciences Faculty, School of Nursing, Belo Horizonte, MG; Ruth
Natalia Teresa Turrini, PhD, RN, Associate Professor, Department of
Medical-Surgical Nursing, School of Nursing, University of S~ao
Paulo, S~ao Paulo, SP; Miriam Aparecida Barbosa Merighi, PhD, RN,
Full Professor, Department of Maternal, Children and Psychiatric,
School of Nursing, University of S~ao Paulo, S~ao Paulo, SP, Brazil
Correspondence: Lilian Machado Torres, Assistant Professor, Med-
ical Sciences Faculty, School of Nursing, Al. Ezequiel Dias, 275,
Centro, CEP 30, 130-110 Belo Horizonte, MG, Brazil. Telephone:
+(55)(31)999710806.
E-mail: lilian.torres@superig.com.br
© 2017 John Wiley & Sons Ltd
Journal of Clinical Nursing, 26, 1011–1020, doi: 10.1111/jocn.13719 1011
Key words: infection control, nursing, patients’ experience, phenomenology, sur-
gical nursing
Accepted for publication: 25 December 2016
Introduction
Healthcare-associated infections are considered a public
health problem, and they drive institutions to undertake effec-
tive measures for prevention and control (Giroti & Garan-
hami 2015). One of the locations with the highest incidence of
infections is the surgical site (Despaigne Alba et al. 2013); in
Brazil, the incidence of surgical site infection (SSIs) is 14–16%
according to the National Health Surveillance Agency (2009).
Factors contributing to the occurrence of SSIs are
grouped into intrinsic or related to individuals, such as
comorbidities, and extrinsic, or modifiable factors, includ-
ing surgical techniques, preparation of the patient’s skin
and surgical time (Harrop et al. 2012).
In orthopaedics, the majority of SSIs are associated with
the use of implants, and some studies have raised the possi-
bility of a progressive increase in the incidence of such
occurrences (Contreras & Sep�ulveda 2014). SSIs are severe
complications with economic, clinical and social impacts
(Campoccia et al. 2013), and its incidence has revealed
rates that have been rapidly increasing annually (Gutowski
et al. 2016). They almost always indicate a failure in the
treatment (Roman�o et al. 2013) that leads to readmission
of the individual with SSI.
A study on a series of 10,158 patients undergoing ortho-
paedic surgery revealed that 2�2% of them returned to the
hospital for reasons directly related to the first surgical proce-
dure, and among them, 21�4% for SSIs (Pujol et al.
2015).
Considering the data presented for the orthopaedic spe-
cialty, readmissions by SSI were considered a quality mea-
sure in research that analysed individuals with a higher
probability of readmissions after 6414 primary total hip
arthroplasties between 2006–2010 (Saucedo et al. 2014).
However, readmissions for SSI that result in new surgeries
are underestimated, and the majority of cases are pre-
ventable, being a relevant indicator in assessing quality of
care and associated risk management (Pujol et al. 2015).
Background
Despite the limited attention dedicated to hospital readmis-
sions (Kirby et al. 2010), a study on possible associated fac-
tors pointed to infection as the main cause of readmission
after six different procedures. Specifically, in cases of knee
and hip arthroplasty, SSI was the main reason for readmis-
sion (18�8%) (Merkow et al. 2015).
In terms of global impacts, SSIs are considered a burden
for healthcare systems because of the associated morbidity,
mortality (Leaper et al. 2013) and its relatively high cost
(Gutowski et al. 2016). Readmissions due to SSIs cost more
than double when compared to readmissions due to other
reasons, such as mechanical failure (Gutowski et al. 2016).
The measures to prevent SSI are well established, and
professionals should know and implement them while pro-
viding health care (Harrop et al. 2012). Specific protocols
for orthopaedic units include actions regarding internal pro-
cedures and strategies for epidemiological surveillance
(R~autia & Nemet 2015).
However, a literature review on the characteristics of
studies that addressed readmissions for SSI after orthopae-
dic surgeries did not find studies that assessed the repercus-
sions for affected individuals (Torres et al. 2015). Pujol
et al. (2015) highlight the importance of investigating revi-
sion surgery and its consequences at the global level.
From the individual’s perspective, being in the hospital
represents a major disruption in their routine (Santos &
Carlo 2013), even with scientific and technological
advances in health recovery (Sanches et al. 2013). In this
context, the associated physical frailty and emotional vul-
nerability are potentialised as a problem that the individual
must experience in the presence of strangers.
