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Pedagogical encounters between nurses and patients in a medical ward—A field study
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International Journal of Nursing Studies 44 (2007) 534–544 www.elsevier.com/locate/ijnurstu
Pedagogical encounters between nurses and patients in a medical ward—A field study F. Friberga,, E. Pilhammar Anderssonb, J. Bengtssonc a School of Health Sciences, University College of Bora˚s, 501 90 Bora˚s, Sweden Department of Health Care Pedagogics, Faculty of Health and Caring Sciences, The Sahlgrenska Academy, Go¨teborg University, Box 457, 405 30 Go¨teborg, Sweden c Department of Education, Go¨teborg University, Box 300, 405 30 Go¨teborg, Sweden
b
Received 1 February 2005; received in revised form 2 December 2005; accepted 13 December 2005
Abstract Background: Patient teaching is regarded as an important aspect of nursing care as well as an essential part of the nursing profession. In nursing practice, a distinction can be made between formal (planned) and informal (spontaneous) patient teaching. The major part of patient teaching research is within the area of formal teaching. In spite of the fact that spontaneous teaching occurs in everyday nursing practice, there is a lack of knowledge in this area. Objectives: The aim was to illuminate pedagogical dimensions in nursing situations and informal teaching. Design: The study is a fieldwork study within the frames of a life-world phenomenological tradition. Participants and setting: Fifteen registered nurses in a general medical ward of a university hospital in Sweden were followed in their daily work with patients. Twelve patients suffering from various chronic diseases were interviewed. Methods: The observations comprised a total of 173 h on 34 separate occasions. Informal dialogues with nurses were carried through. Further, formal interviews were conducted with 12 of the observed patients. The data were analysed by means of a life-world phenomenological approach. Results: Two different pedagogical encounters are presented: ‘‘Players in different field pedagogical encounters’’, in which there is a breakdown in the pedagogical dialogue, and ‘‘Players in same field pedagogical encounters’’, in which the pedagogical dialogue develops. Patients’ experiences of seeking and acquiring knowledge within these two types of encounter are characterised as ‘‘worry’’ versus ‘‘preparedness’’. Patients’ dignity is either threatened or supported, depending on the type of encounter. Conclusions: Health care organisations have to create a pedagogical climate where ‘‘Same field pedagogical encounters’’ can be created. The nurse has to view the patient as a learning person in order to help the patient to achieve ‘‘preparedness’’. ‘‘Preparedness’’ is described as a cognitive–emotive–existential state and emphasised as an important goal of patient teaching. r 2006 Elsevier Ltd. All rights reserved. Keywords: Informal teaching; Life-world phenomenology; Fieldwork; Pedagogical encounters; Preparedness.
What is already known about the topic? Corresponding author. Tel.: +46 33 435 40 00; fax: +46 33 16 40 10. E-mail address: [email protected] (F. Friberg).
Patient teaching is a key nursing activity. The major part of patient teaching research is within
0020-7489/$ - see front matter r 2006 Elsevier Ltd. All rights reserved. doi:10.1016/j.ijnurstu.2005.12.002
the area of formal teaching.
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There is a lack of knowledge about informal patient
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1.1. Informal patient teaching
teaching.
What this paper adds
Informal patient teaching is illuminated. Characteristics of everyday pedagogical
patient– nurse encounters are described. The concept of ‘‘preparedness’’ is identified as a specific teaching goal.
1. Introduction Historically, patient teaching has been regarded as an important aspect of nursing care (Nightingale, 1957) as well as an essential part of the nursing profession (Henderson, 1960). Although patient teaching today is regarded as a key nursing activity (Marcum et al., 2002), many barriers to teaching have been identified, such as lack of time, lack of support from the health organisation and insufficient pedagogical knowledge (BarberParker, 2002; Marcum et al., 2002; Turner et al., 1999). Another problem is lack of documentation of patient teaching in nursing records (Marcum et al., 2002; Karkkainen and Eriksson, 2003). To view patient teaching as important while at the same time having to take various obstacles into account indicates the complexity of being a teaching nurse. In nursing practice, a distinction can be made between formal (planned) and informal (unplanned and spontaneous) teaching (Barber-Parker, 2002; Gregor, 2001; Milazzo, 1980). The major part of patient teaching research is within the area of formal teaching (Wellard et al., 1998). There are many intervention studies available, in which a specific patient group is selected and teaching is implemented and evaluated. Textbooks on the subject of patient teaching also focus on formal teaching (Coates, 1999; Redman, 1993). However, informal teaching frequently takes place in bedside care (Barber-Parker, 2002; Gregor, 2001; Mc Goldrick et al., 1994; Wellard et al., 1998). In spite of the fact that spontaneous teaching occurs in everyday nursing practice, there is a lack of knowledge in this area (Barber-Parker, 2002; Gregor, 2001). Therefore, the focus of this article is everyday nursing practice and specifically the pedagogical dimensions of nursing situations in terms of informal teaching. The term ‘‘pedagogy’’ is used as a comprehensive term for teaching activities in order to highlight both theoretical and practical aspects of teaching situations (van Manen, 1991). In this article, selected findings from a larger fieldwork study on informal patient teaching from a Swedish perspective are reported (Friberg, 2001).
A search in the CINAHL, ERIC and Medline databases revealed few studies on the subject of informal patient teaching in natural settings. For the most part, studies related to informal teaching concern nurses’ attitudes (see Freed, 1998; Karlsen, 1997). In a questionnaire study (Mc Goldrick et al., 1994), American nurses’ opinions of patient teaching in terms of patient groups, teaching strategies, teaching content and the nurses’ educational level as a base for planning future teaching activities were investigated. The result reveals that informal teaching occurred on a 24-h basis, mostly at the bedside. Medication and safety aspects of care were identified as an important content of the teaching. It was also noted that the nurses had a low degree of formal teaching competence, which, according to the authors, highlights the complexity of teaching. Twinn and Lee (1997) studied health teaching in a medical and a surgical ward in Hong Kong by means of observation. They found that teaching occurred spontaneously mainly on admission or on occasions when it was quiet on the ward. It was observed that many teaching opportunities were missed. In a Canadian fieldwork study carried out in a surgical ward (Gregor, 2001), the interaction between patients and nurses was explored in order to identify informal patient teaching. Six different types of interaction constituting patient teaching emerged: questions, explanations, information, instructions, setting expectations and demonstrating correct modes of conduct. Gregor argues that patient teaching is an integral part of everyday hospital practice. It lacks visibility due to the fact that it is usually women’s work. In an American study, Barber-Parker (2002) studied bedside teaching in an oncology ward. According to the results, teaching was carried out as a natural and inherent part of the everyday work with patients. The teaching content was focused on facts of different kinds. Barber-Parker states that the nurses did not identify the patient’s need for knowledge and that evaluation of patient teaching was limited. In a Norwegian fieldwork study (Kloster, 1997), nurses’ pedagogical function and patients’ experiences of patient teaching were studied in an orthopaedic ward. According to the results, teaching activities were seldom planned and mostly occurred at the patient’s bedside. The teaching content focused on facts and was seldom documented as pedagogical actions. The literature review indicates that informal teaching occurs but is often taken for granted. This aspect of nurses’ practical knowledge (Polanyi, 1966) requires further study and is important for the development of nurses’ professional knowledge as well as for improving the care of patients who need knowledge and understanding.
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1.2. Aim The overall aim was to illuminate pedagogical dimensions in nursing situations and informal teaching. More specifically, the aim was to describe the characteristics of pedagogical encounters between nurses and patients on a medical ward as well as patients’ experiences of seeking and acquiring knowledge during periods of illness. In the study, the expression ‘‘pedagogical situation’’ is used and defined as an encounter between patient and nurse, where the patient starts a conversation aimed at obtaining information about the illness or disease and/or its consequences for his/her present situation or life circumstances. The nurse can also initiate a pedagogical situation by saying something with the purpose of increasing the patient’s knowledge about his/her illness or disease and/or its consequences for his/her present situation or life circumstances.
2. Methods 2.1. Theoretical framework Informal patient teaching is a normal part of everyday nursing practice. Life-world theories based on a phenomenological thinking were chosen as the ontological and epistemological point of departure for the study (Bengtsson, 1999). The life-world is the world in which we live our daily lives and understands the reality interdependent as between life and world (Schutz, 1997). Accordingly, the world is not seen as objective in itself, nor is human life considered as an independent existence. The life-world is the unconscious background for our experiences and actions. Since the informal patient teaching is often taken for granted, this approach may help us to understand this part of nursing practice. We consider Schutz’ theory of human actions in the everyday life-world relevant to the understanding of pedagogical situations (Schutz, 1997; Schutz and Luckmann, 1989, 1995). Schutz describes how people meet, communicate and try to understand each other in everyday life. We also regard Merleau-Ponty’s (1995) theory of the lived body useful for understanding patients and nurses in terms of bodily expression. Schutz’ theory of inter-subjective encounters and Merleau-Ponty’s theory of the lived body not only constitute the ontological and epistemological point of departure of the study but also have been used as a frame for the interpretation of the results. 2.2. Data collection and informants A guiding assumption is that the life-worlds of patients and nurses meet in the context of the hospital
ward. If the life-world is the point of departure, we must return to everyday nursing practice in order to identify important aspects of informal patient teaching. Thus, the pedagogical dimensions of nursing situations should be understood in a social and inter-subjective life-world context. Thus, fieldwork appears to be an appropriate methodological approach (Hammersley and Atkinson, 1995). In the field phase, the first author (FF) followed 15 registered nurses in a general medical ward of a university hospital in Sweden in their daily work with patients. The observations took place during the day and at night and lasted for 3–4 h at a time with focus on the morning and afternoon shifts. The observations comprised a total of 173 h on 34 separate occasions. All encounters between nurses and patients were of interest. This assumes being receptive to conversations and intersubjective actions relevant to patient teaching. Activities such as medical rounds and staff meetings were also studied in order to obtain rich data about the pedagogical dimensions of nursing situations. Informal dialogues, in line with what Agar (1980) terms nonlinear conversations, also took place in order to capture the nurses’ version of what happened during the encounter with the patient. Thus, spontaneous questions were asked as soon as possible after the observed situation in order to create an understanding of what had happened. Often, these conversations occurred in the corridor or in the nursing office. To respect the nurses’ privacy, a balance was tried to be attained between asking important questions and respecting the nurses’ free will to answer. No questions were asked in the patient’s room or in situations in which the researcher considered asking as disturbing or unsuitable. Furthermore, formal interviews were conducted with 12 of the observed patients (seven men and five women aged between 35 and 84 years) who were suffering from various chronic diseases (liver, asthma and gastrointestinal diseases). The interviews, which were conducted in the patient’s room on the ward, took the form of a conversation (Mishler, 1986). This involves openness towards the informants’ way of reasoning as well as awareness concerning the researcher’s position in the interview situation. The patients were asked to narrate experiences of trying to obtain knowledge and gain understanding in everyday nursing situations. Follow-up questions were asked in order to deepen the understanding of pedagogical dimensions in nursing situations. Patients’ privacy was respected in different ways. There were no other patients or staff in the room during the interviews, and the patients were encouraged to point out if the conversation was too tiring. The interviews, lasted between 30 and 60 min, were tape recorded and transcribed verbatim. The study was approved by the ethics committee of Go¨teborg University, and informed written consent was obtained from both patients and nurses.
