Norwegian Social Science Data Services Research Articles

The Importance of Being Taken Care of-Patients' Experience with the Quality of Healthcare in a Norwegian Hospital.

As recipients of healthcare, patients provide invaluable contributions when assessing quality. The aim of this qualitative study was to explore and describe how patients experienced quality of care during their stay in a Norwegian hospital. In this study, 39 patients were interviewed. The data were analyzed via conventional content analysis. The results showed that patients' experiences of quality were associated with interactions with medical staff, while their physical surroundings had less of an impact. The quality of healthcare was described on a continuum from good to bad. Patients assessed quality positively when they felt they were taken care of. The feeling of not being taken care of provoked feelings of insecurity, resignation, being "overlooked", and inferiority. A prerequisite for patients to feel cared for was staff presence, which enabled and encouraged patients to share their thoughts. This required medical staff to have competency, interpersonal skills, and time accessibility. In addition, a culture that is person-oriented and not task-oriented was valued. From our study, we see the opportunity within healthcare systems to improve the quality of care by having staff engage in active listening, promote an environment of mutual respect, and encourage active participation from patients in their healthcare decisions and plans. This study was prospectively registered with the Norwegian Social Science Data Services on 9 July 2015 with registration number 44034.

Caring for family members following suicide: Professionals' experiences of responsibility.

When a patient commits suicide while hospitalized in the psychiatric ward, the mental healthcare professionals (MHCPs) who have had the patient in their care encounter the family members immediately following the suicide. Professionals who encounter the bereaved in this first critical phase may have a significant impact on the grieving process. By providing ethically responsible and professionally competent care, they have the opportunity to influence what can alleviate and reduce suffering and promote health in a longer perspective. The aim of this study is to investigate MHCPs' experiences in the encounter with family members who has been bereaved by suicide. Data material consists of text from in-depth interviews with six MHCPs belonging to a total of five different psychiatric units in two hospitals. The findings have emerged through analysis using a hermeneutical approach based on Gadamer's philosophical hermeneutics. The study was approved by the Ombudsman for Privacy of the Norwegian Social Science Data Services and is based on informed consent and confidentiality. Three themes emerged: Confirming the suffering. Creating encounter through dialogue. Providing consolation and reconciliation. Findings illuminate how MHCPs understand their responsibilities and how they act in the encounter with the bereaved following suicide. The participants appear to be led by the responsibility that grows through witnessing the suffering of the bereaved. Encountering the family member's aggression and threats against staff members is an ethical challenge to the professional's ability to confirm the bereaved, create dialogue and provide consolation and reconciliation at the start of their grieving process. MHCPs need to be aware of the different reactions and needs of family members following suicide. More research is needed about how to provide sensitive and flexible care in ways that can be perceived as helpful for those left behind.

A vulnerable journey towards professional empathy and moral courage.

Background: Empathy and moral courage are important virtues in nursing and nursing ethics. Hence, it is of great importance that nursing students and nurses develop their ability to empathize and their willingness to demonstrate moral courage. Research aim: The aim of this article is to explore third-year undergraduate nursing students’ perceptions and experiences in developing empathy and moral courage. Research design: This study employed a longitudinal qualitative design based on individual interviews. Participants and research context: Seven undergraduate nursing students were interviewed during or immediately following their final clinical placement. Ethical considerations: The Norwegian Social Science Data Services (NSD) approved the study. Participants were informed that their participation was voluntary and were assured confidentiality. They were informed that they could withdraw from the study at any time, without providing reasons. Findings: Affective empathy seemed to be strong among third-year undergraduate nursing students. However, they tried to handle the situations in a ‘professional’ way, and to balance their emotions. At the same time, they expressed how difficult it can be to show moral courage when confronted with poor patient care. In addition, they spoke about a lack of role models during clinical practice and supervision. Conclusions: Undergraduate nursing students are in a vulnerable position throughout their journey to become professional and to develop empathy and moral courage. The professional socialisation and forming of professional empathy and moral courage among nursing students, may be seen as a complex interaction of formal and hidden curriculum, where role models play an important role. We argue that the main theme ‘Vulnerable students – a journey towards professional empathy and moral courage’ may cover the longitudinal project as a whole. This vulnerability is something both teachers and supervisors should be aware of when following up with students in their clinical placements.

