44

 

The nature of nursing: can we teach students how to care?

Costello, J., Haggart, M. (University of Manchester)

Abstract Caring in nursing is discussed within this paper as the emotional as well as physical engagement of

nurses with patients in order to improve their health outcomes and experiences. A critical examination

of the literature identifies that caring within nursing has a number of constraints as well as

implications for nurses. Nursing ‘care’ can be subject to the driving or restraining forces of social and

political change and as this happens, care becomes more or less popular within nurse education

curricula. As nurse education has become modular based and teaching to larger and larger cohorts, it

could be argued that caring education may become a casualty of these changes. This paper sets out to

explore the potential for teaching nurses how to care and discusses the notion of the need for shared

beliefs and values and caring for the nurse, in order for the nurse to care for others. A number of

potential strategies for teaching care and indeed developing emotional IQ in nurses are discussed.

Key Words

Care, emotional IQ, therapeutic nursing, education, teaching/learning Introduction

The purpose of this paper is to critically examine the notion of caring in nursing and whether

it is something that can be taught to undergraduate student nurses in adult educational

settings. The authors argue that caring and its absence are of central importance to nursing as

a concept and a professional ideal. The paper critically examines the evidence base, revisiting

some of the debates that have taken place in the last two decades concerning the art and

science of nursing and the role of caring. The discussion explores the notion and nature of

caring, arguing that the caring ethic can be nurtured and developed through nurse education.

Our intention is to explore the values and belief systems which underpin nurse teaching and

to stimulate debate around these core issues. The paper also raises a number of issues about

the consequences of caring and the implications and constraints of emotionally engaging with

45

 

patients in contemporary hospital settings. We conclude that nurses can learn about how to

care effectively in small groups by developing their emotional intelligence, learning to

engage with patients, and developing therapeutic relationships. To do this, nurse educators

need to focus more on exploring students' self-awareness through the medium of small group

work. The essence of this style of learning is the development of empathy as a moral

imperative for enabling nurses to focus on the lived experience of the patients and to adopt

interventions likely to become more meaningful than completing a check list of care

procedures that does not relate to what nurses regard as holistic nursing care.

Background

Most writers who try to analyse the nature of nursing describe the essence of nursing as

‘caring’. Caring is something which rises from the ashes of discussion every few years as

health and political situations change and nursing is perceived as losing this essential art.

There was clear hope in the late 1980s and early 1990s for example, that caring, and indeed

‘therapeutic nursing’, was seeing a resurgence almost as a response to the hard-edged and

managerial (as well as victim blaming) approach to health that had developed over the

preceding years.

This resurgence however, was short lived, and in the changing political environment

‘care’ became something that (with a few notable exceptions), was little discussed in the

literature.

Possibly as a response to this change, we are again beginning to see suggestions that

caring is being lost in nursing. Corbin (2008) for example, argues that caring is an art which

is at odds with the conditions under which nurses are working today. Griffiths (2008) in

response to Corbin argues that caring is something that is constantly challenged in nursing

and that it has to be nurtured within each individual.

46

 

Brykczyńska (1992) explores the five specific constructs of professional caring

identified by Roach (1985); compassion, competence, confidence, conscience and

commitment. This helps to separate out the idea of professional caring as being simply an

emotive response to someone's distress, or a human response that the majority of people will

exhibit. Roach suggests that compassion without competence in nursing is meaningless and

this theme is continued throughout most of the literature on caring, i.e. that caring is more

than just caring about, it is a distinct professional response to an individual’s need and not

something that only professionals recognise. Appleton (1993) in her phenomenological

inquiry using individual and group interviews with both patients and experienced nurses

identified meta-themes which identified ways of being with clients/patients as important to

both patients and nurses. Patients have clearly identified in much of the research the value of

caring in nursing. They can ably discern the difference between being treated in a kindly but

objective way, compared to being treated in an individual person- centred way (Astedt-Kurki

and Haggman-Laitila, 1992; Ersser 1991; Barber, 1989).

The timing of this work is significant as in the late 1980s caring was being discussed

as the heart of a therapeutic nursing approach. Meutzel (1988) for example emphasised the

intimacy, partnership and reciprocity of the nurse- patient relationship as a therapeutic force.

