Prior to this clinical experience, I was silently dreading the rotation. Having no prior experience with developmentally disabled children, I was not sure how I would react or interact with the children.
At the beginning of this clinical rotation, I had a lot of reservations.
I had much apprehension about dealing with physically and mentally handicapped children.
These are a sampling of the comments senior nursing students had written in their clinical journals at the start of a five-week rotation at a school for physically and mentally handicapped children. These quotes support Pagana's (1988) findings regarding stresses reported by baccalaureate students in relation to an initial clinical experience. In her study, 202 (77%) of the 262 students described fears of inadequacy related to their inexperience and lack of knowledge and increased responsibility and expectations of them. In order to help decrease other nursing students' stress regarding their upcoming clinical experiences with physically and mentally handicapped children, a qualitative research study was undertaken to explore the nursing students' caring experiences with these exceptional children. These caring behaviors could be shared with other students prior to their clinical rotation to decrease their stress and to make them more comfortable with these special children. In addition, Appleton (1990) purports that the opportunity to discover the meaning of caring in nursing practice is contingent upon the students experiencing caring during their educational program.
With today's technology, 90% of chronically ill children are expected to live to the age of 20 (Gortmaker & Sappenfield, 1984). Consequently, during their careers, nurses will encounter an increasing number of physically and mentally handicapped children. During their nursing education, students need to discover the meaning of caring with these exceptional children in order to be prepared for encounters with them during their careers.
Caring Nurse-Client Interactions
Nurses' perceptions of their caring behaviors in their nursing practice have been investigated in quantitative studies. Using the Caring Assessment Instrument (CAREQ) with 57 oncology nurses, Larson (1986) obtained their perceptions of important nurse caring behaviors. The 10 items ranked as most important by the nurses were: listens to the patient, touches when comforting is needed, allows expression of feelings, gets to know the patient as an individual, talks to the patient, realizes the patient knows himself best, is perceptive of the patient's needs, gives a quick response to the patient's call, puts the patient first, and gives good physical care.
Wolf (1986) asked 97 RNs to rank 75 caring words and phrases on a four-point Likert scale. The 10 highest ranked caring behaviors included: attentive listening, comforting, honesty, patience, responsibility, providing information, touch, sensitivity, respect, and calling the patient by name. Using the Larson CARE-Q, 110 nurse faculty, managers, and clinical specialists/practitioners indicated what they believed were the most important caring behaviors (Komorita, Doehring, & Hirchert, 1991). The following were the 10 highest ranked caring behaviors: listens to the patient, allows the patient to express feelings, realizes the patient knows himself or Herself the best, touches the patient when comforting is needed, is perceptive of the patient's needs and plans and acts accordingly, gets to know the patient as an individual, talks to the patient, teaches the patient self-care, encourages the patient to ask questions, and tells the patient information about his or her disease and treatment.
Studies of nursing students' perceptions of caring experiences with nursing faculty have been conducted using qualitative research methods (Appleton, 1990; Beck, 1991; HaUdorsdottir, 1990; MiUer, Haber, & Byrne, 1990). In reviewing the literature, however, no studies were found that investigated nursing students' perceptions of their caring experiences with clients. Therefore, the purpose of this study was to explore the lived experience between a caring nursing student and an exceptional child. The research question that guided this study was: What are the necessary and sufficient constituents of a feeling of caring between nursing students and exceptional children?
For the past two years the researcher has worked with physically and mentally handicapped children in the clinical area. During this time she has come to know these children as truly exceptional. They are unique treasures in a self-centered society. These children give of themselves while asking little in return.
The researcher practices caring from Mayeroffs (1971) theoretical perspective. According to MayerofC caring involves being with the person in the other's world. Caring concentrates on the other person's growth. Caring calls for selflessness as the caring person becomes absorbed in helping the other. Mayeroffs major ingrethents of caring include knowing, alternating rhythms, patience, honesty, trust, humility, hope, and courage.
A qualitative research design was chosen to obtain thick slices of data that would reveal the essence of a caring experience between a nursing student and an exceptional child. Specifically, the phenomenological method was chosen. This method is an inductive, descriptive research method that attempts to study the human experience as it is lived. Its purpose is discovery of the meaning of human experiences through the analysis of participants' written or oral descriptions of phenomena.
