,A\‘urse Educotron Todq (1991, II, 3-I? fQ Longman GroupLIK Ltd 1991
The caring attitude in nursing practice: a repertory grid study of trained nurses’ perceptions Paul Morrison
The process of caring is central to nursing practice but it remains a poorly defined concept in nursing practice and education. A small number of studies of caring in the field of nursing have been undertaken, but these have tended to be more quantitative in nature. This paper describes a qualitative study designed to explore nurses’ perceptions of the concept of caring. Kelly’s (1955) personal construct theory and the repertory grid interview technique were used to elicit trained nurses’ views about caring in relation to the practice of nursing. A strategic informant sample of 25 nurses was chosen. A total of 200 verbal descriptions (constructs) were generated from interviews, and these were analysed into similar content areas. Seven categories emerged from the analysis to provide a detailed description of caring. These include: a) personal qualitites; b) clinical work style; c) interpersonal approach; d) level of motivation; e) concern for others; f) use of time; and g) attitudes. There were very few constructs related to physical aspects of care. The findings are offered as reflection of British nurses’ perceptions of caring. Some possible applications of the results for nursing practice, education and research are considered.
INTRODUCTION .t‘he word ‘caring’ is a familiar term to all the helping refers
professions. to caring
importance
The
literature
relationships
of caring
frequently
and stresses
in the helping
role.
the Yet
little has been written about the nature of caring. An important exception is Mayeroffs philosophical analysis of the meaning of caring in human relationships (Mayerofff 1971). Mayer-
Paul &Wrison BA (Hans) RMN RGN PGCE Lecturer,
bchDol oi Nulsing Studies, University of Wales College of Medicine, Heath Park, Cardiff, CF4 4XN, UK (Requests for offprints to PM) Manuscript accepted 23 August 1990
off describes
caring
people
carer
(both
as a process and cared
opportunities for personal of caring in the analysis alternating patience, courage.
rhythms
which offers
for individual),
growth. .Major facets include: knowledge,
(learning
from experience),
honesty, trust, humility, hope and The general theme in this account is
that caring can influence significant way and lead
peoples’ lives in a to a more fulfilled
existence. However, Mayeroff spective fails to acknowledge
s theoretical perthe demanding
role inherent in the practice of professional caring. Nursing is one of the professions involved
in caring
relationship between fully understood.
for
other
nursing
people,
but the
and caring
is not
4
NURSE EDUCATION
TODAY
THE RELATIONSHIP BETWEEN NURSING AND CARING Several authors
have referred
ing as a form of loving,
... a
conceptual
Ray (198 1) found of
the profession
lines,
a specific
developed
to caring in nurs-
analysis
enter
caring
that from
different perspectives is suggestive of a form of loving . . .’ (~32). While Campbell’s (1984) theological analysis of professional care required that
of nursing.
selection
for identifying
to be successful tion Research
the 11 attributes
similar
has been
candidates
in their nursing
Limited,
Along
interview
most likely
careers
(Selec-
1987). Caring was one of
isolated
as likely predictors
of
success. The influence strated able
of caring
in it’s potential
and
desirable
may also be demon-
for determining
levels
accept-
of nursing
care
in
caring be perceived as a form of ‘moderated love’. However, McFarlane (1976) referrred to
practice situations
nursing
as the
Carper (1979) notes that ‘caring as a professional
serving,
caring’
and caring
tings.
This
point
One
attitudes
process
in nursing
of view was taken of caring
set-
up and
and emotions,
into two major
activities
recipient
the
is con-
out her nursing
offered
to carry
specific
of certain
as
role to the
1985).
that a concept of such importance
important
in
this
relationship
therapeutic
the disadvantage
The centrality
as central
of a protheme.
In
analysis has
of being far-removed
from the
and is likely to omit relevant
has
attention
from nurse
1978; on the
Leininger, dearth of
Leininger
(198 lb)
appears
to be the
heart
of
help to clients. (p 137)
has been
number
to nursing
has been
widely affirmed
(Briggs,
Watson, 1979, Briggs Report
1985; Leininger, 1981a). The claimed that nursing was the
1972; McFarlane,
1976;
major caring profession. Indeed Chapman (1983) suggested that one of the main reasons why people enter nursing was their desire to help and care for others at their most needy. Pratt (1980) similarly argued that caring was a major driving force for motivating people to
a notable
empirical of studies
nurse researchers (1977) range
studied
lack of British
and
work in this area, but a small have been
undertaken
based in America. the process
of cultures
collected
of caring
area,
ironic
to nursing
RESEARCH INTO CARING: APPROACHES AND FINDINGS European
practice of nursing, considerations.
(Bendall,
remarked: ‘The relationship between caregivers and care recipients is limitedly known, and yet
There
required
this type of philosophical
the
for
were
affective
While this analysis is useful in that it
who claim caring
(Partridge, Commenting
1981a,b).
those
But it is perhaps
so little empirical
in
care edu-
caring is a key concept
Sarason,
and depth of understanding fession
toward
In health
1977;
suggests points of focus for those interested in the concept of caring, it fails to provide the type
addition,
importance
emotions.
of ‘liking’ and ‘compassion’
tentatively
responses.
out
in a way that conveys
and our attitudes
1987).
which governs
cation generally
research
function.
caring in nursing as process, in which the
standard
we care’ (~11-12).
researchers
expression
The emotions
our action whom
1979; Kitson,
value, is of central
a normative
while the other
Griffin (1983) describes essentially an interpersonal is required
providing
received
with the activities that the nurse engages
related
and personal
deals with the nurses’
of these
in while carrying
nurse
and at the same
on by Griffin. (tSS0; 1983t who div-
ided up the concept domains.
assisting,
that nursing
that some practical activities were
in the caring
expanded
cerned
of ‘helping, suggesting
were inseparable,
time indicating involved
process (pl96),
(Carper,
over
of caring
across
a 15-year-period.
data from almost 30 different
by
Leininger a
She
cultures
and discovered variations systems of her informants,
in the belief and value as well as variations in
the practice settings.
across
of
caring
these
cultural
Leininger (1977) identified a total of 17 constructs related to caring. These were comfort, support, compassion, empathy, direct helping behaviours, coping, specific stress alleviation, touching, nurturance, succorance, surveillance, protection, restoration, stimulation, health
maintenance, sultation.
health instruction
These
and health con-
were subsequently
into a 28 construct
taxonomy
developed
of caring.
used were not reported.
fact that different
constructs
more influential important against
the
universal
should
dangers
of
description
Following
The
were found
across cultures,
and
to be
is particularly
caution trying
open-ended
researchers a
a) a genuine
of another
to
stressed
interviews received
with
nursing
50
care, for
These
cat-
As an alternative the method entailed
viewed
and
asked
the nurse were
in a inter-
an incident
for by a nurse.
analysis of these responses
does.
were reported
Patients
to describe
which they felt cared
listening,
‘task’
dimensions patient
revealed
in
Content
two themes:
to asking patients
of participant
looking
were analysed
does, and c) how much (1982).
those
studies involving
for their views about caring,
nurse
similar findings
of yourself.
were
per-
ceptions.
nurse behaviours.
by Brown
emerged for the well
b) giving
provided
emphasise
in other
egories were: a) what the nurse does, b) how the Remarkably
concern
helping and showing respect, and supporting the actions of others. The nurses’ view obtained
and documents.
study
and
behaviours
failed
to produce
Henry (1975) devised three major categories caring
being Caring
of caring.
people who had recently classifying
which reflected
Details
about the methods
collect this data. Two major categories
to produce
categories.
(cognitive
caring
were
and affective);
classifi-
a) psychological
b) practical
(technical
c) interactional
and d) philosophical
1. what the nurse does, and 2. what the nurse is
ethical
caring were again very evident in this study.
respondents
were
asked
to
been influenced
cal analysis revealed
that patients perceived
tative approaches
of these dimensions
to be equally important.
