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To describe the patients' perceptions of quality of care (QoC) in an emergency department (ED) and to analyse associations between patients' background characteristics and estimated QoC.Each year 1.4 out of every 100 inhabitants are injured in the traffic environment and receive care at the ED. No study has yet analysed different injured road users' perceived QoC, or how important they rate different caring dimensions.Cross-sectional study at the ED, in the University Hospital in Umeå, Sweden.A stratified consecutive sample of 166 car occupants, 200 cyclists and 199 pedestrians, aged 18-70 years, all injured in the traffic environment. Data were collected from medical records and from a mail survey using a short form of the Quality from the Patient's Perspective questionnaire, modified for ED use. The statistical methods used included Mann-Whitney's U-test, the Kruskal-Wallis test and multiple logistic regression.The perceived QoC and the subjective importance of the corresponding QoC dimensions were rated at the 'better' half of the rating scale, with no differences between the different road user categories. The most prominent factors associated with a positive perceived QoC rating were a short waiting time, moderate or serious injuries and high age as well as high educational level of the injury victim. For the subjective importance, a short waiting time was rated as the most important but slight differences were seen, related to education and sex.The association patterns between the areas of perceived reality and subjective importance indicated that expectations were higher than perceived QoC, suggesting that patients expected somewhat higher QoC than they received.Information on factors causing long waiting times, adapted to patients' age, sex and educational level, may reduce dissatisfaction among long waiting patients, especially among those with minor injuries.

The aim of our study was to illuminate the meaning of living with dementia and disturbing behaviour, as narrated by three persons admitted to a residential home.Living with dementia and so-called disturbing behaviour in an institution involves interaction with care providers and fellow residents and poses a challenge to all who are involved.We asked the head nurses at a residential home to select persons with dementia and disturbing behaviour who were willing to be interviewed and able to communicate verbally. We performed 10 informal conversational interviews with three persons. The interviews were transcribed into text and interpreted using a phenomenological hermeneutic method inspired by Ricoeur's philosophy.The findings indicate that the meaning of living with dementia and disturbing behaviour, as narrated by three persons admitted to a residential home, is about being surrounded by disorder, being trapped by restriction and being set aside, as well as about being included. The findings are interpreted as a collapse of relations to self and others intertwined with occasional episodes of togetherness. This is reflected on in relation to the literature on homelessness and at-homeness and loss and maintenance of personal and social selves.The view others have of the person with dementia and of disturbing behaviour determines the nursing care given. Taking the residents' personal history and actual context into account, disturbing behaviour may be seen as a way persons with dementia express their story and maintain their self.

Studies among physicians and nurses in paediatric care reveal experiences of loneliness and lack of open dialogue. The aim of this study was to illuminate the meaning of female Registered Nurses' lived experience of being in ethically difficult care situations in paediatric care. Twenty female Registered Nurses who had experienced being in ethically difficult care situations in paediatric care were interviewed as part of a comprehensive investigation into the narratives of male and female nurses and physicians about being in such situations. The transcribed interview texts were subjected to phenomenological-hermeneutic interpretation. The results showed that nurses appreciated social confirmation from their colleagues, patients and parents very much. This was a conditioned confirmation that was given when they performed the tasks expected from them. The nurses, however, felt that something was missing. They missed self-confirmation from their conscience. This gave them an identity problem. They were regarded as good care providers but at the same time, their conscience reminded them of not taking care of all the 'uninteresting' patients. This may be understood as ethics of memory where their conscience 'set them a test'. The emotional pain nurses felt was about remembering the children they overlooked, about bad conscience and lack of self-confirmation. Nurses felt lonely because of the lack of open dialogue about ethically difficulties, for example, between colleagues and about their feeling that the wrong things were prioritized in the clinics. In this study, problems arose when nurses complied with the unspoken rules and routines without discussing the ethical challenges in their caring culture. The rules and the routines of the caring culture represented structural barriers for creating open dialogue and an ethically justifiable practice, called inauthentic existence, blindness related to our own inauthentic understanding, which focuses on the routines, rules, theories and systems.