For example, few studies have demonstrated experiences
related to being in a hospital due to SSI, regardless of being
the first hospitalisation in people’s lives or subsequent
occurrences. However, admissions or readmissions are
unique experiences that do not repeat in the same manner.
The results of a qualitative study that analysed 14 testimo-
nials from individuals who developed SSI detected signifi-
cant pain, isolation, insecurity and negative economic,
social, physical and emotional impacts, some of which were
long-standing (Andersson et al. 2010). Seventeen patients
who underwent surgery in three hospitals in the United
Kingdom reported experience of despair and a desire to die
when describing how SSI affected their lives and the lives
of their family members (Tanner et al. 2013).
Considering this as a research gap, this study aimed to
explore the experiences of individuals subjected to ortho-
paedic surgical procedures who were readmitted because of
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SSI based on the following questions: What is it like to be
readmitted for SSI? How is the readmission for SSI under-
stood from the personal, family and work perspective?
What personal and social effects related to readmission for
SSI does the individual experience?
At the international level, it is relevant for integral care
policies to consider this history dimension in efforts to
improve the quality of care. Such an expansion with a focus
on the provision of care that directs healthcare provision
and education and that considers the need to invest in the
permanent development of nurses in various contexts and
specialties is encouraged.
The study
Aim
To explore the individual experience of being readmitted
for SSI resulting from orthopaedic surgery.
Design
Qualitative research with a phenomenological focus based
on Martin Heidegger’s theoretical framework. This frame-
work has shown to be consistent with and adequate for
nursing research because of its humanistic principles and
study domains, which involve the theory and practice of
care as an attempt to understand how phenomena impact
the health of individuals, their families and the community
(Paula et al. 2012).
A phenomenon, according to Heidegger (2011), must be
understood as something that manifests in itself and that
constitutes one’s way of being; thus, it is understood as an
encounter and not as an outward projection. First, this
understanding is achieved through the factual dimension,
which in our case relates to the testimonials themselves.
Next, it involves hermeneutics, which through interpreting
and seeking meanings reveals the uncovered, which emerges
as a phenomenon (Paula et al. 2012). Heidegger’s
hermeneutics is a method of interpreting reality that leads
to comprehension (Almeida 2014). Using this process,
understanding the human being who experiences a readmis-
sion for SSI after being subjected to an orthopaedic surgical
procedure becomes a practice of care. Because humans are
not detachable from the world (Roehe & Dutra 2014),
experience affects the relationality between this individual
and the surrounding readmission environment. The method-
ology of this study enabled an understanding of the study’s
subject: the readmission for SSI after an orthopaedic surgi-
cal procedure, from a subjective point of view.
Participants
The study included 11 individuals who underwent ortho-
paedic surgery in a Brazilian public hospital and were read-
mitted for SSI during an 11-month period in 2014–2015.
The following inclusion criteria were used: individuals older
than 18 years of age who returned to the hospital with an
indication for readmission because of SSI and who under-
went their first surgical intervention at the same institution.
The starting point for subject selection was the SSI report
from the Hospital Infection Control Committee, which fol-
lows the international criteria of the National Healthcare
Safety Network (NHSN) (2013). In this health institution,
there are no data on readmission for any cause. Data on
the first admission, surgical intervention, SSI and readmis-
sion were verified by the researcher in the hospital informa-
tion system. After the SSI diagnosis and the fulfilment of
the readmission criteria for SSI were confirmed, the individ-
ual was contacted at the admission unit for the necessary
introductions and the first contact related to the study.
Those who agreed to participate received a consent form,
which contained authorisation for audio-recording and
described the study motivation, objectives and procedures.
After the consent document was signed, individual meetings
to record testimonials were scheduled; the meetings took
place at the participant’s bedside. Only the researcher and
the participant were present at the meetings. The study par-
ticipants were identified with the letter ‘P’ followed by a
personal identification number. The number of interviewees
was not established prior to the study, and the collection of
statements was closed when theoretical data saturation
occurred, or when the interaction between participant and
researcher no longer provided elements to sustain or deepen
theorising of the subject (Fontanella et al. 2011). This crite-
rion was evaluated by the researchers as a group.
