According to research by Drew (1986), patients and their families are not satisfied with the quality of human interaction found in the health care system today. When describing activities of nursing, we say that we give "nursing care," the patient is "cared for," etc. Inherent in these phrases is the concept of "care" as a hands-on process. What is missing is the concept that caring, as a humanistic interaction, may be illusive in the practice of nursing today. This qualitative study attempts to further define the humanistic act or art of caring by asking the question, "What is the meaning and value of caring in the practice of nursing?"
Dolores Gaut (1983), when describing her work on the development of a theoretically adequate definition of caring, stated that although there is no clear-cut rule for the use of the word caring, the family of meanings all relate to three categories: attention to or concern for the patient; responsibility for or providing for the patient; and regard, fondness, or attachment to the patient.
To understand the caring phenomenon as it relates to nursing, or perhaps even more to understand its absence in today's health care system, a historical approach should be considered.
Nursing in the United States adopted the model of Florence Nightingale. Training emphasized character, not skills. To the physician, the nurse was obethent, and to the patient, the nurse was selflessly devoted. Because nursing through the ages was hard work with low pay, it attracted women from the working and lower middle classes. In the United States, many nurses were first-generation daughters of immigrants (Jones, 1988).
Nursing became the discipline of caring and the physician was the professional responsible for curing. Although both caring and curing are parts of the healing process, curing was seen as a much more valuable commodity both in terms of prestige and fees for service (Jones, 1988). This value, established in the middle ages, is still perpetuated and may help to explain the apparent abandonment of caring from the practice of many nurses.
Presently, nursing is being redefined by many nursing leaders as a human science. Thus, the art of human caring has demanded the attention of nursing scholars and researchers. Leininger (cited in Marriner, 1986) used a transcultural and "ethnocaring" model to explore different behaviors among various cultures. She believes that caring behavior is what distinguishes nursing from other disciplines. Using an ethnomethodological approach in studying over 30 different cultures, Leininger found that the concept of helping or assisting others was evident in nurses in all of the cultures studied. She feels that care is the human service quality that makes health consumers either satisfied or unsatisfied with health services, and it is the care, not the cure, that consumers really value.
Studying the perceptions of 57 cancer patients regarding caring behaviors of nurses, Larson (1984) found that competent clinical know-how was ranked very high by the patients surveyed. This differs from nurses who usually regard psychosocial skills as indicative of caring behavior.
Using a phenomenologic approach, Riemen (1986) found three themes emerging from patients' descriptions of noncaring nurse behaviors: physically present but emotionally distant, belittling and inhumane actions, and devaluation of the patient as a unique individual.
Cronin and Harrison (1988) did a quantitative study to identify nursing behaviors that patients perceived as indicators of caring. The behaviors perceived as caring by the patients focused on professional competence. The patients believed that certain minimum care requirements, such as cleanliness and feeding, must be met before more qualitative aspects of care, such as empathy, can be addressed. This is very much in line with Maslow's hierarchy of human needs.
A qualitative study by Ray (1989) compared patients', physicians', and allied health personnel's perceptions of caring. Primarily, patients expressed the need for human care and had to devise strategies to get what they needed or succumb to what they saw as injustices to their humanity. Physicians' descriptions of caring were generally within the technical realm, but they did recognize the need to convey humanistic care to patients. Allied health personnel emphasized the meaning of caring as support both for the organization and the patients.
According to Watson (1985), the process of human care for individuals, families, and groups is a major focus for nursing. It is her argument that caring in nursing is not just an emotion, concern, or benevolent desire; it is the moral ideal whereby the end is protection, enhancement, and preservation of human dignity.
Although it has been discussed and widely accepted by nursing scholars and researchers that caring is essential to nursing practice, relatively few investigations have been conducted regarding the meaning of caring in nursing practice. Caring is still a rather loosely defined concept. Further clarification of the meaning and value of caring in nursing practice is still very much needed. The purpose of this study was to identify situations that were perceived by nursing students as caring and noncaring nurse interactions, to further develop the concept of caring.
The study was conducted at a diploma school of nursing based in a large inner-city Catholic hospital. The participants were 26 second-year nursing students who volunteered to participate after having the project explained to them. The investigator selected student nurses for this study because the diploma school at which they were enrolled was planning a curriculum change based on Watson's Nursing Theory. The results of this study may be useful in determining curriculum content with respect to the caring aspect of nursing practice.
