Restructuring nursing practice, including rethinking, reconfiguring, and redesigning nursing roles, has occurred in most health care institutions (Wunderlich, Sloan, & Davis, 1996). In many situations, the effect of the restructuring has been described as demoralizing to the staff nurses involved (Curtin, 1994). Others, however, have spoken of the potential for positive outcomes from the redesign of nursing roles (Porter-O'Grady & Wilson, 1995).
The purpose of this study was to explore the experience of staff nurses in a long-term care facility whose roles were reconfigured to include home-based care as well as institution-based care. A phenomenological approach was chosen to capture the essence of this experience.
Effect of Restructuring
Current literature on the effects of restructuring focuses primarily on strategies for addressing staff responses (Hastings & Waltz, 1995; Kovner, Hendrickson, Knickman, & Finkler, 1993; Lindstrom & Tracy, 1992; Tappen, Türkei, Hall, Stahura, & Morgan, 1997; Wester, 1994). Although these authors offer ways to ease the pain of transition and help nurses confront change, most do not address directly the experience of the nurses whose roles were restructured.
An exception is the quantitative study conducted by Kovner et al. (1994) who examined the impact of various nursing care delivery models on job satisfaction. Findings of this study revealed that nurses experience a period of initial dissatisfaction prior to coming to terms with the imposed changes and new roles. The most important factors impacting job satisfaction were pay, autonomy, and professional status. Sayler (1995) found environmental turbulence had a direct negative effect on communication skills and interpersonal relationships with patients, families, and peers. A positive correlation between hardiness as a personality trait and the ability to perceive uncertainty as a challenge was noted. Sayler suggested further research to determine if nurses can view uncertainty as a positive force.
Effect of the Practice Setting
Another result of efforts to reduce health-care costs has been the shifting of care into the home environment. There is some evidence in the literature that the practice differs by setting. A focus group study conducted by Tagliareni, Mengel, and Sherman (1992) examined the essential nature of nurses' work in acute and long-term care settings. The experiences related by participants indicated a clear contrast between the two settings. Acute care nursing practice was characterized by standardization of care planning and specialized interventions directed toward specific events. In contrast, long-term care practice was characterized by individualization, creativity, and uniqueness of each caring situation.
Newman, Lamb, and Michaels (1991) used a phenomenological approach to study the experience of nurse case managers involved in home care. The dominant theme of the experience described by the nurses was the relationships formed with the clients. A follow-up study (Lamb & Stempel, 1994) of the clients' experiences during home visits supported the significance of the nurse-client relationship.
The Nurse-Managed Family Follow-Up Project (Tappen et al., 1997) provided the impetus for this study. This project used staff nurses from the inpatient unit of a large rehabilitation and nursing center to provide nursing care management during their patients' stay in the institution and for 3 months postdischarge at home. As the nurses became involved in the project and related their experiences in the home setting to their colleagues and project staff, it became evident these experiences were different from those in the inpatient setting. To more fully understand what these new experiences meant to the nurses, this study was undertaken.
The phenomenological method as explicated by van Manen (1990) was used for this study. This method is appropriate when the purpose of the research is to grasp the essential meaning of a phenomenon from the perspective of those studied. According to Ornery (1983), qualitative methods allow for an intense study of phenomena with no overlying framework, preconceived notions, or expectations to influence the research as data are generated and analyzed.
The purposive sample consisted of five RNs involved in providing follow-up care to patients discharged from a long-term care facility. Their roles were restructured as part of a larger project (Tappen et 1997) to implement a model of care within the facility. All of the nurses interviewed were nurses on the rehabilitation and extended care units of this (272-bed) long-term care facility. All were women; three were Black, and two were Hispanic. Their al preparation in nursing was at diploma or associate level. At time of the interviews, the range years of nursing experience in long-term care setting was from 10 to 20 years. One of the five pants had home health experience years prior in a western country.
Data collection occurred over a year period. Indepth interviews conducted on work time in a area within the facility. The view setting was comfortable, participants were relaxed and able speak freely. Each interview approximately 1 hour and audiotape recorded. After informed consent, participants asked to provide a full description their home visiting including their thoughts, feelings, what the experience meant to them. All interviews were transcribed verbatim and reviewed prior to data analysis to detect errors or omissions that may have occurred during transcription.
