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This is the submitted version of a paper published in Scandinavian Journal of Caring Sciences.
Citation for the original published paper (version of record): Lindahl, B. (2018)
On locating the metaparadigm concept environment withincaring science Scandinavian Journal of Caring Sciences, 32(2): 997-998
https://doi.org/10.1111/scs.12620
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On locating the metaparadigm concept environment within caring science
In this text, I raise awareness of the metaparadigm concept environment and propose that it should be targeted both theoretically and from a practice-oriented perspective within the caring sciences. As a researcher, I build on the fundamental principle that human care is a natural and unselfish commitment and a willingness to care and do good (ethos) for those in need. Further, I argue that all professional health carers have great responsibility in care delivery, as they are educated and paid to prevent suffering and maintain others’ health, integrity and life. Caring also means a responsibility to improve caring practices and
behaviours. I consider these principles to be the starting points for clinical practice, education and research. This guest editorial targets the concept caring environment through the lens of research.
I consider the metaparadigm concept environment to be an area in need of further
examination and analysis concerning meaning for patients, their next of kin and their caring staff. This topic has been overlooked by recent publications of the Scandinavian Journal of
Caring Sciences. In the last decade, the journal published only five papers examining the
physical environment; in elderly care, end-of-life intensive care and nurses’ working environments.
I examine the physical environment in care situations through the lens of an ongoing intervention research project launched in 2011 (1) employing Craig and colleagues’ (2) Complex Intervention Research model. The purpose of the project was to study whether a re-built intensive care unit (ICU) patient room—refurbished according to research-based principles—could impact the wellbeing and health of patients, staff and next of kin. The intervention examined the impacts of light, sound, interior design and view of nature. The number of components studied, the tailoring and adjustment of the intervention to the actual
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context (i.e., a technology-dense ICU patient room) and the use of sustainable and ecological products all contributed to the project’s complexity, as did the responsibility to protect the vulnerability and integrity of patients with critical illness in an ICU context. One could argue that the Complex Intervention Research model is too medical in its perspective; however, the model’s various phases have recently been revised (2), and a linear experimental design process involving randomized controlled trials is no longer the only alternative. Rather, in the examined intervention, the various phases allowed the research team to form their project within a caring science perspective and to combine qualitative and quantitative methods. The principal investigators represented the caring science view, but the team also included
researchers from architecture, design and work-environment medicine. During the
introduction phase (i.e., the pre-clinical and theoretical phase), a very important step when collaborating with researchers representing other traditions and knowledge paradigms, the challenge was to establish a common theoretical framework (i.e., a caring science perspective) and to consider spaces and places as lived. To accomplish this, we built on the theoretical foundations of health geography, healing environments (1) and evidence-based design (3).
Is it possible to create an ICU patient room environment that is conducive to health and wellbeing and that encourages caring behaviours among staff? Could such a technology-dense room be caring in itself? The intervention has now generated three PhD theses (4-6), with a fourth on its way (7). In sum, we can now suggest that the caring environment has a great impact on patients, staff and next of kin. Modern light sedation regimens and analgesics help patients be more alert and awake. Even critically ill patients notice changes in a room’s light and sound environment. Furthermore, staff knowledge about sounds and noises can be improved. Experiences of sounds are subjective and, thus, individual; however, sound levels in ICUs are too high, and there are few differences between day and night. In a six-month follow-up, patients had better recovery when cared for in an intervention room with cyclic
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lightning. Moreover, staff reported that a healing environment cultivated more caring
behaviours. Finally, next of kin made us aware of a special extension of the patient room: the waiting areas outside the room, where they spend significant time.
