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'A caring professional attitude’: What service users and carers seek in graduate nurses and the challenge for educators
Nurse Education Today 32 (2012) 121–127
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Nurse Education Today j o u r n a l h o m e p a g e : w w w. e l s ev i e r. c o m / n e d t
'A caring professional attitude’: What service users and carers seek in graduate nurses and the challenge for educators Jane Griffiths a,⁎, Shaun Speed b, Maria Horne b, Phillip Keeley b a b
School of Nursing, Midwifery and Social Work, University of Manchester, Jean McFarlane Building, Oxford Road, Manchester, M13 9PL, United Kingdom School of Nursing, Midwifery and Social Work, University of Manchester, United Kingdom
a r t i c l e
i n f o
Article history: Accepted 14 June 2011 Keywords: Caring Graduate nurses Service users Carers Communication skills
s u m m a r y With the publication of the new NMC standards for pre-registration nursing education, undergraduate curricula are being written in universities across England. There are many drivers for the curricula but one that has until recently received scant attention is the service user's and carer's voice. This paper discusses the findings of a qualitative study that asked 52 service users and carers about the qualities they sought in nurses and their views on nurse education. Eight focus groups were conducted with a broad range of service users and carers from primary and secondary care, and voluntary organisations. Data were analysed using the framework approach facilitated by a qualitative analysis software programme. The sample was diverse, but there were similarities in the qualities they valued in nurses. They sought technical competence, knowledge and willingness to seek information, but overwhelmingly prioritised ‘a caring professional attitude’. This was articulated as empathy, communication skills and non-judgmental patient centred care: major themes in the new NMC standards. Our participants also expressed concern about whether the educational preparation of nurses can develop these caring qualities. We discuss this concern, the challenges for nurse educators it presents and how we can engage service users and carers in shaping and delivering our new curricula. © 2011 Elsevier Ltd. All rights reserved.
Background In response to the move to all graduate nursing programmes in England by 2013, nursing curricula are being re-written in universities the length and breadth of the country to create the graduate nurse of the future. Nurses work in an ever changing and evermore complex world impacted by many different, often competing, imperatives. Programmes will clearly need to reflect these demands to ensure that graduates are adequately prepared for the expectations of the workplace (Nursing and Midwifery Council [NMC] 2010). The newly published Nursing and Midwifery Council standards for pre-registration education (NMC 2010) are clearly the major driver for the new curricula, and reflect the changing landscape of the workplace, impacted by demographic shifts and technical advances. An obvious driver is the shift in care away from hospitals to service users' and carers' homes and other community locations (Department of Health [DH], 2000, 2001). Curricula will need to reflect this, and in order to understand the contexts of service users' and carers' lives in these different environments, will need a strong focus on the wider determinants of health with their academic roots in sociology, public health and applied social policy.
⁎ Corresponding author. Tel.: + 44 161 306 7681. E-mail address: jane.griffi[email protected] (J. Griffiths). 0260-6917/$ – see front matter © 2011 Elsevier Ltd. All rights reserved. doi:10.1016/j.nedt.2011.06.005
An inescapable demographic driving force impacting on primary and secondary care, is our ageing population living longer with both incurable cancers and chronic non-malignant conditions such as Diabetes, Coronary Heart Disease and Chronic Obstructive Pulmonary Disease (DH, 2005a). As many long term conditions (LTCs) are largely preventable (DH, 2005b), nursing programmes will need to reflect the increasingly important role of nurses in promoting the health of individuals to prevent the occurrence of preventable disease (DH, 1999) and in working with patients living with LTCs to empower them to self manage and live as well as possible (DH, 2004a, 2004b, 2005a). Combine these demands with advances in technical care in the hospital and home requiring a sound foundation in biomedical sciences, and the drive for evidence in most if not all areas of nursing practice (Standing Medical Advisory Committee, 2000), and curricula are already groaning at the seams. The evidence base for many aspects of nursing practice from complex procedures to ‘basic’ care is ever expanding and an understanding of research methods fundamental to nursing practice, but also knowledge of how to access evidence and to read and apply it critically (NMC, 2010). A further vitally important driver for change in curricula is the service user's and carer's voice which is becoming increasingly important in shaping and delivering health care education and practice (Coulter, 2002; Baggot et al., 2005, NMC 2010). The benefit of user involvement in education has been described in numerous research reports in medicine (O'Keefe and Jones, 2007; Bourdreau
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et al., 2008), general nursing (Flanagan, 1999; Costello and Horne, 2001; Repper and Breeze, 2007), mental health nursing (Hanson and Mitchell, 2001; Downe et al., 2007; Repper and Breeze, 2007) and children's nursing (Sawley, 2002). Involvement has been in a number of ways from sharing experiences of health care and views on the education of students (Harrison and Beresford, 1994), to devising learning materials (Ah-Mane, 1999; Coupland et al., 2001), classroom teaching (Repper and Breeze, 2007), developing curricula and planning courses (Khoo et al., 2004). The aim of this paper is to present and discuss findings of a qualitative study that asked 52 service users and carers about the qualities they seek in nurses and their views on nurse education, as part of a larger project aiming to involve service users and carers in the development and delivery of our graduate and postgraduate nursing, midwifery and social work curricula at the University of Manchester. Our sample of service users and carers desired a ‘caring professional attitude’ above all else and was concerned that ‘caring’ has become lost in nursing practice and that higher educational entry and exit requirements will aggravate this. The new NMC standards for pre-registration education give pre-eminance to caring, compassion and client centred care, so how do nurse educators instil these qualities in nursing graduates? There is an extensive international literature on caring, spanning several decades (e.g. Leininger, 1984; Morse et al., 1990; Phillips, 1993; Lui et al., 2006; Finfgeld-Connett, 2008a, 2008b; Chan et al., 2009). Drawing on this body of work, we discuss how as educators we can address service users' and carers' concerns, and involve them in developing and shaping our curricula, to ensure that caring and compassion do not become lost. Methods Setting and Recruitment The study took place at the University of Manchester, North West England. The aim of the larger project was to involve users and carers in the development and delivery of curricula in the school of Nursing Midwifery and Social Work. For the first stage of the project we held a one day conference in May 2009 to engage service users and carers and to elicit their views on the education of nurses, midwives and social workers. This approach has been used successfully elsewhere (Harrison and Beresford, 1994; Ingham, 2001; Sawley, 2002; Levin, 2004; Repper and Breeze, 2007). The research team contacted as wide a variety of service users and carers as possible to take part in the conference day. This was through existing contacts and various voluntary health and social care organisations working with people from a range of age groups and with a variety of health problems. Contact persons/‘gatekeepers’ in the various organisations were sent information packs which they passed on to potential participants, who returned an expression of interest to the research team. These individuals were then sent a written invitation to the conference day. The conference day began with a presentation by key personnel from the school about hopes and expectations of the consultation and collaboration process, followed by a brief overview of the programmes within the school with questions and answers. Seven focus group interviews were then conducted representing service users and carers from primary and secondary care and voluntary organisations. Ethical approval for the study was granted by the University of Manchester Ethics Committee. Study Participants Thirty service users and 22 carers took part in the study (n = 52 Table 1). All provided written consent prior to the focus group discussion. Seven focus groups of 3 to 8 participants were conducted on the conference day itself with: Mental Health Service Users, older people, carers (x2), parents of children with disabilities/long term
Table 1 Participants and groups. Group
Number
Carers' group 1 (6 women and 2 men) Carers' group 2 (5 women and 3 men) Cancer service users' group (2 women and 1 man) Older peoples' group (2 women and 2 men) Men's health group (3 men) Mental Health Service Users' group (3 women and 4 men) Parents' group (6 women and 1 teenage son of parent) HIV service users' (5 women and 7 men) Total
8 8 3 4 3 7 7 12 52
