Suffering related to care among older patients on ... - Sykepleien

Eriksson describes 'suffering related to care' as a violation of the patient's dignity, absence of care, condemnation, punishment and the ... Skiptomaincontent Annonse Annonse Norsk PeerreviewedResearch Published: 11.06.2019 Sufferingrelatedtocareamongolderpatientsonperioperativecarepathways Thisisascientificresearcharticle.IthasbeenreviewedandapprovedbytheeditorinchiefoftheNorwegianJournalofNursingResearchandindependentpeerreviewers.IthasbeentranslatedfromNorwegian.TheoriginalNorwegianversioncanbeaccessedbyclicking'Norsk'intheupperrightcorner. Summary Background: Olderpatientswhoareadmittedtohospitalforsurgeryaremovedquicklybetweendifferentlevelsinthehealthservice.Thesepatientscanbeexposedtounnecessarysufferingrelatedtocare,whichcanbecomeanadditionalburdenandimpedeconvalescence.Objective: Todescribenurses’experienceswithsufferingrelatedtocarethatisinflictedonolderpatientsundergoingsurgicalprocedures.Method: Thestudyhasaqualitative,exploratorydesignandcomprisesatotalofseveninterviews.Weconductedonefocusgroupinterview,fivequalitativein-depthinterviewswithtwoinformantsineachgroupandoneindividualinterviewwithonenurse.Fifteennursesparticipated,whoeitherworkedinthecommunitynursingservice,nursinghomesoroperatingtheatres.Results: Thenurseswhoparticipatedhadexperiencednursesbehavingdisrespectfullytowardsolderpatients.Conflictsofvaluesaroseintheinteractionbetweenpatientsandhealthcarepersonnel,anditwasdifficulttodiscussunethicalbehaviourwithmanagersorcolleagues.Patientsdidnotalwaysreceiveappropriatepainreliefanddidnotalwaysreceivehelpwhentheypressedthealarmbuttonoraskedforhelp.Conclusion: Olderpatientsareatriskofsufferingrelatedtocareintheformofviolationsofdignity,neglectandlackofappropriatepainreliefduringthesurgicalpathway,wherepatientsaremovedquicklybetweendifferentunits.Sufferingthatisunnecessarilyinflictedonpatientscanbepreventedbytalkingtothepatientandhisorherfamily.Ethicallyresponsiblemanagementrequiresgoodcommunicationandethicalreflectionwithcolleaguesonobservedviolationsofdignity.  Perioperativenursing Sufferingrelatedtocare Carepathway Qualitativestudy Majorchangeshavetakenplaceinthetreatmentofsurgical patients.Thechangesmeanshorterstaysinhospitalinconnection withsurgicaltreatment,includingforolderpatients.These patientscanbeexposedtosufferingbeyondtheillnessitselfand thetreatment.Inthisarticle,wechosetousetheterms ‘unnecessarysufferingrelatedtocare’and‘unnecessary suffering’. Erikssondescribes‘sufferingrelatedtocare’asaviolationof thepatient’sdignity,absenceofcare,condemnation,punishment andtheexercisingofpower(1).Dahlberg’sterm‘unnecessary suffering’isdescribedasnegativeencounterswithhealthcare personnelthatmakepatientsvulnerable,andthissufferingis causedbyalackofcare(2). Everyonewantstobewelllookedafter,receiveconsiderate nursingcareandbetreatedwithunderstanding,dignityandrespect bythehealthservice(3,4).However,patientssometimesencounter healthcarepersonnelwhosubjectthemtoindignities,andbyso doingcausethemtosuffer.Healthcarepersonnelcanberudeand disrespectful,andtheycanignoreandhumiliatepatientsandtreat themasiftheyareinvisible(2,5–7). Albinagivesanexampleofanoldermanbeingsubjectedto seriousviolationsofdignityintheformofphysicaltouchingand offensivelanguageinconnectionwithanoperation(8).Willassen etal.refertoanexampleofapatient’spainbeingignored,and giveexamplesofoffensivelanguageintheformofnegative commentsaboutthepatient’sbody(9). Carepathway Inourstudy,thenursesrefertopatientsaged60+.TheWorld HealthOrganization(WHO)definespeoplebetweentheagesof60and 75as‘earlyelderly’,andpeopleover75as‘lateelderly’.Older patientsareoftenmovedtoconvalescencewardsortheirhome shortlyaftersurgery,andthisprocessisreferredtoasacare pathway,treatmentpathway,treatmentlooportraumachain (10). Asurgicalcarepathwayisnormallydividedintothreephases: preoperative,intraoperativeandpostoperative.Thepreoperative phaseisthetimefromwhichitisdecidedthatthepatientshould beoperateduntilthepatientarrivesintheoperatingtheatres. Thisperiodinvolvespreparationsforpatientsandstaff.Inthe operatingtheatre,thepatientsaretakencareofbythesurgical team,whichmainlyconsistsofasurgeon,theatrenurses,an anaesthetistandanurseanaesthetist(3,11,12). Perioperativenursingcare Theterm‘perioperativenursing’wasadoptedintheUSAinthe 1970s.LindwallandvonPostdefineperioperativenursingasthe nursingactionsandnursingactivitiesperformedbytheatrenurses andnurseanaesthetistsduringthepre-,intra-andpostoperative phasesofsurgery,normallyinoperatingtheatres(13). IntheNordiccountries,thequalificationsandareasof responsibilityofthesespecialistnursesvary,andthescopeof workforperioperativenursescanvaryfromhospitaltohospital andfromcountrytocountry(14).Initsbroadestsense, perioperativenursingcannowadaysincludecontactwithandcaring forthepatientatoutpatientclinics,recoveryunits,daysurgery operatingtheatresandcontactwiththepatientviatelephone beforeandaftersurgery(14). Responsibilitytoprotectthepatient Theatrenursesandnurseanaesthetistsworkina multidisciplinarysurgicalteamalongwithdoctors,engineersand porters,andtheentireteamhasadutytoworkinacaringmanner (4).Theatrenurseshaveaspecialresponsibilityforprotecting patientsfromembarrassmentandensuringthattheydonotsuffer indignitieswhentheyarenakedordefenceless(4). Researchsuchasoursonsufferingrelatedtocarethroughout thetreatmentpathwayisnew.Itisimportanttolearnmoreabout thenurses’perspectivesofthesufferinginflictedonpatientsin theperioperativephaseinordertodevelopthenursingcare. Objectiveofthearticle Thepurposeofthisarticleistodescribenurses’experiences withsufferingrelatedtocarethatisinflictedonpatients.The findingsinthisarticleappearedinastudyweconductedon patientsafetyandolderpatients(15). Method Design Wechoseaqualitativemethodwithsemi-structuredinterviews, andacontentanalysisofthedatamaterialwasperformed(16). Sample Weinterviewed15nursesworkinginsmallandlargeurban municipalities.Thesenursesworkedinoperatingtheatres,nursing homesandthecommunitynursingservice.Inordertostrengthenand enrichthestudyandgainaninsideperspectivefromtheentire courseofthepatient’scarepathway,wechoseacombinationofa focusgroupinterviewwithfourparticipants,fiveinterviewswith twoparticipantsandoneindividualinterview.Table1shows detailedinformationabouttheparticipants. Datacollection Wecontactedmanagersinhospitalsandlocalauthorities,who arrangedcontactwiththenursesweinterviewed.Theinterviews wereconductedduringtheperiodMarch2014toSeptember2015.The mainquestionsconcernedpatientsafetyforolderpatients undergoingsurgery.Weusedaninterviewguidethatwedevised basedonliteratureandtheauthors’experiences. Theinterviewscomprisedofatotalof23questions.The questionswereopen-ended,andwealsoaskedforfurtherdetails whenthenursesdescribedexperiencesinwhichpatientshadbeen subjectedtooffensivelanguageorneglect,orhadbeenignored.We alsoaskedifthenursescouldgiveusexamplesofsuchincidents. Weconductedatotalofseveninterviews:oneinterviewwithone participant,fiveinterviewswithtwoparticipantsandonefocus groupinterview. Fournursesparticipatedinthefocusgroupinterview:two workedinanursinghomeandtwowerepartofthecommunitynursing service.Thethirdauthorwasthemoderatorinthisinterview,and hertaskwastogettheparticipantstotalktoeachotherandto managethesocialdynamicssothateveryonewasheard.Thesecond authorconductedalltheinterviews,whilethefirstauthortook notesandaskedsupplementaryquestions(16).Table2showsdetails oftheinterviews. Analysis Aftertheinterviews,wepreparedsummariesandnotedthemain impressions.Thefirstauthortranscribedalltheinterviewsapart fromone.Weperformedaqualitativecontentanalysisofthedata