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2.3. Analysis According to Agar (1980) and Atkinson (1990), a fieldwork study can be analysed in different ways. The present study was analysed by means of a life-world phenomenological approach (Bengtsson, 1999). In order to find relevant answers to the research question, guiding phenomenological principles were openness and pliability towards the phenomenon of interest (Dahlberg et al., 2001). This means openness to the life-worlds of both patients and nurses as well as towards actions and conversations in the study setting, the medical ward. In the analysis phase, the intention was to use the rich life-world data to create an understanding of the pedagogical dimensions in nursing situations. Openness was also achieved by reflexivity. According to Hammersley and Atkinson (1995), reflexivity means reflection on the results during the analysis phase and reflection on the researcher’s approach during the field phase. In this study, reflexivity implies a reflexive movement between different types of empirical data (observations and interviews) and between different levels of analysis. The analysis resulted in themes close to the empirical data in order to endow the complex research phenomena with a deep and nuanced meaning. The analysis was conducted in four steps:
1. In the first step, field notes and interviews were read as a whole, in order to obtain a general impression of the data. 2. In the second step, a search of the field notes was made to explore the pedagogical dimensions of nursing situations. A question was applied to the field notes: ‘‘What does this note tell me about pedagogical dimensions?’’ The definition of a pedagogical situation was used as a guide in the search for pedagogical dimensions in the field notes. Different pedagogical situations (112) were identified. In order to explore the identified pedagogical situations, we first identified nurses’ teaching strategies and then patients’ strategies for seeking knowledge and gaining understanding. The following teaching strategies used by nurses were identified: observing patients’ actions and words, asking questions and waiting for the patient to ask questions, providing information, demonstrating modes of conduct, providing explanations, exhorting and giving reasons. The following strategies used by patients for seeking knowledge and gaining understanding were identified: observing nurses’ words and actions, asking direct (explicit) or indirect (implicit) questions, seeking confirmation of previous experiences and conceptions, and interpreting their own bodily expressions in order to understand the disease and its consequences. Moreover, patients asked other persons as a means of acquiring
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knowledge and understanding about their condition. Finally, they also searched for information in specialised literature pertaining to their disease. The strategies used by nurses and patients show something about how the situations are constructed. Accordingly, the strategies identified reveal characteristics of different encounters. Two comprehensive themes with accompanying categories characterising two widely different pedagogical encounters were formulated. Further, the interviews were scrutinised for their pedagogical dimensions. 3. In the third step, solely the interviews with patients were analysed for experiences of attempting to gain knowledge and understanding in everyday nursing situations. Meaning units were identified and subthemes and themes formulated. 4. In the fourth step, the analysed data were interpreted by means of life-world theories. The intention was to deepen the understanding for the results.
3. Results To describe the two themes, we have used the metaphor of being either on the same playing field or on different playing fields and labelled the encounters: ‘‘Players in same field pedagogical encounters’’ and ‘‘Players in different field pedagogical encounters’’. The metaphor of being in the same or different playing fields is used because it facilitates description and interpretation of nurses’ and patients’ verbal and non-verbal interactions in everyday nursing practice. In addition, it illustrates the differences between various pedagogical encounters. In order to understand the patients’ perspective and to achieve a comprehensive understanding of the differences in the pedagogical encounters, the results of the analysis of ‘‘patients’ experiences of seeking and acquiring knowledge during periods of illness’’ are described within the framework of the two types of pedagogical encounter. 3.1. Players in same field pedagogical encounters: ‘‘following and letting oneself to be followed’’ A same field pedagogical encounter is characterised by ‘‘following and letting oneself to be followed’’. The nurse follows the patient’s verbal and non-verbal expressions such as words and gestures in order to establish what the patient wishes to know. According to the field notes, patients seek confirmation concerning previous experiences and conceptions. They also ask questions in order to increase their knowledge and understanding. Some questions are explicitly formulated, while others are implicit and embedded in the conversation. In a same field pedagogical encounter, there seems to be a clear intention on the part of the
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nurse to interpret the patient’s bodily expression in order to establish what he/she means and wishes to learn about. The nurse also shows an interest in highlighting and clarifying something that the patient has already heard or knows but perhaps forgotten. Sometimes, the nurse also wants to draw attention to something that he/ she considers important for the patient to know. This means interrupting what one is doing and turning one’s gaze towards the patient. The nurse’s gaze indicates that the patient is in his/her field of experience. In another sense, it is a question of showing that the nurse is prepared to engage in a conversation with the patient, which includes listening to the patient’s point of view, even when it differs from a more traditional medical perspective or from the nurse’s understanding. The nurse also allows him/herself to be followed by the patient. To let oneself be followed means to invite the patient to enter into a dialogue, which can be accomplished by both verbal and non-verbal means. Quite often, the nurse ‘‘thinks aloud’’ which allows the patient to follow the nurse’s reasoning. This can be considered an offer to share relevant knowledge with the patient. Thus, different teaching strategies are used to support the patient’s need for knowledge and understanding (Table 1). The following field note illustrates ‘‘same field pedagogical encounters’’ where the nurse follows the patient and allows him/herself to be followed by the patient. The patient, Bob, and a nurse meet in the patient’s room: Bob says: ‘‘I think I need a laxative’’. The nurse stops in front of Bob, looks at him and says: ‘‘You can have some Laxoberal and two Relaxit tablets.’’ ‘‘Hm’’, Bob mutters. The nurse is silent for a while. Then she takes a chair and sits down beside the bed. She looks at Bob and says: ‘‘What do you usually take at home?’’ Bob does not answer immediately, but then says: ‘‘I usually take Toilax or Minilax. I think they work.’’ The nurse tells him that there are suppositories that are equally effective. Bob says that he thinks suppositories hurt. The nurse says: ‘‘I know, but I usually soften them in water.’’ Bob starts
Table 1 Conduct characterising ‘‘Following and letting oneself to be followed’’
To invite the patient to engage in a pedagogical dialogue To find out what the patient wants to know To estimate what the patient needs to know To let the patient follow your reasoning To be with the patient in the course of the learning experience
talking about the importance of a diet containing plenty of roughage to keep the stomach in good order. He continues: ‘‘I don’t know which food is best for me.’’ The nurse says: ‘‘It is important to drink a great deal and eat vegetables.’’ Bob and the nurse continue the conversation about the importance of food and activity. (Field note) The nurse stops in front of Bob, listens to him and turns her gaze towards him. She also devotes time to him. Moreover, she asks questions in order to ascertain his level of knowledge or, alternatively, to find out if there is something he would like to know. Both explanations and exhortations occur. Bob asks questions and gives some previous experiences. A dialogue develops where the nurse points out aspects that Bob needs to know in order to solve the problem with his bowels. 3.1.1. Patients’ experiences of seeking and acquiring knowledge in ‘‘same field pedagogical encounters’’: a feeling of dignity Four sub-themes originating from the analysis of the patient interviews can be illustrated by an upward spiral (see Fig. 1). This is a positive spiral, which begins with a feeling of participation, followed by feelings of skilfulness and of being secure. This in turn gives rise to a feeling of preparedness. The analysis reveals that some patients actively seek knowledge while others are more passive and prefer to wait until the professionals provide them with information. These two groups are described in the following. Quotations from the interviews are presented in order to illustrate the themes. ‘‘P’’ stands for patient and ‘‘I’’ for interviewer. 3.1.1.1. A feeling of participation. A patient experiences participation when a health professional invites him/her to enter into a conversation about different aspects of the health care situation, such as planned treatment or routine nursing duties. It is equally important to participate in decision-making related to changes in treatment and medication. A patient who actively seeks knowledge wants to be involved in various decisions. The following quotation illustrates this: P: I want to know the way they do it and so on. How it worksyboth before and afterwards. If it is effective andy I: Mm. P: If another method is better. I: Mm. P: When they make a suggestionyI would like to know how they do it. I: How they perform the treatment? P: And if it hurts afterwards andy I: Is it important for you to know this?
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encounter, the patient is confident that the nurse will take pedagogical responsibility even if she/he is a passive patient. One of the patients reported: P: Everybody here is so kind and understanding. They care about me. It is important to me to feel that I can express anything I want. I: Why is it important to you? P: One could say it provides a certain amount of relief.
Fig. 1. Patients’ experiences of seeking and acquiring knowledge in ‘‘same field pedagogical encounters’’: a feeling of dignity.