conditions and men (Table 1). One group was unable to attend on the day and was interviewed at another time. This was a group of HIV positive service users, which included asylum seekers and refugees. Each focus group was facilitated by two of the research team, was of 60–90 minute duration and was audio-recorded. Focus group discussions are widely used in healthcare research to investigate user perspectives on a variety of health related topics (Kreuger, 2008; Flick, 2002). They are guided by the researcher's broad questions on the topic of interest (Polit and Hungler, 1999; Kreuger, 2008; Kaufman, 1996) but flexible enough to allow the participants' to influence the direction of the discussion (Kreuger, 2008; Wilkinson, 2004). This was the overriding aim in the research project. To prepare participants for the focus groups, time was allowed in the morning session for people to get to know each other and the facilitators. Although this preparation was not available to the group that was unable to attend the conference day (HIV service users), they were already well known to each other through regular attendance at a local support group. The facilitator also spent time in general discussion with the group before starting the interview to get to know them a little. The questions for the focus group were distributed to participants prior to the interview. All of the facilitators were experienced qualitative researchers. Following previous research in this field, four broad questions developed by Rudman (1996) were used to guide the focus group discussions: 1. What knowledge do you think that health and social care professionals should have? 2. What qualities do you think are important in health and social care professionals? 3. What do you think health and social care professionals ought to do effectively? 4. Is there anything else you would like to say about how health and social care professionals are trained? Participants were also asked a series of questions about how they would like to become involved in curriculum planning and delivery (Harrison and Beresford, 1994; Levin, 2004; Carr, 2004; Doel et al., 2007). The data presented here are the views of users and carers on nurse education, and focus on their answers to the four questions above. Data Analysis All interviews were digitally recorded, transcribed verbatim and analysed using the framework approach (Ritchie and Spencer, 1994). Systematic line by line analysis was undertaken by each of the researchers on their own transcripts and one other person's. The research team met to discuss coding of the interviews, and similarities and differences in the codes were examined. Minor changes were made to the nomenclature of the codes and we began to cluster the codes to create categories. These were compared and contrasted in order to develop more inclusive categories, which were then developed into themes (Ritchie and Spencer, 1994). The themes
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were then compared and contrasted within and across the groups. Negative cases and rival explanations were explored and discussed. ATLAS/ti5.0 (Muhr, 2004) qualitative analysis software programme assisted in data coding, cross-referencing, storage and retrieval. In order to assess the rigour of the coding process (Kreuger, 2008), initial themes were fed back to the service users and carers in a follow up conference day. The same service users and carers from the first conference day were at the follow up day. The themes were presented to the users and carers who were asked to rate their agreement both verbally, and in writing on the presentation handout. The handout had a column next to the themes with “agree, disagree or don't know” and a space for comments. These were then collected and reviewed. One of the research teams also recorded the comments made during the discussions. There was overwhelming agreement that the codes captured the focus of the group discussions. Findings Although our groups of service users were diverse, there were many similarities in the qualities they sought in nurses. There were some minor differences, for example, confidentiality and understanding of the disease/condition featured strongly in the HIV and Mental Health Service Users' Focus Group Discussions (FGDs) and cleanliness and medication management in the Older People's, but in the main, the data were remarkably homogenous. We found that whilst participants sought technical competence, knowledge and a willingness to seek information from a variety of sources, they overwhelmingly prioritised ‘caring’ qualities. These were articulated as empathy, listening, communication skills and non-judgmental patient centred care. Participants also expressed concerns about whether the current educational preparation of nurses can develop these caring qualities. Technical Knowledge and Competence The majority of participants across all focus groups discussed the need for technical competence and knowledge in nurses. They provided examples of where this was clearly evident:
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that need you know [P3: absolutely] asking, because, well at the end of the day we are all human and, you know. HIV Service Users' FGD The majority also wanted nurses to recognise the patient's or carer's own expertise and to ask them questions if they were unsure about something, as these parents commented: Participant 1: That's better because nine times out of ten if you go and ask the patient or the carer they will be more than happy to tell you (P2: Yeah). As opposed to you staying away. Interviewer: So it's not so much about knowing everything, it's about being able to say “We don't know?” Participant 1: Yeah. And can you tell me. Participant 2: And being able to listen. Participant 1: Yeah. I don't know the answer to this, I'll go and find out, or can you help me. Participant 3: Yeah. The worst thing in the world is when people try and bluff it. Parents' FGD
Empathy and Communication More than knowledge and skills however, the participants overwhelmingly sought empathy and the ability to listen, as these quotes from three different focus groups demonstrate: “I've put down actually — I just jotted down some notes. I've put knowledge is not as important as approach and empathy and preparedness to learn from patients and carers.” Cancer Service Users' FGD “It's about communication and understanding and empathy. You might be the best clinician in the world but if you can't communicate and you can't listen properly to people and you don't take on board and understand what they're saying you may as well go dig the street. And no disrespect to road diggers, but…” Parents' FGD “I think they need empathy with the disabled person or the person needing care, you know, to feel, you know, that they understand what it would be like. A good understanding of that person and that person's disabilities.” Men's FGD
“I'm thinking of the nurses I come into contact with on a regular basis that, you know, they are really superb with cancer … the particular ward I go into, they are really, really good … and you feel that when they're administering the chemo or whatever it is, that they are really confident and I feel they know what they're doing.” Cancer Service Users' FGD
Or, as a carer and a parent phrased it in their respective discussions:
They also gave examples of where technical competence and knowledge were lacking, for example:
“It is not what they do it is the way that they do it that matters.” Carers' FGD 2
“When I go to hospital for them to do bloods and stuff, I discovered that lots of them haven't got a clue how to get blood from my vein. I end up taking paracetamol pain killers because they keep missing the vein.” HIV Service Users' FGD Whilst a desire for knowledge and technical competence was not surprising, it was also reassuring that none of the participants expected the nurses to know everything about their specialty. They welcomed honesty, knowledge of how to find information and a willingness to do so, as another quote from the HIV service users' FGD illustrates: Participant 1: I think if they're not sure — because as you've said, there's so much knowledge and it's continually improving and progressing. Not everybody is going to know everything and if somebody says ‘oh well this … but I could go and look up such and such and I'll come back to you’. Participant 2: I'd rather have somebody turn around and do that, yeh, say that they're not certain about something, and ask the questions
“Those old fashioned qualities, they're still really important.” Parents' FGD Participants used different words to describe the qualities they looked for in nurses, but in all but one of the focus groups (HIV service users' FGD), terms synonymous with empathy and communication were the first they mentioned during the interview, as in this excerpt from the Older People's FGD: Interviewer: So the first question I've got for you is about the kind of knowledge that nurses need to have. So the kind of things they need to know in order to do their job well. Participant 1: They need social skills to interact with different people… (P2: Yeah). Participant 3: Definitely social skills, yeah. Participant 4: Because that's what they lack (P3: Yeah). Interviewer: Right. Fascinating that's the first thing that you're saying and you're all agreeing. Participant 2: Yeah, definitely. Older People's FGD