Ersser (1988) emphasised the importance of creating a therapeutic environment and

McMahon identified the nurse-patient relationship as fundamental to therapeutic nursing.

Muetzel, McMahon and Errser based their theories on experiences within the Oxford and

Burford nursing development units and their experiences could be described as the beginning

of an inductive theory which judging from the explosion of writing about these issues within

the next few years, many writers agreed was an appropriate area ripe for research. However,

the closure of the Burford nurse-led unit, seemed to represent the prevailing politics of the

time and the work begun there, did not develop in nursing across the UK.

47

 

More recently, authors, though not as prolific, and mostly from the United States,

explore the continuous theme of caring. Watson (1997; 1999; 2002) has continued her

notable service to the debate on the concept of caring in nursing, labelling it ‘a human science

based on a form of humanism’ (2002: 117). A concept analysis on caring by Brilowski (2005)

found three important attributes of caring; relationship, action and attitude. Within these,

Brilowski identifies that nursing care (action) involves more than just affective issues of

caring about someone, but the implicit responsibility to maintain competence and to use

nursing presence and therapeutic touch as ways of engaging and communicating with patients

to enhance the healing potential. Finfgeld-Connett (2006) had similar findings in her meta-

synthesis when she found caring to be an interpersonal process that is characterized by expert

nursing, interpersonal sensitivity and intimate relationships. Each of the above is consistent

with Wu et al's (2006) research findings which showed caring to have a four factor structure

consisting of knowledge and skill, assurance, respectfulness and connectedness.

The consequences of this approach to caring are clarified in the literature by Finfgeld-

Connett (2006) who identifies a variety of improvements in both psychological and physical

wellbeing in patients/clients. These, it is argued, are partly the result of an increased ability to

care for oneself. Brilowski’s (2005) study highlighted the importance of self care and its

impact on the patient’s ability for self healing. Well documented publications from the

Oxford and Burford Unit (UK) had significantly reduced readmission rates, indicating that

patients were more able to grasp the notion of self-care.

The consequences of caring are of obvious importance for nurses and what is of equal

importance for educationalists in nursing are the antecedents to caring, as these may help us

to explore how caring may or may not be ‘taught’. Antecedents identified by Finfgeld-

Connett (2006) include the notion of professional maturity that incorporates competence and

knowledge as well as emotional maturity which prevents them from becoming over

48

 

emotional (Euswas, 1993) or destructive, controlling or self-centred forms of helping

(Montgomery, 1992; 1997).

Other antecedents to caring include moral foundations which involve a commitment

to act benevolently to enable caring to be enacted in a conscientious and responsible manner.

Interestingly, patient/client openness to caring is identified as an antecedent and this demands

that nurses must have the discernment to recognise when a patient’s anger may impede his or

her ability to benefit from the sort of relational care discussed in the literature. Overall, the

literature suggests that something of the nurse must recognise and value the humanity of all

with whom she/he comes into contact as a pre-requisite for caring. However, the antecedents

of caring are not all internal nursing attributes. Many writers have indicated that an effective

caring environment is one that actively cultivates caring and is supported by shared values in

management systems as well as adequate resources such as time. (Schroeder, 1995). The

question remains therefore - in our post-modern educational environment, how do we enable

nurses to learn caring?

Emotional IQ

Emotional IQ in the context of nursing care, refers to the self-awareness that nurses and

others have of the suffering being experienced by the patient and the patient’s family in a

given situation. The evidence and much clinical reflection on providing care indicate that the

roots of learning to care lie in self-awareness and the development of altruism - a need to

share the pain of others. Emotional IQ has been popularized by a number of writers on both

sides of the Atlantic notably Goleman (1996), who discusses emotional IQ as the (moral)

ability to feel with and for another. Goleman illustrates this as being the notion of caring for

others.