A goal of professional caring is to create places and spaces where people can dwell, feel secure and experience being part of place-specific relations and interactions. One such place, space and caring practice is the home environment. Thus, another project in my research focuses on the life situations of people (children/young people and adults) living at home with ventilator treatment and the corresponding family perspective (8, 9). Ventilator treatment is prescribed to manage alveolar hypoventilation due to, for example, neuromuscular or lung and airway diseases, congenital disabilities or trauma to the spinal cord. The presence of ventilator technology, often in combination with reduced mobility, creates new demands and rearrangements of the home condition, which could threaten feelings of at-homeness. The ventilator and other treatment-related equipment requiring space have the power to change the essence of the home. However, our findings have shown that the most important issue is often the presence of a variety of health care professionals. Knowledge about treatment is sparse; however, it seems that the most important challenge is to prepare professionals to work and inhabit the private area of the home. Values and routines originally derived from hospital traditions often become taken for granted and transferred unreflectingly into the home area. This may lead to an imbalance in power relations and evoke feelings of discomfort among patients, family and professionals. However, we have also collected many stories of professional friendship, i.e. friendship between staff, patients and family. These good examples are the stories that should be told in scientific publications and when lecturing and presenting at conferences, as they teach us about the caring perspective and caring responses.
The two projects described above use a variety of research methods to collect and analyse data; thus, I propose that existing research methods should be stimulated and challenged to
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develop new methods well suited to studying complex environments, such as ICUs and domestic areas or other high-technology environments. Moreover, the metaparadigm
environment and the various meanings ascribed to it need to be theorized, problematized and practically explored to increase understanding and sensibility and guide the improvement of caring practices. Inadequate or diverse societal organizations and care management (e.g., in hospitals, health care centres and at home) create risks not only for inequalities in
prerequisites for treatment, but also for suboptimal environmental safety regimens,
functionality and aesthetics. Health care professionals have a tremendous impact on the caring environment, as their presence has the potential to create (or undermine) a caring and
enriching environment through the way they act and inhabit public spaces, including both patient rooms and private spaces (e.g., patients’ homes). Thus, education programmes and future research projects need to focus more clearly and comprehensively on the metaparadigm concept of the environment. Specifically, in Nordic countries, new health care buildings are currently under construction or being renovated. I suggest that health care professionals, researchers within the caring sciences and people with personal experience as patients should collaborate with architects, building planners and economists in the planning of new health care buildings, as they are the ones who have the competence and lived experiences of inhabiting the environments in which professional caretakes place.
5 References
1. Lindahl B, Bergbom I. Bringing research into a closed and protected place -
development and implementation of a complex clinical intervention project in an ICU. Critical Care Nursing Quarterly 2015;38(4):393-404.
2. Craig P, Dieppe P, Macintyre S, Mitchie S, Nazareth I, Petticrew M. Developing and evaluating complex interventions: the new Medical Research Council guidance. BMJ 2008;337(a1655).
3. Ulrich RS. Evidence base for health care architecture (Swe. Evidensbas för vårdens arkitektur 1.0). Gothenburg: Centre for Healthcare Architecture; 2012.
4. Johansson L. Being critically ill and surrounded by sound and noise - Patient experiences, staff awareness and future challenges. Gothenburg: Gothenburg University; 2014.
5. Olausson S. The meanings of ICU patient room as a place of care from the perspective of patients, next of kin and staff (Swe. Intensivvårdsrummetsbetydelse för vårdande och välbefinnande - patienters, närstående och vårdpersonalens
erfarenheter). [Publication]. Växjö; 2014.
6. Engwall M. A caring light environment in intensive care – patients’ experiences and outcomes from a lightening intervention. (Swe. En vårdande ljusmiljö inom
intensivvård -Patienters upplevelser och effekter av en cyklisk belysningsintervention). Gothenburg: Sahlgrenska Academy; 2017.
7. Sundberg F, Olausson S, Fridh I, Lindahl B. Nursing staff's experiences of working in an evidence-based designed ICU patient room-An interview study. Intensive Crit Care Nurs 2017.
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8. Lindahl B, Kirk S. When technology enters the home – a systematic and integrative review examining the influence of technology on the meaning of home. Scandinavian Journal of Caring Science 2018;In press.
9. Israelsson-Skogsberg A, Hedén L, Lindahl B, Laakso K. 'I am almost never sick': Everyday life experiences of children and young people with home mechanical ventilation. Journal of Child Health Care 2018(1-3):1-13.