Data analysis was guided by the phenomenological method described by van Manen (1990). During the process of discussion, reflection, and writing, the authors saw themes emerging. Themes provide a means for describing the structures of experience. According to van Manen (1990), formulating themes is "not a rule-bound process but a free act of 'seeing' meaning" (p. 79). Through this process of discovering themes, the true nature of the phenomenon is revealed.
The researchers first read the transcripts without supplying explanations or making interpretations. As the researchers studied the data, they developed an awareness of the data's meaning. This information was recorded. The researchers highlighted the text and wrote key phrases in the margins of the text. The researchers continued the analysis to reveal themes described by van Manen (1990) as "threads that weave the experiences together" (p. 63). The task of the researchers is to hold onto these themes by lifting appropriate phrases or by capturing in singular statements the main thrust of the meaning of the themes (van Manen, 1990). The process continued until no additional themes unfolded.
The issue of credibility in qualitative research is important to the scientific merit of a qualitative study. However, validity and reliability as defined within positivist studies do not apply in the phénoménologie method. Guba and Lincoln (1982) proposed auditability be the criterion of rigor relating to qualitative research. To establish auditability in this study, one of the authors (MT) used audiotape recordings, kept field notes, and recorded the procedures used to collect data, including descriptions of the participants and setting. Data analysis procedures were reviewed by the second author (RT) to audit the decision trail. Conclusions were then reviewed by the third author (RH).
Guba and Lincoln (1982) also suggest that credibility, rather than internal validity in the quantitative sense, be the criterion against which the truth value of qualitative research is evaluated. In the phenomenological method, credibility occurs from the participants' point of view first. Participants are credible because they lived the experience. Because in phenomenology all experiences are considered valid sources of knowledge for the respondents living the experience, each experience related to the research is valid (Ray, 1987). To ensure credibility in this study, the researchers kept indepth field notes and provided rich data from the transcripts.
Prolonged engagement and member checks further enhance the credibility of qualitative research (Guba & Lincoln, 1982). In this study, prolonged engagement was achieved through 1 year of individual and group discussions with the nurses involved and the indepth interviews. Member checks involved having the participants review the data analysis and interpretation and provide feedback to the researchers.
Themes of professional transformation, making a difference, mutuality, and feeling rewarded emerged from the data. The themes describe times when nurses feel they are making a difference in their patients' lives. These times are defined as "moments of excellence" and were experienced by the nurses in their newly restructured roles. Some moments of excellence are described in the following discussion.*
As the staff nurses assumed the new role of nursing care manager, they underwent a transformation from insecurity to increased competence, confidence, and personal achievement in the new role. There was a notable change in their practice as participants' perspective changed from a narrow focus on patients' immediate physical needs to a broader, more holistic perspective. They described substantial changes in practice after they had mastered their new role.
At the onset, participants were faced with the challenge of delivering nursing care in an as-yet unfamiliar community setting. Feelings of professional insecurity were related to gaining acceptance and admittance into the patients' homes. One participant shared this recollection:
I sort of talk to myself before I am going: What am I going to say to this patient to make her feel comfortable and make me comfortable in the home?
Nurses also were concerned about personal safety while traveling in strange and perhaps unsafe neighborhoods. One participant said, "I am afraid of certain neighborhoods and I feel very scared..." Another participant added, "....you know, the streets aren't very safe here. Some of the streets aren't marked."
However, as time passed and relationships developed with the patients, the insecurity diminished. As one participant snared the following memory, her voice was filled with emotion:
The last one I visited, it was like it became so easy after a while, it was like you become friends with these patients. Security blankets for them. They welcome you in the home. The shyness disappears.
Working with patients in their homes allowed the nurses to encounter moments of excellence in their practice. These were portrayed as "having patients eagerly waiting for you," "being there to prevent a patient from taking an overdose," and "preventing a tragedy."
A moment of excellence in the home environment was exemplified by the following story:
When I went to see my patient, a Black lady, I noticed she was not wearing her leg prosthesis. It was propped up against the wall. I asked her, "Why is your leg over there?" The patient explained that because it was a White prosthesis, she was afraid her friends would laugh if she wore it. Because it would be obvious in public, she chose not to wear it to avoid being humiliated. I had to call the orthotist to get a prosthesis that was the right color, and she began to wear it.
Within the facility, changes in their patterns of practice included becoming involved in comprehensive discharge planning, taking a holistic approach to determining what patients would need at home, and encountering frustration in the inpatient setting because of lack of time to spend with patients. One participant characterized her approach to discharge planning in the following way:
Well, in my discharge planning now, / think differently, especially when these people are old. I try to be more careful about discharge planning, to make sure the social worker is involved and that they don't send these people home without help [italics added].