49

 

He argues that empathy is the opposite of antipathy and requires the empathic person

to engage with and feel for others as a moral imperative. A number of writers have attempted

to examine what caring means in the context of nursing. Most notably, the philosopher Anne

Griffin (1981) has argued that there are different types of caring related to the provision of

nursing care which she identified as comprising two broad categories operating on a practical

and emotional level. The former enabled the patient to have had all the necessary checks and

procedures carried out that would ensure that the pre-planned treatment regimes were carried

out according to plan. However, this did not necessarily involve the patients feeling cared for

despite all the documentation revealing that care had been given. The second type of care

Griffin describes involved the nurse emotionally engaging with the patient and sharing their

pain and expressing empathy with the situation. To do this, Griffin argued, requires nurses to

develop an altruistic approach based on a form of moderated love for the patient. The

empathic nurse however, may not carry out all their clinical procedures correctly and the

documentation may not be up to date, but the patient feels cared for because their suffering

has been eased and also crucially, because it has been shared.

Constraints to caring

The need for nurses and others to develop a more caring approach to recipients of the NHS is

clearly evidenced by the number of complaints received about lack of care, particularly at the

end of life (Henry, 2008). Hospitals in the UK, especially areas where acute medical and

surgical interventions are required, leave a lot to be desired. Moreover, lack of care

associated with long-term conditions (Costello, 2008), older people (Ronning, 2003; HAS,

2000) and the mentally ill (Healthcare Commission, 2008) indicates that the lack of quality

care is widespread through many institutional settings. Given this evidence, it is important to

recognize and be aware of the many barriers and limitations nurses and others experience

50

 

when trying to provide people with individualized care focused on their emotional needs as

much as their physical problems. A number of authors highlight the invisibility of the patient

when it comes to personalizing care and the lack of individualized care received in hospital

from nurses and midwives, who remain disengaged from the patient (Rogers et al., 2000;

Rogan-Foy and Timmins & McCabe, 2005; Costa, 2001). Others highlight a lack of

proximity, a failure to use touch as a means of communicating and an absence of compassion

(Morrall, 2003). In some cases patients complained of being denied information and treated

with prejudice because of their ethnicity (Davies and Bath, 2001).

It is clear that many of the problems associated with providing quality care stem from

organizational issues, such as lack of time (Mackay, 1993), poor skill mix (Lawler, 1991) and

disempowerment on the part of the nurse (Costello, 2004). All of these can, and often do,

make practitioners feel as if they have neither the motivation, energy nor skill to provide what

the patient needs. Perhaps one of the modern myths about nurses' ability to provide

individualized care that acts as a constraint to adequate care, is the nurse's role as a patient's

advocate. All too often nurses identify their role as a patient's advocate despite the evidence

suggesting that in the context of a modern hospital trust, it is very difficult, if not impossible

for advocacy to become a reality (Willard, 1996; Mallik; 1997). The reasons for this are

argued to be a fear of stepping out of line, whistle blowing and fracturing the team cohesion

by over stepping the mark and speaking out of turn by not following the protocols adopted by

the medical ‘firm’ or the nursing hierarchy. Some of the constraints to improving good nurse-

patient relations are due to organizational culture determining that the needs of the ward or

unit take precedence over those of the patient. Despite the many and varied constraints to

developing good communication between patients and their families and professionals, one of

the clearest indicators is a lack of confidence stemming from limited education and training

in advanced communication skills (Wilkinson et al., 2002).

51

 

Developing therapeutic relationships

For many years nursing and nurses have been striving to develop more positive relationships

with patients and to improve communications (Wilkinson et al., 1998). Developing

therapeutic relationships with patients, whilst obviously involving communication, is not a

skill that can be taught in a lecture theatre format. Haggart's (1994) unpublished research

identified nurse teachers who felt strongly that they ‘nursed’ their students. This translated as

the way that they nurtured relationships with them, interpreted difficult concepts and helped

students to put that into practice.

In this way, both teacher and student created a learning (helping) environment in the

way that they worked together towards the student's personal growth and professional

growth. All of this identified teachers as role modellers. This notion of role modelling

relationships and their development is something that Sorrell and Redmond (1997) identify in

their research of student nurse narratives.

Their qualitative study identified that students experiencing care from faculty (sic)

gain a feeling of belongingness (and value), but also a developing belief in themselves as

practitioners. Their findings demonstrate the need to balance rigid rules of student life with

an appreciation for the vulnerability of learners, especially those on the threshold of their

educational careers.

