emotional nurse being: a heideggerian hermeneutical - rcn
Post on 04-Feb-2022
7 Views
Preview:
TRANSCRIPT
Emotional Nurse Being: A Heideggerian
Hermeneutical Analysis
Kirsten Fiona Jack
A thesis submitted to Manchester
Metropolitan University for the degree of
Doctor of Philosophy
Department of Nursing
April 2011
Abstract
Aim
The work seeks to explore the emotions felt by pre registration nursing students during their programme of study. How nursing students identify and manage their emotions and the effect this has on their lives will be analysed, and suggestions offered on how the findings can influence educational practices.
Background
Emotion work is an important aspect of nursing practice although one which may be overlooked during educational preparation. It is essential to support nursing students in a meaningful way to ensure that they can maintain a sense of self whilst managing the emotional challenges faced. This is important for the sake of their own and the patients well being.
Approach
Data was uncovered using the thoughts and feelings taken from fifteen unstructured interviews involving a sample of pre registration nursing students at a UK University. An exploratory approach underpinned by Heideggerian hermeneutic phenomenology has been taken. Written in first person, the work takes a reflexive stance and uses the researcher’s own stories and thoughts alongside the work of other authors and the data, to fully co-constitute the text. In this way a different understanding of the issues surrounding emotional nurse being is uncovered.
Findings
The findings revealed emotional nurse being as a multi faceted phenomenon with three main constituents. These relate to authenticity, being professional and coping. Emotional nurse being was found to be characterised by anxiety, frustration, anger and sadness. At times nursing students struggled to cope with their emotions and felt they did not get the necessary support. In some cases they felt isolated and one student left the programme. Their ability to cope related to feelings of vulnerability, past coping mechanisms and the amount of external support offered to them from practice and University staff. The findings suggest that further ways are required to support the emotional needs of nursing students.
Conclusion
The work adds to the growing body of knowledge on emotion work amongst nursing students. The term emotional nurse being is used to identify the phenomenon and provide a way of thinking about this important aspect of nursing work. Creative ways in which educators can provide mutual support and sharing with students is offered. In this way nursing students can retain a sense of who they are, and grow emotionally through their work which will ultimately become more meaningful both to themselves and those for whom they care.
Acknowledgements
I would like to thank:
Dr Christopher Wibberley for his amazing ability to make me think just a little
bit more; Dr Maureen Deacon for her encouragement and support.
The nursing students at Manchester Metropolitan University who made this
work possible by giving me their precious time and thoughts.
The Department of Nursing, Manchester Metropolitan University; for allowing
me the time and financial support to continue my studies.
My critical friends for their honesty, particularly Anne Smith for helping me
keep things in perspective.
Mike; for always being himself.
Contents
Chapter One: Background and Overview Page 1
Chapter Two: Contextualising the Issue Page 9
Chapter Three: Methodology Page 15
Chapter Four: The Reality Page 81
Chapter Five: Introduction to the analysis Page 99
Chapter Six: Constituent One: Threat to the authentic self Page123
Chapter Seven: Constituent Two:
Feeling the need to be emotionally professional Page 166
Chapter Eight: Constituent Three:
Experiencing ways of coping Page 263
Chapter Nine: Implications of the work Page 304
References Page 352
Appendix One: Example Consent Form Page 371
Appendix Two: Informant Information Sheet Page 372
Appendix Three: Part of a Transcript; ‘Fran’ Page 376
List of Tables
Table 1: Final Sample Page 96
Table 2: Contexts of Interpretation Page 106
Table 3:
The Co-constituted Approach and Relation to Heideggerian
Thinking Page 122
1
Chapter One
Background and overview
This thesis is made up of nine chapters. Chapter one provides the reader
with a background and overview of the contents of the thesis; an introduction
to me as a researcher and nurse lecturer, and to the events which lead to me
pursuing this subject area. This culminates in the setting of the aims of the
piece which are clearly articulated within this chapter. Chapter two
contextualises the work by discussing some of the published research
available on this subject and the position of the Nursing and Midwifery
Council (NMC, 2010) on the interpersonal nature of pre-registration nursing.
Chapter three provides a background and discussion of the chosen approach
to the work. Different phenomenological approaches are discussed and the
chapter culminates in a discussion of the chosen approach; Heideggerian
hermeneutical phenomenology, and the rationale for this way of working.
Chapter four provides a discussion of the realities of the interview process.
This includes an example of problems encountered during one particular
interview; events which taught me a lot about myself both as a researcher
and person. Chapter five provides an introduction to the analysis and
discussion chapters, including a discussion of my views and expectations
prior to setting out on this research project; an important consideration when
working within the chosen approach. Chapters six, seven and eight provide
analysis and discussion of the data, including literature found relevant once
the focus of the research became clearer to me. Explicit reference to
Heideggerian thinking is made within these chapters to assist in illuminating
2
the data and explaining ways of „emotional nurse being‟. Chapter nine
discusses the implications of the work; including ways in which the learning
gained from this journey has influenced my own way of being and ways of
working with pre-registration nursing students.
Purpose
The purpose of this study is to generate an exploration of emotional nurse
being amongst a sample of pre-registration nursing students studying at
Manchester Metropolitan University. For the purposes of this work I have
used the term emotional nurse being to describe the emotions felt by the
sample of nursing students; the way in which they identify their emotions,
and their ways of coping with how they feel. However, the meaning of this
term developed, as will be shown later in the work. Having explored
emotional nurse being I will then show how my thinking and practice has
changed as a result of the work.
Heidegger has been described first and foremost as a teacher (Gray, 2004).
The purpose of this work is also to show how the work of Heidegger has
been instrumental in teaching me, not only as a nurse researcher and
lecturer, but also about my own personal way of emotional nurse being.
Getting started
The choice of research subject area can be personally significant to the
researcher, whether they realise it or not (Devereux, 1967). My choice of
research topic is significant on both a personal and professional level and I
will explore these levels in this section.
3
There is a need for the researcher to consider not only the topic that they
wish to research but also their relationship to it and Finlay (2002: 536)
suggests:
„….researchers could fruitfully examine their motivations, assumptions, and interests in the research as a precursor to identifying forces that might skew the research in particular directions‟
The following is an entry from my reflective journal. This journal at the time of
writing was not a „research‟ journal as such but a space in which I explored
practice, events and my own emotions. In a way my journal has helped me
make sense of many situations that I have encountered over my years as a
nurse and more recently as an academic. At the time of writing, I did not
know that the event would begin this research journey. In the context of
journal writing as part of the research method, Etherington (2004) describes
the process as a means of uninhibited exploration for the writer. She views
the journal as enabling us to „create a coherent narrative that helps us to
develop a sense of who we are, while still remaining uncertain and open to
change‟ (Etherington, 2004: 127). Written in 2005 I feel that this passage
provides a strong sense of where and who I was at that time.
„I cannot erase the image of a male nurse shouting at a sick elderly gentleman. It has stayed in my mind ever since I watched the Panorama programme. A young fit male, shouting at a frail older gentleman – has nursing lost its way? I had deliberately avoided watching this programme for some time after it had been aired on the TV. Any sort of abuse delivered by my own profession usually reduces me to tears‟
The programme was entitled “Undercover Nurse‟‟. I found it to be a shocking
television programme uncovering abuse in a hospital ward. There is not an
4
easy answer to my question following this programme and there are many
explanations for this nurse‟s seemingly abusive behaviour. The programme
suggested that staff shortage and poor management were significant factors
leading to the abuse uncovered in this ward.
In some ways I was not surprised by the examples of poor practice displayed
on that programme. My nursing education began in 1988 and I am still
troubled by much of what I saw then, and have seen since, in my varied
nursing roles over the last twenty years. I do not think that I could ever be
accused of looking back at a „Golden Age‟ (Dingwall and Allen, 2001: 64) of
healthcare, when nurses smiled and held patients‟ hands, untroubled by
political targets and staff shortages. Occasions like the one above have been
plentiful. However it is only recently when reflecting on the past that I have
truly understood the implications of some of the emotionless practice that I
have seen. A similar experience is described by Koch (1994) who took part
in the „geriatric routine‟ as a second year student nurse. She describes how
she did not question this practice which she realised later was
„depersonalising‟ in nature (Koch, 1994: 982). Returning later to elderly care
wards as a researcher she describes her ability to „reassess such practices‟.
I recall as a first year student nurse, a group of us making a complaint about
similar „geriatric care‟ witnessed on my second ward. As students we were
horrified by what we saw. Patients were dragged from beds by staff, shouted
at and left exposed on commodes at the bedside, with no curtains to protect
either their privacy or dignity. On reflection I am surprised that so many of us
completed our three year education. The majority of us were young and not
prepared, particularly at such an early stage in our nursing lives. Bond (1986:
5
14) made the following observation two years before I commenced my
nursing education;
„Follow the progress of the learner nurse and note the progressive emotional coldness which is imposed on her by the climate of the nursing culture‟
This may be viewed as something of a sweeping statement, although the
discussion supporting this view has since been developed by other writers.
Randle (2002) describes the pressure for student nurses to remain passive
and conform in order to fit in with the existing culture. She interviewed two
cohorts of pre-registration nursing students and found that the students,
rather than challenging distressing practice, continued with placements,
knowing they would soon be able to leave. The reluctance to question
practice comes as no surprise since it is the qualified staff who will be signing
the student off as competent at the end of the experience. The feeling of not
wanting to „rock the boat‟ was certainly familiar to me as a student. However,
by conforming and not speaking out we begin to lose our sense of self and
who we really are. Randle describes the way in which the students studied
felt incongruence, between the nurse they really wanted to be and the nurse
they were becoming.
On a personal level, as a student nurse, it was more about how you did
something rather than what you did. A glance, a smile, spending some time
with a patient, were the sorts of things I felt made a difference and had the
potential to heal. Freshwater (2003) holds the same view. I felt unfulfilled
carrying out the more technical tasks although many of my colleagues
relished being given these jobs to do. I did not want to work in intensive care
6
or accident and emergency departments as they seemed like very technical
areas to me. It was in the community setting that I found my niche and I
particularly enjoyed the „luxury‟ of being able to build up long and lasting
relationships with so many patients and families. There has been something
of a tension, which has existed throughout my nursing career; tension
between how I wanted nursing to be, with a focus on the interpersonal
aspects of care, and how it actually was. To a certain extent I resisted the
technological task orientated culture which was and I suggest is still so
prevalent. However I have often felt somewhat „soft‟ for wanting to prioritise
the interpersonal aspect of my practice. As recently as 2007 I derided my
own research choice;
„Is the culture that I am resisting actually creeping up and influencing what I am saying? To others I describe it (my area of research) as „airy fairy‟. Why? One thing is for sure – I wouldn‟t be doing this if my research was about the accuracy of blood pressure measurements would I?‟
This excerpt from my reflective diary describes my reaction when questioned
by my peers about my research. It is clear that I was uncomfortable when
disclosing how I am spending my research time, as if it would be better spent
researching something that really „mattered‟. So the tension which pervaded
my nursing practice still exists today in my practice as a researcher. In the
early stage of this work I felt a sense of guilt about my choice, although by
the time I had completed, this guilt no longer existed.
Watching the Panorama programme encouraged me to consider how we, as
educationalists, facilitate emotional development amongst student nurses.
For many weeks I examined my own practice as a nurse lecturer alongside
7
the pre-registration nursing curriculum that I was partly responsible for
delivering. I recognised that facilitation of emotional development, in terms of
enabling students to identify and manage their emotions, wasn‟t something
that seemed to be high on the list of „lessons‟ being taught. Of course, it
could be argued that these aspects of practice are developed through
reflective practice and experiential learning. They do not necessarily lend
themselves to formal classroom teaching. However, examining my
curriculum, many of the reflective pieces written by students are summatively
assessed, which can be problematic as students may write what they think
the lecturer wants to see, not what they really feel.
I was aware of other writers who had shared my interest in this aspect of
practice and I began by reading the work of Menzies (1960). Menzies (1960)
explored the way in which patients were labelled by the medical problem
they had rather than their name, the nurse/patient relationship was split by
task allocation and there was a strong resistance to change. All of the
systems were designed to help protect the staff and avoid the nurse having
to get too close to the patient and thus assisted in the repression of any
emotion. However, rather than protect staff, the losses of identity led to the
feeling that practice was worthless (Menzies, 1960). Loss of self has been
highlighted more recently by Freshwater (2002) who suggests that
awareness of our own feelings and our „self‟ disappears when we are
engaged in repetition and the carrying out of routine tasks. If practice is not
considered, thought about or reflected upon, how do we know it is in fact
intentional? (Freshwater, 2002). In the example from Panorama given
above, it could be argued that the nurse did not intend to behave in the way
8
he did. Here was a man whose emotions had taken over the situation and he
was a helpless bystander. It could be suggested that his practice may not
have been intentional at all.
After watching the programme and from my reading and practical experience
so far, it seemed to me that the issues of emotion in nursing work certainly
weren‟t new, and were still an issue which warranted further investigation.
With these thoughts in mind the aims of my study were developed;
1. To analyse the emotions felt by student nurses in practice.
2. To analyse how student nurses identify and manage their emotions.
3. To analyse the effect of „emotion work‟ on student nurses‟ lives.
4. To offer suggestions of how the findings impact on the delivery of
patient centred nursing and the preparation of student nurses.
5. To contribute to the growing body of knowledge of nurses use of
emotion in their relationships with patients.
Using an interpretive approach, which I will go on to explain in more detail
later, the need to travel from „whole – parts – new whole‟ entails reviewing
existing literature as part of the analysis. Knowledge gained from the
literature is combined with the data collected to reach a new interpretation of
events (Dahlberg et al, 2008). Therefore, most of the literature on this subject
will be discussed in the Discussion and Analysis chapter. However, to begin
the work I will provide some context by exploring two important pieces of
research and highlight the current view from the NMC (NMC, 2010).
9
Chapter Two
Contextualising the issue
Before commencing this study I was aware of two important pieces of work
relating to this subject. I needed to explore these works further so that I could
provide some context to my own work, and learn how others have
approached the subject. I felt that doing this could help me decide upon a
useful approach to my own study. However I was concerned at this stage
that by reading other works, I may become influenced by the findings and
merely produce work to support their position. It is difficult to predict how
reading may affect the self, either consciously or otherwise, and a balance
needs to be reached. Rowan (1997) suggests that extensive engagement
with the literature may influence the research question being asked. Talking
from a grounded theory perspective Corbin and Strauss (2008) have ideas
which I feel have relevance here. They suggest that reading other work may
stifle creativity and lead to an inflexible piece of work. Indeed, it seems that
there is a risk that the researcher‟s expectations could be too narrowly
framed by the literature. The expectations become not the ones I began with,
but those imposed by my reading of previous published work. I will argue
later that we are all influenced by our past history and experiences and these
have a bearing on how we are in our current lifeworlds. Therefore, I suggest
that we should not add even further influences on the way we see the world
when undertaking qualitative work by reading too many ideas of other
researchers. Indeed, this seems a key point in that the risk is considerably
greater when undertaking qualitative research.
10
In addition it could be argued that we are living in „emotional times‟ in that the
discourse of emotion could be linked to a particular cultural force at this point
in time. The need to acknowledge our emotions has never seemed greater,
explored most notably by Furedi (2004:25) who states;
„The state of our emotion is now represented as the cause of many of the problems faced by contemporary society. The way we feel about ourselves – our self-esteem – has become an important explanatory tool for making sense of the world‟
This could provide further influence on my way of thinking. I suggest that I
am writing at a time when the acknowledgement of emotion is in fashion.
Clearly this cultural force could have a bearing on me and also that of the
informants being interviewed.
As I was already most aware of the following two works I feel obliged to
discuss my understanding of them here. However, other contemporary
literature relating to this subject will be used to illuminate the findings of this
work, and be used in the discussion and analysis section. For the most part I
will be engaging with the literature after collecting my own data. This is
where it is best placed in terms of assisting with the interpretation, and
helping with future understanding and implications.
I have already mentioned the work of Menzies (1960) who undertook a
study, A Case Study in the Functioning of Social Systems as a Defence
against Anxiety. Staff in a London hospital had been finding it increasingly
hard to manage staffing and training needs. The researchers had been
invited in to look at ways in which the methods could be altered. Menzies
11
(1960: 97) does not focus on this problem in her paper, although some of the
issues raised are relevant. Her main focus centres on the following finding:
„....our attention was repeatedly drawn to the high level of tension, distress and anxiety among the nurses. We found it hard to understand how nurses could tolerate so much anxiety, and, indeed, we found much evidence that they could not‟
Furthermore Menzies (1960) found that the anxiety could not be explained
solely by the nature of nursing work. Indeed, the techniques employed by the
nursing staff, in attempting to contain the anxiety, actually made the anxiety
and distress worse. Take, for example, the splitting of the nurse-patient
relationship so that the nurse only has a few tasks to perform for each
patient. This ensures that the nurse can never develop a meaningful
relationship with the patient. Menzies (1960: 113) states, „The nurse misses
the reassurance of seeing a patient get better in a way she can easily
connect with her own efforts‟. Attempts made to reduce the anxiety by
ensuring that the nurse does not develop the relationship and become too
„attached‟, only serve to make the situation worse.
Menzies data were collected through interviewing approximately seventy
nurses, both individually and in small groups, and through observation. The
informants knew the „formal‟ problem that was being studied but were invited
to discuss other relevant issues that they felt important to their working
practice.
Menzies (1960) work is around the use of the social defence system, and the
fact that it fails to alleviate the anxiety felt by the nursing staff. Indeed, this
work suggests that the natural anxiety felt in nursing practice, is actually
12
relieved by the nurse investing some of her own self within the relationship;
the exact opposite of what was being encouraged though the cultural
system.
The second was the work of Smith (1992) who explored the emotional labour
of nursing. Like me, it was a particular incident which motivated Smith to
undertake her detailed study. Drawing on sociological and feminist texts,
Smith shows the value of the emotional nature of nursing and the influence
of the ward manager on whether emotion work takes place. She uses the
term „emotional labour‟ which was first used by the sociologist Arlie
Hochschild, who explored the way in which much care work is undertaken by
women and goes unrecognised and unrewarded. Hochschild‟s work was
originally undertaken using air hostesses, another group comprising mainly
female employees (Hochschild, 2003). Smith (1992) used a grounded theory
approach which uses multiple data collection methods to develop categories,
which lead to theory generation; this helps to describe the subject in question
(Glaser and Strauss, 1967). The data collection methods employed included
questionnaires, interviews and participant observation and involved data
collection from qualified staff, student nurses and patients.
Smith suggests that her findings have relevance to nurse educators and
highlight the fact that the technical and medical aspects of their education did
little to prepare them for the „emotionally charged situations‟ they often
encountered (Smith, 1992: 139). Smith concludes that a more formal
approach to this aspect of „training‟ is required and that this will assist in
helping emotion work not only to become more visible but also more valued.
13
To summarise, what both of these studies suggest is that more attention
needs to be afforded to the emotional aspects of nursing practice. Smith
(1992) suggests a more formal approach and Menzies (1960: 110) states the
following as a problem of the social defence structure: „...true mastery of
anxiety by deep working-through and modification is seriously inhibited‟.
Therefore, both authors seem to suggest the same thing in that, in order to
cope with the emotion felt, nurses need more attention to be paid to this
aspect of their work.
Since I began this study the NMC (2010) have published their new
Standards for Pre-Registration Nursing Education and I think it is worthwhile
mentioning these here. There now seems to be more focus on compassion
and the emotional aspects of practice to the extent that „Communication and
Interpersonal Skills‟ have now got their own discreet domain. Within this
domain, a „generic standard for competence‟ includes the following (NMC,
2010: 15);
„All nurses must use excellent communication and interpersonal skills…must demonstrate the ability to listen with empathy….all nurses must recognise when people are anxious or in distress and respond effectively, using therapeutic principles, to promote their well being, manage personal safety and resolve conflict…‟
I suggest that it is unclear how this ideal can be achieved if we do not first
take into account how nurses can manage their own distress, their own
anxiety and promote their own well being. If nurses are unable to recognise
their own anxiety, how can they be expected to recognise this state in
another? The findings from the two pieces of work described above are
14
clearly important although I suggest that as a profession, we have not
embraced their thoughts to any great extent.
In this chapter I have attempted to contextualise the work by drawing on a
small amount of the research available. These works were familiar to me and
I suggest they have had most influence on my way of thinking. By discussing
further literature later in the work, alongside the data and my own reflection, I
am staying more faithful to my chosen approach which I will now explore in
detail.
15
Chapter Three
Methodology
Introduction
It can be easy for the researcher to consider a data collection method and
get on with the „doing‟ of the research long before the choice of methodology
is made (Gray, 2005). However, unless we have an approach in mind it
would be difficult to know in which direction we need to travel. For example,
the underlying approach helps us to decide on our method. I knew that I
wanted to move away from the positivist paradigm which had dominated my
master‟s level work. Having re-read the systematic review undertaken as part
of my master‟s level study, I was disappointed to find my „self‟ not featuring.
The work reads as a detached piece where my reflective insights are not
evident. Of course a systematic review of quantitative randomised controlled
trials does not necessarily require the obvious presence of the researcher in
the final written piece, in order to be a sound piece of work. Indeed, I
achieved a high mark for my work although I never really felt very proud of it
in a personal sense. The topic was a comparison of satisfaction felt after
consulting with a nurse practitioner or a general practitioner, for a minor
illness or ailment. Reflecting on that work, I feel the methodology I used was
packed with problems. Using quantitative scales to measure a personal,
changeable feeling such as satisfaction seems inadequate. The subject
lends itself to personal description, for example; how it felt to be treated by a
different professional; what the experience was like; how the perception
changed over time; how the feelings differed from person to person. None of
16
this was captured in the final report and on reflection this seems a shame as
it doesn‟t do justice, in my opinion, to this important subject.
In addition, apart from the inability to capture this rich data, the other problem
was the distance I felt, metaphorically, from the research endeavour.
However, at that time that is how I viewed research, as an impersonal
process. My research „upbringing‟ was from a very rational technical
perspective. I agree with Parse (1998) who suggests the links to medicine
have led traditionally to a more positivist approach to nursing research. The
research journey felt mechanistic, similar to a recipe book approach, a
process to be gone through rather than lived with any great feeling or
passion. By this stage I knew that I wanted to pursue a qualitative approach,
but was still trying to find a methodology with which I felt comfortable.
My interest in phenomenological research and particularly that with a
reflexive focus developed after reading Koch‟s work (Koch, 1994, 1995,
1996, Koch and Harrington, 1998). Koch wanted to understand the
experiences of older people in an acute care setting. Her work, from that
period of time, explores the use of reflexivity as a way of enhancing rigour in
qualitative studies (Koch and Harrington, 1998); the use of story-telling in
research (Koch, 1998) and the influence of philosophy on phenomenological
research (Koch, 1995, 1996). It was then that I began to understand the
world of phenomenology as one in which the presence of the researcher in
the research can be welcomed and valued. This was a stark contrast to the
style of research with which I was familiar. Not only did Koch introduce me to
the idea of reflexivity in qualitative research, but also to the influence of
philosophy, particularly the thinking of Heidegger, a German philosopher who
17
in more ways than one, spoke a completely different language. Most
importantly from what I had read, what better way to explore the emotional
world of the student nurse than phenomenology?
Not so fast
The subject of phenomenological research was not as straight-forward as I
may have first thought. The process seemed fascinating albeit fraught with
difficulties. Firstly what I needed to understand was that there is more than
one style of phenomenology, and it seemed necessary to unpack the
philosophical underpinnings of the methodology chosen, in order to stay true
to that tradition. Caelli, (2001: 275) suggests that the phenomenological
researcher has a difficult task, „…to navigate the abundant and conflicting
literature on phenomenology…..there exist few sources that offer concrete
directions…‟
The lack of direction can seem prohibitive. How does the researcher know if
she is „doing it right‟ if there is no recipe book to follow? However, from my
master‟s level experiences, it was this very recipe book that I was so keen to
discard. Looking more closely I suggest that it is the lack of „concrete
directions‟ that is part of the appeal of phenomenological research. The
insights and creativity which can be achieved in phenomenological studies
may be constrained by using a „recipe book‟ style set of directions which may
actually serve as a methodological strait-jacket. Indeed, attempting to
combine theoretical frameworks with phenomenological approaches may in
fact show a poor understanding of phenomenology (Cohen and Omery,
1994). The freedom and flexibility seemed appealing as the work could
18
become more of a living feeling entity, which breathes and grows; twists and
turns depending on what the informant and researcher is thinking and feeling
at that time. It is this that makes it so truly fascinating but also so very
difficult. It is also worth mentioning that this approach isn‟t truly „free‟; there
are still certain „rules‟ which should be obeyed. For example Ray (1994)
suggests that the credibility of a phenomenological study is seriously
impeded if some knowledge of the underlying philosophy is not shown. The
philosophy can be difficult to understand and Paley (1997, 1998) has
criticised some nurse researchers for misinterpreting the philosophy of both
Husserl and Heidegger in their research. This issue will be discussed in more
detail later.
Epistemological Perspectives
At this stage I felt I needed to rewind a little and explore the epistemological
and ontological perspectives that would inform my study. Epistemology is
concerned with deciding what kind of knowledge is true and legitimate (Gray,
2005) and it would seem important for a researcher to consider this before
proceeding further. For example Husserl‟s epistemology was concerned with
the essential structures of things; he believed that truth was to be found in
discovering the concrete essence of a phenomenon as it appeared through
consciousness (Cohen and Omery, 1994). Ontology may be described as
the „study of being‟ (Gray, 2004: 16) and my ontological question concerned
the exploration of what it is like for student nurses to „be‟, in an emotional
sense, when dealing with others. Bringing together a way of knowing
(epistemology) and a way of being (ontology) assists us in moving away from
19
purely epistemological ways of understanding which can be found in the
natural sciences (Holroyd, 2007). My belief is that understanding other
people is concerned more with a way of being rather than adhering to a set
of rules which must be followed in order to reach the „truth‟. Indeed, it is not
so much about knowing more as understanding differently, the lifeworld in
question (Holroyd, 2007).
Considering these questions of reality and understanding reminded me of a
book from my childhood by Margery Williams (1922/1991) entitled, „The
Velveteen Rabbit or, How Toys Become Real‟. I suggest that this best
illuminates both my epistemological and ontological inclinations. The Rabbit
and the Skin Horse are two toys having a conversation about what it is to be
real (Williams, 1922/1991: 6):
"What is REAL?" asked the Rabbit one day, when they were lying side
by side near the nursery fender, before Nana came to tidy the room.
"Does it mean having things that buzz inside you and a stick-out
handle?"
"Real isn't how you are made," said the Skin Horse. "It's a thing that
happens to you. When a child loves you for a long, long time, not just
to play with, but REALLY loves you, then you become Real"
"Does it hurt?" asked the Rabbit
"Sometimes," said the Skin Horse, for he was always truthful. "When
you are Real you don't mind being hurt"
"Does it happen all at once, like being wound up," he asked, "or bit by
bit?"
20
"It doesn't happen all at once," said the Skin Horse. "You become. It
takes a long time. That's why it doesn't happen often to people who
break easily, or have sharp edges, or who have to be carefully kept.
Generally, by the time you are Real, most of your hair has been loved
off, and your eyes drop out and you get loose in the joints and very
shabby. But these things don't matter at all, because once you are
Real you can't be ugly, except to people who don't understand"
This conversation has relevance to me when asking questions about
epistemology and ontology. Rabbit, as researcher, has decided that the Skin
Horse, as informant, and his experiences of being Real, can provide the
answers on the subject. The Skin Horse is living in the world of being Real
and has become Real. Through the Skin Horse the Rabbit begins to
understand the lifeworld of another. Rabbit has some pre-understandings
about what it is to become Real such as having a stick out handle, but he
understands differently after his conversation with the Skin Horse. Through
his experiences of becoming Real, the Skin Horse has become old and
shabby. However this doesn‟t matter as it is this very experience of being
that provides Rabbit the researcher with the information he needs. I think that
this excerpt also makes a point about the difference between qualitative and
quantitative research. This is because in this conversation, „bias‟ seems to
be celebrated in the form of „reality‟ which can‟t be „ugly‟, except of course to
those who don‟t „understand‟. The amount of perceived „bias‟ may indeed
seem ugly to a quantitative researcher who seeks to eliminate this as much
as possible. By contrast, in qualitative research „bias‟ can be welcomed and
used constructively in all stages of the project.
Later in the work, the Velveteen Rabbit meets some „real‟ live wild rabbits in
the woods. The live rabbits approach him and mock him as he has no hind
21
legs. The real rabbits realise that the velveteen rabbit is not like themselves
and approach him (Williams, 1922/1991: 16):
„The strange rabbit stopped dancing, and came quite close.....his long whiskers brushed the Velveteen Rabbit‟s ear, and then he wrinkled his nose suddenly and flattened his ears and jumped backwards.
“He doesn‟t smell right!” he exclaimed. “He isn‟t a rabbit at all! He isn‟t real!”
“I am Real!” said the little Rabbit. “I am Real! The Boy said so!” And he nearly began to cry‟
I have used this important excerpt to capture my belief that „reality‟ depends
on context, on feeling, and the way in which life is viewed. This will differ
from being to being, or in this case, rabbit to rabbit. Relating this to my study,
my belief is that there is not one true reality to be discovered and that
perception, context and shared experiences with others, play an important
part when uncovering truths. In this excerpt reality is made; the Velveteen
Rabbit believes that he is Real, as The Boy has told him so. I will now
explain this idea further.