P: YesyI will base my decision on the informationywhat I will do. Thus, participation is never one sided. It presupposes the participation of another. Patients observe and listen to the nurse in order to ascertain whether or not he/she is receptive to the patient’s opinion. For the passive patients, a feeling of being included in the daily care and in the planning of treatments is decisive for experiencing participation. Experiencing the nurse’s purposefulness in actions and speech is of great importance for the passive patients. 3.1.1.2. A feeling of skilfulness. It is essential that health professionals treat a patient who is actively seeking knowledge as a knowledgeable person and acknowledge his/her need for information. Knowledgeable patients can ask questions that are deemed relevant by nurses and doctors. This motivates the patient to continue to be active. Knowledge can also minimise unrealistic conceptions about the disease or health situation. A patient commented: P: Due to this illness I have read a lot. I am quite knowledgeable. I am interested and can ask questions. And I have noticed that questions can easily be answered. I know what to ask 95% of the time. Knowledge creates competence to formulate intelligible questions. 3.1.1.3. A feeling of being secure. The passive patients do not have the same motivation to seek knowledge, although they would like to understand and to be involved in what happens around them. A feeling of participation induces a feeling of safety, which enables the patient to ask relevant questions. In a same field
3.1.1.4. A feeling of preparedness. Feelings of preparedness are important both for the patients who are actively seeking knowledge and for the passive patients, although in different ways. For patients who are actively seeking knowledge, preparedness is of significance for making correct decisions and ultimately for judging nurses’ or doctors’ actions. Preparedness also enables the patient to cope with the different consequences of his/her illness in everyday life. P: Then you know in advance and are prepared for it. I have a family and they want to know. I have a small business and must arrange everything before a hospital stay. I want to know if it will take a couple of days or a week. For passive patients, preparedness is not related to action. Instead, it concerns trying to understand the present situation and/or life circumstances. A lack of understanding of the situation or nursing activities can result in worry. P: I want to know how they plan to do the treatment. I: Why do you want to know? P: One will not be worried if things are fully explained. It is most important to ensure that they don’t do something they are incapable of doing. 3.2. Players in different field pedagogical encounters: ‘‘questions and answers’’ In ‘‘different field pedagogical encounters’’, the dialogue is characterised by questions and answers. A question from a patient is followed by an answer, but the nurse does not appear willing to continue the conversation. This results in a broken dialogue. The patient is left alone with various questions. In ‘‘different field pedagogical encounters’’, there is a risk that nurses may not notice or be fully aware of the patient’s concerns and need for knowledge and understanding. Most problematic is the fact that patients’ implicit questions are ignored. Such questions are embedded in the conversation in which the patient speaks between the lines. Implicit questions are often existential in nature. Another area where there is a risk that nurses may not notice or be fully aware of the patient’s concerns and
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Table 2 Conduct characterising ‘‘Questions and answers’’
To end the conversation too early To reinterpret what the patient says To comment on what the patient has said but not pursuing the matter further To change the topic of conversation
need for knowledge and understanding is the patient’s conceptions of illness. Thus, the patient’s desire for confirmation of their conceptions is ignored. In the following table, conduct illustrating ‘‘questions and answers’’ in relation to failure to pay attention to patients questions is described (Table 2). The following field note illustrates ‘‘different field pedagogical encounters’’, where there is a breakdown in the dialogue between patient and nurse. One patient, Ellen, and a nurse meet in the patient’s room and Ellen expresses concern about her swollen legs: Ellen is sitting up in bed. The nurse places a bottle of medicine on the bedside table and says: ‘‘Here is your heart medicine’’. Ellen looks at the nurse and says: ‘‘I wonder if my swollen legs are due to the heart medication. I think that I am oversensitive to the tablets.’’ The nurse says: ‘‘No, this medication is for the heart and it will help you.’’ The patient doesn’t say any more. The nurse continues: ‘‘It will be lunch time soon. Remember not to drink too much Ellen’’. (Field note) Even if the nurse gives information and explanations, Ellen’s questions and conceptions are not met. In this encounter, Ellen’s question about her swollen legs is ignored and the topic of conversation is changed. 3.2.1. Patients’ experiences of seeking and acquiring knowledge in ‘‘different field pedagogical encounters’’: a feeling of threatened dignity Three sub-themes from the analysis of the patient interviews are illustrated by a downward spiral. This is a negative spiral, which begins with feelings of exclusion, followed by feelings of inferiority. This in turn gives rise to the experience of worry. Interview quotations are presented to illustrate the sub-themes. ‘‘P’’ stands for patient and ‘‘I’’ for interviewer (Fig. 2). 3.2.1.1. Feeling excluded. The withholding of essential knowledge for understanding the situation can result in a feeling of exclusion. In a sense, the patient is excluded from a course of events that affects him/her in different ways, thus leading to uncertainty. Both the patients who actively seek knowledge and the passive patients experience feelings of being excluded. Patients who seek knowledge actively cope with the situation in their own
Fig. 2. Patients’ experiences of seeking and acquiring knowledge in ‘‘different field pedagogical encounters’’: a feeling of threatened dignity.
way. They refuse to allow themselves to be hindered, continue the search for knowledge on their own and turn to persons other than nurses and doctors for information. Some of the passive patients remain silent because they are not accustomed to initiating a conversation while others do not want to cause trouble. The following patient commented on the aspect of being unable to express oneself in a way that is understood or acknowledged by the health care personnel: P: It is difficult when you see a doctor and have a question. It is difficult to ask when you do not know the correct terms. 3.2.1.2. Feeling inferior. The hierarchical medical context is one contributory cause of patients’ feelings of inferiority. The medical round is one example. Even though the doctors and nurses observe the patients, the patients may feel reluctant to ask questions due to their inability to express what they want to know. Another aspect is the daily nursing routines, which seem to be more important than a pedagogical encounter. An unfamiliar environment is another contributory factor in patients’ experiences of feeling inferior and being in a disadvantaged position. Yet another factor is the patients’ experiences of being dependent on help from others. In the following quotation, a patient states: P: I feel a bit inferior. I feel that perhaps I’m unable to understand the situation. It gives me a feeling of incompetence.
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3.2.1.3. Worry. Helplessness and frustration lead to resignation and worry, undermining the patients’ feeling of being regarded as competent. A feeling of being worthy of teaching is important. It is essential that the patient feels that he/she is worthy of instruction. In the absence of this feeling, lethargy and a reduced ability to search for knowledge can occur. A patient commented: P: You start worrying when you are alone in bed at night. You think and think. But if you get a proper answer you don’t feel like that. You prepare yourself and you know what’s going to happen. You prepare yourself in a different way. Worry can have many grounds, one of which is lack of knowledge.
3.3. Interpretation of the results based on life-world theories In the following, Schutz’s theory (Schutz, 1997; Schutz and Luckmann, 1989, 1995) about inter-subjective encounters is used to illuminate ‘‘Different field pedagogical encounters’’ and ‘‘Same field pedagogical encounters’’. Schutz argues that individuals meet in the everyday world with different degrees of anonymity and makes a distinction between a ‘‘they-relationship’’ and a ‘‘we-relationship’’. In a ‘‘they-relationship’’, the individuality and uniqueness of the other person is disregarded. Instead, the person is seen as part of a crowd and categorised as a person of a particular kind, e.g. a patient with heart failure. According to the data analysed in this study, parallels can be drawn with ‘‘Different field pedagogical encounters’’, where the dialogue between patient and nurse either never started or started but was discontinued (see Table 2). In Schutz’ description of a ‘‘they-relationship’’, the other person is not considered as a unique being, but rather as a ‘‘type’’, e.g. a typical patient with identical information needs to other patients in that specific group, i.e. patients with heart failure. A ‘‘thou-orientation’’ is quite different, as it can be unilateral or reciprocal. In a unilateral thou-orientation, the relationship is one sided in that only one of the parties is oriented towards the other as an individual subject, a thou. The field note concerning Ellen illustrates this. Ellen asked a question about her swollen legs. The nurse answered, but turned her attention to a different aspect, which she presumably judged to be more important (exhorting Ellen not to drink too much). Ellen’s question remained unanswered and her need for knowledge unsatisfied. She attempted to establish contact with the nurse but the conversation broke down due to the nurse’s change of subject.
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However, Schutz emphasises that a unilateral ‘‘thouorientation’’ can be transformed into a reciprocal ‘‘thouorientation’’ where the parties are aware of each other and a social relationship is established, whereby a ‘‘werelationship’’ emerges. Parallels can be drawn with ‘‘Same field pedagogical encounters’’ where the nurse follows the patient’s verbal and non-verbal expressions in order to identify the patient’s need for information and knowledge (see Table 1). According to Schutz, a ‘‘we-relationship’’ is an inter-subjective encounter where the parties observe, listen to and actively try to understand each other. Schutz uses the expression ‘‘face-toface’’ relationship and states that the parties ‘‘grow old together’’. If we return to the patient with heart failure, the nurse in a ‘‘we-relationship’’ opens up to the individual patient’s way of expressing his/her need for knowledge both verbally and non-verbally. According to Merleau-Ponty (1995), the nurse is open to bodily expression. This does not mean that the nurse is not familiar with the information needs of heart failure patients. However, in a ‘‘we-relationship’’, there is pedagogical relationship between the nurse’s and the patient’s life-world. To use Schutz’s words, the two types of encounter represent different ‘‘realms’’. ‘‘A same field pedagogical encounter’’ involves an atmosphere that enables the pedagogical potential of the nursing situation to develop. This also implies a view of the patient as a learning person and involves a focus on helping the patient to be prepared for both physical changes and changes in his/her life situation due to the illness. The concept of ‘‘preparedness’’ emerges as a specific goal of teaching activities.
