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Nurses' and students' perceptions of care: a phenomenological study

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VOL: 98, ISSUE: 34, PAGE NO: 32

Chris Bassett, BA, RN, is nurse lecturer, school of nursing, University of Sheffield

This article reports on a study that aimed to understand and illuminate the lived experiences of nurses. Using a phenomenological approach, it explored the attitudes of a group of nurses and nursing students towards care and caring.
This article reports on a study that aimed to understand and illuminate the lived experiences of nurses. Using a phenomenological approach, it explored the attitudes of a group of nurses and nursing students towards care and caring.


Norris (1989) stated that caring is expected to change theories that guide practice, foster research that tests theories and modify nursing practice. Greater insight into and understanding of caring therefore has practical implications for the profession and is not simply an academic exercise.


Methodology
As with any study, the methodology was the key to success (Parahoo, 1997). Using a phenomenological approach, the study focused on the lived and expressed experiences of the participants - 15 nurses and six nursing students, two from each year of a three-year advanced diploma in nursing programme.


Data analysis followed Colaizzi's (1978) approach. Transcriptions of all the interviews were read to develop a 'feeling' for them and to make sense of them. The taped interviews were listened to and categorised according to several emerging themes.


Significant statements pertaining to the phenomenon of care and caring were collected. These statements were then categorised according to their perceived meanings. The formulated meanings were then arranged into the following themes:


  • Encouraging autonomy;
  • Giving of oneself;
  • Taking risks;
  • Supporting care;
  • Emotional labour.
The themes are presented with selected examples of the interview transcripts to illustrate the participants' beliefs and views.


Encouraging autonomy
The notion of patient empowerment appeared to be important to the nurses who participated in this study. It was the only theme that could not be broken down into subcategories, which may indicate how strongly they feel about it.


Anne: 'I'd say it's definitely about providing the patient with something, but it's also about empowering that patient where possible.'


She seemed to want to allay patients' fears and anxieties by giving them greater autonomy and more control over their care.


Jill: 'To give the patients real independence and control of their own care, which is what modern nursing is about, rather than doing everything for them. Then you have to do a certain amount of teaching of patients in terms of health promotion, health education, and in some cases teaching how to actually give physical care - like for someone with diabetes, how to give their injections.'


I asked Cathy, a psychiatric nurse, what she thought were the main functions of her role. Among other aspects of care, she thought it was important to encourage patient autonomy:


Cathy: 'I'm quite interested in all the issues around what empathy really is and actually being able to demonstrate it, and how patients perceive that and, as part of that, actually being able to empower people. Because obviously if you work in psychiatry you are dealing with a fairly down-trodden group of people in our society so it's also really important to be able to make people have control and not feel controlled, and have choice and not feel as though choices are being made for them, and be able to influence what happens to them and what happens in the service.'


Cathy linked empathy with empowerment. She seemed to have a strongly developed sense of justice and sometimes saw her patients as being at the powerless end of the continuum.


Like their more experienced colleagues, students saw empowerment as an important way to underpin the care they gave. Its significance can be seen in the response of Alice, a first-year student, to the question: in what way do you care for your patients?


Alice: '... being able to get alongside that, hmm, and maybe try and help them through that, to be a guide and kind of be part of the process, to make decisions. You may not have a totally positive outcome, but you may be able to help somebody live with the situation.'


Alice saw empowerment as an important aspect of caring for her patients, even those who were dying.


There are strong indications that nurses see increased patient autonomy as a positive part of caring. This theme also exists in some of the nursing literature. However, some caution may be necessary when attempting to empower patients.


Giving of oneself
Caring, it can be argued, is the essence of giving of oneself. Nurses give to patients in terms of time, energy and effort. They spend time learning skills and gaining knowledge, both as students and throughout their nursing careers. To simply provide mechanical care may not be enough in their eyes - providing care without genuineness was not seen as adequately caring for patients.


It appears that there may be at least two distinct levels of care that can be given to patients. Jack gave a personal definition of care, and seemed to see it as giving something of himself or giving something up:


Jack: 'I think care is about giving something up. Care is about giving up part of yourself, whatever that might be. It could be time, energy, commitment to other people - which a person either chooses to appreciate or not. So it's giving anything of yourself so that a person can benefit from it.'


Cathy was working as a psychiatric nurse when she was interviewed, but she had previously worked as a general nurse. She also described giving something of herself in the way she cared for her patients:


Cathy: 'I find it really rewarding to work with people where you are having to give of yourself an awful lot.'


The students also seemed to be 'picking up' the importance of different ways of caring from the experienced nurses they worked with on the wards. Like the ward nurses, they too expressed a belief in the importance of caring for patients in both physical and emotional ways:


Carl: '... care, I think, is a whole range of things really. But I mean that if you want to kind of try and put it in a nutshell I think caring is basically identifying what people's needs really are, and that's not only the physical need, all sorts of different other needs - I suppose psychological and emotional needs as well.'