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Later in their discussion participants elaborated on some of the terms they had used: Participant 1: A caring, professional attitude, that's the main thing. … Interviewer: So just explain what a caring professional attitude means to you? Participant 1: Well they listen to you, they understand you and they take interest in what's wrong with you. Participant 2: Yeah, it's the patience isn't it that they show. Caring. Participant 3: And that's all you need. It makes you feel better if you think somebody knows what they're talking about. Because you don't see the doctor but once a day if you're lucky. The only thing is the nurses, and if there's somebody there who's caring enough to ask you and talk to you it makes all the difference. (P2: Yeah). Participant 4: Treating you as a person. (P1: As a person, yeah). Participant 3: As a person, yeah. As a human being actually. Participant 4: Yeah. Instead of just another number [laughs]. Older People's FGD
Non-judgmental Approach Another recurrent theme was the importance of nurses being nonjudgmental in their interactions with patients and carers: “I think with nursing staff, with health care staff ….like you meet somebody in a highly emotional situation or you're judging their…you're coming into a really personal situation dead quickly and it's really important I think not to judge a book by its cover and not saying like I know who you are because of this, this and this.” Parents' FGD “I've written it down, like it's compassion, dignity, tolerance and non judgmental attitude. Most of all it's the humanity, it's the most essential quality in life.” Carers' FGD 1 Some of the participants reported situations when they had felt judged by nurses. The Mental Health Service Users' group for example described how side effects from medications can leave them exhausted and unable to do housework. One participant reported an occasion when she had felt judged by a community nurse who said “look at the state of your house, it's very untidy”. Similarly, the HIV group described themselves as being treated as a “special case”, or as one participant commented “a dirty case”, implying a spoiled identity. Another of the HIV positive participants described challenging a nurse about perceived racism: “[laughing] I said are you, are you racist in any way at all? You know, because my understanding … you come across as if you are knowledgeable about your profession, you're skilled and everything, but it's just the case that you don't just like me, you don't just like my colour [P2: really?] And that seems to be affecting the way you are talking to me, the way, the general demeanour, your body language, your tone, intonation and everything.” HIV Service Users' FGD Similarly, the older people's group described ageist attitudes in nurses they had come into contact with: Participant 3: Therefore they think you're past it and you're just… Participant 1: And that's the attitude that they do have. Participant 2: They do, don't they? Participant 3: They do have that oh, she's getting old, she doesn't know what she's talking about. That's the attitude. Participant 2: And they don't actually talk to the person. Participant 1: No they don't. Older People's FGD
Listening Skills Listening was therefore not surprisingly the skill that participants repeatedly described as essential, as in these two excerpts: “Good essential listening skills, 'cos sometimes what you find in professionals is what they do is they listen but they talk over…they know better than you, so they're not really listening, they're listening to what they need to hear and then they tell you. But it shouldn't be like that, they should actually really listen to what you're saying and the person that you're caring for. You know their symptoms better than a professional, you know, and for them to really listen, I think that's a fundamental one.”Carers' FGD 1“I think to …listen, because a lot of professionals come out and they're there but they don't listen.” Mental Health Service Users' FGD Listening was also discussed in relation to the importance of careful assessment, history taking and person centred care: “They should say to people; what has brung [brought] you here and what has got you to this service? And I don't mean, as I say, bus, taxi or tram. [Laughter from group] They should say: what has happened in your life that's got you to this stage?” Mental Health Service Users' FGD “I think to judge each individual, and then each individual should be assessed and their needs be assessed and implemented on that particular individual, rather than this is a basic rule for all. Because it has personally affected me that way where I just feel it's a conveyor belt system. Get them in and get them out sort of thing.” Carers' FGD2 Participant 2: The system's got to adapt to the individual needs as opposed… [That's right, yeah]… to try and make the kids square pegs in round holes. It's not hard to do. It's little things that… Participant 3: No, it's not. Just requires a change in mind set. Participant 2: …are quite easy to change. They just don't happen because people don't think. Participant 1: Parents do it with no training whatsoever. You adapt to your child. You adapt to their needs and you learn how to address their needs. It's about staff opening their eyes. Parents' FGD
Individualised Care The majority of participants were clear that they wanted the nurses to get to know them as individuals: “Almost like becoming one of the family and knowing what's important to people because it's an individual thing and what's important to me wouldn't be important to you.” Men's FGD “You know it like getting to know you … you as a person what it is like for you and so that you don't have to explain all the time about yourself and the person you are caring for … but that relies on consistency and that doesn't happen.” Carers' FGD 2 “I don't need that nurse to be a friend of mine … not a friend, but just, just showing me I'm here for you, you know.” HIV Service Users' FGD
The Over Educated Nurse Many participants speculated about why the skills they desired in nurses were sometimes absent. Whilst in their discussions they
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Participant 2: But has it almost become over-career, overeducated… (P4: Technical) …over-technical (P3: Over-paper worked). Participant 4: Oh yes. Participant 3: Is it attracting… the right people who maybe didn't have the academic level to take on a degree but actually were the most fabulous nurses. They may well have started as auxiliaries – I know that's not the correct word now – and built up and went on to do this. Participant 5: But that was the way the training was. When [son] used to first go into hospital all those nurses then were retrained. Fantastic. Absolutely fantastic. Participant 2: Real down to earth stuff. Don't have any problem going and sitting on your bed and going right, alright, what's up with you. Parents' FGD
written debate initiated by Corbin (2007) unease has even been expressed by nursing academics that caring might have become a ‘lost art’ (Flately and Bridges, 2007; Griffiths, 2007; Maben, 2007; Pajnkihar, 2007). Yet the new NMC standards for pre-registration education of nurses give pre-eminance to caring and compassion, leaving educators in no doubt that it needs to central to everything we teach in both theory and practice. Caring has long been considered by nursing academics as the basis of everything that we do (Leininger, 1984; Morse et al., 1990; Phillips, 1993; Lui et al., 2006; Morse et al., 1992). It has an extensive presence in the theoretical nursing literature with many eminent nursing academics devoting their careers to explicating the complexities of this deceptively simple term (Leininger, 1984; Benner and Wrubel, 1989; Morse et al., 1990; Watson, 1999). Nursing theory, with caring at its heart, was hugely popular in the 1980s in the UK and has remained so in North America. In the USA, for example, a nursing model has recently been published entitled simply “Nursing as Caring” (Boykin and Schoenhofer, 2001).
Participant 3: I don't think the nursing trade is what it used to be.
Nursing Theory
Participant 5: You know, often it being academic, it's not all academic is it? Participant 6: No, no, people skills as well, you know, you had the matron that ran the ward, and it was more, a profession and it was something that people wanted to go into because they had a caring nature [R: exactly] and now I don't think that. HIV Service Users' FGD
In the UK in recent years interest in nursing theory appears to have waned with other subjects edging it out of curricula. The concerns of our participants about the ‘over educated nurse’ therefore present an interesting paradox. Academic nursing theory developed in the 60s, 70s and 80s because nursing had moved away from ‘caring’ towards task allocation to increase productivity, relegating the patient to the ‘appendicectomy in bed 14’. Maybe some of this so called ‘nursing of the past’ is a chimaera. It is timely to return to our theoretical roots and to remind ourselves that caring is a complex ‘academic’ subject worthy of undergraduate study that can and should be taught. Caring is not just worthy of study in its own right, however, but integral to the subjects demanded by the changing demographic and disease patterns of the population. Health promotion to prevent the onset of long term conditions involves empowering individuals to change, and to empower, nurses need to be taught to practice with empathy and without judgement: recognised elements of caring (Watson, 1999; Rollnick and Miller, 1995; Morse et al., 1992). To encourage self management of a long term condition, empathy and listening skills are vital to work with the patient to find a strategy that works for them (Watson, 1999; Kennedy et al., 2007). Likewise evidence based practice: it is not just about knowing the right things to do, but teaching nurses how to work with individuals to facilitate them to make the best choices (Closs and Cheater, 1999). We can ill afford to ignore caring and partnership working if we are serious about changing behaviour to improve health.
