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Living theory: enhancing the psychological support of patients

Jen Hawkins, Helen Hollinworth
iving theory is the creation of new knowledge that leads to enhanced pro'fessional practice (Whitehead, 2000). New knowledge emerges as a result of four interlinked stages: # Reflection on and evaluation of known knowledge # This !S closely followed by the integration of newly taught and relevant knowledge # Self-exploration, which includes understanding and reflecting on the implications of the previous rwo stages for personal and professional practice, and their application to new professional experiences # The emergence of new knowledge, and acknowledgment of the impact this will have on the practitioner as he/she strives to improve professional practice. Completing the process requires sharing this new knowledge with others, by going public, and making the work accessible. A major principle of living theory is that one's values arc questioned, modified, clarified and sometimes changed completely in the emergence of the new knowledge. The concept of living theory was first presented by Whitehead (2000) in relation to action research in different spheres of education. His original contribution was to educational knowledge and included the idea that each one of us can create our own living theory in the descriptions and explanations we offer for improvements in managing our professional practice. In living theory, practical explanations are particularly powerful because they form part of the process of trying to improve the quality of professiona! practice. It involves practitioners reflecting on and evaluating actions as they try to hring about improvement by working to reduce rhe gap hetween their values and their practice. From this process, new knowledge emerges that, if sustained over time, will enhance and improve the individual's professional practice (Whitehead, 2000). Living theory is not ahout creating one unified way of thinking or practising to which all

Abstract
This article explores how nurses invoived in a research project, that incorporated teaching psychological theories and counselling skiils to enhance the psychoiogicai support of patients with wounds, had, one year on, changed their professional practice. This inquiry was framed by living theory, a concept previously only used in education, which is based on the integration of known knowledge, newly taught knowledge and increased self-awareness. The major principle of living theory is that one's values are questioned, modified, ciarified and sometimes changed completely in striving to improve one's professional practice. This research showed nurses creating their own living theories, aspiring to really care for the whole person by developing strong, meanin0ul relationships with patients. The steps that participants took from first using this enhanced way of working with patients with wounds, to using it to support aii patients psychoiogicaliy, are demonstrated.

must suhscribe, rather it is about encouraging people to reflect on whatever new knowledge they create in striving to improve their practice. This research set out to identify whether new knowledge was demonstrated rhrough the creation of living theories in nursing. The .authors helieve that holistic care of patients requires the inclusion of psychoiogicai helping skills, and this belief informed previous research that investigated whether teaching psychoiogicai theories and coLinselling skiils ro nurses improved their care of patients with wounds (Hollinworth and Mawkins, 2002). The authors shared their knowledge, experience, ideas and values with the participants through workshops. They then wanted to explore whether or how participants had applied this information in a way consistent with their own living theories. One year after the original research, participants were contacted to determine whether their professional practice had further advanced through their commitment to patients' psychological needs and the creation of participants' living theories. As psychological support and counseiiing skills formed the basis of the new knowledge taught in the workshop, and this underpins

Jen Hawkins and Helen Hoilinworth are Senior Teaching Practitioners, School of Health, Suffolk College, Ipswicli Accepted for publication: March 2003

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a major part of the research findings presented here, an explanation of its application is given next.
FIRST PHASE OF THIS RESEARCH

Nurses supply a range of emotional support from 'tea and sympathy' to giving professional advice. For this research, participants were required to tailor their relationship with the patient to the patient's individual needs. The teaching strategy used in the workshop involved separating nursing tasks from time spent talking to patients. This was a set time in which to offer careful, sensitive listening, exploration of significant personal problems and encouragement to recognize and express painful or disturbing thoughts and feelings (Hawkins, 2003}. In their classic study, Weisman and Worden (1977} found that cancer patients who received even minimal psychological support had a significantly better outcome than those receiving no psychological support. It was the authors' intention to enable participants to offer specific psychological support to patients with wounds to address possibly significant levels of distress caused by immobility, isolation, fear, anxiety and lack of control. It is not possible to determine fully what participants took from the workshop, or how they might value or disregard the knowledge and skills taught, rather it was important to acknowledge all the participants' experiences as valid in creating their living theories. The first phase of this inquiry used research diaries, in conjunction with a reflective tool, to explore how nurses provide holistic care for patients with wounds (Hollinworth and Hawkins, 2002). Forty-three qualified nurses Table 1 . Questions posed to allow data collection