Carl seemed to be strongly influenced by experienced nurses and went on to point out:


Carl: 'But it's his or her [the nurse's] ability as people to relate to someone with a medical or psychological need.'


Motive and action seemed to be linked in the minds of the participants who shared their thoughts in this study.


Taking risks
This theme comprises the subcategories 'taking risks', 'getting a buzz' and 'challenge'. Taking risks in nursing is not about putting patients at risk by acting in a cavalier fashion or randomly experimenting with medications or care. The term was associated with testing the boundaries of accepted care, moving from the defined boundaries of the profession, and developing new and innovative ways of caring for patients.


Jack seemed to believe that nurses who truly cared sometimes took risks:


Jack: 'Because if you are really delivering care then you are not worried about what you do ... In practice, if you are really caring then perhaps no one is going to trip you up ... People recognise that you are caring ... - she gives [of] herself, she stops afterwards, she never has a break - you know you really think she is a caring person. But when it comes down to it - will I get a complaint or will I get anything said against me, or this might go to court - and you think: 'Oh, she's not caring.' It's a form of self-protection, and she's thinking about herself and not her patients.'


Jack's statement indicates that an element of courage is required to care for patients in a more radical way. To care fully, the courageous nurse meets the patient in what some might consider to be a deeper way.


I asked Cathy, the only psychiatric nurse among the participants, to describe a situation from her practice that might sum up caring in a psychiatric unit.


Cathy: 'I remember being in the situation where I was, in a human sense, dealing with this lady who was really high and unable to concentrate - and all those other problems - and her communication was a bit disrupted but was really saying: 'I don't need that injection, I don't want it, I just need not to drink, calm down and keep taking the lithium.' I ended up refusing to give the injection against the psychiatrist's wishes, and this went on for a number of weeks and there were some really difficult issues around stopping the other nurses giving the injections.'


In not obeying the doctor's order to give the injection, Cathy took a professional risk. It is difficult for nurses to refuse medical orders, but this is sometimes essential to protect patients from harm.


The extracts from the participants' accounts clearly indicate that some nurses feel that, in the cause of caring for their patients, it is sometimes necessary to take a stand against their professional colleagues' interpretations of normal nursing procedures or protocols.


Students also need to be courageous and also take risks at times. Like the nurses, the students saw taking risks as an essential part of caring for patients. In their case 'taking risks' seemed to mean 'standing up' for patients when the students felt that the care they had received was less than they deserved.


Although only in the first year of her diploma programme, Alice reported that she had at times stood up for patients when she felt they were not being cared for in the right way:


Alice: 'I think the key to good care is being strong enough to object if you don't agree with something.'


Issues related to the theme 'taking risks' indicate that some of the participants thought that they had to step out of the normal parameters of nursing care at times to provide a high standard of care. The culture of nursing tends to be rigid or even constricting in the way it makes nurses conform to its norms. I believe that nurses need to strike out from positions of 'professional safety' and begin to take risks for their patients.


Supporting care
Participants identified the fact that they believe that certain supporting factors are essential to ensure that care can be delivered effectively. These are managerial, organisational and psychological support systems.


Anne acted as operating theatre manager for half her working time. Her priorities for care seemed to incorporate a wider, more encompassing view than simply providing hands-on patient care. She felt that, to provide good care for patients, the members of her team needed to be cared for as well.


Anne: 'The first thing from a priority point of view would be the care of the patient, but thereafter my role is definitely to make sure that the staff are OK. There's this old adage 'Who cares for the carers?' And I don't think a lot of people do, and I don't think we are very good at caring for each other.'


Some nurses identified that a major part of their caring role is the creation of a caring environment. Lynn enjoyed one-to-one contact with her patients but also pointed out that it was vital to have a system of organisation in place to support care.


Lynn: 'Dealing with patients, that's obviously the most important part. But what I'm learning more and more is that I love that side of it, I love that contact and I love making patients feel welcome and that they are being looked after properly. But, increasingly, there are problems with actually getting systems of work in place so that can occur and increasingly I'm looking at these important things.'


Emotional labour
This theme was unique to the students in this study and seemed to reflect the fact that learning to nurse can constitute an emotional assault.


Alice: 'I think that when you stop caring is when you become hardened to things that it's just matter of fact. And maybe that's just a defence mechanism, you don't want to be affected by it.'


Joan had also found things difficult at times:


Joan: 'I think there is a big difference between hardness and being able to bottle up your emotions until there is an appropriate time to let it all out. I think hardness, you know, that's basically being desensitised or something, and when you do that you don't treat the person as a person.'


Chris: 'How do you mean?'


Joan: 'You kind of keep yourself at a distance ...'


Carl had experienced situations that seemed to upset him, particularly when he did not have enough time to do all he wanted to do for patients:


Carl: 'I've seen examples of, say, nursing staff who really give the individual patients the very minimum access to their time. That they perform the task or the clinical operation procedure that is required, and basically that is it. Don't go beyond that. Also, the use of rather abrupt language as well. That makes me sad.'