acknowledged constraints such as time pressure, all expressed concern about their perceptions of the ‘over educated nurse’:
Or, as one participant summarised it, reflecting on the presentation we had given that morning: “What concerned me this morning about the description of the qualifications that you were providing, in a sense particularly the emphasis on education which tends to imply knowledge — predominance of knowledge possibly predominance of knowledge over skills and attitudes and values. It could mean that we are producing more and more academically qualified nurses without the commensurate concurrent understanding and desire to provide care.” Cancer Service Users' FGD
Discussion Our sample of service users and carers reported that nurses need to be technically competent and knowledgeable, and able to find information or to seek help when they lack knowledge or skills. However they unequivocally prioritised ‘softer’ nursing qualities, attitudes and skills such as empathy, listening, a non-judgmental attitude and individualised care, which they perceived have sometimes become lost within nursing. They also expressed concern that the softer skills they valued were incompatible with ‘academic’ nursing. The following discussion will address the concerns of our participants and the challenges for nurse educators in teaching these skills. Finally we discuss how we can engage service users and carers in shaping our curricula. Care and Compassion These concerns of our participants echo the British media that reports a public fearful of the graduate nurse, fuel stories of lack of caring in the health service and a suspicion that driving up academic standards will drive down care and compassion. These fears are not helped by selective quotations in the media from our spokespersons that imply ‘care and compassion’ versus ‘academic theory’ dualism, stating that both are needed, but without explaining the relationship between the two (Independent, 2009). Lack of care is not just the concern of service users, carers and ‘the public’ however. In a recent
Defining Caring In order to teach caring first it is has to be described. In a recent meta-synthesis of caring, Finfgeld-Connett (2008b) analysed 49 qualitative reports and six concept analyses and arrived at a definition of caring as a complex interplay between expert nursing practice, interpersonal sensitivity and intimate relationships. Each element she describes as multi-faceted with expert nursing practice encompassing, for example, excellent assessment skills and empowerment, interpersonal sensitivity describing centering completely on the patient, nonjudgmentally and with openness and availability and intimate relationships becoming deeply involved with patients and their families and sharing personal thoughts and feelings, whilst avoiding crossing the line into a ‘personal’ relationship. Teaching Caring If caring can be broken down into its component parts then, arguably, it can be taught (Finfgeld-Connett, 2008a, 2008b; Chan et al.,
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2009). The challenge for educators is how. Clearly students need to work in an environment where caring is modelled: to care, it could be argued, nurses need to feel cared for (Clarke and Wheeler, 1992). In universities we can role model caring in our relationships with students as individuals and in the classroom. This is challenging with changing student to staff ratios, but we need to draw on our creativity to consider how it can be done. One example for a particular unit of learning might be a blended learning approach incorporating blogs, blackboard and other online resources to achieve a more intimate and personalised learning environment than is possible in large group lectures (Kiteley and Ormord, 2009; Rigby et al., 2010). During practice placements where there are increasing demands on clinical colleagues we have less control, but nurturing close relationships with our colleagues in which they feel cared for and through which optimal learning environments are facilitated, has to be key. The concepts of ‘patient centred care’ and ‘health promotion’ preeminent in the present and previous decade (Kerr, 2002; Childs et al., 2009), leave us in no doubt that if it is the ‘simple things’ that will promote the health of a patient, then that is ‘nursing care’ and what we should be teaching. Our data support this. Some of us qualified sufficiently long ago to remember the value given to what Pearcey (2009) describes as “the little things we're not allowed to do anymore” such as the back rub, the bath and walking the patient (Corbin, 2007). Corbin (2007) expresses concern that these caring acts that are “simple in nature” could potentially disappear. Nursing theorists have consistently argued however that the physical task might sometimes be simple, but the nursing skills required to execute it well, are anything but (Orem, 1991; Roy and Andrews, 1991). Perhaps our job as educators is to sanction such tasks and to help our students to analyse and critique their deceptive simplicity. There is arguably nothing simple about ‘caring’. Similarly, really “listening” is not a simple skill, and it is now recognised that communication skills are not innate but need to be taught. Communication skills training aims to teach active listening, empathy and individual empowerment (Maguire and Pitceathly, 2002; Connolly et al., 2010), the qualities and skills that our participants sought and that our regulating body require in graduate nurses (NMC 2010). Teaching sessions on anti-discriminatory practice can help nurses to question their judgement of others and to attempt to nurture empathy, and we can invite patients and carers in to our universities to narrate their stories and answer questions about their experiences. Students' learning can then be assessed, perhaps, though role play and feedback with service users and carers. With imagination and a clearer understanding of what caring comprises, there are arguably many ways caring can be taught. Engaging Service Users and Carers To ensure that care and compassion are predominant within our new curricula we need to develop strategies to continually and meaningfully engage service users and carers. In recognition of this at the University of Manchester we have ring-fenced a dedicated budget to enable the continuous involvement of service users and carers in developing and delivering our curricula. We have invited service user and carer representatives to our curriculum planning meetings, curriculum development and field groups and are involving them in recruitment and interviewing prospective candidates so that they can inform our selection process. We have invited them to our programme committees as a regular agenda item so that their voices continue to be heard, and we will continue to involve them in teaching and evaluation of students in increasingly imaginative ways, face to face, but also using e-learning technology. To ensure meaningful engagement in these activities we have so far provided four full days training on: programme committees and meetings, large and small group teaching, recruitment and admissions, and interviewing. These have been very well evaluated.
It is important however not to lose sight of the very purpose of an undergraduate education and how it can help us to nurture caring compassionate nursing graduates. We perhaps need to reassure our service user and carer representatives that in order to recognise the need for skills such as empathy, person centredness, listening and empowerment, nurses need critical skills: precisely those skills instilled at degree level. It is not just what is taught, but how it is taught and the level expected. It is the critical thinker, surely, who can move beyond the task, reflect on practice, truly see and hear the individual, and, with them, create optimal nursing care. Conclusion In this paper we have provided data from a project that asked users and carers about their views on nursing qualities and education based on their experiences of receiving nursing care in the hospital and home. The patients we interviewed were clear that above all else they wanted nursing to retain – nay ‘return to’ – the care and compassion of ‘the past’. We have explored why caring and attendant ‘softer skills’ are more important than ever in contemporary nursing practice and are optimistic that as caring can be described, it can be taught. With the publication of the new standards for pre-registration nurse education (NMC 2010) the time is right to return to our theoretical roots and take another look at caring and the nursing theories underpinning it. We need to continuously engage service user and carer representatives in developing and delivering our new curricula to ensure that the qualities that they seek in nurses are enhanced by appropriately designed graduate programmes, and not, as they fear, harmed. Limitations This is a qualitative study and therefore relatively small scale, and whilst transferable to other populations is not statistically generalisable. Fifty two is however a substantial sample size in qualitative work and data saturation was achieved with remarkable homogeneity of the data. The sample were largely self selected through support groups which could imply that these are the more proactive service users and carers who have had a poorer experience of services. On the other hand, all of the focus groups gave examples of excellent as well as poor practice and were on the whole fairly balanced in their responses. Although participants were selected from support groups they were by no means homogenous in terms of education, culture, occupation, sexuality, disability and other variables. Whilst we did not collect these biographical data from participants, it was evident that we had a very wide range of service user and carer representatives. References Ah-Mane, S., 1999. Clinical view — learning from psychosis. Nursing Times 95, 43–47. Baggot, I.R., Allsopp, J., Jones, K., 2005. Speaking for Patients and Carers: Health Consumer Groups and the Policy Press. Palgrave Macmillan, London. Benner, P., Wrubel, J., 1989. The Primacy of Caring: Stress and Coping in Health and Illness. Addison-Wesley, Menlo Park, California. Bourdreau, J., Jagosh, J., Slee, R., 2008. Patient perceptions of physicians roles: implications for curricula. Academic Medicine 82 (8), 744. Boykin, A., Schoenhofer, S.O., 2001. Nursing as Caring: A Model for Transforming Practice. Jones and Bartlett, Sudbury, Massachusetts. Carr, S., 2004. Has Service User Participation Made a Difference to Social Care Services. SCIE, London. Chan, E.A., Mok, E., Ho P-yig, A., Hui Man-chun, J., 2009. The use of interdisciplinary seminars for the development of caring dispositions in nursing and social work students. Journal of Advanced Nursing 65 (12), 2658–2667. Essential Skills Clusters for Nurses: Theory for Practice. In: Childs, L., Coles, L., Marjoram, B. (Eds.), Wiley-Blackwell, Chichester. Clarke, J.B., Wheeler, S.J., 1992. A view of the phenomenon of caring in nursing practice. Journal of Advance Nursing 17 (11), 1283–1290. Closs, S.J., Cheater, F., 1999. Evidence for nursing practice: a clarification of the issues. Journal of Advanced Nursing 30 (1), 10–17. Connolly, M., Perryman, J., McKenna, Y., Orford, J., Thomson, L., Shuttleworth, J., Cocksedge, S., 2010. SAGE & THYME™: a model for training health and social care
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Kiteley, R., Ormord, G., 2009. Towards a team based, collaborative approach to embedding e-learning within undergraduate nursing programmes. Nurse Education Today 29 (6), 623–629. Kreuger, R.A., 2008. Focus Groups: A Practical Guide for Applied Research, 3rd Edition. Sage, London. Leininger, M., 1984. Care: The Essence of Nursing and Health. Wayne State University Press, Detroit, Michigan. Levin, E., 2004. Involving Service Users and Carers in Social Work Education. SCIE, London. Lui, J.-E., Mok, E., Wong, T., 2006. Caring in nursing: investigating the meaning of caring from the perspective of cancer patients in Beijing, China. Journal of Clinical Nursing 15, 188–196. Maben, J., 2007. The art of caring: invisible and subordinated? A response to Julit Crobin: ‘Is caring a lost art in nursing?’. International Journal of Nursing Studies 45, 335–338. Maguire, P., Pitceathly, C., 2002. Key communication skills and how to acquire them. British Medical Journal 325, 697. Morse, J., Soldberg, S., Neander, W., Bottorff, J., Johnson, J., 1990. Concepts of caring and caring as a concept. Advances in Nursing Science 13 (1), 1–14. Morse, J., Bottorff, J., Anderson, G., O'Brein, B., Solberg, S., 1992. Beyond empathy: expanding expressions of caring. Journal of Advanced Nursing 17, 809–821. Muhr, T., 2004. ATLAS.ti 5.0. Scientific Software Development, Berlin. Nursing and Midwifery Council, 2010. Standards for Pre-registration Nursing Education. NMC, London. O'Keefe, M., Jones, A., 2007. Promoting lay participation in medical school curriculum development. Lay and faculty perceptions. Medical Education 41 (2), 130. Orem, D.E., 1991. Nursing: Concepts of Practice, 4th edition. McGraw-Hill, New York. Pajnkihar, M., 2007. Is caring a lost art in nursing? International Journal of Nursing Studies 45 (5), 807–808. Pearcey, 2009. Caring? It's the little things we are not supposed to do anymore. International Journal of Nursing Practice 16, 51–56. Phillips, P., 1993. A deconstruction of caring. Journal of Advanced Nursing 18, 1554–1558. Polit, D.F., Hungler, B.P., 1999. Nursing Research: Principles and Methods. JB Lippincott Company, Philadelphia. Repper, J., Breeze, J., 2007. User and carer involvement in the training and education of health professionals: a review of the literature. International Journal of Nursing Studies 44 (3), 511. Rigby, L., Wilson, I., Walton, T., Baker, J., Dunne, K., Keeley, P., 2010. Bridging the gap: an experiential enquiry-based learning approach in mental health education. Case Studies: CEEBL-Supported Projects, 2008–2009. Centre for Excellence in EnquiryBased Learning, Manchester, pp. 229–237. Ritchie, J., Spencer, E., 1994. Qualitative data analysis for applied policy research. In: Bryman, A., Burgess, R.G. (Eds.), Analysing Qualitative Data. Routledge, London. Rollnick, S., Miller, W.R., 1995. What is motivational interviewing? Behavioural and Cognitive Psychotherapy 23, 325–334. Roy, C., Andrews, H., 1991. The Roy Adaptation Model. Pearson Education, New Jersey. Rudman, M.J., 1996. User involvement in the nursing curriculum: seeking users' views. Journal of Psychiatric and Mental Health Nursing 3, 195–200. Sawley, L., 2002. Consumer groups: shaping education and developing practice. Paediatric Nursing 14 (3), 18–21. Standing Medical Advisory Committee, 2000. Evidence into Practice: Standing Medical Advisory Committee Advice. SMAC, London. Watson, J., 1999. Nursing: Human Science and Human Care: A Theory of Nursing, New Ed edition. National League for Nursing, New York. Wilkinson, S., 2004. Chapter 10: focus group research. In: Silverman, D. (Ed.), Qualitative Research: Theory, Method and Practice. Sage, London.
