Facilitating and hindering experiences to the development of humanistic caring in the academic and clinical settings: an interpretive phenomenological study with nursing students and nurses

Ethical considerations

The ethical review board of the hospital where nurses were recruited approved this study (certificate No. FUM-8038). This certificate was recognized by the ethical review board of the university. All participants (nursing students and nurses) provided written consent before their interview. To ensure confidentiality, a code and a fictitious name were firstly attached to each participant. In other words, real names are absent from sociodemographic questionnaires, transcripts, and primary investigator’s (PI) journal. In order to avoid coercion in the recruitment of student participants, the PI did not teach undergraduate courses while the study took place.

Setting

The study was conducted in a French-Canadian university where its 3-year undergraduate nursing education program (2-year with an associate degree in nursing) leads to registration as a nurse. Graduates from this university were recruited from an affiliated French-speaking university hospital located on three geographical sites.

Sample

A convenience sample of nursing students (n=18) and nurses (n8) were recruited (Gray, Grove, & Sutherland, 2017). For sampling criteria, all participants had to speak and understand French, and be interested in sharing their experiences pertaining to their own development of humanistic caring. Nursing students had to be studying in a specific competency-based approach program comprising a humanistic caring competency. They were recruited according to the number of academic years they had completed in the baccalaureate program: 1) first year completed, 2) second year completed, and 3) reached the end of the third year.

Nurses had to hold a baccalaureate from the same competency-based approach program in which nursing students were enrolled. Nurses were recruited according to their expertise using some of Benner’s (1984/2001) categories: 1) newly graduated (6–18 months of clinical practice), 2) experienced (2–4 years of clinical practice), and 3) accomplished (at least 5 years of clinical practice and be recognized as an “expert” by one peer). In order to facilitate the identification of this expertise, these accomplished nurses had to be “exemplary individuals … who [were] really caring and [humanistic] in their interactions with patients” (Graber & Mitcham, 2004, p. 88) or received praise from peers or patients for their humanistic nursing care. In this study, all accomplished nurses self-reported that they either received this praise directly from patients or their colleagues.

An invitation letter was sent to all eligible students via their academic email address. Also, the PI and a research assistant presented the study in few courses as a recruitment strategy. More recruitment strategies were deployed for nurses (see Table 1) because it took longer than expected to achieve a reasonable sample; that is, approximately 17 months. Sociodemographic characteristics of nursing students and nurses are summarized in Table 2.

Data collection

Data were collected through a semi-structured individual interview with each participant (n=26) from September 2015 to February 2017 (Munhall, 2012). The PI used an interviewing guide that had been elaborated through the lens of this study’s disciplinary perspective (Cara et al., 2016) and previously validated by both his dissertation supervisors (JG and CC). Participants were asked questions such as: “What is the meaning of caring for a person with humanism?”; and “Tell me of an experience where you believe you have been humanistic with a person, a family, or a community.” All interviews were recorded, lasting between 40 and 119 min (average: 63 min). They were transcribed by an experienced typist and reread by the PI to ensure accuracy.

After 17 months, data collection was discontinued in spite of not achieving redundancy (Benner, 1994) in each of the six groups of participants. This decision was made in order to respect the academic deadlines for completing the PI’s doctoral studies.

Data analysis

Verbatim transcripts were imported into the qualitative data analysis software ATLAS.ti 8. The analysis was adapted from Benner’s (1994) phenomenological method, conceptualized in five iterative stages: 1) lines of inquiry, 2) central concerns and exemplars, 3) shared meanings, 4) final interpretations, and 5) dissemination of the interpretation (Crist & Tanner, 2003). Individual analysis was mostly undergone throughout the first two stages, interparticipant analysis in the third stage, and intergroup analysis in the fourth stage. For the individual analysis (stages 1 and 2), the PI attempted, to understand participants’ central concerns within their experiences by naming meaning units (Benner, Tanner, & Chesla, 2009). These central concerns were summarized in a document in which exemplars were added and served as a basis to create a more interpretative summary. Exemplars are a salient verbatim representation of a similar or divergent dimension about participants’ development (Benner, 1994). The first two individual analysis, central concerns summaries (including exemplars) and interpretative summaries were revised by one dissertation supervisor who is an expert in phenomenology, before proceeding. Then, the PI proceeded to interparticipant analysis, one group at a time, and uncovered shared meanings (stage 3) that were summarized in interpretative group summaries (Benner, 1994). In terms of interparticipant analysis, the PI read each summary (central concerns summary and individual interpretative summary), one participant of a given group at a time, in order to bring out emerging similarities pertaining to that specific group. Regarding intergroup analysis, the six interpretative group summaries (one per group) have been examined iteratively by the PI with the intention of identifying the learning differences between the groups. All six summaries were revised by the research team and interpretations were discussed and challenged.