The convenience sample consisted of 31 female and five male senior nursing students. Their age range was 21 to 49 years. All of the nursing students attended a caringbased nursing program in a state university in the southeastern United States. The nursing students were just completing their clinical rotation pertaining to a long-term health alterations nursing course.
The setting for this study was a public school in southern Florida that provides instructional and related services for multihandicapped students ages 3 to 21. Children at this school have a wide variety of handicaps including mental, physical, behavioral, communication, and sensory disabilities. The major programs of the children served are classified as: educable, trainable, and profoundly mentally handicapped; physically impaired handicapped; and autistic-impaired handicapped. The focus of the educational program is assisting all students to reach and maintain their individual potential, whatever the level. Daily living and self-help skills are emphasized along with basic academics. Art, music, media, and physical education programs support and enrich classroom instruction. Students build lifelong practical skills through training in home economics, vocational agriculture, and job skills.
At the end of their five-week clinical rotation at this school for physically and mentally handicapped children, the nursing students were asked to voluntarily describe a caring experience with a physically or mentally handicapped child. They were instructed to write all of the thoughts, perceptions, and feelings that they could recall until they had no more to say about the experience.
Prior to participating in the study, informed consent was obtained from all of the nursing students. Their written descriptions were anonymous. Age and gender were the only demographic variables on which data were collected. Data collection was purposely scheduled at the end of the clinical rotation so that students could be assured that their grades would not be in jeopardy. The faculty member conducting the research was then no longer their clinical instructor.
Van Kaam's (1966) phenomenological methodology was used to analyze the nursing students' written descriptions of their caring experiences with exceptional children. His procedure of data analysis entails the following six steps: listing and preliminary grouping, reduction, elimination, hypothetical identification, application, and final identification. Van Kaam warns that these steps do not always follow the indicated order and at times they may overlap.
In the first step of data analysis the researcher reads each subject's written descriptions. A list is made of descriptive expressions related to the phenomenon under study. Next, the researcher classifies the data into categories. These preliminary categories come from empirical data consisting of a large random sample of cases obtained from the complete pool of participants' descriptions. These preliminary groupings must be reviewed by other experts to ensure the validity of this procedure. Intersubjective agreement of these expert judges with the initial categories is required. Following this, the researcher analyzes all of the remaining descriptive expressions in the sample. If necessary, the initial categories are supplemented by others to cover all the basically different statements made by the participants. Each category is ranked according to a percentage score derived from the number of times these descriptive expressions were listed by the subjects. A final listing must again be agreed upon by expert judges.
Reduction is the second step. Here the researcher reduces the vague, intricate, and overlapping descriptive expressions of the subjects into more precise descriptive terms. Once again intersubjective agreement among expert judges is required to prevent subjectivism.
In the third step, the researcher attempts to eliminate those descriptive expressions or elements that are not inherent to the phenomenon under study.
Next, the first hypothetical identification and description of the phenomenon under study is written.
Application of the hypothetical description to randomly selected cases of the sample is the fifth phase of data analysis or scientific explication. If some cases do not correspond to the hypothetical description, the reasons must be explored. Possibly, the hypothetical description contains something more than the necessary and sufficient constituents of the phenomenon. If this is the case, the hypothetical description needs to be revised to correspond with the evidence in the cases used in the application. Another possibility is that the hypothetical description may contain elements that are not inherent in the experience of the phenomenon being studied but instead characterize either the experience in a specific situation, or an experience other than the one being investigated. After the necessary revisions are made, the new hypothetical description needs to be tested again on a new random sample of cases. This process is continued until no new categories of explanation are found. When this has occurred, the formerly hypothetical identification of the phenomenon under study is considered to be a valid identification and description.
Efforts to limit potential bias included identification of the researcher's perspective and bracketing it prior to data collection and analysis. To help ensure the credibility of the data, numerous quotes from the nursing students' written descriptions of caring were included in the results of the study. Also, intersubjective agreement between the researcher and an expert judge was achieved at each phase of data analysis. This step of peer review called "member check" (Guba & Lincoln, 1981) also highlighted the ability to audit the data. Inclusion of both male and female nursing students and their wide age range of 21 to 49 addresses the fittingness of the sample.