Indeed there is growing evidence that a nurse's experience can influence their ability

to develop effective nurse-patient relationships (e.g. Schroeder, 1995; Ebersole, 1996;

Sanford, 2000). This should be recognised within nurse education. Student nurses need to

experience therapeutic relationships where they are valued, and interaction occurs which

values them as people, where teachers come alongside them as people or professional friends,

(not simply because of their label student). This kind of authentic care, based on their

humanity, not on a set of external skills or standards, is more likely to strengthen and enable

52

 

the student to build these relationships within their own practice (with patients). Mentors,

managers and lecturers need to learn how to unleash the human potential of their students.

Teaching and learning about caring

One of the fundamental questions arising from the evidence base related to teaching and

learning about care is not whether students can learn how to care, but how educators design

teaching and learning situations that facilitate students to learn to care more effectively. This

could include learning how to share and utilize their care experiences. In this way educators

can capitalize on previous student experiences to help them discover ways of intervening

when situations arise where emotional engagement with the patient would be appropriate.

Reflection on practice experiences has become a traditional educational strategy for

the last 20 years as a way of helping students develop effective meaning from both their

clinical and life experiences. Various models of reflection advocate that practitioners develop

their knowledge through reflection, utilizing their clinical experiences to develop and

promote different and more enlightened ways of managing difficult situations (Johns, 2002),

or tackling problematic clinical issues by learning from and developing insights using

different ways of reflecting on practice (Schon, 1987). Both models and other advocates of

reflection (Jarvis, 1992; Freshwater, 2002; Taylo,r 2006; Ekebergh, 2007) relating to nursing

practice, place emphasis on utilizing clinical practice as a means of improving future

performance. Taylor identifies different ways of using reflection using the term kitbag of

strategies which include art, drawing, poetry, creative music and many others. She highlights

technical, practical and emancipatory types of reflection as a way of helping to understand

some of the often hidden or deeper meanings behind clinical practice incidents. More recently

the debate regarding the use of reflection has turned to consider the use of patient narrative

53

 

(Baumann, 2008) as a means of helping nurses to develop ways of caring for patients in a

more humanistic way. Baumann (2008: 260) argues that:

Narratives are useful ways to develop understanding of other cultures, families and

persons, as well as ourselves. Stories can play a defining role in professional groups.

The use of narratives provides students the opportunity to develop their use of

imagination, make sense of their actions and gain ability to shift perspective.

Despite the plethora of different approaches to using reflection in nurse education and the

value of listening to patients’ stories, it is not always possible to accommodate this type of

activity within contemporary nurse education because of curricula restrictions. The

organization of educational programmes into modular systems and the large numbers of

students involved often influence the development of education which utilizes the power and

importance of reflection. Tightly designed modules of study involving large numbers of

students limit exploration of students’ experiences in practice and as such constrain the

development of a culture of caring. Teachers of nursing have to take the responsibility of

identifying ways of helping students of nursing to engage their heart and soul as well as their

brain, in their professional practice.

Conclusion

This paper has critically reviewed some of the salient literature relating to the concept of

caring in nursing. Moreover, the paper has argued that the teaching of caring is a highly

significant issue that challenges nurse educators as they and others struggle with public

criticism citing uncaring nursing and negative experiences or a lack of care. The authors are

aware that what is being proposed is very challenging given some of the constraints to

54

 

providing quality care discussed. However, the evidence suggests that there are more

examples of poor care within NHS trusts in the UK, than exemplars of excellent care. This

remains a major challenge. Evidence also suggests that when people complain about their

health service experiences, it is often based on the absence of what people perceive to be

good care which is often related to poor communication. The future challenge is to address

the issue of caring through the development of robust evidence-based curricula which have

caring as a key component. Education at both pre- and post-registration can, and should, play

a leading role in helping nurses to become more aware of the power and importance of

caring.

Bibliography

Appleton, C. 1993. ‘The Art of Nursing: The Experience of Patients and Nurses’. Journal of

Advanced Nursing, 18: pp.892-899.

Astedt-Kurki, P., Haggman-Laitila, A. 1992. ‘Good Nursing Practice as Perceived by Clients:

A Starting Point for the Development of Professional Nursing’. Journal of Advanced

Nursing, 17: pp.1195-99.