who regularly care for patients with wounds recorded how they supported patients holistically before and after attending a workshop on psychological support and counselling skills. Of this group, 39 nurses then attended focus groups to share their experiences. Participants represented varied practice settings, with 581 patient situations recorded in the diaries. Data from the diaries completed before the workshop demonstrated that patients' feelings were identified, but the nurses did not attend to them fully (Hollinworth and Hawkins, 2002}. However, after the workshop on psychological theories and counselling skill acquisition, a number of participants showed a major shift in their understanding and provision of psychological support to patients. Others, having reflected on the workshop content, were unwilling to integrate the psychological theories and counselling skills into their care of patients at this time. Dryden (1985} explains that not all are ready (or wiliing) to 'engage in the self-exploration that accompanies training in counselling skills' and that comprises a major principle of living theory. One year later after ethical approval, participants were again invited to attend focus groups. This approach to data collection proved problematic for participants owing to pressures in practice. A semistructured telephone interview with participants by either one of the researchers was adopted instead, using the same questions planned for the focus groups {Table 1). Telephone interviews seem to yieid similar data to face-to-face interviews (Breakwell et al, 1995}. Framed by the questions posed, data analysis again followed the stages for working with qualitative data described by Taylor and Bogdan (1998}.
DISCUSSION

It is almost a year since you came to the counselling skills workshop and tiie focus group to share your experiences. What influence, if any, has this had on your current practice? Please give e)ramp(es from practice Many of you said developing counselling skills was not easy has time helped you consolidate these skiiis? How is it for you now? Do you manage, to maintain the task/taiking divide as presented at the workshop? Do ymi use counsellir^ skiiis with patients ottier than those with wounds? Please describe patient situations to illustrate this

The purpose of quahtative inquiry is to produce findings and interpret the essence of what the data reveal (Patron, 1990}. In an attempt to achieve clarity and understanding, and avoid repetition, the findings, discussion and interpretation are combined. Analytical themes, linked closely to the interview questions, are used to structure the presentation. The perspective of the researchers has relevance here. One is a nurse-teacher with specific expertise in wound care, the other is not a nurse, but has a psychology background with many years' experience teaching health

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and counselling psychology. The researchers' differing knowledge and perspectives on practice converge, and bring focus to this inquiry. Thirty nurses who regularly care for patients with wounds (from the 39 participants who completed the earlier study) responded. Participants again represented acute and community hospital nurses, practice nurses, community nurses and nurses working in nursing homes. This part of the research sought to explore whether participants' commitment to their patients' psychological needs had enhanced their practice and demonstrated the creation of their living theories. The evidence for living theory was exposed by the themes that emerged from the data analysis: 'influence on current practice', 'developing counselling skills' and 'psychological support of other patients'. The first theme relates to the influence on participants' current practice of learning to use counselling skills to give psychological support to patients with wounds.

A number mentioned cascading counselling skills to other healthcare colleagues. While acknowledging that they were using counselling skills more, feeling more confident in their use and were more aware of their importance, a number of participants made reference to the impact providing psychological support was having on their workload: Participant #14:'[ use time more effectively now through using the [counsellingl skills.' Although reflection, cUnical role models and work environment all influence nurses' ability to recognize and act effectively on patients' nursing problems (McMahon and Pearson, 1998), commitment to maintain caring as a central value is less straightforward (Woodward, 1997). Holistic caring includes an emotional element, which some practitioners may choose to ignore by focusing mainly on nursing tasks. Greenwood (1993) gives a possible explanation for discrepancies between what nurses are taught and what they actually practise. Nurses often learn incidentally and largely unconsciously through repeated everyday experiences in clinical practice focused on physical disease rather than on the whole person and this impacts on their personal philosophy of care. This finding is comparable witb espoused theories and theories-in-use (Argyris and Schon, 1974). At the other end of the continuum, testimony from practitioners {n = l\) demonstrates a significant influence on their current practice, illustrated by self-exploration and insightful patient situations. Participants describe how being able to provide psychological support using counselling skills has affected how they feel, how they approach people and has raised their awareness of cues or non-verbal communication indicating patients' psychological needs. It is the selfexploration and the use of T explanations for changes in an individual's professional practice, as demonstrated in the following examples, that show participants' increased confidence and creation of their living theories: Participant #36; 'The biggest influence is recognizing when people are wanting to open up and talk, and I am now able to take that concern forward...I actually feel I have achieved something and make a difference to people's lives."

Participants describe how being able to provide psychological support using counselling skills has affected how they feel, how they approach people and has raised their awareness of cues or non-verbal communication indicating patients* psychological needs.