Shared experiences
Discussing reflective phenomenology Finlay (2003: 106) suggests, „the focus
needs to be on identifying that inter subjective lived experience which resides
in the space between subject and object‟. Schutz (1967: 113) uses the term
„inter subjectivity‟ to describe understanding that comes from shared
experiences with others. In the example given above, the Velveteen Rabbit
22
understands reality by sharing experiences with the boy and the Skin Horse.
Understanding may occur with or without communication with the other
person. We can identify with the other person as we share the same
experiences. An example of this is provided by Walsh (1996), in a
phenomenological study underpinned by Gadamer‟s philosophical
hermeneutic, who describes how his own and his informants understanding
are fused to inform a new „vision‟ of meaning of a nurse/patient encounter.
However, I needed to consider whether this way of thinking would be
appropriate when exploring my area of concern; was it the best „fit‟?
My area of interest centres on emotional being in nursing. This relates to the
moment when I watched the Panorama programme described earlier and
began to wonder how nurses become aggressive towards patients. For
example, what is it that leads to them losing control of their emotions? A
phenomenological approach could help me to understand the „reality‟ of the
emotional lifeworld of the nurse. This approach could help me to explore the
elusive aspects, the hard to describe nuances of emotional nurse being. As
with patient satisfaction described earlier, it would seem more meaningful to
talk with the informants in order to elucidate the real issues which are
meaningful for them. I will now continue by discussing phenomenological
approaches further to explain my choice of approach in more detail.
Phenomenology
Phenomenology as a research methodology is becoming increasingly
popular in the health care professions (Clarke and Iphofen, 2006). Cohen
(1987:31) describes phenomenology as:
23
„….a rigorous science in the service of humanity. This rigor involves going to the roots or foundations, to be more clear about what the basic concepts are and what they mean. This science intends to provide answers to important questions and deep human concerns‟
One way to look at phenomenology, which in light of the earlier discussion
may not be what this approach means to me, is as a „rigorous science‟ which
involves going back to the essential structures and elements which make up
the phenomena as they appear. Looking at phenomenology in this way
suggests that all previous assumptions held need to be put aside so that the
„truth‟ about the phenomena can be clearly seen. This leaves us with an
absolute description of the phenomena in question. For example, in my
study, using this approach would enable me to identify the „essential
structures‟ of emotional nurse being. This implies that there is one „true‟
reality to be found which informs the basis for human knowledge. In the
words of Van Manen (1990:10), „…phenomenology is the systematic attempt
to uncover and describe the structures, the internal meaning structures, of
lived experience.‟
By laying aside our current understandings of phenomena and by looking
again at them as they appear in our conscious mind, new meaning or at least
an enrichment of earlier meaning will come to the fore (Crotty,1996). Gray
(2004: 21) agrees that phenomenology asks us to put aside current
understandings so that we can „revisit our immediate experience of them in
order that new meanings may emerge‟. This is so that we can reach a new
meaning not obscured by our preconceptions.
24
The value of a phenomenological study lies in what Ray (1994: 117)
describes as its „richness‟ which concerns „how well somebody else can use
it‟ and this may be different for each person who approaches it. Ray (1994:
118) describes phenomenology as „first and foremost, a philosophy or a
variety of distinctive, yet related, philosophies. But it is also concerned with
approach and method‟. Cohen (2000: 4) describes phenomenology as being
„ideally suited‟ to research aimed at exploring nursing care. It is a way of
understanding others‟ experiences which is important for example when
trying to understand patients‟ needs. Gaining fuller understanding of the
meaning patients place on their experiences could help us as nurses to
interact with them in a different way. Similarly gaining a richer picture of the
meaning the nurse places on their experiences helps us to understand their
world more fully; different understandings emerge concerning what it is to be
a nurse. The reaching of a true understanding comes from the „texts‟ which
emerge from the data collection (Walsh, 1996). This is „the type of
understanding that brings a smile to your face…‟ (Walsh, 1996: 236) and
comes as you become emerged and engrossed in the „lifeworld‟ of another
person. This becomes all the more poignant if you have been in their shoes
and felt what they have felt, leading to a „genuine dialogue‟ with the text
(Walsh, 1996: 236). Cohen (2000) suggests that phenomenology is useful
when studying topics which have not been studied before or when a fresh
perspective on a topic is needed. It could be argued that using this approach,
understanding the lifeworld of the informant, may lead to a rather „insular‟
study. By that I mean one which places the focus solely on the individual
rather than taking into account the context and culture in which the informant
25
resides. However using this interpretative approach takes into account the
context of the situation described as „background meaning‟ (Walsh, 1996:
235), which is so important to this tradition. Taking into account context is
described as essential in ethnography (Boyle, 1994) in that behaviour can
only be understood in terms of the backdrop of the context in which it occurs.
As is the case with phenomenology, Boyle (1994) suggests that there are
many variations within ethnography and one „type‟ does not exist. While both
may adopt an interpretive approach, ethnographic research places more
emphasis on culture and how that relates to behaviour. I have already
mentioned the influence of what Furedi (2004) describes as the therapy
culture in which we all live at the current time, and this has clear relevance.
The importance of culture on emotion, particularly the expression of emotion,
should not be underestimated in this study. For example, it will be interesting
to explore what the „norm‟ is in relation to displays of emotion on the part of
student nurses and how much is deemed suitable by others in the same
culture, for example qualified nurses.
As suggested earlier, there is a need for researchers to explore the
philosophical underpinnings of the phenomenological methodology chosen. I
will now go on to discuss this issue further.
Philosophical Issues
Some writers believe that many nurse researchers have misinterpreted
phenomenological methodology. Although not devaluing the research
undertaken, they take issue with the fact that nurse researchers are not
staying true to the methodology of, for example, the transcendental
26
phenomenology of Husserl or the existential phenomenology of Heidegger
(Paley, 1997, 1998, Crotty, 1996), even though they explicitly state that this
thinking is underpinning their work. Furthermore, there is much discussion
between writers, see for example Darbyshire et al (1999: 17), who provide a
response to Crotty‟s „narrow‟ view of Heidegger‟s work. However, reading the
original philosophical texts is not easy and they can be difficult to follow
(Cohen, 2000). As they were originally written in German, they may not
readily translate into English, or not in a way that is familiar to us. In addition,
Husserl‟s philosophy changed over time, so reading his first phase will be
different to reading his later work (Cohen, 1987). Nurse researchers
interested in pursuing the phenomenological approach are left to „piece
together their own understandings‟ which in turn leaves them open to the risk
of misunderstanding (Priest, 2004: 4). Koch (1999: 28) isn‟t sure that nurse
researchers even need to understand these „impenetrable texts‟. What she
suggests is a selective read, with some guidance in the process. However, it
can be difficult to know what to select and it is easy to be drawn in and read
further, in order to select what is relevant. The fear of missing something
crucial can tempt us to read further, and further still. However it is important
to remain flexible and not get so attached to the method that we lose sight of
the focus of the enquiry, a problem described by Janesick (2000) as
„methodolatry‟. Therefore a balance is needed. It would seem sensible to
return to the original texts not least so that we can come to our own
interpretation of them rather than rely on one from someone else. As Koch
(1999: 29) highlights, a lot of what is written about phenomenological
methodology in the nursing literature is „unreflective and regurgitated‟. If the
27
researcher does not return to the original texts then they are using others‟
interpretations on which to base their own methodology. This may be at odds
with the interpretation they would have reached themselves had they read
the original work. It is with this thought in mind that I decided to selectively
read for myself some original texts, beginning with Husserl, so that I could
reach my own conclusion. This discussion will also be supported by the
secondary literature relating to the work of these philosophers.
The Phenomenology of Edmund Husserl
The historian Spiegelberg (1984) splits the phenomenological „Movement‟
into three phases; the preparatory, German and French phases. By using the
word „Movement‟, Spiegelberg is showing that phenomenology is always on
the move, and changes considerably over time (Cohen, 1987). Husserl and
his former student Heidegger feature in the German phase, with Husserl
being viewed as a key figure in phenomenology, its „acknowledged founder‟
(Crotty, 1996: 29). Husserl began his career as a mathematician before
turning to philosophy which he viewed as a rigorous science. Walsh (1996)
observes that Husserlian thought is closer to how nurses traditionally view
research; with the researcher acting as a detached observer so that the true
untainted meaning of the issues may be uncovered. Husserl was concerned
with the reality of things, as they present to human consciousness hence his
statement, „We must go back to the things themselves‟ (Husserl, 1913/1970:
252). He proposed that as we live each day in our „natural attitude‟, we take
every day events and experiences for granted, to the extent that we fail to
notice what is around us. Phenomenological enquiry is needed in order to
return to the „things‟ in a critical way, in order to reveal their essences and
28
structures. Husserl wanted truth which was not grounded in time or culture
but „were true for all time‟ (Walsh, 1996). Husserl‟s phenomenology requires
us to search for the truth, to find clarity and the foundation of knowledge
without presupposition (Cohen, 1987). Three ideas dominate his philosophy;
phenomenological reduction, or bracketing; intentionality, and essences
which will now be explored.
Phenomenological Reduction (Bracketing)
To be true to Husserl‟s transcendental phenomenological approach it is
necessary to go through the process known as phenomenological reduction
which is also known as eidetic reduction, bracketing or epoche. This involves
the researcher identifying and laying aside any preconceptions, experiences
or thoughts in order to investigate the phenomenon in a „pure‟ way. Using
this method the researcher would not be looking to confirm any pre-selected
frameworks or ideas (Omery, 1983). The researcher would attempt to go in
„cold‟ in order to seek the truth of the phenomenon in question. Husserl,
(1913/1970: 110) describes it thus:
„We put out of action the general thesis which belongs to the essence of the natural stand point; we place in brackets whatever it includes respecting the nature of Being‟
We are required to put any prior thoughts and assumptions into imaginary
brackets. This is an extreme process in which the researcher has to free
themselves from any preconceptions, beliefs, and experiences of the
phenomenon to be examined (Moustakas, 1994). This is in keeping with
Husserl‟s desire that philosophy would be seen as a „rigorous science‟
29
whose findings would be taken seriously (Paley, 1997). Paley, (1997: 188) is
critical of many nurse researchers who view the process of bracketing as
simply part of the research method which can be adopted. He views it as
going even further than that:
„The epoche is a philosophical device which simply cancels the natural attitude as a preliminary to phenomenological enquiry. It is not a „research method‟ which can be adopted within the natural attitude. No social scientist……can claim to use the epoche as a research technique, since performing the reduction would immediately remove her from the social world. Even „lived experience‟….would be inaccessible to her, because any judgements she might make about it are among those which, after the reduction, she is barred from using‟
According to Paley (1997) the process of epoche involves more than simply
putting aside our beliefs and knowledge about a subject before we begin our
research of that same area. We are obliged to go in „cold‟ as we are
prohibited from considering our own or even our informant‟s lived
experiences; „Even lived experience….would be inaccessible to her…‟
Therefore we are not only unable to consider our own previous experiences
but also those of our informants in order to find the „essence‟ of the
phenomenon. Husserl accepts the existence of the informant‟s thought
processes. However what needs to be put aside is the knowledge that these
processes relate to, that is to their experience and understanding of the
phenomenon in question (Beech, 1999). All judgements would be suspended
and the aspects of the phenomenon would be described as they surface.
There is no interpretation, underlining the fact that the phenomenology of
Husserl was a descriptive phenomenology rather than an interpretative one.
30
However, there are some writers who disagree with the suggestion that it is
both the researcher‟s and the informant‟s „experiences‟ which need to be
„bracketed out‟. Giorgi (1997) states that it is the researcher‟s task to
undertake bracketing, not the informant‟s, as it is the informant‟s „natural
attitude‟ which the researcher needs to understand. It would be difficult to
achieve this if the informant had also been through the bracketing process.
As with phenomenological methodology, there is no prescriptive method of
how to undertake bracketing. I agree with Wall et al (2004: 22) who describe
it as a „psychological orientation towards oneself rather than an observable
set of procedures‟. It needs to be a frame of mind which is to be reached and
maintained throughout the research process.
Oiler (1982: 179) describes one way to „practice‟ bracketing:
„…..to wonder, to allow oneself to feel confused, in conflict, or uncertain, and to ask for opinions and really want to hear them. Nurses need to ask, “What does he mean? What do I mean?” In this way, a person can identify what he thinks about experience and bracket it more effectively‟
Oiler (1981) highlights the complex nature of the process and the uncertainty
which accompanies bracketing. Interestingly, Oiler seems to refer to „him‟
and „I‟ thus perhaps implying that bracketing is not solely the task of the
researcher to adopt on her own, but also a state for the informant.
In order to achieve bracketing Wall kept a reflective diary (Wall et al, 2004).
She felt it important to keep a very structured account of her reflection and
proposed a very practical framework for this process, starting with pre
reflective preparation and ending with action as a result of learning from the
31
bracketing process. It is interesting to consider the process described by
Wall, as not all researchers explicate their method to achieve the bracketing
they describe. Rose (1990: 59) describes the need to bracket when following
Husserl‟s approach to phenomenology and explains that her „personal and
theoretical assumptions‟ were put to one side at the start of the study, in
writing. This was accompanied by an attempt to keep any prior knowledge
away from the data as it emerged. However, Rose does not state how she
achieved this complex process. Apart from writing it down, Rose does not
give the reader any idea of whether writing was enough to stop her thoughts
creeping into the research process, or as described by Wall, how it could be
used to inform new learning. Caelli (2001: 276) describes undertaking the
reduction as her „first major hitch‟. Caelli questioned how it was done, and
agreed that researchers tend not to explicate the method of reduction in their
studies, and who should be involved, researcher alone or researcher and
participants. In her view, carrying out the reduction is a key process in
phenomenological research in order that the essential structures that make
up the phenomenon in question are revealed. Transparency and description
of the attempts made to isolate the researcher‟s thoughts and experiences
could reassure the reader that an attempt to bracket has indeed been
undertaken. This could assist in making the research seem more credible
and faithful to the Husserlian tradition. Through honest reflection the extent
to which the process was successful could be discussed, with ongoing
learning being applied to future interviews and data analysis.
However, the enormity of the task of „bracketing out‟ our thoughts and
preconceptions should not be underestimated. As I explore Husserlian
32
phenomenological methodology further I begin to wonder whether this
approach is returning me to my positivist research upbringing, which is the
style of research that I wanted to move away from. Indeed, this approach
seems similar to the „recipe book‟ style of research that I used during my
master‟s level study. I also begin to wonder firstly whether we can ever truly
bracket out our thoughts and feelings and secondly, why bother?
Bracketing; An Unnecessary Task?
My feelings on the issue of bracketing are that it is at best problematic and in
addition it seems a rather unnatural process. Partly this could be because it
is incongruent with contemporary nursing education, which values
experiential learning in the form of reflective practice. As nurses it is our very
thoughts, preconceptions and experiences that we use to inform future
learning. Through this process we can reveal greater insights both about
ourselves and the world around us. Therefore, rather than viewing our
preconceptions as getting in the way, we can view them as enhancing our
future thought. However returning to my own research, I am now left with a
problem. If I do not undertake the process of bracketing I will never uncover
the essential structure of the phenomenon under scrutiny. Moving forward in
a Husserlian way would enable me to uncover the essential structure and the
„truth‟ of the phenomenon of emotional nurse being, untainted by my own
thoughts and preconceptions. However this way of thinking is incongruent
with my view of what constitutes „truth‟ and „reality‟. Being an experienced
nurse and having knowledge of the issues being discussed, I can ask
questions that I may not have done had I been forced to remain objective
and detached. This gives me the potential to „reach understandings that
33
would not have been reached‟ (Walsh, 1996: 234). Rather than view my pre
understanding as a hindrance, it can potentially enrich the new way of
thinking. In addition, pursuing the goal of uncovering the „essential structure‟
of emotional nurse being would do little to enhance my understanding of how
the phenomenon is „lived‟ in practice by nurses. Husserl‟s phenomenology is
concerned with revealing a truth which will stand the test of time. However,
as will be discussed later, we are all bound to time, culture and context and
this cannot be ignored. In a sense it is a moveable feast, and indeed, isn‟t
this what makes life more interesting? What is required is a methodology
which can reveal how emotion influences day to day practice and the way
nurses feel about emotional effects on their decision making, behaviour and
life outside practice. The influence of my thoughts about bracketing will be
discussed in more detail later when exploring the work of Heidegger and his
philosophy. It is only when I have explored the different underpinning
philosophies that I will be in a position to decide how I will proceed with my
own study. So for now I will continue to explicate the work of Husserl by
discussing the concepts of intentionality.
Intentionality
Husserl‟s thought was the culmination of the Cartesian tradition that we are
all „subjects‟ relating to „objects‟. Rene Descartes (1596 – 1650) was a
French philosopher and also a mathematician. Descartes argued that
although at times he was sure he could see and feel physical objects, there
were also as many occasions when he had actually been dreaming, and the
„objects‟ around him had been an illusion. Therefore, at any moment in time,
how could he be sure that what was around him was not also illusion?
34
Everything, even one‟s own body as a physical object could also be an
illusion (Dreyfus, 2000). The one certain thing we do have is our own
conscious awareness and thought and this is the place to start our
investigations (Dreyfus, 2000). However, our thoughts and awareness are
always directed towards something and Husserl termed this idea
„intentionality‟. Husserl (1913/1970) viewed intentionality as the starting point
of phenomenology. In this sense „intentionality‟ means „relatedness‟, in that
our conscious thought is always related to something. In Husserl‟s words
(1913/1970: 242), „We understood under Intentionality the unique peculiarity
of experiences “to be the consciousness of something”. When we think,
each thought is of something, when we reflect, it is always on something.
Subject and object are always united. Experiences cannot be separated from
the objective world, the two are always united (Crotty, 1990). Thinking along
this theme, Crotty (1998: 32) is critical of what he describes as the „overriding
subjectivism of the new phenomenology‟ found in nursing research. He
believes that many examples of nursing phenomenology fail to unite
objectivity and subjectivity, being too concerned with the subjective. He
examined thirty pieces of nursing research claiming to be phenomenological
in nature and believes that researchers are missing out by not looking to
phenomenology in a more mainstream sense, thus making it more critical
and objective (Crotty: 7):
„That so called phenomenology simply describes the state of affairs instead of problematising it….it perpetuates traditional meanings and reinforces current understandings. It remains preoccupied with „what is‟ rather than striving….towards „what might be‟. At best, this entails a failure to capture new meanings and a loss of opportunities for revivifying the understandings that possess us‟
35
The focus of what Crotty describes as the „new‟ phenomenology is on the
informants‟ subjective experiences, thoughts and feelings rather than on the
phenomenon itself being revealed objectively. Not only would traditional i.e.
Husserlian phenomenology be more objective but also more critical. Many of
the pieces examined by Crotty use informants‟ experiences to develop their
understandings of the phenomenon, the phenomenon is described as it is
subjectively experienced by the informants. For example, the
phenomenological study by Rose (1990) who investigated inner strength as
experienced by women, was described earlier in relation to bracketing.
Rather than talk about inner strength as the object of the women‟s
experience, the informants in this study were asked about their lived
experience of inner strength in terms of thoughts, feelings and perceptions.
Thus the opportunity to investigate the phenomenon objectively and critically
is lost. In a similar vein Corben (1999: 56) describes the work of Beck (1992)
who, in a phenomenological study of post natal depression, focuses on the
informants‟ experience of it rather than „the nature of the depression itself as
perceived by them‟. However, I suggest that this is an easy „mistake‟ to
make. That is because everything we do is bound by experience and the
context in which we live and exist. It is difficult to describe anything without
relating it to our experiences of it. It is in this way that we make sense of our
lives and this sense making will differ from person to person.
Essences
Van Manen (1990) describes essences as a „universal‟ which makes a
phenomenon what it is, something which needs to be present in every
experience of a particular type. In Husserl‟s words (1913/1970: 45):
36
„The transition to the pure Essence provides on the one side a knowledge of the essential nature of the Real, on the other, in respect of the domain left over, knowledge of the essential nature of the non-real (irreal)‟
However, I suggest that the essence, or what makes a thing „real‟ for one
person may be at odds with what makes a thing „real‟ for someone else. This
was explicated earlier during the discussion of the Velveteen Rabbit. Indeed
it is this very diversity which I suggest contributes to the richness of the
research. The uncovering of different essences, which make up the
phenomenon as it is lived by the informants can only serve to enhance our
understanding. What makes the phenomenon different for each of us can
promote our thinking and development of knowledge. As discussed Husserl‟s
preoccupation was with clarity and the need for a reliable unquestionable
source of knowledge. Therefore it is not surprising that his philosophy
included tenets such as bracketing, intentionality and essences.
Husserl believed that there was a fact of the matter; an entity which is
independent of our experiencing of it. However it could be suggested that the
different essences which are of interest here are all relational, including our
relationship to our own emotions. Returning to the Velveteen Rabbit, the
„living‟ rabbits say that he cannot be real because he does not have any hind
legs (and indeed he doesn‟t). However he feels Real because he is valued
and, in this context, it could be argued that feeling Real is tantamount to
being Real. The Velveteen Rabbit‟s idea of what is Real, when it comes to
his own self image and emotions, is as valid as any other.
37
Exploring Husserl‟s work has raised many questions for me about the style of
phenomenology I intend to pursue. I have highlighted some perceived
problems in the preceding discussion. My main reservations about this
approach centre on the Husserlian idea that we can arrive at a true structure
of something and that this can be achieved in part through bracketing out our
pre-conceptions and experiences. What seems clear to me is that people
experience life in different ways and the meaning we ascribe to things differs
from person to person. This would seem to me to be at odds with Husserlian
thought therefore after exploring his work I turned my attention to the work of
Martin Heidegger.
Heidegger was Husserl‟s student and believed that every experience was
different and was perceived in a different way by each person. Existence can
only be discovered in relation to its context; for example, its culture and
relation to others (Fleming et al, 2003). The pre suppositionless „I‟ cannot
exist since we are all already involved in the world, we already have a
primordial style of knowing, before we are even conscious of it (Heidegger,
1926/1962). Already this seemed more in line with my epistemological
position.
The Phenomenology of Martin Heidegger
Frede (1993: 42) suggests that when considering „great minds‟ there is one
question which can be said to have guided their thinking. This is simple in
Heidegger‟s case; „what is the meaning of being?‟ That is not to say that the
question itself is a simple one. This ontological question with various
changes in meaning remained the focus of Heidegger‟s thought until the end
38
of his life (Frede, 1993). He viewed phenomenology as his way into ontology
(Heidegger, 1926/1962: 60):
„Phenomenology is our way of access to what is to be the theme of ontology, and it is our way of giving it demonstrative precision. Only as phenomenology is ontology possible’
(Note: when using direct quotes from the work of Heidegger, unless stated
otherwise the italics are in line with the original work). Heidegger rejected the
Cartesian view that we are subjects surrounded by objects which we try to
identify. He questioned the adequacy of the subject-object relation to things
and whether conscious awareness actually plays a part in our relation to the
world (Dreyfus, 2000). Heidegger (1926/1962: 98) describes a carpenter
hammering with a hammer as an example of how things just „go on‟ without
necessarily mentally processing them:
„…. but in such dealings an entity of this kind is not grasped thematically as an occurring Thing, nor is the equipment-structure known as such even in the using‟
As Dreyfus (2000: 257) explains, if the carpenter is hammering and the job is
going well, the hammer is almost invisible to him, he is not consciously
thinking about it; „He is not a subject directed, to the object, hammer‟. We are
in the world, amongst it all, coping with it, coping beings or even „being‟
beings, already in the world (Magee, 2000). Heidegger‟s concern was not,
how do we as subjects, have knowledge of objects. These things are so
transparent that they do not need to pass through the human consciousness
(Dreyfus, 2000). We are not outsiders looking in on a reality, we are already
in the world and this is where we start. Why would we need to prove the
39
existence of an external world? Heidegger‟s view was that we are all beings
living in an already existing world, in a sense, we are the world and the world
is us (Heidegger, 1926/1962: 78); „Being in the world indicates the very way
we have coined it, that it stands for a „unitary phenomenon.‟
In contrast to Husserl, Heidegger challenged the view that there is one
independent reality and that we can stand outside a situation in order to
generate theory (Koch, 1995). Of course there are times, going back to the
hammering example, when we do need to consider the hammer, for
example, if we have a faulty hammer then we will have to get a replacement.
However, we were not thinking about it all along. Heidegger describes
thinking about these objects in this way as „unreadiness to hand‟ compared
to „readiness to hand‟ which is when we are not thinking about the hammer
at all (Heidegger, 1926/1962: 98). This „unready to hand‟ state is where
Husserl is starting from, which according to Heidegger is a stage too late
(Dreyfus, 2000).
Dasein
According to Heidegger the self and the world are always already united in
„Dasein‟. Dasein is a German word which does not translate exactly into
English and may refer to a „single person or a „general way of being‟
(Annells, 1996: 706). Heidegger uses „Dasein‟ which translates as „being
there‟ to describe our connectedness with the world (Dreyfus, 2000: 263);
„…this activity of human being is an activity of being the situation in which
coping can go on and things can be encountered‟. In this sense, the situation
and our selves are linked; we are totally connected to the situation. Dasein
40
can be whatever it wants to be; this „being of humans‟ is different to that of
other entities (Inwood, 1997: 23). Dasein represents a possibility of many
ways of being (Heidegger, 1926/1962: 68); „The essence of Dasein lies in its
existence……in each case Dasein is mine to be in one way or another‟.
Firstly Dasein has „attunement‟, „the best example of which is mood‟
(Dreyfus, 2000: 264), and because of this things „matter‟ in some way. We
are born into a world which already exists and it is us who decides what
matters to us (Dreyfus, 2000). „Mood‟ relates to our already existing world
and is an awareness that we are alive occurring before conscious thought. It
is our bare existence before we start thinking, judging or being aware of
things. The second element is to do with discourse. In our daily world we
interact with what is already „articulated‟ using interpretation already evident
in public language (Guignon, 1993: 8). This could be a piece of equipment
for example, and Dasein articulates the significance of the equipment by
using it. Discourse helps us to make sense of the world and our own
existence. The third element of Dasein relates to the fact that we are always
moving towards something and „pressing into new possibilities‟ (Dreyfus,
2000: 265). As part of our everyday activity we are always working toward
the future although we do not necessarily have a specific goal or life plan in
mind. However, achieving goals leads us to the potential for our way of being
(Reed, 1994). These three elements are the structure of Dasein and relate to
the past, present and future (Dreyfus, 2000: 265):
„….being already in a mood so things matter, using things so as to articulate their capacities, and pressing into new possibilities – is the structure of Dasein itself‟
41
Reed (1994) believes that phenomenology in social science has
concentrated on the „articulation‟ element, that is, as phenomena as
immediately experienced by people, and not so much on the „attunement‟
(past) and „potential‟ (future) elements. Reed (1994) attempted a
phenomenological study to explore expertise in nurses working in long term
elderly care settings. Being inspired by the work of Benner (1984), Reed
adapted Benner‟s methodology and asked the informants to describe
significant incidents which demonstrated expertise. Her research was
curtailed as the nurses when questioned were unable to identify any
significant incidents since this was not how they viewed their work. They
preferred to discuss their work in more general terms, meaning that any
discussions about expertise based on specific incidents, was impossible. The
nurses questioned, had worked in that setting for many years and worked in
elderly care for longer. Reed later found that a group of first year student
nurses were much more able to isolate specific incidents. The feeling
amongst the students was that student life is more akin to a set of incidents;
the difficult part is being able to join them up. This is in contrast with the
qualified nurses who spoke in more general terms. Returning to
Heideggerian philosophy, Reed (1994: 338) viewed the generalisations in a
new light, in terms of attunement, „the way in which we meet experience‟ and
potential, „where our experience leads us‟. Reed herself seemed to have
focussed on the articulation element of Dasein and concludes that the other
elements of Dasein are often missing in phenomenological studies. Indeed it
would seem that some of the jigsaw of Dasein would be missing if we
concentrated solely on the where we are now, without exploring where we
42
have been and where we are going. In my study this will be interesting to
consider, especially since I have chosen to interview student nurses, who are
new to the profession, rather than qualified staff. However I have not
restricted myself to one particular year; I have chosen to interview students
from all three years which I hope should reveal where they have been and
where they see themselves going, in an emotional sense.
Dasein consists of possibilities of ways of being which may not always be
freely chosen by us. Indeed Dasein is already present in the world and we
„become Dasein‟ or „get Dasein in us‟ when we are socialised into the shared
practices and meanings and skills in the world and begin to do what other
people do (Dreyfus, 2000). Dasein is always „thrown‟ into a situation and
context „where things already count in determinate ways in relation to a
community‟s practices‟ (Guignon 1993: 8). Any action that is taken by us,
such as hammering, takes place against a backdrop of skills and practice,
what Heidegger calls „the world‟ (Dreyfus, 2000). Our relationship to the
world becomes possible through these shared practices and meanings which
already exist. Heidegger describes it thus (Heidegger, 1926/1962: 167):
„The Self of everyday Dasein is the they – self, which we distinguish from the authentic self – that is, from the Self which has been taken hold of in its own way‟
Thinking of human beings in this way, in terms of doing whatever everyone
else does, seems rather unsettling. It raises the question, can we never think
for ourselves and „be‟ in the way we think is right for us? According to
Dreyfus (2000), if we conform, this means leading inauthentic lives, doing
what everyone else does and saying what everyone else says, and
43
disowning Dasein. In other words we would disown our own authentic way of
being. Alternatively we can choose to lead an authentic life. Of course we
would still be doing the same things within authenticity (otherwise we run the
risk of being classed as too „different‟) but how we do them would change.