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Nurse Education Today j o u r n a l h o m e p a g e : w w w. e l s ev i e r. c o m / n e d t
'A caring professional attitude’: What service users and carers seek in graduate nurses and the challenge for educators Jane Griffiths a,⁎, Shaun Speed b, Maria Horne b, Phillip Keeley b a b
School of Nursing, Midwifery and Social Work, University of Manchester, Jean McFarlane Building, Oxford Road, Manchester, M13 9PL, United Kingdom School of Nursing, Midwifery and Social Work, University of Manchester, United Kingdom
a r t i c l e
i n f o
Article history: Accepted 14 June 2011 Keywords: Caring Graduate nurses Service users Carers Communication skills
s u m m a r y With the publication of the new NMC standards for pre-registration nursing education, undergraduate curricula are being written in universities across England. There are many drivers for the curricula but one that has until recently received scant attention is the service user's and carer's voice. This paper discusses the findings of a qualitative study that asked 52 service users and carers about the qualities they sought in nurses and their views on nurse education. Eight focus groups were conducted with a broad range of service users and carers from primary and secondary care, and voluntary organisations. Data were analysed using the framework approach facilitated by a qualitative analysis software programme. The sample was diverse, but there were similarities in the qualities they valued in nurses. They sought technical competence, knowledge and willingness to seek information, but overwhelmingly prioritised ‘a caring professional attitude’. This was articulated as empathy, communication skills and non-judgmental patient centred care: major themes in the new NMC standards. Our participants also expressed concern about whether the educational preparation of nurses can develop these caring qualities. We discuss this concern, the challenges for nurse educators it presents and how we can engage service users and carers in shaping and delivering our new curricula. © 2011 Elsevier Ltd. All rights reserved.
Background In response to the move to all graduate nursing programmes in England by 2013, nursing curricula are being re-written in universities the length and breadth of the country to create the graduate nurse of the future. Nurses work in an ever changing and evermore complex world impacted by many different, often competing, imperatives. Programmes will clearly need to reflect these demands to ensure that graduates are adequately prepared for the expectations of the workplace (Nursing and Midwifery Council [NMC] 2010). The newly published Nursing and Midwifery Council standards for pre-registration education (NMC 2010) are clearly the major driver for the new curricula, and reflect the changing landscape of the workplace, impacted by demographic shifts and technical advances. An obvious driver is the shift in care away from hospitals to service users' and carers' homes and other community locations (Department of Health [DH], 2000, 2001). Curricula will need to reflect this, and in order to understand the contexts of service users' and carers' lives in these different environments, will need a strong focus on the wider determinants of health with their academic roots in sociology, public health and applied social policy.
⁎ Corresponding author. Tel.: + 44 161 306 7681. E-mail address: jane.griffi[email protected] (J. Griffiths). 0260-6917/$ – see front matter © 2011 Elsevier Ltd. All rights reserved. doi:10.1016/j.nedt.2011.06.005
An inescapable demographic driving force impacting on primary and secondary care, is our ageing population living longer with both incurable cancers and chronic non-malignant conditions such as Diabetes, Coronary Heart Disease and Chronic Obstructive Pulmonary Disease (DH, 2005a). As many long term conditions (LTCs) are largely preventable (DH, 2005b), nursing programmes will need to reflect the increasingly important role of nurses in promoting the health of individuals to prevent the occurrence of preventable disease (DH, 1999) and in working with patients living with LTCs to empower them to self manage and live as well as possible (DH, 2004a, 2004b, 2005a). Combine these demands with advances in technical care in the hospital and home requiring a sound foundation in biomedical sciences, and the drive for evidence in most if not all areas of nursing practice (Standing Medical Advisory Committee, 2000), and curricula are already groaning at the seams. The evidence base for many aspects of nursing practice from complex procedures to ‘basic’ care is ever expanding and an understanding of research methods fundamental to nursing practice, but also knowledge of how to access evidence and to read and apply it critically (NMC, 2010). A further vitally important driver for change in curricula is the service user's and carer's voice which is becoming increasingly important in shaping and delivering health care education and practice (Coulter, 2002; Baggot et al., 2005, NMC 2010). The benefit of user involvement in education has been described in numerous research reports in medicine (O'Keefe and Jones, 2007; Bourdreau
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et al., 2008), general nursing (Flanagan, 1999; Costello and Horne, 2001; Repper and Breeze, 2007), mental health nursing (Hanson and Mitchell, 2001; Downe et al., 2007; Repper and Breeze, 2007) and children's nursing (Sawley, 2002). Involvement has been in a number of ways from sharing experiences of health care and views on the education of students (Harrison and Beresford, 1994), to devising learning materials (Ah-Mane, 1999; Coupland et al., 2001), classroom teaching (Repper and Breeze, 2007), developing curricula and planning courses (Khoo et al., 2004). The aim of this paper is to present and discuss findings of a qualitative study that asked 52 service users and carers about the qualities they seek in nurses and their views on nurse education, as part of a larger project aiming to involve service users and carers in the development and delivery of our graduate and postgraduate nursing, midwifery and social work curricula at the University of Manchester. Our sample of service users and carers desired a ‘caring professional attitude’ above all else and was concerned that ‘caring’ has become lost in nursing practice and that higher educational entry and exit requirements will aggravate this. The new NMC standards for pre-registration education give pre-eminance to caring, compassion and client centred care, so how do nurse educators instil these qualities in nursing graduates? There is an extensive international literature on caring, spanning several decades (e.g. Leininger, 1984; Morse et al., 1990; Phillips, 1993; Lui et al., 2006; Finfgeld-Connett, 2008a, 2008b; Chan et al., 2009). Drawing on this body of work, we discuss how as educators we can address service users' and carers' concerns, and involve them in developing and shaping our curricula, to ensure that caring and compassion do not become lost. Methods Setting and Recruitment The study took place at the University of Manchester, North West England. The aim of the larger project was to involve users and carers in the development and delivery of curricula in the school of Nursing Midwifery and Social Work. For the first stage of the project we held a one day conference in May 2009 to engage service users and carers and to elicit their views on the education of nurses, midwives and social workers. This approach has been used successfully elsewhere (Harrison and Beresford, 1994; Ingham, 2001; Sawley, 2002; Levin, 2004; Repper and Breeze, 2007). The research team contacted as wide a variety of service users and carers as possible to take part in the conference day. This was through existing contacts and various voluntary health and social care organisations working with people from a range of age groups and with a variety of health problems. Contact persons/‘gatekeepers’ in the various organisations were sent information packs which they passed on to potential participants, who returned an expression of interest to the research team. These individuals were then sent a written invitation to the conference day. The conference day began with a presentation by key personnel from the school about hopes and expectations of the consultation and collaboration process, followed by a brief overview of the programmes within the school with questions and answers. Seven focus group interviews were then conducted representing service users and carers from primary and secondary care and voluntary organisations. Ethical approval for the study was granted by the University of Manchester Ethics Committee. Study Participants Thirty service users and 22 carers took part in the study (n = 52 Table 1). All provided written consent prior to the focus group discussion. Seven focus groups of 3 to 8 participants were conducted on the conference day itself with: Mental Health Service Users, older people, carers (x2), parents of children with disabilities/long term
Table 1 Participants and groups. Group
Number
Carers' group 1 (6 women and 2 men) Carers' group 2 (5 women and 3 men) Cancer service users' group (2 women and 1 man) Older peoples' group (2 women and 2 men) Men's health group (3 men) Mental Health Service Users' group (3 women and 4 men) Parents' group (6 women and 1 teenage son of parent) HIV service users' (5 women and 7 men) Total
8 8 3 4 3 7 7 12 52