In this qualitative study, participants were asked to describe critical incidents in which they observed nursing behaviors conducted in caring and noncaring ways. The investigator interviewed the students individually to clarify and expand upon the incidents that they had recorded.
The data were then compared, searching for emerging themes or categories of caring. The qualitative data were analyzed by comparing and contrasting the reported incidents of the informers. Emerging themes of caring phenomena were grouped together.
It was interesting to note that none of the respondents talked about or wrote about technical competence as a caring nurse behavior. All of the nurse behaviors considered to be caring were described in humanistic terms. Those behaviors included:
* giving of self,
* meeting patients' needs in a timely fashion, and
* providing comfort measures for patients and their families.
Giving of self
Responses categorized as "giving of self ranged from taking extra time with a patient or family to actually spending off-duty time to be with a patient. The following response illustrates a nurse taking extra time.
I saw a nurse sit and ask a client how she was doing today. She sat and asked if there was anything that was bothering her. The nurse stayed overtime, listening to the patient and holding her hand while the patient was telling her the problem . . .
The following informant's response is an example of a nurse spending "off-duty" time to care for a patient.
The patient was a 17-year-old quadriplegic ... He sustained an injury causing a C2 fracture which left him ventilator-dependent . . . The only movement he has is facial and turning his head from side to side. A male nurse was caring for him this particular day. An order was written that he could be taken outside for short periods. The nurse took time out of his busy schedule to meet the patients request. The patient was placed in a wheelchair connected to an apnea monitor, and to a portable ventilator. This nurse purchased a loaf of bread on his lunch hour. He took the patient to the roof of the garage and fed the pigeons bread. I don't think I will ever forget the smile on the patient's face when he returned. It was the first time I had seen him smile since he came.
The incidents that were categorized as meeting the patient's needs qualified time as a factor in meeting those needs. This is evident by the following responses.
E. was a very difficult patient to care for. She was demanding and had her call light on every 10 minutes (unless she was sleeping). She was dissatisfied with every nurse who came in contact with her except for one, nurse R. D., a male RN - he appeared very tough. However, the floor staff nicknamed him "our gentle giant." R. would volunteer to care for patient E.; he would sit beside her while writing notes just to keep her company. R. would respond each time E. put on the call light - within a few days E. began showing trust, knowing that someone would always answer the light.
I was working on a unit in the hospital and a patient had her light on three times. All she wanted was some pain medication. The unit became very busy and staffing was short. This patient's nurse was very busy and she decided the pain medication could wait (patient was waiting for 45 minutes by now). There was another nurse who was just as busy as this patient's nurse and I told her what was going on. She went in and spoke to the patient for a few minutes then got the medication herself I thought that was wonderful. She dropped everything for a patient in need. Needless to say, the patient's primary nurse screamed and yelled at her when she found out, but the other nurse told me she didn't even care. She knew that patients come first and she was very happy that she could help the patient when she needed help.
There was a situation I observed in which a nurse was very caring to a patient. The patient was very upset and anxious about having a sonogram done because she had never had one and didn't know what it was and that her doctor didn't tell her a thing. This poor girl was hysterical. A nurse was walking around and noticed her crying and began to talk to her. She found out the problem and explained the whole procedure to the patient. When the patient returned from the test she thanked the nurse for taking the time to help her.
Meeting patients' needs
Patients' needs reported by the informants included pain relief, attention, self-esteem, and religion. Interestingly, not one informant mentioned meeting patients' basic needs as being a caring behavior. Perhaps it can be assumed that the basic needs of food, fluid, elimination, and ventilation must have been met in order for the patients to experience - and nurses to identify - those of a higher level. It leads one to wonder if "uncaring' nurses are adept at recognizing higher level patient needs, or if they have been "programmed" to function at the basic level.
The last category that many informants identified was providing comfort to patients and their families. According to Maslow, once an individual's physiological needs have been met, the next priorities that demand attention are safety and comfort (Rambo, 1984). Comfort was considered very important by the informants. This reflects Watson's theory that human care requires the knowledge of how comfort is an important variable in the caring aspect of nursing (Watson, 1985).