We all live in inauthentic ways for a lot of our lives as this is necessary for us
if we are to fit in with society. This is part of life and should not be seen as
such a bad thing, or as Inwood (1997:27) describes it, as an „unqualified
blemish‟. However we can from time to time make a decision to return to
authenticity. According to Heidegger, (1926/1962: 358) this state is very hard
to maintain and may lead us to a state of anxiety although it can lead to great
joy:
„Along with the sober anxiety which brings us face to face with our individualised potentiality - for - Being, there goes an unshakable joy in this possibility‟
I will now return to the nursing research to bring this idea to life. Nelms
(1996) describes the possibility of authentic being in a Heideggerian analysis
of „living a caring presence in nursing‟. Nelms analysed five stories written by
nurses which described living a caring presence. „Brenda‟ described a
patient „Marge‟ who was admitted to a „trauma-neuro‟ unit and needed more
intensive treatment than the unit was set up to cater for. Marge started by
being described as a „good patient‟ but then became more and more
questioning. This already „inappropriate‟ admission became more demanding
and then finally Marge asked for someone to sit with her all of the time. Each
nurse was assigned to Marge on different days to prevent burn out, although
Brenda finally recognised that Marge was herself becoming burned out and
44
„slowly dying alone‟ as nobody really knew her schedule. Eventually Brenda
assigned Marge to herself, managing to sort out her pain relief, getting her to
a stage where she could be more self caring, and giving her time to talk.
Marge was then no longer alone and not using the call button. I have
explained this data in detail as Nelms (1996: 372) describes this story as a
„paradigm experience of the call of conscience‟. Nelms (1996) describes the
staff as having fallen into the „„they‟ of nursing‟, in that they were doing what
everyone else was doing and not nursing in an authentic way. Brenda had
found her way to authenticity by hearing the „call of conscience‟, another
Heideggerian term which comes from Dasein.
Dasein is never completely lost in the „they‟ (other people) and can respond
to the „call of conscience‟; it keeps a „residual awareness of its authentic self‟
and it is this that means that Dasein can at times call to itself and respond to
that call (Inwood, 1997: 80). Conscience calls to everybody all of the time
although „not everyone responds to it, and no one responds all the time‟
(Inwood, 1997: 79). Conscience in the Heideggarian sense is a voice within
ourselves which calls us to make choices and take responsibility for our
actions. Heidegger (1926/1962: 314) states, „The call of conscience has the
character of an appeal to Dasein by calling it to its ownmost potentiality – for
– Being – its – self…‟
Brenda heard her call from inside herself and was then moved into an
authentic way of being. Nelms (1996: 372) describes the „silent call‟ which
came over Brenda. In Brenda‟s words;
45
„I knew deep inside that I cared about this woman and her experience. So I took over co-ordinating her care and assigning her to myself every day‟
Heidegger describes the state of authenticity, when one has attended to the
call of conscience, as „resoluteness‟ (Heidegger, 1926/1962). However he
suggests that this state is hard to maintain due to the anxiety which goes
with it. So we can „flee into inauthenticity‟ or keep the anxiety and be „thrown
into a different way of being human‟ (Dreyfus, 2000: 267). In a profession
which involves working with people, psychologically it is suggested that there
is a requirement for „professional detachment‟ (Menzies, 1960: 102).
Considering Heidegger‟s thoughts on inauthenticity, behaving „not as
ourselves‟ is behaving in an inauthentic way. This is reminiscent of the
techniques described as the „social defence system‟ as discussed earlier
(Menzies, 1960) which assist the individual in avoiding uncomfortable
feelings such as anxiety and indecision. As humans we may not normally
behave in this way and it is the culture of the environment which promotes
this behaviour. In fact, the social defence system does little to alleviate and
may indeed promote feelings of anxiety within nursing (Menzies, 1960). For
example, working in a task orientated way may alleviate the anxiety arising
from becoming „closer‟ to one patient. Conversely, anxiety may actually
increase as the satisfaction which accompanies efficient working practice is
rarely experienced (Menzies, 1960). In addition, there may be some anxiety
related to ignoring the „call of conscience‟, or at least a psychological price to
pay. Encouraging detachment may cause more stress than being „allowed‟ to
become closer to patients, which may be a more authentic way of being for
most nurses. Taking this view may be problematic since according to
46
Heidegger (1926/1962) behaving authentically may also cause stress. This
discussion of Heideggerian thinking on authenticity is important as I suggest
it could have meaning in my own study. It will be interesting to explore
whether the encouragement of a detached stance is still prevalent in nursing
life today and if so, what effect it has. Secondly, does the thought or the
actual effect of behaving authentically, in this case, not like everybody else,
cause anxiety and stress? Thirdly, how is the anxiety and stress caused, by
whatever reason, recognised and managed by student nurses?
As I am leaning toward a Heideggerian approach, I thought it would be
worthwhile exploring research studies which have been underpinned by
Heideggerian thought. My first impression of Heidegger‟s work was that it
seemed very complicated and at that stage I was not clear about what would
be involved in the actual practicalities if I was to adopt this way of working. Is
a Heideggerian phenomenological study „do-able‟? It seemed prudent to
begin with the work of Draucker.
How could Heidegger help me with my study?
Draucker (1999) provides a critique of Heideggerian hermeneutic nursing
research over the preceding ten years. The aims of the critique were firstly to
ascertain whether the methodology used was consistent with Heideggerian
philosophy. The second aim was to review the extent to which the findings of
the studies were „informed and enriched‟ by Heidegger‟s writing (Draucker,
1999: 360). It is important, if staying true to Heideggerian philosophy, to see
a merging of the informants‟ perspectives with those of the researcher, along
with other data sources. The process by which these viewpoints have been
47
merged should be transparent to the reader (Draucker, 1999, Koch, 1996).
Indeed the reader may come to a different conclusion upon reading the
analysis and interpret the findings of the research in a different way to that of
the researcher. Each of us has our own „interpretive lens‟ and texts are open
to many different interpretations (Ray, 1994: 117). In addition although
obvious reference to Heideggerian thought as seen above may not be
necessary to stay true to the tradition, in order to explicate further the
philosophical stance of the researcher, explicit reference to his thought
seems appropriate (Draucker, 1999). Frameworks such as the one proposed
by Diekelmann et al (1989) may also be used when analysing data collected.
As with the Husserlian phenomenological studies, Paley (1998) is critical of
what he describes as „lived experience research‟ (LER) which he believes to
be based on a misinterpretation of Heidegger‟s work. He believes that many
of these studies are Cartesian in their approach which is at odds with
Heidegger‟s ontology. Paley (1998: 823) suggests „Experience has been
stripped off „world‟ by the LER programme, and has been designated the
nursing research enclave‟.
Merely describing experiences is at odds with the union of self and world, the
„unitary phenomenon‟ as described earlier. He cites the study undertaken by
Koch (1996) which investigates older people‟s experiences of being in
hospital. Indeed Koch does describe the experiences of older people
although she does not claim to present a Heideggerian analysis within it.
However, returning to the elements of Dasein, there are some nurse
researchers who explicitly refer to Heideggerian thought when analysing their
data. For example, Gullickson (1993) explored the experiences of patients
48
with chronic illness; „being towards death‟ (Heidegger, 1926/1962). However
it was Nelms‟ study, mentioned earlier, which I found the most fascinating.
This was because the subject was related to the focus of my own study and
also because of its explicit discussion of Heideggerian themes; the call to
conscience, being at home in the world and „falling‟ into the inauthentic
practices of the „they‟ for example. However as Draucker (1999) states,
Nelms (1996) does not fully „co-constitute‟ the data. Her presence in the
research may have been more explicit if she had written her own story of
„living a caring presence‟ to place alongside those of the informants. As
Draucker continues, one researcher who does make explicit her own
personal thoughts is Koch (1996), whose father had died in hospital following
a fall the previous year. This will have an influence on how she appears
through the data and from a credibility point of view Koch (1996) suggests
that this can be useful, as it shows how decisions have been made and how
interpretations have been reached. However this is not the only reason for
researchers to make themselves visible in the research. Researchers take
part in making the data alongside the informants. A way to record the pre
understandings which make up the researcher‟s data is through use of a
reflexive journal (Koch, 1996). Koch (1996) viewed this as an essential act in
recording her own way of thinking. Understanding is reached through the
merging of the two data sources that is, the thoughts of the informant and
those of the researcher. The journal consisted of Koch‟s interpretation of
events which were influenced by her background both personal and
professional. Further interpretation and understanding is reached over time
and as Koch (1996) suggests, others who then read the dialogue may reach
49
another interpretation altogether. The dialogue which takes place between
the researcher and the text which is formed following interpretation of the
informant‟s story may be seen as a dynamic one, with no end. This implies
that it is circular in nature although this should not be viewed as something
which prohibits progression, rather as something to deepen our
understanding, allowing forward movement in the circularity.
Before returning to the issue of bracketing, I think it would be worthwhile
summarising my position on phenomenology so far. Having unpacked the
views of many other authors, and read some of Heidegger‟s work already, it
is time to articulate my own view and understanding.
As I have already suggested, I feel that phenomenology underpinned by the
philosophy of Husserl, would not be the best fit for my purposes. Emotional
nurse being, in my view, cannot be „defined‟ in a way that will stand the test
of time. The way in which we identify and manage our emotion is different for
us all and no single definition exists. My thinking is more in line with
Heidegger in that all of our „being‟ is context bound which on the one hand
makes life more fascinating although on the other raises more challenges, as
the „one size fits all‟ approach to life cannot work.
With this in mind, the following summarises an emerging plan, based on my
understanding thus far:
50
· Heideggerian thinking will be explicit throughout the work. I suggest
that the findings can be enriched through consideration and
application of his thinking throughout.
· The work will be organised in such a way as to value the uniqueness
of each informant‟s thoughts rather than focus on the generation of
common themes. Similarities between the interview data will be
acknowledged, and these could be described as themes, although the
primary focus lies with what makes emotional nurse being different for
each informant, rather than what makes it the same. This is in line
with the philosophy that suggests that all being is context bound and
will be different for everybody, albeit it is acknowledged that we
subscribe to common practices and shared meanings in order to fit in
with the life -world we inhabit.
I will now return to another important aspect of this approach, the subject of
hermeneutics.
Hermeneutics and the hermeneutic circle
As stated earlier it is my belief that the researcher‟s pre understandings and
past experience of the subject matter serves to enrich the data rather than
invalidate it. Rather than use bracketing in order to promote validity,
Heidegger introduces the notion of the hermeneutic circle which values our
pre understanding of situations and ourselves as already in the world.
Hermeneutics is derived from the Greek word hermeneia. Hermes was a
Greek god who interpreted messages from the Gods for mortals to
understand (Thompson, 1990). Indeed the main focus of philosophical
51
hermeneutics is related to understanding (Annells, 1996). According to
Gadamer, a philosopher mentored by Heidegger, understanding and
interpretation are very closely linked (Gadamer, 1960). Heidegger presents
an interpretive phenomenology which views us as self interpreting beings
(Koch, 1995). Interpretation is based on our historicality (Heidegger,
1926/1962: 191):
„In every case interpretation is grounded in something we see in advance – in a fore having….An interpretation is never a pre suppositionless apprehending of something presented to us‟
In contrast to Husserl, rather than bracket out our pre understanding of
something, research undertaken in this way, values understandings we
already hold. Our new understanding is made from corrections and
modifications of our pre understandings (Koch, 1995). This may seem like
we are going round in a circle although this is necessary for our
understanding.
An example of the hermeneutic circle and its use is described by Walsh
(1996). Walsh (1996) describes his frustration when asking nurses to
describe a significant encounter with a patient they had met. The nurses
questioned could not stick to the encounter itself and would start to describe
how long they had known the patient, their feelings for them and other
background details. What in fact they were doing was moving between their
total relationship with the patient to the smaller part of the detail of the
encounter and back again, in a circular motion. This leads to further
understanding in that encounters can only be understood and interpreted, in
relation to the backdrop of the whole relationship (Walsh, 1996). Alongside
52
this process sits our pre understanding as nurses and the two horizons,
those of ourselves and our informants are merged to make new meanings.
Our pre understanding is crucial and if we view it as a „blemish‟, or
something which we need to rid ourselves of, then the chance for
understanding is lost (Heidegger, 1926/1962: 194):
„But if we see this circle as a vicious one and look out for ways of avoiding it, even if we just sense it as an inevitable imperfection, then the act of understanding has been misunderstood from the ground up‟
Heidegger did not believe in an „external vantage point‟ from which we can
take a disinterested view of things (Guignon, 1993: 6). Indeed it is inevitable
that we bring with us some „baggage‟ in terms of our understanding of the
world described by Heidegger as „fore-having‟, „fore-sight‟ and „fore-
conception‟ (Heidegger, 1926/1962: 195). Fore-having refers to our own
„background practices‟ which illuminate the world and make our
„interpretation possible‟; fore-sight refers to the „background practices‟
accompanied by a „point of view from which the interpretation is made‟; fore-
conception refers to „background practices‟ which help us to create an
expectation about what we may anticipate in our interpretation (Geanellos,
1998: 155). These „pre understandings‟ are already in the world with us and
cannot be bracketed. For example, being human makes some interpretation
possible, although being a nurse adds another level of background practice.
This is accompanied by my point of view which is, for example, that
emotional self awareness is an important part of the nurse‟s lifeworld which
helps nurses not only understand their own emotional needs but also the
emotional needs of others. I anticipate that the „good‟ nurse understands that
53
being aware of their own emotional self, helps with the process of developing
relationships with others. As part of the hermeneutic circle, this „pre
knowledge‟ and understanding of the world can lead us to even greater ways
of knowing (Heidegger, 1926/1962: 195):
„In the circle is hidden a positive possibility of the most primordial kind of knowing. To be sure we genuinely take hold of this possibility only when, in our interpretation, we have understood that our first, last, and constant task is in never to allow our fore-having, fore-sight and fore-conception to be presented to us by fancies and popular conceptions, but rather to make the scientific theme secure by working out these fore structures in terms of the things themselves‟
We need to bring our „pre understandings‟ into focus so that we can
endeavour to understand them more fully (Koch, 1995). To help answer
Heidegger‟s question of the meaning of Being we must explain our „being in
the world‟ beforehand (Heidegger, 1926/1962: 42). It is only when we hold
them up to be scrutinised that we can go on to understand in different ways.
With these ideas in mind I am now able to present further ways of working
which make up the phenomenological approach I intend to take;
· My pre understanding will be explicitly stated to provide the reader
with my understanding of emotional nurse being. This provides a
sense of my way of being when analysing and interpreting the data. It
can also serve to make the piece more trustworthy as my viewpoint is
clear from the start.
54
· The data will be co-constituted to create a new „whole‟ of meaning.
The interview data will be merged with my own reflection where
appropriate alongside the literature already available on this subject.
In this way it is hoped that different insights and thinking on the
subject will emerge.
How is examination of pre understanding achieved?
Geanellos (1998) in a study on residential adolescent mental health nursing
generated twenty statements, which she then interpreted and re
conceptualised. This process helped prevent her „only finding what I already
assumed I would find‟ (Geanellos, 1998: 238) as her understanding was
examined beforehand. Pre understanding was described by Gadamer as
prejudice (Gadamer, 1976). The term prejudice may have a negative
connotation in today‟s society although Gadamer presents it in a more
positive light. Rather than view it as something which we should try to get rid
of, Gadamer views prejudices as pre understandings, and as our way into
the world. They are the means by which we understand the world
(Gadamer, 1976). We bring an attitude to everything we encounter, and
being aware of what the attitude is, can help us be prepared to modify it.
Generating statements as Geanellos did could be viewed as a useful starting
point when attempting to draw out ideas we already believe about our
subject. However, I suggest that this could be problematic as our ways of
thinking and viewing our subject matter can and does change over time.
Indeed Fleming et al (2003) suggest that our pre understandings change
55
throughout the process of the research through ways such as data collection
and interpretation, further reading and the keeping of a research journal. We
need to keep a check on changes to our pre understandings as the research
develops and one way to do this is via conversations with colleagues; our pre
understandings then become visible and we can document and analyse
them in the research report (Fleming et al, 2003). As researchers, pre
understandings can assist us in reaching the first understanding and
interpretation of the research stories we collect. From this primary
understanding our initial interpretation can take place (Walsh, 1996).
As a nurse lecturer I hold pre understandings about the importance of
emotion within nursing practice. Unless I examine these, my interpretation of
the stories I gather from my informants, may not reveal their „true‟ thoughts
and words. This would mean that the ensuing texts are based on my pre
understandings and the voices of the informants would be lost. A new and
deeper understanding is reached by my placing my thoughts alongside the
voice of my informants. As Walsh (1996) suggests, these new
understandings may not have been reached had I tried to bracket out my pre
understandings. In this sense, prior thought is used as an aid to the
researcher rather than being viewed as something which may distort the
truth of the situation. The interpretation that is reached is firmly grounded in
the facts as told by the informants although it is my interpretation. However,
having explicated my prejudices relating to the use of emotion in nursing
work, the interpretation which is reached is clearly visible to the reader, who
is then at liberty to reach a different interpretation if they so choose. Koch
(1996) provides an example of this in her study of older patients. Her father
56
had died in hospital following a fall the year before she undertook her
research. As she states, „…it was inevitable that falls became very important
in my interpretation of the data‟ (Koch, 1996: 179). Her awareness of this
influence could lead her to ask questions she may not have asked before
and come to richer understandings, having been very close to the same sort
of situation herself.
How much do you want to know?
I can see explication of pre understandings as being important to the
development of the research, although the process of doing it remains
problematic. This is because by its very nature it involves some sharing of
the self with both the informants and the reader of the completed research.
On the one hand there has to be enough sharing to make it a worthwhile
exercise but on the other, how much is enough? It would be embarrassing
and inappropriate to discuss my own thoughts and experiences at the cost of
other voices. The danger is that the research turns into a narcissistic
exercise with me always being at the centre of my own narrative. The choice
to be made is how much of our self we choose to use and expose in the
research. Finlay (2002) suggests that researchers should question how to
bring themselves into the research rather than question whether they need
to. Qualitative researchers should accept that they are „a central figure‟ within
the research process and research is „co-constituted, a joint product of the
participants, researcher and their relationship‟ (Finlay, 2002: 212).
Furthermore, in terms of staying true to Heideggerian philosophy, stating pre
understanding, in this sense by describing my reflective thoughts would be
seen as necessary. If we subscribe to the belief that we interpret events and
57
situations based on our background pre understanding then it would seem
strange not to explicate what that background was. It could be difficult for the
reader to understand my interpretation of an event described by an informant
if they were not privy to my reflective thoughts at that time. I suggest that if I
do not state my reflective thoughts and stories then I would be working
outside the hermeneutic circle. The world that I already understand can,
through the data, be modified so that I understand differently (Heidegger,
1926/1962). I suggest that if I do not write reflexively I would be unable to
continue with a Heideggerian study.
However the reflexive process is a difficult one, described by Finlay (2002:
532) as treading „a cliff edge where it is all too easy to fall into an infinite
regress of excessive self-analysis‟. It almost seems too fraught with difficulty
to proceed. Etherington (2004) discusses different ways to bring the self into
the research process giving examples such as poetry, dreams and painting
amongst others. She charts her own and others‟ journeys to becoming
reflexive within research. Interestingly she did not feel confident to position
herself explicitly in her doctoral thesis. (Etherington, 2004: 19) states:
„By the time I came to write up my PhD, I believed that even though it might be acceptable to use my self in the field of counselling, in the wider world of academia my subjectivity and reflexivity would almost certainly be seen as self-indulgent or narcissistic....‟
However, she goes on to say that when she decided to write a book, after
being awarded her PhD:
58
„...I was less concerned about the judgements of the „academy‟ and more concerned with producing a book that was readable...and in using methods that were in tune with my personal philosophy, worldview and ways of knowing, and which satisfied my ethical beliefs about conducting research‟
Concerns about whether her reflexive writing would be recognised as being
valuable at PhD level led Etherington to wait until post doctoral work to „come
out‟ reflexively and it was only then that she felt comfortable staying true to
her personal beliefs in a public arena. She gives examples of other students
who have done the same.
I now feel faced with something of a problem; maybe I should take the
cautious approach and take myself out of what I write. In this way my work
may be more acceptable to a wider academic community. This would of
course compromise what I believe research to be about and all that I
subscribe to from a philosophical perspective. Conversely I could leave
myself in the work knowing that even though to some, this may be viewed as
narcissistic and too subjective, to me it would be a more meaningful piece of
work in line with my philosophical beliefs. Ultimately I have to write a
meaningful piece of research, although achieving a balance between how
much of myself features alongside the voices of others will be important.
In light of this discussion my belief is that my pre understandings need to be
identified if I am going to move beyond them to understand the
phenomena of interest in a different way in this research. Before
commencing this study I already held the belief that reflective practice was a
sound way to promote my learning (one which I advocate to student nurses
as being valid). I have maintained a reflective journal about the thoughts I
59
had before starting the research „proper,‟ for example, the thoughts relating
to my choice of topic. Finlay (2002) suggests that the reflective process
should begin at the same time as the topic of the research comes to mind.
She suggests an examination of „motivations, assumptions and interests in
the research‟ as a way to identify issues which may take the research in one
direction or another (Finlay, 2002: 536). Therefore I intend to continue this
practice. This will enable me to analyse my thoughts and experiences, which
will include exploring feelings on my own emotional experiences as a nurse.
As a nursing student my over-riding aim was to connect with patients
emotionally. Being able to intuit how someone was feeling without them
needing to speak was in my opinion the ultimate nursing care. This has been
a huge motivator in my choice of research topic. My pre understandings are
regularly questioned by colleagues during peer support meetings, which
involve other research students who are within my discipline and a
supervisor who is experienced in facilitating groups of this kind. Therefore I
will use this group to assist me in reviewing my pre understandings, which
will enable me to remain focussed on the phenomena in question. However I
also wish to replicate the practice of Geanellos (1998) who explicitly
generated and interpreted twenty statements relating to the prejudices she
held relating to the phenomena under study. The statements were written
spontaneously and reflectively and reflected the researcher‟s beliefs about
the nature of adolescent mental health nursing (Geanellos, 1998). However, I
suggest that generating the statements only leads to superficial
understanding and the statements could be viewed as only being valid at
that moment. Life changes, and over the course of my study I am sure that
60
there will be many new influences on myself and my work. I may even
disagree, by the end of the study, with the statements I generate now. It
could be argued then that there is no point in generating statements so early
on although if, as researchers, we are going to acknowledge our presence in
the co-creation of the text, it is important to go through this process before
rather than after the interviews (Geanellos, 1998). However, even as I write
my statements down it seems almost like a forced and artificial exercise with
almost positivist leanings. Is it really so important at this stage to get these
thoughts out into the open? If we believe, as Heidegger suggests, that all of
life is linked to experience, then experiences will change and my
understanding of the situation will change as the work progresses. Smith et
al (2009) state that it is only when we engage with the text, that we are in a
position to consider what our pre understandings were. It is almost like
reading a text reminds us of what we thought about it beforehand.
However, including my pre understandings gives the reader a sense of
where I am and who I am as a person before data collection starts. It is an
important process to undertake especially as pre understandings may
unconsciously present an obstacle to the interpretation of the data. By
getting them „out in the open‟ I can question them and use them
constructively to make different meaning of the data. Having said that, I
predict that a lot of my past thinking will only surface when triggered by
listening to new stories and it may only be then that I can fully work out my
pre understandings of the phenomenon in question.
61
Pre understandings (based on Geanollos, 1998)
I began by asking myself the following questions:
· What are my strongly held beliefs about pre registration nursing
before interviewing?
· What are my stories about my practice as a pre registration nursing
student?
· What are the key statements from these stories which act as my pre
understandings?
I then reflected on these thoughts, feelings and stories which are essentially
what could lead me to „premature interpretative closure‟. Doing this helped
me to create the following ten statements.
Statement One
The nurse creates an emotional home for the patient.
Statement Two
The good nurse is emotionally self aware.
Statement Three
The patient needs emotional support.
Statement Four
Emotional care is central to effective nursing practice.
62
Statement Five
The background practice of nursing is not conducive to providing emotional
support.
Statement Six
It is easy to ignore emotional needs, as they may not be as visible to the eye
as physical ones.
Statement Seven
Caring for patients‟ emotional needs comes at an emotional cost to the
nurse.
Statement Eight
Nurses set the emotional tone of the environment and „allow‟ certain
amounts of display on both sides.
Statement Nine
Emotional support is not always valued by the profession.
Statement Ten
Providing emotional support is hard work, requiring the nurse to „perform‟.
From the statements generated I have made the following assumptions:
· Emotional support is valued by patients.
· Emotional support is difficult for nurses and comes at a cost to them.
63
· Emotional self-awareness and monitoring could help with this.
· Some nurses find this work too hard and disengage with the process.
· The background, for example the cultural environment, is important.
Going through this process has felt valuable in that it has encouraged me to
think about a „baseline‟ relating to my starting point in relation to the
research. However, it seems to only scratch the surface, by which I mean it
does not enable depth of feeling to manifest itself and many statements are
context specific. For example the phrase, „the background practice of nursing
is not conducive to providing emotional support‟ could be viewed as a
generalisation and not true of certain areas. Moreover, just because
background practices, whatever they may be, are not conducive to emotion
work, nursing staff may still provide emotional support. So already, at this
early stage, I am questioning my pre understandings! I view this as a positive
consequence of this exercise in that if I am not prepared to question my prior
thoughts then how will I write a critical piece of research? In addition, whilst
interviewing, thoughts and reflections could be triggered which could add to
these statements. I will endeavour to include these as I continue with this
study and in each case discuss what they mean to the study in the sense of
the interpretation.
Fusing horizons
The importance of our historicality cannot be underestimated as it has an
effect on all of our future understanding (Heidegger, 1926/1962).
Understanding grows when we transform our own position and that of the
64
„text‟ in what Gadamer terms a „fusion of horizons‟ (Gadamer, 1960/1989:
302). Our horizon represents „the range of vision that includes everything
that can be seen from a particular vantage point‟ (Gadamer, 1960/1989:
302). We understand differently when the horizon of another fuses with our
own thus extending how far we can see, but how exactly do we achieve this
fused state? As suggested earlier a problem when undertaking interpretive
hermeneutic studies is the lack of guidance on how to do it (Holroyd, 2007).
As Holroyd (2007) suggests, the importance lies in the uniqueness of the
researcher and their horizon. Trying to find solid examples may lead the
researcher to begin from a fixed meaning or horizon, for example, one which
represents the view of another. By doing this we can restrict our opportunity
to reveal different meanings which will be unique to us and our interpretation.
This is another reason for not undertaking an extensive literature review prior
to beginning the data collection. We risk rediscovering what we have already
read. What Gadamer encourages us to do is consider the potential of our
own consciousness in the pursuit of different understanding; and trying to
apply a fixed method can prohibit this from taking place (Holroyd, 2007). I
suggest that this could be problematic at the analysis stage of the research.
For example, Diekelman and Allen (1989) developed a seven stage
approach to analysis in their hermeneutic study of the criteria for appraisal of
Baccalaureate programmes. This process involved a team approach in which
each team member‟s interpretation of the documents was compared with
others to ascertain any differences or similarities. This was repeated in an
attempt to reach group consensus in interpretation, and served as a means
of bias control, although I suggest that this could perhaps allow the stronger
65
willed or more „senior‟ group members to be granted priority. By using this
method inaccurate interpretations which were seen to be unsupported by the
text would be exposed (Diekelman and Allen, 1989). However I suggest that
using this approach is problematic when grounding a study in the
Heideggarian tradition. Firstly, bias is seen as something which should be
identified and used to assist in reaching full understanding and secondly as
researchers we will each interpret text in a slightly different way. This does
not make our interpretation any more „inaccurate‟ than the next researcher. It
just makes it „different‟ and this is something that as interpretive researchers
we need to accept. Indeed in a more recent paper (Andrews et al, 2001) in
which Diekelmann was a co-author, the point is made that, „...an underlying
assumption of hermeneutical analysis is that no single correct interpretation
exists‟. Our interpretation of data may even be different to that of the
informant, and consensus may be difficult to reach. Indeed we need to
consider the potential of our own consciousness in the pursuit of different
understanding; trying to apply a fixed method can prohibit this from taking
place (Holroyd, 2007).
I will return in more detail to the approach used for data analysis later in the
work. Before this I need to think about the informants and how they will be
chosen.
Sampling
Before I go on to discuss my choice of method I will discuss how my
informants were chosen. Gray (2005: 87) provides a concise description of a
purposive sample as one in which „the researcher deliberately selects the
66
subjects against one or more traits to give what is believed to be a
representative sample‟. As suggested by Steeves (2000: 50), the „picking
their names from a hat‟ method is not suitable for hermeneutic
phenomenological research where the focus is on gaining in depth
information. Indeed purposive sampling could increase the possibilities of
gaining rich data. The emphasis here is not about generalising findings but
on gaining a different understanding of the phenomenon in question.
However, I suggest that it does seem to be something of a crystal ball
exercise, in that we do not know for sure, even though we have hand-picked
the informants, whether they are going to tell us anything during the interview
itself. The most „purposive‟ informant may in fact tell us very little during the
data collection stage. All of the student nurses on the programme will have
been exposed to practice and therefore will have experienced the emotional
nature of the work, therefore all sharing a similar trait. However, I have to
accept that some student nurses may be totally unmoved by the nature of
the work. In addition, I cannot assume that they will all be forthcoming in an
interview; therefore another „filter‟ had to be applied. Due to the emotional
nature of the interviews I felt that I had to choose students that I knew a little
better, for example my personal students with whom I had already forged a
relationship. Choosing these students could also protect against the issue
just mentioned, that of the student who may be „naturally‟ emotionally
detached. I felt that by choosing this sample, the students might feel more
comfortable with me and be more willing to share their stories. According to
Steeves (2000: 50) a principle of hermeneutic phenomenology is not to look
at variables within groups of people but to look at informants, „...as people
67
who offer a picture of what it is like to be themselves as they make sense of
an important experience‟. This reinforced my view that I should choose
students that I felt I knew a little better, who may feel more relaxed in my
company having already met me a few times, so that they really could „be
themselves‟.