4. Discussion The aim of this study was to illuminate pedagogical dimensions in nursing situations and informal teaching. More specifically, the aim was to describe the characteristics of pedagogical encounters between nurses and patients in a medical ward in addition to describing patients’ experiences of seeking and acquiring knowledge during periods of illness. The results show two different types of pedagogical encounters ‘‘Same field pedagogical encounters’’ and ‘‘Different field pedagogical encounters’’. In same field pedagogical encounters, the patient is regarded as a learning person, a pedagogical dialogue develops and the encounter is characterised by ‘‘following and letting oneself to be followed’’. In different field pedagogical encounters, there is a breakdown in the dialogue, and the pedagogical potential is not developed. The conversation takes the form of unrelated questions and answers. Patients’ dignity is either threatened or supported, depending on the type of encounter. Worry and
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preparedness are deemed aspects of this. Before the discussion of the results, some methodological reflections should be considered. 4.1. Methodological considerations Trustworthiness of the study was tried to be attained through a reflective attitude during the field phase and analysis phase and in the writing of the results. In the field phase, we attempted to achieve a balance between research needs and our responsibility to the informants. The intention was to capture rich field data without unduly disturbing the ward activities. This also implied continuous reflection on the researcher’s role during data collection. The data in this study were collected from a single medical ward. One or two more wards could have been included in the study. However, the ward studied was large and contained 50 beds. One advantage of using a single ward was that it was easier to become familiar with the ward culture as well as making it easier for the staff to get to know the researcher. Prior to the data collection, the first author (FF) visited the ward everyday for a week with the intention of familiarising herself with the physical surroundings, the staff and the daily routines. Trustworthiness also concerns the use of two kinds of data to explore the everyday nursing situations. Observations and interviews complemented each other, which involved a more comprehensive understanding of the phenomena. As described earlier, the characteristics of the pedagogical encounters are based in the analysis of nurses’ teaching strategies and patients’ strategies for seeking knowledge and gaining understanding. However, these strategies are not described in detail in this study (see Friberg, 2001), which can be seen as a limitation. Informal teaching has been studied earlier and the results point to aspects found in for instance Gregor (2001) and Kloster (1997). Another aspect worth noting is that the study reflects a Swedish perspective. The results cannot be generalised in a traditional sense. It is up to the reader to decide how the results can be understood and implemented in other contexts. 4.2. Discussion of the results Pedagogical encounters between nurses and patients, as described in this article, illuminate one aspect of informal teaching, namely the characteristics of pedagogical encounters. The results complement with Gregor’s (2001) description of strategies used by nurses in informal teaching situations. Gregor stressed the importance of incorporating informal teaching activities in the definition of patient teaching. The results of the
present study may be regarded as a contribution to the knowledge of informal teaching. ‘‘Same field pedagogical encounters’’ and ‘‘Different field pedagogical encounters’’ can be considered two extremes, between which a variety of encounters occur in everyday nursing practice, where different encounters lead to differing experiences. What makes a pedagogical encounter special? A pedagogical encounter involves the aim that somebody (the patient) should understand and learn something. One may question whether it is appropriate to employ the term ‘‘pedagogical’’ to describe ‘‘different field encounters’’. Perhaps it would be more correct to describe them as ‘‘apedagogical’’, because there appears to be no pedagogical aim. Some examples are when the patient asks questions in order to gain knowledge and understanding and the nurse changes the subject of the conversation, ends the conversation too early or reinterprets what the patient said. According to the interviews, the patients experienced feelings of exclusion and inferiority, which resulted in worry. However, we have chosen to use the term ‘‘pedagogical’’ since the analysed situations contain important pedagogical potential that needs to be developed. Furthermore, one could ask how a pedagogical encounter can be distinguished from a caring encounter in general. Parallels can be drawn with Halldorsdottir’s (1996) distinction between caring and uncaring encounters in the context of cancer nursing. A caring encounter results in increased well-being and health, denoted as empowerment. An uncaring encounter, on the other hand, leads to decreased well-being and health and can be described as discouragement. ‘‘Same field pedagogical encounters’’ have similarities with Halldorsdottir’s (1996) ‘‘caring encounter’’ and results in patients’ preparedness. ‘‘Preparedness’’ means helping the patient to discover meaning and reducing anxiety, which is sometimes due to a feeling of not being prepared for the actual situation or the future. ‘‘Preparedness’’ is a cognitive–emotive–existential state and a more distinct pedagogical term than ‘‘well-being’’. It also has more pedagogical connotations than the term ‘‘empowerment’’. The term ‘‘preparedness’’ is oriented towards ‘‘the future’’ and reveals a potential for development. Introducing the concept of preparedness is an attempt to create a complementary basis for informal patient teaching, the implementation of which in clinical practice is the duty of the nurse. Thus, a pedagogical encounter prepares the patient for different changes in the current situation and/or life situation as a result of illness. Preparedness can also have a deeper meaning such as being prepared for death. All these situations or life circumstances are related to learning and understanding. Parse’s (1981, 1998) theory of ‘‘human becoming’’ illuminates this. Parse stresses that human becoming is an ever-changing process. As
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described in the present study, ‘‘Same field pedagogical encounters’’ characterised by ‘‘following and letting oneself to be followed’’ can be related to Parse’s (1998) theory of human becoming. As we see it, Parse’s concepts ‘‘powering’’, ‘‘originating’’ and ‘‘transforming’’ are of particular importance for the pedagogical aspects of nursing situations. According to Parse, ‘‘Powering’’ is a way of revealing and concealing of imaging, leading to a new meaning. ‘‘Originating’’ is a manifestation of enabling and limiting of valuing whereby the patient becomes aware of different choices and their consequences. Finally, ‘‘transforming’’ unfolds in the languaging of connecting and separating. This means that verbalising enables understanding and facilitates the opportunity for change within the existing situation. ‘‘Powering’’, ‘‘originating’’ and ‘‘transforming’’ are important for assisting the patient to achieve a state of preparedness. Thus, the term ‘‘preparedness’’ can be related to the meaning of ‘‘becoming’’. Stamler (1996) uses the term ‘‘enablement’’. To enable learning as well as preparedness, the patient must be regarded as a learning person. Maslow (1970, p. 48) discusses the desire to know and understand. Learning is not limited to childhood or youth, but is a constituent part of the human being. Accordingly, it cannot be excluded from periods of illness and/or suffering, as it forms a part of the sick/unwell person’s everyday life. Thus, enabling learning situations in order to assist the patient to become knowledgeable and to understand is an important prerequisite of preparedness. Therefore, patient preparedness can be regarded as a primary teaching goal. However, the meaning of preparedness as a pedagogical goal needs to be investigated in further studies. How can nurses be encouraged to continue everyday informal teaching? In line with previous research (Barber-Parker, 2002; Marcum et al., 2002; Turner et al., 1999), our result confirms the importance of developing supportive health organisations where time is allocated for informal patient teaching. This implies organisations where informal teaching is deemed important and nurses are supported in developing this part of nursing practice. Parallels can be drawn with Sanford’s (2000) distinction between a caring and an uncaring context. A caring context is characterised by relationship, dialogue, mutual trust, shared meaning and receptivity. An uncaring context, on the other hand, focuses more on the mediation of information. According to Sanford, a caring context must be facilitated. Previous research reveals a lack of documentation on patient teaching activities (Ehrenberg et al., 2001; Karkkainen and Eriksson, 2003). If nurses act in accordance with ‘‘Different field pedagogical encounters’’ they will probably fail to identify patients’ need for knowledge. Thus, there is a risk that possible teaching moments will be lost or remain unidentified.
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5. Conclusion Pedagogical encounters occur in everyday nursing practice. Nurses’ pedagogical awareness must be supported in different ways. Health care organisations have to create a pedagogical climate, and the nurse should view the patient as a learning person in order to help the patient achieve preparedness. Both nurses and the health care organisation must decide on whether the pedagogical potential should be developed or remain undiscovered. The findings of the present study could serve as a reflective tool for nurses and health care organisations in order to reveal and make full use of taken-for-granted everyday nursing situations of pedagogical importance.
References Agar, M., 1980. The Professional Stranger. An Informal Introduction of Ethnography. Academic Press, New York. Atkinson, P., 1990. The Ethnographic Imagination, Textual Constructions of Reality. Routledge, London and New York. Barber-Parker, E.D., 2002. Integrating patient teaching into bedside patient care: a participant—observation study of hospital nurses. Patient Education and Counseling 48 (2), 107–113. Bengtsson, J., 1999. (Ed.) Med livsva¨rlden som grund (With the Life World as a Point of Departure). Studentlitteratur, Lund. Coates, V.E., 1999. Education for Patients and Clients. Routledge, London and New York. Dahlberg, K., Drew, N., Nystro¨m, M., 2001. Reflective Lifeworld Research. Studentlitteratur, Lund. Ehrenberg, A., Ehnfors, M., Smedby, B., 2001. Auditing nursing content in patient records. Scandinavian Journal of Caring Sciences 15, 133–141. Freed, P., 1998. Perseverance: the Meaning of Patient Education in Psychiatric Nursing. Archives of Psychiatric Nursing 12 (2), 107–113. Friberg, F., 2001. Pedagogiska mo¨ten mellan patienter och sjuksko¨terskor pa˚ en medicinsk va˚rdavdelning. Mot en va˚rddidaktik pa˚ livsva¨rldsgrund (Pedagogical encounters between nurses and patients on a medical ward. Towards a caring didactics from a life world approach). Dissertation, Go¨teborg University, Department of Health Care Pedagogics, Go¨teborg, Sweden. Gregor, F., 2001. Nurses’ informal teaching practices: their nature and impact on the production of patient care. International Journal of Nursing Studies 38 (4), 461–470. Halldorsdottir, S., 1996. Caring and uncaring encounters in nursing and health care-developing a theory. Dissertation, Linko¨ping University, Department of Caring Sciences, Linko¨ping, Sweden. Hammersley, M., Atkinson, P., 1995. Ethnography, Principles in Practice, second ed. Routledge, London and New York. Henderson, P., 1960. Basic Principles of Nursing Care. ICN House, London.
