A model of professional nurse caring: nursing students' experience

Journal of Advanced Nursing, 1998, 27, 582–589 A model of professional nurse caring: nursing students’ experience Lesley M. Wilkes RN PhD MHPEd BSc(Hons) Grad. Dip. Nurs. Ed. Renal Cert. Professor of Clinical Nursing, Wentworth Area Health Service/University of Western Sydney and Marianne C. Wallis RN PhD BSc(Hons) CardioThor. Cert. Lecturer, Department of Professional Nursing Development, Australian Catholic University, Sydney, Australia Accepted for publication 3 March 1997 Journal of Advanced Nursing 27, 582-589 A model of professional nurse caring: nursing students’ experience Research into caring from the perspective of nursing students is poorly documented. This paper presents a study which described the construct of caring as experienced by students in pre-registration programmes at two universities in New South Wales, Australia. Qualitative data were collected using a questionnaire and semi-structured interviews. From the analysis of the data a model of professional nurse caring from the student’s perspective was created. In this model, compassion, as the core of caring is actualized in the students’ nursing of patients by communicating, providing comfort, being competent, being committed, having conscience, being confident and being courageous. Communication is not only an actualization of this caring but constitutes an important medium for the expression of caring actions. WILKES L.M. & WALLIS M.C. (1998) Keywords: caring, professional nursing, nursing students, nurse education, qualitative research INTRODUCTION Caring has been labelled as nursing’s ‘special knowledge’ (Olson 1993). Caring in nursing has been seen as the essence of nursing, as the tradition of nursing, and as a process of interaction and communication in nursing (Locsin 1995). The immense diversity and complexity of the conceptualization of caring in the literature has increased its elusiveness (Morse et al. 1990). However, nurses continue to see it as a reflection of nurses’ doing, being and knowing (Davies & Lynch 1995). This paper reports on a research project which employed a descriptive, qualitative approach to explore professional nurse caring as expressed by student nurses from two different universities in New South Wales, Australia. The Correspondence: Dr M. Wallis, Australian Catholic University, PO Box 968, North Sydney, NSW 2060, Australia. 582 research project replicated and expanded a previous study involving undergraduate nursing students at one tertiary education establishment (Wilkes & Wallis 1993). LITERATURE REVIEW The concepts of caring and nursing have long been linked (Maggs 1996) and many attempts have been made to explore this link. An examination of the literature reveals that caring and caring in nursing have been studied using a number of approaches including the cultural, the social/ feminist and the humanistic (Fry 1991). One of the first ways caring in nursing was explored, in the more recent nursing literature, was in its cultural context. The cultural model of caring, while developing out of the disciplines of sociology and anthropology, has been significantly contributed to by nurses. The work of nurse academics such as Madeleine Leininger has sought to uncover the © 1998 Blackwell Science Ltd Professional nurse caring relationships between caring and cultural beliefs, practices and the survival of the human race (Leininger 1985), and then to relate these to human health, and in particular, to the practice of nursing. At about the same time as the first work was being conducted into culture and caring the disciplines of social psychology, feminist social science and ethics education began to explore the feminist aspect of caring. The feminist model describes caring from the perspectives of moral development and gender differences. Gilligan (1982), who had worked alongside Kohlberg during the development of his model of moral development, sought to explain the apparent difference between the moral decision making processes of men and women. She saw women’s basic way of being as that of relationship to others in the world. As a result of this she posited that women base their moral decision making on different foundations to those of men. Noddings (1984) continued from this premise to delineate an ethic of care. This model has stimulated much interest in a discipline which is female dominated. Indeed aspects of this model feature implicitly or explicitly in a number of nursing care theories (see Watson 1985). Following this early work into the cultural and social aspects of caring various commentators and researchers began to explore more humanistic facets of caring. Authors such as Roach (1984) and Watson (1985) explored caring as a mode of being that is born of a commitment to protecting and preserving humans and their dignity. From this work and the work of Noddings (1984), the relationship between caring and moral obligation or duty, emerged as an area of study. In this view, caring is enacted by someone in a specific role (such as a health care worker) toward some other person with whom she/he has a special relationship (such as a patient) (Pellegrino 1985). Others, such as Reverby (1987), stated that nurses are expected to act out of obligation or duty of care, taking on caring more as an identity than as work, and expressing humanitarianism without thought of autonomy either at the bedside or