The critical attributes of comfort identified by the informants were: to ease psychological discomforts such as grief, fear, anxiety, or depression; and to provide a calming, soothing environment. The first attribute was evident in the following situational description.
Last year, I was assigned to care for a patient whose roommate was in renal failure and was refusing dialysis. She was 92 years old with a decubitus on her sacrum and had other problems. She was not expected to live longer than 48 hours when I arrived on the unit at 7:00 a.m., and no extraordinary measures were to be taken. I heard several staff members stating that she was extremely demanding and they couldn't stand taking care of her. The staff had said that she always had her call light on, and they were in no hurry to see what she needed. A new graduate nurse had just started working on our unit, and was assigned to care for this patient. Since this was not an extremely busy day, E. (the new graduate) would check on Mrs. S. (my patient's roommate) at least once an hour. At about 11:00 a.m., Mrs. S. took a turn for the worse and her doctor said she would not live through the night. About 15 minutes later, Mrs. S. began crying out in pain. Most of the nurses were at the nurses' station and they just looked at each other and shook their heads. E. hurried into Mrs. S.'s room to see what was the matter. Mrs. S. said she was scared and just wanted someone to sit with her. E. sat down next to Mrs. S. and held her hand to try to comfort her. The next day when I arrived on the unit, I learned that E. had missed her lunch and that when Mrs. S. died, she had been sitting beside her, holding her hand.
The next incident describes a nurse providing a patient with a calming, soothing environment.
Mr. S., an elderly patient, admitted for depression and attempted suicide, had requested ECT treatment because he felt it would help his depression. However, on the morning of his first treatment he became very apprehensive. He sat in his wheelchair weeping quietly. One of the nurses noticed him, approached his chair and knelt down beside him. She placed her hand on his arm and stroked him gently while speaking in a soothing tone. She remained with him until it was time for him to leave. I couldn't hear what was said, but Mr. S. was calmed and comforted by her presence and contact. Her action demonstrated genuine concern for Mr. S.
The last incident is an example of a nurse caring behavior that extended to family members.
My father passed away 2 years ago - suffering from lung cancer. The last time he entered the hospital my family was with him 24 hours a day. Generally, my brothers and I split the night sitting with Dad. It was on this occasion that I observed the night nurse (I never learned her name) caring for not only my father, but my family. She was working a long, dark hall on the oncology unit alone. She made sure to stop in and ask us if we needed anything, or if we thought my dad needed anything. Sitting alone in a dark room - it meant a lot to each of us. She carried a flashlight in one hand and usually coffee, juice, and a donut in the other. She always had a little story or something to chat about. Being in nursing school, I realize now that she was caring for the family, as well as the patient.
The informants in this study were asked to describe an incident in which they observed noncaring nurse behavior. The situations described were antagonistic to those behaviors perceived as caring, thus enhancing and lending credibility to those reported as caring nurse behaviors. The noncaring behaviors were categorized as:
* not giving of self,
* not meeting patient's needs in a timely fashion, and
* not providing comfort to the patient, or aiding in his discomfort.
The following incident gives an example of non-selfgiving behavior on the part of a nurse.
Another student and I were walking between two buildings. I saw a man kneeling next to a wheelchair on the curb. He had fallen. We ran up to the site and there was a hospital escort at the site. All three of us tried to lift the man into the wheelchair, but he was just too heavy. We couldn't do it. The escort told me to go to the emergency room and ask for T. and some other guys to help us lift. I ran to the ER and when I got there all of the nurses were sitting at the desk. I told them what had happened and they didn't even care. Their biggest concern was why a student was in the ER. They all refused to help, they said, "call 911 Security." Finally, the security men helped us lift the man. It took four men to lift him. A nurse from the ER walked out to the site with us. She took one look at the man and stated, "There is no way I'm going to lift him, he's too heavy, 111 hurt my back." I really thought that was uncaring of all the emergency room nurses. I can understand that it might be against hospital rules, but they didn't have to give me the run-around like they did. It took me 15 minutes to get help. I think that is ridiculous. We all work in a hospital, isn't that what we're here for, to help people?
The second category, not meeting patients' needs, was described by the informants in incidents that ranged from not relieving pain to not providing privacy for the patient. The following incident described a nurse not relieving pain.