This article is part of an ongoing study aimed at illuminating the meaning of dependency on care. The aim of this particular study is to illuminate the meaning of the phenomenon 'dependency on care' as narrated by nurses. Interviews with 20 nurses were conducted, tape-recorded and transcribed verbatim. A phenomenological-hermeneutic approach was used to interpret the data. The meaning of dependency on care is revealed as laborious for both patients and nurses. The nurses' text discloses that for patients, dependency on care is a miserable loss of self-determination and self-worth. Nurses appear to be moved by dependents' difficult life and want to do whatever they can for the dependent. Dependency on care is a burdensome responsibility for nurses. For nurses dependency on care is revealed as evoking feelings of guilt and insufficiency and of being constantly concerned and worried. It is to struggle to be patient and understanding, having the arduous task of putting oneself into the dependent patients' shoes in order to cope with the demanding task of balancing between helping and not helping too much. The interpretation discloses, however, that nurses distinguish between easy and trying dependency on care. The understanding indicates that when they meet 'good' patients, nurses reappraise the situation, transform it into something new and meaningful, that is dependency on care is disclosed as 'easy to take'. When coming across'difficult' patients dependency on care is disclosed as trying. It seems that within the unique nurse-patient relationship patients may participate in such a way as to facilitate or inhibit nurses in finding meaning in the immediate caregiving situation. Nurses' evaluations of what constitutes a 'good' or a 'difficult' patient, respectively, seem to play an important role in distinguishing between dependency on care that is easy and that which is trying. The result is viewed through an existential paradigm and there is also reflection about what nurses perceive as valuable qualities in patients which might influence the quality of care.

Five care providers particularly successful at communicating with patients with communication difficulties were video-recorded together with three patients with aphasia after stroke, during morning care activities. The care providers were then interviewed immediately after the video-recordings, about their experiences of communicating with such patients. The interviews with the care providers were interpreted by means of a phenomenological hermeneutic method. Co-creating was the main theme found. Care providers invite the patient to participate in the creative act of communication. They have a communicative attitude and show interest in the patients' personal desires. The care providers encounter the patient as a presence in a caring communion. In part, care providers communicate by continuously conveying their presence to the patient and even creating availability in a close and open intersubjective relationship. A relaxed and supportive atmosphere facilitates reciprocity between care provider and patient. The communication is not technical or strategic; instead care providers share the patients' experiences in a silent dialogue. This silent dialogue involves sharing the patients' feelings and thus receiving messages from the patient.

Understanding between care providers and patients with stroke and aphasia: a phenomenological hermeneutic inquiry The present study illuminates the understanding in communication between formal care providers and patients with stroke and aphasia. Five care providers and three such patients participated in the study. Video recordings were made during conversations about pictures (n = 15), and the care providers were also interviewed (n = 15) after the video-recorded conversations. A phenomenological hermeneutic method of interpretation of the interview text was used. The findings showed that a range of conditions for 'understanding and being understood' in the communication on the part of the care providers exists. These different conditions are: lacking both knowledge and understanding; having knowledge but not necessarily accompanied by understanding; and being in understanding. Within the condition 'being in understanding', the care providers create a feeling of at-homeness in a relaxed atmosphere and thus have the opportunity to be in 'understanding and being understood' together with the patient. The condition 'being in understanding' appears in connection with the care providers' creating of a 'calm liturgy of caring' by mediating humility and calm vitality affects to the patients, and further, when needed, being present on the level of mystery, i.e. caring communion.

The study aims to illuminate how one woman with severe dementia and so-called behavioural disturbances acts in relation to her care providers and how the care providers act in relation to her.Fourteen participant observations, including one woman with dementia and six care providers, were performed. A reflective dialogue focusing on the interaction between the woman and her care providers followed each observation. The tape-recorded observational notes and reflective dialogues were fixed as a text, which was subjected to a thematic content analysis.The main findings are that the interaction between a woman with severe dementia and "behavioural disturbances" and her care providers relates to privacy, identity, autonomy and security. The phenomena are intertwined and also in conflict with each other. Interaction is a complex dialectic process in which those who are engaged meet problems that can be solved and are involved in dilemmas that cannot be solved, only related to.

Patterns in midwives’ and expectant/new parents’ ways of relating to each other in ante- and postnatal consultations Patterns in midwives’ and expectant/new parents’ ways of relating to each other in ante- and postnatal midwifery consultations were described by means of qualitative content analysis of 58 video-recorded consultations in a Swedish primary care setting. The midwives appeared to steer the consultations by adopting a basic pattern and occasionally including other patterns. Of the five patterns disclosed, three were revealed as basic and named ‘the respectful gardener and her developing plants’, ‘the propagandist teacher and her ignorant pupils’ and ‘the steering inspector and the representatives of the population at disposal’. The midwives related in individually oriented ways in the first pattern while the latter two indicated generalized ways of relating. The expectant/new mothers were more active in the two additional patterns ‘the mediating counsellor and the discreet seekers of guidance’ and ‘the personal women-friends’. The expectant/new fathers mostly had a minor role, only appearingly actively involved within the ‘gardener’ pattern. Midwives need to reflect over their ways of relating as these influence how expectant/new parents deal with the information given and their satisfaction with the care.