Patient perceptions also been explored Q-sort
technique
reported frequently, and
(Larson,
that a) accessibility responding
so on),
through
and
(knowing
give an injection,
b)
have
nursing using the (checking
quickly
patients
been
when to call a doctor,
how to
meaning
and how to manage
equip-
field
ment) as the most important
nurse caring behav-
iours. Larson (1984) stated that this is in contrast to the views of nurses
working
in the oncology
area who ranked ‘listening’ and ‘comfort’ important. talking, nurses,
She
cautions
psychosocial appear
that:
skills
to become
as most
‘Listening
highly important
and
valued
by
process
must include
a patient
perspective. In contrast
In summary
it has also received
(Watson,
l!lX5:
have
Kennel-.
1986). then few empirical
01’ nursing.
studies of the
have been carried While
some
out in the
of these
have
patients’ views, only two ( Ford,
198 I :
Larson, 1984) have attempted nurses’ perspective. Differences nurses’
and
patients
to explore the in the ways in pert eibe
appear to be emerging but these require exploration and description.
c-aring f‘urther
AIM OF THE STUDY The
to the patient
findings
of caring
examined
which
large
of particu-
to these
patients only after their basic “getting better” needs are met’ (~50). The most valuable insights into the caring
1984; Dunlop,
follow
quanti-
and more qualit,ative procedures
recommended
and
so far has
emphasising
the frequency
of’
While this trend has produced
interesting
criticism,
to call alarms
monitoring
to research.
lar ‘behaviours’. some
Patients
1984).
aspects
by the more rraditional
samples and counting
of caring behaviours
in oncology
practical
The trend in the studies examined
complete a Likert scale to assess the importance of’ ‘task’ and ‘aff-ective’ elements of care. Statistiboth
The
(social
(spiritual,
like.
In addition,
and cultural).
units
responses
which had four impor-
These
physical);
and this
clinical
a conceptual
and social organisation); and
roles,
1362
cation system of caring tant
observation,
at people, Some
or nurses
Ray ( 198 la) used
perspective,
Ford
( 198 1) also asked a sample of nurses (n = 192) to define caring in their own words to describe their caring behaviours. A questionnaire was used to
present
perceptions
study about
set out to explore the
meaning
nurses’
of caring
in
nursing practice. Kellys’ Personal Construct Theory (PCT), (Kelly, 19%: Bannister & Fransella. 1986) and repertorv grid tee-hnique were
6
NURSE EDUCATION
Table 1 Characteristics
TODAY
of the sample Male
Sex Nursing Specialty Specialty Classification
Female
4 General 10
Totals
21
Midwifery 8 Community 6
25
Psychiatric 5
Paediatric 2
25
Hospital 19
25
used. The grid technique has the advantage of being flexible enough to combine both qualita-
The
‘strategic informant
sampling’
tive and quantitative
important
feature
of this method
researcher
taps persons
qualitative
data, but in this paper the
aspects will be emphasised.
sampling
about
the
Typically,
grid technique
framework
for
Recently,
personal
grid technique
(Wilkinson,
1982;
et al. 1983; Costigan, Pollock,
as a
informants.
construct
theory
and
the
studies involving
Davis, 1983;
1985; Costigan
through
a snowball
Heyman
et al, 1987;
1987).
provided sample
being
of different method
respondents
1958).
for the
occasions
to recommend
other
people with different views and perspectives on the topic. Second by means of an expert choice method ation.
where senior nurse managers Both
procedures
provided
in the organis-
are outlined
in Smith
(1981).
SAMPLE
Although A sample
of
25
informants
was selected
to
this form of sampling is acceptable
does have a number
participate
in the study. While a large population
those informants
of nurses
existed,
organisation
within
a variety settings,
of clinical,
educational,
and managerial
sister/charge
nurse group was pinpointed
relevant starting point. shown to be influential
educational
those
at the outset
On several
were asked
was
ways. First
in which
contacted
the names of typical individuals
most been
leadership operation
the name of one other person (Coleman,
the
investigated.
sampling
who were
as
1981). An is that
occupying
The
in a number
is known
(Smith,
who are well informed
setting
initiated
individuals
has been successfully
applied in a variety of research nurses
was selected
interviewing
repertory
social
employed
individuals
roles are selected.
DESIGN OF THE STUDY The repertory
method
and training
the ward as the
This group has in determining
opportunities
at ward
key informants other
trained
occupying
it necessarily nurses,
such as nurse
helpers,
patients
well
may
caring.
provide
PROCEDURE
a significant
influence
on
the
work
how this group had a key role in the collection and dissemination of information to nurses in clinical settings. In practice they hold a pivot position with the power and influence that goes with it. Characteristics of the sample are shown in Table 1.
key roles within the
Similarly, relatives
have
Other
at this stage were
registered
and students in training.
it
By selecting
omits others.
not considered
level (Orton, 1981; Marson, 1982; Ogier, 1984). In addition they were found to be important role model figures for learners and other nurses, and situation and climate (Choppin, 1983; Fretwell, 1982; Pembrey, 1987). Lelean (1973) observed
of limitations.
and enrolled, other groups and especially
alternative
views
of
Initial contact with informants was followed up by visits to each informant in their working environment. This visit was used to provide details about the project, the repertory grid format (devoid of technical language), and to answer any questions. Confidentiality was assured. The investigator emphasised that the
procedbre right
was not a test and that there were no
or wrong
opinions. them
answers,
only their
views and
Full details about what was required
were
(elements)
provided.
A
list
of
role
to be used at the later meeting
also provided.
These
of
titles was
were:
nurse I know I know
5. a person
I care a lot for I don’t care much for
chosen
of the area
how do carers construe
caring.
namely
Informants
had
to write down
There
are
have
different
to know
these.
they
A further
should
choose
people for each role element.
Informants
were asked to consider
viduals they had matched
the indi-
to these role titles in
of their work as professional
Constructs
were elicited by a self-identification (Fransella
& Bannister,
‘myself‘ as a care?
element
carers.
1977).
tant ‘differences’
was compared ‘likenesses’or
between
veyed this characteristic
these.
number
with was
impor-
produced
it’s oppo-
a bi-polar
and
set of constructs. for elements
8 (ideal self) was examined
and
Bannister
but only the content method
Stewart,
ordering
of content
understanding
of‘ the concept
of
the grid to be an unusual task, but quickly adjusted to it and completed it without difficulty. ranged
from
single
words to sentences. Some individuals were adept a! formulating one word likenesses or differ-
&I
to gain
some
oi caring
rep-
relation-
and in a stud? to evaluate
training practices in social work (LilshitL. 1974i. Duck (1973) devised a four categorv sc.heme to classify
role
here.
(Stewart
resented in the grid data for this group of’ nurses. Similar forms of content ;malysis have
mation of friendships.
salient dimen-
of
on the
is reported analysis
198 1), was employed
l-6. on
Mair
construct system. Both content of the approaches have been used in the present stuclv,
The
resulted in an 8 (elements)
produced
by
One involves looking at the structure
to the study of personal
for looking at potentially
constructs
outlined
to the
and these
1973).
bv 8 (constructs) grid for each informant. Most informants found the administration
I‘he
two approaches grid matrices,
ships (Duck,
was adopted
sions. ‘The procedure
essentially
AND
been applied
two occasions as it was felt to be an important element
for &tails).
the
was then asked to describe
Element
198%
con-
procedure meaningful
AIIV discrep-
to the researcher,
informant
same procedure
to explore
Having
site. This personally
1989a:
of analysing
been
(1968).