One day while on clinical, I sat down in the conference room to chart on one of my patients. While I was charting, I heard a conversation between one of the nurses on the unit and an elderly patient. The patient had to be transferred to a wheelchair to go down to dialysis, but she was pleading to be transferred to a carriage instead because she had a compression fracture of the spine and said she was in severe pain. The nurse insisted that she was able to sit up, because she wasn't in "that much pain." The patient began crying because the nurse wouldn't listen to her. The nurse asked a nursing assistant to help her transfer this patient to the wheelchair. The nursing assistant asked if she should be sent to dialysis on a carriage instead, but again, the nurse insisted that the wheelchair was what they were going to use. In the middle of being transferred, the patient started screaming and crying, and the nurse, instead of trying to comfort her, told her to stop "acting like a baby."
Not providing privacy is exemplified in the next incident.
I was in the operating room with a patient. Prior to surgery, I walked in the room to find this woman completely exposed while the nurses were standing around chitchatting. I understand that at a certain point this might be necessary, but at that time I would have taken a moment to put a drape over her. I just kept thinking of my mother and grandmother lying there and I was appalled.
The third category of noncaring behavior is failing to provide comfort or adding to a patient's discomfort. The following description is of a nursing behavior that did not meet the attribute of easing psychological discomfort such as grief, anxiety, or depression.
When I assessed Mr. C, an elderly patient, admitted to rule out myocardial infarction, he was alert and oriented. He spoke at length about his family and his childhood in Germany. The following morning, Mr. C. awoke confused and disoriented. He believed he was at home and that I was his daughter (who had recently died). Although I was unprepared for this behavior, I tried to reorient him. He seemed to understand me and appeared upset and embarrassed by his "forgetfulness." At this time, a staff nurse entered and began to care for Mr. Cs roommate. When she heard the exchange between Mr. C. and I, she whistled loudly, tapping her temple and rolling her eyes. She commented that Mr. C. was "really out in left field today" and that I should "just ignore him.'' She showed an absolute disregard for Mr. Cs embarrassment and obviously didn't care about his feelings. A comment like this would have been bad enough said in private, but to discuss a patient's mental status in front of both the patient and his roommate bordered on cruelty. Mr. C. was keenly aware of, and sensitive about, his own mental confusion. He did not need to hear derogatory comments about it. I felt this behavior was uncaring and unprofessional.
This last incident gives example of adding to the discomfort of the patient and to the anxiety of the family.
A patient came into the emergency room and was admitted to our unit. This patient was well-known to us due to numerous pathological fractures. She has cancer of the bone. With each admission, you could see how she was deteriorating. The RN assigned to her was less than tactful in her approach. As I was taking her vital signs the RN was doing the assessment sheet. She started by saying *Gee, you look terrible. You must have lost at least another 10 pounds. Soon you'll just wither away. Did you fall again? I bet you did, that's what always happens. You know you should use your walker or were you using it?" She barely gave the patient a chance to respond. The patient's family were at the bedside with her and they all looked at the RN in disbelief The RN then turned to the patient's husband and remarked, TJo you remember the nurse aide?" He responded, "Yes". She went on to say, "Well, you won't believe this, but she just died a week ago. When they did an autopsy they found cancer just like your wife has. Isn't that terrible?" I walked out of the room. This RN does some pretty dumb things, but I felt this was one of the worst, I don't know what else was said then. Two hours later, the operating room called for the patient. As we were pushing her out of the door (with her family in attendance) the RN turned to the patient and said "I bet you're scared to death. I would be if I were you."
In reporting the critical incidents of caring and noncaring nurse behaviors, it is evident that student nurses are able to identify and distinguish between these behaviors. As was noted, all of the behaviors that were reported involved a humanistic, rather than technical, belief in the term caring. According to Watson (1985), the nurse must be a competent clinician and a humanitarian. To humanistically "care" requires the presence and use of the nurse "self and the sharing of the "self with another. It would seem then that a nursing curriculum should include not only knowledge of the physical sciences and technical skills, but also ways in which nurses can use "self therapeutically.
Mynatt (1985) found that student attitudes are socialized by the expectations, attitudes, and values of role models. Through faculty effort, the art of humanistic caring that has been identified as an important nursing behavior by patients, nurses, and students should be integrated throughout a nursing curriculum. This might help to prevent the modeling of student behavior after those noncaring nurse behaviors described in this study.
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