conditions and men (Table 1). One group was unable to attend on the day and was interviewed at another time. This was a group of HIV positive service users, which included asylum seekers and refugees. Each focus group was facilitated by two of the research team, was of 60–90 minute duration and was audio-recorded. Focus group discussions are widely used in healthcare research to investigate user perspectives on a variety of health related topics (Kreuger, 2008; Flick, 2002). They are guided by the researcher's broad questions on the topic of interest (Polit and Hungler, 1999; Kreuger, 2008; Kaufman, 1996) but flexible enough to allow the participants' to influence the direction of the discussion (Kreuger, 2008; Wilkinson, 2004). This was the overriding aim in the research project. To prepare participants for the focus groups, time was allowed in the morning session for people to get to know each other and the facilitators. Although this preparation was not available to the group that was unable to attend the conference day (HIV service users), they were already well known to each other through regular attendance at a local support group. The facilitator also spent time in general discussion with the group before starting the interview to get to know them a little. The questions for the focus group were distributed to participants prior to the interview. All of the facilitators were experienced qualitative researchers. Following previous research in this field, four broad questions developed by Rudman (1996) were used to guide the focus group discussions: 1. What knowledge do you think that health and social care professionals should have? 2. What qualities do you think are important in health and social care professionals? 3. What do you think health and social care professionals ought to do effectively? 4. Is there anything else you would like to say about how health and social care professionals are trained? Participants were also asked a series of questions about how they would like to become involved in curriculum planning and delivery (Harrison and Beresford, 1994; Levin, 2004; Carr, 2004; Doel et al., 2007). The data presented here are the views of users and carers on nurse education, and focus on their answers to the four questions above. Data Analysis All interviews were digitally recorded, transcribed verbatim and analysed using the framework approach (Ritchie and Spencer, 1994). Systematic line by line analysis was undertaken by each of the researchers on their own transcripts and one other person's. The research team met to discuss coding of the interviews, and similarities and differences in the codes were examined. Minor changes were made to the nomenclature of the codes and we began to cluster the codes to create categories. These were compared and contrasted in order to develop more inclusive categories, which were then developed into themes (Ritchie and Spencer, 1994). The themes
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were then compared and contrasted within and across the groups. Negative cases and rival explanations were explored and discussed. ATLAS/ti5.0 (Muhr, 2004) qualitative analysis software programme assisted in data coding, cross-referencing, storage and retrieval. In order to assess the rigour of the coding process (Kreuger, 2008), initial themes were fed back to the service users and carers in a follow up conference day. The same service users and carers from the first conference day were at the follow up day. The themes were presented to the users and carers who were asked to rate their agreement both verbally, and in writing on the presentation handout. The handout had a column next to the themes with “agree, disagree or don't know” and a space for comments. These were then collected and reviewed. One of the research teams also recorded the comments made during the discussions. There was overwhelming agreement that the codes captured the focus of the group discussions. Findings Although our groups of service users were diverse, there were many similarities in the qualities they sought in nurses. There were some minor differences, for example, confidentiality and understanding of the disease/condition featured strongly in the HIV and Mental Health Service Users' Focus Group Discussions (FGDs) and cleanliness and medication management in the Older People's, but in the main, the data were remarkably homogenous. We found that whilst participants sought technical competence, knowledge and a willingness to seek information from a variety of sources, they overwhelmingly prioritised ‘caring’ qualities. These were articulated as empathy, listening, communication skills and non-judgmental patient centred care. Participants also expressed concerns about whether the current educational preparation of nurses can develop these caring qualities. Technical Knowledge and Competence The majority of participants across all focus groups discussed the need for technical competence and knowledge in nurses. They provided examples of where this was clearly evident:
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that need you know [P3: absolutely] asking, because, well at the end of the day we are all human and, you know. HIV Service Users' FGD The majority also wanted nurses to recognise the patient's or carer's own expertise and to ask them questions if they were unsure about something, as these parents commented: Participant 1: That's better because nine times out of ten if you go and ask the patient or the carer they will be more than happy to tell you (P2: Yeah). As opposed to you staying away. Interviewer: So it's not so much about knowing everything, it's about being able to say “We don't know?” Participant 1: Yeah. And can you tell me. Participant 2: And being able to listen. Participant 1: Yeah. I don't know the answer to this, I'll go and find out, or can you help me. Participant 3: Yeah. The worst thing in the world is when people try and bluff it. Parents' FGD
Empathy and Communication More than knowledge and skills however, the participants overwhelmingly sought empathy and the ability to listen, as these quotes from three different focus groups demonstrate: “I've put down actually — I just jotted down some notes. I've put knowledge is not as important as approach and empathy and preparedness to learn from patients and carers.” Cancer Service Users' FGD “It's about communication and understanding and empathy. You might be the best clinician in the world but if you can't communicate and you can't listen properly to people and you don't take on board and understand what they're saying you may as well go dig the street. And no disrespect to road diggers, but…” Parents' FGD “I think they need empathy with the disabled person or the person needing care, you know, to feel, you know, that they understand what it would be like. A good understanding of that person and that person's disabilities.” Men's FGD
“I'm thinking of the nurses I come into contact with on a regular basis that, you know, they are really superb with cancer … the particular ward I go into, they are really, really good … and you feel that when they're administering the chemo or whatever it is, that they are really confident and I feel they know what they're doing.” Cancer Service Users' FGD
Or, as a carer and a parent phrased it in their respective discussions:
They also gave examples of where technical competence and knowledge were lacking, for example:
“It is not what they do it is the way that they do it that matters.” Carers' FGD 2
“When I go to hospital for them to do bloods and stuff, I discovered that lots of them haven't got a clue how to get blood from my vein. I end up taking paracetamol pain killers because they keep missing the vein.” HIV Service Users' FGD Whilst a desire for knowledge and technical competence was not surprising, it was also reassuring that none of the participants expected the nurses to know everything about their specialty. They welcomed honesty, knowledge of how to find information and a willingness to do so, as another quote from the HIV service users' FGD illustrates: Participant 1: I think if they're not sure — because as you've said, there's so much knowledge and it's continually improving and progressing. Not everybody is going to know everything and if somebody says ‘oh well this … but I could go and look up such and such and I'll come back to you’. Participant 2: I'd rather have somebody turn around and do that, yeh, say that they're not certain about something, and ask the questions
“Those old fashioned qualities, they're still really important.” Parents' FGD Participants used different words to describe the qualities they looked for in nurses, but in all but one of the focus groups (HIV service users' FGD), terms synonymous with empathy and communication were the first they mentioned during the interview, as in this excerpt from the Older People's FGD: Interviewer: So the first question I've got for you is about the kind of knowledge that nurses need to have. So the kind of things they need to know in order to do their job well. Participant 1: They need social skills to interact with different people… (P2: Yeah). Participant 3: Definitely social skills, yeah. Participant 4: Because that's what they lack (P3: Yeah). Interviewer: Right. Fascinating that's the first thing that you're saying and you're all agreeing. Participant 2: Yeah, definitely. Older People's FGD