The
The
each of the others in turn and the informant asked to identify important
part
climen-
the data while the other involves focusing
the context method
the construct
METHOD OF ANALYSIS RESULTS
for the
that
elicitation
wert’ asked to rate
using a 7-point rating scale. This
(see Morrison,
problem
was
for clarification.
of the construct informants
pro-
I’hese were
so as to be
of inquiry,
were instructed
researcher
differences,
and recording
an informant
back to the informant
along
to use
ancies between the ‘self and ‘ideal self elements
only the initials of people as it was not necessary requirement
or
in sequence,
allowed the researcher
to identify and match real people to these in their own time. The
likenesses
the eight elements
7. myself as a carer
were
happier
task was one facili-
labels). Occasionally
of the interview
8. how I would like to be as a carer (ideal self) titles
for
sions produced,
6. a person
role
(asking
sorting the elements construct
appeared
researcher’s
On completion
3. the most caring person
representative
tation
others
The
referred
4. the least caring person
Element
sentences.
vided several ideas in one sentence.
1. a caring nurse ‘2. an uncaring
ences whereas
the constructs
1. psychological; other constructs. procedure
people
WY
in
the for-
The four categories
were:
2. role;
3. interaction;
Lifshitz
( 1974). using a similar
found
constructs employed social workers. The
differences
in the
and 4. types
of
by experienced and trainee latter group tended to use
concrete
descriptive constructs Such 35 age, sex used more and so on, while their mentor5 abstract constructs related to ideals and values. Landheld (197 1) also employed ‘i fi)rm ot content analysis in a study of ps\~chotherapy, while Neimever et al (1984) described a content
8
NURSE EDUCATION
TODAY
Table 2 The seven category scheme, displaying the number and percentage
of constructs in each of the categories
Category
Number of constructs
Percentages (%)
Personal qualities Clinical work style Interpersonal approach Level of motivation Concern for others Use of time Attitudes Totals
78 39 35 21 14 9 4 200
39 19.5 17.5 10.5 7 4.5 2 100
analysis
technique
for
about death. Recently
classifying
that the analysis of content important
constructs
Honess (1985) has argued
as structural
or themes
is just as
relationships
in grid
data, but that much of the research the significance The
content
analysis
Stewart and Stewart category
has ignored
of content. procedure
(1981)
outlined
was used to devise a
scheme for the 200 constructs
This method
requires
by the
allocation
of individual
these categories.
collected.
that key content
identified
researcher, The operation
(Ashworth,
1987).
These
agreed that the scheme appeared tory
way of organising
constructs
obtained.
proved
very useful
equacy
in the
categories
participants
to be a satisfac-
the large
The and
number
comments highlighted
category
scheme.
an inad-
Two
of the
could not be clearly differentiated
the informants
and
were
of
received
therefore
by
collapsed
into one category.
areas are
followed
constructs
as follows. Each construct
by
checked
by the
to each
of
was completed
(both poles) was writ-
THE CONSTRUCT SCHEME
CATEGORY
ten on a small card and sorted by the investigator into homogenous Then
each
ponding
content
category
areas
was given
to the type of content.
of colleagues
were
asked
or categories. a label corres-
A small number
to check
the match
Categories
pole
was
between content type and the label supplied by the researcher. They were invited to offer alternative labels if they so wished.
constructs
This resulted
being generated
in
and a minor
category
all the constructs labels.
were assigned
A small number
the appropriate
under
number
in which
the
each
of constructs
construct
sub-heading
to correspond informant
when completing
and
to each of these. -
with the used
these
the grids. A small
were difficult
to classify
and could be sorted into more than one category.
revision of two of the other labels. Then
placed
and ‘uncaring’
manner
by the researcher
were assigned
Within each category ‘caring’
one new category
were identified
then constructs
to the
of constructs
The
main
bi-polar
reason
for
this appears
nature of the constructs.
in number,
they
have
been
to be the
Although
allocated
few
to one
were marked to indicate to the researcher their category allocation. Again some helpful col-
category
leagues were asked to sort these into the category framework. In this way reliability checks for the
The seven category framework presented Table 2 shows the number and proportion
category labels and for the assignment of individual constructs were undertaken (Stewart &
constructs
Stewart,
‘personal qualities’ accounted for 39% of the construct pool while ‘attitudes’ accounted for only 2%. The nature of the category types too was diverse. It ranged from personal qualities attributed to individuals, to how they work in the clinical field, how they interact with others, and
198 1).
Three of the informants were also invited to re-examine their own constructs in the light of the category scheme developed, and to consider the category framework as whole. In this way the adequacy
of the descriptive
framework
could be
only in this instance.
allocated
The proportions
in of
to each of the categories.
vary considerably,
for example
provides
Table 3 Personal qualities (constructs used to attribute particular qualities to individuals)
us with many
details
of the specific
facets involved. This picture is only partially true however
since nursing
Caring
Uncaring
occupation
kind patient helpful genuine
unkind impatient
interview.
relates to a limitation
unhelpful
an
false
is very much
also. A second
possible
of the sample chosen
of charge
All nurses that
they
tunities
to provide
function
generally
have
which
freer
oppor-
.,
role then. included vation,
constructs their
about peoples level of moti-
concern
for others,
their
use of
time, and attitudes.
Examples
of the categories
and their construct
composition
are provided
Tables
in
3 - 9.
may
-
bedside
nursing
their
colour
perceptions
category
A comparison
may
be made
Bogdan
( 1984)
bearers’,
(see also Goffman
outlined
picture
practice.
a British
It offers
above
of caring
pro-
in nursing
perspective
based on
qualitative practising
data, and is grounded in the views of nurses. The categories that were
generated
enable
means
to care
us to look closely
for a patient
and as a person.
constructs
at what it
as a professional
Surprisingly,
very few
relating to physical care emerged,
a great many could be referred sense as ‘psychological’. rants further
research,
but
to in a general
This finding alone warat this stage however,
we
can only speculate about some of the possible reasons why this should occur. The
strong
constl-ucts
psychological
produced
orientation
in the
may be accepted
at face
the
(1961)
provided
me with data on psychological
particular searcher.
storyline This
spent
reflecting
not
outside
irlclutie
a rc-
other
of caring. The]-e are several
The large proportion qualitites’
to convey
as XI
may
visiting
may have the current
needs.
other possible explanations dealt with in this paper. ‘personal
of insititurions
time
to me
picture
relevant dimensions
whit h cannot
of constructs
be
classed as
is also very surprising.
All of’
the sample were highly trained and experienced nurses,
yet their
perceptions
that it is a process lvhich with training more
of caring
suggest
have verv little to do
may
and experience,
to do with the personal
and considerably traits and char-
acteristics which individuals bring with them into the field of nursing. It is also possible that these qualities
are developed
the view of caring
may be drawn.
and
during
standard
are the individuals
impressions
emphasis
value as a snapshot picture of this groups’ perception of caring. This would in part support ‘attitude’
this
for a discuss-
In this sense informants
role through
as a particular
between
call the ‘institutional
acquire
institutions.
vides a detailed
nurse
manage
outsiders
framework
about
sample of nurses occupying leadership roles within the organisation and what Taylor and
ion of the staff world). These
I‘he
.
care. Thei
caring in nursing.
who
DISCUSSION
fog
nurse grade have
managerial
important
ensures
a ‘doing’
explanation
research
as part ot. the nursing
the process ofsocialisarion.
is required
befor?