Anton spoke about ways in which he controlled his emotions when he was upset:


Anton: 'I think I can manage, whereas I can, err, take my emotions away and put them somewhere in a drawer.'


Chris: 'So you can suspend or hide your sadness?'


Anton: 'Yeah.'


This theme reflected the intense, emotional difficulties that at times are associated with learning to nurse. It was not identified in interviews with the more experienced nurses, but that is not to say that it is not an important factor for them. It simply means that this theme was not referred to by them.


Emotional labour describes the often difficult things that nurses are expected to do in their daily work. It probably affects all nurses, but this study seems to identify student nurses as being particularly susceptible to its influence. This is a concern as it is important to nurture newcomers to the profession. If students experience sadness and emotional trauma that is unresolved or buried there may be a danger that they will leave nursing or may not develop the caring attributes necessary for quality nursing care.


The study: summary and limitations
This study has allowed the nurses and nursing students who participated to discuss personal examples of their roles. In doing so it has provided important insights into some of the ways in which they provide care for their patients.


However, the expressed experiences recorded and interpreted are applicable only to each particular nurse at the time of the interview, and as such can provide only some degree of light on their views of what care might be. Nurses are not all the same in the ways in which they care for their patients, and they reflect patients' changing needs by giving different types and intensities of care. These differences in care requirements and provision are dependent on the context.


However, the themes that emerged from this project are generally well represented in the literature. The findings and expressed beliefs certainly appear to underline and reinforce the complexity of the phenomenon of care.


Recommendations
Nurses need to be cautious about implementing strategies of care that they feel will enhance the patient experience. First, they need to be sure that their patients want these strategies to be implemented. This raises the issue of the need for more research on the relationship between nurses' and patients' perception of what constitutes 'good' care. This study considers the views of a small group of nurses and nursing students only, and although its findings are interesting and valuable it does little to indicate what patients may need or want.


The themes 'taking risks' and 'supporting care' are not as widely represented in the literature, and this study may provide new insights into these concepts. My view is that nurses need to innovate and implement changes in their practice where this will improve the care they give. However, there is an associated risk - of stepping from the norm, of challenging more dominant professional groups such as doctors, managers and even academics. This requires considerable courage and strength from nurses wishing to make changes.


Supporting care would seem to be associated with nurses who have developed a more managerial or organisational role. The issues surrounding the need for effective management systems that streamline communication and decision-making are clearly expressed in the views of some of the nurses.


Leading on from this is the value placed on psychosocial support by both the nurses and the students involved in the research. Commitment and ideals are considered important to nursing, although they are rarely explicitly mentioned. However, when they were referred to they were considered to be very important and were a source of frustration if other members of the team did not share them. The students appeared to be badly affected by emotional stress at times and placed great value on support from senior colleagues. This thread runs in to the next theme, 'emotional labour'.


Emotional labour, a theme that was unique to the students participating in the study, appeared to centre on what some of them saw as the difficulties they faced in dealing with emotional assaults while caring for their patients. This appeared to be caused by the students being unable to deal with distressing situations and also, significantly, by situations in which the students saw what they believed was 'poor care' being delivered to patients by more experienced nurses around them.


Implications for practice
This research is qualitative and cannot provide us with absolute truths about care, caring, and the ways that nurses understand and provide that care. It is therefore only possible to provide greater understanding and insight into what it is to care as a nurse or nursing student, which I feel this study has achieved.


Nursing is accepted as an important part of the health care system throughout the world. This study illustrates some nurses' feelings about caring for their patients. They speak of encouraging greater independence in their patients, enabling deeper involvement in the caring process, with patients and their families becoming full partners in care. They speak about giving something of themselves so that patients can benefit from the nurses' skills and knowledge.


They also describe the ways in which they take risks to improve the services they provide for patients. Finally, students describe the emotional pressure and pain that they feel in learning to care for patients. All these factors show that nurses and nursing are of great value to patients in need of timely and expert care.


Implications for education
This study has also shown how some nurses and nursing students understand care, and clearly has implications for nurse educators. The main issues are related to the identification of care as being at the centre of the curriculum.


I believe that care has been pushed from its central position by various forces in recent years and that it is important to reaffirm it as the central and unifying tenet of nursing. This involves placing care at centre stage, not just by referring to it constantly in lectures but also by identifying the need to provide real support for both nurses and students. Nurse educators need to remember what it is like to begin to learn to nurse and so help students to cope better with the emotional assaults that occur when they enter nursing.


Conclusion
This study has provided some interesting insights into nurses' conceptualisations of their own nursing care. If this group is representative of other British nurses and nursing students then I have real faith that nursing care is alive and well in British health care, and has a bright future.


It is important for policy-makers on all levels to accept that nurses want to provide quality care for their patients. To enable them to do so, the government, educators, managers and nurses themselves need to ensure that the necessary structures are put into place. This is vital for the sake of patients - which all of us may become one day.
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