Standing on their own two feet. The role of nursing education in the life stories of nurse teachers from Bangladesh

[eng] The nursing profession in Bangladesh has undergone substantial development over recent decades but still faces significant challenges. A remarkable gap has been described between the institutionally-accepted image of nursing as the provision of hands-on care and the small amount of time that nurses allocate to it, especially in government hospitals. The reasons for this contradiction have shown a complex interaction between historical, socioeconomic and cultural factors. These are mainly related to the conflict between the British-inherited curriculum, with a strong emphasis on basic care activities, social and gender norms, and longstanding discrimination against nurses in their institutional settings and society. This research aims to provide a theoretical analysis of the ways in which structural factors intersect with the professional and social experiences of a group of nurse teachers. The objectives of the thesis are to describe nurses’ views about nursing care and their profession, to discuss to what extent nursing education has been an empowering tool, and to analyse how the nurses’ socioeconomic background, personal experiences and life events have influenced their professional careers and their conceptualisation of nursing and care. A critical phenomenological analysis of the nurses’ life stories has been used, relating the stories to the broader history and political economy of nursing in Bangladesh. Twenty-two nurses were selected and interviewed over an eight-month fieldwork period, of which seven were selected as key informants. The discussion is mainly based on theoretical contributions from anthropology, practice theory, feminism and a critical analysis of nursing knowledge. A common rhetoric was found among the nurses: namely that nursing care has ‘deteriorated’. They tended to emphasise hands-on care and the ‘old’ apprenticeship model, while also approving moves towards a more professional model. Nursing care activities were understood as a mixture of service and management of the wards and patients, linked to a wish to ‘utilise’ the knowledge that they were continuously acquiring. Therefore, nursing education was broadly empowering in terms of knowledge, independence, and self-realization. Nevertheless, at some moments social and institutional discrimination made the m feel disempowered, frustrated and vulnerable. Even so, the nurses interviewed have achieved successful professional careers, together with a significant amount of social recognition. Without ignoring their outstanding individual capacities, the role that key people and institutions had in supporting them in their eagerness to learn has to be considered. Finally, the act of caring itself and the knowledge that it produces may also be a source of personal and collective agency. However, work is needed in order to create and maintain the necessary conditions for the caring experience to be empowering. This responsibility falls beyond the nursing field, as it involves structural changes, especially in terms of gender and class inequalities.[cat] La professió infermera a Bangladesh ha experimentat importants avenços en les últimes dècades, tot i que encara presenta reptes considerables. La imatge institucionalment acceptada de la infermeria com la provisió de cures i contacte continuat amb els pacients contrasta amb la poca dedicació de moltes infermeres a aquestes activitats, especialment en els hospitals públics. Aquesta contradicció s’explica per una complexa interacció entre factors històrics, socioeconòmics i culturals. Existeix un conflicte entre un pla d’estudis heretat de l’època colonial Britànica, amb un fort èmfasi en les activitats de cures bàsiques, les normes socials i de gènere, i la històrica discriminació de les infermeres en els seus entorns institucionals i socials. Aquesta tesi pretén teoritzar sobre les formes en què els factors estructurals s’interseccionen amb les experiències professionals i socials d’un grup de professores d’infermeria. Els objectius de la tesi són: descriure les visions de les infermeres sobre el concepte de cura i sobre la seva professió; discutir fins a quin punt l’educació en infermeria ha estat una eina empoderadora, i analitzar de quina manera el context socioeconòmic, experiències personals i esdeveniments vitals de les professores han influït en la seva carrera professional i en la seva conceptualització de les cures infermeres. La recerca ha realitzat una anàlisi fenomenològica crítica de les històries de vida de les professores d’infermeria, relacionant-les amb la història i economia política de la infermeria a Bangladesh. Vint infermeres van ser entrevistades durant un període de vuit mesos, entre les quals set professores van ser escollides com a informants clau. La discussió es basa principalment en les aportacions teòriques de l'antropologia, la teoria de la pràctica, el feminisme i l’anàlisi crítica del coneixement infermer. Les infermeres entrevistades sostenien, en general, que les cures d'infermeria s’havien ‘deteriorat’. Les seves narratives tendien a emfatitzar el ‘vell’ model d’aprenentatge pràctic, alhora que es valorava l’evolució cap a un model més professional. Les infermeres conceptualitzaven la cura com una barreja entre les nocions de servei i de gestió de les sales i dels pacients, juntament amb un desig d’utilitzar els coneixements que constantment adquiriren. Per tant, l’educació en infermeria ha estat en general empoderadora quant a coneixements, independència i sentit d’auto-realització. Tot i així, en certs moments, la discriminació social i institucional viscuda, els va fer sentir impotents, frustrades i vulnerables. Malgrat les dificultats, però, les infermeres d’aquesta tesi han aconseguit un exitós desenvolupament professional, així com un grau de reconeixement social considerable. Sense ignorar les seves notables capacitats individuals, cal considerar també el suport rebut per part de diferents persones i institucions en el seu constant desig de formar-se i aprendre. Finalment, l’acte de tenir cura i el coneixement que se’n deriva, són en si mateixos una font d’agència personal i col·lectiva. No obstant això, cal treballar per crear i mantenir les condicions necessàries perquè l’experiència cura sigui empoderadora. Aquesta és una responsabilitat que excedeix l’àmbit infermer, ja que implica canvis estructurals, especialment en relació a les desigualtats de gènere i classe