311~
hrm
Further
conclusions
Table 4 Clinical work style (constructs which refer to the way people work in clinical settings) Caring
Uncaring
treats everyone as an individual skillful counsellor reliable explains adequately to patients treatment
works like a production line unskilful counsellor unreliable ignores psychological needs of patients
and care
10
NURSE EDUCATIOK
TODAY
Table 5 Interpersonal approach (constructs dealing with the way people act in relation to others) Caring
Uncaring
approachable sensitive approach listens to people empathic
unapproachable thoughtless approach doesn’t listen lacks empathy
for understanding
Personal
qualities:
wide range
many of the essential characteristics nursing
practice.
develop
an ideal picture
combining
From
these it was possible of a caring
the most frequently
(caring pole), into a character constructs
mentioned
were considered,
conveys
of caring in nurse,
by
used constructs
profile. Only those
on two occasions
archically
so that
most
frequently
constructs
are listed first. The
honest,
relaxed,
cate-
gory is the weakest in the sense that it is based on only four constructs. This
composite
description
represents
ideal type and as such it would be impossible those
nurses
high standards intended Instead
in clinical
practice
to meet
all of the time. However
to be a prescriptive it is offered
an for these
it is not
set of standards.
as a descriptive
assertive,
experienced,
compassionate,
flexible,
is tolerant
genuine, is helpful, con-
has a pleasant
and understanding.
Table 7 Concern for others (constructs which emphasise unselfishness) Caring
Uncaring
puts others before self gives freely of themselves concerned for people
selfish selfish (egocentric) disinterested in peoples welfare lacks awareness of others
aware of others
hiercited
‘attitudes’
for
is seen to possess a
She is kind,
or more
and these are organised the
to
the caring
of qualities.
patient, calm, has a sense of humour,
disposition,
The synthesis of these varied categories
to care
context.
The profile is as follows:
siderate,
THE CARING NURSE: AN IDEAL PROFILE
what it means
people in a professional
framework
work style: in work settings
the caring
nurse is seen to treat people/patients
as individ-
Clinicat
uals, and tries to identify knowledgeable,
patients
organised,
needs.
She is
puts the patient first,
is reliable and skillful. Interpersonal
approach:
in relationships
nurse is seen to be empathic, listens to people. Her approach easy to get on with, polite
the caring
approachable,
and
is sensitive, she is
and communicates
well. Table 6 Level of motivation (constructs which refer to a person’s degree of commitment) Carino
Uncaring
highly motivated dynamic nothing is too much trouble conscientious
unmotivated apathetic only does what they have to do negligent
Level of motivation: the caring nurse is seen to be very interested, conscientious, committed and motivated. Concern for others: the caring nurse is seen to put others before
herself,
and gives freely of herself.
Use of time: the caring nurse always has time for people.
Table 8 Use of time (constructs which focus on how people utilise available time) Caring
Uncaring
always has time for people has time for supporting relationships always has time to talk to people would like to be able to make more time to listen
pretends to be busy lacks time for supporting relationships always got something else to do pressurised into doing other things (other priorities)
Table 9 Attitudes attitudes
application (constructs which refer to particular
These ceptions
Uncaring
of nurses.
consistent in attitude easy attitude towards work
inconsistent in attitude flippant attitude condescending attitude lets personal problems interfere with work
remains
Attitudes: the caring nurse is seen to be consistent, down to earth, and professional in attitude, and has an easy attitude
towards work.
POSSIBLE APPLICATIONS The
findings
important
of this research
applications.
may have several
Theoretically
possible to use this category range of nursing
areas, for example,
peer assessment,
in organisational
the setting
of nursing
programmes, and perhaps nurse and
it will be
framework
standards,
across a
in self and
appraisals,
in
in research
in education and training courses, in the selection of candidates for
training.
However
empirical
support
further for
findings must follow before can he developed.
LIMITATIONS An important
these
clarification descriptive
useful applications
OF THE STUDY
limitation
of the study is the fact
that it has not included
a patient
perspective
about the nature of caring. Earlier studies have shown how patients and nurse may have contrasting views and priorities, so both perspectives are needed to achieve a balanced picture. In addition,
the perceptions
need to be documented will be addressed
of other grades of staff also. Both of these issues
in the next stage of the study.
CONCLUSION The preliminary
findings
outlined
in this paper
provide many details about nurses’ perceptions of the process of caring, using a qualitative
repertory
reflect
However,
grid
procedure.
some of the shared
of the meaning
Caring
down to earth attitude professional attitude
of the
findings
per-
of caring for this group
a great
deal of research
to be done to describe
clearlv the nature
of caring relationship.
References Ashrvorth P D 1987 Adequacy of description. The validity of qulitative findings. Sheffield papers in Education Management 67. Department of Education Management. Sheffield City Polytechnic Bannister D, Mair ,J M M 1968 The Evaluation of Personal Constructs. Academic Press, London Bannister D. Fransella F 1986 Inquiring Man 3rd ed. Croom Helm, London Bendall E 1977 The future of British nurse education. Journal of Advanced Nursing 2: 17 l--IX 1 Benner P 1984 From Novice to Expert. Addison-Weslev Publishing Company, California Briggs A 1972 Report of the Committe on Nursing. HMSO, London Brown L 1982 Behaviours of nurses perceived by hospitalized patients as indicators ot care. Dissertation Abstracts International 42, 1 I : 436 l-b. Campbell A V 1984 Moderated love: a theology of professional care. SPCK. London Carper B A 1979 ‘l-he ethics of caring. 2dvances in Nursing Science 1, 3: 1 I-19 Chapman C M 1983 The paradox ot nllrsing.,Journal of Advanced Nursing 8: 269-272 Choppin R G 1983 The role of.the ward sister: a review of the British research literature since 1967. Kings Fund Centre (KF project paper number 33). London Coleman J S 1958 Relational analysis: the studv of social organiaations with survel methods. Human Organisation 17: 28-36 Costigan J 1985 Personal construct psvchology : a theoretical and methodological framework for nursing research. The Australian ,Jorlrnal of Advanc-e Nursing 2. 4: 1.5-23 Costigan J, Humphrey J, Murphv C: i9Xi Attempted Suicidr: a personal construct psychology exploration. The Australian Journal of .4dvanred Nursing 4. 2: X-50 Davis B 1) 1983 A reperror) grid stud) of formal and informal aspects of student nurse training. PhD ‘Thesis, London University. School of Economics Duck S W 1973 Personal Relationships and Personal (:onstructs. John Wilev and Sons. C:hiche%er Dunlop >I J l&j6 Is a science of carinq possible? Journal of Advanced Nursing 1I : tiii I-ti’ilj Ford M B 198 1 Nurse professionals and the caring process. Dissertation for EdI). Cnivvt-sir\ of Northern (Zolorado Franselbd F. Bannister D 1977 A Manual for Repertor! Grid Technique. Academic Press. London Fretwel1.J 1982 Ward Teaching and Lxar-ning. Roval College of Nursing, London Hoffman E 1961 .\sylmns. Penguin. Harmondsworrh
12
NURSE EDUCATION
TODAY