Barber, P. 1989. ‘Developing the ‘Person’ of the Professional Carer.’ In S.M. Hinchliff, S.E.

Norman and J.E. Schober (eds.) Nursing Practice and Health Care. London: Edward

Arnold.

Bauman, S.L. 2008. ‘Improving our stories’. Nursing Science Quarterly, 21(3): pp.260-267.

Brandes, D., Phillips, H. 1985. Gamesters' Handbook. London: Hutchinson.

Booth K., Mcguire P.M., Butterworth, T. 1996. ‘Perceived Professional Support and the use

of Blocking Behaviours by Hospice Nurses’. Journal of Advanced Nursing, 24:

pp.522-7.

55

 

Brilowski, G. 2005. ‘An Evolutionary Concept Analysis of Caring’. Journal of Advanced

Nursing, 50(6): pp.641-650.

Brykczyńska, G. 1992. ‘Caring - A Dying Art?’ In M Jolley, and G Brykczyńska (eds.)

Nursing Care. The Challenge to Change. London: Edward Arnold.

Corbin, J. 2008. Is Caring a Lost Art in Nursing? (editorial), International Journal of Nursing

Studies, 45: pp.163-65.

Costa, M.J. 2001. ‘The Lived Peri-operative Experience of Ambulatory Surgical Patients’.

AORN Journal, 74(6): pp.874-81.

Costello, J. 2004. Nursing the Dying Patient. London: Palgrave.

Costello, J. 2007. ‘Teaching and Learning in Small Groups.’ In B. Wee and N Hughes (eds.)

Teaching and Learning in Palliative care. Oxford: Oxford University Press.

Costello, J. (in press). Caring for Someone with a Long-Term Illness. Manchester:

Manchester University Press.

Davies, M.M., Bath, P.A. 2001. ‘The Maternity Information Needs of Somali Women.’

Journal of Advanced Nursing, 36(2): pp.237-45.

Ebersole, M.E. 1996. ‘Hormonal Administration in Prostate Cancer: A Caring Approach’.

Urologic Nursing, 16(3), pp.23-26.

Ekebergh, M. 2007. ‘Lifeworld-based reflection and learning: a contribution to the reflective

practice in nursing and nursing education’. Reflective practice, 8(3): pp.331- 343.

Ersser, S. 1988. ‘Nursing Beds and Nursing Therapy.’ In A. Pearson (ed.) Primary Nursing.

London: Chapman & Hall.

Ersser, S. 1991. ‘A Search for the Therapeutic Dimensions of Nurse Patient Interaction.’ In

R. McMahon, A. Pearson (eds.) Nursing as Therapy. London: Chapman & Hall.

56

 

Euswas, P. 1993. ‘The actualized Caring Moment: A Grounded Theory of Caring in Nursing

Practice.’ In D.A. Gaut (ed.) A Global Agenda for Caring. New York: National

League for Nursing, pp 309-326.

Finfgeld-Connett, D. 2008. ‘Meta-synthesis of Caring in Nursing.’ Journal of Clinical

Nursing, 17: pp.196-204.

Freshwater, D. (ed.) 2002. Therapeutic nursing: improving nursing care through reflection.

London: Sage.

Goleman, D. 1996. Emotional Intelligence. London: Bloomsbury.

Griffin, A. 1981. ‘A Philosophical Analysis of Caring in Nursing.’ Journal of Advanced

Nursing, 8 (4): pp.289-95.

Griffiths, P. 2008. ‘The art of losing…..? A response to the question ‘is caring a lost art?’’

International Journal of Nursing Studies, 45: pp.329-32.

Haggart, M. 1994. Clinical Credibility. A Philosophical approach to nurse teaching.

Unpublished MSc Thesis University of Manchester.

Health Advisory Service 2000. Not because they are Old. London: Department of Health.

Healthcare Commission 2008. The Pathway to Recovery. A Review of NHS Acute In-patient

Mental Health Services. London: Healthcare Commission.

Henry, C. 2008. ‘End of life care programme’ paper to the National Association of Palliative

Care Educators, London 14th and 15th September.

Jarvis, P. 1992. ‘Reflective practice in nursing’. Nursing Education Today, 12: pp.174-81.

John, C. 2002. Guided reflection: advancing practice. Oxford: Blackwell.