Coping with moral distress on acute psychiatric wards: A qualitative study.

Background:Nurses working within acute psychiatric settings often face multifaceted moral dilemmas and incompatible demands.Methods:Qualitative individual and focus group interviews were conducted.Ethical considerations:Approval was received from the Norwegian Social Science Data Services. Ethical Research Guidelines were followed.Participants and research context:Thirty nurses working within acute psychiatric wards in two mental health hospitals.Results:Various coping strategies were used: mentally sorting through their ethical dilemmas or bringing them to the leadership, not ‘bringing problems home’ after work or loyally doing as told and trying to make oneself immune. Colleagues and work climate were important for choice of coping strategies.Discussion:Nurses’ coping strategies may influence both their clinical practice and their private life. Not facing their moral distress seemed to come at a high price.Conclusions:It seems essential for nurses working in acute psychiatric settings to come to terms with distressing events and identify and address the moral issues they face. As moral distress to a great extent is an organisational problem experienced at a personal level, it is important that a work climate is developed that is open for ethical discussions and nourishes adaptive coping strategies and moral resilience.

Ethical dilemmas embedded in performing fieldwork with nurses in the ICU.

Background:Background: In general, qualitative research design often involves merging together various data collection strategies, and researcher’s may need to be prepared to spend longer periods in the field to pursue data collection opportunities that were not foreseen. Furthermore, nurse researchers performing qualitative research among patients and their relatives often experience unforeseen ethical dilemmas.Aim:This paper aimed to explore aspects of ethical dilemmas related to qualitative nursing research among patients and their relatives in the intensive care unit (ICU).Research design:This paper is based on a qualitative researcher’s personal experience during a hermeneutic phenomenological study involving close observation and in-depth interviews with 11 intensive care nurses. Data were collected at two ICUs in two Norwegian university hospitals.Ethical considerations:The study was approved by the Norwegian Social Science Data Services (NSD). The Regional Committee for Medical and Health Research Ethics (REK) granted dispensation to the project regarding health personnels confidentiality of the patients who were present during the observation (2012/622-4).Findings:Close observation with nurses in the ICU requires the researcher to balance being a qualitative researcher, an ICU nurse and a sensitive fellow human being open to the suffering of the other—that is, being embodied, engaged and affected by sensitive situations and simultaneously constantly stepping back and reflecting on the meaning of those situations.Conclusions:The qualitative researcher’s ethical awareness also entails knowing and acknowledging his or her own vulnerability, which becomes apparent in the researcher-participant relationship and settings in which being a fellow human always overrules the researcher’s role in ethical dilemmas.

Nursing Staff’s Knowledge and Attitudes towards Dementia in an Indian Nursing Home: A Qualitative Interview Study

Background: Despite the increased prevalence of dementia in India, there is reported to be little awareness of the disease. This could lead to a late diagnosis, a reduced number of choices regarding future care, and misinterpretation of the symptoms or neglect. Taking into consideration that most nurses caring for older people in the future will work with people with dementia, there is concern that they may not be able to meet the needs of this group of patients unless they have the necessary knowledge and a positive attitude. Aim: To explore the knowledge about and attitude towards dementia among nursing staff working in residential care facilities for older people in India. Method: An explorative and descriptive qualitative design was used. Two semi-structured focus group interviews were conducted with nursing staff working in 6 nursing homes in India. Qualitative content analysis was used. Ethical approval was granted by the Norwegian Social Science Data Services. Findings: The participants highlighted the following 3 dimensions in relation to their knowledge of and attitudes toward dementia in residential care facilities in India: (1) people with dementia – a walking mystery; (2) we need to go along with them, but it is challenging; and (3) if we know, we can care for them in a better way. Conclusion: The findings revealed a wide range of differences in attitude towards and inadequate knowledge of dementia among nursing staff. However, their overall attitudes toward people with dementia was positive.