Arterial Transit Time Mapping Obtained by Pulsed Continuous 3D ASL Imaging with Multiple Post-Label Delay Acquisitions: Comparative Study with PET-CBF in Patients with Chronic Occlusive Cerebrovascular Disease

<div><p>Arterial transit time (ATT) is most crucial for measuring absolute cerebral blood flow (CBF) by arterial spin labeling (ASL), a noninvasive magnetic resonance (MR) perfusion assessment technique, in patients with chronic occlusive cerebrovascular disease. We validated ASL-CBF and ASL-ATT maps calculated by pulsed continuous ASL (pCASL) with multiple post-label delay acquisitions in patients with occlusive cerebrovascular disease. Fifteen patients underwent MR scans, including pCASL, and positron emission tomography (PET) scans with ¹⁵O-water to obtain PET-CBF. MR acquisitions with different post-label delays (1.0, 1.5, 2.0, 2.5 and 3.0 sec) were also obtained for ATT correction. The theoretical framework of 2-compartmental model (2CM) was also used for the delay compensation. ASL-CBF and ASL-ATT were calculated based on the proposed 2CM, and the effect on the CBF values and the ATT correction characteristics were discussed. Linear regression analyses were performed both on pixel-by-pixel and region-of-interest bases in the middle cerebral artery (MCA) territory. There were significant correlations between ASL-CBF and PET-CBF both for voxel values (r = 0.74 ± 0.08, slope: 0.87 ± 0.22, intercept: 6.1 ± 4.9) and for the MCA territorial comparison in both affected (R² = 0.67, y = 0.83x + 6.3) and contralateral sides (R² = 0.66, y = 0.74x + 6.3). ASL-ATTs in the affected side were significantly longer than those in the contralateral side (1.51 ± 0.41 sec and 1.12 ± 0.30 sec, respectively, p <0.0005). CBF measurement using pCASL with delay compensation was feasible and fairly accurate even in altered hemodynamic states.</p></div

Comparison between MR and PET in a typical case of left MCA severe stenosis.

<p><b>a)</b> Comparison between PET-CBF and ASL-CBF. From top to bottom rows, PET-CBF, ASL-CBF, ASL-ATT (transit time map) are calculated from the multiple PLD data and ASL-CBF calculated from single PLD (1.5s) data based on the simple single-compartment model (see text). <b>b)</b> MRA reveals that left MCA branches are less bright than those of the contralateral side. <b>c)</b> 2D-plots of PET and ASL-CBF on a pixel-by-pixel basis. The plotted CBF images through the ventricle body level correspond to third column images from the right side in 1st and 2nd rows. Abscissa and ordinate axes represent PET and ASL CBF, respectively.</p

The ASL signal changes for model parameters.