I planned to interview a total of fifteen students for this study. This figure was
based on my analysis of phenomenological studies that I had found
particularly meaningful. For example I have already discussed Nelms (1996)
who explored living a caring presence in nursing. Nelms‟ (1996) study
involved five nurses who each told a story of what it meant to live a caring
presence. Walters‟s (1995) study exploring the caring experiences of nurses
working in an intensive care unit involved eight nurses. Morse (1994)
recommends a sample size of six informants when undertaking
phenomenological research. Patton (1990) states that in qualitative work it is
the quality of the information gained which is important, rather than the size
of the sample. If the sample size is too large, there is a risk that detailed
analysis cannot take place (Sandelowski, 1995). I decided to aim to interview
fifteen students and I appreciate that this was more than the sample sizes
described in the above studies. This was for two reasons. Firstly, I believed
that in reality the students probably would not want to say much to me.
Interviewing fifteen would allow for this, whilst offering some protection
against the threat of ending with insufficient data to enable useful research.
Secondly, I felt that if I aimed to interview fifteen, then I may in reality only
get around eight students to talk to me. This was working on the basis of
asking for twice as much as I thought I would actually get. My confidence as
68
a researcher at this time was low, and even though I hoped differently, my
belief was that students just would not want to talk or engage with the
research.
Method - Interviews
Interviews are used to help the researcher understand not only the
experiences of another person but also the meanings they give to their
experience (Seidman, 1998). They can be useful when trying to understand
the world from the informant‟s perspective (Kvale, 1996). However,
sometimes that perspective can be very difficult to discuss and interviews
have the potential to provoke hidden emotions which may be very painful to
reconsider (James &Whittaker, 1998). This issue will be among the ethical
considerations discussed later in the work.
Initially I did not feel confident to use an unstructured approach to the
process. I designed a structured interview schedule with questions arranged
in order to ensure that the process did not „dry up‟. On reflection this
approach was too restrictive. I piloted the schedule with two students and,
indeed, it was inhibiting. It led to stilted conversation, with the informants
never getting into a flow about their experiences, let alone attempting to
ascribe meanings to them. The Heideggerian hermeneutical study by Nelms
(1996) presents a series of stories written by five participants enrolled on a
master‟s level nursing course. The poignancy of the stories at times made
them difficult to read and the power of this approach, however upsetting
some of the stories were, was appealing to me. I wanted to reproduce
something similar and agree with Nelms (1996: 369) who states:
69
„When we listen for the stories of our colleagues or clients we are practicing hermeneutically and, as such, hermeneutics has the potential to increase our understanding of our everyday lives, transform our thinking and create for us a future of new possibilities‟
By reading others‟ stories our thinking can be transformed; we can begin to
view things in a different way and our „bigger picture‟ can change. Reading
the stories Nelms presents, my ideas about how to conduct the interviews for
my research changed. I decided to structure them in a way which asked the
informants to tell stories about their practice, times which they found
emotionally challenging in a good or bad way. I considered that they may
think that I would only want what they thought to be „emotion laden‟ stories or
alternatively, tell a story which may not be of interest to me. However as
suggested by Kahn (2000) if the informants do not include something as part
of their story, then it was probably not an important part of their experience
and so not worth pursuing on the part of the researcher. Kahn (2000) gives
examples of opening questions such as „Tell me of a time recently which was
particularly happy‟ or „Tell me the most important thing that has happened to
you recently‟. I initially decided on the question „Can you tell me a story, one
that you will never forget, about living an emotional presence in practice?‟ In
doing this I was using the same question as Nelms used, just substituting the
word „emotional‟ for „caring‟. I worried that the question may sound a little
abstract and so I reconsidered and assisted by the thoughts of McCracken
(1988) decided on an initial question, „What is it like to be a student nurse,
from an emotional point of view?‟ A second question was, „Tell me about a
time, one you will never forget, that was emotionally significant to you?‟ Apart
from these two questions I decided not to commence the interviews in any
70
other way. I decided to let the informants guide the process with me
intervening and probing when necessary. By this time, I had gained a little
more confidence in my ability to conduct an interview and was feeling less
nervous. I suggested to the informants that the interviews could last up to
one hour although I also told them that they could end the interview at any
time. Describing not only a story, but the meaning of the story, could be
rather time consuming with Seidman (1998) suggesting as long as ninety
minutes. I had to be mindful that all of the students were being interviewed in
their own time and I did not want to take advantage of their kindness. As
many came for interview at lunchtime, an hour seemed acceptable. Holloway
and Wheeler (1996) suggest that the informant should determine the length
of the interview. With this in mind I decided to let the interviews continue for
as long as the informant continued to talk to me, believing that when they
had had enough, the interview would come to a natural conclusion.
In line with my earlier discussion about the amount of myself that should be
visible in the thesis, I needed to consider how much of myself I shared in the
interviews. Gough (2003) explores this issue when discussing focus groups
undertaken to investigate masculinity. He describes different types of
researcher intervention, such as „researcher as pundit,‟ which describes
times when his intervention during the focus groups could be deemed
narcissistic. This is when the researcher gets involved in the conversation
but not on a personal level, more like a sports commentator, reflecting back
what has been said by a fan but with more jargon. This avoids the need to
get involved in a more personal honest way, more valuable to the
development of the meshing of views, which is so important to this style of
71
research. On reflection, I myself am aware that I often reflect back what a
student has said but perhaps with reference to some research which
supports my point. Without doubt I do this to support the student and confirm
to them that this is a valid point, backed up by research on the subject.
However within the research interview interventions such as this could
influence the structure of the conversation even though it can help to make
the researcher feel more secure. Gough (2003) describes another type of
intervention, which is the researcher as „professional‟. Roles may be
reversed during the research interview and it can be easy to feel vulnerable
or self-conscious as a researcher, especially when the interviews are with
students. To a certain extent the student in this scenario is the „expert‟ as
they hold the information the researcher needs. Even though I have been a
student nurse, I do not have contemporary experience of student life having
been qualified for almost twenty years. Kvale (1996), states that the research
interview can never be equal in nature and in this case, the power was with
me as lecturer. However, from my current perspective, since without the
student my study was a non-starter, I suggest that the informant was indeed
in quite a powerful position.
Usually there is a „distance‟ between myself and the students, in that they do
not know much about me as a person. I do not divulge personal information
to students as I feel that this would be inappropriate. Therefore I wondered at
this stage how much of me it was acceptable to reveal during the interview
without disrupting my future relationship with them. Kvale (1996) suggests
that there should be some reciprocity in what an informant gives and
receives when participating in research. If I had extended this point of view
72
as far as the information exchange, it would have been reasonable to reveal
some of myself during the interview and indeed, I could argue that this is in
line with my chosen reflexive approach to my work. However this could be
problematic in that firstly, I would not want to burden the informant with
emotional stories of my own and secondly, I would feel uncomfortable
revealing personal issues. This could leave the informant feeling worse post
interview than when they entered the interview room. Hubbard et al (2001),
state that when researchers share their own stories it becomes difficult to
maintain any professional detachment and this is something that I had to
accept. I agree with Gough (2003: 157) who suggests that researchers
should go into interview situations with „open minds‟ and continually monitor
themselves during and following the encounter. This required self-awareness
on my part to be able to closely monitor my feelings and thoughts about the
situation. I felt that if bringing in some of my own feelings and thoughts about
past emotional encounters would be constructive and may even help the
informant to make sense of their own feelings then I would proceed in that
way. This would not entail me revealing extremely personal information as I
envisaged I would be talking about situations I had been in as a nurse rather
than burdening them with my own angst. Realistically, I suggest that until
researchers are in an interview situation, it can be hard to predict what will
happen although remaining aware of the potential issues is sensible.
There is another aspect of interviewing of which I needed to be mindful.
Whilst taking part in in-depth interviews has been shown to be therapeutic for
informants (Colbourne & Sque, 2005), this may not be the case for the
researcher. Undertaking research on sensitive subject areas can leave the
73
researcher feeling drained (Gair, 2002). Brannen (1988) suggests that
interviewers are left to cope with any emotional fall out following an interview,
with lone researchers being most at risk as they are unable to talk to others
in the same dilemma. Therefore it was important that I continued to seek
clinical supervision during the study and remained alert to the impact that
listening to emotional stories had on me. This is in addition to the academic
support I received through my supervisors and taking part in group academic
supervision.
Putting my own emotions to one side for now, being aware of and bringing
our pre understandings to light before we start enables us to be challenged
more explicitly by the informants. If we are not aware of where we are
starting from and what we believe initially, then how can we even know when
we are being challenged? We run the risk of distorting our research if we
begin by acknowledging only half truths about ourselves. If we do not begin
with a certain understanding of ourselves then the risk is that we fail to
understand others and the opportunity to develop a different understanding
based on the fusion of the two perspectives is lost. I have already discussed
my pre understandings earlier in the work as I suggest that this process fits
in with my philosophical leanings. Consideration of these during the interview
would also seem practical.
74
Ethical Considerations
As mentioned earlier, this study raises its own particular ethical
considerations relating to two main factors. Firstly, I had to consider the
issues around power difference. Although personally as described above, I
felt that the students as informants were in a very powerful position, I had to
acknowledge the very real power difference between myself, as tutor, and
them as students at the University. Because of this I considered the
possibility of approaching students from another University to take part in the
research. This seemed a practical way forward as I would not be directly
responsible for issues such as marking their work. My own students may
perceive that if they did not say what I wanted to hear in the research
interview, there may be repercussions and I did not want to lay myself open
to any potential accusations. Just as crucially, I did not want to inhibit their
contributions and undermine the veracity of the research. However as
suggested above, I did not feel that interviewing students who were
„strangers‟ to me would afford me the best opportunities to obtain the rich
data I wanted. It would go against a purposive sampling method, as I
understand it, and so would seem incongruous with my way of working. I
doubted whether students I did not know would feel comfortable telling me
stories from practice, some of which they may find upsetting. In addition,
sharing my own stories may be more difficult with a student I had never met
before. Therefore I made the decision to interview students I knew.
At this stage I also started to consider the potential benefits that interviews
can afford to the informant. It seemed easy to only consider ethical issues
from a negative point of view, in terms of harm I may do to the students. This
75
was my main worry when living through the ethics process. However as
Murray (2003) states, most informants benefit from having someone to listen
to their story and the process of storytelling can serve as a sense-making
exercise for them. I hoped that for some, if not all, of the informants the
interview would serve as a transformatory experience. I can relate to
Heidegger (1959/1971: 57) who states:
„If it is true that man finds the proper abode of his existence in language – whether he is aware of it or not – then an experience we undergo with language will touch the innermost nexus of our existence. We who speak language may thereupon become transformed by such experiences, from one day to the next or in the course of time‟
I hoped that by sharing emotional stories the students might begin to think
about their experiences in different ways. Verbalising their feelings could
encourage them to consider their emotional being in ways they may not have
had the opportunity to before. This could then lead to a shift in how they felt
about the situation. It may mean that they could now make sense of what
happened or even feel differently or more positive about situations.
I am not a counsellor and my intention was not to provide therapy for the
students. It is acknowledged that interviews can afford the opportunity for
catharsis (Kvale, 1996) although development of a therapeutic relationship
could lead to the aims of the study being lost (Paterson, 1994). On the one
hand, cathartic release could be beneficial although this could be problematic
in the sense that I could not send away a distressed student at the end of the
interview without ensuring their emotional health was being cared for.
Therefore I made sure that with the informant‟s approval, I could use the
76
University Counselling Service for further support if a student became very
upset. In addition it was made clear on the informant information sheet that
the student could withdraw from the study at any time, before, during or
following the interview and that this would not affect their progress on the pre
registration nursing programme.
On the information sheets I stated that I would request an answer to my
request after two weeks although in reality, if the student did not approach
me, I did not seek them out as I worried that I may be seen as hassling them.
The reality was that most students were happy to sign up immediately and I
found myself in a strange position of almost discouraging students from this
practice and urging them to think about what was being asked of them,
before being interviewed. On reflection the eagerness of some of the
students to come and share their stories should have given me a hint of what
was to come, although at the time I did not see it.
The second important ethical consideration was around confidentiality and
the fact that this would have to be limited if I felt that a student, through
telling their story, highlighted poor patient care or bad practice in the clinical
area. If during the course of the interview I believed that patient care was
being or had been compromised I would have a responsibility as an NMC
registrant to report this to the Practice Education Lead of the Trust
concerned. Through the ethical process it was agreed that I would tell the
informants of this duty before every interview and the need was also outlined
on the information sheet so that there could be no ambiguity about this
important aspect.
77
Ethical approval was gained from the University Ethics Committee and the
Local Research Ethics Committee.
Reliability in Qualitative Work
It would seem that there are no firm rules when it comes to ensuring
reliability in qualitative studies. Even use of the term itself is open to question
with some suggesting that trustworthiness is a more important goal than
validity or reliability (Gray, 2005). Kahn (2000) suggests that there are two
main areas for discussion when it comes to „reducing biases‟. In my opinion,
even this term is problematic since, as I have already discussed, the term
„bias‟ does not mean the same to all researchers. To some, it could be
argued that my being „present‟ in my study, introduces bias at a very early
stage. I have reviewed the work of Etherington (2004) on the subject of
reflexivity already and the issue that to some, such „biased‟ work would not
be viewed as academically credible. However, that is not so say that as a
qualitative researcher, I need not take measures to ensure my work is
credible. Returning to the subject of bias, it is clear that interpretations of
stories could indeed be biased in the sense that the researcher tells the story
of how they would like it to be, rather than how the informant originally told it.
Kahn (2000) advocates a process of critical reflection by writing down any
assumptions and beliefs previously held by the researcher in order to identify
any prejudices which may be held. I have discussed this already in my
exploration of pre understandings. The purpose of this process during the
analysis stage is to afford the reader an insight into where the researcher is
„coming from‟ when reaching their interpretation. Then the reader is free to
78
make up their own mind; indeed their interpretation may be different to that of
the researcher.
To achieve this it seems important to include reflective accounts written by
the researcher, which will serve to offer a sense of logic to the interpretation.
However proceeding in this way could lead to an introspective study and
Koch and Harrington (1994) suggest the inclusion of many voices within the
text. Etherington (2004: 82) also calls for „multiple voices‟ to „give broad
enough perspectives‟ to provide views on the subject being studied.
Therefore the literature on this subject will be brought into the Analysis and
Discussion chapter.
Member checking, or returning the transcript to the informants to check for
accuracy has been suggested as another way to ensure that qualitative work
is credible. Fleming et al (2002) suggest that the researcher ensures
confirmability by returning to the informants throughout the analytical stages
to ensure that the texts have been faithfully represented; this is also a way of
showing objectivity in this style of research. However this could prove to be
an endless process, as understanding and interpretation may change over
time. There could be a positive aspect to this in that understanding may grow
on both sides, through further discussion and clarification. When would this
process stop? I agree with Koch and Harrington (1994) who suggest that the
„member checking‟ approach can be problematic. From a practical point of
view, returning transcripts to students to check for accuracy could be time
consuming for them and having already conducted a hopefully lengthy
interview, it seems unfair to then ask the student to check through the
79
transcript for accuracy. Moreover this process seems a little incongruous with
the interpretive approach I am pursuing.
In subscribing to the belief that the moment a word or a thought leaves
someone‟s mouth, it is interpreted; the transcripts become my „interpreted‟
property the minute they are transcribed and analysed. Therefore it would
seem almost like paying lip service to the students if I merely return the
transcript to them to ask, „is this what you said and meant?‟ Believing that
interpretation begins during the interview itself, what would seem most
important is to discuss the conditions under which I made my interpretation.
This leads us back to discussion of my pre understandings and my reflective
thoughts and the need to make these explicit as I have already begun to do
so.
To summarise there are no hard and fast rules when it comes to credibility of
qualitative research. For the purposes of my study I intend to consider the
following thoughts which relate to my view of what makes this style of work
credible:
· The use of my own reflective stories will sit alongside the voices of the
informants as a means of showing the reader how I came to my
interpretation of the data.
· Stating my pre understandings earlier on in the work gives the reader
a sense of me as a person both on a personal and professional level.
80
· Using perspectives from other authors alongside my own in the
analysis stage of the work, assists in protecting the piece from being
an introspective endeavour.
· As this is claiming to be a Heideggerian study, explicit reference to the
work of Heidegger will be made throughout.
81
Chapter Four
The Reality
Before moving on to the analysis of the data I have decided to devote a
section of this work to the actual reality of the interview process. This is
because it heralds the start of a shift in my view of what my research was
really about, not least in terms of its importance. Until I began the process of
data collection, I was still rather dismissive of my research topic, almost
believing that I was being a bit „soft‟ for wanting to pursue it. Of course to me
it was really important, but my belief was that to others it would not be seen
as a good investment of time. At the time one of my colleagues was
researching the widening participation agenda, another, the public health
agenda. Both of these subjects seemed much more worthy than a slippery
soft subject such as emotional nurse being.
I began my interviews, as I have already stated, in the belief that the
students would not want to be interviewed and that, even if they did, they
would not have much to say to me. Even if student nurses wanted to talk
about this subject, I worried that they probably would not want to talk to me,
their tutor who I thought they perceived as being far removed from their
world. Even though the truth was that I still felt very close to their world,
remembering stories from my own education as if I had lived them only
yesterday. I suggest that one of the problems of emotional stories that we
want to „go away‟ is that they never seem to go far.
The other motivational factor for bringing the reality into print is that most
research reports I have read, do not discuss what really happened and seem
82
to present a process which ran smoothly throughout. Feeling that other
people may have had the same problems as you can be reassuring. In
addition journeys like this one are bound to encounter problems; it is through
this journey that growth and learning takes place and comes as part of the
process.
Returning to the interviews my first surprise occurred when I realised that
many students were very keen to talk to me. As stated earlier, some students
did not seem to want to read the information sheet before signing up for the
interviews. I did not realise at that time that some of them were in great need,
almost desperate; to unload stories of emotional nurse being and my
invitation was the chance they had been waiting for. So in no time at all I had
my fifteen interviews, some were short, lasting less than thirty minutes; some
of them almost one hour long, and some longer than that.
I was happy about the length of the interviews until I began to transcribe
them. It never crossed my mind to pay a professional transcriber to
undertake this task. I believed and still do, that interpretation starts as early
as the interview stage. Sitting with a student and listening to their stories, the
„working–out of possibilities‟ described by Heidegger (1926/1962: 189) has
already started. Therefore giving the tapes to someone else to transcribe,
would have deprived me of a step in the process. I am reminded of Walsh
(1996: 236) who states:
„Now as I sit transcribing my interviews with these nurses I am again engaged in a circle of understanding as I move from the part, a word in a sentence, to the whole of the sentence; from a paragraph on the page to the whole of the page; from the emphasis placed on a word to the emotion expressed by the whole of the story‟
83
This is a time-consuming although worthwhile process. Walsh (1996) goes
on to describe how his pre understandings combined with the voices of the
informants to extend his vision of the nurse-patient encounter, the subject of
his research. This process of co-constitution takes time. In my case I found
myself transcribing passages which provoked such deep feeling within me
that it was at times difficult to continue. Sitting at my desk watching the
minutes of my precious „research day‟ tick away was sometimes frustrating.
However what I could not see at the time but what I see more clearly now
was that this wasn‟t only a process useful for me to understand the students‟
emotional nurse being. The process also helped me to understand my own
being. Through understanding others, I began to make sense of myself. For
Heidegger (1926/1962) understanding is not so much a way of knowing, as
was the case for example with his predecessor Husserl, but more as a way
of being. Through being comes understanding, and it was only after
understanding the being of others that I understood myself. This process
takes time and effort and there were times when it was emotionally draining
as I recalled painful stories from my past.
I hardly talked to the informants about my own meaningful stories during the
fifteen interviews. However during the transcription stage I began thinking
about similar stories from my own past, which began a process of catharsis.
There were occasions when I sat in tears remembering those times,
occurring over twenty years ago, which I had never let surface. Furthermore,
during the analysis of the interviews, in line with my philosophical approach, I
placed the reflective stories from my past next to the informants‟ stories. It
was then that they were truly „in the open‟ for all to see. This process helped
84
me to accept my way of being as a student nurse, even though I felt, and at
times showed emotion. At that time, when I was a student, behaving in this
way hadn‟t seemed good enough or acceptable. There were some students
in my group who seemed to „toughen up‟ straight away but a few of us did
not seem to find it so easy. Remembering the stories made me feel glad that
I had never toughened up too much. I cherish the stories, which I will tell
further on in the work, as they are who I am, and trying to be someone else,
then or even now, would be turning my back on my own way of being.
Duncombe and Jessop (2002) suggest that it is hard to draw the line
between research and counselling during interviews, which may become
therapeutic for the informant. Indeed, it felt at times as though the informants
were benefitting from the interview experience, by the fact that they were
able to offload and „give‟ their stories to me. An example of this was Jan‟s
interview, in which she seemed relieved to tell me a story which uncovered,
in her view, unacceptable nursing practice. It could be suggested that the
interview process was indeed therapeutic for her in that she had shared the
burden of the story she had held onto for some time.
However, I had to be mindful that I do not hold a counselling qualification. I
am an experienced nurse and my natural desire is to try and support and
help another person, but I cannot enter into a counselling relationship. In
addition this would be incongruous with the research process in that these
are research interviews, not counselling sessions. Having said that, I think it
would be unrealistic of me to think that at times I did not challenge, albeit in
my view in a gentle way, the views of the informants. This underlines to me
the need for ongoing self monitoring during the interview; the requirement for
85
a persistent reflection in action process which can at times be hard to
maintain, especially during lengthy interviews. As Warne and McAndrew
(2010) suggest, the informant should not be challenged with the researchers
own interpretations during the interview. The thoughts of the researcher
should be held back, to be explored later in terms of their own thoughts and
experiences. This seems easier to do in theory rather than in practice,
especially when enthusiasm for the research subject and desire to obtain rich
data is paramount in the researchers mind. Reviewing my own interviews I
feel that I did indeed challenge the informants at times. This did not happen
often but was most noticeable to me in the interview with Steve. I challenged
him by suggesting that he was actually a little more emotionally attached to a
patient than he had suggested he was. He goes onto describe that it wasn‟t
an „official‟ attachment as a means of explanation. I had to be careful not to
upset the informants throughout the process, and remaining mindful of the
impact I could have on the encounters was important.
Apart from drifting into a therapeutic encounter, my position at the University
as a Lecturer was another issue to consider during the interview process. At
the end of the interviews, some of the informants were keen to question
whether or not they had given me the „right‟ type of information. There was
an eagerness to please evident amongst some of the interviewees, and a
desire to „give me what I wanted‟. I knew some of the informants quite well
and our research relationship could be viewed as something of a cosy one. I
had been keen to avoid the „picking their names from a hat‟ method,
described by Steeves (2000: 50), as being unsuitable for this style of
research. However, I have to accept that the Lecturer/Student relationship
86
may have had an effect on the research encounter. From an ethical point of
view, I was keen to ensure that the students would not be treated any
differently, based on their responses in the interviews. I had not been as
mindful of the fact that the informants themselves may still feel the power
imbalance, and this could affect what they said to me. Indeed, as I will
discuss further in the thesis, one of the most productive interviews was in
fact quite challenging to me. This was with a student that I did not know as
well as the other informants, but who lead me to challenge my interpretation
of the subjects under discussion. On starting the interviews, I had thought
that a cosy relationship with the informants would be most useful. By
undertaking the process, my thinking has changed, and the impact of me as
a Lecturer on the students in the interviews may have been greater than I
had first thought.
From a researcher perspective, hearing the informants‟ stories triggered off a
process for me that continued during transcription and analysis. This was
something I had not foreseen happening but was the start of a very
therapeutic process for me. It also was then that I finally began to take my
own research very seriously. On the one hand this was a positive experience
although on the other, very time consuming. Remembering and working
through reflections and stories of my own, coming to terms with how I was
feeling and then trying to write it all down took a long time. In addition I was
grappling with Heideggerian thinking and language, all of which does not
happen quickly.
Another „surprise‟ uncovered during the interview process was the exposure
of potentially poor practice. This was revealed through the informants‟ stories
87
during the interviews and involved poor practice on behalf of the permanent
members of staff. From the outset hearing this was problematic to me in
many ways. Firstly, I could not be sure whether the poor practice described
to me was in fact poor practice, in the sense of neglect of patients, or
whether it was the informants‟ perception of the issues. For example a
student nurse may perceive that a trained member of staff is being lazy and
neglecting patients by sitting at the nurses‟ station and not answering
buzzers. However the reality may be different in that the trained member of
staff may actually be talking to doctors on the phone, writing up notes,
discussing issues with other members of the multi disciplinary team and
doing work which the student cannot, or does not want to see. Secondly, I
did not want to wade in, complaining to Practice Educational Leads when
really I only had one side of the story, in that I had only the student‟s word for
it; the other side of the story was unheard. In addition to this, I know that
placements are at a premium and I did not want the constructive relationship
that I currently have with practice staff to be threatened by my going in and
complaining about various staff members in practice placements. All of the
practice areas are audited and deemed suitable for student nurses to attend
and I only had the word of a student, taking part in research about the
emotional nature of nursing, to go on. However, part of my ethical approval
involved my reporting of any poor practice. In addition, I felt that
professionally I had a duty to follow these issues up as an NMC registrant. I
decided that rather than view my relationship with practice as being
weakened through this process, I should take it as potentially positive, in that
I was using the productive relationship I have with practice staff to my
88
advantage. I knew that my thoughts would be taken seriously and followed
up. Therefore each time I suspected poor practice revealed through the
interviews, I rang the Practice Educational Lead for the Trust concerned, and
outlined my concerns. It is not my intention to discuss each issue in turn as I
believe that this could compromise confidentiality. However, in each case my
concerns were taken seriously. In some instances, the ward area involved
was already „known‟ to the Facilitator and measures were already in place to
deal with the issues raised. Most of the areas discussed were undergoing
periods of change and some were in the process of employing a new ward
manager. Many areas were short of mentors but were going through the
process of employing more in the near future. I had assurances that
measures were already in place to address concerns. I feel confident that I
have done all that I can in each case and through formal student evaluations
and practice audits, quality processes are ongoing.
My chosen approach to this work has been an interpretive one and I have
argued that we are all as humans a product of our own past; our own
historicality has a bearing on how we are today. Because of this we interpret
issues and events in different ways and there is not one true reality to be
found. Any interpretations we make will also change over time and will
potentially be viewed differently by others. Coming from this school of
thought it was difficult for me to report issues from practice as „reality‟ to
practice staff concerned with maintaining high educational standards. I am
not trying to say that we should not believe students when they tell us about
goings on in practice. However, it has reinforced to me that there are many
influences on how we feel and perceive life and this should always be borne
89
in mind when dealing with these issues. I have widened my thinking on this
subject and this has been brought about by undertaking this work.
I will now discuss in more detail one of my first interviews. I will return to this
informant later in the analysis section of this thesis. However, for now I will
use some of the data to highlight how qualitative interviews can go astray. In
this example I feel that I was almost trying to sabotage my own research. I
think the following story also highlights the minefield that is the qualitative
research interview. I will begin by giving some context with a brief description
of the informant, a student nurse who I will call „Jenny‟.
Description of Jenny
Jenny is a 22-year-old pre-registration student nurse half way through her
second year of nurse education. She had previously studied psychology at
Sixth Form College and during this time had been involved in some voluntary
work with mental health groups whilst studying for her degree in psychology
at university. She had also been involved with some community groups and
this interest had led her to pursue a career in nursing. I knew Jenny as I had
met her during the first year of the pre registration nursing course and had
taught her group many times. During that time I had often felt that the first
year work that I had set the group had been simple for her and she seemed
at times, bored and distracted. She had not been a student I had felt drawn
to as a person and it was for these reasons that I did not choose her as part
of my purposive sample, assuming that she would not be forthcoming during
an interview (for the reasons described above). However she had been with
one of my personal students when they came to see me to arrange an
90
interview time. She showed interest in my research and asked whether I
needed any more volunteers. At that time I was worried that I may not get
enough data and felt almost grateful that someone was interested.
Having said that, I cannot deny that I had felt a little ambivalent about the
interview beforehand; half believing that Jenny would not attend. It is
interesting that as a lecturer it is easy, as in life, to form opinions of students
when we know very little about them and what we do know is formed on the
basis of our experience of them in an unnatural setting such as a lecture
theatre. When she was a few minutes late, I immediately thought she was
not coming and began to pack away my tape recorder. I was quite surprised
when she knocked on my door and appeared, late, having had difficulty in
finding a parking space. As Sandelowski (1986) suggests qualitative
research may be viewed as more credible when the researcher describes
their own behaviour in relation to that of the informant, I feel it important to
note my frame of mind here as I believe that it had a bearing on what was to
follow and I will now explain what I mean by this.
Reflections on the effect of myself on this interview
I felt that the interview would be constrained and that Jenny would not want
to talk to me. I felt that with her psychology background she might not be
taking the qualitative unstructured interview seriously. I had felt that when
she had read the information sheet in my presence, she had been nodding in
a knowing way, as if to say, „I know more about this than you do!‟ My view
speaks volumes about the level of confidence I had in my ability as a
researcher and also my knowledge of the subject matter. My concerns were
91
around my own level of knowledge at that time and my perception that I
might not be taken seriously by the students I wanted to interview. Reflecting
on my feelings it is clear that I had no need to feel this way. Even if she had
known more than me about the subject matter, this would not have been a
negative aspect of the interview and could have assisted in the development
of different understandings, which is after all the focus of this methodology.