in their profession. Fry (1991) characterized humanistic caring from the ‘moral point-of-view’. Citing Frankena (1983) she suggested that the person who cares from a ‘moral point-ofview’ subscribes to a view of caring that encompasses respect and love for others and then lives this view in his or her life. This idea can be seen also in the work of Mayeroff (1972) who saw caring as helping the other to grow and suggested that the major ingredients of caring are knowing the other, alternating rhythms, patience, honesty, trust, humility, hope and courage. Fry (1991) continued on to outline a thesis that suggested that we should move away from exploring caring along the lines of models such as cultural, feminist and humanistic, saying that this confines the scholar to arguments and explorations that are discipline bound. Rather she advocated a pluralist model of caring that includes both obligation and covenant formation. This model combines the duty to care aspects with which nurses have been linked, historically and bureaucratically, with the partnership and advocacy aspects of caring that nurses aspire to in current practice (Fry 1991). Caring and the nursing student Caring, thus, emerges as a concept which is central to the theory of nursing (Kitson 1987, Leininger 1988, Benner & Wrubel 1989, Halldorsdottir 1990). As a result much research has been conducted in the clinical area from the perspectives of the patient and the qualified nurse (for example, Watson 1979, 1985, Swanson-Kaufmann 1986, Mayer 1986, 1987, Bowman 1988). Emerging from this body of literature the central question appears to be, ‘is caring a distinctive aspect of professional nursing’? Professional nurse caring is said to be directed towards sustaining and improving the health and well-being of clients (Leininger 1988). It is said to be variously: ‘a humanistic-scientific combination’ (Watson 1979); ‘culturally diverse and universal’ (Leininger 1978); ‘a special way of being, knowing and doing with the goal of protection and enhancement of human dignity’ (Watson 1988); and ‘the synthesis of a motor component, a cognitive component, an affective component and a cultural component’ (Metcalfe 1990). It is distinct from generic caring which is depicted as a fundamental aspect of humanness and may include assisting, supporting or facilitating others in such a way as to improve their life (Mayeroff 1972, Hult 1980, Roach 1984, Leininger 1988). Professional nurse caring recognizes that a set of learned actions, techniques and processes exist which can be communicated to the learner and the client (Leininger 1988). Thus if caring is, as Roach (1984) says, ‘... not unique to nursing but unique in nursing’ and if it can be learned, then students should show a change from generic caring to professional nurse caring over the duration of their course. Jan Owens of the University of Wollongong completed a study on nursing students’ perceptions of caring (Owens 1990). In this study she interviewed students in the 3 years of a diploma programme for nurses at the University of Wollongong, using a structured interview schedule. Her results revealed that the students found caring a difficult concept to describe. They stated that they did not talk about caring in the classroom, instead they felt constructs of caring came from the clinical area. In a previous study of the students in a 3-year undergraduate nursing programme (Wilkes & Wallis 1993), the five categories of professional caring described by Roach (1992), were used as a framework to explore the development of caring attributes in nursing students. The major attribute of caring seen in beginning nursing students was compassion. Competence and confidence as attributes of caring emerge as the students move through their second © 1998 Blackwell Science Ltd, Journal of Advanced Nursing, 27, 582–589 583 L.M. Wilkes and M.C. Wallis and third years of study. The other two attributes of commitment and conscience were only being kindled in the third-year students. The results of this study indicated that the caring attributes of students develop during their 3-year programme and it may be speculated that these caring attributes are best learned through experience (Wilkes & Wallis 1993). However, at this stage further studies of students in other programmes were needed to clarify the picture of professional nurse caring in student nurses. THE STUDY The aim of the study was to determine the discernible patterns of growth or development in the definition or description of caring in students of nursing across the 3 years of a tertiary nursing programme. The study was designed to provide a qualitative description of the phenomenon of professional nurse caring as it develops in nursing students. Qualitative data were collected using questionnaires and semi-structured interviews. Data collection Questionnaire Data were collected using a written survey. The survey had been used in the prior study (Wilkes & Wallis 1993). The survey consisted of two open ended questions: $ $ What is the meaning of caring to you?; Describe an incident in which you have been caring to someone (1st year students only). or $ Describe an incident during your last practicum in which you perceive you were caring to a patient/client. The questionnaires were distributed in class time to all the students present. Sample Questionnaires were distributed, at the end of one academic year, to students who were in