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Karkkainen, O., Eriksson, K., 2003. Evaluation of patient records as part of developing a nursing care classification. Journal of Clinical Nursing 12, 198–205. Karlsen, B., 1997. Hospital Nurses’ Perceptions of Patient Teaching. Scandinavian Journal of Caring Sciences 11, 97–102. Kloster, T., 1997. Nurses’ pedagogical function and patients’ experiences. A fieldwork study (In Norwegian: Hvordan ivaretar sykepleierne sin pedagogiske funksjon og hvordan opplever pasienterne dette? Feltstudie i en ortopedisk avdeling). Va˚rd i Norden 17 (3), 14–20. Marcum, J., Ridenour, M., Shaff, G., Hammons, M., Taylor, M., 2002. A study of professional nurses’ perceptions of patient education. The Journal of Continuing Education in Nursing 33, 112–118. Maslow, A.H., 1970. Motivation and Personality, second ed. Harper & Row, New York. Mc Goldrick, T.B., Jablonski, R.S., Robinson, Wolf.Z., 1994. Needs assessment for a patient education program in a nursing department. Journal of Nursing Staff Development 10 (3), 123–130. Merleau-Ponty, M., 1995. Phenomenology of Perception (trans. C. Smith). Routledge, London and New York. Milazzo, V., 1980. A study of the difference in health knowledge gained through formal and informal teaching. Heart & Lung 9, 1079–1082. Mishler, E.G., 1986. Research Interviewing. Context and Narrative. Harvard University Press, Cambridge. Nightingale, F., 1957. Notes on Nursing. J.B. Lippincott, Philadelphia. Parse, R.R., 1981. Man-Living-Health: a Theory of Nursing. Delmar Publishers, New York. Parse, R.R., 1998. The Human Becoming School of Thought. A Perspective for Nurses and Other Health Professionals. Sage, Thousand Oaks, CA.
Polanyi, M., 1966. The Tacit Dimension. Routledge and Keagan Paul, London. Redman, B., 1993. The Process of Patient Education. Mosby Year Book, St. Louis. Sanford, R., 2000. Caring through relation and dialogue: a nursing perspective for patient education. Advances in Nursing Science 22 (3), 1–15. Schutz, A., 1997. The Phenomenology of the Social World (trans. G. Walsh & F. Lehnert) (Sixth Paperback Printing). Northwestern University Press, Evanston. Schutz, A., Luckmann, T., 1989. The Structures of the LifeWorld, vol. II (trans. R. Zaner & D. J. Parent). Northwestern University Press, Evanston. Schutz, A., Luckmann, T., 1995. The Structures of the LifeWorld, vol. I (trans. R.M. Zaner & H.T. Engelhardt) (Third Paperback Printing). Northwestern University Press, Evanston. Stamler, L., 1996. Toward a framework for patient education. An analysis of enablement. Journal of Holistic Nursing 14 (4), 332–347. Turner, D.S., Wellard, S., Bethune, E., 1999. Registered nurses’ perceptions of teaching: constraints to the teaching moment. International Journal of Nursing Practice 5, 14–20. Twinn, S.F., Lee, D.T.F., 1997. The practice of health education in acute care settings in Hong Kong: an exploratory study of the contribution of registered nurses. Journal of Advanced Nursing 25, 178–185. van Manen, M., 1991. The Tact of Teaching. The Meaning of Pedagogical Thoughtfulness. State University of New York Press, Albany. Wellard, S., Turner, D.S., Bethune, E., 1998. Nurses as patient teachers: exploring current expressions of the role. Contemporary Nurs 7 (1), 12–17.
International Journal of Nursing Studies 44 (2007) 534–544 www.elsevier.com/locate/ijnurstu
Pedagogical encounters between nurses and patients in a medical ward—A field study F. Friberga,, E. Pilhammar Anderssonb, J. Bengtssonc a School of Health Sciences, University College of Bora˚s, 501 90 Bora˚s, Sweden Department of Health Care Pedagogics, Faculty of Health and Caring Sciences, The Sahlgrenska Academy, Go¨teborg University, Box 457, 405 30 Go¨teborg, Sweden c Department of Education, Go¨teborg University, Box 300, 405 30 Go¨teborg, Sweden
b
Received 1 February 2005; received in revised form 2 December 2005; accepted 13 December 2005
Abstract Background: Patient teaching is regarded as an important aspect of nursing care as well as an essential part of the nursing profession. In nursing practice, a distinction can be made between formal (planned) and informal (spontaneous) patient teaching. The major part of patient teaching research is within the area of formal teaching. In spite of the fact that spontaneous teaching occurs in everyday nursing practice, there is a lack of knowledge in this area. Objectives: The aim was to illuminate pedagogical dimensions in nursing situations and informal teaching. Design: The study is a fieldwork study within the frames of a life-world phenomenological tradition. Participants and setting: Fifteen registered nurses in a general medical ward of a university hospital in Sweden were followed in their daily work with patients. Twelve patients suffering from various chronic diseases were interviewed. Methods: The observations comprised a total of 173 h on 34 separate occasions. Informal dialogues with nurses were carried through. Further, formal interviews were conducted with 12 of the observed patients. The data were analysed by means of a life-world phenomenological approach. Results: Two different pedagogical encounters are presented: ‘‘Players in different field pedagogical encounters’’, in which there is a breakdown in the pedagogical dialogue, and ‘‘Players in same field pedagogical encounters’’, in which the pedagogical dialogue develops. Patients’ experiences of seeking and acquiring knowledge within these two types of encounter are characterised as ‘‘worry’’ versus ‘‘preparedness’’. Patients’ dignity is either threatened or supported, depending on the type of encounter. Conclusions: Health care organisations have to create a pedagogical climate where ‘‘Same field pedagogical encounters’’ can be created. The nurse has to view the patient as a learning person in order to help the patient to achieve ‘‘preparedness’’. ‘‘Preparedness’’ is described as a cognitive–emotive–existential state and emphasised as an important goal of patient teaching. r 2006 Elsevier Ltd. All rights reserved. Keywords: Informal teaching; Life-world phenomenology; Fieldwork; Pedagogical encounters; Preparedness.
What is already known about the topic? Corresponding author. Tel.: +46 33 435 40 00; fax: +46 33 16 40 10. E-mail address: [email protected] (F. Friberg).
Patient teaching is a key nursing activity. The major part of patient teaching research is within
0020-7489/$ - see front matter r 2006 Elsevier Ltd. All rights reserved. doi:10.1016/j.ijnurstu.2005.12.002
the area of formal teaching.
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There is a lack of knowledge about informal patient
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1.1. Informal patient teaching
teaching.
What this paper adds
Informal patient teaching is illuminated. Characteristics of everyday pedagogical
patient– nurse encounters are described. The concept of ‘‘preparedness’’ is identified as a specific teaching goal.
1. Introduction Historically, patient teaching has been regarded as an important aspect of nursing care (Nightingale, 1957) as well as an essential part of the nursing profession (Henderson, 1960). Although patient teaching today is regarded as a key nursing activity (Marcum et al., 2002), many barriers to teaching have been identified, such as lack of time, lack of support from the health organisation and insufficient pedagogical knowledge (BarberParker, 2002; Marcum et al., 2002; Turner et al., 1999). Another problem is lack of documentation of patient teaching in nursing records (Marcum et al., 2002; Karkkainen and Eriksson, 2003). To view patient teaching as important while at the same time having to take various obstacles into account indicates the complexity of being a teaching nurse. In nursing practice, a distinction can be made between formal (planned) and informal (unplanned and spontaneous) teaching (Barber-Parker, 2002; Gregor, 2001; Milazzo, 1980). The major part of patient teaching research is within the area of formal teaching (Wellard et al., 1998). There are many intervention studies available, in which a specific patient group is selected and teaching is implemented and evaluated. Textbooks on the subject of patient teaching also focus on formal teaching (Coates, 1999; Redman, 1993). However, informal teaching frequently takes place in bedside care (Barber-Parker, 2002; Gregor, 2001; Mc Goldrick et al., 1994; Wellard et al., 1998). In spite of the fact that spontaneous teaching occurs in everyday nursing practice, there is a lack of knowledge in this area (Barber-Parker, 2002; Gregor, 2001). Therefore, the focus of this article is everyday nursing practice and specifically the pedagogical dimensions of nursing situations in terms of informal teaching. The term ‘‘pedagogy’’ is used as a comprehensive term for teaching activities in order to highlight both theoretical and practical aspects of teaching situations (van Manen, 1991). In this article, selected findings from a larger fieldwork study on informal patient teaching from a Swedish perspective are reported (Friberg, 2001).
A search in the CINAHL, ERIC and Medline databases revealed few studies on the subject of informal patient teaching in natural settings. For the most part, studies related to informal teaching concern nurses’ attitudes (see Freed, 1998; Karlsen, 1997). In a questionnaire study (Mc Goldrick et al., 1994), American nurses’ opinions of patient teaching in terms of patient groups, teaching strategies, teaching content and the nurses’ educational level as a base for planning future teaching activities were investigated. The result reveals that informal teaching occurred on a 24-h basis, mostly at the bedside. Medication and safety aspects of care were identified as an important content of the teaching. It was also noted that the nurses had a low degree of formal teaching competence, which, according to the authors, highlights the complexity of teaching. Twinn and Lee (1997) studied health teaching in a medical and a surgical ward in Hong Kong by means of observation. They found that teaching occurred spontaneously mainly on admission or on occasions when it was quiet on the ward. It was observed that many teaching opportunities were missed. In a Canadian fieldwork study carried out in a surgical ward (Gregor, 2001), the interaction between patients and nurses was explored in order to identify informal patient teaching. Six different types of interaction constituting patient teaching emerged: questions, explanations, information, instructions, setting expectations and demonstrating correct modes of conduct. Gregor argues that patient teaching is an integral part of everyday hospital practice. It lacks visibility due to the fact that it is usually women’s work. In an American study, Barber-Parker (2002) studied bedside teaching in an oncology ward. According to the results, teaching was carried out as a natural and inherent part of the everyday work with patients. The teaching content was focused on facts of different kinds. Barber-Parker states that the nurses did not identify the patient’s need for knowledge and that evaluation of patient teaching was limited. In a Norwegian fieldwork study (Kloster, 1997), nurses’ pedagogical function and patients’ experiences of patient teaching were studied in an orthopaedic ward. According to the results, teaching activities were seldom planned and mostly occurred at the patient’s bedside. The teaching content focused on facts and was seldom documented as pedagogical actions. The literature review indicates that informal teaching occurs but is often taken for granted. This aspect of nurses’ practical knowledge (Polanyi, 1966) requires further study and is important for the development of nurses’ professional knowledge as well as for improving the care of patients who need knowledge and understanding.