<p><b>a)</b> ASL signal dependency to T_1e. The single-compartment model is constant along with T_1e value, since labeled spins are retained in the vascular space and correspond to the relaxation of T_1b, while the other model assumption with venous outflow has an increasing trend along with the increase of T_1e. <b>b)</b> ASL signal dependency to CBV. ASL signal has an increasing trend along with CBV increase. Changes are quite stable in the normal brain CBV range (2.0 to 5.0 ml/100 g) (see text). <b>c)</b> ASL signal dependency to PS. PS is also constant despite the wide range of 20 to 200 ml/min/g, which adequately covers the physiological cerebral blood flow range.</p

Patient characteristics, clinical data, and MRI findings.

<p>Patient characteristics, clinical data, and MRI findings.</p

Comparison between MR and PET in a typical case of left ICA obstruction.

<p><b>a)</b> Comparison between PET-CBF and ASL-CBF. From top to bottom rows, PET-CBF, ASL-CBF, ASL-ATT (transit time map) are calculated from the multiple PLD data and ASL-CBF calculated from single PLD (1.5 s) data, based on the simple single-compartment model (see text). The decreased signal in the right frontal cortex corresponds to cystic change after infarction. <b>b)</b> MRA revealing the complete obstruction of left ICA suggests the left MCA territory is fed through collaterals of A-Com and/or left IC-PC. <b>c)</b> 2D-plots of PET and ASL-CBF on pixel-by-pixel basis. The plotted CBF images through ventricle body level correspond to the third column images from the right side in the 1^st and 2^nd rows. Abscissa and ordinate axes represent PET and ASL CBF, respectively. Scale bars and units as indicated.</p

Linear regression analysis of PET-CBF and ASL-CBF.

<p>The ROI values from affected and contralateral normal sides are plotted using a diamond shapes (◊) and crosses (x), respectively. <b>a)</b> 2D-plots of PET and ASL CBF using gray and white matter ROIs in both affected and contralateral cerebral hemispheres. The regression lines and the coefficient of determination (R²) are shown as insets on the graph. <b>b)</b> Bland-Altman plots of ROI-based CBF comparison between ASL-CBF and PET-CBF. Bias and mean ± 2 SD precision lines are drawn on the graph as thick lines and dashed lines, respectively. <b>c)</b> Extracted Bland-Altman plots of affected ROI of ASL-CBF data calculated from multi-PLD data. There is no significant regressed line. The regression lines and the coefficient of determination (R²) are shown as insets of the graph, but were not significant statistically.</p

Linear regression analyses of PET-CBF and ASL-CBF.

<p>ROI values from affected and contralateral normal sides are plotted as diamond shapes (◊) and crosses (x), respectively. <b>a)</b> 2D-plots between PET and ASL CBF using gray and white matter ROIs in both affected and contralateral cerebral hemispheres. The regression lines and the coefficient of determination (R²) are shown as insets of the graph. <b>b)</b> Bland-Altman plots of ROI-based CBF comparison between ASL-CBF and PET-CBF. Bias and mean ± 2 SD precision lines are drawn on the graph as thick lines and dashed lines, respectively. <b>c)</b> Extracted Bland-Altman plots of affected ROI of ASL-CBF data calculated from single PLD = 2.0 s data. The regression lines and the coefficient of determination (R²) are shown as insets of the graph, but were not significant statistically.</p

ROI selection for ROI-based comparison between PET-CBF and ASL-CBF maps.

<p><b>a)</b> PET-CBF map, <b>b)</b> ASL-CBF map. ROI selections for 12 gray matter and 4 white matter areas were exactly the same for PET-CBF and ASL-CBF maps.</p

The comparison between PET and ASL CBF on Bland-Altman plots.

<p>The comparison between PET and ASL CBF on Bland-Altman plots.</p