Dignity of older home-dwelling women nearing end-of-life: Informal caregivers' perception.

Background:Most older people wish to live in the familiar surroundings of their own home until they die. Knowledge concerning dignity and dignity loss of home-dwelling older women living with incurable cancer should be a foundation for quality of care within municipal healthcare services. The informal caregivers of these women can help increase the understanding of sources related to dignity and dignity lossAim:The aim of this study was to explore informal caregivers’ perceptions of sources related to dignity and dignity loss in end-of-life of older home-dwelling women with incurable cancer.Research design and method:The study was founded upon Gadamer’s philosophical hermeneutics. In-depth interviews with 13 informal caregivers were carried out, and four participant observations were performed during home meetings.Ethical consideration:The study was based on voluntary participation, informed consent, confidentiality and the opportunity to withdraw at any time. The Norwegian Social Science Data Services approved the study.Results:Three main sources important in preserving the older women’s dignity were identified: maintaining one’s self-concept, remaining hopeful and sustaining freedom of choice. We also identified three main sources that lead to dignity loss: Sensing loss of human value, experiencing absence of gentleness and feelings of being treated as an object.Discussion and final considerations:On the individual level, the opportunity to maintain one’s self-concept and control in life, preserved dignity, while feelings of existential loneliness led to dignity loss. On the relational level, being confirmed as worthy human beings promoted the women’s dignity, whereas dignity loss was related to uncaring behaviours from healthcare professionals. On the societal level, individual decisions concerning travel situations and the place to stay when nearing end-of-life were of crucial importance. Constituting these women’s living space, these perspectives should be emphasized in healthcare professionals’ educational training and in the municipal end-of-life care of these patients.

Association Between Performance in Muscle Fitness Field Tests and Skeletal Muscle Mass in Soldiers.

Muscle strength and muscle endurance are important fitness components related to safe and efficient execution of physically demanding military work. In soldiers, these components are traditionally measured from simple field tests like push-ups, sit-ups, and pull-ups. However, the validity of such muscle fitness field tests is questioned due to reports of low association between test performance and the ability to conduct strength demanding military work (eg, lift and carry tasks). It is therefore necessary to study, develop, and implement more valid field tests, which are still feasible for mass testing in the military. Skeletal muscle mass (SMM) is an important physiological component related to maximal muscle force generation (strength). Thus, an alternative way of validating muscle fitness field tests is by comparisons against SMM. The purpose of the present study was to investigate the association between SMM and performance in five muscle fitness field tests. A total of 275 military cadets (including 27 women) participated in this method comparison study. The field tests included push-ups, sit-ups, pull-ups (vertical for men, horizontal for women), standing medicine ball throw, and Sargent jump (peak power and jump height). SMM was estimated from bioelectrical impedance analysis and expressed in absolute values (kg) or relative to body mass. Pearson correlation coefficients (r) were calculated to investigate associations between SMM and performance in the five field tests. The study was submitted to the Regional Committee for Medical and Health Research Ethics prior to startup, and the Committee considered the study to be exempted from notification. The study was reviewed and approved by the Norwegian Social Science Data Services. In men, the highest correlation against absolute SMM was found for the Sargent jump (peak power) and the medicine ball throw (r=0.71 and 0.54, respectively). The same trend was evident for women (r=0.85 and 0.61, respectively) and for the two genders combined (r=0.85 and 0.79, respectively). All these r-values were significant (P<0.001). In men, the highest r against relative SMM was found for pull-ups (r=0.50, P<0.001). The same pattern was found in women, but the association was not significant (r=0.36, P=0.07). The sit-ups test demonstrated low or nonsignificant associations with both absolute and relative SMM. Among the five muscle fitness field tests investigated, the Sargent jump (peak power) and the medicine ball throw demonstrated the strongest correlation coefficients against absolute SMM. Thus, these two tests should be better alternatives for assessing relevant upper and lower body strength and power in soldiers compared with push-ups, pull-ups, and sit-ups. Pull-ups generally demonstrated the strongest correlation against relative SMM. Sit-ups demonstrated low or nonsignificant associations with both absolute and relative SMM. Consequently, the test should be considered for removal from military fitness test batteries or replaced by alternative abdominal tests that are more valid.