In addition, having reflected on what she said to me, it is clear that she takes
this subject just as seriously as I do and this will be explored later.
My feelings prior to the interviews had been that I wanted to view the
informants as co-researchers, meaning that they were in equal „charge‟ of
the interviews. Maybe this was a naïve place for me to be as in this case I
felt I needed to be „in charge‟ and know more. This is important to mention as
I felt that this desire to take control and not be seen as „knowing less‟ might
have inhibited the discussion and course of the interview. Having said that,
on reading the transcript, there are only a couple of examples of this attitude
coming through, which I will now explain. (I will discuss the issues raised
during the interview more fully later on in the thesis, but for now will use
these examples to explain how the influence of my „defensive self‟ could
have stopped Jenny from opening up further to me). I am conscious that I
began the interview by saying things such as: „I want this to be as informal as
possible‟ and „There are no right and wrong answers here‟. Gough (2003)
adopted a similar approach when interviewing a group of male students
about masculinity. He returned to the interviews carried out in 1999 and
came to some new conclusions. He suggests that he was in a position where
he had to maintain two identities, which resulted in some conflict. On the one
92
hand he viewed his role as being one of a „question master‟ and then on the
other, an interested „co-participant‟ who contributed to the conversation, not
only by asking questions. I was eager to not ask too many questions and
allow the conversation to follow a course led by the student, not led by
myself. I was also keen not to „give‟ too much of myself, feeling the need for
security, which comes from my position as a lecturer. I wanted to maintain a
professional distance as this was a student that I would have to teach in the
future. However, in places, further questioning, rather than what I perceive
now as my „blocking‟ the conversation, would have been beneficial. For
example I asked Jenny how she dealt with the emotional work involved in
nursing practice:
Me: „…because there is a massive emotional cost to nursing, I suggest, ……how do you deal with emotion yourself?‟
Jenny: „Do you mean emotion generating from work specifically or in general?‟
Me: „Do you think it‟s linked?‟
Jenny: „I think coping mechanisms apply to both and they are probably quite similar ones‟
Me: „Okay‟
Fortunately for my research, Jenny was not put off by my blocking „Okay‟ as
she then went on to discuss the coping mechanisms she adopted. Reflecting
on this interview now, did I want to seem so knowledgeable that I did not
need to pursue this line of questioning further? Did I want to seem like I
already knew what coping mechanisms she meant? Or was I worried that if
the conversation went further, she would ask me about my own mechanisms
for coping? Some very insightful data followed (which will be discussed
later), so important for my research. Could I be classed in a role of
93
Researcher as „Saboteur‟ here? In a way I was blocking the discussion to
protect myself, thus potentially sabotaging part of this interview and my own
research.
Later in the interview Jenny described her frustration about the lack of time
members of staff spent talking to patients in the clinical setting. She told me
that it irritated her to see nurses talking with each other, about trivial things,
rather than talking to the patients. I immediately picked up on this, with a
comment I may have meant to be „authoritative‟ in some way:
Jenny: „…why don‟t they have a chat with them and maybe spend a bit of therapeutic time with them informally, why aren‟t we doing that, why are we sitting here discussing your new car?‟
Me: „But, you know, I could argue, I need some time away‟
Jenny: „Yeah, okay, but…‟
Me (interrupting): „You need some time away to discuss things that aren‟t very important…‟
Jenny: „Yeah, maybe so but, I mean…..‟
Gough (2003) describes times when the researcher „weighs in‟ in an
authoritative way, and as he suggests, could this be a way to influence the
discussion, and was I using my status to do this? Certainly it would seem
that I am acting here from an „I know best‟ position by saying „I need some
time away‟. However, as before, Jenny resisted my comment and
interruption and went on to provide reasons why we need to get to know
patients better, thus supporting her earlier statements. On the other hand, I
could have been seen to be playing devil‟s advocate, although I wasn‟t
intentionally doing this, and in that sense, she may have seen it as
encouragement to continue.
94
What I learned
I suggest that the main problem underpinning this experience was that I had
not chosen Jenny purposefully as one of my sample. She had volunteered to
take part without being chosen by me. This was problematic as I did not feel
relaxed in her company based on my past experience with her, and because
of my worry that she in some way „knew more‟ than me. On reflection I feel
that I was very unfair to her due to my own insecurities as a researcher and
lecturer at that time. She did in fact give me some very useful data although
the unseen „gel‟ between researcher and informant was missing. Research is
„co-constituted, a joint product of the participants, researcher and their
relationship‟ (Finlay, 2002: 212). In this case, the relationship aspect, for me,
was missing. Therefore I did not feel I ever „got started‟ during the interview
and the reality was that I wanted it to be over.
This raises issues around sampling. My perception of the students whether I
like to admit it or not, was important to the flow of the interview, and formed
the basis of the interview relationship. Feeling uneasy with, or not knowing
an informant so well, seems prohibitive to a meaningful interview experience,
certainly from my point of view as the researcher. Therefore I decided to
continue with a purposive sample. I would choose the informants and if
anyone else approached me, I would say that I had a big enough sample
and needed no more. However adopting this approach became problematic.
Working in this way did not always give me what could be described as rich
data. Some of my purposive sample, students who I felt I connected with, did
not want to say a lot to me and some of the interviews did not yield the data I
thought they would. On the one hand I felt that the important relationship was
95
there between us; I felt relaxed and happy to talk and listen, but on the other
hand, at times, not a lot was said. The prime example was that of the
interview with the informant „Joan‟. I felt we had been through similar
experiences in that both of our mothers had died just before or during our
journey through part of our nurse education. Hers, just before her pre
registration education and mine during my post registration degree
programme. I felt we had a connection because of this (we had discussed it
in the past), and that the interview would go well. The interview did not flow
as well as I had hoped and although she gave me much to think about, the
interview at times felt stilted. She seemed uncomfortable and I wondered
whether it was the very fact that we did know each other quite well and had
shared some stories already that she felt awkward and embarrassed to talk
to me. It was a useful lesson to learn, one which led to me once again
accepting offers from students who volunteered to be part of my sample
without being asked. It seemed that these students wanted to help me with
my work, after hearing about it from their friends.
96
In summary my final sample was made up of the following informants;
Table 1 Final Sample
Informant Mode of entry into the research
Year of Study
Fran Purposive sampling Second year
Anne Purposive sampling First year
Jim Purposive sampling First year
Jan Purposive sampling First year
Joan Purposive sampling First year
Eve Purposive sampling First year
Carol Purposive sampling First year
Andy Purposive sampling Second year
Paul Purposive sampling Second year
Jilly Purposive sampling Third year
James Purposive sampling Third year
Jenny Volunteered to take part
Second year
Steve Volunteered to take part
Third year
Emily Volunteered to take part
Third year
Laura Volunteered to take part
Third year
97
As can be seen in Table 1 there were five male informants and ten female.
Only four students were from the second year of the course with the most
informants being first year students, except, interestingly, for the volunteers.
The informants, who gave me what I consider to be the most data in terms of
amount, were Fran, Anne and Jenny. I have referred to some informants less
than others throughout this work and this was for various reasons. Some of
these informants quite literally talked less and the interviews were quite
short, for example James and Jim. In these cases I had no choice but to
include less of their voices when writing up the analysis and discussion. One
of the respondents Paul spoke with a strong regional accent and when it
came to transcribing the tapes, I found it difficult to hear accurately what he
was saying. This reinforces the need for up to date recording equipment,
which may have helped me to hear more clearly. Some students, most
notably Laura, tended to repeat similar sentiments so although the interview
was lengthy, the same issues were repeated by her. This, of course, is data
in itself in that she may have felt a need to get her points across over and
over again. However including the repetition would make a lengthy piece of
work and I suggest it would serve no real purpose. Some students, most
notably Eve, were keen to criticize staff members with whom they had
worked during the interview so I deemed much of this inappropriate for
inclusion. As before, this finding is still interesting in that this student felt the
need to use the interview as an opportunity to vent issues about other
members of staff.
To summarise, I had to make decisions in terms of what I wanted to include
and what I felt was not as relevant and could be omitted. Apart from the
98
choices I made which are described above I have included all data I feel is
relevant to the discussion of emotional nurse being. I understand that it could
be considered a limitation of the work that I, as a lone researcher, am the
one who made these decisions, although at the time I was regularly
discussing my work with colleagues in a formal research group, and also with
my supervisors. The main deciding factor centred on how much the students
said and in what depth. For example it is noticeable that some informants
made a lot of their replies surrounding what they did before coming into
nursing. I used this as an ice-breaker question at the start of the interviews.
Some informants gave very brief answers or hardly responded at all whilst
others such as Fran, Jan and Anne, gave lengthy answers and seemed
comfortable doing so. The answer to this question seemed to set the tone for
the rest of the interview; if they gave a lengthy response to this question, I
could predict that they would talk in more depth during the rest of the
interview. So in a sense, the decisions about what to include were already
made by the informants, based on how much or how little they said to me
even at this early stage of the interview.
99
Chapter Five
Introduction to the analysis
When reflecting on ways to analyse the data for this study I felt that there
were a few considerations which needed to be borne in mind.
Firstly was my desire to analyse the data using Heideggerian thinking taken
mainly from Being and Time (Heidegger 1926/1962). This was for many
reasons already discussed, including the allure of the hermeneutic circle
although at the time I did not fully understand how the circle worked. I had to
trust Heidegger (1926/1962: 195) who suggests, „In the circle is hidden a
positive possibility of the most primordial kind of knowing‟. In stark contrast to
my quantitative Masters level “upbringing” here lies an opportunity to allow
my pre understandings to be revealed and used effectively to reach different
understandings of emotion in nursing practice. Of course by doing this I am
not letting my prior thoughts and reflections cloud the analysis rather, as
Heidegger (1926/1962: 195) would have it, to „make the scientific theme
secure by working out these fore-structures in terms of the things
themselves‟. My pre understandings relating to the research subject have
been discussed earlier. What I want is for my thoughts and reflections to
mesh and weave with the thoughts of the informants to develop different
meanings about the emotional nature of nursing. Rather than view them as
potential bias, they become valid data, making up part of the new
interpretation. According to Gadamer (1960: 305) „the horizon of the present
cannot be formed without the past‟ and it is by „understanding the tradition
from which we come‟ that we understand the present. Acknowledging my pre
100
understandings of emotion in nursing work enables me to see further than I
may have seen had I decided to „bracket‟ them to one side and deny their
existence. Being „in step‟ with my informants by keeping my pre
understandings in mind enables me to ask questions I may not have asked, if
not for my own experiences. The informant‟s background is also part of the
hermeneutic circle and is essential to consider during interpretation.
According to Koch (1995: 831) „the notion of background is an inescapable
part of the hermeneutic circle‟. Walsh (1996) gives examples from his own
research to describe the necessity of including background which is essential
for understanding to take place. It is difficult to understand a phenomenon if it
is not put into context; situated against a backdrop of some kind. Walsh
(1996) describes his frustration when he interviewed nurses for his study.
The nurses involved did not stick to the phenomenon in question but
described many other contextual details. However, understanding took place
when he moved from the parts to the whole of the story and vice versa; using
the context to assist in understanding the phenomenon. Contemplating the
nature of emotion it is clear that there are many influences and contextual
details which could have an impact on the emotional working lives of pre
registration nurses. To exclude the background influences would mean I
might only get half a story, almost like only watching part of a television
programme and having to guess and fill in the bits I did not see.
Secondly, I had a desire to enable the voices of the informants to be heard in
as much detail, and as faithfully, as possible in the final research product.
Sandelowski (1986) describes qualitative research as more artistic in its
approach when compared to the quantitative paradigm. Qualitative research
101
values the uniqueness of the subject and it is important to remain faithful to
the „unique visions of those involved in the research process‟ (Sandelowski,
1986: 29). In phenomenological research of this kind, the uniqueness refers
not only to the voice of the informant, but also to the joined voice of the
informant and the researcher. Of course the joined voice may prohibit the
detailed description that the informants may give, as in describing the data
„other forms of expression‟ may occur and different conclusions may be
found (Debesay et al, 2008: 62). I suggest that some detail may get lost
when the researcher attempts to formulate themes. It could be easy to
become sucked into fulfilling a theme at the cost of detail which may not
quite „fit‟. Therefore I made the decision initially to present each informant‟s
story as a separate entity. So keen was I to show difference and variety that I
could not see a way to achieve this without presenting each informant on
their own. However this approach became problematic. After writing up one
informant‟s story I realised that actually there were many commonalities
which were shared across the informants. It began to seem like an artificial
process to me and I began to wonder whether I was working in this way to
prove a point. The reality was that it just did not work. I predicted that the
analysis would become repetitive and unwieldy and would not achieve as
much as placing the informants thoughts side by side. I reassured myself
that the uniqueness of what they were saying would still not be lost and it
never became my intention in the analysis to find „common themes‟. The
interest in this research is what makes emotional work different for each
person interviewed, not what is common about the experience. That is not to
say that there are not commonalities to be found and these will be
102
acknowledged. For example, from my own experience of nursing practice, I
suggest that the support of the mentor or other team member will assume
great importance to the students when describing their emotional journey
through their nurse education. However the primary focus is on the variety,
the difference between the informants‟ experiences. It is on the uniqueness
of ways of feeling and describing the phenomenon in question. Nurse
researchers following the Heideggerian style of phenomenology may be
keen to look for shared understandings and common meanings in their
findings as they believe that by doing this they are remaining true to the
Heideggerian tradition. However, as Paley (2005: 109) suggests, „the things
that are most meaningful to us are – precisely – the things we do not share
with anyone else‟. Paley provides an example by describing the meaning of
childbirth. His list of „categories‟ of meaning are wide ranging. They move
from the semantic, to the actual physical and psychological experience of
giving birth. That is not to leave out the meanings in between such as the
consequences, reasons and purpose of childbirth. The point being made is
that with this level of diversity in meaning, how could the researcher ever
reach a „common theme‟, or for that matter, why would they want to?
The beauty of qualitative research lies in the belief that because the sample
is small and the descriptions thick, voice can be given in great detail to the
informants involved. This, in my view, should be viewed as a strong point of
the research rather than a restriction in that different understandings can be
reached by the reader through research that celebrates meaningful
experiences rather than shared ones.
103
Indeed, by viewing phenomenological research as a means of understanding
differently, rather than more, in a quantitative sense, this approach allows us
to connect with a meaning with such intensity that it would seem wrong to
reduce the findings to „common themes‟ or „essences‟. The value lies in that
which is unique, not that which is common. Reviewing pieces of
Heideggerian nursing research reveals findings formatted using phrases
such as „constitutive patterns‟ alongside „themes‟ or „relational themes‟.
According to Diekelmann and Allen (1989: 12), a relational theme, „cuts
across all texts‟. „Constitutive patterns‟ are viewed as the „highest level of
hermeneutical analysis‟ (Diekelmann and Allen, 1989: 12). The terminology
can be confusing and misleading. I feel that Heidegger‟s work already
translated from German can be difficult enough to understand, and I wanted
my work to be accessible, not presented in abstract themes and patterns.
I decided to return to Heidegger‟s own words in Being and Time (1926/1962)
for inspiration on a way forward. In Chapter Two, Division One is what
Heidegger describes as „A Preliminary Sketch of Being-in–the-World‟. As
already discussed, Heidegger believed that humans and the world are a
„unitary phenomenon‟, everything is context bound; the expression „Being-in-
the-world‟ is coined to indicate this viewpoint. He goes on to say the
following:
„But while Being-in-the-world cannot be broken up into contents which may be pieced together, this does not prevent it from having several constitutive items in its structure‟ (p78)
104
My interpretation is that Heidegger was against classification of knowledge
and facts. However, I interpret what he is saying here as meaning that a „way
of being‟, in this case what I term emotional nurse being, may be made up of
many aspects or characteristics which make up our whole way of being. To
put it another way, he might be saying that we cannot fully comprehend a
cake from a list of its ingredients, but nevertheless, there are different
ingredients. Translating this into a way of analysis would mean that it is
acceptable to discuss different constituent parts which make up the whole
way of being. I suggest that this is different to „contents‟, in terms of „themes‟
which are pieced together to give a more formal classification. I suggest that
proceeding in this way affords more freedom to the researcher in contrast to
a way which requires data to be classified into common themes. Therefore I
will describe different aspects of the data as „constituents‟. Students may
disagree within each „constituent‟ but I suggest that exploring differing
thoughts within the constituent parts will add interest to the analysis.
Extricating different views from the transcripts will require a questioning style
described by Dalhberg et al (2008: 237) as „interrogating the text‟. It is also
important not to reach interpretive closure too soon. According to Kvale
(1996) it is not so much the many different interpretations reached that is the
problem, more the lack of research questions put to a text. He describes two
types of subjectivity, biased and perspectival. He describes biased work as
„sloppy and unreliable‟; work in which the researcher only notices evidence to
support their own opinion. Researchers only report on statements which
support their own thoughts, „overlooking any counterevidence‟ (Kvale, 1996:
212). Conversely perspectival subjectivity occurs when the researcher
105
examines different perspectives and asks different questions of the text,
therefore coming up with different interpretations. With this in mind and
almost as a „trial run‟ I applied the different contexts suggested by Kvale
(1996) to the data provided by Jenny. I have presented this in tabular form
for ease of reading:
106
Table 2 Contexts of Interpretation
Contexts of Interpretation Examples from Transcript
Self understanding:
The researcher condenses what the
informants understand to be the meaning
of their comments
I interpret that Jenny thinks it takes
time and effort to analyse our
emotions but the culture in nursing
doesn‟t encourage this. This
causes her some dissatisfaction
Critical commonsense understanding:
This goes beyond self understanding
and may go further than the
understanding of the informants
themselves
Jenny finds this situation difficult to
deal with. Her voice becomes
louder and she becomes more
animated. Another interpretation
could be that she has tried to
discuss her emotions in practice
but has been discouraged; she has
found this difficult
Theoretical understanding:
Exceeds both self and common sense
understanding and incorporates other
theory
Jenny could be struggling to live
nursing in an authentic way and
this could cause her to feel
anxious. Living authentically can
lead to anxiety as we may then not
fit in with others, although joy can
be found by being in this way
(Heidegger, 1926/1962)
107
Kvale (1996: 212) views the „multiple perspectival interpretations‟ as outlined
in Table 2 as a strong point of this style of research. By keeping an enquiring
mind, different contexts of interpretation can be revealed. As Kvale (1996)
suggests, questions are not only posed to the informants, but to the interview
texts as well. Rather than view the different interpretations as „haphazard or
subjective‟ Kvale (1996: 216) views them as being the answers to the
questions we pose to the text. As part of the theoretical understanding, I
have chosen to bring in the work of Heidegger (1926/1962) and his thoughts
on authenticity. In this way both self and common sense understanding can
be developed. The text remains alive and we reduce the risk of reaching a
subjectivity which is biased; one in which the only interpretation found is that
which supports our initial pre understanding of the situation being
investigated. It is one way to illuminate the varied interpretations which can
be reached and reinforces the fact that truth can easily be „made‟ through the
research process.
However this way of working seems problematic to me. Analysing in this way
could continue indefinitely as different questions are posed of the text and
different perspectives considered. What would be left would be many
different interpretations, all formed by the same researcher, which begs the
question; how different would they all be? They are all still basically my view.
It could also make for an extremely long piece of work which, in itself may
not be so bad, but how much more meaning would it add? I suggest that
there has to come a time when the researcher has to pose their
interpretation of the data, in the knowledge that others may reach a different
interpretation altogether. An interpretive researcher has to accept that this
108
will happen, that readers will agree or disagree with the interpretation
reached. I do not view the researcher as being the one who has to suggest
to the reader, the different understandings which the reader themselves
could reach alone. This is not to suggest that the researcher should not have
an enquiring mind and ask questions of the text. In addition, returning to my
pre understandings throughout the analysis stage can assist in checking
whether or not I have merely sought out interpretations which back up what I
already thought, or whether in fact the data „disagree‟ with me.
I propose to join the voices of the informants with that of Heidegger, other
authors writing about similar issues, and myself. This will lead to an analysis
made up of different materials, almost akin to a collage effect. The use of my
own voice will include not only my immediate thoughts on the issues but also
those developed through my reflective diary. Interpretation of any picture is
different for each person viewing it. Indeed, some will agree with others‟
interpretation whilst others disagree strongly. Reflecting back to my
childhood, making collages out of different materials feels like a similar
process to this one. I reflect back on the glitter, buttons, felt and tissue paper
used to provide the picture. Taken separately, they may make little sense as
„art‟. Even when stuck onto the card, they may still not instantly provide us
with a picture we relate to. Consider being given a picture drawn by a child.
We may hold it upside down or sideways on; we may mistake a space rocket
for a house. We do this until we get a sense of what has been created. As
with this research process, one lone voice does not create the picture. The
different voices make up the various sources of the finished text. We put our
efforts into coming to an interpretation and the picture emerges; only for the
109
next person to hold it upside down and see something completely differently
to us. This is all right; this is how they are reaching their own meanings and
interpretation of the subject and we accept this as part of the process. In
addition due to the temporal nature of understanding our interpretation will
change over time (Gadamer, 1976). For example, my initial interpretation will
be different to that reached some weeks or months later. I agree with
Fleming et al (2003: 118) who caution that our „understanding remains
transient‟ during this style of research process. However I disagree with their
suggestion of speaking to informants two or three times based on the fact
that their understanding will have changed over time. By inviting the
informants to reprocess their statements, I could run the risk of being taken
even further, rather than closer, to the emotional states my research seeks to
investigate. Returning to informants numerous times is a futile endeavour for
this very reason – their understanding of the subject matter will have
changed most likely and this process could continue ad infinitum. It could be
tempting to think that working in this way would lead me to the „real meaning‟
of what the informant wants to say. However the philosophy I want to
celebrate, that of working together with the informants to reach a shared
understanding, relies on the basis that truth is „made‟ rather than „found‟. I
am not seeking „real meanings‟ that can be applied to a larger population.
Smith et al (2009:91) summarise the position well:
„At each stage the analysis does indeed take you further away from the participant and includes more of you. However „the you‟ is closely involved with the lived experiences of the participant – and the resulting analysis will be a product of both of your collaborative efforts‟
110
The quest is for a different understanding of the situation, however slight that
may be. Kvale (1996: 225) describes an „inter relational‟ approach whereby
conversational meaning exists within the interaction rather than either party
being able to suggest the „real meaning‟ of the statement. In my opinion
searching for a „real meaning‟ would be akin to working from a Husserlian
point of view, that the indisputable truth is out there, waiting to be uncovered.
Of course, the researcher finally has to reach a meaning about statements
made by the informant. However as suggested earlier, the reader is then at
liberty to reach a different interpretation if they choose.
I summarised my feelings in the following way and recorded them in my
reflective diary:
„I am torn between wanting to ensure that the students voices are heard as faithfully as possible and interpretation which, whether we like it or not, is inherent in everything we read and hear. Of course, I can rely on the fact that whatever my interpretation, the reader or author of the text can disagree and this is fine. I can interpret safe in the knowledge that I can never get it „wrong‟; just get it „different‟. I am reminded of excerpts from the research journal cited by Etherington (2004: 130). „Catherine‟, an MSc student describes her feelings whilst undertaking heuristic research:
“I let go and allow myself to be carried along on a journey into the unknown….I like order in my life; it helps me to feel safer somehow. But this process throws up disorder and yet is able to bring with it new discoveries, new insights”
Being able to trust in this process does not sound like an easy journey although the potential reward in terms of reaching different insights is too hard to resist. I have to accept that these may differ to the conclusions others may draw‟
111
A model of analysis
I needed to decide on a way of analysing my data, a way of working which
would stay true to my philosophical leanings. Dahlberg et al (2008: 277)
suggest that hermeneutic understanding very often happens „without
reference to distinguishable phases‟. During this process I have read many
pieces of research claiming to follow the hermeneutic tradition. Diekelmann
and Allen (1989) propose a seven stage analysis involving a team of
researchers in their research into the appraisal of Baccalaureate Nursing
Programmes. The team attempted to reach group consensus as to the
meaning of the texts which, as explained earlier, seems problematic.
Working from the belief that there is no one „correct‟ interpretation reaching
consensus may require one team member to compromise their interpretation
just a little too much. It could be argued that this is irrelevant to me as I am a
lone researcher although what this way of working may signify is a difference
in belief in the philosophical underpinnings of this approach. Fleming et al
(2003) suggest a four step process to analysis which they describe as being
Gadamerian based, therefore in line with the hermeneutic tradition within
which I am working. The four steps are as follows:
· The whole interview text should be read to gain an initial
understanding and an expression should be found within the text
which reflects the meaning of the text as a whole.
· Each small part of the text should be explored for its meaning which
will facilitate the identification of themes. The themes identified can
112
then be used to challenge the researcher‟s pre understandings and
the text in turn, can be challenged by them.
· In line with the hermeneutic circle, each part of the text is „related to
the meaning of the whole text and with it the sense of the text as a
whole is expanded‟ (Fleming et al, 2003: 118).
· Passages are identified, which are representative of the shared
understanding, between the researcher and informant. This gives the
reader further insight into the phenomenon being discussed. (I
suggest that this is an example of co-constitution of the data whereby
the horizon of the researcher is fused with that of the informant and
the different understanding is reached).
The stages described above would seem useful as a starting point for
analysis and this is why I have listed them in detail. However, I suggest that
they are just that, a starting point rather than a methodological rule book
which could constrain, rather than facilitate the development of meaning. As
Dahlberg et al (2008) suggest a strict adherence to methodological rules can
prevent creativity. What seems problematic to me with these steps is the
need to find an expression within the text which reflects the meaning of the
text as a whole. With transcripts so lengthy and varied, would it be possible
or indeed necessary to try to sum up what is going on with an expression to
reflect the whole text? This could inhibit creative interpretation. In addition, as
already discussed, I am choosing to identify constituent parts rather than
general themes. Therefore I intend to work from the following hybrid model,
113
based on the thinking of Fleming et al (2003) with a few alterations of my
own:
· The whole interview transcript should be read many times to gain an
initial understanding.
· Each small part of the transcript should be explored for its meaning
which will facilitate the identification of constituents. These are then
compared and contrasted to the researcher‟s pre understandings as
already identified.
· In line with the hermeneutic circle, each part of the text is „related to
the meaning of the whole text and with it the sense of the text as a
whole is expanded‟ (Fleming et al, 2003: 118).
· Passages from the transcripts are identified, which illuminate the
constituent parts. Morse (1994) suggests that when writing
qualitatively, quotations should be used to illustrate the interpretations
reached, rather than „descriptive text‟. Therein lies a problem in that
by presenting a lot of quotations, the researcher could run the risk of
the informant‟s identity being recognised by the reader. Therefore a
balance needs to be reached, one which does justice to the voice of
the informant, without exposing their identity.
· The identified passages are placed alongside the reflections and
thoughts of the researcher, Heideggerian philosophy, and other
literature. This gives the reader further insight into the phenomenon
114
being discussed. I suggest that this is an example of co-constitution of
the data whereby the horizon of the researcher is fused with that of
the informant. I agree with Whitehead (2004: 516) who states that in
hermeneutic phenomenological research, „It is vital that some
information about the researcher is included‟. This information in the
form of reflective thoughts and stories will be placed alongside other
literature.
I suggest that there are two ideas which warrant a little further discussion
here. Firstly, the way in which, „each small part of the transcript should be
explored for its meaning‟. I began to wonder how exactly I would go about
this exploratory process. In my own mind I had a feel for what I meant but
needed a more robust way to proceed. I was concerned that not giving
myself at least some guidance may lead to confusion or merely a descriptive
presentation of the data. I have already discussed the way in which this work
should be interpretive rather than descriptive in nature in line with the
philosophical approach, but there would seem to be no fixed method to guide
the researcher through the interpretive steps. I see this as a benefit in that it
affords the researcher more artistic freedom in contrast to a more rigid
approach.
Kvale (1996) describes three different contexts of interpretation as presented
earlier. The third level, theoretical understanding exceeds both self and
common sense understanding and incorporates other theory into the
interpretation. The third level seems to be the ultimate interpretive level in
115
which understanding can be rather far removed from what the informant
actually said. Smith et al (2009: 89) suggest making exploratory comments
on the transcript at the initial stages of the analysis and indeed highlight the
fact that making comments at this level „may feel like stretching the
interpretation pretty far‟. However I suggest that exploring the data in this
way, challenging the data and making meaning of it is all part of the process.
The important part is showing how the interpretation was reached and this
can be achieved by referring back to pre understandings, presenting
reflective self stories, and discussing relevant literature during the process.
The second idea warranting further discussion is that of the hermeneutic
circle as it is an important part of the analytical process. The idea of moving
from parts to whole and then back again still seems a little vague to me.
However, this could be an inescapable tension, in that it is difficult to have
„artistic freedom‟ without a certain amount of vagueness. Smith et al (2009)
attempt to explain the different levels at which the process can occur. for
example a „part‟ may be a single word placed against the „whole‟ which is the
sentence in which the word sits. Another „part‟ may be a single interview
placed against the „whole‟ of the research project. Another way to think about
the circle is the way in which I move from my view, which could be seen as a
„part‟ to a „whole‟ of understanding given to me by the informants. Whichever
„whole-part-whole‟ movement is taking place; it is a dynamic, critical and
hopefully sense-making process and overlaps with the meaning-making
process outlined above. Indeed, it is by entering the hermeneutic circle that I
can make sense and meaning out of the data and attain an interpretive level.