the last weeks of their course, at two Sydney tertiary institutions. Sixty students from each university were given questionnaires. At the beginning of the following academic year all students in the 3 years of the undergraduate nursing course at the same institutions were asked to complete the same questionnaire. There were #150 students in each year at both institutions. The questionnaire was distributed to the students during free class time and collected immediately after completion. The students who were willing to be interviewed were asked to sign the bottom of the survey and to provide a contact number. For the graduating students questionnaires were distributed in the last week of semester. Questionnaire sample The response rate from the first, second and third year student groups was above 90%. From the completed questionnaires received from these groups, samples of 30 for each year of the programme, in each institution, were randomly selected. For the graduating students the response rate was lower, thus, the total response at each institution was included in the sample. Twenty-six students formed the graduating student sample at one institution and 30 at the other. Interview sample From each of the questionnaire samples attempts were made to interview five students from each year. This was 584 not successful with all cohorts. Only three first-year students from each institution were interviewed and in the case of the graduating students three were interviewed from one institution and two from the other. Interviews Interviews were conducted to expand the questionnaire data by allowing more in-depth exploration of emergent themes. Using the samples described above audiotaped, semi-structured, telephone interviews were conducted with each student. The interviewer requested that the student elaborate on the content of their questionnaire and prompted the student when necessary. Analysis of data As stated above, 26 and 30 questionnaires, respectively, were returned by the graduating students of the two universities. For each of the three undergraduate years 30 surveys were picked randomly and these were analysed. This number was chosen as no new concepts appeared in the data after this point. All texts of surveys and transcribed interviews of students in the four cohorts were examined and coded by the researchers for emerging themes. The coded themes were sorted and searches for particular sections of test were undertaken with the assistance of the Ethnograph computer program (Siedel et al. 1988). The texts were coded for themes in three interlinked stages. Firstly the descriptive texts were highlighted for contextual themes (actual words of the students). Secondly, a number of minor conceptual themes were classified following the interpretive reflecting of the researchers. In this way the history of the researchers’ own meaning was brought into the description of the phenomenon. Finally, the minor themes were further categorized into major themes. Using both contextual and conceptual © 1998 Blackwell Science Ltd, Journal of Advanced Nursing, 27, 582–589 Professional nurse caring themes a model of ‘professional nurse caring from the perspective of nursing students’ was written. Ethical considerations The research proposal for this study was reviewed by panels at the researchers’ institution and participating institutions. All students taking part in the study were fully informed of the purpose of the research and assured that their anonymity would be maintained during analysis and publication of the findings. Any student who did not wish to complete the questionnaire or participate in the interviews was assured that it would not affect their role at the institution in any way. Verbal consent was given by all students. All data were stored in a locked filing cabinet in the principal researcher’s university office. researchers’ intuitive grasp of the whole experience, the researchers’ use of cumulative knowledge (literature on the phenomenon under study) and the researchers’ creativity in the organization and explication of the phenomenon (van Manen 1984). First-year students The first-year students, of both institutions, chose to illustrate their lived experiences of caring with reference to incidents which, even if they related to the clinical setting, referred to friends, family or client as family. This was very evident when they were expressing compassion, communication and comfort. Predominantly the incidents related to being friendly, nice and loving. Examples: ... so, knowing you are there for them, like with friends when their relatives die. Just looking for clues in the way they are acting or FINDINGS Nine themes emerged from the data. The researchers’ definitions of these themes are presented in Table 1. The major themes that emerged from the data will be described and illustrated using verbatim quotes from the students to provide a perspective for the reader. To assist with continuity and comparison previous knowledge of the subject obtained from the literature will be integrated at times with the findings from the present study. In this way the phenomenon of caring from the perspective of nursing students is described from the integration of the participants’ descriptions of their experiences, the speaking... People don’t come right out and say they are upset... so you have just got to be aware of how people act or how they are saying things and... you