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1.2. Aim The overall aim was to illuminate pedagogical dimensions in nursing situations and informal teaching. More specifically, the aim was to describe the characteristics of pedagogical encounters between nurses and patients on a medical ward as well as patients’ experiences of seeking and acquiring knowledge during periods of illness. In the study, the expression ‘‘pedagogical situation’’ is used and defined as an encounter between patient and nurse, where the patient starts a conversation aimed at obtaining information about the illness or disease and/or its consequences for his/her present situation or life circumstances. The nurse can also initiate a pedagogical situation by saying something with the purpose of increasing the patient’s knowledge about his/her illness or disease and/or its consequences for his/her present situation or life circumstances.
2. Methods 2.1. Theoretical framework Informal patient teaching is a normal part of everyday nursing practice. Life-world theories based on a phenomenological thinking were chosen as the ontological and epistemological point of departure for the study (Bengtsson, 1999). The life-world is the world in which we live our daily lives and understands the reality interdependent as between life and world (Schutz, 1997). Accordingly, the world is not seen as objective in itself, nor is human life considered as an independent existence. The life-world is the unconscious background for our experiences and actions. Since the informal patient teaching is often taken for granted, this approach may help us to understand this part of nursing practice. We consider Schutz’ theory of human actions in the everyday life-world relevant to the understanding of pedagogical situations (Schutz, 1997; Schutz and Luckmann, 1989, 1995). Schutz describes how people meet, communicate and try to understand each other in everyday life. We also regard Merleau-Ponty’s (1995) theory of the lived body useful for understanding patients and nurses in terms of bodily expression. Schutz’ theory of inter-subjective encounters and Merleau-Ponty’s theory of the lived body not only constitute the ontological and epistemological point of departure of the study but also have been used as a frame for the interpretation of the results. 2.2. Data collection and informants A guiding assumption is that the life-worlds of patients and nurses meet in the context of the hospital
ward. If the life-world is the point of departure, we must return to everyday nursing practice in order to identify important aspects of informal patient teaching. Thus, the pedagogical dimensions of nursing situations should be understood in a social and inter-subjective life-world context. Thus, fieldwork appears to be an appropriate methodological approach (Hammersley and Atkinson, 1995). In the field phase, the first author (FF) followed 15 registered nurses in a general medical ward of a university hospital in Sweden in their daily work with patients. The observations took place during the day and at night and lasted for 3–4 h at a time with focus on the morning and afternoon shifts. The observations comprised a total of 173 h on 34 separate occasions. All encounters between nurses and patients were of interest. This assumes being receptive to conversations and intersubjective actions relevant to patient teaching. Activities such as medical rounds and staff meetings were also studied in order to obtain rich data about the pedagogical dimensions of nursing situations. Informal dialogues, in line with what Agar (1980) terms nonlinear conversations, also took place in order to capture the nurses’ version of what happened during the encounter with the patient. Thus, spontaneous questions were asked as soon as possible after the observed situation in order to create an understanding of what had happened. Often, these conversations occurred in the corridor or in the nursing office. To respect the nurses’ privacy, a balance was tried to be attained between asking important questions and respecting the nurses’ free will to answer. No questions were asked in the patient’s room or in situations in which the researcher considered asking as disturbing or unsuitable. Furthermore, formal interviews were conducted with 12 of the observed patients (seven men and five women aged between 35 and 84 years) who were suffering from various chronic diseases (liver, asthma and gastrointestinal diseases). The interviews, which were conducted in the patient’s room on the ward, took the form of a conversation (Mishler, 1986). This involves openness towards the informants’ way of reasoning as well as awareness concerning the researcher’s position in the interview situation. The patients were asked to narrate experiences of trying to obtain knowledge and gain understanding in everyday nursing situations. Follow-up questions were asked in order to deepen the understanding of pedagogical dimensions in nursing situations. Patients’ privacy was respected in different ways. There were no other patients or staff in the room during the interviews, and the patients were encouraged to point out if the conversation was too tiring. The interviews, lasted between 30 and 60 min, were tape recorded and transcribed verbatim. The study was approved by the ethics committee of Go¨teborg University, and informed written consent was obtained from both patients and nurses.
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2.3. Analysis According to Agar (1980) and Atkinson (1990), a fieldwork study can be analysed in different ways. The present study was analysed by means of a life-world phenomenological approach (Bengtsson, 1999). In order to find relevant answers to the research question, guiding phenomenological principles were openness and pliability towards the phenomenon of interest (Dahlberg et al., 2001). This means openness to the life-worlds of both patients and nurses as well as towards actions and conversations in the study setting, the medical ward. In the analysis phase, the intention was to use the rich life-world data to create an understanding of the pedagogical dimensions in nursing situations. Openness was also achieved by reflexivity. According to Hammersley and Atkinson (1995), reflexivity means reflection on the results during the analysis phase and reflection on the researcher’s approach during the field phase. In this study, reflexivity implies a reflexive movement between different types of empirical data (observations and interviews) and between different levels of analysis. The analysis resulted in themes close to the empirical data in order to endow the complex research phenomena with a deep and nuanced meaning. The analysis was conducted in four steps:
1. In the first step, field notes and interviews were read as a whole, in order to obtain a general impression of the data. 2. In the second step, a search of the field notes was made to explore the pedagogical dimensions of nursing situations. A question was applied to the field notes: ‘‘What does this note tell me about pedagogical dimensions?’’ The definition of a pedagogical situation was used as a guide in the search for pedagogical dimensions in the field notes. Different pedagogical situations (112) were identified. In order to explore the identified pedagogical situations, we first identified nurses’ teaching strategies and then patients’ strategies for seeking knowledge and gaining understanding. The following teaching strategies used by nurses were identified: observing patients’ actions and words, asking questions and waiting for the patient to ask questions, providing information, demonstrating modes of conduct, providing explanations, exhorting and giving reasons. The following strategies used by patients for seeking knowledge and gaining understanding were identified: observing nurses’ words and actions, asking direct (explicit) or indirect (implicit) questions, seeking confirmation of previous experiences and conceptions, and interpreting their own bodily expressions in order to understand the disease and its consequences. Moreover, patients asked other persons as a means of acquiring
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knowledge and understanding about their condition. Finally, they also searched for information in specialised literature pertaining to their disease. The strategies used by nurses and patients show something about how the situations are constructed. Accordingly, the strategies identified reveal characteristics of different encounters. Two comprehensive themes with accompanying categories characterising two widely different pedagogical encounters were formulated. Further, the interviews were scrutinised for their pedagogical dimensions. 3. In the third step, solely the interviews with patients were analysed for experiences of attempting to gain knowledge and understanding in everyday nursing situations. Meaning units were identified and subthemes and themes formulated. 4. In the fourth step, the analysed data were interpreted by means of life-world theories. The intention was to deepen the understanding for the results.
3. Results To describe the two themes, we have used the metaphor of being either on the same playing field or on different playing fields and labelled the encounters: ‘‘Players in same field pedagogical encounters’’ and ‘‘Players in different field pedagogical encounters’’. The metaphor of being in the same or different playing fields is used because it facilitates description and interpretation of nurses’ and patients’ verbal and non-verbal interactions in everyday nursing practice. In addition, it illustrates the differences between various pedagogical encounters. In order to understand the patients’ perspective and to achieve a comprehensive understanding of the differences in the pedagogical encounters, the results of the analysis of ‘‘patients’ experiences of seeking and acquiring knowledge during periods of illness’’ are described within the framework of the two types of pedagogical encounter. 3.1. Players in same field pedagogical encounters: ‘‘following and letting oneself to be followed’’ A same field pedagogical encounter is characterised by ‘‘following and letting oneself to be followed’’. The nurse follows the patient’s verbal and non-verbal expressions such as words and gestures in order to establish what the patient wishes to know. According to the field notes, patients seek confirmation concerning previous experiences and conceptions. They also ask questions in order to increase their knowledge and understanding. Some questions are explicitly formulated, while others are implicit and embedded in the conversation. In a same field pedagogical encounter, there seems to be a clear intention on the part of the
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nurse to interpret the patient’s bodily expression in order to establish what he/she means and wishes to learn about. The nurse also shows an interest in highlighting and clarifying something that the patient has already heard or knows but perhaps forgotten. Sometimes, the nurse also wants to draw attention to something that he/ she considers important for the patient to know. This means interrupting what one is doing and turning one’s gaze towards the patient. The nurse’s gaze indicates that the patient is in his/her field of experience. In another sense, it is a question of showing that the nurse is prepared to engage in a conversation with the patient, which includes listening to the patient’s point of view, even when it differs from a more traditional medical perspective or from the nurse’s understanding. The nurse also allows him/herself to be followed by the patient. To let oneself be followed means to invite the patient to enter into a dialogue, which can be accomplished by both verbal and non-verbal means. Quite often, the nurse ‘‘thinks aloud’’ which allows the patient to follow the nurse’s reasoning. This can be considered an offer to share relevant knowledge with the patient. Thus, different teaching strategies are used to support the patient’s need for knowledge and understanding (Table 1). The following field note illustrates ‘‘same field pedagogical encounters’’ where the nurse follows the patient and allows him/herself to be followed by the patient. The patient, Bob, and a nurse meet in the patient’s room: Bob says: ‘‘I think I need a laxative’’. The nurse stops in front of Bob, looks at him and says: ‘‘You can have some Laxoberal and two Relaxit tablets.’’ ‘‘Hm’’, Bob mutters. The nurse is silent for a while. Then she takes a chair and sits down beside the bed. She looks at Bob and says: ‘‘What do you usually take at home?’’ Bob does not answer immediately, but then says: ‘‘I usually take Toilax or Minilax. I think they work.’’ The nurse tells him that there are suppositories that are equally effective. Bob says that he thinks suppositories hurt. The nurse says: ‘‘I know, but I usually soften them in water.’’ Bob starts
Table 1 Conduct characterising ‘‘Following and letting oneself to be followed’’
To invite the patient to engage in a pedagogical dialogue To find out what the patient wants to know To estimate what the patient needs to know To let the patient follow your reasoning To be with the patient in the course of the learning experience
talking about the importance of a diet containing plenty of roughage to keep the stomach in good order. He continues: ‘‘I don’t know which food is best for me.’’ The nurse says: ‘‘It is important to drink a great deal and eat vegetables.’’ Bob and the nurse continue the conversation about the importance of food and activity. (Field note) The nurse stops in front of Bob, listens to him and turns her gaze towards him. She also devotes time to him. Moreover, she asks questions in order to ascertain his level of knowledge or, alternatively, to find out if there is something he would like to know. Both explanations and exhortations occur. Bob asks questions and gives some previous experiences. A dialogue develops where the nurse points out aspects that Bob needs to know in order to solve the problem with his bowels. 3.1.1. Patients’ experiences of seeking and acquiring knowledge in ‘‘same field pedagogical encounters’’: a feeling of dignity Four sub-themes originating from the analysis of the patient interviews can be illustrated by an upward spiral (see Fig. 1). This is a positive spiral, which begins with a feeling of participation, followed by feelings of skilfulness and of being secure. This in turn gives rise to a feeling of preparedness. The analysis reveals that some patients actively seek knowledge while others are more passive and prefer to wait until the professionals provide them with information. These two groups are described in the following. Quotations from the interviews are presented in order to illustrate the themes. ‘‘P’’ stands for patient and ‘‘I’’ for interviewer. 3.1.1.1. A feeling of participation. A patient experiences participation when a health professional invites him/her to enter into a conversation about different aspects of the health care situation, such as planned treatment or routine nursing duties. It is equally important to participate in decision-making related to changes in treatment and medication. A patient who actively seeks knowledge wants to be involved in various decisions. The following quotation illustrates this: P: I want to know the way they do it and so on. How it worksyboth before and afterwards. If it is effective andy I: Mm. P: If another method is better. I: Mm. P: When they make a suggestionyI would like to know how they do it. I: How they perform the treatment? P: And if it hurts afterwards andy I: Is it important for you to know this?