Moral distress in acute psychiatric nursing: Multifaceted dilemmas and demands.

In this article, the sources and features of moral distress as experienced by acute psychiatric care nurses are explored. A qualitative design with 16 individual in-depth interviews was chosen. Braun and Clarke's six analytic phases were used. Approval was obtained from the Norwegian Social Science Data Services. Participation was confidential and voluntary. Based on findings, a somewhat wider definition of moral distress is introduced where nurses experiencing being morally constrained, facing moral dilemmas or moral doubt are included. Coercive administration of medicines, coercion that might be avoided and resistance to the use of coercion are all morally stressful situations. Insufficient resources, mentally poorer patients and quicker discharges lead to superficial treatment. Few staff on evening shifts/weekends make nurses worry when follow-up of the most ill patients, often suicidal, in need of seclusion or with heightened risk of violence, must be done by untrained personnel. Provision of good care when exposed to violence is morally challenging. Feelings of inadequacy, being squeezed between ideals and clinical reality, and failing the patients create moral distress. Moral distress causes bad conscience and feelings of guilt, frustration, anger, sadness, inadequacy, mental tiredness, emotional numbness and being fragmented. Others feel emotionally 'flat', cold and empty, and develop high blood pressure and problems sleeping. Even so, some nurses find that moral stress hones their ethical awareness. Moral distress in acute psychiatric care may be caused by multiple reasons and cause a variety of reactions. Multifaceted ethical dilemmas, incompatible demands and proximity to patients' suffering make nurses exposed to moral distress. Moral distress may lead to reduced quality care, which again may lead to bad conscience and cause moral distress. It is particularly problematic if moral distress results in nurses distancing and disconnecting themselves from the patients and their inner selves.

Trading company for privacy: A study of patients' experiences.

The study was conducted according to the principles of Declaration of Helsinki, and was approved by the Norwegian Social Science Data Services. To describe patients' experiences of staying in multiple- and single-bed rooms. This qualitative study employed a descriptive and exploratory approach, and systematic text condensation was used to analyze the material. Data were collected in a hospital trust in Norway. A total of 39 in-depth interviews were performed with patients discharged from the medical, surgical, and maternity departments. Patients had ambiguous views on whether multiple-bed rooms or single-bed rooms were to be preferred. Main results include how patients cherished "the importance of others" but at the same time valued "the importance of privacy." Being hospitalized in multiple-bed rooms was for many patients a very positive experience in terms of social interaction. Patients in single-bed rooms reported being more dependent on nurses to maintain social contact and obtain safety. This research provides new knowledge on how the need for privacy can be in contradiction with the need for socializing with other patients. When hospitalized, the physical structure of a hospital impacts with whom patients interact and to what extent they depend on the nursing staff to have their social needs met.

Nurses' experiences of compassion when giving palliative care at home.

Compassion is seen as a core professional value in nursing and as essential in the effort of relieving suffering and promoting well-being in palliative care patients. Despite the advances in modern healthcare systems, there is a growing clinical and scientific concern that the value of compassion in palliative care is being less emphasised. This study aimed to explore nurses' experiences of compassion when caring for palliative patients in home nursing care. A secondary qualitative analysis inspired by hermeneutic circling was performed on narrative interviews with 10 registered nurses recruited from municipal home nursing care facilities in Mid-Norway. The Norwegian Social Science Data Services granted permission for the study (No. 34299) and the re-use of the data. The compassionate experience was illuminated by one overarching theme: valuing caring interactions as positive, negative or neutral, which entailed three themes: (1) perceiving the patient's plea, (2) interpreting feelings and (3) reasoning about accountability and action, with subsequent subthemes. In contrast to most studies on compassion, our results highlight that a lack of compassion entails experiences of both negative and neutral content. The phenomenon of neutral caring interactions and lack of compassion demands further explorations from both a patient - and a nurse perspective.