Griffin A P 1980 Philosophy and nursing. Journal of Advanced Nursing 5: 261-272 Griffin A P 1983 A philosophical analysis of caring in nursing. Journal of Advanced Nursing 8: 289-295 Henrv 0 M M 1975 Nurse behaviours nerceived bv patients as indicators of caring. Disshrtation Abstracts International 75-16, 299, 652-b Heyman R, Shaw M P, Harding J 1983 A personal construct theory approach to the socialisation of nursing trainees in two British general hospitals. Journal of Advanced Nursing 8: 59-67 Honess T 1985 Repertory grids and the psychological case study. In: Beail N Ed Repertory Grid Technique and Personal Constructs, Croom Helm, London: 243-255 Kelly G 1955 The Psychology of Personal Constructs. Norton, New York, (2 volumes) Kitson A L 1987 A comparative analysis of lay-caring and professional (nursing) caring relationships. International Journal of Nursing Studies 24, 2: 155165 Lanelield A W 1971 Personal Construct Systems in Psychotherapy. Rand McNally and Company, chicago Larson P J 1984 important nurse caring behaviours perceived by patients with cancer. Oncology Nursing Forum 11,6: 4650 Leininger M M 1977 The phemomenon of caring, Part 5. Nursing Research Report 12, 1, 2, 14 Leininger M M 1981a The phemomonon of caring: importance, research questions and theoretical considerations. In: Leininger MM Ed Caring: An Essential Human Need. Charles B. Slack Inc., New Jersey: 3-15 Leininger M M 198 1b Some philosophical, historical, and taxonomic aspects of nursing and caring in American culture. In: Leininger M M ED Caring: An Essential Human Need. Charles B. Slack Inc., New Jersey, 133-143 Lelean S R 1973 Ready for Report Nurse? A Study in Nursing Communication in Hospital Wards. RCN, London Lifshitz M 1974 Quality professionals: does training make a difference? A personal construct theory study of the issue. British Journal of Social and Clinical Psychology 13: 183-189 Marson S N 1982 Ward sister - teacher or facilitator? An investigation into the behavioural characteristics of effective ward teachers. Journal of Advanced Nursing 7: 347-357 Mayeroff M 1971 On Caring. Harper and Row, London McFarlane J 1976 A charter for caring. Journal of Advanced Nursing 1: 187-196 Morrison P 1989 The caring attitude: nurses’ selfperceptions. Nursing Times 85: 4, 56
Morrison P 1989 Nursing and caring: a personal construct theory study of some nurses’ selfperceptions. Journal of Advanced Nursing (in press) Neimeyer R A, Fontana D J, Gold K 1984 A manual for content analysis of death constructs. In: Epting F R, Neimeyer R A Personal Meanings of Death. McGraw Hill, London: 2 13-234 Orton H D 1981 Ward Learning Climate: a Study of the Role of the Ward Sister in Relation to Student Nurse Learning on the Ward. RCN, London Ogier M 1984 How do ward sisters influence learning by nurses in the wards. In: Skevington S Ed. Understanding Nurses, Wiley, Chichester: 81-99 Partridge K B 1978 Nursing values on a changing society. Nursing Outlook June: 356360 Pratt R 1980 A time to every purpose...The Australian Nurses’Journal 10, 3: 50-53,56 Pembrey S 1987 Support your ward sister. Nursing Times 30: 39.27-29 Pollock L C 1987 Community psychiatric nursing explained: an analysis of the views of patients, carers and nurses. PhD Thesis, Edinburgh University Ray M A 198 1 A philosophical analysis of caring within nursing. In: Leininger M M Ed. Caring: An Essential Human Need. Charles B. Slack Inc., New Jersey: 25-36 Ray M A 1981a A study of caring with within an institutional culture. Dissertation abstracts international 42, 6: 2310-b. Sarason S B 1985 Caring and Comnassion in Clinical Practice. Jossey-Bass, London ’ Selection Research Limited 1987 A selection interview for nurses in the national health service. Selection Research Ltd, Surrey Smith H W 1981 Strategies of Social Research: the Methodological Imagination, 2nd ed. Prentice-Hall, New Jersey Stewart V, Stewart A 1981 Business Applications of Repertory Grid, McGraw Hill, London Taylor S J, Bogdan R 1984 Introduction to Qualitative Research Methods: the Search for Meanings. Wiley, Chichester Watson J 1979 Nursing: the philosophy and science of caring. Little Brown and Company Inc, Boston Watson J 1985 Nursing: Human Science and Human Care: A Theory of Nursing, Appleton-CenturyCrofts, New York Wilkinson D The effects of brief psychiatric training on the attitudes of general nursing students to psychiatric patients. Journal of Advanced Nursing 7: 239-253.
The caring attitude in nursing practice: a repertory grid study of trained nurses’ perceptions Paul Morrison
The process of caring is central to nursing practice but it remains a poorly defined concept in nursing practice and education. A small number of studies of caring in the field of nursing have been undertaken, but these have tended to be more quantitative in nature. This paper describes a qualitative study designed to explore nurses’ perceptions of the concept of caring. Kelly’s (1955) personal construct theory and the repertory grid interview technique were used to elicit trained nurses’ views about caring in relation to the practice of nursing. A strategic informant sample of 25 nurses was chosen. A total of 200 verbal descriptions (constructs) were generated from interviews, and these were analysed into similar content areas. Seven categories emerged from the analysis to provide a detailed description of caring. These include: a) personal qualitites; b) clinical work style; c) interpersonal approach; d) level of motivation; e) concern for others; f) use of time; and g) attitudes. There were very few constructs related to physical aspects of care. The findings are offered as reflection of British nurses’ perceptions of caring. Some possible applications of the results for nursing practice, education and research are considered.
INTRODUCTION .t‘he word ‘caring’ is a familiar term to all the helping refers
professions. to caring
importance
The
literature
relationships
of caring
frequently
and stresses
in the helping
role.
the Yet
little has been written about the nature of caring. An important exception is Mayeroffs philosophical analysis of the meaning of caring in human relationships (Mayerofff 1971). Mayer-
Paul &Wrison BA (Hans) RMN RGN PGCE Lecturer,
bchDol oi Nulsing Studies, University of Wales College of Medicine, Heath Park, Cardiff, CF4 4XN, UK (Requests for offprints to PM) Manuscript accepted 23 August 1990
off describes
caring
people
carer
(both
as a process and cared
opportunities for personal of caring in the analysis alternating patience, courage.
rhythms
which offers
for individual),
growth. .Major facets include: knowledge,
(learning
from experience),
honesty, trust, humility, hope and The general theme in this account is
that caring can influence significant way and lead
peoples’ lives in a to a more fulfilled
existence. However, Mayeroff spective fails to acknowledge
s theoretical perthe demanding
role inherent in the practice of professional caring. Nursing is one of the professions involved
in caring
relationship between fully understood.
for
other
nursing
people,
but the
and caring
is not
4
NURSE EDUCATION
TODAY
THE RELATIONSHIP BETWEEN NURSING AND CARING Several authors
have referred
ing as a form of loving,
... a
conceptual
Ray (198 1) found of
the profession
lines,
a specific
developed
to caring in nurs-
analysis
enter
caring
that from
different perspectives is suggestive of a form of loving . . .’ (~32). While Campbell’s (1984) theological analysis of professional care required that
of nursing.
selection
for identifying
to be successful tion Research
the 11 attributes
similar
has been
candidates
in their nursing
Limited,
Along
interview
most likely
careers
(Selec-
1987). Caring was one of
isolated
as likely predictors
of
success. The influence strated able
of caring
in it’s potential
and
desirable
may also be demon-
for determining
levels
accept-
of nursing
care
in
caring be perceived as a form of ‘moderated love’. However, McFarlane (1976) referrred to
practice situations
nursing
as the
Carper (1979) notes that ‘caring as a professional
serving,
caring’
and caring
tings.
This
point
One
attitudes
process
in nursing
of view was taken of caring
set-
up and
and emotions,
into two major
activities
recipient
the
is con-
out her nursing
offered
to carry
specific
of certain
as
role to the
1985).
that a concept of such importance
important
in
this
relationship
therapeutic
the disadvantage
The centrality
as central
of a protheme.
In
analysis has
of being far-removed
from the
and is likely to omit relevant
has
attention
from nurse
1978; on the
Leininger, dearth of
Leininger
(198 lb)
appears
to be the
heart
of
help to clients. (p 137)
has been
number
to nursing
has been
widely affirmed
(Briggs,
Watson, 1979, Briggs Report
1985; Leininger, 1981a). The claimed that nursing was the
1972; McFarlane,
1976;
major caring profession. Indeed Chapman (1983) suggested that one of the main reasons why people enter nursing was their desire to help and care for others at their most needy. Pratt (1980) similarly argued that caring was a major driving force for motivating people to
a notable
empirical of studies
nurse researchers (1977) range
studied
lack of British
and
work in this area, but a small have been
undertaken
based in America. the process
of cultures
collected
of caring
area,
ironic
to nursing
RESEARCH INTO CARING: APPROACHES AND FINDINGS European
practice of nursing, considerations.