The aim of this study was to elucidate the experiences of the women with severe, recurrent attacks of porphyria and how they coped with them successfully. A total of five women were interviewed and were encouraged to describe their experiences. Thematic content analysis was used to interpret the significance of their narratives. The result demonstrated that the women's experience was of living in deepest darkness with inexpressible pain, both physical and mental. Coming into contact with health care had its good and bad points. It was often difficult to cope with life during severe periods of the disease. The process of maturation towards a more positive existence seemed to follow a pattern of accepting the disease, continuing the fight until it was finally possible to discover a pattern and meaning in life that suited the individual concerned.

To illuminate patients' experiences of suffering from care, ten former patients in somatic wards narrated a desirable care episode (n = 39) and an undesirable care episode (n = 51). The interviews were analysed using a phenomenological hermeneutic method inspired by Ricoeur's philosophy. Four themes were found: having a good rest, suffering through, searching for autonomy and being cared for by attentive and committed staff. The findings were interpreted in light of Eriksson's description of suffering, which describes three kinds of suffering: 'suffering of life', 'suffering of illness' and 'suffering of caring'. Although not mentioned explicitly, it was evident that cases of suffering from care were indicated in the patients' narratives. The themes were related to the patients' states of health, their experience of the care situation and their descriptions of themselves, and could be understood as related to the acts of the 'drama of suffering' described by Eriksson. The study highlights the need for the patient to find a co-actor in the drama of suffering in order to prevent suffering from care, i.e. prevent hindrance to the patient in her/his struggle against the 'suffering of illness' and the 'suffering of life'. The patients must be seen as the directors of their own dramas of suffering.

In order to explore the manner in which parenthood was discussed in midwifery consultations, 58 video-recorded consultations were analysed. A content analysis revealed a variety of topics concerning conversation on parenthood--topics of an intimate nature and discussions from a societal perspective. Parenthood was not of primary importance in visits, which were mostly directed by the midwives. A phenomenological hermeneutic analysis of the meaning of being a mother revealed a complex and difficult situation of being both needed and dependent. The meaning of being a father revealed a struggle between distancing from and closeness to the child. The mate relationship was indicated as important and under strain. The metaphor of the 'spiders web', where the mother is the spider with the child mostly on her back, the father entering the web on her terms, summarizes the understanding. The results from this study could provide a basis for reflection on the status of the topic of parenthood, on the meaning of being a mother and a father disclosed in the consultations, and ultimately on the organization of ante- and postnatal midwifery care.

Logstrup's ethics were used as a theoretical framework when interpreting 18 nurses' narratives about situations where it had been hard to know what was the right and good thing to do for a cancer patient. The phenomenological hermeneutic interpretation focused on (a) the nurses' experiences of sovereign and perverted utterances of life, ethical demands, interdependence and power; and (b) on the nurses' ways of relating to the ethical dimensions of the situation. In narratives about overwhelming care situations, the nurses did not make a conscious interpretation of whether the patients' demands were also the ethical demands of the situation. In these situations there seemed to be distrust and destructive interdependence between the co-workers and it was seemingly difficult to be moved by the sovereign utterances of life. In narratives about situations which were possible to grasp, the nurses made a conscious effort to interpret the ethical demands of the situation and acted in accordance with their interpretation until a new interpretation was necessary. The interdependence among the co-workers was used constructively in order to care for the patient.

Registered nurses regarded as “experienced and good” in dementia care were interviewed about the feeding of a severely demented patient who showed refusal-like feeding behaviour. Not one of the twenty nurses could see herself using force against her patients. Most interviewees justified their decisions to feed a severely demented patient and answered questions about whether they would change their minds if there were certain circumstances in terms of words that could be interpreted as referring to the ethical principle of beneficence. The nurses stressed the difficulty to understand the meaning of severely demented patients' feeding behaviour and decide when force-feeding occurs. When asked to rank ethical principles of importance for the decision, however, the most common answer was that they would give priority to the ethical principle of autonomy. The nurses did not see the ethical principles as separate entities, that could be applied one by one, but tried to integrate them into a whole. The findings of this study were interpreted as indicating that principled ethics is not an adequate model to describe experienced nurses' ethical reasoning.