Data collection
The data were collected through face-to-face nonstructured
interviews conducted by the first author, who is a nurse
with previous experience in surgical centres and with infec-
tion control. A total of 12 interviews were conducted, and
the interviews were not repeated. However, one interview
was discarded because the interviewee withdrew consent
and did not present the reasons why they made this deci-
sion. To reveal the phenomenon of readmission for SSI
from a perspective congruent with the methodological
choice of Existential Phenomenology, the following guiding
question was used: What is it like for you to be readmitted
because of an infection in your surgery site? The question
© 2017 John Wiley & Sons Ltd
Journal of Clinical Nursing, 26, 1011–1020 1013
Original article Patient readmission for surgical site infection
was tested with two individuals to assess its pertinence, and
the testimonials were stored exclusively through recordings.
The question should enable a favourable environment for
intensifying the participant’s verbalisation during the testi-
monial and encouraging the experiential description of the
phenomenon so that meanings are expressed (Paula et al.
2014). The duration of the meetings varied from 30–
45 minutes and respected the participant’s desire for
expression related to the topic. After each testimonial, we
transcribed the interviews without returning to the partici-
pants. We then engaged in repetitive reading of the tran-
scripts to consider the situations that the participant’s
experienced from multiple angles. The interviews were orig-
inally conducted in Portuguese with Brazilian respondents.
The responses were then translated into English by a pro-
fessional translation service.
Ethical considerations
The study complied with the ethical principles of human
subject research and was approved by the Research Ethics
Committee of the School of Nursing of the University of
S~ao Paulo, Brazil, and the coparticipating institution (Dr.
Luisane Maria Falci Vieira – Protocol number 527.293).
Among the fundamental ethical aspects, we emphasise that
there was nondiscrimination in the selection of the partici-
pants, who were not exposed to risks other than discomfort
arising from verbalising their experiences, impressions and
desires, and that the privacy and confidentiality of the testi-
monials were ensured. The interviewed individuals did not
show or express such discomfort.
Data analysis
For the organisation and analysis of the meanings contained
in the testimonials, we sought to identify the units of meaning
that were most significant to the participants and aim of the
study. This methodology, recommended by a Brazilian
researcher who supports a rigorous delimitation of the study
theme, facilitates a deep analysis of the meaning of expres-
sions (Josgrilberg 2000). Units of meaning are expressions or
phrases that contain a meaning related to the experiences
specific to individuals who are readmitted because of SSI. The
careful reading of each interview enabled the extraction of
units of meaning that were grouped with the units of meaning
from other testimonials. Thematic categories were derived
from the interrelation of the units, linking the meanings that
the individuals revealed. A phenomenological analysis based
on Martin Heidegger’s framework revealed what was latent
or concealed in the experiences.
Rigour
The methodological rigour included the systematic collec-
tion of data from the institutional reports and systems; the
respect for the participants’ privacy during the interviews,
which were conducted exclusively by one of the researchers;
the verbatim transcriptions of the testimonials; the identifi-
cation of the units of meaning; and the categorisation of
the discovered meanings. In qualitative research, it is neces-
sary to pay attention to the delimitation of the study object,
research issues, strategies and attitudes during data collec-
tion and to the choices made during data organisation,
analysis and propositions. Empathy, understood as the abil-
ity to feel what it would be like to be in another person’s
situation and circumstance, is also essential for creating an
environment favourable to intensifying the experiential
description of the study object and encouraging the expres-
sion of meanings (Paula et al. 2014).
Results
The 11 participants included six men and five women with an
average age of 54 years. Five were retired, two were unem-
ployed, and four were formally employed. Eight were mar-
ried, two were single, and one was a widow. During the
reading of all of the testimonials, the units of meaning were
highlighted and grouped according to the following thematic
categories, which revealed the readmission phenomenon
essence: Experiencing insecurity and fear, experiencing frustra-
tion, perceiving that time is passing you by, impaired social
relationships, experienced neglect and attachment to God.
Experiencing insecurity and fear
Insecurity is embodied in statements about not knowing
what could happen:
I went back to the emergency room and the doctor said: “Oh!
Things got complicated.” A whole world goes through your mind.
The doctor said that the infection is subsiding, but it is hard to
believe. You do not see it. It gives you a certain fear about what
might happen. (P8)
I was afraid of everything but mostly of losing my leg. . .. I do not
want to talk anymore. I am sorry, but it bothers me a lot because I
am still afraid. (P6)
Not knowing about the future is reflected as uncertainty
about what could still happen:
What can still happen to me? I do not know. It seems that it’s get-
ting better, but I am even afraid to look and see if it really is. (P9)
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1014 Journal of Clinical Nursing, 26, 1011–1020
LM Torres et al.