Influence on current practice

All participants considered they had learnt from the experience of attending the vyorkshop. In addition, awareness of the holistic needs of patients and the value of supporting patients psychologically had been raised for all concerned. Nevertheless, the influence on participants' current practice appeared to be on a continuum. At one end of the continuum, participants {K=1I) either considered they had already been providing a form of psychological support for their patients and acknowledged there was no real change in their practice, or (in the words of participant #33) had gone back to their 'old ways of working'. For these participants, reflection on what had been advocated at the counselling skills workshop had not significantly changed their practice. Having reflected on, questioned and clarified the newly taught knowledge, the decision to return to their 'old way of working' was participants' adherence to their preferred way of practice their living theory. Further along the continuum, the range was from some influence (n = 3) to increasing influence on practice (n = 5). Participants articulated how important it was to consider the whole person and his/her lifestyle and not just to look at the wound. They found they were reflecting more on patients and how they felt.

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Participants commented that time had definitely helped. They were looking and listening more intently and, importantly, they had proved to themselves that patients could prioritize their concerns into the 5 minutes offered after wound care. They no longer had to think what comes next in the model; instead the whole processes flowed automatically and participants found this powerful and enabling.

Participant #20: 'Had quite a lot of influence. T have stopped assuming things, making assumptions about things, or people's problems.' However, it is these participants' confident descriptions of how they provide psychological support to patients with wounds that clearly ilkistrares this major int-'lucnce on their practice. Participant #30 described a female patient wirh extensive cancer of the face, who was aware no further treatment was possible. Daily cleansing and dressing f)f the nasal cavity, extending right into rhe buccal cavity, was necessary. The patient spoke of an overwhelming urge to scream at people when they were doing her dressing. It was as if they were "iti' her face. Several short sessions of sitting with the patient, enabling ber to talk, exposed her one great fear was losing her mind: Participant #30: 'On one occasion, when we were alone, I even tried getting the patient to scream.' Heron (1990) confirms chat to release tension, encourage screaming and tears, to facilitate: the ventilation of strong emoti()ns and Throughout enable the patient to feel secure, is an evtremely difficult task. This led to his claim chat cathartic interventions were the least effectively used of his six category interventions {Meron, 1976). Another influence on practice was enabling practitioners to better understand a patient's problem or situation, and sometimes this led to impSemeiuing different or more appropriate care. A real sense of personal fulfilment permeated the dialogue of these nurses, their living theories being rooted in the philosophy of patient-centred care. This first tbeme relates to participants' perceptions of the influence learning co use counselling skills as presented in the workshop one year previously has had on tbeir current practice. Counselling skills are best delivered in a structured way, within a specified rimeframe and only on completion of che nursing task (Hawkins, 2003). However, our earlier research demonstrated that many participants found developing counselling skills was not easy, and they felt similarly about separating wound care from their provision of psychological support (Hollinworth and Hawkins, 2002). The second theme 'developing counselling skills' revisits these issues one vear later.

Developing counselling skills

I he same distribution along a concinuum seen in rhe first theme is mirrored in this second cheme. Some participants (n= 1 1) acknowledged chat rime had not made any noticeable difference to their development of counselling skills. These nurses still found it difficult to separate tbeir care of the person's wound from providing psychological support. One nurse found this separation really difficult, admitting she needed to have something active to do to cake rhe emotional pressure off her when talking about a patient's concerns. Another commented: Participant #17: 'Time is a big factor, and if under pressure 1 still talk while doing [the dressingi or writing up case notes afterwards.' While a few nurses ( = 3) perceived their use of counselling skills had become somewhat easier over time, others {n-5) felt more relaxed and more at ease wirh people. Use of che counselling skills model presented in the workshop had gradually become more natural and having a specific timeframe had proved helpful. However, participants from both chese groups did not always find it easy to separate talking while doing the dressing from their provision of psychological support. Somecimes they were able to and acknowledged ir was more powerful if done separately; at otber times it was a bit of both. Tbis demonstrated a valid range of experiences. Ir was evident that other participants {n=[\.) had consolidated their counselling skills. Participants commented that time had definitely helped. They were looking and listening more intently and, importantly, they had proved to themselves that patients could prioritize their concerns into che 5 minutes offered after wound care. They no longer had ro think what comes next in tbe model; instead the whole processes flowed automatically and participants found this powerful and enabling. One participant talked about no longer being afraid to use counselling skills: Participant #6: 'I thought if someone cried, I had made them cry, and this was a bad thing. I now recognize I have helped them to say things they would have had difficulty in saying.' I'hese participants were very clear that tbey maintain che separation of doing the wound