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encounter, the patient is confident that the nurse will take pedagogical responsibility even if she/he is a passive patient. One of the patients reported: P: Everybody here is so kind and understanding. They care about me. It is important to me to feel that I can express anything I want. I: Why is it important to you? P: One could say it provides a certain amount of relief.
Fig. 1. Patients’ experiences of seeking and acquiring knowledge in ‘‘same field pedagogical encounters’’: a feeling of dignity.
P: YesyI will base my decision on the informationywhat I will do. Thus, participation is never one sided. It presupposes the participation of another. Patients observe and listen to the nurse in order to ascertain whether or not he/she is receptive to the patient’s opinion. For the passive patients, a feeling of being included in the daily care and in the planning of treatments is decisive for experiencing participation. Experiencing the nurse’s purposefulness in actions and speech is of great importance for the passive patients. 3.1.1.2. A feeling of skilfulness. It is essential that health professionals treat a patient who is actively seeking knowledge as a knowledgeable person and acknowledge his/her need for information. Knowledgeable patients can ask questions that are deemed relevant by nurses and doctors. This motivates the patient to continue to be active. Knowledge can also minimise unrealistic conceptions about the disease or health situation. A patient commented: P: Due to this illness I have read a lot. I am quite knowledgeable. I am interested and can ask questions. And I have noticed that questions can easily be answered. I know what to ask 95% of the time. Knowledge creates competence to formulate intelligible questions. 3.1.1.3. A feeling of being secure. The passive patients do not have the same motivation to seek knowledge, although they would like to understand and to be involved in what happens around them. A feeling of participation induces a feeling of safety, which enables the patient to ask relevant questions. In a same field
3.1.1.4. A feeling of preparedness. Feelings of preparedness are important both for the patients who are actively seeking knowledge and for the passive patients, although in different ways. For patients who are actively seeking knowledge, preparedness is of significance for making correct decisions and ultimately for judging nurses’ or doctors’ actions. Preparedness also enables the patient to cope with the different consequences of his/her illness in everyday life. P: Then you know in advance and are prepared for it. I have a family and they want to know. I have a small business and must arrange everything before a hospital stay. I want to know if it will take a couple of days or a week. For passive patients, preparedness is not related to action. Instead, it concerns trying to understand the present situation and/or life circumstances. A lack of understanding of the situation or nursing activities can result in worry. P: I want to know how they plan to do the treatment. I: Why do you want to know? P: One will not be worried if things are fully explained. It is most important to ensure that they don’t do something they are incapable of doing. 3.2. Players in different field pedagogical encounters: ‘‘questions and answers’’ In ‘‘different field pedagogical encounters’’, the dialogue is characterised by questions and answers. A question from a patient is followed by an answer, but the nurse does not appear willing to continue the conversation. This results in a broken dialogue. The patient is left alone with various questions. In ‘‘different field pedagogical encounters’’, there is a risk that nurses may not notice or be fully aware of the patient’s concerns and need for knowledge and understanding. Most problematic is the fact that patients’ implicit questions are ignored. Such questions are embedded in the conversation in which the patient speaks between the lines. Implicit questions are often existential in nature. Another area where there is a risk that nurses may not notice or be fully aware of the patient’s concerns and
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Table 2 Conduct characterising ‘‘Questions and answers’’
To end the conversation too early To reinterpret what the patient says To comment on what the patient has said but not pursuing the matter further To change the topic of conversation
need for knowledge and understanding is the patient’s conceptions of illness. Thus, the patient’s desire for confirmation of their conceptions is ignored. In the following table, conduct illustrating ‘‘questions and answers’’ in relation to failure to pay attention to patients questions is described (Table 2). The following field note illustrates ‘‘different field pedagogical encounters’’, where there is a breakdown in the dialogue between patient and nurse. One patient, Ellen, and a nurse meet in the patient’s room and Ellen expresses concern about her swollen legs: Ellen is sitting up in bed. The nurse places a bottle of medicine on the bedside table and says: ‘‘Here is your heart medicine’’. Ellen looks at the nurse and says: ‘‘I wonder if my swollen legs are due to the heart medication. I think that I am oversensitive to the tablets.’’ The nurse says: ‘‘No, this medication is for the heart and it will help you.’’ The patient doesn’t say any more. The nurse continues: ‘‘It will be lunch time soon. Remember not to drink too much Ellen’’. (Field note) Even if the nurse gives information and explanations, Ellen’s questions and conceptions are not met. In this encounter, Ellen’s question about her swollen legs is ignored and the topic of conversation is changed. 3.2.1. Patients’ experiences of seeking and acquiring knowledge in ‘‘different field pedagogical encounters’’: a feeling of threatened dignity Three sub-themes from the analysis of the patient interviews are illustrated by a downward spiral. This is a negative spiral, which begins with feelings of exclusion, followed by feelings of inferiority. This in turn gives rise to the experience of worry. Interview quotations are presented to illustrate the sub-themes. ‘‘P’’ stands for patient and ‘‘I’’ for interviewer (Fig. 2). 3.2.1.1. Feeling excluded. The withholding of essential knowledge for understanding the situation can result in a feeling of exclusion. In a sense, the patient is excluded from a course of events that affects him/her in different ways, thus leading to uncertainty. Both the patients who actively seek knowledge and the passive patients experience feelings of being excluded. Patients who seek knowledge actively cope with the situation in their own
Fig. 2. Patients’ experiences of seeking and acquiring knowledge in ‘‘different field pedagogical encounters’’: a feeling of threatened dignity.
way. They refuse to allow themselves to be hindered, continue the search for knowledge on their own and turn to persons other than nurses and doctors for information. Some of the passive patients remain silent because they are not accustomed to initiating a conversation while others do not want to cause trouble. The following patient commented on the aspect of being unable to express oneself in a way that is understood or acknowledged by the health care personnel: P: It is difficult when you see a doctor and have a question. It is difficult to ask when you do not know the correct terms. 3.2.1.2. Feeling inferior. The hierarchical medical context is one contributory cause of patients’ feelings of inferiority. The medical round is one example. Even though the doctors and nurses observe the patients, the patients may feel reluctant to ask questions due to their inability to express what they want to know. Another aspect is the daily nursing routines, which seem to be more important than a pedagogical encounter. An unfamiliar environment is another contributory factor in patients’ experiences of feeling inferior and being in a disadvantaged position. Yet another factor is the patients’ experiences of being dependent on help from others. In the following quotation, a patient states: P: I feel a bit inferior. I feel that perhaps I’m unable to understand the situation. It gives me a feeling of incompetence.
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3.2.1.3. Worry. Helplessness and frustration lead to resignation and worry, undermining the patients’ feeling of being regarded as competent. A feeling of being worthy of teaching is important. It is essential that the patient feels that he/she is worthy of instruction. In the absence of this feeling, lethargy and a reduced ability to search for knowledge can occur. A patient commented: P: You start worrying when you are alone in bed at night. You think and think. But if you get a proper answer you don’t feel like that. You prepare yourself and you know what’s going to happen. You prepare yourself in a different way. Worry can have many grounds, one of which is lack of knowledge.
3.3. Interpretation of the results based on life-world theories In the following, Schutz’s theory (Schutz, 1997; Schutz and Luckmann, 1989, 1995) about inter-subjective encounters is used to illuminate ‘‘Different field pedagogical encounters’’ and ‘‘Same field pedagogical encounters’’. Schutz argues that individuals meet in the everyday world with different degrees of anonymity and makes a distinction between a ‘‘they-relationship’’ and a ‘‘we-relationship’’. In a ‘‘they-relationship’’, the individuality and uniqueness of the other person is disregarded. Instead, the person is seen as part of a crowd and categorised as a person of a particular kind, e.g. a patient with heart failure. According to the data analysed in this study, parallels can be drawn with ‘‘Different field pedagogical encounters’’, where the dialogue between patient and nurse either never started or started but was discontinued (see Table 2). In Schutz’ description of a ‘‘they-relationship’’, the other person is not considered as a unique being, but rather as a ‘‘type’’, e.g. a typical patient with identical information needs to other patients in that specific group, i.e. patients with heart failure. A ‘‘thou-orientation’’ is quite different, as it can be unilateral or reciprocal. In a unilateral thou-orientation, the relationship is one sided in that only one of the parties is oriented towards the other as an individual subject, a thou. The field note concerning Ellen illustrates this. Ellen asked a question about her swollen legs. The nurse answered, but turned her attention to a different aspect, which she presumably judged to be more important (exhorting Ellen not to drink too much). Ellen’s question remained unanswered and her need for knowledge unsatisfied. She attempted to establish contact with the nurse but the conversation broke down due to the nurse’s change of subject.