material(17,18).Thismethodofanalysiswaschosenbecauseitis consideredtobesuitableforexaminingparticipants’experiences, attitudes,motivesandthoughts,aswellasforexaminingsomeof thetopicsinmoredepth. Thefirstandsecondauthorslistenedtotherecordingsandread throughthetextsseveraltimes.Thestatementswerethenbroken downintomeaningunits,whichwerethencondensed,codedand thematised(17,18). Thefirstauthorhadthemainresponsibilityfortheanalysis, butregularmeetingswereheldwithalltheauthorswhereanalyses, interpretationsandtextwerereviewedandanalysed.Table3gives examplesofhowthestatementswerebrokendownintomeaningunits, condensedmeaningunitsandcodes,andhowtheseweresortedinto sub-themesandmainthemes. Ethicalconsiderations Weprovidedwrittenandoralinformationaboutthestudytothe managersandinformants.Thenursessignedaninformedconsent form.Theystatedtheirage,qualificationsandnumberofyearsin theprofessionpriortointerview,withtheexceptionofthefirst interview,wherethisinformationwasprovidedduringtheinterview itself. Weinformedthenursesthatthestudywasvoluntaryandthat theyhadtherighttowithdrawwithoutgivingareason.Four informantswithdrewonthedaywehadarrangedtoconductthe interviews.ThestudywasreportedtotheNorwegianCentrefor ResearchData(projectnumber37833). Results Thenursesinthestudyhadexperiencedthatsufferingrelated tocare,suchasdisrespectfulbehaviour,wasbeinginflictedon patients,andthathealthcarepersonnelneglectedpatientswhowere tryingtogettheirattention.Conflictsofvaluesmadeit particularlydifficultforthenursestodiscussthesuffering inflictedonpatientswithcolleaguesandmanagement. Disrespectfulbehaviourtowardspatients Thenursesfromnursinghomesgaveexamplesofpatientswith cognitiveimpairmentsanddementiadiagnosesbeingsubjectedto offensivelanguage.Theyalsoprovidedexamplesofstaff non-conformancenoticesbeingsubmittedbecausepersonnelhadacted inappropriatelytowardspatients. Youdoseepatients’dignitybeingviolated,particularlyinrelationtooffensivelanguage,bythenursesanddoctorsinthesurgicalteam,andit’sverydifficulttoaddresstheissue. Theatrenurses Thetheatrenursesdescribedincidencesofviolationsofdignity bybothnursesanddoctorsinthesurgicalteam.Thisrelatedto swearingandotherlanguagethatthenursesconsideredtobe inappropriate.Onetheatrenursedescribeditasfollows: ‘Youdoseepatients’dignitybeingviolated,particularlyin relationtooffensivelanguage,bythenursesanddoctorsinthe surgicalteam,andit’sverydifficulttoaddresstheissue.’ Anothertheatrenursesaidthefollowing: ‘Thenurseanaesthetistactuallysedatedapatientsothatthey didn’thavetoexperiencethesurgeon’sinappropriatelanguage.I don’tthinkwe’retheonlyhospitalinNorwaythathasthis problem.’ Severaltheatrenursesclaimedthatoffensivelanguagetowards patientswasacommonprobleminmanyoperatingroomsandthatit wasdifficulttoraisetheissuewithcolleagues. Lackofappropriatepainrelief Thenursesreportedthatolderpatientsdidnotalwaysreceive appropriatepainrelief.Onenurseemployedinthecommunity nursingservicesaidthefollowing: ‘Violationsofdignityinrelationtopain.I’veexperienced thatalot,whereapatient’sclaimsofpainaretreatedwith scepticism.’ Nursesfromthecommunitynursingserviceandnursinghomeshad witnessedthestigmatisationofpatientswithsubstanceabuse problems.Theyhadalsoexperiencedpatientsnotbeinggiven appropriatepainreliefaftersurgery.Onenursesaidthe following: ‘Unfortunately,it’sperhapsalltoocommonforustohavea highthresholdforprovidinganymedication.There’sprobablya reluctancetogivemorphine,forexample,becauseyouthenneedto keepaclosereyeonthepatientwhenwe’reunderstaffed,and nursesmayalsobeafraidthatthepatientwillfall.’ Anurseintheconvalescencewardsaidthatapatienttoldthe doctorthathehadreceivedpoorpainreliefaftersurgery.It transpiredfromhismedicalrecordsthatthepatienthadnot receivedanyofthepainmedicationthathadbeenprescribedfor useasneeded.Thenursemadethefollowingobservation: ‘Notprovidingmedicinewhenneeded,that’stotallywrong.Maybe we’reafraidofgivingtoomuchpainreliefasthere’sbeenalot ofpresscoverageaboutpatientsbeingsedated,soit’savery complicatedissue.’ Patientstryingtogetthenurses’attentionwereignoredor neglected Intheinterviews,nursesdescribedhowpatientswhotrytoget thenurses’attentionareneglected.Thenursesworkinginnursing homessaidthatpatientswereignored,andthattheydidnotget helpwhentheypressedthealarmbutton.Onesaidthe following: ‘They’vebeenignored.Whensomeonepressesthealarmbutton it’sregisteredasanon-conformance,andnoonegoestoseeto them.’ Nursesdescribeditasverydifficultforpatientsandan affronttotheirdignitywhentheydonotreceivehelpwhenthey areinpainordiscomfort,orneedassistanceforother reasons. Discussion Thisarticlehighlightssufferingrelatedtocarethatis inflictedonolderpatientsundergoingsurgicaltreatmentandcare. Inthestudy,wefinddisrespectfulbehaviourtowardspatients, lackofpainreliefandneglectonthepartofthehealthcare personnelwhenpatientstrytogettheirattention.Vulnerable groups,suchaspatientsinastateofconfusionorwithcognitive impairments,wereparticularlyatrisk,aswereolderpatientswith substanceabuseproblems. Studies,includingfromoperatingtheatres,showthatpatients aresubjectedtoseriousandunacceptableviolationsofdignity(7, 9).Albinagivesexamplesofseriousviolationsofdignityina patientreceivingperioperativenursingcare.Shepointsoutthat patientsundergoingsurgeryareinaparticularlyvulnerable situationbecausetheyareanaesthetised(8). Itcanbedifficulttogethealthcarepersonneltotalkabout suchreprehensiblebehaviour.AccordingtoEriksson,patientscan feelspiritualandmentaldistressasaresultofhumiliationby fellowhumanbeings.Theymayalsofeelasenseofguiltin relationtotheirtreatmentorillness.Thesearefeelingsthatare manifestedwithinthepatient,buttheycanalsooccurduetothe judgmentalattitudeofnursingstaff(1). Conflictsofvaluesarisewhennurseswitnessrudebehaviourbyotherhealthcarepersonnel. LindwallandvonPostdescribehowpatientssufferduring humiliatingactions.Theyexplainthatifhealthcarepersonnel reallywanttoprotectapatient’sdignity,theymustforce themselvestoseewhattheydonotwanttosee.Furthermore,they arguethatconflictsofvaluesarisewhennurseswitnessrude behaviourbyotherhealthcarepersonnel.Theyconcludethatitis necessarytodiscussandreflectonsuchreprehensiblebehaviour, whichcausesthepatientstosufferandleavesthemfeeling humiliated(19). Perioperativecareinvolvestheatrenursesandnurse anaesthetistssafeguardingpatientcare.Theirroleistoprotect patientsfromsufferingbeyondthatcausedbythesurgical procedure.DahlbergandMartinsendescribehowperioperativenurses aretheretoprotectpatientsfromviolationsofdignityandensure thattheyarenotsubjecttoanyunnecessarysuffering(2,4). Nordtvedtbelievesthatmoralsensitivityischaracterisedby identifyingandinterceptingthemorallyrelevantfeaturesofa situation.Toillustrateasituationwherenursesshouldbe particularlycarefulwithpatients,heusestheexampleof protectingapatient’sdignitywhenexposed(20).Theatrenurses arewell-versedinsuchsituationsinconnectionwiththesurgical positioningofpatients,i.e.placingtheminaparticularphysical positiontoenabletheoperationtobecarriedout.Thetheatre nursemustsafeguardthepatient’sintegrityanddignityby preventingtheirbodyfrombeingexposed(20). Guidelinesonprofessionalethicsstatethatthenursemust safeguardtheindividualpatient’sdignityandintegrity,andthat thepatienthastherighttocomprehensivenursingcare,theright toshareddecision-makingandtherightnottobesubjectedto indignities(21).Accordingtothelegislation,healthcare personnelmustperformtheworkinawaythatmeetstherequirement forprofessionallyresponsibleandcaringnursing(13).Ourstudy showsthatseriousviolationsofdignityhaveoccurredandthat sufferingrelatedtocarehasbeeninflictedonpatients. Disrespectfulbehaviourtowardspatients Nurseshaveaprofessional,ethicalandlegalresponsibilityto