In their restructured roles, nurses reported "trying to get [patients] the help they need before they go out there alone," "being more focused," and "starting the planning earlier."
Another participant referred to "looking at the whole picture." It is more than physical care; participants said it is emotional, spiritual, and family-oriented care as well. A holistic approach to practice encompassed "not just dealing with the broken hip or broken arm but dealing with the family and all the resources that the patient needs."
Visiting in the patients' homes afforded participants the opportunity to sit and talk and "get to know" their patients in ways that had not occurred in the inpatient setting. As a result, the restrictions of the inpatient setting became a source of frustration in their clinical practice. Viewing practice from a different perspective increased their feeling that some aspects of caring were suppressed in the institutional setting. Participants characterized their inpatient practice as "not allowing enough time," "just doing tasks," "giving medications but never being able to stop and talk," and "I find myself giving them less and less."
Making a Difference
Participants used traditional and nontraditional interventions when providing care to the patients in the home environments. The unique combination of overcoming patient resistance, identifying needed community resources, going to extra lengths for their patients, and just being available for the patient allowed participants to feel their individual actions made a difference in their patients' lives.
At times, participants had to overcome patient resistance before they could make a difference. Their persistence was usually worthwhile. One of the participants described a situation where a patient adamantly refused to take his cardiac medications as prescribed. The nurse persisted and finally persuaded him to use the medication. By the final visit, the patient had been adhering to his recommended medication routine for 2 weeks and had increased mobility as a result.
Identifying resources consisted of more than just having a list of community services available for patient referral. It also meant finding creative solutions when standard services were not readily available. One participant said:
We had one patient who kept losing weight and was afraid to eat because she might choke on her loose dentures. Her dentist would not accept Medicaid, and she didn't have the money.
After numerous phone calls and considerable persistence, the nurse was able to locate a dentist who would accept Medicaid reimbursement as full payment. On the final visit, the nurse noted the patient had received her new dentures and could eat without choking.
Often the nurses needed to find resources for the spouse as well as the patient. One participant recalled a situation where the spouse actually required more home care than his wife:
I was very frightened. This old man was walking almost on his face, and his wife was crying and she said, "If anything happens to him, God knows what will happen to me." The husband needed care, and we had to get home health to come in and provide services for both of them.
At times, the participants saw themselves going to extra lengths to do something special for their patients. One participant recalled:
I even bought her some iron pills out of my own money because she was anemic and didn't have enough money to buy the tablets.
At times, it was just being available for the patients that made a difference. Many were elderly, lived alone, and did not qualify for traditional home health services. One participant vividly described being with a patient who wanted to commit suicide:
I think we were a great help to her. Well, she did say that. I know if we hadn't gone there that time, something would have happened. This woman was distraught.
Being in the home environment allowed participants to be aware of relationships with the patients and families. This mutuality involved acceptance by the families, showing affection for each other, and having difficulty saying goodbye.
The relationship that developed transcended the nurse-patient relationship in an inpatient setting. Revealing personal information and sharing feelings resulted in greater trust between nurses and patients. One nurse told the interviewer:
It's a unique relationship because on one hand we go in to help them, to assess and evaluate them, but on the other hand, we tend to get so close to these people because you are a part of their lives, and they share very personal information with you.
One participant described the reciprocity that developed in the nurse-patient relationship:
I could get very attached to her, and I can see she can get attached to me. She needs this kind of relationship.
Others said, "It was something money couldn't buy," "I care about my patients when they leave," "They want us to come and visit more often," and "Sometimes they trust us more than their own family." As a result of this relationship, the nurses felt they "became accepted and trusted by the whole family." Intimate details and "family secrets" were shared with the nurses as they visited in the home.
Nurses and patients expressed difficulty with saying goodbye. Many of the patients continued to telephone the nurses at home, and a few of the nurses have telephoned the patients at home. The nurses expressed a need to "make sure everything was okay."
The following is one participant's description of her experience of saying goodbye:
It was sad leaving them. We were crying, they were crying. They were all standing, even the grandchildren, they were all standing at the door waving goodbye and crying. It was a sad feeling.