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care from providing psychological support, and considered this very important: Participant #6; '...if we don't separate these out, the patient only remembers what you did, not what you said...It docs work if I say "I have five minutes" (after completing the dressing).' Participants were not merely impieriienring the authors' living theories and values drawn from the theories and skills taught at the workshop. Rather they had used reflection to question, modify, clarify and sometimes completely change their values, leading to re-evaluation of their practice and the creation of their own living theories. The final theme explores participants' use of their developed counselling skills with patients other than rhose with wounds.

know where to turn. Her new knowiedge and use of counselhng skills had 'enabled' him to utiburdcn himself. All these nurses described their provision of psychological support using a broad spectrum of patient situations, including people undergoing difficult and painful procedures. The participants" integration of new knowledge and skills and their ongoing reflection clearly encouraged this holistic, individualized and creative approach to care, and demonstrated the creation of their living theories. Many of the participants described how caring for the whole person makes the job more enrichmg. One nurse summarized embracing this approach to practice: Participant #3: 'It becomes a way of life after a while.' The authors propose that this also provides evidence for tbe creation of living theories by nurses. Those nurses who demonstrated living theory appear to be those wbo bave a personal philosophy of tiursing that really aspires to caring for the whole person by deveioping meaningful relationsbips with patients, despite the many constraints and demands of healthcare settings. Ramos (1992) identified three qualitatively different levels of nurses' invoivement with patients, ranging from an instrumental level of a 'job to be done", to a reciprocal relationship considered to be 'the very cornerstone of nursing care'. Interestingly, this intimate professional relationship was only demonstrated by one third of the nurses involved, which mirrors these findings. in another study identifying nurse-patietit relationships, Morse (1991) confirms commitment on the part of the nurse has considerable implications for developing relationships. Patient-centred nursing embraces this commitment of attending to patients' psychological, social and emotional needs, as well as their physical needs (Titchen, 1996). Roach (1984) describes commitment as one of five categories of human behaviour within whicb professional caring can be expressed. However, the authors contest that living theory exposes a higher levci of practice that cannot be explained solely by a commitment to care it must also include a commitment to ongoing personal and professional development.

Psychological support of other patients

Both phases of this inquiry were concerned with rhc psychological support of patients with wounds. However, must nurses also care for a range of other patients. While those participants who expressed varying degrees of difficulty in developing counselling skiiis implied they bad extended tbeir skills to supporting other patients psychologically, this did not always correspond with their responses to otber questions. Only those participants who had consolidated tbeir counselling skills and were committed to separating psychological support from nursing activities or 'tasks' showed use of counselling skills to provide psychological support to other patients. Tbese nurses ( - 1 1 ) described usitig this approach wich all patients and relatives where a possible psychological need or concern was identified. Following che workshop, these participants felt enabled to understand the patient from the patient's owu frame of reference and then to communicate their understanding in an empathetic way, with clarity and sensitivity. Palliative care patients were frequently mentioned. One participant (#51) described a very private single woman receiving palliative care. This woman appeared very anxious and scared. The use of counselling skills enabled her to talk through her problems, disclosing that she is petrified of abrupt staff. Another nurse (#42) spoke about a young man who had been drinking a lot, had recently split from a loug-tcrm relationship and did not

Only those participants who had consolidated their counselling skills and were committed to separating psychological support from nursing activities or "tasks" showed use of counselling skills to provide psychological support to other patients. These nurses described using this approach with all patients and relatives where a possible psychological need or concern was identified.

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DISCUSSION/CONCtUSIONS

KEY POINTS
Living theory is the creation of new theory that leads to enhanced professional practice. It involves reflecting on and evaluating actions, and working to reduce the gap between values and practice. i Nurses supply a range of emotional support, but for this research participants were required to tailor their relationship with a patient to his/her individual needs. I This research sought to explore whether participants' commitment to patients' psychological needs had enhanced their practice and demonstrated the creation of their living theories. I The living theories of some practitioners have remained unchanged; for others, commitment to patients' psychological needs has dramatically changed the way they work. I Many participants are now seeding the community with enhanced practice, demonstrating to colleagues the importance and value to practitioner and patient of offering holistic care in the form of psychoiogicai support.