speakoutagainstviolationsofpatients’dignityandtonot participateinortolerateunacceptablebehaviour(3,21,22).The nursesdescribedhowtheyfeltuncomfortablewhensuchundesirable eventsoccurred,whichconcurswiththefindingsofLindwalland vonPost(13). Thenurseshadexperienceddifficultsituationsandhadchosen togivethepatientsextrasedativestomakethemsleep.They wantedtosparepatientsfromverbaloutburstsbymembersofthe surgicalteam.Thismethodofprotectingvulnerablepatientsis debatable,butnursescanfeelpressuretoactandresolvethe situationinthebestwaypossible. Itisimportantthathealthcarepersonnelhavegood collaborationskillsandthattheyfindgoodwaystocommunicate. Itisnotuncommonforconflictstoariseintheoperatingroom.In theworstcase,conflictscanposearisktoapatient’ssafety,or thepatientcanfeelviolated(13,14). OurfindingsareconsistentwithWillassenetal.(15),who describeundignifiedcareandviolationsofdignityin perioperativepracticesandconcludethatthereisaneedfor reflectionanddiscussiononethicsanddignityinthefield.They furtherconcludethattheseissuesneedtobediscussedinstudy programmesinordertoraiseawarenessofattitudesandhelpchange theseforthebenefitofpatients,staffandstudents(9). Therearemanydifferentexplanationsfordisrespectful behaviourtowardspatients.Itcanbeblamedonwork-relatedstress factors,physicalormentalillness,abuse,thoughtlessnessorfear ofmakingamistake(18).Powerhierarchies,fearofreprisalor bullyingaresomeofthereasonswhyhealthcarepersonnelare unabletodealwiththesedifficultsituations.Various communicationproblemsalsocauseadverseevents(15). Nordtvedtbelievesthattherearemanyexplanationsforhowa moralbreakdowncanoccur.Hecitespowerhierarchies,blind obedience,emotionalnumbness,ideology,sadismandlackofempathy ascausesofmoralbreakdown(23).Thedegreeofopennessinthe patientsafetyclimatewilldeterminehoweasystaffthinkitisto talkaboutrisksandadverseeventsintheworkplace(24). IntheUSA,professionaldevelopmentcoursesfornursesand doctorswhoseconductposesarisktopatientsafetyhavelongbeen usedasatoolforbehaviouralchange.Earlyfeedbackfromstaff andmanagersisimportantfortheemployeetounderstandtheimpact ofhisorherbehaviour(25). Lackofappropriatepainrelief Ourfindingsshowthatpatientsdonotalwaysreceive appropriatepainrelieffollowingsurgicalprocedures.Thenurses gaveexamplesofindividualpatientsbeingstigmatised.The examplesconcerneddrugaddictsandaretakenfromnursinghomes andthecommunitynursingservice. Thelackofappropriatepainreliefforvulnerablepatient groupsaftersurgeryisaserioussituationthatleadstosuffering forthepatients.Pain-basedbehaviour,pain-basedemotionsand experiencesofpaindifferfrompatienttopatient,andtheyare alsocontingentonculture(26). Itisessentialtodevelopgreatercollaborationacrosstreatmentlevels. Failuretogivepatientsappropriatepainreliefrepresentsa seriouslackofcare(1).Possiblesolutionsfornursesmaybeto updatetheirknowledgeofpainandpain-basedbehaviourand emotionsindifferentcultures,participateinlearningnetworks andformacloserworkingrelationshipwithpharmacistsand doctors.Painreliefcanhelppreventfallsamongolder patients. Multidisciplinarycollaboration,annualmedicationreviewsand homecarerehabilitationallplayamajorroleinfallprevention. Fallpreventioninhealthcareinstitutionsisapriorityareafor theNorwegianpatientsafetyprogramme(27). Closercollaborationbetweenthespecialisthealthserviceand theprimaryhealthservice,betternursingdocumentation,theuse ofinterpretersandthesharingofnecessaryinformationwhen patientsaremovedbetweendifferentlevelsinconnectionwith surgicalproceduresareallcrucial(28).Itisessentialto developgreatercollaborationacrosstreatmentlevels. Patientstryingtogetthenurses’attentionwereignoredor neglected Thenursesfromthenursinghomesprovidedexamplesofpatients notreceivinghelpwhentheypressedthealarmbutton.Dahlberg alsoreferstoexampleswherepatientsdonothaveaccesstothe