(Bendall,
remarked: ‘The relationship between caregivers and care recipients is limitedly known, and yet
There
required
this type of philosophical
the
for
were
affective
While this analysis is useful in that it
who claim caring
(Partridge, Commenting
1981a,b).
those
But it is perhaps
so little empirical
in
care edu-
caring is a key concept
Sarason,
and depth of understanding fession
toward
In health
1977;
suggests points of focus for those interested in the concept of caring, it fails to provide the type
addition,
importance
emotions.
of ‘liking’ and ‘compassion’
tentatively
responses.
out
in a way that conveys
and our attitudes
1987).
which governs
cation generally
research
function.
caring in nursing as process, in which the
standard
we care’ (~11-12).
researchers
expression
The emotions
our action whom
1979; Kitson,
value, is of central
a normative
while the other
Griffin (1983) describes essentially an interpersonal is required
providing
received
with the activities that the nurse engages
related
and personal
deals with the nurses’
of these
in while carrying
nurse
and at the same
on by Griffin. (tSS0; 1983t who div-
ided up the concept domains.
assisting,
that nursing
that some practical activities were
in the caring
expanded
cerned
of ‘helping, suggesting
were inseparable,
time indicating involved
process (pl96),
(Carper,
over
of caring
across
a 15-year-period.
data from almost 30 different
by
Leininger a
She
cultures
and discovered variations systems of her informants,
in the belief and value as well as variations in
the practice settings.
across
of
caring
these
cultural
Leininger (1977) identified a total of 17 constructs related to caring. These were comfort, support, compassion, empathy, direct helping behaviours, coping, specific stress alleviation, touching, nurturance, succorance, surveillance, protection, restoration, stimulation, health
maintenance, sultation.
health instruction
These
and health con-
were subsequently
into a 28 construct
taxonomy
developed
of caring.
used were not reported.
fact that different
constructs
more influential important against
the
universal
should
dangers
of
description
Following
The
were found
across cultures,
and
to be
is particularly
caution trying
open-ended
researchers a
a) a genuine
of another
to
stressed
interviews received
with
nursing
50
care, for
These
cat-
As an alternative the method entailed
viewed
and
asked
the nurse were
in a inter-
an incident
for by a nurse.
analysis of these responses
does.
were reported
Patients
to describe
which they felt cared
listening,
‘task’
dimensions patient
revealed
in
Content
two themes:
to asking patients
of participant
looking
were analysed
does, and c) how much (1982).
those
studies involving
for their views about caring,
nurse
similar findings
of yourself.
were
per-
ceptions.
nurse behaviours.
by Brown
emerged for the well
b) giving
provided
emphasise
in other
egories were: a) what the nurse does, b) how the Remarkably
concern
helping and showing respect, and supporting the actions of others. The nurses’ view obtained
and documents.
study
and
behaviours
failed
to produce
Henry (1975) devised three major categories caring
being Caring
of caring.
people who had recently classifying
which reflected
Details
about the methods
collect this data. Two major categories
to produce
categories.
(cognitive
caring
were
and affective);
classifi-
a) psychological
b) practical
(technical
c) interactional
and d) philosophical
1. what the nurse does, and 2. what the nurse is
ethical
caring were again very evident in this study.
respondents
were
asked
to
been influenced
cal analysis revealed
that patients perceived
tative approaches
of these dimensions
to be equally important.
Patient perceptions also been explored Q-sort
technique
reported frequently, and
(Larson,
that a) accessibility responding
so on),
through
and
(knowing
give an injection,
b)
have
nursing using the (checking
quickly
patients
been
when to call a doctor,
how to
meaning
and how to manage
equip-
field
ment) as the most important
nurse caring behav-
iours. Larson (1984) stated that this is in contrast to the views of nurses
working
in the oncology
area who ranked ‘listening’ and ‘comfort’ important. talking, nurses,
She
cautions
psychosocial appear
that:
skills
to become
as most
‘Listening
highly important
and
valued
by
process
must include
a patient
perspective. In contrast
In summary
it has also received
(Watson,
l!lX5:
have
Kennel-.
1986). then few empirical
01’ nursing.
studies of the
have been carried While
some
out in the
of these
have
patients’ views, only two ( Ford,
198 I :
Larson, 1984) have attempted nurses’ perspective. Differences nurses’
and
patients
to explore the in the ways in pert eibe
appear to be emerging but these require exploration and description.
c-aring f‘urther
AIM OF THE STUDY The
to the patient
findings
of caring
examined
which
large
of particu-
to these
patients only after their basic “getting better” needs are met’ (~50). The most valuable insights into the caring
1984; Dunlop,
follow
quanti-
and more qualit,ative procedures
recommended
and
so far has
emphasising
the frequency
of’
While this trend has produced
interesting
criticism,
to call alarms
monitoring
to research.
lar ‘behaviours’. some
Patients
1984).
aspects
by the more rraditional
samples and counting
of caring behaviours
in oncology
practical
The trend in the studies examined
complete a Likert scale to assess the importance of’ ‘task’ and ‘aff-ective’ elements of care. Statistiboth
The
(social
(spiritual,
like.
In addition,
and cultural).
units
responses
which had four impor-
These
physical);
and this
clinical
a conceptual
and social organisation); and
roles,
1362
cation system of caring tant
observation,
at people, Some
or nurses
Ray ( 198 la) used
perspective,
Ford
( 198 1) also asked a sample of nurses (n = 192) to define caring in their own words to describe their caring behaviours. A questionnaire was used to
present
perceptions
study about
set out to explore the
meaning
nurses’
of caring
in
nursing practice. Kellys’ Personal Construct Theory (PCT), (Kelly, 19%: Bannister & Fransella. 1986) and repertorv grid tee-hnique were
6
NURSE EDUCATION
Table 1 Characteristics
TODAY
of the sample Male
Sex Nursing Specialty Specialty Classification
Female
4 General 10
Totals
21
Midwifery 8 Community 6
25
Psychiatric 5
Paediatric 2
25
Hospital 19
25
used. The grid technique has the advantage of being flexible enough to combine both qualita-
The
‘strategic informant
sampling’
tive and quantitative
important
feature
of this method
researcher
taps persons
qualitative
data, but in this paper the
aspects will be emphasised.
sampling
about
the
Typically,
grid technique
framework
for
Recently,
personal
grid technique
(Wilkinson,
1982;
et al. 1983; Costigan, Pollock,
as a
informants.
construct
theory
and
the
studies involving
Davis, 1983;
1985; Costigan
through
a snowball
Heyman
et al, 1987;
1987).
provided sample
being
of different method
respondents
1958).
for the
occasions
to recommend
other
people with different views and perspectives on the topic. Second by means of an expert choice method ation.
where senior nurse managers Both
procedures
provided
in the organis-
are outlined
in Smith
(1981).
SAMPLE
Although A sample
of
25
informants
was selected
to
this form of sampling is acceptable
does have a number
participate
in the study. While a large population
those informants
of nurses
existed,
organisation
within
a variety settings,
of clinical,
educational,
and managerial
sister/charge
nurse group was pinpointed
relevant starting point. shown to be influential
educational
those
at the outset
On several
were asked
was
ways. First
in which
contacted
the names of typical individuals
most been
leadership operation
the name of one other person (Coleman,
the
investigated.
sampling
who were
as
1981). An is that
occupying
The
in a number
is known
(Smith,
who are well informed
setting
initiated
individuals
has been successfully
applied in a variety of research nurses
was selected
interviewing
repertory
social
employed
individuals
roles are selected.