It is like reexperiencing something that I did not know about the
first time. It is a feeling of not knowing what to do. I’m apprehen-
sive. . . let’s see what will happen. (P4)
The absence of experts or medical specialties in all care
settings when health care is needed causes insecurity:
I had to come to a larger center. I am afraid of going my town,
getting there and not finding resources. Will the doctors be able to
get rid of this infection that is stuck in my bone?
(P1)
Frustrations arise in relation to the (im)possibilities that
the participants envision and are associated with the way
they perceive the care provided.
Experiencing frustration
Experiencing the readmission process for SSI results in frus-
tration, grief and fatigue, and the participants associate it
with suffer
ing:
I have never imagined having to go back: doctor, hospital, we want
distance from everything that can mean pain. One imagines that
the hospital means pain, death, and suffering. (P9)
I was feeling fatigued when it started all over again: being admitted
again, suffering again, always hoping to get better. (P3)
Frustration appears in response to SSI and readmission
and to the time spent on something unexpected:
The word that sums up what we are feeling after 10 months in the
hospital is frustration with always being hospitalized. This going to
and coming from hospitals. . . the frustration continues. Perhaps
because of the delay in getting here, the lack of concrete answers,
and what is more frustrating is that those who live in the country
are at the mercy of anything; in my case, “anything” did not solve
the problem. (P1)
Time appears in different ways in the reports. Although
it is always verbalised in chronological order (days, weeks,
months), it is associated with its individual and familiar
meaning.
Perceiving that time is passing one by
The temporal or chronologic dimension has various
angles among the interviewees, but it is always associated
with what is lost in life, with what is not being carried
out:
Only at the end, the doctor said that it would be about six weeks.
Oh! Six weeks is not six days. I’ve been here for three months, and
nobody tells me how much longer I will stay. (P9)
The professionals collect material for tests. They have already dis-
continued the antibiotic for 10 days. And I am still here for two
months. . . Do you know what this is? (P3)
The information about days and weeks does not have the
same connotation for the affected individuals that it has for
health professionals:
The doctor says it is simple, just a little infection, a few more days
and it will be resolved. But when you are admitted for this reason
and time passes by. . . (P11)
I don’t know what to say because it was a month that disap-
peared from my mind. I don’t know what to say about this time
period, and I am here with no perspective of when I will leave.
(P1)
Some of the interviewees live far away from the admit-
ting institution, which evokes experiences such as missing
family members and home and a preoccupation with their
routine activities.
Impaired social relationships
In the reports, it was clear that the hospital is not like
home for the participants. They have wistful memories of
the people, spaces and situations of their daily lives and
expressed as experiencing isolation:
This is not our home. I keep remembering my city, family,
friends. . . I miss the folks a lot. (P2)
You would like to be in your own home, with your family. This is
not my home. I would like to be lying down on my bed, receiving
visitors with my mom’s coffee, which is really good, strong, and
sweet. You know that family never leaves my mind? (P10)
There is a certain discomfort among interviewees when
they perceive that they are a burden to their family mem-
bers and are altering family dynamics:
Our absence is a sacrifice for our children. Being here complicates
things for everyone. (P7)
Now, being here again. . .I wonder about the house, the people,
how they organize things, food, clothes. You cannot focus on here
or there. (P8)
Affective life is also impaired, and the participants ver-
balised the fear of disruptions in their relationships with
their spouse and children:
I worry whether I will be able to ride a bicycle again. My girlfriend
comes here now because I am hospitalized. We are not seeing each
other much. (P10)
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The questions I ask are not the same ones my son asks me. The
same way I wanted to have him around, he also wanted me over
there. There is no way you can stop thinking about the children,
about the family. . . (P1)
Social issues and work activities also stood out in the
interviewee statements:
I hope to get out of this situation because I think I am still young,
I love life, I really want to enjoy life, I love to dance, walk,
travel. . . (cried). (P4)
Because I am a school teacher, I had many activities, and today
there are seven families being fed because seven people substituted
for me. That is good, because I must be very good at what I do.
(P1)
There were also obvious issues related to experiences
about the care (or lack of care) they received.