Involving relatives in consultations for patients with long-term illnesses: Nurses and physicians' experiences.

Due to the major changes occurring in the demographic composition of the world's population, the number of older individuals is increasing, which puts pressure on the healthcare systems in many different countries. The involvement of volunteers and family members may become necessary to fulfil a patient's needs for follow-up treatments and long-term care in their homes. This study aimed to explore how nurses and physicians experienced and addressed ethical challenges when they dealt with relatives in what have traditionally been one-on-one consultations at two Norwegian hospital outpatient clinics. A total of eight nurses and two physicians from two different hospitals participated in individual in-depth interviews. The transcribed interviews were analysed using an eclectic approach called 'bricolage' inspired by Kvale and Brinkmann. We combined cross-case thematic and theoretical normative analyses. The principles of voluntariness, confidentiality, withdrawal and anonymity were respected throughout the research process. In addition, the Norwegian Social Science Data Services approved this study. The findings showed that respect for a patient's autonomy was used as an argument for delimiting the relatives' access to the patient's consultations. We found that there were insufficient routines in place for inviting and involving relatives in the patient consultations in the outpatient clinics. The traditional Western attitudes towards the principles of patient autonomy will likely be challenged due to the growing need for family involvement in the care of a patient in the future. This study's description of the nurses and physicians' interpretations of 'patient autonomy' as a phenomenon uncover the need for systematic ethical deliberation in the clinical setting. On an organisational level, there is a strong indication of the need to discuss the routines that are in place to invite the next of kin to participate in such patient's healthcare consultations.

The paradoxical body: A glimpse of a deeper truth through relatives' stories.

People with progressive cancer experience that their bodies change due to disease and/or treatment. The body is integral to the unity of the human being, a unity that must be perceived as whole if dignity shall be experienced. Relatives are in touch with the suffering bodies of their dear ones, physically, socially, mentally, and existentially, and thus the relatives' experiences of the bodies of their dear ones might yield insight into the concept of dignity. The aim of this study is to explore relatives' experiences of the patients' bodily changes from a perspective of dignity. A total of 12 relatives from a hospice in Norway were interviewed. Gadamer's ontological hermeneutics inspired the interpretation. The principles of voluntariness, confidentiality, withdrawal, and anonymity were respected during the whole research process. The Norwegian Social Science Data Services approved the study. The conversations about the body were conversations about ambivalent or paradoxical matters that shed light on the concept of dignity. The results show that the relatives got in touch with elements that otherwise would have remained tacit and unspoken, and which gave glimpses of a deeper truth, which might reveal the core of dignity. Furthermore, the relatives' confirmation of the ambivalence might be understood as a strong ethical obligation to treat the other with dignity. The confirmation may also reveal the relatives' unselfish love of the other, which can be understood as the core of ethics and ethos. Finally, the results reveal the relatives' limited insight into their dear ones' bodily changes, and we discuss the challenges of truly seeing the other. Body knowledge and the relationship between body and dignity as phenomena cannot be ignored and needs more attention and articulation in clinical nursing practice and in nursing research.

Ethics and quality care in nursing homes: Relatives' experiences.