Participants enjoyed the experience, obtained positive feedback, and gained personal satisfaction. This contrasted with the frustrations they encountered in the inpatient setting. According to one nurse:
I just loved being there and being able to talk to her and hear her expressions .... It is short-lived on the unit. When you are running to get stuff done, you just don't have the time. In the home, it is so exciting, I just love it. You can see who your patients really are.
Positive affirmation from the patients was one reason the nurses felt rewarded. Nurses expressed this did not happen frequently on inpatient units. One nurse said:
Oh yes, they recognized me from before and she said, "Oh, my angel, my angel of mercy is here." She began hugging me and crying. How glad she was to see me. She was very happy to have me there. ..and every time she would say, "If it weren't for you, I don't know what would have happened to me."
The personal satisfaction nurses received helped them cope with the challenges of the new role. As one nurse said:
I had an 86-year-old lady. She was not taking her Lasix and when we got there, her legs were very swollen. We elevated her legs, called her doctor, and instructed her on taking Lasix. If we hadn't gotten there in time, this lady would have ended up back in the hospital. I felt good because I was there to help. I was very happy that I could help and it felt good.
Another participant shared the following with the interviewer as she reflected on her experience:
...on the last visit, I felt fulfilled because I did a lot during the time I was visiting the patients. I felt fulfilled because I was doing something meaningful in the community.
Participants also received gifts from their patients:
I got one gift from a rehab patient. She looked all over until she found a special gift for me and she waited until I visited her to give it to me. It gives me a good feeling that I did something very good, because if I hadn't, she wouldn't bring me a gift. I was very surprised. The lady is walking with a cane and she came to me with a gift wrapped. Makes me feel like I am doing something meaningful out there.
The restructuring associated with the changes in the health care system has left many nurses feeling conflicted and frustrated. In a struggle to "get the job done," caring and compassion are sometimes given low priority or abandoned altogether. Yet it was evident in this study that developing caring relationships with patients was essential to nurses feeling rewarded in their work. One of the notable differences in the two practice environments, the inpatient and community setting, was the impact on the nurses' ability to care about the feelings of individual patients.
On the inpatient unit, the nurses focused on completing tasks, managing multiple priorities, and accomplishing more tasks in less time. As a result, the nurses felt frustrated that they had little time to "be caring" or "just sit and talk."
Conversely, the home visits provided the opportunity for nurses "to get to know the patients and families in their own environment." Having the time to establish caring relationships through bonding with patients made the experience rewarding. Nurses became willing, even eager, to be part of the role restructuring that had occurred.
Moments of excellence in practice were defined as the occasions when nurses felt they made a difference in their patients' lives. Making a difference included both specific nursing actions and "being there" for the patients and families. Experiencing these moments of excellence gave the nurses a renewed passion for their professional practice as they realized their impact on patient outcomes.
One of the primary driving forces behind redesign has been the pressure to reduce cost. Often clinical decisions are made on the basis of who will pay and how much they will pay. However, in this study, nursing interventions and actions were quality driven. Having the freedom to practice without economic constraints allowed nurses to approach practice from a different perspective. They did what was best for each individual patient or family member, not what would be reimbursable.
IMPLICATIONS FOR PRACTICE AND RESEACCH
Home visits allowed nurses to see patients one at a time without distractions and without strict limitations on time. Nurses were able to break the inpatient routine and have an opportunity to focus on an individual patient, the family, and all of their immediate needs and concerns.
The results of this study indicate nurses' caring values remain strong even as their ability to care is being compromised in the current health care environment. Practicing nurses may find it increasingly difficult and frustrating to make time to care. However, use of the strategies described in this article may help nurses in any setting engage in caring relationships with their patients. In the acute care setting, nurses should convey to patients that they have time, however brief, to be with them instead of rushing in and out of the rooms. When a patient calls for assistance, simply spending an extra moment focused only on that patient may make a difference. Instilling an initial sense of presence can lead to a relationship characterized by caring and trust.
For the caring process to flourish in a clinical setting, it also must be recognized and valued by administration and nursing management. The intangible benefits and nontraditional interventions described in this study are not reimbursable under the current economic structure of health care. However, they were the catalyst for the rewards for the nurses and benefits for the patients. Before health care policy will be revised to include reimbursement for these less tangible components of nursing care, further evidence of their effect is needed. Caring is a complex concept to measure (Miller, 1995; Valentine, 1989). However, studies can be conducted to examine the effects of caring on patient outcomes including satisfaction with care and the outcomes of that care.
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