116
I feel it is worthwhile discussing three issues relating to the layout of the rest
of this work, beginning with contextualisation. As I have decided to include
the relevant subject literature within the analysis, the formal „literature review‟
presented earlier was short and focussed and was described as a means of
providing some context. Anything longer would be a duplication of text and
therefore redundant. When undertaking interpretive approaches to research
Koch (1995) states that literature reviewing is a continuous activity which
informs the whole research process. It assists in informing new perspectives
and sits alongside other influences such as personal reflection and other
aspects which are informing the way the researcher views the world at that
particular time.
Another issue surrounds the „Analysis‟ and „Discussion‟ sections. Initially I
wrote the „Analysis‟ section and then presented a „Discussion‟ section as two
separate parts. However, on reviewing this way of working it seemed to
present the work in a disjointed way and it was not easy to present other
„voices‟ physically alongside my own. I began to repeat myself in the
„Discussion‟ section, bringing in data which I had already presented in the
„Analysis‟. This method wasn‟t working and I had to consider other ways of
presenting the work. What follows is a combined „Analysis/Discussion‟ which
I believe is more coherent and more in line with my chosen approach.
The third issue is to do with the fact that I have returned at times to
discussion of methodological process issues, within the combined
„Analysis/Discussion‟ chapters. This was done purposefully to show the
reader how issues surrounding the process i.e. the approach and method
chosen, is continuously informing the work at every stage. By splitting the
117
work into very discrete sections the reader does not get the idea of how the
approach informs the progress at all stages and may be left wondering how it
actually works in action. In addition, making reference to process at this
stage helps me be more certain that I am staying true to it, which I suggest
gives the work more credibility. As suggested earlier there is not one fixed
approach when it comes to phenomenology, therefore highlighting the
ongoing process is important. By referring back to process issues I was able
to provide real world examples of the theories and concepts in action.
Working in this way explicitly links the process decisions to the actual reality
of the research, side by side, on the page.
At this stage I was also giving careful consideration to how best to achieve
the aims of my study which I feel it is worthwhile revisiting below:
· To analyse the emotions felt by student nurses in practice.
· To analyse how student nurses identify and manage their emotions.
· To analyse the effect of emotion work on student nurses‟ lives.
· To examine how the findings impact on the delivery of patient centred
nursing and the preparation of student nurses.
· To contribute to the growing body of knowledge of nurses use of
emotion in their relationships with patients.
By becoming too immersed in the approach and laying out of the work, it
could be easy to forget the primary aims of the piece. I envisage that through
118
the choices made thus far, I will be able to meet the aims, which I will revisit
later.
The Constituents
The data revealed the structure of emotional nurse being to be one that
included periods of isolation when the students felt both anger and anxiety
relating to care giving issues but also periods of joy. It involved at times a
feeling of potential loss of self and tension between wanting to fit in with
other nurses whilst trying to stay true to the person they knew they really
were. It included the need to recognise the emotionally upsetting nature of
nursing work and the need to remain „professional‟. Nursing work was seen
as unpredictable and challenging and at times the students felt unsupported,
misunderstood and isolated. Central to the structure of emotional nurse
being were the following three constituents:
1. Feeling threat to the authentic self as it once was.
2. Feeling the need to be emotionally „professional‟.
3. Experiencing ways of coping.
Much of the data could be placed within more than one constituent; for
example, feeling the need to be „professional‟ may include a need to change
and „lose‟ the self as it once was. I suggest that this is not problematic as the
real focus is on displaying the data, and not so much about strict
119
classification which would be incongruous with my chosen methodology.
That said an effort will be made to analyse the data coherently so that the
structure of emotional nurse being can be seen clearly.
To begin with, in line with my chosen approach I have presented each
constituent in tabular form with the titles of my own stories side by side to
show how the data is co-constituted. I agree with Draucker (1999: 362) who
states that co-constitution of data is „the cornerstone of hermeneutic
interpretation‟. I plan to show how using my own stories has assisted with the
understanding of the data and the revelation of different insights. In addition,
to show how the data relates to Heideggerian structures, these are also
included in the table. I suggest that if a researcher is going to state that their
work is truly Heideggerian then explicit reference to his thinking is necessary.
In Table 3 the reader can see immediately both the co-constitutive approach
and in what way each constituent relates to Heideggerian thinking. The titles
of the co-constituent stories may seem abstract to the reader at this stage
although they will be explained in more detail later in the work. The reflective
stories came into my consciousness at different stages of the research
process. I had not written all of them down at the time they occurred. For
example, some stories date back to 1988 when reflective story writing was
not something I practiced. I remembered some stories during the interviews
themselves; a word or sentence from an informant was enough to trigger the
process. I remembered others during train journeys to and from work. If I had
interviewed at lunchtime for example, thinking about the data on the way
home started to rekindle old memories from my past. I remembered other
stories during the transcription stage; it was as if getting to know the data on
120
a more intimate level helped me to remember my own past. I found no
difficulty in recalling stories even those I had not consciously thought about
for many years. It was as if they had been waiting all of this time to be
remembered and I feel comfortable that they are being used purposefully in
this way. Of course, our historicality makes us who we are today, whether we
realise it or not and it may be that there are lots of stories I have not
remembered; I have no way of knowing whether that is the case. As
Heidegger (1926/1962: 41) suggests, „....any Dasein is as it already was, and
it is „what‟ it already was. It is its past, whether explicitly or not‟. My way of
being is in part because of these events, these stories which I have chosen
to bring to life again in this work and also those I haven‟t remembered. In
addition, I have no way of knowing how „true‟ the stories I am telling really
are. However, I suggest what is important is the impact they have had on me
and how they have become part of my lifeworld. The importance lies in my
understanding of the event, not necessarily whether the event took place
exactly as I have remembered it. When exploring lifeworld events an
awareness of this seems important. The focus is on how the event was
experienced not necessarily whether it actually took place as described
(Johnson, 1998).
Deciding when to introduce the stories was another issue to be considered.
As suggested earlier I did not want the work to read as a narcissistic piece
although in order to fully co-constitute the data I needed to be present within
the work. Therefore my own reflective stories and thinking have been
introduced at times when fusing them with those gained from the data has
led to a different understanding of the subjects under discussion. For
121
example, I recount my own story of when I felt sad when I thought that a
nurse was laughing at a distressed patient. I have fused this story with one
from an informant and by doing so, a different understanding of the issue, in
this case, the use of humour as a way of coping, has been gained.
122
Table 3 The Co-constituted Approach and Relation to Heideggerian
Thinking
Constituent Co-constituent Heideggerian Structure
Feeling threat to the
authentic self as it once
was
The Man in the Green
Pyjamas
Authenticity
The „They‟
Conscience
Resoluteness
Feeling the need to be
emotionally „professional‟
The Lady in the Marks
and Spencer Nightdress
Pillows in short supply
The creation of a dual
emotional home
Emotions as tools
„unready to hand‟
emotion
Calculative and
meditative thinking
Death, „everydayness‟
and „covered up-ness‟
Experiencing ways of
coping
„Just stick it up his nose
and get some big
bogeys‟
Understanding
Discourse
„Leaping in‟ and „leaping
ahead‟
123
Chapter Six
Constituent One: Threat to the authentic self
Comments made by some informants revealed emotional nurse being as a
state which is threatening to their authentic self. The informants felt
pressured to change from being the person they were on entering nurse
education and become someone else. The tension this invoked led to the
informants feeling emotionally isolated from other staff and in one case
socially isolated. I will begin by offering some context in terms of introducing
the informants discussed in this section.
Fran
I had come to know Fran very well over the three years of her study and she
had always taken an active interest in me and my own studies and career.
Many students seem to treat the personal tutor role as one of „a means to an
end‟ in that they will use the tutor to get paperwork signed off and provide
answers to their questions. However, Fran seemed to view the relationship
as more of a two-way equal association, and our conversations resembled
those between peers rather than typical student/lecturer exchanges.
Fran had studied psychology at university before beginning her nurse
education. She was twenty five years old but did not complete her
psychology degree as she wasn‟t enjoying it, knowing from the very first
„moment I was there, I hated it‟. She realised that she wanted to do
something related to health and applied for nurse education. Part of the swap
to nursing was linked to her splitting up with her long-term partner whilst she
was still on her psychology course. She met another boyfriend and realised
124
then that „I didn‟t have to be the same person that everyone expected me to
be all of the time‟. As she said, „I was, like, this new person‟. My experience
of Fran, other than as her personal tutor, had been positive. In the classroom
she had always seemed engaged and willing to participate in the
discussions.
Jan
Jan was a thirty five year old student who had been an office worker before
entering nurse education. I did not know her as well as I knew Fran but my
experiences of her had always been positive. She had always engaged with
class discussions and I was used to her volunteering constructive answers
and adding to class debates. What I found most interesting about Jan was
her motivation for entering a career in nursing. Jan had been a school
secretary before starting her nurse education and it was watching the school
nurses working with the children that had motivated her.
She explained her reasons for joining the programme:
„With me, I was in a school environment......., I saw what the school nurses did with the children and that was what actually brought me into it‟
Jan was interested in the social aspects of care much more than what she
described as the „clinical work‟. She explained:
„Well I think because it went more into the social background of the children, you know those at risk and you were working with the head teacher and the parents and the children and I thought well there is nothing clinical. That didn‟t appeal to me at all, the clinical...‟
125
It is interesting to note that Jan left nursing before completion of her
education for reasons relating to not being able to care properly for patients
due to the constraints of the ward environment. To her, nursing was not how
she had wanted it to be. She gave examples such as lack of time and the
uncaring attitude of staff on the wards, which she summarised as follows:
„I just think it‟s very uncaring. I just find the whole …….. process of the wards that I have been on is just.....just, there‟s not enough time to care, to give the patient the time to care for them, even feeding, I know feeding is a massive thing but if on that first ward I hadn‟t made sure that the old lady who couldn‟t feed herself and get a drink, if I hadn‟t given her a drink, no one would have given her a drink. It was boiling. It was June and erm I made sure she had a drink but no I just (big sigh) it‟s all to do with handing the pills out and writing and not enough time to actually....I didn‟t see anyone just going having, I didn‟t see anyone just sit down and talk to a patient . It was just erm, you talk to them while you give the pills and that was it unless the buzzer went, they were sat at the station‟
Jan did not seem able to accept the way nursing is although in a sense it did
surprise me that she did not feel able to challenge, if not as a student, to wait
until she qualified, to try to change the status quo. Maybe she felt she would
never have the power to do so. I felt I could relate to what she was saying
and as Fleming et al (2003: 118) state, „already the first encounter with the
text is influenced by a sense of anticipation, which has developed through
the pre understanding of the researcher‟.
Because I have been a student nurse and already recognise parts of myself
in these excerpts I felt eager to analyse them. In Jan‟s case I already felt
saddened to speak with a student nurse who was so disillusioned and was
keen to uncover the reasons for this. Her data was in agreement with my pre
understanding of the background practice of nursing not being conducive to
126
providing emotional support, as she stated „there‟s not enough time to care,
to give the patient the time to care for them‟. I also suggest that Jan and I are
in agreement with my pre understanding that providing emotional care to
patients is central to effective nursing practice as she stated:
„....not enough time to actually...I didn‟t see anyone just going having, I didn‟t see anyone just sit down and talk to a patient. It was just erm, you talk to them while you give the pills and that was it unless the buzzer went, they were sat at the station‟
It is worthwhile noting that Jan does not go so far as to say that emotional
care is central to practice. However, it seems to be something she views as
being important. The way in which she mentions the need to „sit down and
talk‟ suggests at least that it is something she thinks about and this is in
relation to not having enough time.
As I read and reflected on these transcripts even at such an early stage, I
was reminded of an event from my own pre registration nursing education
which I will expand on later. Even though I had stated that I would combine
reflective thoughts with the data collected, I was not ready for the speed with
which I started to remember in vivid detail, emotional occasions from my past
and it came as something of a shock. I noted in my reflective diary:
„These events are some twenty years apart but the feelings are still the same. The feelings of helplessness and frustration that I felt then, I can feel now, when I hear these stories. Of course I can only assume that the students have the same feelings as me. I feel immersed in these stories from the start because of this strength of feeling but there is a problem with this. If I already „know‟ this story so well, feeling that I have already experienced it, what new insights can emerge? I feel that my informant‟s life is already part of my world; I have already „been there‟. But is it exactly because of this that I can gain a different understanding of the issues? I have to keep faith with
127
this process and wait for something „new‟ to emerge. This won‟t be easy‟
As I reflect on my own thoughts I am reminded of the work of Buber (1958)
who suggests that when there is so little space between the two people in
the research relationship, the relationship falls apart. However, I suggest that
the relationship does indeed need to be close enough for understanding to
take place, but not so close that the researcher cannot see what is going on.
At this stage I am also drawn to a story described by „Paula‟ who chose a
reflexive approach to her research (Etherington, 2004: 119). She describes
how the researcher is, „allowed to go back further into yourself... It‟s almost
as if the research participant is stimulating you to...your self discovery‟.
As I have already discussed, during the transcription stage, I was already
rediscovering buried emotional stories from my own past. Considering the
words of both Buber and „Paula‟ the worry is that the voyage to self-
discovery consumes the endeavour at the cost of meaningful research. As I
read this excerpt I reflect that self-discovery although useful to the process is
not enough. As Smith et al (2009: 90) state, „If you start becoming more
fascinated by yourself than the participant, then stop, take a break – and try
again!‟
Of course, my development and journey is part of the story and indeed part
of the methodology which underpins this work. However, my quest for a
different insight into emotional work in nursing will not be found in this way
128
alone. Just as I did at the interview stage, I question this approach again for
different reasons. As I read Etherington‟s (2004) work, I reflect:
„Am I prepared for my own emotions to be brought into the bull ring? Because that‟s how it feels right now, to resurrect the feelings I had on my very first ward placement and that‟s how it felt then when I experienced it. The feelings of, „Can I stay in nursing?‟ „Am I cut out for this work?‟ I still can‟t remember what made me stay apart from feeling, „Well this is how it is and you had better get used to it!‟ Did I lose some of myself by thinking in this way?‟
However, as I read my reflective thoughts I see how rather than lead me
down a narcissistic path, I am being prompted into thinking of other works on
this subject most notably the work of Randle (2002) who suggests that as
nurses, in order to improve how we look to other nurses, we conform to what
is expected by them, a concept described as „professional socialisation‟. By
not working in ways we would really choose to and being our authentic self,
there is an impact on our own sense of self which in turn affects other
aspects of our lives (Randle, 2002). Randle (2002) undertook a study which
involved interviewing two cohorts of student nurses at the beginning and end
of their course. The process of socialisation into nursing had a massive effect
on their sense of self. At the end of their course, ninety five percent of
students had experienced a decrease in self-esteem. As Randle (2002: 89)
states:
„....the majority felt anxious, depressed and were unable to act towards patients and colleagues in a therapeutic manner. For the students involved in the study it was a hard price to pay in order to gain professional status, as their self was fragmented and their personal resources depleted‟.
129
When I read Randle‟s findings I am reminded of why these stories feel
important to me. This is because it seems that both Fran and Jan broke
away from the need to conform to social nursing norms and be their own
person.
Keeping in line with my analytical stages, I read through the transcripts
several times to get a sense of the power within them. Fran tells a story from
her second year as a student nurse. It was an emotionally powerful story for
her and her perception of being alone in caring for a patient, was very strong.
She begins the story by saying:
„I was putting myself out there but it wasn‟t doing any good because no one else on the team was, so I was literally the only person who was there for the patient‟
Her story is about a very nervous female patient who had never been in
hospital before and was admitted to the ward where Fran was a student on
placement. Fran was asked to complete the admission paperwork and during
this process the lady told Fran that she was very depressed and having
suicidal thoughts. She told Fran that her emotional state was linked to her
skin condition; she felt very ashamed of the way her skin looked and
because it was visibly flaky and red she thought that people were looking at
her and passing comments about her image.
A sense of responsibility
Fran began to feel very worried about this lady and felt responsible for her.
As the week went by the lady repeatedly wanted to talk to Fran but Fran felt
that „nobody else wanted to give her the time of day‟. I suggest that Fran‟s
130
thoughts confirm my pre understanding that it can be easy to undervalue
emotional support. This is in the sense that I perceive that this patient needs
emotional support, but that it is not valued or provided by the qualified
nurses. Fran passed on the information about the lady‟s suicidal thoughts to
other members of the nursing team and was astonished by the response she
got from one particular member of the qualified staff who said „Well she
should just do it then!‟ Fran was very shocked and upset by this comment
and said:
„I couldn‟t believe that people could be like that. It seems naive but you can‟t believe that someone would come into a caring profession who doesn‟t really care‟
Fran was very worried and was keen to let the lady know that she was „there
for her‟. Fran felt very anxious because she did not know what was
happening to the lady when she wasn‟t there on a shift. She felt a sense of
responsibility to this patient, but felt that „there was only so much I could do‟.
Jan‟s story raises similar issues. Jan had been working on a ward with a care
assistant and describes a situation where the care assistant had „left us to do
all of the work‟ and returned when there was one female patient to bed bath.
Jan and another student were meant to be assisting the care assistant but
they had been left unsupervised. On her return the care assistant went to the
female patient‟s bed and lifted up the covers and said, „You‟ll do won‟t you!‟
(the meaning being that the patient did not need to be bathed) Jan was very
upset by this action and stated, „I went home with that one. There was no,
nothing there and I took that one home with me‟.
131
When Jan says, „There was no, nothing there‟. I interpret this to mean that
there was no feeling, no caring or thought for what the patient wanted or
needed. Jan states that she took her feelings home with her and I wondered
what effect this would have had on her and her family later on in the day and
days to come. Like Fran, Jan felt a sense of responsibility to the patient and
proceeded to wash her herself. Jan also wondered why people choose this
nature of work when they do not seem to really care. She stated:
„She was one of a couple on that ward. The old health care assistant type that felt they didn‟t need to do a lot of work, I mean some of them sat reading magazines when the buzzer was going (sighs) I am just angry that they shouldn‟t be doing the job, you know why is she doing that job because she doesn‟t care?‟
Jan‟s interpretation of events suggests that this Care Assistant is a non-
caring individual and this has provoked a lot of anger in Jan who questions
why this person is still doing the job. She likens her to a particular „type‟ of
nurse which is very far removed from the type of person who Jan thinks
should be in nursing. Already Jan is making the distinction between different
types of nurses and, from her perspective, is being exposed to negative role
models.
One morning Fran went onto the early shift and began listening to the
handover from the night staff. It transpired that the lady with the skin
condition had approached a member of the night staff and handed over her
medicine cabinet keys (she was self medicating) and asked the member of
staff to take the keys as she felt she may do something she might regret, i.e.
132
kill herself. Fran was horrified by the response from the night staff which was
recounted during the handover. Fran described how she felt:
„....their attitude to that was hilarious and that they should have just left her with the keys and let her get on with it and how melodramatic it all was. They just didn‟t have time for people like that....I was just like, “Can you hear yourselves talking?”.... It was really hard because I felt really responsible and at the same time I didn‟t know how much I could actually do‟
Feelings of horror, shock and confusion seems to prevail in this last excerpt
in which Fran silently asks the question, “Can you hear yourselves talking?”
She is obviously stunned by this behaviour but feels helpless due to her
student nurse status. She repeats the word „really‟; „It was really hard
because I felt really responsible‟ and I could relate to her sense of frustration
and worry about the events unfolding before her eyes. The lady eventually
got discharged without her mental health problems being addressed, but with
her skin much improved. She came back to the ward to say thank you on
one of Fran‟s final shifts. Fran felt a sense of relief to see her and it was clear
that the lady‟s confidence had been boosted by an improvement in her skin
condition. Fran felt that her mood had improved in line with her skin healing
and concluded her story by saying, „It felt like, well, even if I have just done
something to make her feel like a worthwhile person then that‟s been worth
it‟. I suggest that Fran means that it has been worth all of her own personal
heartache to know that the patient now feels more „...like a worthwhile
person‟.
Jan felt like she needed to help despite the attitude of others around her. Jan
went over to the bed and started to draw the curtains around to begin
133
washing the patient. It was at this point she was challenged by the care
assistant but defended what she was doing, an act which, for a first year
student nurse, I found very brave:
„She went, “what are you doing?” And I said, I am giving this lady a wash and cleaning her teeth because it‟s the least she deserves. So she comes back straight away and helps me but she never spoke to me...never spoke to me again, never‟
Jan explains her stark feelings of isolation when she says; „never spoke to
me...never spoke to me again, never‟. There was anger in her voice as she
said it and I considered the pain she was in having isolated herself by
standing up for what she believed to be the correct course of action.
Disagreeing with an established member of staff is difficult and I felt a sense
of pride that Jan was one of my students.
Both students stood by their beliefs and remained authentic in different ways.
Fran did not feel able to speak up and challenge the staff members although
she still did what she thought was right in a discreet way. Conversely, Jan
through her actions, challenged the care assistant, as she believed that the
patient deserved to be washed. Both were behaving as the patient‟s
advocate and Jan verbalised this during her interview:
„She wasn‟t getting the treatment she deserved and she couldn‟t speak, she had no way of communicating so that‟s when you become the advocate for the patient isn‟t it, that‟s what it‟s all about‟
What was clear to me during both interviews was the powerful emotion that
both students felt about the perceived injustice that was going on. Similar
134
findings have been shown when medical students go through comparable
encounters (Conroy & Dobson, 2005). However, taking a step back, there
could be another side to this story. I agree with the students and take the
view that it sounds like there is inadequate care being given by the nurses
described in the stories. However, it could be the case that Fran is only
seeing half of the picture. The nurses who are laughing may be using this
mechanism as a form of defence; almost a type of gallows humour to protect
them from the reality of what was unfolding. They may not after all be
uncaring individuals. Even if they are, this does not mean that they are, on a
practical level, providing poor care. Fran may see only what she wants to see
or even just be telling me what she thinks I want to hear; giving me a „good‟
story for my research. Starting with a pre understanding that emotional
support is not valued by nurses, I am more likely to interpret both Fran‟s and
Jan‟s stories in this way. In addition I now begin to question my pre
understanding. Continually supporting a patient who states suicidal thoughts
can be emotionally challenging for nurses who use humour as a means of
dealing with the circumstances. It may not be so much that nurses do not
value the emotional nature of their work, more that supporting patients in this
way is simply too hard to continue on a regular basis.
It has also been shown that nursing students may actually value clinical
teachers who use humour in the learning environment. A phenomenological
study by Lopez Nahas, (1998) showed that clinical teachers can use humour,
by sharing funny stories from their own nurse education, or by helping to
allay stress during difficult circumstances. However, humour is a very
personal issue and what is funny to one person is not always funny to
135
another, as can be seen in the case of Fran. This study showed that for
some, humour was not appreciated and actually restricted some students
learning. The fact that these two stories relate to the first year of the students
education may go some way to explaining why they did not „get the joke‟ if,
indeed, in Jan‟s case, the nursing assistant was joking (her subsequent
behaviour suggests she was not). Their understanding of how humour could
be used to deal with these situations may not yet have been developed. In
Fran‟s case, humour could have been used to help allay the stress of the
situation, although this was not explained to Fran, maybe because she did
not voice her discomfort when the humour was being used, or maybe
because the qualified nurses did not consciously realise what they were
doing.
Shock, anger, worry and tension
The structure of emotional nurse being has already raised issues around
authenticity. Not surprisingly, when the students perceive that the „way‟ to
nurse that they are witnessing differs from how they think it should be they
feel many emotions.
Fran felt very shocked and let down by the qualified staff members attitude to
her having reported that the lady was having suicidal thoughts. During the
interview when she repeated the line, „She should just do it then!‟ Fran
audibly gasped and her eyes widened on reporting what she had heard. Fran
was shocked and angered when she perceived that a qualified member of
staff would not want to know about a mental health issue. As Fran described:
136
„they just didn‟t have time for people who had mental health issues, even though more people they could possibly know have them, but the fact that someone had been brave enough to come forward and say “I do and it might be an issue whilst I am in here”, they just didn‟t want to know‟
A pre understanding I held before starting this work was that I believed that
nurses are emotionally self-aware and able to at least recognize how they
are feeling. However, I was not sure whether nursing students at an early
stage of their education would be so aware. Jan was able to recognize
overwhelming feelings of anger towards the care assistant in her story. She
emphasises her anger by repeating the word „angry‟. She states, „I was
upset, I was, I was angry as well...I am just angry that they shouldn‟t be
doing the job‟.
Another feeling that came through very strongly from both informants here
was one of worry. Fran was very worried that when she wasn‟t on shift the
lady may not be able to come forward and say things that may be bothering
her. This worry was fuelled by the fact that the lady had approached the night
staff and Fran felt that they had not taken her concerns seriously.
Jan was worried about the fact that the care assistant in question could still
be providing poor care to patients after Jan had left the placement area and
moved on. She was worried because she hadn‟t reported what had
happened and if the care assistant wasn‟t bathing patients then potentially
she wasn‟t checking their pressure areas either. Repeated questioning in this
next excerpt confirms her anxiety and worry. She described her concerns to
me:
137
„You know really I should have reported this person because basically if we hadn‟t have checked her could her skin have broken down? Would she have been responsible ultimately for that? You know and am I responsible? Is she still doing it with other patients though, that‟s the thing. Is she still there doing that with someone else and I haven‟t reported it?‟
Finally, Fran felt very tense as she was trying to remain authentic but felt she
could only work within certain confines as she was still a student nurse and
did not feel able to challenge the attitude of the other members of staff.
However, she did not join in with them, remaining true to herself and her own
values and beliefs.
Jan did challenge the behaviour of the other staff members, feeling the need
to be true to her own beliefs and feelings about the situation although this led
her to worry that she hadn‟t been very professional:
„I probably didn‟t do it in a good way, a professional way...but that‟s because I didn‟t know how. I hadn‟t worked in that environment before, being office based before‟
I suggest that Jan is showing feelings of loss of status and power in this
excerpt. She does not see herself as skilled yet and has a lack of knowledge
about how to behave towards the care assistant in a professional way. I
wondered at this point whether she looks back at when she was „office
based‟ and wishes she was there again; the office based work gave her
security and familiarity, feelings which are now long gone. Certainly trying to
care for the needs of the patient was coming at an emotional cost to Jan.
138
Part of the reason why these stories are so important to me is because they
remind me of a story from my own pre registration nurse education. I can
relate to the words of Finlay, (2003: 110) an occupational therapist
researching other therapists, who reflects in her own diary:
„The researcher in me wants to probe and challenge the therapists. The therapist in me wants to “save their face”. I want them to perform well and say professionally sound things‟
I too want the nursing students to say and do „sound‟ things which includes
them staying true to the person they are. Although honestly, as a researcher
I felt a little excited to hear stories which were so „meaty‟ and at the time, felt
a little controversial. Reflecting later I was appalled both by the stories
themselves and by my own feelings at hearing something that, with my
researcher hat on, I had felt was intriguing. Maybe this is an example of me
as researcher-as-voyeur?
I felt that Fran had done a „sound‟ thing by remaining true to her own self and
not joining in with the others who were trivialising and laughing about the
lady‟s mental state. Jan had behaved in a similar way, acting as an advocate
and recognising the need to provide care to the female patient. Having read
and re-read the stories I had a nagging sense that I had somehow, „been
there before‟. Returning to Finlay‟s (2003: 117) reflexive diary I agree when
she says:
„Where is the dividing line between my own experience and that of the creative writer capable of getting inside a character? Might this all just be an excuse to „play‟ with my own emotions through the fairytales I am weaving? Is this study of mine simply a reflection of my personal,
139
as opposed to shared, emotional responses? Can it be anything else?‟
Finlay is describing an experience described by one of her informants, not
one which has actually happened to her. She feels like she has become the
informant, and the boundaries become blurred between herself and the
informant who is telling the story. I too felt, after reading the stories many
times that I had no sense of where the students stopped and I began. I feel
that this is mainly in part due to my having experienced something similar, or
did I? Am I just imagining that my feelings are the same as those
experienced by the two students? Could I be doing as Finlay (2003: 117)
describes, „...imposing my own experience in a desperate attempt to
empathise‟?
I can still sense my own feelings of shock, anger, worry and tension when I
think about the story which I believe to be similar to the two described. It is
easy in one way to tell my story as it feels like it happened just yesterday. It
is hard to tell it as I still find it upsetting to think about and the strength of the
feelings will have a bearing on how I feel the stories, as if they were my own.
The Man in the Green Pyjamas
I was a first year student nurse on my first placement on a male medical
ward. Harry had been admitted in a confused state and had been placed in a
bed near to the nurse‟s station so that he could be clearly seen. He needed
to be watched as he was very agitated and was trying to get out of bed. Cot
sides had been placed on the bed to stop him from getting out. He was
140
refusing all food and a naso-gastric tube had been passed so that he could
be fed in this way. Due to his agitation he began to pull the naso-gastric tube
out and he had done this so many times that his nose was bleeding. He had
been dressed in hospital issue green pyjamas with buttons missing on the
shirt so it was flapping open, exposing his chest. The pants were ill fitting and
were gaping exposing his genitalia for all to see. He was moaning and
wailing and in such a state that eventually the curtains were drawn a little so
that other patients could not see him so clearly. A decision was made to bind
his hands in bandages so that he would not be able to pull the tube out of his
nose (This was common practice in those days). This procedure was
performed and resulted in him becoming more agitated. I felt that even
though he had been placed near to the nurse‟s station, the staff could see
him but could not really „see‟ him. It was as if they were looking straight
through him. Maybe they felt so helpless that it was easier to behave in this
way. I expressed my worry to the qualified nurses that he may fall out of bed
as he was trying to get over the top of the cot sides. One of the staff nurses
laughed and described him as a character from a horror film that was popular
at that time. The way in which I imagined Fran was feeling was the way I felt
when she said this. I felt shocked and angry and worried that no one would
be concerned for him when I wasn‟t there. I too felt helpless and frustrated
that I could not do anything further, but I was determined not to laugh with
her or join in with her comments.