A total of 71,000 people in Norway suffer from some form of dementia in 2013, of whom approximately 30,000 are in nursing homes. Several studies focus on the experiences of those who have close relatives and who are staying in a nursing home. Results show that a greater focus on cooperation between nursing staff and relatives is a central prerequisite for an increased level of care. Benefits of developing systematic collaboration practices include relief for nursing staff, less stress, and greater mutual understanding. Going through studies focusing on the experiences of nursing home patients' relatives, negative experiences are in the majority. In this study, relatives are invited to share positive experiences regarding the care of their loved ones; a slightly different perspective, in other words. The aim of the study is to investigate relatives of persons with dementia's experiences with quality care in nursing homes. The study is a part of a larger project called Hospice values in the care for persons with dementia and is based on a qualitative design where data are generated through narrative interviews. The chosen method of analysis is the phenomenological-hermeneutical method for the study of lived experiences. Participants in the project were eight relatives of persons with dementia who were living in nursing homes, long-term residences. The sampling was targeted, enrolment happened through collective invitation. All relatives interested were included. The Norwegian Regional Ethics Committee and the Norwegian Social Science Data Services approve the study. Findings show that relatives have certain expectations as to how their loved ones ought to be met and looked after at the nursing home. The results show that in those cases where the expectations were met, the relatives' experiences were associated with engagement, inclusion and a good atmosphere. When the expectations were not met, the relatives experienced powerlessness, distrust and guilt. The results are discussed considering the concepts of trust, power and asymmetry. When asked about experiences with quality care, the relatives spoke both of expectations met and of expectations not met. Results in this study are important knowledge for developing units where performing quality care is the overall aim.

Conflicting rationales: leader's experienced ethical challenges in community health care for older people.

Ethical challenges arise in all types of care, and leaders need to be aware of how to resolve these challenges. Healthcare systems tend to be organised around medical conditions, and the patient is often faced with a series of uncoordinated visits to multiple specialties. Ideally, care should be organised around the patient's needs. The purpose of this article was to highlight some ethical challenges perceived by leaders with responsibility for management and service distribution, finance and ensuring quality of community health services for older people. This study had a qualitative design with a qualitative content analysis of one focus group with six leaders that met four times in total. Leaders from the community healthcare sector in one Norwegian municipality were included, representing both nursing homes and home-based health care. The study followed the intentions of the Declaration of Helsinki and standard ethical principles. The Norwegian Social Science Data Services approved the study. All participants voluntarily gave written informed consent. The main theme that emerged from this study was the ethical challenge leaders felt in the form of an inherent conflict between a caring rationale versus economic or technological rationales. Four categories emerged: (i) Management: quality versus economy; (ii) Prioritisation: fair distribution of healthcare services; (iii) Responsibility: considering individuals' needs versus the needs of the whole community; and (iv) Welfare technology: possibilities and challenges. Leaders' responsibilities in community health care for older people need to strike a balance between ethical principles in the management of limited resources.

Sense of responsibility in ICU end-of-life decision-making: Relatives' experiences.

Relatives of intensive care unit patients who lack or have reduced capacity to consent are entitled to information and participation in decision-making together with the patient. Practice varies with legislation in different countries. In Norway, crucial decisions such as withdrawing treatment are made by clinicians, usually morally justified to relatives with reference to the principle of non-maleficence. The relatives should, however, be consulted about whether they know what the patient would have wished in the situation. To examine and describe relatives' experiences of responsibility in the intensive care unit decision-making process. A secondary analysis of interviews with bereaved relatives of intensive care unit patients was performed, using a narrative analytical approach. In all, 27 relatives of 21 deceased intensive care unit patients were interviewed about their experiences from the end-of-life decision-making process. Most interviews took place in the participants' homes, 3-12 months after the patient's death. Based on informed consent, the study was approved by the Data Protection Official of the Norwegian Social Science Data Services and by the Regional Committee for Medical and Health Research Ethics. The results show that intensive care unit relatives experienced a sense of responsibility in the decision-making process, independently of clinicians' intention of sparing them. Some found this troublesome. Three different variants of participation were revealed, ranging from paternalism to a more active role for relatives. For the study participants, the sense of responsibility reflects the fact that ethics and responsibility are grounded in the individual's relationship to other people. Relatives need to be included in a continuous dialogue over time to understand decisions and responsibility. Nurses and physicians should acknowledge and address relatives' sense of responsibility, include them in regular dialogue and help them separate their responsibility from that of the clinicians.

Smartphone application for women with gestational diabetes mellitus: a study protocol for a multicentre randomised controlled trial

IntroductionThe promotion of a healthy diet, physical activity and measurement of blood glucose levels are essential components in the care for women with gestational diabetes mellitus (GDM). Smartphones offer a...