Usitig a reflective framework, one year after the workshop and focus groups on psychological theory and counselling skill acquisition, a major shift was demonstrated in the provision of psychological support by all participants. Some nurses consciously chose not to change their practice, whereas others found developing counselling skills difficult or were less willing to be involved in change. Possihly they found it difficult to work with the contradictory elements of nursing based on competence and expertise, and the counselHng ethos of acknowledging weaknesses, anxieties and doubts. This article summarizes the second part of this research exploring the current influence on practice of this teaching strategy. Underpinning both parts of this inquiry was the concern that there is a lack of professional expertise in providing appropriate psychological support in aspects of wound care. The authors maintain active clinical iinks as well as teaching roles and recognize that the current healthcare culture, political initiatives and nursing shortages impact on nurses and the care given to their patients. Practitioners may be educated to provide patient-centred nursing, but the tension between espoused theories and theories-in-use (Argyris and Schon, 1974) is still current. However, it is very important that nursing does not lose sight of its goal of holistic care. While teaching specific counselling skills can foster the development of empathy (Cutcliffe and Cassedy, 1999), enabling nurses to use psychological caring skills in practice remains a challenge to nurse-lecturers (Priest, 1999). Mezirow (1981) describes how, through education, critical reflectivity can transform people's perspective, but Heath (19^8) points out that a satisfaction with our own level of performance may be the most potent block in the development of expert practice. Although learning nursing is an ongoing project (Brookfield, 1993), one year after the authors' original research, it is evident that practice has advanced in varying degrees for participants. The living theories for some have remained unchanged; for others [n = ll), commitment to patients' psychological needs has dramatically changed the way they work with patients. One year after the original research., it is exciting to see that many of the nurses involved are demonstrating their new living

theories. These participants, in sharing their professional practice through involvement in this research, have made a contribution to public theory and knowledge. They have fully contributed to the development of living theories in nursing. These practitioners are now seeding the nursing community with enhanced professional practice, demonstrating to colleagues the importance and value to practitioner and patient of offering truly holistic care in the form of psychological support. HBi
The authors would like to thank Matthew Ganda, a critical friend, for his encouragement and support. Argyris C, Schon D (1974) Theory in I'ractice. lossey Biiss, San Francisco Breakwell 0, Hammond S, Fife-Schaw C, eds (1995) Research Methods in Psychology. Sage, London Brookfield S (1993) On impostorship, cultural suicide, and orher dangers: fiow nurses ltarn critical thinking, j Contin Educ Nurs 24(5): 197-205 CiiEchffe JR, Cassedy P (1999) The developmenr of empathy in students on a short, skills-based counselling course: a pilot study. Nurse Educ Today 19: 250-7 Dryden W (1985) Ttaciiing counselling skills to non-psychologists. BrJ Med Psychol 58: 217-22 (Ireenwood J (1993) Reflective practice: a critique of the work of Argyris and Schon. / Adv Nurs 18:1183-7 Hawkins J (2003) T h e Hawkins Model': from task to talking, a five-minute model. Nurs Stand 17(31): 63-6 Heath H (1998) Reflections and patterns of knowing in nursing. / Adv Nurs 27(5): 1054-9 Heron j (1976) A six category intervention analysis. British journal of Guidance Counselling 4:

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Flerun J (1990) Helping the Client: A Creative Practical Guide. Sage, t.ondon Hollinworth H, Hawkins J (2002) Teaching nurses: psychological support of patients with wounds. BrJNurs (Tissue Viability Suppl) 11(29): S8-S18 McMahon R, Pearson A (1998) Nursing as Therapy. 2nd edn. Stanley Thornes, Cheltenham Mezirow J (1981) A critical theory oj^ adult learning and education. Adult Educ 32(1): 3-24 .Morse J (1991) Negotiating commitment and involvement in the nurse-patient relationship. / Adv Nurs 16: 455-68 Patron MQ (1990) Qualitative Evaluation and Research Methods. Sage, Newbury Park, California Priest HM (1999) Psychoiogicai care in nursing education and practice: a search for definition and dimensions. Nurse Educ Today 19: 71-8 Ramos MC (1992) The nurse-patient relationship: theme and variations. / Adv Nurs 17: 496-506 Roach S (1984) Caring: The Human Mode of Bein^. University of Toronto, Toronto Taylor' A, Bogdan R (1998) Introduction to Qualitative Research Methods. 3rd edn. John Wiley and Sons, New York Titchen' A (1996) A case study of a patient-centred nurse. In: Fulford KWM, Ersser S, Hope T, eds. Essential Practice in I'atient-Centred Care. Blackwell Science, Oxford: 182-97 Weisman AD, Worden JW (1977) Coping and Vulnerability in Cancer Patients. Massachusetts General Hospital, Boston Whitehead J (2000) How do I improve my practice? Creating and legitimating an epistemology of practice. Reflective Practice 1(1): 91-103 Woodward VM (1997) Professional caring: a contradiction m terms? / Adv Nurs 26: 999-1004

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