Descriptions of nursing students' caring experiences with 36 exceptional children were obtained. These 36 descriptions focused on caring experiences with 11 profoundly mentally handicapped, nine autistic, seven physically handicapped, five trainable mentally handicapped, and four educable mentally handicapped children. The experiences concerned 20 boys and 16 girls with an age range of 3 to 17.
Analysis of the data using Van Kaam's modification revealed 199 descriptive expressions and six necessary constituents of a caring experience between a nursing student and an exceptional child. A necessary constituent, acording to Van Kaam (1966, p. 324), is "a moment of the experience which, while explicitly or implicitly expressed in the significant majority of explications of subjects, is also compatible with those descriptions which do not express it." Intersubjective agreement between the researcher and an expert judge was achieved at each step of data analysis. A master's-prepared nurse who was experienced in the phenomenological method was the expert judge. The six necessary constituents of a caring experience between a nursing student and an exceptional child that emerged were: authentic presencing, physical connectedness, reciprocal sharing, delightful merriment, bolstered self-esteem, and an unanticipated self-transformation. The two expert judges (the researcher and the master'sprepared nurse) tried these six hypothetical constituents on a random sample of 20% of the subjects. The final identification of these six constituents resulted from the successful "trying out* of the hypothetical constituents on this random sample. Examples of these six necessary constituents are found in Figure 1. The percentages of the 36 nursing students expressing each of the six necessary constituents follow in Figure 2.
Next, the six necessary constituents were synthesized into one description, which then identified the total experience of caring with physically and mentally handicapped children as perceived by undergraduate nursing students.
A caring experience between a nursing student and an exceptional child is described as an interweaving of authentic presencing with physical connectedness and reciprocal sharing overflowing into delightful merriment, bolstered self-esteem, and an unanticipated selftransformation .
Authentic presencing: The nursing student puts all else aside and enters into the world of the child.
Examples of Students' Descriptive Expressions
Physical connectedness: The nursing student and exceptional child embrace in touch. It can range from a gentle caress to an enthusiastic hug. This touching can be as tranquil as gently stroking a child's forehead and as exuberant as playful tickling.
Reciprocal sharing: A meaningful interchange of selves occurs between the nursing student and exceptional child. This exchange involves feeling secure in a sharing of selves, of dreams for the future, and of time together.
Delightful merriment: The nursing student and the physically/mentally handicapped child are encompassed in happiness. Contagious smiles and laughter abound.
Bolstered self-esteem: Fortified with patience, the nursing student encourages the exceptional child to complete as much of his or her work, art project, or activities of daily living as the child is able to do. Praise for even the smallest of accomplishments is generously bestowed upon the child. The nursing student focuses on helping the child grow.
Unanticipated self-transformation: Unexpected changes emerge in the nursing student's attitude toward physically and mentally handicapped children. Unforgettable experiences with these exceptional children inspire the nursing student.
Percentages of 36 Students Expressing Each Constituent
An excerpt from one nursing student's written description of her caring experience with a profoundly mentally handicapped 5-year-old girl illustrates both necessary constituents of physical connectedness and delightful merriment.
The radio was on so I began singing to her and rocking to the music. The little girl was smiling and laughing and moving with me. She liked the movement and she would lean way back, then I would make a funny sound and bring her back up and we'd start all over again!
The following quote from a nursing student's caring description portrays the necessary constituent of an unanticipated self-transformation.
I've gotten more of an appreciation for life and the little miracles that take place every day. I feel she has forced me to look at life and physically and mentally handicapped children from a different perspective. She was so inspirational!
The necessary constituent of reciprocal sharing is illustrated by the following excerpt of a caring experience with a 9-year-old physically handicapped girl.
Through interacting with her 1 felt as if I was entering her world. Our openness toward one another helped us to develop a trust and understanding. We felt safe with each other. She was able to tell me of her dreams for the future - hopes of becoming a nurse one day. And I was able to be open and honest about how helpful working with her was to me.