Experienced neglect
Experiences of the quality of care and the divergent
responses of professionals or institutions to the individual
or his/her family caused great disappointment and are
defined by a large gap between the care and what is actu-
ally experienced:
The doctor discharged me twice with generalized infection. . . it
was the worst part of the treatment. This coming and going was
because of a medical error and left me extremely disappointed. My
foot became crooked, the implant was removed, and the doctor
discharged me with septicemia. (P1)
I was operated on again after three days in the emergency room.
My surgery was because of a bad job by a doctor who should not
be a doctor, should choose another profession. (P6)
The participants also evaluate the healthcare system in
relation to the quality of the service provided. There is a
general belief that one cannot expect much from the public
service, reinforcing the experience of disappointment and
neglect:
How many hospitals will I need to go to for an answer? All they
have done is push me from one place to another. Rarely in the
public health care network can you find a good infectious disease
specialist, and when you do, they are scarce and expensive. (P1)
Complaints surface that the professionals do not
acknowledge the patients’ symptoms:
I become outraged. I went to the doctor who operated on me
and he said, “It is a problem with the muscles”. A kind of tor-
ture. I went back several times, would get an x-ray, a test, and
would tell myself, “there is something wrong”. . . and now, I am
like this. (P4)
It creates the feeling that everything went wrong when the doctor
examines you and says “It is simple, just a small infection; a few
more days and everything will be resolved”. (P11)
The distrust regarding the care being provided leads indi-
viduals to question the treatment or instructions – even as
they related to taking antibiotics, for example:
A “drain” was going to be placed, but it took too long, and I
asked, “Aren’t you putting in the drain?” I waited so it wouldn’t
become too swollen. The doctor said, “We won’t put it in.” I
waited, disoriented. And confusion grows in your mind. (P3)
I was counting the 14 days of antibiotics, but the doctor said,
“You don’t need to count; we are counting.” But I counted any-
way. (P5)
Finally, the religiosity demonstrated in the next category
expresses the participants’ faith in a superior being that sees
everything and decides.
Attachment to God
Faith in God is related to healing and the possibility of
going home. It includes the consideration that everything
happens according to divine will, including the SSI:
Deep inside, I wait for God. He knows what He does; what is sup-
posed to be will be. God will be around. (P11)
Everybody says it will improve, and we are waiting because this is
what everybody wants. To leave cured. In fact, I wanted this since
the first time. . .. I believe in God, and He wanted me to come
back. (P9)
There is hope that God will lead the treatment and labo-
ratory tests, will intervene in the results and will enlighten
professionals so that drugs will work to cure the SSI that
caused the readmission and prevent the patient from leav-
ing:
With faith in God, it won’t be long before I leave. I ask God for
the strength to get treatment and get out of this situation. I came
with the certainty that under God, I would be cured. (P2)
There are still two weeks to finish the antibiotics. I do not know if
I will be able to go then, but God willing, everything will be all
right. (P7)
I hope from the bottom of my soul that I will get out of here
cured! God is good! I very much hope and pray to God to
enlighten the doctors, get my treatment right. I want to leave! (P8)
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LM Torres et al.
Some doubts and issues are dissipated because of faith
and hope in a God who has the power to define, decide,
resolve and ultimately to cure:
Oh my God, how is it going to be? I thought I was going to die,
but I thought, “God is the only one who can decide,” and I was
thinking of God, waiting for God. I have faith! (P3)
Actually, I do not know if I am going for surgery again. The doctor
told me that he would check if the medication is working. I have
faith that I will be healed. (P5)
Finally, readmission for SSI is associated with the possi-
bility of death. Although there is a divine plan, the partici-
pants have hope and faith that they will survive:
There was a man in the other room who died of infection. I think
it is not my case, but God is with me, and it will not happen. (P8)
Everything will be all right. Hope and faith in God are what make
us endure the wait. Even death comes only when God wishes,
right? (P5)
These ontological unifications revealed the sense behind
their readmission for SSI, according to the patient perspec-
tive.
Discussion
SSI concretises the readmission that again brings the indi-
vidual in contact with health professionals in the hospital
environment. These individuals feel fear and insecurity
because they have already faced a similar situation.