As I re-read my story about this event which took place in 1988, I reflect:
141
„The horror of this story still brings tears to my eyes. Partly because this man could have been my own father; he was very similar in build, tall and slim. I can still picture Harry trying to get his long slim legs over the cot sides and being so frustrated that he couldn‟t do it. Maybe this is why this story is so powerful to me as my own father died in the same hospital ten years previously, in a series of events that remain as much a mystery now as they did at the time, when I was ten years old‟
As I read these words I have shocked myself as this is the first time I have
thought about this incident in terms of my own father. But then I ask myself,
apart from it having personal significance in these terms, how else is it
important to my research? I conclude that it is important because the
powerful feelings I still feel now can help me to understand the feelings of
others about their stories which in turn will help me achieve the aims of my
research. For example, I was dismayed by the behaviour of the nurse in my
own story, just as Fran and Jan were about their own experiences. In
contrast to me, Fran and Jan stay true to themselves in different ways, which
is something that I did not feel able to do at that time. Although I felt
concerned that nobody else would help Harry when I was not there, I did not
feel able to voice this concern at that time. This is in contrast to Jan for
example, who was able to challenge perceived poor practice. Maybe I am
using their behaviour to compensate for what I feel were inadequacies in my
own behaviour. By listening to their stories and remembering my own, I am
laying some ghosts to rest and in this sense, undergoing a form of catharsis.
But my relation to their stories serves another important function; if I hadn‟t
been through what I perceive to be a similar situation, I question whether I
would gain a true understanding of the emotions felt by the informants. This
could detract from my understanding and analysis of the data. For example,
142
when the staff nurse described Harry as a character from a horror film, I felt
angry. These remembered feelings of anger help me to relate to Jan when
she describes her anger towards the care assistant. In addition I am moving
from the whole of my understanding based on my past experiences, to parts
of the transcript which relate to the use of humour and authenticity, then on
to a different „whole‟ of understanding. This different understanding relates to
my view of how it is possible to remain authentic in spite of the challenges
this may raise. Remaining authentic is difficult and humour can be used to
cover up true feelings which may be difficult to face if they were to come out
into the open. Through this entry into the hermeneutic circle, I understand the
situation and myself differently. Returning to ideas around authenticity, I will
now return to Heideggerian thinking and begin with a discussion of the
„They‟.
The ‘They’
Heidegger (1926/1962) makes many references to the „they‟ in Being and
Time. He explains it thus (Heidegger 1926/1962: 167):
„The Self of everyday Dasein is the they-self which we distinguish from the authentic Self – that is, from the Self which has been taken hold of in its own way‟
Dasein is „dispersed into the „they‟, and must first find itself‟ (167). To
explicate this idea further it is almost as if we become „lost‟ in the „they‟,
losing some of our identity in the process. Indeed, we need to do what
everyone else does, and behave in a similar way, for us to be seen as
normal, and be accepted into society (Heidegger, 1926/1962). In addition, life
143
can become rather unsettling if we deviate from the „they‟. Heidegger
describes this as unheimlich, which translates as „uncanny‟ or „unhomelike‟
(Heidegger, 1926/1962: 233). Thus, moving away from what everyone else
does can cause us anxiety. However, Heidegger points out that we do not
need to do what everyone else does, but we have to accept the unsettling
nature of this if we don‟t (Heidegger, 1926/1962).
Nowhere would this seem truer than in the world of nursing and this is
reflected in the words of Fran and Jan. I introduced the informant Jenny
earlier in the work in relation to the realities of interviewing. As part of her
interview we discussed issues around violence and aggression in nursing
and how this can be upsetting for student nurses. Thinking in Heideggerian
terms, the „they‟ would see the risk of physical aggression as being part of
the job of a nurse. Jenny stated that when she had raised the issue of
aggression, something which had been worrying her, she was told, „You take
that risk on so you shouldn‟t worry about it‟. The fact that Jenny had raised
the issue, and the suggestion that she had been worried about aggressive
behaviour, lead me to believe that this was an issue she had wanted to
discuss with her colleagues (later in the thesis, her statements reinforce my
opinion). The „they‟ discouraged the sharing of emotions around this subject.
In Jenny‟s words, „they maybe frown on you expressing that you had
concerns...some people don‟t encourage talking...‟
Jenny finds this aspect of her work „a bit scary‟ but in order to fit in with the
crowd, she decides not to say anything about it and keep in with the status
quo. I suggest that some of her other comments reinforce this point:
144
„I think there is a certain culture of nursing which is quite macho and doesn‟t allow you to express.......people say you should be able to set your emotions aside as you come into work...there is a culture of it, but there is a culture that your emotions shouldn‟t come into play when you are dealing with somebody else....‟
Reflecting on my own story about Harry, I can relate to how Jenny may be
feeling at this point. I felt that there was an expectation that I should try to
„set my emotions aside‟, when showing concern about Harry falling out of
bed. My comments were met with humour, and although I could not see it
then, this may have been a coping mechanism on the part of the staff nurse.
As with Jenny, being told not to „worry about it‟ may have been a coping
mechanism within what she describes as the „macho culture‟. Even though
Jenny believes differently, in order to fit in with the „culture‟ and the „people‟
she chooses not to express how she is feeling at work. She uses the term
„culture‟ repeatedly as if to reinforce the difference between herself and
„them‟, the culture, which she seems to want to separate herself from.
However, she finds it impossible to set her „emotions aside‟ or stop her
emotions coming „into play‟ when dealing with others. This is easier as
emotions can‟t always be „seen‟ in the way that talking about emotions can
be. So, in that sense, she „gets away‟ with behaving differently to the „they‟.
In this sense, Jenny is behaving authentically in that on the face of it, she is
doing the same as everyone else is doing. However, there is a slight
difference in that her emotions are part of her work and she acknowledges
this to herself. She is remaining „true‟ to herself whilst working. In this way
she is „being herself‟ rather than doing what everyone else does, for
example, being „emotionless‟ when at work. Jenny‟s authentic way of being
145
may cause some anxiety, as she is deviating from the „norm‟ although as
Heidegger states (1926/1962: 232):
„Anxiety makes manifest in Dasein its Being towards its ownmost potentiality-for-being – that is, its Being-free for the freedom of choosing itself and taking hold of itself‟
Heidegger seems to be saying that anxiety makes us aware of the gap
between our (potentially) authentic self and conformity to the They, rather
than it being a sudden awareness of that gap which gives rise to the anxiety.
Jenny is working to her true potentiality-for-being. By working in this way she
is becoming liberated from the usual way of doing things, from the norm
which presides in the environment she is in. I had pre understood that the
environment was an important factor and here Jenny is moving away from
the emotional tone of the environment and the amount of emotion which is
„allowed‟ to be shown.
When thinking of authenticity in a Heideggerian sense, it is useful to consider
another of his ideas, that of „conscience‟, as the two seem linked.
Conscience
In a traditional sense, because we „have a conscience‟, we are forbidden
from acting in certain ways in our daily lives and conscience may be
perceived as a voice that speaks to us (Inwood, 1997). However, Heidegger
has his own meaning for the word „conscience‟. Conscience in the
Heideggerian sense, rather than telling us what to do, calls on us to make a
choice. According to Heidegger (1926/1962: 312) the „they‟ (i.e. other
people) stop us from being ourselves and „taking hold of these possibilities of
146
Being‟. The „they‟ even take away our choice in the matter, so we then fall
into inauthenticity from which we must return ourselves. Heidegger
(1926/1962: 313) states:
„This must be accomplished by „making up for not choosing‟. But „making up‟ for not choosing signifies choosing to make this choice‟ – deciding for a potentiality–for–Being, and making this decision from one‟s own Self. In choosing to make this choice, Dasein makes possible, first and foremost, its authentic potentiality–for–Being‟
So it is by hearing the call of conscience that we can remain true to our own
selves. To explain further, conscience according to Heidegger calls on us not
only to choose, but to choose to choose. It is only when we have done this
that we have a conscience in the traditional sense (Inwood, 1997).
I suggest that the stories I have told previously relating to Fran, Jan and
Jenny are model examples of this concept in action. Rather than „losing‟
themselves, each student hears the call of conscience in contrast to the
„they‟ who according to Heidegger (1926/1962: 343):
„hear and understand nothing but loud, idle talk....the „they‟ merely covers up its own failure to hear the call and the fact that its „hearing‟ does not reach very far‟
He uses the term „tranquillized familiarity‟ to describe where we can „dwell‟
when we become lost in the „they‟. Although in different contexts and to
differing degrees, none of the students already discussed became lost in the
„they‟. I suggest that if they had done, then their behaviour would have been
different. Fran would have joined in with the trained staff and their seemingly
uncaring discussions about the lady with the skin condition. Similarly, Jan
147
would have gone along with the wishes of the care assistant by not bed
bathing the patient. Jenny would have agreed with other members of staff
about the need to leave emotions out of work. However, I suggest that it
could be easy for student nurses to become professionally socialized into
„tranquilized familiarity‟ due to peer pressure and wanting to fit in with the
other staff. During the interview with Fran I suggested that it must have been
difficult for her not to join in with the other staff members who were joking
about the lady with the skin condition:
Me: „Were you tempted to join in? It must have been hard to be on your own and not join in with the culture?‟
Fran: „I just didn‟t want to because I thought, „that‟s just not me‟. If I do become like that then obviously I have completely lost who I was who came into my training because I just, (pause), couldn‟t look at myself if I suddenly became that sort of person who thinks it‟s funny that someone had mental health problems so, (pause), I just thought, “no”‟
I interpret the pauses as a way of Fran sharing her sadness at the choice
she had to make between losing herself and becoming like other nurses in
order to be one of them. The phrase „couldn‟t look at myself‟ provokes a very
powerful image of Fran not being able to look at herself in a mirror if she
behaves in a different way and also in a psychological sense of not being
able to „face myself‟. I suggest that Fran is being emotionally self aware here
which relates to a pre understanding I held before starting this work. Fran
hears the call of conscience and remains true to herself. She makes the
choice of not joining in with the „they‟; the choice between „losing‟ „who I was
who came into my training‟ and becoming „the sort of person who thinks it‟s
funny that someone had mental health problems‟. She reinforces her feelings
148
with the use of the word „no‟ which emphasises the strength of her feeling on
this issue. I wondered to what extent she even made a choice. It was as if
being like „them‟ was never really a possibility for her.
The idea of conscience and needing to remain true to one‟s own ideals has
parallels with an American study by Kelly (1998) who studied new graduate
nurses adapting to the real world of nursing. Although the nurses in my study
are not yet qualified the similarities in how they are feeling are apparent.
Kelly (1998) identified six stages of adaptation one of which included
„Alienation from Self‟. For example, Kelly‟s informants described four types of
loss which included a loss of the image of nursing as they had perceived it
and loss which related to being able to work as an equal with other members
of the team. I suggest the students I have introduced are struggling at this
stage between the nurse they want to be and the nurse that they are being
encouraged to become. There is perceived pressure to behave differently but
also stay true to the person they were when they entered their nursing
education. They are all resisting the risk of becoming alienated from
themselves.
Resoluteness
The students also become resolute, another Heideggerian theme described
by Inwood (1997: 83) in the following way:
„The best one can do is to be resolute, to withdraw from the crowd, and to make one‟s decision in view of one‟s life as a whole‟
149
Being resolute doesn‟t detach us from our world so that we become „a free
floating „I‟‟ (Heidegger, 1926/1962: 344). Indeed, we can‟t be like this as we
are still living in the world of the „they‟. However, we can do as much as we
possibly can, „by seizing upon it in whatever way is possible for it as its
ownmost potentiality–for–Being in the „they‟‟ (Heidegger, 1926/1962: 346). In
other words we can‟t go too far within the world of the „they‟ but can do as
much as we can to be ourselves. I suggest that Jan does become more of a
„free floating I‟. She deliberately disagrees with the care assistant and
continues to wash the patient even though the care assistant had suggested
there was no need. However, this has a consequence in that Jan is then
ignored by the care assistant who did not speak to her whilst washing the
patient and for the rest of the placement. By being herself and not fitting in
with the crowd, Jan has to pay the price.
An example of Fran‟s resoluteness was shown when I asked her about how
she felt when the qualified nurses were laughing about this patient:
Fran: „I was very sad, it definitely was sad. I felt angry with myself because I thought well really, if you want to be true to yourself, you should say to them, “What? I can‟t believe you just said that!” But I just wasn‟t at a stage when I felt I could do that so I thought the next best thing I can do is carry on and still be there for the patient and just get on with it myself‟
Fran is showing how she can continue in a resolute way but still within the
confines of the „they‟. She identifies feelings such as sadness and anger but
does not see a way in which she can articulate how she feels. There is a
sense of disempowerment as she feels she is not „at a stage when I felt I
could do that‟. As she says, she intends to „carry on and still be there for the
150
patient‟ but the cost to her is that she has to „get on with it myself‟ implying
isolation, as in the case of Jan earlier. I can relate to Fran‟s feelings of
isolation when remembering my story of Harry, as if I was the only person
who really cared for him, to others, he was just another confused man. As
Heidegger (1926/1962: 346) states:
„Resolution does not withdraw itself from „actuality‟, but discovers first what is factically possible; and it does so by seizing upon it in whatever way is possible for it as its ownmost potentiality–for–Being in the „they‟‟‟
It is possible for Fran to still be in the „they‟ whilst still being true to herself
and remaining there for the patient. As she was in the first year of her course
and felt very junior, she did not feel able to challenge the qualified members
of staff about their behaviour or attitudes. In contrast, Jan does challenge the
care assistant by her actions. Both informants, feeling sad and angry,
resolutely continue to realise their own potential for being „themselves‟ by
carrying on but in slightly different ways. Fran does this with some success
as shown by the next excerpt. I suggested that the patient must have valued
Fran‟s care to which she replied:
„Well she came back which was really lovely....when I was on one of my final shifts on the ward, to say thank you for everything you have done.....so that was really, really nice, for her to have remembered what you did for her whilst she was in‟
I considered the way in which Fran uses the second person in the phrase,
„for you to have remembered what you did for her whilst she was in‟ was
interesting. I wondered whether Fran lapsed into second person as a way of
151
disassociating herself from the care she had given; to have remembered
what you did for her...‟ I suggest that she may have felt that she could have
done more for the lady by challenging the attitudes of the other staff
members. However, it did seem clear that Fran was pleased that the lady
had returned; she uses the phrase, „really lovely‟ and „really, really nice‟ as a
way of reinforcing the point. This feeling was tied to a sense of relief as Fran
describes:
Fran: „I felt really relieved to see her because I wasn‟t sure which way it would go when she had been discharged.....I didn‟t know how stable she was but for her to come back in and be feeling quite positive „cause her skin was under control and (pause), like her confidence had been boosted so she had got this new haircut, so it was really nice. It felt like, well even if I have just done something to make her feel like a worthwhile person then it‟s been worth it‟
Fran here has returned to first person, taking ownership of the situation, as
she describes her relief that she had seen the lady again. I suggest that she
is so relieved by that fact that the lady has not killed herself and in fact has
shown an increase in confidence in relation to improvements in her skin
condition. Fran has identified one good thing to have come from the
situation, from her own caring perspective, when she says that „even if I have
just done something to make her feel like a worthwhile person‟ which I
suggest highlights the fact that she feels she could have done more. Fran
may be highlighting an element of emotional nurse being here in the sense
that whatever she does, it will never be as much as she might have done.
The emotionally engaged nurse may run the risk of always feeling that she
could have done more. As I read this excerpt I am reminded of Heidegger‟s
description of the „unshakeable joy‟ which is found when we realise our
152
„ownmost potentiality for being ourselves‟. By being herself and having „just
done something to make her feel like a worthwhile person‟ Fran has shown
authenticity and resoluteness which has led to some success. I suggest that
this is the counter-argument to the previous comment: the nurse who „risks‟
emotional engagement, also reaches for the rewards of such commitment.
Jan had also shown authenticity but did not seem so positive about her
situation. This seemed in part because she did not feel that she had anyone
to discuss the situation with;
Jan: „My mentor was off sick and my associate mentor was on nights so I just attached myself to people. I didn‟t have anyone I felt I could go to. If I could go and talk to someone they could clarify or give me their point of view then I could disassociate myself with it‟
The „feeling‟ on a ward is important when staff members are attempting to
„be themselves‟. A hermeneutic phenomenological study undertaken by
Rytterstrom et al (2009) found that the personalities of staff on a ward could
assist nurses in their quest to be themselves. The study explored the impact
felt by nurses working on different wards in terms of care and caring
attitudes. Wards which had personnel who shared both their personal and
professional lives were seen as more „comforting‟. However as Jenny
described, this can go too far at times when staff spend more time talking
about „new cars‟ rather than talking to the patients. Some nurses in the study
felt that they had to adapt to different care and caring cultures depending on
which ward they were on. On their „home‟ wards they felt they did not need to
play a role and could be themselves, a way of being which they perceived to
be the best for the patient. The difficulty of being a student nurse is that in
153
order to gain experience of many different specialities, there is a need to
move from ward to ward, thus the challenge to „be yourself‟ could prove all
the more difficult. Rytterstrom et al (2009) described „unspoken routines‟
which nurses need to adapt to if they are to be a success on that particular
ward. They suggest that the unspoken routines do not greatly have an effect
on the care given to patients and can be as trivial as the placing of a cream
jug on a tray.
In my study I suggest that what has been described is more about „ways of
being‟ which need to be adapted to if the student is to fit in on the ward in
question, and this clearly does have an impact on care giving. These ways of
being included: trivialising a patient‟s mental anxiety; ignoring the basic need
for bed bathing, and not discussing concern about potential patient
aggression. I suggest that in these three cases, the way of being is perceived
as one of lack of care, which has a detrimental effect on the three students
who are being encouraged, at times implicitly to behave in the same way.
This can be at odds with the beliefs that students hold about nursing on entry
to the profession. Davis (1975) identified six stages of socialisation, with
students entering nurse education with a certain amount of innocence as to
what the job entails. They arrive with images around helping those who are
suffering through providing acts of love and kindness. As can be seen here,
when the reality is somewhat different, they may become anxious and upset.
Rytterstrom et al (2009) suggest that capacity to adapt to new wards was
greatly facilitated by finding someone with a similar belief system. None of
the three students reported having done this, indeed Jan in the above
154
excerpt expresses both her yearning for someone to turn to, and the
absence of any such person.
Other perceived „uncaring ways of being‟ faced by students have been well
documented in the literature. Alavi and Cattoni (1995) describe uncaring
practices involving trained staff sniggering at a student who questioned
whether a patient was dead or sleeping, and asking students to take the
observations on a dead patient. The trained staff then went on to discuss
these „initiation ceremonies‟ over coffee. This raises issues around how
much we care for students; if we want them to care for others, do we need to
care for them more? However uncaring ways of being manifest, be it trained
staff ignoring patients needs or humiliating students directly, the impact on
the student is great and can lead to a feeling of loss of self. Ways in which
we as educators can care for students will be explored in more detail in the
final chapter of this work.
Randle (2002) suggests that the socialisation process can have an impact on
the sense of self as a student. Students in her study felt powerless to
challenge staff due to their social position as a student nurse. I found
evidence of this in my own data for example, when interviewing Fran, who
felt powerless as a student to challenge members of staff who were laughing
at a patient with mental health problems. In line with my own findings, other
students in Randle‟s study expressed hurt and were upset by their
experiences, causing them disturbed sleep and emotional confusion. In
addition to this, nursing students have reported physical signs such as
coming out in a rash and not sleeping related to shocking aspects of practice
such as sudden death (Loftus, 1998). Students have to deal not only with
155
staff members but the reality of nursing practice itself. As reported earlier,
Jan discontinued her nursing education due to the culture of the nursing
world in which she found herself. Many students in Randle‟s study coped by
becoming passive and conforming, the worry being that if they were to speak
out, it may have an effect on their reference or even their passing of the
placement.
The social position of student nurses has been explored in detail in the
seminal work of Menzies (1960) and was discussed earlier. Her work
uncovered high levels of stress and anxiety amongst the nursing staff. One
third of students did not complete their nursing education, leaving at their
own request, not because of academic or practical failure. There were high
levels of sickness and a high frequency of senior staff members changing
their jobs which could also be linked to the stress of the work. Increasing
priority was given in the study to exploring the nature of the anxiety and how
it could be relieved. As expected the study found that nurses are exposed to
high levels of psychological stress due to the nature of the work and this in
turn causes anxiety. However, the high level of anxiety could not be
explained by this factor alone. Menzies (1960) recognised a social defence
system, a way of working put in place to protect the nurse from the anxiety
aroused by nursing work. For example, the basis of the anxiety lies within the
nurse/patient relationship. The closer the relationship the more likely the
nurse is to suffer from the effects of the anxiety. A way of protecting the
nurse from the anxiety is to split up the contact with patients and patient care
is reduced to tasks which ensure some protection from the anxious state.
156
Other methods to reduce anxiety included depersonalisation and the
detachment and denial of feelings.
She goes on to suggest that the anxieties are „too deep and dangerous‟ to
be confronted and discusses the fact that it is the social defence system itself
which causes an added layer of anxiety in addition to the original anxiety
caused by the nature of the nursing work itself. It would be reassuring to
discuss the work of Menzies (1960) in a „bad old days‟ way and as practice
that no longer has a place in the contemporary nursing world. Unfortunately,
as I read this work I am reminded of my own data as I seem to be uncovering
similar issues.
My research stories have uncovered depersonalisation which may have
been used as a form of defence, for example in Fran‟s story, of the patient
with mental health issues; Jan‟s story of the dependent lady in need of a
wash and Jenny being encouraged not to think too deeply about emotion
and to leave it out of the workplace. Moreover the implicit pressure put on all
students to detach caused a second layer of anxiety, on top of the anxiety
they already felt. I recognise their being in my own story and my own anxiety,
firstly for the agitated man in the green pyjamas and secondly because the
trained staff were laughing at him. I also feel a third level of anxiety as I am
reminded of my own father and his death as I see him in this story.
Therefore, in addition to the secondary level of anxiety suggested by
Menzies (1960) I propose that there is potential for a tertiary level of anxiety
to be felt by some students. This third layer relates to feelings about our own
families which are not easy to „bracket‟ out as we are faced with similar
situations and feelings. Students may find it difficult to recognise where
157
feelings of loss and distress for grandparents or other family members stop
and feelings for their patients begin. This may not always be recognised by
academic and mentoring staff particularly when students present themselves
as coping and resilient practitioners, keen to pass their objectives and move
on to the next placement. Menzies (1960: 114) continues by discussing the
issue of authenticity and explores the way the task-based system denies the
student nurse the satisfaction of „investing her own personality thoroughly in
her work‟. By not being able to properly give anything of herself, her own
needs are not met which adds to the distress. The nurse eventually has to fit
in with the norms of the environment or be a nonconformist which is likely to
meet with hostility (Menzies, 1960). This finding was borne out by my own
findings in the case of Jan, who challenged the status quo and was ignored
even after the incident was over.
The idea of getting used to „normal‟ practices is explored by Greenwood
(1993) who refers to the term „habituation‟. This occurs when people are
exposed repeatedly to stimuli which, to them, becomes the norm but to
others new on the scene, such as student nurses, is alarming and
disappointing. When I am discussing emotional issues and events with
students, the phrase which repeatedly comes up is, „well nobody else
seemed bothered so I thought it must be me‟. This refers to the shock and
alarm felt by students on seeing certain practices but because other
members of staff are not behaving in the same way, they put it down to their
own inexperience or inadequacy to cope. I suggest that reassurance that
what they are feeling is not unusual could be useful in supporting them
through these experiences. Ways in which we can do this will be explored
158
later in the work. I told a story earlier in the work from my own practice; „The
Man in the Green Pyjamas‟. Because no one else seemed horrified about
this man‟s state, I thought it must be me that was different and not „normal‟.
This story related to patient care although I can also relate to the humiliating
practices described earlier by Alavi and Cattoni (1995) and will now tell a
story from later in my career which I feel has relevance here.
Teaching by humiliation
As a post registered nurse I undertook an MSc in Clinical Nursing, the aim
being to be able to assess and diagnose illness, a role which had traditionally
been the remit of a medical practitioner. Part of the course involved a
practical placement with a General Practitioner to learn assessment and
diagnostic skills. Until this placement I had been doing well, achieving
excellent marks and passing all placements without problem. However, this
was a twelve week placement in which the „teaching by embarrassment and
humiliation‟ approach was adopted by the GP. Rather than finding myself in
a supportive environment, I felt that an attempt was being made to catch me
out. By the end of the placement I had lost confidence to the extent that I
was questioning my ability to continue with the course, and people were
remarking that my usual happy manner seemed to have gone. I felt
devastated, my self-esteem had plummeted and I had lost sight of who I was
as a person. Just as the student nurses felt in my own study, I too felt
vulnerable, exposed and extremely upset to the extent that like Jan, I wanted
to discontinue my studies.
159
By remembering and including my own story in this work I feel more able to
relate to the feelings of the informants. Here it is in terms of their feelings of
isolation and of worry about not passing the placement if they were to speak
out. However, it goes further than that as it is also concerning the level of
disappointment felt on discovering that the role you wanted so badly, is not
what you wanted it to be. I, like Jan, was enthusiastic about the prospect of
taking on a new and exciting role. For her it was becoming a qualified nurse.
For me, I would be undertaking a more advanced role in an area I felt
passionate about. Jan left the programme and I was very close to doing so.
Remembering my own feelings from that time leaves me with a different
understanding of what is needed, in that I suggest that there is a need for
educators to show care for students. In this way they can be nurtured and
learning becomes easier. Reflecting on this experience is the first time I have
thought of myself as being vulnerable. It is not only a sense of vulnerability
about failing but also the effect on my own self worth and emotional state. I
have moved from my original whole of understanding to the smaller parts of
the story. These smaller parts include my own feelings of vulnerability. This
leads me to a different whole of understanding, and as I write, I remember
the phrase „crushing vulnerability‟ from reading the work of Morrison (1994).
He uses the term when discussing the way patients feel when they enter a
care setting. My different understanding begins with a look at vulnerability
from an altered perspective. I shall now continue by discussing the issue of
vulnerability in the context of the student nurse and how they feel when
entering the same care setting.
160
Vulnerability
It is interesting that words which previously may have had a negative
connotation can be resurrected and „rebranded‟ later as being less
threatening or even positive in their meaning. A prime example of this has
already been discussed; the word prejudice in Gadamerian thinking takes on
a more positive connotation. Heidegger (1926/1962) describes our pre
understanding as a state which enables us to understand differently, what we
see before us today. In this way, new knowledge about phenomena is
gained. For example, I understand what the informants in my study are
describing because I already „pre judge‟ it; I have „been there‟ and can relate
to the emotions and experiences. I suggest that my understanding of the
word „vulnerability‟ is ready to be transformed and I do not seem to be
completely alone in this way of thinking. Daniel (1998) explored the word
vulnerability both in the traditional sense and from a more existential
perspective. Daniel (1998: 191) concludes a piece on the subject by
suggesting the following:
„To be authentic, nurses must be aware of their own vulnerability, recognize themselves in others, and be willing to enter into mutual vulnerability. If nurses deny the opportunity to be vulnerable, they deny the opportunity to participate in humanness and are more likely to dehumanize others‟
On reading this, I immediately think of Fran, „I was putting myself out there‟.
Fran was struggling to be vulnerable, to enter into mutual vulnerability, to
recognise herself in another, but felt isolated in doing this. She perceived that
she had no support from the trained members of staff who, if we are to take
161
Daniel‟s line, were more likely to dehumanize the patient in the ways they
practiced. It could be suggested that they went further than dehumanizing
the patient and were actually dehumanizing themselves. Fran wants to ask
the trained staff, „Can you see yourselves?‟ However, I suggest that seeing
the self in these situations can at times be too painful and better not pursued.
As I write this, I am keen to not seem „holier than thou‟ in my attitude. I
understand the harsh reality of practice and I can very clearly see why
nurses behave in this way. It can be easier to detach and dehumanize than it
is to face up to the reality of practice. However, that doesn‟t make it the most
„correct‟ way of being. I suggest that as educators if we see the vulnerability
in our students then we may be more likely to care for them and not resort to
practices such as those outlined above for example in my own story about
teaching by humiliation.
I agree with Daniel (1998: 191) who continues by describing vulnerability as
a way of „celebrating humanness‟. This may seem like a strange way to
describe being vulnerable but she goes on to explain:
„...it is the abandonment of participating in vulnerability that makes us susceptible, for when we seek to protect our own vulnerability by numbing ourselves to another‟s, we are susceptible. When we are no longer able to recognize our own pain in the pain of others, then we are capable of inflicting pain on others‟
In Fran‟s words, if we do not „put ourselves out there‟ we run the risk of
becoming vulnerable in a negative sense, and causing harm to others. In
Jan‟s story, it could be suggested that the health care assistant „numbed‟
herself to another person‟s pain; she then became susceptible to inflicting
162
„pain‟ on another person. So it is the abandonment of vulnerability that is the
risky business, not vice versa. Of course this is all very well in theory, but as I
write this I am wondering how the idea of being vulnerable could be put into
practice. Denying vulnerability, as a form of defence, would seem a natural
state for a human being. I agree with Daniel (1998) in the sense that we as
nurses need to be vulnerable to recognise it in another. However, we also
need a safety net, a method or mechanism whereby we feel protected in our
vulnerability. We need to feel that we can „put ourselves out there‟ because
we know it is safe to do so. With this in mind I propose the term „cushioned
vulnerability‟. In this way the nurse feels safe in being vulnerable, safe to be
exposed as she knows that she is „cushioned‟ in this act. She is able to be
freely susceptible as she knows that she has a safe place, be that in her own
mind or through interaction with another person, where she can go for some
care for herself. Having said all of this, how do we do it? Where does the
nurse „go‟ to get the care she needs? As Randle (2001) suggests,
encouragement and support from mentors and educators is crucial.