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Later in their discussion participants elaborated on some of the terms they had used: Participant 1: A caring, professional attitude, that's the main thing. … Interviewer: So just explain what a caring professional attitude means to you? Participant 1: Well they listen to you, they understand you and they take interest in what's wrong with you. Participant 2: Yeah, it's the patience isn't it that they show. Caring. Participant 3: And that's all you need. It makes you feel better if you think somebody knows what they're talking about. Because you don't see the doctor but once a day if you're lucky. The only thing is the nurses, and if there's somebody there who's caring enough to ask you and talk to you it makes all the difference. (P2: Yeah). Participant 4: Treating you as a person. (P1: As a person, yeah). Participant 3: As a person, yeah. As a human being actually. Participant 4: Yeah. Instead of just another number [laughs]. Older People's FGD
Non-judgmental Approach Another recurrent theme was the importance of nurses being nonjudgmental in their interactions with patients and carers: “I think with nursing staff, with health care staff ….like you meet somebody in a highly emotional situation or you're judging their…you're coming into a really personal situation dead quickly and it's really important I think not to judge a book by its cover and not saying like I know who you are because of this, this and this.” Parents' FGD “I've written it down, like it's compassion, dignity, tolerance and non judgmental attitude. Most of all it's the humanity, it's the most essential quality in life.” Carers' FGD 1 Some of the participants reported situations when they had felt judged by nurses. The Mental Health Service Users' group for example described how side effects from medications can leave them exhausted and unable to do housework. One participant reported an occasion when she had felt judged by a community nurse who said “look at the state of your house, it's very untidy”. Similarly, the HIV group described themselves as being treated as a “special case”, or as one participant commented “a dirty case”, implying a spoiled identity. Another of the HIV positive participants described challenging a nurse about perceived racism: “[laughing] I said are you, are you racist in any way at all? You know, because my understanding … you come across as if you are knowledgeable about your profession, you're skilled and everything, but it's just the case that you don't just like me, you don't just like my colour [P2: really?] And that seems to be affecting the way you are talking to me, the way, the general demeanour, your body language, your tone, intonation and everything.” HIV Service Users' FGD Similarly, the older people's group described ageist attitudes in nurses they had come into contact with: Participant 3: Therefore they think you're past it and you're just… Participant 1: And that's the attitude that they do have. Participant 2: They do, don't they? Participant 3: They do have that oh, she's getting old, she doesn't know what she's talking about. That's the attitude. Participant 2: And they don't actually talk to the person. Participant 1: No they don't. Older People's FGD
Listening Skills Listening was therefore not surprisingly the skill that participants repeatedly described as essential, as in these two excerpts: “Good essential listening skills, 'cos sometimes what you find in professionals is what they do is they listen but they talk over…they know better than you, so they're not really listening, they're listening to what they need to hear and then they tell you. But it shouldn't be like that, they should actually really listen to what you're saying and the person that you're caring for. You know their symptoms better than a professional, you know, and for them to really listen, I think that's a fundamental one.”Carers' FGD 1“I think to …listen, because a lot of professionals come out and they're there but they don't listen.” Mental Health Service Users' FGD Listening was also discussed in relation to the importance of careful assessment, history taking and person centred care: “They should say to people; what has brung [brought] you here and what has got you to this service? And I don't mean, as I say, bus, taxi or tram. [Laughter from group] They should say: what has happened in your life that's got you to this stage?” Mental Health Service Users' FGD “I think to judge each individual, and then each individual should be assessed and their needs be assessed and implemented on that particular individual, rather than this is a basic rule for all. Because it has personally affected me that way where I just feel it's a conveyor belt system. Get them in and get them out sort of thing.” Carers' FGD2 Participant 2: The system's got to adapt to the individual needs as opposed… [That's right, yeah]… to try and make the kids square pegs in round holes. It's not hard to do. It's little things that… Participant 3: No, it's not. Just requires a change in mind set. Participant 2: …are quite easy to change. They just don't happen because people don't think. Participant 1: Parents do it with no training whatsoever. You adapt to your child. You adapt to their needs and you learn how to address their needs. It's about staff opening their eyes. Parents' FGD
Individualised Care The majority of participants were clear that they wanted the nurses to get to know them as individuals: “Almost like becoming one of the family and knowing what's important to people because it's an individual thing and what's important to me wouldn't be important to you.” Men's FGD “You know it like getting to know you … you as a person what it is like for you and so that you don't have to explain all the time about yourself and the person you are caring for … but that relies on consistency and that doesn't happen.” Carers' FGD 2 “I don't need that nurse to be a friend of mine … not a friend, but just, just showing me I'm here for you, you know.” HIV Service Users' FGD
The Over Educated Nurse Many participants speculated about why the skills they desired in nurses were sometimes absent. Whilst in their discussions they
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Participant 2: But has it almost become over-career, overeducated… (P4: Technical) …over-technical (P3: Over-paper worked). Participant 4: Oh yes. Participant 3: Is it attracting… the right people who maybe didn't have the academic level to take on a degree but actually were the most fabulous nurses. They may well have started as auxiliaries – I know that's not the correct word now – and built up and went on to do this. Participant 5: But that was the way the training was. When [son] used to first go into hospital all those nurses then were retrained. Fantastic. Absolutely fantastic. Participant 2: Real down to earth stuff. Don't have any problem going and sitting on your bed and going right, alright, what's up with you. Parents' FGD
written debate initiated by Corbin (2007) unease has even been expressed by nursing academics that caring might have become a ‘lost art’ (Flately and Bridges, 2007; Griffiths, 2007; Maben, 2007; Pajnkihar, 2007). Yet the new NMC standards for pre-registration education of nurses give pre-eminance to caring and compassion, leaving educators in no doubt that it needs to central to everything we teach in both theory and practice. Caring has long been considered by nursing academics as the basis of everything that we do (Leininger, 1984; Morse et al., 1990; Phillips, 1993; Lui et al., 2006; Morse et al., 1992). It has an extensive presence in the theoretical nursing literature with many eminent nursing academics devoting their careers to explicating the complexities of this deceptively simple term (Leininger, 1984; Benner and Wrubel, 1989; Morse et al., 1990; Watson, 1999). Nursing theory, with caring at its heart, was hugely popular in the 1980s in the UK and has remained so in North America. In the USA, for example, a nursing model has recently been published entitled simply “Nursing as Caring” (Boykin and Schoenhofer, 2001).
Participant 3: I don't think the nursing trade is what it used to be.
Nursing Theory
Participant 5: You know, often it being academic, it's not all academic is it? Participant 6: No, no, people skills as well, you know, you had the matron that ran the ward, and it was more, a profession and it was something that people wanted to go into because they had a caring nature [R: exactly] and now I don't think that. HIV Service Users' FGD
In the UK in recent years interest in nursing theory appears to have waned with other subjects edging it out of curricula. The concerns of our participants about the ‘over educated nurse’ therefore present an interesting paradox. Academic nursing theory developed in the 60s, 70s and 80s because nursing had moved away from ‘caring’ towards task allocation to increase productivity, relegating the patient to the ‘appendicectomy in bed 14’. Maybe some of this so called ‘nursing of the past’ is a chimaera. It is timely to return to our theoretical roots and to remind ourselves that caring is a complex ‘academic’ subject worthy of undergraduate study that can and should be taught. Caring is not just worthy of study in its own right, however, but integral to the subjects demanded by the changing demographic and disease patterns of the population. Health promotion to prevent the onset of long term conditions involves empowering individuals to change, and to empower, nurses need to be taught to practice with empathy and without judgement: recognised elements of caring (Watson, 1999; Rollnick and Miller, 1995; Morse et al., 1992). To encourage self management of a long term condition, empathy and listening skills are vital to work with the patient to find a strategy that works for them (Watson, 1999; Kennedy et al., 2007). Likewise evidence based practice: it is not just about knowing the right things to do, but teaching nurses how to work with individuals to facilitate them to make the best choices (Closs and Cheater, 1999). We can ill afford to ignore caring and partnership working if we are serious about changing behaviour to improve health.