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However, Schutz emphasises that a unilateral ‘‘thouorientation’’ can be transformed into a reciprocal ‘‘thouorientation’’ where the parties are aware of each other and a social relationship is established, whereby a ‘‘werelationship’’ emerges. Parallels can be drawn with ‘‘Same field pedagogical encounters’’ where the nurse follows the patient’s verbal and non-verbal expressions in order to identify the patient’s need for information and knowledge (see Table 1). According to Schutz, a ‘‘we-relationship’’ is an inter-subjective encounter where the parties observe, listen to and actively try to understand each other. Schutz uses the expression ‘‘face-toface’’ relationship and states that the parties ‘‘grow old together’’. If we return to the patient with heart failure, the nurse in a ‘‘we-relationship’’ opens up to the individual patient’s way of expressing his/her need for knowledge both verbally and non-verbally. According to Merleau-Ponty (1995), the nurse is open to bodily expression. This does not mean that the nurse is not familiar with the information needs of heart failure patients. However, in a ‘‘we-relationship’’, there is pedagogical relationship between the nurse’s and the patient’s life-world. To use Schutz’s words, the two types of encounter represent different ‘‘realms’’. ‘‘A same field pedagogical encounter’’ involves an atmosphere that enables the pedagogical potential of the nursing situation to develop. This also implies a view of the patient as a learning person and involves a focus on helping the patient to be prepared for both physical changes and changes in his/her life situation due to the illness. The concept of ‘‘preparedness’’ emerges as a specific goal of teaching activities.
4. Discussion The aim of this study was to illuminate pedagogical dimensions in nursing situations and informal teaching. More specifically, the aim was to describe the characteristics of pedagogical encounters between nurses and patients in a medical ward in addition to describing patients’ experiences of seeking and acquiring knowledge during periods of illness. The results show two different types of pedagogical encounters ‘‘Same field pedagogical encounters’’ and ‘‘Different field pedagogical encounters’’. In same field pedagogical encounters, the patient is regarded as a learning person, a pedagogical dialogue develops and the encounter is characterised by ‘‘following and letting oneself to be followed’’. In different field pedagogical encounters, there is a breakdown in the dialogue, and the pedagogical potential is not developed. The conversation takes the form of unrelated questions and answers. Patients’ dignity is either threatened or supported, depending on the type of encounter. Worry and
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preparedness are deemed aspects of this. Before the discussion of the results, some methodological reflections should be considered. 4.1. Methodological considerations Trustworthiness of the study was tried to be attained through a reflective attitude during the field phase and analysis phase and in the writing of the results. In the field phase, we attempted to achieve a balance between research needs and our responsibility to the informants. The intention was to capture rich field data without unduly disturbing the ward activities. This also implied continuous reflection on the researcher’s role during data collection. The data in this study were collected from a single medical ward. One or two more wards could have been included in the study. However, the ward studied was large and contained 50 beds. One advantage of using a single ward was that it was easier to become familiar with the ward culture as well as making it easier for the staff to get to know the researcher. Prior to the data collection, the first author (FF) visited the ward everyday for a week with the intention of familiarising herself with the physical surroundings, the staff and the daily routines. Trustworthiness also concerns the use of two kinds of data to explore the everyday nursing situations. Observations and interviews complemented each other, which involved a more comprehensive understanding of the phenomena. As described earlier, the characteristics of the pedagogical encounters are based in the analysis of nurses’ teaching strategies and patients’ strategies for seeking knowledge and gaining understanding. However, these strategies are not described in detail in this study (see Friberg, 2001), which can be seen as a limitation. Informal teaching has been studied earlier and the results point to aspects found in for instance Gregor (2001) and Kloster (1997). Another aspect worth noting is that the study reflects a Swedish perspective. The results cannot be generalised in a traditional sense. It is up to the reader to decide how the results can be understood and implemented in other contexts. 4.2. Discussion of the results Pedagogical encounters between nurses and patients, as described in this article, illuminate one aspect of informal teaching, namely the characteristics of pedagogical encounters. The results complement with Gregor’s (2001) description of strategies used by nurses in informal teaching situations. Gregor stressed the importance of incorporating informal teaching activities in the definition of patient teaching. The results of the
present study may be regarded as a contribution to the knowledge of informal teaching. ‘‘Same field pedagogical encounters’’ and ‘‘Different field pedagogical encounters’’ can be considered two extremes, between which a variety of encounters occur in everyday nursing practice, where different encounters lead to differing experiences. What makes a pedagogical encounter special? A pedagogical encounter involves the aim that somebody (the patient) should understand and learn something. One may question whether it is appropriate to employ the term ‘‘pedagogical’’ to describe ‘‘different field encounters’’. Perhaps it would be more correct to describe them as ‘‘apedagogical’’, because there appears to be no pedagogical aim. Some examples are when the patient asks questions in order to gain knowledge and understanding and the nurse changes the subject of the conversation, ends the conversation too early or reinterprets what the patient said. According to the interviews, the patients experienced feelings of exclusion and inferiority, which resulted in worry. However, we have chosen to use the term ‘‘pedagogical’’ since the analysed situations contain important pedagogical potential that needs to be developed. Furthermore, one could ask how a pedagogical encounter can be distinguished from a caring encounter in general. Parallels can be drawn with Halldorsdottir’s (1996) distinction between caring and uncaring encounters in the context of cancer nursing. A caring encounter results in increased well-being and health, denoted as empowerment. An uncaring encounter, on the other hand, leads to decreased well-being and health and can be described as discouragement. ‘‘Same field pedagogical encounters’’ have similarities with Halldorsdottir’s (1996) ‘‘caring encounter’’ and results in patients’ preparedness. ‘‘Preparedness’’ means helping the patient to discover meaning and reducing anxiety, which is sometimes due to a feeling of not being prepared for the actual situation or the future. ‘‘Preparedness’’ is a cognitive–emotive–existential state and a more distinct pedagogical term than ‘‘well-being’’. It also has more pedagogical connotations than the term ‘‘empowerment’’. The term ‘‘preparedness’’ is oriented towards ‘‘the future’’ and reveals a potential for development. Introducing the concept of preparedness is an attempt to create a complementary basis for informal patient teaching, the implementation of which in clinical practice is the duty of the nurse. Thus, a pedagogical encounter prepares the patient for different changes in the current situation and/or life situation as a result of illness. Preparedness can also have a deeper meaning such as being prepared for death. All these situations or life circumstances are related to learning and understanding. Parse’s (1981, 1998) theory of ‘‘human becoming’’ illuminates this. Parse stresses that human becoming is an ever-changing process. As
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described in the present study, ‘‘Same field pedagogical encounters’’ characterised by ‘‘following and letting oneself to be followed’’ can be related to Parse’s (1998) theory of human becoming. As we see it, Parse’s concepts ‘‘powering’’, ‘‘originating’’ and ‘‘transforming’’ are of particular importance for the pedagogical aspects of nursing situations. According to Parse, ‘‘Powering’’ is a way of revealing and concealing of imaging, leading to a new meaning. ‘‘Originating’’ is a manifestation of enabling and limiting of valuing whereby the patient becomes aware of different choices and their consequences. Finally, ‘‘transforming’’ unfolds in the languaging of connecting and separating. This means that verbalising enables understanding and facilitates the opportunity for change within the existing situation. ‘‘Powering’’, ‘‘originating’’ and ‘‘transforming’’ are important for assisting the patient to achieve a state of preparedness. Thus, the term ‘‘preparedness’’ can be related to the meaning of ‘‘becoming’’. Stamler (1996) uses the term ‘‘enablement’’. To enable learning as well as preparedness, the patient must be regarded as a learning person. Maslow (1970, p. 48) discusses the desire to know and understand. Learning is not limited to childhood or youth, but is a constituent part of the human being. Accordingly, it cannot be excluded from periods of illness and/or suffering, as it forms a part of the sick/unwell person’s everyday life. Thus, enabling learning situations in order to assist the patient to become knowledgeable and to understand is an important prerequisite of preparedness. Therefore, patient preparedness can be regarded as a primary teaching goal. However, the meaning of preparedness as a pedagogical goal needs to be investigated in further studies. How can nurses be encouraged to continue everyday informal teaching? In line with previous research (Barber-Parker, 2002; Marcum et al., 2002; Turner et al., 1999), our result confirms the importance of developing supportive health organisations where time is allocated for informal patient teaching. This implies organisations where informal teaching is deemed important and nurses are supported in developing this part of nursing practice. Parallels can be drawn with Sanford’s (2000) distinction between a caring and an uncaring context. A caring context is characterised by relationship, dialogue, mutual trust, shared meaning and receptivity. An uncaring context, on the other hand, focuses more on the mediation of information. According to Sanford, a caring context must be facilitated. Previous research reveals a lack of documentation on patient teaching activities (Ehrenberg et al., 2001; Karkkainen and Eriksson, 2003). If nurses act in accordance with ‘‘Different field pedagogical encounters’’ they will probably fail to identify patients’ need for knowledge. Thus, there is a risk that possible teaching moments will be lost or remain unidentified.
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5. Conclusion Pedagogical encounters occur in everyday nursing practice. Nurses’ pedagogical awareness must be supported in different ways. Health care organisations have to create a pedagogical climate, and the nurse should view the patient as a learning person in order to help the patient achieve preparedness. Both nurses and the health care organisation must decide on whether the pedagogical potential should be developed or remain undiscovered. The findings of the present study could serve as a reflective tool for nurses and health care organisations in order to reveal and make full use of taken-for-granted everyday nursing situations of pedagogical importance.
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