The testimonials point to fear in the sense of the possibil-
ity of being in danger of death, sequelae, or reduced mobil-
ity or independence. Studies on direct and indirect impacts
of SSI in orthopaedic surgery, or only related to recovery
have shown that individuals anticipate a threat to their
ability to participate in routine activities or the need to
adapt after orthopaedic surgeries (Rodrigues et al. 2012,
Nagai et al. 2014). Fear implies perceiving what will or
may happen through concrete means (Heidegger 2011).
Health professionals identify fear but do not sufficiently
value it. In the absence of such reflection, the fear reflects
the conception of the one who cares rather than one who is
cared for. Consequently, the patient does not have the
opportunity to talk about what he/she feels and to have the
professional listen what is said, understand its meaning and
translate it back, and an opportunity is lost for care provi-
ders to amplify their ability to understand the experience of
readmission due to SSI.
Those issues add to patients’ frustration with healthcare
professionals and their competence and with the perceived
poor quality of healthcare institutions. A Romanian study
that assessed patient satisfaction on SSI associated with
health care in an orthopaedic unit found that care providers
should be concerned with providing clear and objective
information because it directly influences patients’ percep-
tions regarding the health professionals and the healthcare
institution (R~autia & Nemet 2015). An understanding of
the course of the disease and of the received care minimises
patient frustration about what happened during the read-
mission. Heidegger (2011) shows that in the absence of a
service with desired quality, there is a gap, and what is
pending in the healthcare provision is not available.
Readmission status removes the opportunity for individu-
als to follow and participate in their own care. Heidegger
(2011) shows that there is the desire for something that is
already understood, a role in determining the way individu-
als would like to be cared for. Frustration arises from a
possibility-of-being, which readmission patients perceive as
different from what they actually experience.
The illness experience is unique and individual. Such an
understanding constitutes a conceptual richness that needs
to be internalised by nurses (Queiroz 2015) so that they
can better attend to care demands.
The true sense of care presupposes a communication pro-
cess that enables the individual to participate in the interlocu-
tion in a context that follows them and that is not complete
without them. Welcoming, care and attention are competen-
cies that need to be developed and, from the patient’s perspec-
tive, are based on an intersubjective relationship that respects
and considers the individual, sharing decisions and listening to
reports that demand to be listened to. According to Heidegger
(2011), what comprises an individual’s being only makes
sense when, within the self, the individual becomes under-
standable from the perspective of being.
One of the issues that justify the improvement of care is
the prolonged time of orthopaedic treatments, which
imposes a financial burden on the individual and on health-
care institutions (Rodrigues et al. 2012, Kapadia et al.
2014). American and European studies reported that SSIs
in general require readmissions, long recoveries, the
increased use of antimicrobials and increased lengths of
stay (Harrop et al. 2012, Zimmerli & Moser 2012, Nacke
et al. 2013). However, this chronological time has different
meanings for the professionals and the readmitted individu-
als. The former quantify time without considering its mean-
ing for those who are no longer able to live how and where
they used to.
The participants perceive time passing them by and
removing from them the possibility of being. They describe
and identify spaces in their homes, scents and the activities
© 2017 John Wiley & Sons Ltd
Journal of Clinical Nursing, 26, 1011–1020 1017
Original article Patient readmission for surgical site infection
of family members; to those who listen and look for what
is hidden, such comments point to an ‘existence that disap-
pears’ because they are readmitted. These memories and
references comfort those who need to feel that they belong
and are sheltered; they become a form of living ‘what can-
not be lived’ during readmission and are relevant to an
understanding of the experience of individuals who remain
in hospitals for months.
Given the threat of disruption, patients need to have their
absence recognised because their readmission leaves an
unoccupied space. In Heidegger (2011), to occupy a place
is being in this place, and the desire to be close to others
may be understood as being where humans are never only
in themselves, but relating with others and with things.
Surgical procedures must be followed, but a gesture or a
look beyond what can be seen and the sharing of care
allows the individual to realise that their care provider can
give meaning to what they cannot verbalise. Allowing
patients to participate requires nurses to judicially evaluate
the risks and benefits of each situation (Tobiano et al.
2015).
When readmitted patients perceive that they are not wel-
come to participate in the construction of an intersubjectiv-
ity that respects and considers their suffering (2015,
Queiroz 2015), they experience neglect from the healthcare
institutions, which minimise their history and complaints
and demand additional time for treatment, which means
less time for the patient to live his or her life. The construc-
tion of a dialogue in a relationship requires listening
because it allows speaking.