DESIGN OF THE STUDY The repertory
method
and training
the ward as the
This group has in determining
opportunities
at ward
key informants other
trained
occupying
it necessarily nurses,
such as nurse
helpers,
patients
well
may
caring.
provide
PROCEDURE
a significant
influence
on
the
work
how this group had a key role in the collection and dissemination of information to nurses in clinical settings. In practice they hold a pivot position with the power and influence that goes with it. Characteristics of the sample are shown in Table 1.
key roles within the
Similarly, relatives
have
Other
at this stage were
registered
and students in training.
it
By selecting
omits others.
not considered
level (Orton, 1981; Marson, 1982; Ogier, 1984). In addition they were found to be important role model figures for learners and other nurses, and situation and climate (Choppin, 1983; Fretwell, 1982; Pembrey, 1987). Lelean (1973) observed
of limitations.
and enrolled, other groups and especially
alternative
views
of
Initial contact with informants was followed up by visits to each informant in their working environment. This visit was used to provide details about the project, the repertory grid format (devoid of technical language), and to answer any questions. Confidentiality was assured. The investigator emphasised that the
procedbre right
was not a test and that there were no
or wrong
opinions. them
answers,
only their
views and
Full details about what was required
were
(elements)
provided.
A
list
of
role
to be used at the later meeting
also provided.
These
of
titles was
were:
nurse I know I know
5. a person
I care a lot for I don’t care much for
chosen
of the area
how do carers construe
caring.
namely
Informants
had
to write down
There
are
have
different
to know
these.
they
A further
should
choose
people for each role element.
Informants
were asked to consider
viduals they had matched
the indi-
to these role titles in
of their work as professional
Constructs
were elicited by a self-identification (Fransella
& Bannister,
‘myself‘ as a care?
element
carers.
1977).
tant ‘differences’
was compared ‘likenesses’or
between
veyed this characteristic
these.
number
with was
impor-
produced
it’s oppo-
a bi-polar
and
set of constructs. for elements
8 (ideal self) was examined
and
Bannister
but only the content method
Stewart,
ordering
of content
understanding
of‘ the concept
of
the grid to be an unusual task, but quickly adjusted to it and completed it without difficulty. ranged
from
single
words to sentences. Some individuals were adept a! formulating one word likenesses or differ-
&I
to gain
some
oi caring
rep-
relation-
and in a stud? to evaluate
training practices in social work (LilshitL. 1974i. Duck (1973) devised a four categorv sc.heme to classify
role
here.
(Stewart
resented in the grid data for this group of’ nurses. Similar forms of content ;malysis have
mation of friendships.
salient dimen-
of
on the
is reported analysis
198 1), was employed
l-6. on
Mair
construct system. Both content of the approaches have been used in the present stuclv,
The
resulted in an 8 (elements)
produced
by
One involves looking at the structure
to the study of personal
for looking at potentially
constructs
outlined
to the
and these
1973).
bv 8 (constructs) grid for each informant. Most informants found the administration
I‘he
two approaches grid matrices,
ships (Duck,
was adopted
sions. ‘The procedure
essentially
AND
been applied
two occasions as it was felt to be an important element
for &tails).
the
was then asked to describe
Element
198%
con-
procedure meaningful
AIIV discrep-
to the researcher,
informant
same procedure
to explore
Having
site. This personally
1989a:
of analysing
been
(1968).
The
The
each of the others in turn and the informant asked to identify important
part
climen-
the data while the other involves focusing
the context method
the construct
METHOD OF ANALYSIS RESULTS
for the
that
elicitation
wert’ asked to rate
using a 7-point rating scale. This
(see Morrison,
problem
was
for clarification.
of the construct informants
pro-
I’hese were
so as to be
of inquiry,
were instructed
researcher
differences,
and recording
an informant
back to the informant
along
to use
ancies between the ‘self and ‘ideal self elements
only the initials of people as it was not necessary requirement
or
in sequence,
allowed the researcher
to identify and match real people to these in their own time. The
likenesses
the eight elements
7. myself as a carer
were
happier
task was one facili-
labels). Occasionally
of the interview
8. how I would like to be as a carer (ideal self) titles
for
sions produced,
6. a person
role
(asking
sorting the elements construct
appeared
researcher’s
On completion
3. the most caring person
representative
tation
others
The
referred
4. the least caring person
Element
sentences.
vided several ideas in one sentence.
1. a caring nurse ‘2. an uncaring
ences whereas
the constructs
1. psychological; other constructs. procedure
people
WY
in
the for-
The four categories
were:
2. role;
3. interaction;
Lifshitz
( 1974). using a similar
found
constructs employed social workers. The
differences
in the
and 4. types
of
by experienced and trainee latter group tended to use
concrete
descriptive constructs Such 35 age, sex used more and so on, while their mentor5 abstract constructs related to ideals and values. Landheld (197 1) also employed ‘i fi)rm ot content analysis in a study of ps\~chotherapy, while Neimever et al (1984) described a content
8
NURSE EDUCATION
TODAY
Table 2 The seven category scheme, displaying the number and percentage
of constructs in each of the categories
Category
Number of constructs
Percentages (%)
Personal qualities Clinical work style Interpersonal approach Level of motivation Concern for others Use of time Attitudes Totals
78 39 35 21 14 9 4 200
39 19.5 17.5 10.5 7 4.5 2 100
analysis
technique
for
about death. Recently
classifying
that the analysis of content important
constructs
Honess (1985) has argued
as structural
or themes
is just as
relationships
in grid
data, but that much of the research the significance The
content
analysis
Stewart and Stewart category
has ignored
of content. procedure
(1981)
outlined
was used to devise a
scheme for the 200 constructs
This method
requires
by the
allocation
of individual
these categories.
collected.
that key content
identified
researcher, The operation
(Ashworth,
1987).
These
agreed that the scheme appeared tory
way of organising
constructs
obtained.
proved
very useful
equacy
in the
categories
participants
to be a satisfac-
the large
The and
number
comments highlighted
category
scheme.
an inad-
Two
of the
could not be clearly differentiated
the informants
and
were
of
received
therefore
by
collapsed
into one category.
areas are
followed
constructs
as follows. Each construct
by
checked
by the
to each
of
was completed
(both poles) was writ-
THE CONSTRUCT SCHEME
CATEGORY
ten on a small card and sorted by the investigator into homogenous Then
each
ponding
content
category
areas
was given
to the type of content.
of colleagues
were
asked
or categories. a label corres-
A small number
to check
the match
Categories
pole
was
between content type and the label supplied by the researcher. They were invited to offer alternative labels if they so wished.
constructs
This resulted
being generated
in
and a minor
category
all the constructs labels.
were assigned
A small number
the appropriate
under
number
in which
the
each
of constructs
construct
sub-heading
to correspond informant
when completing
and
to each of these. -
with the used
these
the grids. A small
were difficult
to classify
and could be sorted into more than one category.
revision of two of the other labels. Then
placed
and ‘uncaring’
manner
by the researcher
were assigned
Within each category ‘caring’
one new category
were identified
then constructs
to the
of constructs
The
main
bi-polar
reason
for
this appears
nature of the constructs.
in number,
they
have
been
to be the
Although
allocated
few
to one
were marked to indicate to the researcher their category allocation. Again some helpful col-
category
leagues were asked to sort these into the category framework. In this way reliability checks for the
The seven category framework presented Table 2 shows the number and proportion
category labels and for the assignment of individual constructs were undertaken (Stewart &
constructs
Stewart,
‘personal qualities’ accounted for 39% of the construct pool while ‘attitudes’ accounted for only 2%. The nature of the category types too was diverse. It ranged from personal qualities attributed to individuals, to how they work in the clinical field, how they interact with others, and
198 1).