alarmbuttonandarethereforeunabletocallforhelpwhenneeded (2). Reportno.13totheStorting,‘QualityandPatientCare’, statesthatpatients’familiesareconcernedaboutthelackof dignity,care,trustandsafetyforfrailpeopleovertheageof80 livingathome.Theydonotreceivehelpattheagreedtime,and therearenotenoughqualifiedstaff(24).Thefamiliesareoftena sourceofstrengthforolderpatientswhentheyareadmittedtoa hospitalornursinghomeandwhentheyreceivehomenursing care. Martinsengivesanexamplewhereawomanwithcancerwhoisin thelastweekofherlifewasdeniedassistancefromanurseto findamorecomfortableposition.Thewomanpressedthealarm button,butdidnotgethelp.Thenurseactedshamelesslyandused thefactshewasbusyasanexcusefornothelpingavulnerable patientinseverepain(28).Malmedalpointsoutthatbadattitudes andpoormanagement,lackofknowledgeandtightfinancial frameworksmaybethereasonsbehindpatientsnotreceivinghelp (6). Conclusion Wecollecteddataacrosshealthservicelevels.Inthestudy, thereareexamplesofdisrespectfulbehaviour,lackofappropriate painreliefandneglectwhenthepatientstriedtogetthestaff’s attention,andthefindingssuggestthatunnecessarysufferingis inflictedonolderpatients.Thenurses’mostimportanttaskisto alleviatesufferingandpromotegoodhealth.Nurses,managersand otherhealthcarepersonnelmustworktogethertopreventmore sufferingbeinginflictedonolderpatients,particularlywhen continuityinthenursingisachallenge. Thestudyshowstheimportanceofperson-centredcare,better collaborationbetweenthedifferentservicelevelsandbetterpain management.Perioperativenursesmustcommunicatewiththepatient throughouttheentirecourseofthepatient’scarepathway,andnot justatthetimeofsurgery. Thenurses’mostimportanttaskistoalleviatesufferingandpromotegoodhealth. Thestudyalsoshowsthattheprimaryandspecialisthealth servicesshouldincludeLindwallandvonPost’sperioperative dialoguemodel.Thismodelplacesthefocusonpatientdignity, whichincludescontactwithpatientsandtheirfamilies,and dialoguebetweenstaffwithinandbetweenunits.Opennessand discussioninconnectionwithviolationsofdignityintheworking environmentareneededtoimprovethesafetyclimate.Itiscrucial thatnursesdiscusshowtodealwithsuchsituations. Moreresearchisneededinthisarea,whichalsoencompasses patients’andtheirfamilies’experiencesofsufferingrelatedto carethatisinflictedinconnectionwithsurgery.Nursesshould leadthewayinpromotingacaringenvironmentforpatientsand staff,andtheymusthavethecouragetoaddressadverseevents.By notreportingunacceptablebehaviour,theyareallowingsuch attitudesandbehaviourtocontinue. Wethanktheinformantswhoparticipatedinthestudyandthe managerswhohelpedusgainaccesstothefield.Wealsothankthe NorwegianAssociationofOperatingRoomNursesforproviding projectfunds,whichmadethestudypossible. 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Foto:LightField/Mostphotos Didyoulikethearticle?Giveaheartandshare Up 71 Seecomments Hidecomments Writenewcomment Name Jobtitle Emne Comment Annonse Annonse Authors EliEliassen Universitetslektorogoperasjonssykepleier Norduniversitet,Bodø SisselHolla Universitetslektorogoperasjonssykepleier Norduniversitet,Bodø TereseBondas Professoroghelsesøster Dethelsevitenskapeligefakultet,UniversitetetiStavanger DOInumber 10.4220/Sykepleienf.2019.77201en Bibliographicdata SykepleienForskning2019;14(77201):(e-77201) Commentonarticle Ledigestillinger Flereledigestillinger Sykepleiere/kreftsykepleiere Tromsø Sykepleiere/intensivsykepleiere/kreftsykepleiere Tromsø Vernepleiere/sykepleiere Lier Sykepleierer Gratangen Førsteamanuensis/universitetslektor Gjøvik Spesialkonsulent Drammen Sykepleiereogvernepleieresøkes Moss Operasjonssykepleier Oslo Avdelingsleder Sandvika Sykepleier Oslo Fagsjefsykepleie Nesodden DekanvedDethelsevitenskapeligefakultet Ullandhaug Whatimpactdidastudentexchangehaveonparticipatingnursesinthelongerterm? 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