Patients know how they feel and how they are treated,
regardless of their technical ability to evaluate the health-
care service (R~autia & Nemet 2015). Health care, specifi-
cally of physicians and nurses, shows paths that allow
patients facing readmission the necessary autonomy for
self-care. Heidegger (2011) defines authentic care as care
that establishes a bond between the one who provides care
and the one who is cared for. Configuration of the care
provided is based on reliability and in the expectation of
the responses required from the understanding of those
involved (Graham et al. 2015).
Confronted with these experiences, the readmitted indi-
vidual connects to religion and spirituality in the light of
the inevitable: the SSI that led to the readmission. Reflec-
tion on the relationship between humanity and God has
various aspects: proximity, following and divine blessing,
including salvation of the soul in the case that death, which
is always present, prevails.
To identify the role of spirituality in the context of an ill-
ness with some risk of death, Yong et al. (2015) analysed
their results according to the phenomenological view; they
verified that spiritual beliefs gave seriously ill individuals a
greater sense of purpose, which helped them make neces-
sary adjustments. Despite this, there is a need for studies
that clarify its influence in health and its mechanisms of
action (Reinert & Koenig 2013).
The testimonials contributed to an understanding that
the work of professionals, especially nurses, should not be
limited to what is described and recommended. It is impor-
tant for nurses in infection prevention control too. The
experiences of readmitted individuals included the most
intimate and subjective aspects of their current way of
being: the desire to have their feelings recognised, to have
time to live during readmission, to feel like they are wel-
come, to be working towards autonomy and to be able to
organise their relationships with themselves, with others,
and with their spirituality.
Limitations
The study was conducted at a single healthcare institution
with a sample of subjects that was relatively small,
although adequate for qualitative research. Therefore, the
generalisability of the results is constrained, although con-
sistent with previous literature. Considering the search by
understanding such experience, there is no intent to univer-
sally generalise the study conclusions or to close the investi-
gation. Given the lack of publications on this theme, other
studies that cover different aspects of readmission for SSI,
both for individuals at risk of this event and for those who
provide care, will enhance the results of the present study
by continuing in the same direction, that is, promoting true
care that liberates the individual (receiving care).
As a global contribution, it should be emphasised that
international protocols for SSI may and should consider the
experiences of the individual exposed to the unexpected
event. Epidemiologic data could consider not only measures
related to health and disease but also the more subjective
aspects of health problems.
Conclusion
Research conducted in the light of the existential frame-
work of Martin Heidegger allowed us to understand the
experience of individuals subjected to orthopaedic surgical
procedures and readmitted for SSI. This experience is
unique and personal, and it requires a sensitive view of
needs that are not obvious. The work of nurses requires an
attitude that considers the individual as more than a bearer
of illness. Quality listening allows the speaker to say more
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LM Torres et al.
than what is spoken. Viewing all these dimensions demands
a professional with reflective training based on the experi-
ence of the other to potentialise true care, which is a libera-
tor in an existential dimension.
Given that protocols and guidelines on the prevention
and control of SSI are available, it is up to health profes-
sionals to develop competencies that include openness, lis-
tening and comprehension of experiences beyond the
health–disease process to provide better care for those who
are readmitted for SSI and to promote care that transcends
‘knowing how to do’ and achieves ‘knowing how to do
with sensitivity’.
Relevance to clinical practice
Nursing care requires an attitude that considers the patient as
more than an object or a carrier of illness and should not be
limited to what is described and prescribed, although the lat-
ter cannot be excluded in an organisational point of view.
Quality listening leads health professionals to reflect on car-
ing for someone who, after being readmitted, shares the most
intimate and subjective experiences that comprise the self.
Widening the horizon beyond the quantitative aspects of
SSI improves the quality of care and contributes to greater
attention to prevention and control. Disciplines that include
a philosophical component in healthcare training, especially
a Heideggerian approach, will help to develop professionals
with empathy, that is, those who in addition to looking
and hearing will be able to see and listen, allowing patients
to be themselves in their singularity and plenitude.
Funding
This research received no specific financial support from
any funding agency in the public, commercial or not-for-
profit sectors.
Contributions
All authors have agreed on the final version and met at
least one of the following criteria: substantial contributions
to conception and design, acquisition of data or analysis
and interpretation of data, and drafting the article or criti-
cally revising it for important intellectual content.
Conflict of interest
No conflict of interest has been declared by the authors.
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