Lawler, J. 1991. Behind the screens, somology and the problem of the body. London:

Churchill Livingstone.

Mackay, L. 1993. Conflicts in care: medicine and nursing. London: Chapman and Hall.

57

 

Mallik, M. 1997. ‘Advocacy in nursing a review of the literature.’ Journal of Advanced

Nursing, 25: pp.130-138.

Montgomery, C.L. 1992. ‘The spiritual connection: nurses' perceptions of the experience of

caring.’ In D.A. Gaut (ed.) The Presence of Caring in Nursing. New York: National

League for Nursing: pp.39 -52.

Montgomery, C.L. 1997. ‘Coping with the emotional demands of caring.’ Advanced Practice

Nursing Quarterly, 3: pp.76-84.

Morrall, P. 2003. ‘Social factors affecting communication.’ In R.B. Ellis, R.J. Gates and N.

Kenworthy (eds.) Interpersonal skills in nursing theory and practice (second edition).

London: Churchill Livingstone: pp.33-51.

Muetzel, PA., 1988. ‘Therapeutic Nursing.’ In A. Pearson, (ed.) Primary Nursing. London:

Chapman & Hall.

McCabe, C., Timmins, F. 2006. Communications skills for nursing practice. London:

Palgrave.

Roach, S.M. 1985. ‘A Foundation for Nursing Ethics.’ In A. Carmi and S. Schneider (eds.)

Nursing Law and Ethics. Berlin: Springer-Verlag.

Rogan–Foy, C., Timmins, F. 2004. ‘Improving communication in day surgery settings.’

Nursing Standard, 17(9): pp.37-43.

Rogers, A., Karlsen S., Addington-Hall, J. 2000. ‘All the services were excellent. It is when

the human element comes in that things go wrong: dissatisfaction with hospital care at

the end of life.’ Journal of Advanced Nursing, 31(4): pp.768-774.

Ronning, R. 2003. ‘The importance of care as a positive concept.’ Quality in Ageing, 3(4):

pp.34-43.

Sanford, R.C. 2000. ‘Caring through relation and dialogue: a nursing perspective for patient

education.’ Advances in Nursing Science, 22(3): pp.1-15.

58

 

Schon, D.A. 1987. Educating the reflective practitioner. London: Jossey-Bass.

Schroeder, R.C. 1995. ‘From the editor: caring must be a part of a quality health care

experience.’ Journal of Nursing Care Quality, 9(4): vii.

Sorrell, A.M., Redmond, G.M. 1997. ‘The lived experiences of students in nursing: voices of

caring speak the tact of teaching.’ Journal of Professional Nursing, 13: pp.228-235.

Taylor, B. 2006. Reflective practice: a guide for Nurses and Midwives (second edition).

Buckingham: Open University Press.

Timmins, F., McCabe, L. 2005. ‘Nurses' and midwives' assertive behaviour in the

workplace.’ Journal of Advanced Nursing, 51(1): pp. 38-45.

Watson, J. 1997. ‘The theory of human caring; Retrospective and prospective.’ Nursing

Science Quarterly, 10(1): pp.49-52.

Watson, J. 1999. Post-modern nursing and beyond. Edinburgh: Churchill Livingstone.

Watson, J. 2002. ‘Intentionality and caring-healing. Consciousness: a practice of

transpersonal nursing.’ Holistic Nursing Practice, 16(4): pp.12-19.

Willard, C. 1996. ‘The nurse's role as patient’s advocate: obligation or imposition?’ Journal

of Advanced Nursing, 24: pp.60-66.

Wilkinson, S.M., Roberts A., Aldridge, J. 1998. ‘Nurse-patient communication in palliative

care: an evaluation of a communication skills programme.’ Palliative Medicine, 12:

pp.13-22.

Wilkinson, S.M., Gambles, M., Roberts, A. 2002. ‘The essence of cancer care: the impact of

training on nurses' ability to communicate.’ Journal of Advanced Nursing, 40(6):

pp.731-738.

Wu, Y., Larrabee, J.H., Putman, H.P. 2006. ‘Caring behaviours inventory: a reduction of the

42-item instrument.’ Nursing Research, 55: pp.18-25.