Learning from humanistic and caring role models or dehumanizing counterexamples

The participants’ experiences highlighted approaches of educators, nurse preceptors, and faculty members that were either congruent or incongruent with humanism and caring. When approaches were congruent, the development of humanistic caring appeared facilitated by role modeling. Incongruent approaches seemed to be either facilitating or hindering. Several participants were inspired by the way they were accompanied by their educators, identifying them as role models for their future nursing practice. These educators offered availability (i.e., to answer questions or listen to concerns), appeared to be authentically committed to their success, development, and in some cases, their well-being. The following statement, from Yunan, a second-year student, is an exemplar:

“I admit I was highly influenced by the teacher who taught us a course. From my perspective, she was an example of caring. The way she behaved with us, her way of being as a person, it was as if she was caring […]. Then she embodied it, when she spoke about humanism, the examples she had from her clinical practice or everything she had read about caring, it was as if she demonstrated it herself, in her attitude, and in what she said throughout the course.”

Students felt inspired witnessing their nurse preceptors’ acts of humanistic caring. A third-year student remembered her nurse preceptor showing interpersonal dexterity and ease in her commitment. This nurse preceptor was particularly good at putting patients at ease despite not knowing them extensively, in addition to finding “the right things” to say in delicate end-of-life situations, as illustrated by the following exemplar:

“Oh, I don’t know, she was just really humane, I think. But she was detached from the situations a little bit, but at the same time, she had a lot of compassion you know. She was very good at being ‘detached but attached’ […]. She was like comfortable with patients, even though she didn’t know them, […] and she always knew what to say, “the right words”, and I kind of admired her for that. […] And I was like, maybe I too will become a good nurse one day.” (Felicia, a third-year student)

However, several participants recognized that not all their nurse preceptors were role models. Nevertheless, in some instances, these dehumanizing counterexamples also engendered development, because it seemed to upset nursing students about a practice that they did not want to reproduce. An accomplished nurse divulged how one of her nurse preceptors did not encourage humanistic caring and that she promised herself not to become like this:

“I had a nurse preceptor who criticized me, and I have to say it shocked me. She told me I needed to be fast, to be faster and she even stated: ‘Okay, it’s all nice to ask him how he’s doing, but we know it alright? Now you’re going to do your things’. […] I was not even delaying anything, I was doing my dressing and talking [to the patient] at the same time, without making any mistakes. […] I promised myself I would never become a nurse like this.” (Mihaela, an accomplished nurse)

Yet, several nursing students considered that their development had been impeded by their nurse preceptors. Numerous nursing students felt that there was little room for establishing a relationship with their patients and that it was more important to learn how to improve their dexterity and rapidity with technical procedures. A few nurse preceptors also gave nursing students the impression that they did not value humanistic caring. Additionally, in the academic setting, several nurse educators’ ways of interacting with students were incongruent with the nursing school’s humanistic framework: some sounded haughty and hierarchical; others allegedly failed to display concern and empathy while few appeared uninterested in their students. Few participants felt there was incongruence between these counterexamples and what was promoted in their curricula, as if what they observed and experienced did not match what they were encouraged to become. The following excerpt highlights this incongruence:

“The students’ stress level was ‘+++’. I saw many students crying, I even cried myself at home because of the pressure […]. When a student explained that our grades […] didn’t represent the workload and the effort put into our work, we were answered: ‘I’m not here to assess the effort you put into your work’. It’s true […] it’s not the effort and all that, but there’s a way [to say it], it was completely devoid of empathy. And then after we were taught to ’care for the person with humanism’, and we are like: ‘Yeah, well nobody is listening to us’.” (Hallay, a second-year student)

Learning in environments in which humanistic caring is exalted or trivialized

Development was supported in environments that gave importance to humanistic caring and was hindered when it was devalued. Several nursing students pinpointed that the omnipresence and the iteration of humanistic caring throughout their curriculum contributed to their development because it “was everywhere”: the program’s disciplinary perspective, the courses’ contents, their assignments, as well as the assessment criteria. This following exemplar illustrates how this facilitated the development of humanistic caring:

“Well honestly, I would say it is the concept of caring that we keep on pointing out since we started [the baccalaureate]. […] For us, I think that the concept of caring is a central aspect of everything we learn, everything we do, internships, even the theoretical parts, even when we learn in [problem-based learning], it’s there. So just wagering on that from the beginning, I think it helped us to better predict what to expect in our internships and what patients should live in our presence.” (Dencia, a second-year student)

However, several nurses confessed that they dwelled in environments where they either received disheartening comments by their colleagues about humanistic caring or were compelled to reduce the amount of time given to their patients. For instance, an accomplished nurse remembered that, as a newly graduated nurse, she used to be reprimanded by senior nurses not appreciating how devoted she was to her patients:

“Yeah, jealousy. […] At the beginning [of my clinical practice], it was like: ‘Yeah, she’s the boss’ favourite. We all know that this patient likes you, it’s only because you do everything he wants’. But it wasn’t about that, you know? So yeah, comments like this, [from] senior nurses, not the newly grads, it was from experienced nurses. Not many, but one or two who verbally assaulted me.” (Mihaela, an accomplished nurse)

Another accomplished nurse experienced a similar pattern with her colleagues and her head nurse where she felt pressurized to decrease the intensity of interactions with her patients:

“Yeah, I was reprimanded, sometimes they [nurses] even told me: ‘If you’re not taking your break, others will be delayed’. A social-like pressure, and I responded: ‘No it’s okay, I remain available on the ward’. I even met a head nurse for this reason, and I had to explain that it was the kind of nursing care I wanted to provide, but she considered that I was ‘chitchatting’ a lot.” (Pavlina, an accomplished nurse)

Learning from communication-related courses and patient storytelling

Most student participants associated nurse-patient communication to humanistic caring and it may be why courses focusing on this dimension were perceived as contributions to their development. According to participants, such courses were specific to mental health, palliative care, family systems, and communication workshops. For instance, Shélanie witnessed the therapeutic added value of care-related communication skills to the family in a course:

“For me, the course that has struck me the most […] is the [one related to family systems approach]. Well, I was doing interventions without realizing that it was really a therapeutic intervention, nor did I realize that by asking a specific question, it would allow me to explore [the family’s] strengths. I became more aware of communication skills, circular questioning, and I adopted a more systemic vision in front of a group of people, with family members.” (Shélanie, a third-year student)

Several nursing students stated learning from patients who were invited to tell their stories in the classroom while few others recommended increasing the amount of patient storytelling in the curriculum. Participants agreed that this pedagogical strategy contributed to their development because it made them realize that they could “make a difference” for patients in terms of transforming the ways in which health experiences are lived, as stated by Laurence, a first-year student:

“She [the patient] said how she used to be around nurses, and just being there and listening was what really changed her experience for her. So, even if for us [nursing students] we say that it is insignificant […] to hear it from the perspective of a patient […], it allowed me to realize, ‘yeah, even a seemingly trivial gesture such as listening to the person can change their experience or how they live the situation

Learning to cope with work overload

Work overload was a salient hindering aspect acknowledged by at least one participant in each group. Several students mentioned that they were able to embrace humanistic caring because of their lighter workload as students or nursing externs. Some of them, mostly third-year students, feared that they would not be able to sustain such a practice after their graduation. A newly graduated nurse repeatedly mentioned that she felt torn between her humanistic and caring ideals and what she was able to put into practice, explicitly because of work overload. Most experienced and accomplished nurses conceded that there were instances where it was a serious issue. In the following exemplar, Pavlina, an accomplished nurse explains how care safety was compromised in a nursing home where she practiced:

“You know, every minute was counted, but like, you were there for your technical skills. It’s okay, you know, I’m comfortable with that [technical skills], but that evening, administering medication was like working on an assembly line factory. I could not fulfil everything, even when I was giving medication, I was asking myself: ‘I think I need to assess the apical pulse, do I have time to do it?’ It was bad to the point that I was ‘prioritizing my priorities’. And that evening, I did not offer humanistic care.”

However, the importance given to work overload tended to fade over time as nurses gained clinical experience. Experienced and accomplished nurses highlighted that their acquired expertise allowed them to be more efficient with time management, which in turn gave them the feeling of having “more time” as compared to when they were newly graduated nurses, as underscored in the following excerpt:

“At one point I became [humanistic and caring] again because, for example when you work, you become more comfortable, you understand your role, what your job is, you know what needs to be delegated [to a nursing assistant], what you have to monitor.” (Kim, an experienced nurse)

Limitations

It is important to point out some limitations. A first limitation stems from the fact that there were more students (n=18) who participated in the study as compared to nurses (n=8), in addition to gathering the experience of only one newly graduated nurse. It would have been valuable to integrate the perceptions of a greater number of nurses to ensure redundancy (Benner, 1994) in each group. However, it was not possible despite the multiple recruitment strategies and incentives used. A second limitation arises because of the rather specific sampling criteria that were used, which could impair the transferability of the findings (Lincoln & Guba, 1985). Indeed, the findings reflect the development of participants who studied in a setting where humanistic caring is at the cornerstone of its baccalaureate program (Cara et al., 2016). It is plausible that some dimensions pertaining to the development of humanistic caring, its omnipresence in a curriculum among other things, might have been overemphasized because of the above-stated reason. A third limitation, a strong contextualization of the findings, results from recruiting students and graduates of the same undergraduate nursing education program. In return, this methodological choice contributed to ensure a certain amount of congruence within the study and to recognize the learning trajectory of participants that had gone through comparable training.