Two of the six necessary constituents of a caring experience between a nursing student and an exceptional child, authentic presencing and physical connectedness, are similar to caring behaviors ranked by RNs as most important in their practice. In studies by Larson (1986) and Komorita et al. (1991), the nurses identified "listens to the patient" and "touches when comforting is needed" as important caring behaviors. This touching is different, however, from the physical connectedness described by the nursing students. With the physically and mentally handicapped children, touching was not reserved for just comforting. Much of the touching was involved in their delightful merriment - hugging and tickling amidst smiles and laughter. The "listens to the patient" ranked highly by the RNs can be subsumed under authentic presencing. In authentic presencing the nursing student did listen but first he or she entered the world of the other.
The RNs in Wolfs (1986) study identified patience along with touch and attentive listening in the top 10 caring behaviors. Patience was described by the nursing students as necessary to enhance the children's self-esteem.
Marck (1990) identified therapeutic reciprocity as one phenomenon of caring that permits both the nurse and the client to benefit from their relationship in a mutually empowering manner. She defined therapeutic reciprocity as "a mutual, collaborative, probabilistic, instructive, and empowering exchange of feelings, thoughts, and behaviors between nurse and client for the purpose of enhancing the human outcomes of the relationship for all parties concerned" (Marck, p. 57). The necessary constituent of reciprocal sharing that was revealed in this study illustrates Marck's therapeutic reciprocity.
The necessary constituent of authentic presencing that emerged from this phenomenological study illustrated MayeroiFs (1971) caring. For Mayeroff, being with the person in the other's world is an essential aspect of caring. Caring concentrates on the other person's growth, identified by the nursing students in the constituent of bolstered self-esteem. In helping another person grow, the caregiver actualizes himself or herself (Mayeroff). This actualization of self was beautifully revealed in the nursing students as a result of their caring. The following quote illustrates this.
It was a memorable experience I most treasure. She taught me a lot about what it's like to have a disability. Her strength and inner drive have been an inspiration to me!
Mayeroff (1971) also identified patience as one of the major ingrethents of caring. The nursing students revealed that patience was necessary in their caring for the exceptional children.
Implications for Nursing
Sharing the findings of this phenomenological study with nursing students is one approach that faculty can use to help reduce their fear and anxiety regarding an upcoming clinical rotation with physically and mentally handicapped children. During their actual clinical rotation the nursing students can then share with their fellow nursing students their own caring experiences with exceptional children. In a qualitative study of the lived experience of a nursing student (Nelms, 1990), students revealed that the recognizing and sharing of their clinical experiences was not an integral part of their nursing education. Nelms stressed that the sharing of these clinical experiences is needed in nursing education programs where it is believed that curriculum is not curriculum until its meaningfulness is revealed in the lives of those experiencing it.
Roach (1984) advocates that an essential challenge of nursing is to professionalize human caring through the development of the capacity to care. The caring capacity is not an automatic way of relating to persons. It remains dormant if it is not affirmed and actualized. Leininger (1986) also warns nursing that the concepts and practices related to human care have not been institutionalized as a normative expectation. Care, therefore, cannot be ensured as a major component of nursing education and practice. Leininger (1980) stressed that without specific teaching and practice opportunities of care in nursing schools, faculty cannot ensure that their graduates will know and practice care later. Faculty need to focus on promoting caring interactions between nursing students and exceptional children. Not only faculty but fellow nursing students can act as role models of caring with physically and mentally handicapped children. The six necessary constituents of caring identified in this study can be a starting point to further define and practice caring with these special children.
Parents of chronically ill children have reported that hospitalizations are critical times for their children and families (Clements, Copeland, & Loftus, 1990). With the increasing number of chronically ill children in the United States, nurses will be encountering these special children more frequently in the health care system. If nursing students have learned to be caring with these children, they can use this expertise to decrease the stress and anxiety the children and their families experience when it becomes necessary for recurring hospitalizations.
Lastly, as highlighted in the following quote concerning a 12-year-old autistic boy, faculty need to alert nursing students not to become discouraged in their caring with these special children for, at times, nurses may be unaware of the impact their caring has had on the children.
We were walking with the class outside of the school when all of a sudden I felt a hand in mine. He was walking next to me and he wanted to hold my hand. Before that I thought he hadn't even noticed me. I guess my efforts with reaching out to him had been noticed and I gained his trust at the end of the day.
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Examples of Students' Descriptive Expressions
Percentages of 36 Students Expressing Each Constituent