can’t be too blasé about what people say. Another said: At work, one of my patients was diagnosed HIV positive and I listened, touched and cried. I felt I cared and helped him. I referred him to more knowledgeable people that could advise him, e.g. social worker and counsellor, etc. Additional themes of reward, respect for personhood and privacy indicated how caring was expressed at different levels within this first year group. For example: Table 1 Definitions of the themes that emerged in this study ... she was fully exposed, I mean the curtains were drawn but the Major theme Definition doctor and nurse were taking no notice that they hadn’t pulled her nightie down and she was fully exposed. I just went and Compassion Love and friendship, being concerned for another. All aspects including verbal, non-verbal and physical contact. Actual instances when the students used the word. The ability to use cognitive, affective and psychomotor attributes that are particular to that clinical situation. Doing things they did not want to do. Expression of the activity of ‘love’. Not showing bias. Being able to do things without doubting yourself. Taking account of their actions. Looking at the person as an individual deserving of respect. Conscious that the person is as ‘good’ as themselves. When the students stood up for patients. When the student spoke to other staff on behalf of the patient. pulled her nightie down and she said thank you. I thought it was Communication Concern Competence Commitment Confidence Conscience Courage sort of ignorant of these people. The majority of the first-year students could be classified as caring in the generic sense that Leininger (1988) refers to and differentiates from professional caring and professional nurse caring. First-year students demonstrated their caring through being compassionate and by communicating, comforting and being concerned. The examples of caring through communication were expressive of a face-to-face relationship cultivated through dialogue. When these students reported incidents involving communication, they mainly described this within a relationship which Buber (1923/1970) would classify as an intimate ‘I-Thou’ relationship. The only obvious examples of competence in these students occurred when seeking the advice of others and identifying that this was necessary and appropriate at their level. This can be seen in the previous example with the HIV positive patient. © 1998 Blackwell Science Ltd, Journal of Advanced Nursing, 27, 582–589 585 L.M. Wilkes and M.C. Wallis ports the findings of a previous study by the authors (Wilkes & Wallis 1993). Second-year students As we move to a second-year perspective, compassion remains pre-eminent and it is again expressed and enacted by communication. However, the communication has changed in emphasis. Some of the second-year students described encounters with clients which evidenced the ‘triadic dialogue’ described by Bishop & Scudder (1990). In this type of dialogue the nurses are more than just partners with their patients. They have a goal of ‘care of the patient who is ill’ and they are working side-by-side with the patient rather than face-to-face. For example: Practice requires that the helping relationship be the nature of the client–nurse interaction. Third-year and graduating students Once again for third-year and graduating students of both institutions communication is a major ‘caring action’. An increasing number describe incidents in which the dialogue could be said to be ‘triadic’. The following example relates to an incident in which a student is with a young woman after the birth of a stillborn baby: I let her talk — um — let her cry, I cried with her. There were times when I just went in and sat with her, she just wanted someone to sit there, not to do anything — um — I think that was important. And again: He was in a very advanced stage of his disease and I realised that I had to do an assessment... I guess I looked at it from a moral perspective that I could very well have gone in there and been very cold got the information and left but I didn’t, I more or less spoke to him when he was not as laboured in his breathing... On the second day he was frightened and started to talk about being horrified of sleeping... we talked... I put the client first, instead of what I have to do. In this sense there may be moral ‘good’ coming out of the relationship. This relationship is moving away from the ‘I-Thou’ that Buber (1923/1970) describes and begins to approach the ‘We’ relationship described by Schutz (1932/1967). This particular sharing relationship was more evident in specific individual students. The other obvious expression of care in students from both institutions was the ‘doing’ related to fulfilling the personal physical needs of the clients. For example: To me caring is taking care of another person who needs my help, that is, psychologically, biologically, socially, environmentally, spiritually. And Helping a client with their normal everyday activities which they were not capable of doing. Another change, discernible in the second year students, was their increasing use of a specialist, professional body of knowledge to express and describe caring. For example: Caring means using my knowledge and skills to promote positive feelings within my patient. Caring can be indicated by a successful The example cited above appears to demonstrate that some of the students