Three of the informants were also invited to re-examine their own constructs in the light of the category scheme developed, and to consider the category framework as whole. In this way the adequacy
of the descriptive
framework
could be
only in this instance.
allocated
The proportions
in of
to each of the categories.
vary considerably,
for example
provides
Table 3 Personal qualities (constructs used to attribute particular qualities to individuals)
us with many
details
of the specific
facets involved. This picture is only partially true however
since nursing
Caring
Uncaring
occupation
kind patient helpful genuine
unkind impatient
interview.
relates to a limitation
unhelpful
an
false
is very much
also. A second
possible
of the sample chosen
of charge
All nurses that
they
tunities
to provide
function
generally
have
which
freer
oppor-
.,
role then. included vation,
constructs their
about peoples level of moti-
concern
for others,
their
use of
time, and attitudes.
Examples
of the categories
and their construct
composition
are provided
Tables
in
3 - 9.
may
-
bedside
nursing
their
colour
perceptions
category
A comparison
may
be made
Bogdan
( 1984)
bearers’,
(see also Goffman
outlined
picture
practice.
a British
It offers
above
of caring
pro-
in nursing
perspective
based on
qualitative practising
data, and is grounded in the views of nurses. The categories that were
generated
enable
means
to care
us to look closely
for a patient
and as a person.
constructs
at what it
as a professional
Surprisingly,
very few
relating to physical care emerged,
a great many could be referred sense as ‘psychological’. rants further
research,
but
to in a general
This finding alone warat this stage however,
we
can only speculate about some of the possible reasons why this should occur. The
strong
constl-ucts
psychological
produced
orientation
in the
may be accepted
at face
the
(1961)
provided
me with data on psychological
particular searcher.
storyline This
spent
reflecting
not
outside
irlclutie
a rc-
other
of caring. The]-e are several
The large proportion qualitites’
to convey
as XI
may
visiting
may have the current
needs.
other possible explanations dealt with in this paper. ‘personal
of insititurions
time
to me
picture
relevant dimensions
whit h cannot
of constructs
be
classed as
is also very surprising.
All of’
the sample were highly trained and experienced nurses,
yet their
perceptions
that it is a process lvhich with training more
of caring
suggest
have verv little to do
may
and experience,
to do with the personal
and considerably traits and char-
acteristics which individuals bring with them into the field of nursing. It is also possible that these qualities
are developed
the view of caring
may be drawn.
and
during
standard
are the individuals
impressions
emphasis
value as a snapshot picture of this groups’ perception of caring. This would in part support ‘attitude’
this
for a discuss-
In this sense informants
role through
as a particular
between
call the ‘institutional
acquire
institutions.
vides a detailed
nurse
manage
outsiders
framework
about
sample of nurses occupying leadership roles within the organisation and what Taylor and
ion of the staff world). These
I‘he
.
care. Thei
caring in nursing.
who
DISCUSSION
fog
nurse grade have
managerial
important
ensures
a ‘doing’
explanation
research
as part ot. the nursing
the process ofsocialisarion.
is required
befor?
311~
hrm
Further
conclusions
Table 4 Clinical work style (constructs which refer to the way people work in clinical settings) Caring
Uncaring
treats everyone as an individual skillful counsellor reliable explains adequately to patients treatment
works like a production line unskilful counsellor unreliable ignores psychological needs of patients
and care
10
NURSE EDUCATIOK
TODAY
Table 5 Interpersonal approach (constructs dealing with the way people act in relation to others) Caring
Uncaring
approachable sensitive approach listens to people empathic
unapproachable thoughtless approach doesn’t listen lacks empathy
for understanding
Personal
qualities:
wide range
many of the essential characteristics nursing
practice.
develop
an ideal picture
combining
From
these it was possible of a caring
the most frequently
(caring pole), into a character constructs
mentioned
were considered,
conveys
of caring in nurse,
by
used constructs
profile. Only those
on two occasions
archically
so that
most
frequently
constructs
are listed first. The
honest,
relaxed,
cate-
gory is the weakest in the sense that it is based on only four constructs. This
composite
description
represents
ideal type and as such it would be impossible those
nurses
high standards intended Instead
in clinical
practice
to meet
all of the time. However
to be a prescriptive it is offered
an for these
it is not
set of standards.
as a descriptive
assertive,
experienced,
compassionate,
flexible,
is tolerant
genuine, is helpful, con-
has a pleasant
and understanding.
Table 7 Concern for others (constructs which emphasise unselfishness) Caring
Uncaring
puts others before self gives freely of themselves concerned for people
selfish selfish (egocentric) disinterested in peoples welfare lacks awareness of others
aware of others
hiercited
‘attitudes’
for
is seen to possess a
She is kind,
or more
and these are organised the
to
the caring
of qualities.
patient, calm, has a sense of humour,
disposition,
The synthesis of these varied categories
to care
context.
The profile is as follows:
siderate,
THE CARING NURSE: AN IDEAL PROFILE
what it means
people in a professional
framework
work style: in work settings
the caring
nurse is seen to treat people/patients
as individ-
Clinicat
uals, and tries to identify knowledgeable,
patients
organised,
needs.
She is
puts the patient first,
is reliable and skillful. Interpersonal
approach:
in relationships
nurse is seen to be empathic, listens to people. Her approach easy to get on with, polite
the caring
approachable,
and
is sensitive, she is
and communicates
well. Table 6 Level of motivation (constructs which refer to a person’s degree of commitment) Carino
Uncaring
highly motivated dynamic nothing is too much trouble conscientious
unmotivated apathetic only does what they have to do negligent
Level of motivation: the caring nurse is seen to be very interested, conscientious, committed and motivated. Concern for others: the caring nurse is seen to put others before
herself,
and gives freely of herself.
Use of time: the caring nurse always has time for people.
Table 8 Use of time (constructs which focus on how people utilise available time) Caring
Uncaring
always has time for people has time for supporting relationships always has time to talk to people would like to be able to make more time to listen
pretends to be busy lacks time for supporting relationships always got something else to do pressurised into doing other things (other priorities)
Table 9 Attitudes attitudes
application (constructs which refer to particular
These ceptions
Uncaring
of nurses.
consistent in attitude easy attitude towards work
inconsistent in attitude flippant attitude condescending attitude lets personal problems interfere with work
remains
Attitudes: the caring nurse is seen to be consistent, down to earth, and professional in attitude, and has an easy attitude
towards work.
POSSIBLE APPLICATIONS The
findings
important
of this research
applications.
may have several
Theoretically
possible to use this category range of nursing
areas, for example,
peer assessment,
in organisational
the setting
of nursing
programmes, and perhaps nurse and
it will be
framework
standards,
across a
in self and
appraisals,
in
in research
in education and training courses, in the selection of candidates for
training.
However
empirical
support
further for
findings must follow before can he developed.
LIMITATIONS An important
these
clarification descriptive
useful applications
OF THE STUDY
limitation
of the study is the fact
that it has not included
a patient
perspective
about the nature of caring. Earlier studies have shown how patients and nurse may have contrasting views and priorities, so both perspectives are needed to achieve a balanced picture. In addition,
the perceptions
need to be documented will be addressed
of other grades of staff also. Both of these issues
in the next stage of the study.
CONCLUSION The preliminary
findings
outlined
in this paper
provide many details about nurses’ perceptions of the process of caring, using a qualitative
repertory
reflect
However,
grid
procedure.
some of the shared
of the meaning
Caring
down to earth attitude professional attitude
of the
findings
per-
of caring for this group
a great
deal of research
to be done to describe
clearlv the nature
of caring relationship.
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