acknowledged constraints such as time pressure, all expressed concern about their perceptions of the ‘over educated nurse’:
Or, as one participant summarised it, reflecting on the presentation we had given that morning: “What concerned me this morning about the description of the qualifications that you were providing, in a sense particularly the emphasis on education which tends to imply knowledge — predominance of knowledge possibly predominance of knowledge over skills and attitudes and values. It could mean that we are producing more and more academically qualified nurses without the commensurate concurrent understanding and desire to provide care.” Cancer Service Users' FGD
Discussion Our sample of service users and carers reported that nurses need to be technically competent and knowledgeable, and able to find information or to seek help when they lack knowledge or skills. However they unequivocally prioritised ‘softer’ nursing qualities, attitudes and skills such as empathy, listening, a non-judgmental attitude and individualised care, which they perceived have sometimes become lost within nursing. They also expressed concern that the softer skills they valued were incompatible with ‘academic’ nursing. The following discussion will address the concerns of our participants and the challenges for nurse educators in teaching these skills. Finally we discuss how we can engage service users and carers in shaping our curricula. Care and Compassion These concerns of our participants echo the British media that reports a public fearful of the graduate nurse, fuel stories of lack of caring in the health service and a suspicion that driving up academic standards will drive down care and compassion. These fears are not helped by selective quotations in the media from our spokespersons that imply ‘care and compassion’ versus ‘academic theory’ dualism, stating that both are needed, but without explaining the relationship between the two (Independent, 2009). Lack of care is not just the concern of service users, carers and ‘the public’ however. In a recent
Defining Caring In order to teach caring first it is has to be described. In a recent meta-synthesis of caring, Finfgeld-Connett (2008b) analysed 49 qualitative reports and six concept analyses and arrived at a definition of caring as a complex interplay between expert nursing practice, interpersonal sensitivity and intimate relationships. Each element she describes as multi-faceted with expert nursing practice encompassing, for example, excellent assessment skills and empowerment, interpersonal sensitivity describing centering completely on the patient, nonjudgmentally and with openness and availability and intimate relationships becoming deeply involved with patients and their families and sharing personal thoughts and feelings, whilst avoiding crossing the line into a ‘personal’ relationship. Teaching Caring If caring can be broken down into its component parts then, arguably, it can be taught (Finfgeld-Connett, 2008a, 2008b; Chan et al.,
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2009). The challenge for educators is how. Clearly students need to work in an environment where caring is modelled: to care, it could be argued, nurses need to feel cared for (Clarke and Wheeler, 1992). In universities we can role model caring in our relationships with students as individuals and in the classroom. This is challenging with changing student to staff ratios, but we need to draw on our creativity to consider how it can be done. One example for a particular unit of learning might be a blended learning approach incorporating blogs, blackboard and other online resources to achieve a more intimate and personalised learning environment than is possible in large group lectures (Kiteley and Ormord, 2009; Rigby et al., 2010). During practice placements where there are increasing demands on clinical colleagues we have less control, but nurturing close relationships with our colleagues in which they feel cared for and through which optimal learning environments are facilitated, has to be key. The concepts of ‘patient centred care’ and ‘health promotion’ preeminent in the present and previous decade (Kerr, 2002; Childs et al., 2009), leave us in no doubt that if it is the ‘simple things’ that will promote the health of a patient, then that is ‘nursing care’ and what we should be teaching. Our data support this. Some of us qualified sufficiently long ago to remember the value given to what Pearcey (2009) describes as “the little things we're not allowed to do anymore” such as the back rub, the bath and walking the patient (Corbin, 2007). Corbin (2007) expresses concern that these caring acts that are “simple in nature” could potentially disappear. Nursing theorists have consistently argued however that the physical task might sometimes be simple, but the nursing skills required to execute it well, are anything but (Orem, 1991; Roy and Andrews, 1991). Perhaps our job as educators is to sanction such tasks and to help our students to analyse and critique their deceptive simplicity. There is arguably nothing simple about ‘caring’. Similarly, really “listening” is not a simple skill, and it is now recognised that communication skills are not innate but need to be taught. Communication skills training aims to teach active listening, empathy and individual empowerment (Maguire and Pitceathly, 2002; Connolly et al., 2010), the qualities and skills that our participants sought and that our regulating body require in graduate nurses (NMC 2010). Teaching sessions on anti-discriminatory practice can help nurses to question their judgement of others and to attempt to nurture empathy, and we can invite patients and carers in to our universities to narrate their stories and answer questions about their experiences. Students' learning can then be assessed, perhaps, though role play and feedback with service users and carers. With imagination and a clearer understanding of what caring comprises, there are arguably many ways caring can be taught. Engaging Service Users and Carers To ensure that care and compassion are predominant within our new curricula we need to develop strategies to continually and meaningfully engage service users and carers. In recognition of this at the University of Manchester we have ring-fenced a dedicated budget to enable the continuous involvement of service users and carers in developing and delivering our curricula. We have invited service user and carer representatives to our curriculum planning meetings, curriculum development and field groups and are involving them in recruitment and interviewing prospective candidates so that they can inform our selection process. We have invited them to our programme committees as a regular agenda item so that their voices continue to be heard, and we will continue to involve them in teaching and evaluation of students in increasingly imaginative ways, face to face, but also using e-learning technology. To ensure meaningful engagement in these activities we have so far provided four full days training on: programme committees and meetings, large and small group teaching, recruitment and admissions, and interviewing. These have been very well evaluated.
It is important however not to lose sight of the very purpose of an undergraduate education and how it can help us to nurture caring compassionate nursing graduates. We perhaps need to reassure our service user and carer representatives that in order to recognise the need for skills such as empathy, person centredness, listening and empowerment, nurses need critical skills: precisely those skills instilled at degree level. It is not just what is taught, but how it is taught and the level expected. It is the critical thinker, surely, who can move beyond the task, reflect on practice, truly see and hear the individual, and, with them, create optimal nursing care. Conclusion In this paper we have provided data from a project that asked users and carers about their views on nursing qualities and education based on their experiences of receiving nursing care in the hospital and home. The patients we interviewed were clear that above all else they wanted nursing to retain – nay ‘return to’ – the care and compassion of ‘the past’. We have explored why caring and attendant ‘softer skills’ are more important than ever in contemporary nursing practice and are optimistic that as caring can be described, it can be taught. With the publication of the new standards for pre-registration nurse education (NMC 2010) the time is right to return to our theoretical roots and take another look at caring and the nursing theories underpinning it. We need to continuously engage service user and carer representatives in developing and delivering our new curricula to ensure that the qualities that they seek in nurses are enhanced by appropriately designed graduate programmes, and not, as they fear, harmed. Limitations This is a qualitative study and therefore relatively small scale, and whilst transferable to other populations is not statistically generalisable. Fifty two is however a substantial sample size in qualitative work and data saturation was achieved with remarkable homogeneity of the data. The sample were largely self selected through support groups which could imply that these are the more proactive service users and carers who have had a poorer experience of services. On the other hand, all of the focus groups gave examples of excellent as well as poor practice and were on the whole fairly balanced in their responses. Although participants were selected from support groups they were by no means homogenous in terms of education, culture, occupation, sexuality, disability and other variables. Whilst we did not collect these biographical data from participants, it was evident that we had a very wide range of service user and carer representatives. References Ah-Mane, S., 1999. Clinical view — learning from psychosis. Nursing Times 95, 43–47. Baggot, I.R., Allsopp, J., Jones, K., 2005. Speaking for Patients and Carers: Health Consumer Groups and the Policy Press. Palgrave Macmillan, London. Benner, P., Wrubel, J., 1989. The Primacy of Caring: Stress and Coping in Health and Illness. Addison-Wesley, Menlo Park, California. Bourdreau, J., Jagosh, J., Slee, R., 2008. Patient perceptions of physicians roles: implications for curricula. Academic Medicine 82 (8), 744. Boykin, A., Schoenhofer, S.O., 2001. Nursing as Caring: A Model for Transforming Practice. Jones and Bartlett, Sudbury, Massachusetts. Carr, S., 2004. Has Service User Participation Made a Difference to Social Care Services. SCIE, London. Chan, E.A., Mok, E., Ho P-yig, A., Hui Man-chun, J., 2009. The use of interdisciplinary seminars for the development of caring dispositions in nursing and social work students. Journal of Advanced Nursing 65 (12), 2658–2667. Essential Skills Clusters for Nurses: Theory for Practice. In: Childs, L., Coles, L., Marjoram, B. (Eds.), Wiley-Blackwell, Chichester. Clarke, J.B., Wheeler, S.J., 1992. A view of the phenomenon of caring in nursing practice. Journal of Advance Nursing 17 (11), 1283–1290. Closs, S.J., Cheater, F., 1999. Evidence for nursing practice: a clarification of the issues. Journal of Advanced Nursing 30 (1), 10–17. Connolly, M., Perryman, J., McKenna, Y., Orford, J., Thomson, L., Shuttleworth, J., Cocksedge, S., 2010. SAGE & THYME™: a model for training health and social care
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