go beyond a triadic dialogue and reintroduce intimate aspects into the relationship to develop a fully experienced ‘We-relationship’ (Schutz 1932/1967 p.172). These third-year students expressed compassion both in a professional sense and were reintroducing a personal sense. In their ‘doing’ they were including technical knowledge to express caring. Conscience was seen not just in their definitions but also in their actions and expression of care. There were few examples of conscience in the first year students’ definitions. Those that were cited were mainly related to acting in a way that respected the personhood of the patient. In the third year students this was extended and incorporated not just seeing the person in an individual, personal sense but actioning this in the ‘professional/ technical’ sense. For example: It is respect and equal consideration for all people. Caring needs to be expressed through actions and behaviours. By the time the students were graduating some were able to express their approach to caring in a professional action sense: Caring is beyond action. It stems from actual feelings of concern. In the nursing situation this feeling of concern extends to actually attempting to improve a person’s condition or illness. It means doing something just because it has to be done. In order to care one must accept responsibility and carry out nursing inter- recovery or a contented, unfearful death in a patient. ventions as a professional and in the capacity on a level with the nurse’s knowledge and abilities. A succinct example of this is that some of these students are able to express their meaning of competence as a caring attribute in definitive terms but not contextual terms. So for the first time competence occurs in the written definitions but not in the descriptions of lived experience. This growth in professional nurse caring attributes sup- This particularly came out in the lived experiences described by the students and could be linked with the themes of comfort and concern as well as communication. These students frequently expressed the ways in which they helped patients make sense of what was happening to them. An example of this is: 586 © 1998 Blackwell Science Ltd, Journal of Advanced Nursing, 27, 582–589 Professional nurse caring [There was a] patient who was very frustrated about her condition — I sat down with my patient and let her express all feelings. The patient felt better that I took time to listen to her problems, empathised with her situation. Gadow’s (1980) description of the nurse as ‘existential advocate’ who ‘affirms the value of the lived body through the intimacy of physical care and comforting’ and ‘the reality of the body object by interpreting to the patients their experience in terms of an objective framework’ fits well with what these students were beginning to approach. Polyani (1962) differentiates between the formal knowledge of a discipline and the personal knowledge that the professional brings to the situation. Evidence of personal knowledge, which is best expressed in context, begins to emerge by the end of third year. This is apparent as the graduating students cite competence in their descriptions of lived experience whereas the second-year students used it, only, as part of a definition of caring. An example from a graduating student was: A client had just come back from theatre and needed to have a catheter inserted. She was very distressed about this and I ensured that she was reassured and had privacy and I inserted it as quickly as possible to cause as little discomfort as possible. A MODEL OF PROFESSIONAL NURSE CARING From the researchers’ examination of the data a theory of meaning of caring for students of nursing emerged. The visual model as seen in Figure 1 depicts a theory of meaning of a moment in the lived experience of students in nursing. From the perspective of students who are growing through people, patients and their educational courses, there seems to be a momentary pinnacle of professional nurse caring that they are striving for but which not all necessarily achieve. This theory of meaning of professional nurse caring attempts to bind the core of caring — compassion — with a number of ‘caring actions’ specific to the nurse. Compassion, as the core of this caring, is seen as: to love, to have and share feelings, to be a friend and to be concerned for others. This caring and compassion is actualized in the students’ and the graduates’ nursing of patients (clients) by: communicating (listening, talking, explaining, touching, educating, expressing feelings); providing comfort (doing, assisting, helping); being competent (assessing, watching for cues, having knowledge and skills, being responsible and being professional); being committed (doing, loving, showing no bias, ‘being there’); having conscience (attending, giving the person dignity and respect, doing, treating as oneself ); being confident (knowing what to do without hesitation); being courageous (advocating for a person’s needs and rights to treatment, intervening for and with the person), The first of these caring actions (communication) is not only an actualization of this professional nurse caring but often forms the link between the core of the caring (compassion) and the other caring actions. In this way, communicating constitutes an important medium for the expression of the caring actions. Figure 1 Model of professional nurse