Remaining in the nursing profession: The relevance of strong evaluations.

Why nurses remain in the profession is a complex question. However, strong values can be grounds for their remaining, meaning nurses evaluate the qualitative worth of different desires and distinguish between senses of what is a good life. The overall aim is to explore and argue the relevance of strong evaluations for remaining in the nursing profession. This theoretical article based on a hermeneutical approach introduces the concept strong evaluations as described by the Canadian philosopher Charles Taylor and provides examples of nurses' experiences in everyday nursing care drawn from a Norwegian empirical study. Data collected in the original study consisted of qualitative interviews and qualitative follow-up interviews with 13 nurses. The research context was the primary and secondary somatic and psychiatric health service, inside as well as outside institutions. The article uses data from an original empirical study approved by the Norwegian Social Science Data Services. Information was given and consent obtained from the participants. Remaining in the nursing profession can be understood as revolving around being a strong evaluator. This has been concretized in issues of being aware of different incidents in life and having capacities as a nurse. Why nurses remain is discussed in relation to how nurses have shaped themselves by reflecting on what is of significance in their life. However, being a strong evaluator cannot be seen as the casual condition for remaining. Remaining in the nursing profession is obviously not a contingent matter, rather it is a matter concerned with the qualitative worth of different desires and values. Nurses' awareness of a life choice impacts on whether they remain or not. Consequently, nurses may need to articulate and reflect on their priorities for remaining.

Undergraduate nursing students' ability to empathize: A qualitative study.

Empathy is of great importance in nursing, as it helps us to see and meet the needs of patients and hence to care for patients in an appropriate way. Therefore, it is of great importance that nursing students and nurses develop their ability to empathize. The study aimed at gaining knowledge on what characterizes undergraduate nursing students' ability to empathize with patients during their first practice in a nursing home. In addition, the aim of the study was to investigate what nursing students think is important with regard to upholding their ability to empathize with patients in a professional way. This research has a phenomenological and hermeneutic design, based on qualitative interviews. Participants and research context: A total of 11 undergraduate nursing students participated in interviews during or right after their first practice in a nursing home. Ethical considerations: Norwegian Social Science Data Services approved the study. Participants were informed that their participation was voluntary. The participants were also assured confidentiality, and they were informed that they could withdraw from the study at any time, without providing any reasons. What the findings show is that affective empathy is strong among undergraduate nursing students in their first practice. They think the emotions are important to be able to empathize, and they are afraid of becoming indifferent. At the same time, they are afraid that the feelings will hinder them from acting in a professional manner. The findings are discussed in light of previous theories on empathy, and especially perspectives on empathy, emotions, and morality. Affective empathy seems to be strong among nursing students, and this may be of great importance to be sensitive to patients' well-being. However, affective and cognitive empathy should be balanced if nurses will have to meet patients in a professional way.

When trust matters—a multilevel analysis of the effect of generalized trust on political participation in 25 European democracies

ABSTRACTGeneralized social trust has been argued to have positive effects for both individuals and society, but despite solid theoretical arguments in favour of different contextual effects, the empirical evidence remains scant. We here examine whether and how the effect of generalized trust on the propensity to become politically active is moderated by the level of generalized trust in society. We inspect two different causal mechanisms: The rainmaker effect, which entails that the effect of generalized trust is weaker at the individual level when there is a high level of generalized trust in society; and the sunmaker effect, which entails that the effect of generalized trust is strengthened by a high level of generalized trust in society. We examine the links for three forms of political participation: voting, institutionalized participation, and non-institutionalized participation. The data come from the fourth round of the European Social Survey from 2008 [European Social Survey. (2008). Data file edition 4.0. Norwegian Social Science Data Services, Norway—Data Archive and distributor of ESS data], and we include 47,489 respondents in 25 democratic countries. The results from a series of multilevel logistic regressions suggest that the effect of generalized trust varies depending on the level of generalized trust in the surrounding community but the causal mechanisms differ for different kinds of political participation.