caring from the perspective of nursing students © 1998 Blackwell Science Ltd, Journal of Advanced Nursing, 27, 582–589 587 L.M. Wilkes and M.C. Wallis DISCUSSION LIMITATIONS OF THE STUDY Whilst the model of ‘professional nurse caring from the perspective of nursing students’ can be seen as a pinnacle of the whole experience of caring to which students could aspire, there are overt and obvious changes in this caring, as expressed by the themes extracted from the data of the students as they pass through their course. There were differences in these themes of caring at the two institutions and in the sophistication with which these themes were expressed by the students from each. However, these differences could not be attributed to the institutions but rather reflect the individual differences of the students. The model of ‘professional nurse caring from the perspectives of nursing students’ which has been described in this study affirms the belief of Leininger (1988) that professional nurse caring is directed towards the health and well-being of patients. The students in this study, whilst seeing and expressing caring predominantly as compassion ‘... a way of compassion, a journey of love’ (Ray 1991), were directed in their care, particularly in later years, to the health and well-being of patients. The professional nurse caring, as described in this study, is not necessarily that of expert nurses, further research would be necessary to ascertain this. It is, however, as Fry (1991) postulates, ethically orientated to a moral obligation of care and a covenant to care. Its ethical orientation arises out of the nurse’s role as a health care worker (Pellegrino 1985; Fry 1991). From the point of view of Pellegrino (1985) the nurse is there to help by forming a special relationship with the patient (client). In this ethic of professional nurse caring there is a second dimension. As Frankena (1983) found, the caring must encompass a respect and love for others allowing both the cared and the carer to grow. In sum, a beginning student of nursing brings some caring attributes such as compassion with her/him on entering nursing. Over the duration of their undergraduate course the students develop and add to their personal caring attributes but to different degrees. Throughout the course the students are taught and experience ways of actualizing these caring attributes through relationships within a nursing context. Sometimes their enactment of these attributes falls short of the demands of the situation or of the nurse themselves. This can be painful but will probably always be a learning experience for the professional nurse. This study has shown that ‘professional nurse caring’ can be described by students of nursing and that there is a change in the emphasis in components of caring as a student moves from one year to another. In addition, individual differences in students provide an added dimension to the model. Professional nurse caring takes place in a nursing context and is enacted through relationships that have the capacity to develop from an ‘I-Thou’ to a ‘We’ relationship. In a qualitative study such as this it is not appropriate to generalize the results to all students of nursing programmes. The study rather describes the phenomenon as it is discovered in this time and place. Methodologically the researchers had difficulty following-up respondents for interview. Because of time and financial constraints telephone rather than personal interviews were conducted and this may have interfered with the personal nature of the inquiry. One major limitation of the study is that in order to realize a natural growth of professional nurse caring a cohort of students needs to be followed from first year to graduation and beyond. Another factor that limits the study is that the data collection only involved written and verbal descriptions of lived experience by the subjects. Observation of students in the clinical area and follow-up interview may be beneficial in explicating more fully their ‘caring actions’. 588 RECOMMENDATIONS This study has allowed the development of a model of ‘professional nurse caring from the perspective of nursing students’. A second phase of this project explored how this model is affected when students start work as registered nurses (Wilkes & Wallis 1995). However, further work needs to be conducted to determine if this model describes the ‘caring actions’ of more advanced practitioners. In addition, it is important to examine in what way the constraints of the work environment, such as high nursing workloads and decreasing time for nurse–patient interaction, affect the ‘caring actions’ of nurses. Acknowledgements This study was made possible by the cooperation of students and academic staff at the two institutions involved. The study was supported with funds from the Nurses Registration Board of New South Wales and by the Research Grants Scheme of the Australian Catholic University. References Benner P.D. & Wrubel J. (1989) The Primacy of Caring: Stress and Coping in Health and Illness, Addison Wesley, Menlo Park, California. Bishop A.H. & Scudder J.R. (1990) The Practical, Moral, and Personal Sense of Nursing: A Phenomenological Philosophy of Practice. State University of New York Press, Albany. Bowman L. (1988) A phenomenological analysis of the experience of being caring in a nurse–client interaction. 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