Opportunity needs to be given for students to be listened to and understood.
However, in the study by Menzies (1960) senior members of staff at that time
did not feel confident in dealing with the students‟ emotional stress. The
behaviour of other more experienced staff in the situations described earlier
would seem to prohibit the seeking of emotional support. Teaching which
exists as a one way street, carried out in an authoritarian or humiliating style,
does little to encourage students to become engaged in the process. This
would seem to take on even greater importance when students are
concerned about feelings and the emotional nature of their work. The
163
creation of safe places for students to express worries and concerns is
important although it could be viewed as only half of the story. A more „formal
and systematic training to manage feelings‟ as described by Smith (1992:
139) may be viewed as an important part of nursing education. I suggest that
the panacea is to provide a kind of education so that in any situation the
nurse finds themselves, they have an „emotional tool kit‟ that they can use, to
help ensure they maintain a healthy emotional self.
However, in recent years placing value on emotional work has been a
problem as Randle (2001) and Freshwater and Stickley (2004: 93) state that
contemporary nurse education seems to place more emphasis on technical
rather than emotional skills. If emotional skills are ignored and educators
focus solely on rational elements the danger of the „unbalanced practitioner‟
is realised. They suggest a process of transformatory learning which requires
the student to engage in reflective practice, reflecting on the self to reveal
new insights which can inform change. Engaging in reflection can bring
tensions to the surface but this should not be viewed as a negative
experience in that the new insights gained can be acted upon and change
needs to be valued. Relating back to the earlier discussion, through this
process the anxiety and vulnerability felt by nurses would be valued as part
of the learning experience, rather than denied and brushed aside.
Another point raised by Freshwater (2000) centres on the fact that student
nurses are taught mainly by experienced nurses both in the university and
practice setting. There is a danger that teaching in this way merely reinforces
the oppression which is felt within nursing as it may be the case that nurse
educators feel oppressed and reinforce the position during the educational
164
process. They haven‟t necessarily been encouraged to expose their
anxieties and vulnerability and consequently they find it difficult to deal with
these issues if raised by students. Clearly this presents a potentially
significant obstacle to change. More hopefully, Freshwater and Stickley
(2004:96) outline elements of a curriculum model which are commensurate
with a transformatory learning process. They use the term „emotionally
intelligent curriculum‟ which would incorporate aspects such as:
„reflective learning experiences, supportive supervision and mentorship, focus on developing self and dialogic relationships….a commitment to emotional competency…self inquiry...reflective discussion and writing…‟
Indeed the use of these techniques could assist nurses in exploring their
anxieties and vulnerability, so that they will be more able to practice
authentically and less at risk of becoming detached and depersonalising
patients.
Smith (1992: 139) suggests a more formal method. During a discussion of
the emotional training needs of nursing students she concluded that,
„....the emotional components of caring require formal and systematic training to manage feelings, grounded in a theoretical base such as psychology, sociology and the acquisition of complex interpersonal skills‟
I question, based on my own findings and those of others, whether nursing
education has developed a form of education which meets either of these
goals. I am interested in a transformatory mode of learning, and the issues
under discussion would seem to lend themselves to a more experiential
approach. In addition, as I have shown in my approach to this work, I am
165
drawn to reflective practice and believe that experiential learning is an
important way to develop new knowledge. Conversely, the words of Smith
(1992), „the emotional components of caring require formal and systematic
training…‟ conjure up a more didactic approach to learning to deal with
feelings. Suggestions on a way forward will be discussed later in this thesis.
166
Chapter Seven
Constituent Two: Feeling the need to be emotionally ‘professional’
During the interview process I was keen to let the informants have freedom
to tell their stories. In this way, they would raise issues important to them,
rather than being directed with issues important to me. An idea raised by
many of the informants was that of overt emotional displays on their part, and
whether this was professional behaviour. For example, when asked to
describe aspects of practice which the informants felt were emotionally
challenging, they described stories in which they may have cried or got
upset. They then voluntarily linked this to „not being very professional‟. This
theme was so prevalent amongst some informants that I began asking others
whether they thought that showing emotions such as sadness and physically
crying in front of staff and patients was professional. This relates to the
overall aims of the thesis in that it explores the emotions felt by the students
and how these are identified and managed in practice.
This part of the thesis includes the voices of some pre registration nursing
students who have not yet been introduced. It is my intention to provide
some information about each student as their thoughts are introduced. In this
way the reader gets some context relating to each informant, close to their
thoughts on the page.
167
Feeling the need to change
One of the informants, Fran, has already been introduced giving her thoughts
on remaining true to herself, and I discussed this previously in relation to
Heidegger‟s thinking on authenticity. In this section she pursues this theme
to some extent as she describes herself in terms of two „me‟s‟. I will discuss
this idea later. Before this I will present her feelings relating to the early days
of her first placement in which she felt very shocked at what she
encountered. This will lead into the discussion about being emotionally
professional.
Fran had swapped courses from psychology to nursing and I asked her
whether she had made the right move, and whether nursing was how she
thought it would be. My rationale for asking these questions was partly to
encourage her to talk, but also based on my own feelings on starting my
nurse education. I agree with Heidegger who states that we base all of our
current interpretation on our own historicality, which cannot be ignored
(Heidegger, 1926/1962). Indeed, it assists us in the journey to understand
differently.
On commencing my first ward placement I had been taken aback by the
rawness of the job, and nothing could have prepared me for the feelings of
loss of control and shock at the nature of the work. Fran‟s thoughts seem to
echo my own:
Fran: „It‟s not what I thought it was gonna be. That‟s not to say it‟s been worse or better or anything. It‟s just that I think you get an idea in your head …and I didn‟t get any care experience so it wasn‟t like I could even say like a little bit about what it would be like or be about...
168
erm... so ……..it was quite a shock, like my first placement was quite shocking‟ (voice gets quieter)
I can fully relate to her feeling of shock as I felt the same on starting my first
placement. I was not surprised that her voice became more quiet as she
continued to talk; almost as a way of making her point even more strongly.
My overwhelming memory of my first days concerns the various smells on
the ward. This was something that had never occurred to me until my first
early shift, but if I close my eyes and concentrate I can still smell it. I had
worried about my lack of knowledge and experience and the way I would be
perceived by my assessor but nothing further than that. I can still remember
the smell of breakfast which was being served, mixed with the smell of
faeces, and unwashed patients who had been in bed all night in the warm
stuffy ward. I remember getting ready for the shift and being totally
unprepared for the heavy and dirty work I was about to undertake. I can
relate to Fran‟s feeling of being thrown in at the deep end and it somehow
not feeling „real‟. I was interested to explore her feelings of shock as I wanted
to understand the nature of her shock; was it the same as mine?;
Me: „Shocking….in what way?‟
Fran: „Erm…my only experience of health care was being a patient so being on the other side and sort of being thrown in at the deep end and it was a really busy acute medical elderly ward and erm… and straight away they, they were really good with me but straight away they were like, “Do you want to do this?” “Do you want to see this?” And I was just all over the place. I really wanted to get involved but it was just quite daunting because I didn‟t…like we‟d been shown how to make beds and give people a wash but I had never actually done it and to be a couple of hours into your very first shift and be left on a ward and be bed bathing someone…it was an ooooo an out of body experience really. A few weeks ago I was a psychology student
169
(laughs) and now I‟m bed bathing someone so it was very strange‟ (voice gets quieter)
The phrase „I was just all over the place‟ summarises for me, the feelings of
unpreparedness when beginning life on a first placement as a student nurse.
By this I do not mean unprepared in terms of performing tasks such as bed
making which was something learned in university before entering the ward. I
am talking about the type of unpreparedness for actually dealing with real
people, in real life situations, not simulation in the skills laboratory at the
university. This includes the feeling of loss of control, in that student nurses
are being faced with sights and experiences they have never had to deal with
before. I am not sure whether as educators we can ever truly prepare
students for the reality of nursing before they begin their first placement.
However I suggest that there may be a case for some nursing stories to be
shared with nursing students‟ pre placement, and I will discuss this later in
the work.
I was interested in the phrase „it was an ooooo an out of body experience
really‟. As a student nurse on my first placement I often felt like I was on the
outside looking in on myself. It was almost like being in a film in that what I
was doing wasn‟t really real; I was an actor, watching myself. This was my
way of detaching myself from what I was doing; the form of defence
described by Menzies (1960). I was performing tasks and feeling emotions I
had never experienced before and it became overwhelming. It seems to me
that Fran is saying the same thing and the way we cope with it is to detach
from what is going on and almost „come out of the body‟. This has clear links
170
to the concept of emotional labour as described by Hochschild (1983).
Emotional labour relates to this discussion in that in order to „be a
professional‟, the shock felt by both myself and Fran had to be suppressed.
Hochschild (1983: 7) states that emotional labour is:
„the induction or suppression of feeling in order to sustain an outward appearance that produces in others a sense of being cared for in a convivial safe place‟
Clearly neither of us could let the feelings of shock show on our faces if we
were going to be successful nurses. We both wanted the patients to feel
cared for so our own feelings had to be suppressed. However, this takes a
lot of energy, as we are suppressing our natural self and our usual way of
being. Feeling such loss of control is exacerbated by having little knowledge,
particularly when starting out. Not being able to see the reasons behind
decisions about care given can be very frustrating. As Fran describes:
Fran: „I think because I was so new to it I didn‟t have, maybe the boundaries that other people take into work with them, like „I‟m a professional and I‟m here to do a job‟. I was like, I was Fran still and really new to everything and I just couldn‟t sort of do anything with those feelings cause I knew I was supposed to be professional and like I shouldn‟t cry and I tried to ask questions which did help because when you are just faced with someone who is unwell and nobody seemed to be doing anything about it you know like on the surface we were just like cleaning people up and feeding them and I was thinking „Well what are we gonna do, he is really unwell‟ and so asking questions, what‟s happening with the diagnosis and illness did help me and then you can sort of say „Right, so I can see how I am helping‟ but before I sort of got to that stage I was just feeling ….quite helpless and not really knowing what was going on‟
171
This excerpt summarises the tension experienced when starting as a student
nurse and something I expected as suggested by my pre understanding that
caring for patients emotional needs comes at an emotional cost to the nurse.
On the one hand there is the need to show ultimate control at exactly the
time we are feeling very much out of control. In addition, our knowledge base
is lacking so it is difficult to make sense of what is going on. However, we
want to suppress all of this in order to keep control and maintain the charade
that we are coping. This is summed up by the phrase „...I just couldn‟t sort of
do anything with those feelings „cause I knew I was supposed to be
professional and like I shouldn‟t cry...‟ It is interesting to note here that Fran
feels she should not cry just as I did when I started my nurse education. I
just knew that I had to keep myself together and crying in front of others on
the ward would not be acceptable even though nobody explicitly said this to
me. It is almost as though as nurses we wear emotional self control as a
badge and the more we are able to keep control, the more badges we
receive.
However as Fran suggests in this next excerpt, allowing ourselves to feel
emotions can be just as draining as keeping them bottled up inside us. This
was not something I had expected, believing that keeping emotion
suppressed and inside us was draining, not the other way around. I was
interested to explore whether Fran‟s sense of who she was had altered
during her placement. She uses the phrase „I was Fran still...‟ which implied
to me that potentially she would not „be Fran‟ for very much longer, a
transformation that she was ready to undergo in order to do the work. This
was in part based on my own experience as a nurse in that I felt that I had
172
changed; I felt that I had to change in order to cope with the stress of the role
in terms of management of my emotions in practice. I had a feeling that I
could not let things „get‟ to me or I would be getting upset for a lot of the time
spent in practice. I was interested in pursuing the idea of transformation and
whether or not she felt that she had changed into someone else:
Me: „Do you consider yourself as being the same sort of person?‟
Fran: „Yeah I do. I find it really hard though too, I feel like there are two „me‟s‟ – the me that came into nursing that would see somebody unwell and be like „Oh, I need to do something‟ and be quite upset about it and there‟s the me now that like knows that in order to be effective in what I‟m doing, I need to like take a step back and be quite calm about it and it‟s quite hard in some situations not to, to decide which one I need to be and sometimes I go home and think „Well it wouldn‟t have been so bad if I was the first one today‟ but I have made myself be you know really professional and it would actually have been alright and OK to have shown a bit more emotion today. So it is quite difficult‟
I find the idea of two different selves interesting and also the fact that Fran
seems to be making a conscious choice as to which self she presents. She
has realised that in order to be effective she needs to manage her emotions
by taking a step back and remaining calm. However, she also acknowledges
that on some occasions it would be acceptable to show some emotion and
my interpretation is that this self is more like her true and authentic self. She
seems to be showing a great amount of self-awareness in that she can look
into herself and decide who she wants to be at a certain time.
Her way of being, in that she can recognise, integrate and manage her
emotions, has parallels with the concept of emotional intelligence explored
by McQueen (2004). Emotional intelligence concerns the ability to monitor
our own and others‟ emotions and use the information to facilitate our
173
thoughts (Mayer et al, 2004). Cadman and Brewer (2001) believe that
assessment of emotional intelligence should be part of the recruitment
process into nurse education. They use Goleman‟s (1998) description of
emotional intelligence which relates to competencies such as self
awareness; self regulation; motivation; empathy and social skills, such as
communication and leadership skills. Cadman and Brewer (2001) suggest
that although emotional intelligence can be developed, there is not enough
time within most pre registration nursing programmes for this development to
occur. It is an interesting concept to consider and will be discussed in more
detail later in this work as part of the implications of what has been found.
I was interested by Fran‟s choice of words, „I have made myself be you know
really quite professional...‟ This was firstly because she used the phrase
„made myself‟ which implies some emotional labour or emotional intelligence
on her part, by the suppression of feeling, needed to do this. This agrees
with my pre understanding that nurses need to be emotionally self-aware, in
that she was thinking about her feelings and deciding how she would be in a
particular situation.
Secondly, I was interested in the link she made between this and being a
professional. I assumed from this that she did not equate showing emotion
with being a professional, which prompted my next question:
Me: „So you equate that more detached stance with being professional whereas the other you; is that not a professional?‟
Fran: „No I don‟t think so, I think it‟s like looking at people as though they are members of your own family, you know becoming really
174
attached to them and thinking „This is someone‟s family‟ and getting quite like upset and getting quite involved with patients‟
I think this excerpt is a little ambiguous. My interpretation is that treating
someone like they are a member of your own family requires a certain
amount of attachment and involvement and this behaviour is unprofessional.
However, it could be interpreted as meaning that looking at people as if they
are your own family is the professional way to proceed. The nursing mantra
has traditionally been that we should treat patients as if they are members of
our own family, in terms of the care we give, although this doesn‟t
necessarily extend to the giving of emotion. According to Fran, there is a
balance that needs to be achieved, as she describes later; a thought echoed
by another informant yet to be introduced. Before I go on to explore the next
excerpt I will describe a story from my own practice, which I feel has
relevance here. In this story I was not consciously treating someone like they
were a member of my own family. However, I did spontaneously show
emotion due to feelings of complete sadness about the situation unfolding
before me. Unlike Fran, I suggest that this was not emotionally intelligent
behaviour in that my emotions took me by surprise; I was not identifying
them and consciously using them to guide my actions. In a sense, my
emotions were out of control, although I still believe that this was not a bad
thing.
The lady in the Marks and Spencer nightdress
I was a third year student nurse and had almost completed my pre
registration education. I was working on a female medical ward and had
175
been caring for a lady who had suffered a myocardial infarction. She had
recovered well and was due to be discharged. However her physical history
was not what sticks most in my mind. Each time her husband came to visit I
remember feeling that I had never witnessed a more loving and caring
relationship between a husband and wife and his devotion to her seemed
obvious to me. At that time many patients on the ward were dressed in
hospital nightdresses, but this lady always wore lovingly ironed Marks and
Spencer night wear. I had been brought up to believe Marks and Spencer to
be an expensive shop, so the fact that she wore a night gown from there
seemed to reinforce my view that she was a very well cared for lady. The day
before she was due to be discharged she suffered a cardiac arrest and died.
This was a complete shock to everyone. It hadn‟t been expected, as she had
until then made an excellent recovery. Her husband was called and came to
see her on the ward, having been told the bad news. I was there and I
remember his face was one of a lost man; he seemed very confused about
what had happened but as ever was extremely grateful to us for the care we
had given her. I felt very sad for him and very upset that his wife had died.
What happened next took me by complete surprise. I walked over to him and
gave him a hug which lasted for a few seconds and as I did this I filled up
with tears. As I let go of him he looked at me and smiled. I think my actions
shocked the staff nurse I was with as she glared at me with wide eyes and
then told me to go and get a drink for myself. Hugging him had felt like the
right thing to do at the time and anything less would not have seemed
enough under the circumstances. I felt so sad for him that words could not
have said what I wanted to say. After I had done it I felt embarrassed and felt
176
it had been the wrong thing to do. Later the staff nurse asked me whether I
was alright and after that the incident was never mentioned again. I had
given some emotion and some of my real self to this man and I felt that it had
been appreciated by him. Whether I had found the right „balance‟ remains a
question to me. The staff nurse I was with at the time seemed uncomfortable
with my actions. I certainly felt uncomfortable after the event, as if I had been
weak by filling up with tears, rather than maintain a cool persona, which I felt
was expected.
The effect of emotion on the patients and families
Having had this experience and having felt that what I did had been
appreciated by the man, I was interested to know Fran‟s thoughts on how
showing emotion was perceived by patients and families. I thought that this
was particularly relevant as she had made her comment about the need to
treat people as if they were family members:
Me: „Do you think the family and patients do value that, showing more emotion?‟
Fran: „I think they do yeah in some situations. I think there is definitely a balance and I do find it hard to like to get the balance, because I think we are taught so much in practice and you see people being so professional and you think like „Oh how can you be like that?‟ Erm... it‟s really really hard. There have been situations like in my training, and recently in my training when I‟ve definitely been the former and definitely been really involved and really emotional and I don‟t think it‟s made the way that I have looked after someone like, I don‟t think it has negatively affected it but I don‟t know if I could do that all the time because I would get really drained. I think if you had that level of, sort of, involvement and emotion with every single patient on every single day that you went in, then you just wouldn‟t be able to keep up. I think it‟s like specific cases that sort of leap out at you and you end up sort of unintentionally getting involved and it happens every now and again when you are on a placement and you meet some particular patient‟
177
Fran acknowledges here the draining nature of getting emotionally involved
and again suggests that there is difficulty in being professional, in the sense
of not showing emotion. She believes that showing emotion does not
negatively affect the care given although the ultimate cost would be to the
nurse who „just wouldn‟t be able to keep up‟. I thought that her use of the
phrase was interesting as it conjures up images of racing and maybe pre
registration nursing is a race, to get from start to finish without emotionally
„falling over‟. Certainly, remembering my story helped me to relate to the
imagery of emotionally „stumbling‟. In addition, if I had continued to give so
much of my emotional self to a larger amount of patients, I wonder whether I
may have struggled to „keep up‟. Indeed I can relate to Fran when she
suggests that some cases „leap out at you and you end up sort of
unintentionally getting involved...‟ There is a contradiction here in comparison
to Fran‟s earlier comments in which she sounded more in control of her
emotions. However, in this excerpt her wording implies that emotional
management isn‟t that easy and sometimes emotions cannot be intentionally
managed. In my story, I had not intended to hug this man and begin to cry.
However I suggest that there is more to this story in that it relates more to the
fact that the staff nurse I was with, sent me away to have a cup of tea. After
that, the issue was not mentioned again. It was as if she did not want me to
„be myself‟ with this man. However, it has been shown that patients in certain
settings value more of a personal style (Carlsson et al, 2006). This will be
discussed in more depth, later in the thesis.
I was interested to hear that Fran felt that it was certain patients with whom it
was more difficult to remain detached. This was a feeling echoed by the next
178
informant I will introduce. Certainly from my perspective I had found it difficult
to remain detached from the man in my story due to the huge sense of loss I
felt for him. The challenge for nurses is to find the balance between giving
enough of ourselves to make a difference to patients and also being able to
„keep up‟ ourselves. We need to care for the emotions of others whilst caring
for our own, rather than promote a situation where emotions are suppressed
on both sides. I will now present the thoughts of the next informant, Anne,
and begin by providing some background.
Anne
Anne was a first year student nurse when I interviewed her. She was part of
my purposive sample and I had felt that I could relate to her particularly from
my experience of her in class. This is because she seemed to me to be a
very caring individual, caring not only about her friends in the group but also
about staff members. She always asked how I was and in the corridors of the
university she always waved or said hello when she saw me. What had
always been apparent to me was that Anne cared, not just as part of the job
but really cared generally about people and this is reflected in the next
excerpt. She had moved away from home to join the course and had come to
university directly from college. I asked her what had made her choose a
career in nursing:
Anne: „First of all as a kid I wanted to be a vet and then I grew up (laughs) and decided I didn‟t want to be a vet but I have always been very, don‟t know how to put it, not caring but always cared what‟s going on with other people and to try and help in a way you can if that makes sense. My friends a lot of them, work in an office just doing things they hate, train every day, commuting back and forwards and that‟s it and I could never sit in an office and do that or do something I didn‟t enjoy doing or didn‟t think I was putting just my little spot on the
179
world if that makes sense, like even affecting one person‟s life. I just think with nursing it gives you so much more than sitting in an office doing something you are not enjoying‟
The phrase, „...putting just my little spot on the world....like even affecting one
person‟s life‟ seems the best way to sum up Anne‟s personality. Anne
wanted to make a difference to others even in a small way and felt that
nursing would give her that opportunity. Because of this, what followed
seemed particularly distressing to me. This wasn‟t because I felt worried from
the patient‟s or family‟s perspective, but I was concerned about Anne and the
way she talked about what had happened. I knew that Anne was alone in the
area, having moved away from her close knit family and I was not sure what
sort of support structures she had in place. There are times that I go home
and worry about particular students; it does not happen often, but this was
one of those times.
‘A complete and utter mess’
I had asked her to describe a time in practice that she had felt to be
emotionally challenging. She talked about a Jewish lady who had died and
because Anne was of the same religion, she was asked by the other staff to
explain the procedure following a death:
Anne: „It was a lady, I put her to bed that night and she was a Jewish lady as well so we just used to talk, I went to wake her up in the morning but there was nothing but cause no one knew what to do because of the religious thing, they called on me. I had only been there two weeks and they said, “What happens next?” and I said “Well, someone‟s got to stay with her until the family come”. I was just explaining what the process is so they made me stay with her which, I was just a bit freaked out because you hear all the after effects of death and everything and I was in the room just me and her and (voice gets much quieter) I didn‟t like it‟
180
Me: „So what did you do?‟
Anne: „I didn‟t handle the situation well at all. I sat there literally just crying and then when the family came I quickly got off my seat, I paid my respects, I wished them a long life, because that‟s what we say, “I wish you a long life”, and then I went and they said to me, “Thank you for staying” and I just went out as soon as I could and they let me go home. I was so distraught by the whole thing. But that‟s when I knew I needed to, if I was gonna carry on with nursing, then I needed to pull my act together‟
Me: „What do you mean?‟
Anne: „Not let it affect the rest of my day‟s work or things like that. Like deal with it really „cause I didn‟t did I? I just turned into a complete and utter mess and you can’t, so I knew from that experience that if it did happen again then I couldn‟t let it turn me into that again‟ (her emphasis)
For me reading this excerpt brings the idea of phenomenology to life. The
power of these words is able to bring to life what it really means to
experience such heartfelt emotion with which the reader can identify and
nods knowingly as they have been in the same or a similar situation. The
combination of the two experiences leads to a different understanding of
what is going on, which I will go on to describe. Reading this excerpt also
embodies all of my pre understandings about what it is to be a student nurse
in an emotional sense. Even though I have written them in an earlier chapter,
the feeling I get when I read Anne‟s words sums my pre understandings up
much more accurately, and this would be much more difficult to pin down in
words. Feelings of inadequacy, confusion and fear are central to this state.
Physical feelings follow; a hollow sensation in the pit of my stomach best
embodies how I feel as I write.
Anne, like Fran earlier, seems to view herself as another person, or object,
by describing herself as „that‟. She refers to herself as a „complete and utter
181
mess‟ and this was a consequence of her not being able to deal with the
situation. She feels that she did not deal with the situation well and she
should not let it have an effect on the rest of her day. As I sit here typing, I
take a few moments out to imagine myself in Anne‟s position sitting next to a
dead body, in a room, listening to sounds that dead bodies make. I imagine
how it feels to have never done this before and the feelings of fright sitting
there alone with my thoughts and the unusual noises. As I imagine this, I
start to feel anxious myself, and this is me, an experienced nurse, merely
imagining how it feels to be someone else. I ask myself the question, is it any
wonder that Anne could not cope with this situation? Anne was sent home
following this experience as she was so distressed by it. It seems that she
was put in this situation for cultural reasons and the cost to her as a person
was not considered. Anne berates herself for not being able to cope and has
not considered for a moment that her feelings and actions were completely
normal. She feels that if she is going to carry on with her nursing career, she
needs to cope with things differently and it would seem clear that she does
need to manage her emotions in a different way for her own sake. However,
it is interesting that she then says that there is a need for her to „pull my act
together‟. This seems not only harsh, but also an automatic reaction to the
preceding events. Her real self needs to become invisible if she is going to
carry on with her career. My understanding before beginning this work was
that nursing practice is hard and does carry an emotional cost, as outlined in
my pre understandings described earlier. However, the way in which Anne
described the need to change seems particularly harsh. She seems to
exaggerate the enormity of her way of being when she describes herself as a
182
„complete and utter mess‟. This conjures up an image above and beyond one
of a student nurse becoming tearful whilst sitting with a dead body. However,
this is how Anne perceived the situation and I was glad in a way that she had
been able to tell me about it. I hoped that this had been of some therapeutic
value to her.
Reflecting on my own experience I believed that, like Fran, I had no real
„right‟ to get upset. Indeed, this was not a member of my own family so why
should I be upset about her death or the feelings of her husband? Even if I
did feel upset, this should not have been enough to make me cry in front of
others. This was my current whole of understanding at that time. However, I
now look at the power of both situations, both that of Anne and myself, and
feel a different understanding. I now ask myself the question, how could we
not get upset under the circumstances and how does that make us
unprofessional? Does it not simply make us human? Reflecting on these
situations more closely I begin to think that it is morally wrong to be expected
not to show emotion at these times, if indeed the need to cry is what makes
us our real and authentic self. By examining the smaller parts of these
situations I am left with a different whole of understanding to the one I started
with.
The idea that showing emotion is unprofessional returns in this next excerpt
as does Fran‟s feeling of needing a balance. Anne and I had been talking
about a male nurse who had been laying out a body and this had been her
first experience of the laying out procedure. I wanted to understand exactly
what her idea of being professional in an emotional sense, really was:
183
Me: „Do you think it‟s okay to show some emotion, I mean those people must have seen you crying?‟
Anne: „Yeah, I wasn‟t sure if that was good or bad, „cause then they know obviously that... erm... you are not just looking at it as a job that you did actually care about their loved ones but it‟s so much harder for them that, I think I should have been a little bit more professional, not saying like, completely straight and you know, hard, but I was a complete and utter mess and I don‟t think it looked very good‟
Me: „It‟s quite interesting as before when you were talking about the guy laying out the body, he was being very professional and you were talking about that as if he was quite detached from the situation, and now you are talking about being a professional in a different way, you should have been more professional…‟
Anne: „I think there is a certain level there but it‟s just finding it and I haven‟t found it yet.‟ (laughs)
Here Anne is supporting the showing of emotion in that it shows that as
nurses we care about the patients we look after. However, she too feels that
there is a level of self control which as a first year student she has not yet
reached. Returning to her feelings when watching the male nurse carry out
last offices on the patient, she describes the need to be a professional and
its link to remaining detached:
Anne: „I think I had only met the lady once but to me that was enough and she died just as we came onto our shift so the nurses brought us in to see what happens next kind of thing, and just standing there watching just didn‟t seem real in a way, like that there was someone there but because I‟d interacted with her it was more real. It was just a weird scenario do you know what I mean? I had never seen that before and just the way everyone was so professional around you and I was there in shock and the girl standing next to me was a student as well and we were standing there not knowing what to do and then the family were there in the room as well which I thought was a bit wrong in a way, that we were standing there, and they didn‟t know us and... erm... yeah, but the doctors and everyone around were just so like it was just such a normal thing, that‟s what I felt‟
Me: „So by professional you mean getting on with the job?‟
184
Anne: „Yeah, a professional getting on with the job not interacting with the family, they weren‟t even explaining to the family what they were doing which I thought was quite wrong, not even to us like, we obviously come second to the family, but I think if the family are standing there they should have explained what they are doing to their loved one. That was hard‟
Anne describes the issue of reality as introduced by Fran earlier and also
reflected on by myself. She also describes being in shock, which seems
already to be a feature of emotional nurse being and not one that I had
imagined before starting this work. To me, the feeling of shock is quite an
extreme state to be in and usually occurs after receiving bad news or being
frightened in some way. She repeats the word „wrong‟ using the phrase „a bit‟
and the word „quite‟ before it. I suggest that Anne felt that the way in which
the male nurse was laying out the patient was „wrong‟ in that he wasn‟t
interacting with the family. Of course, it‟s possible this was a coping
mechanism for him. However, I found it interesting that Anne wasn‟t able to
say that it was wrong without the words „a bit‟ and „quite‟ in front, almost as a
way of „softening the blow‟. I suggest that this is a symptom of some identity
loss on her part, and her feeling uncertain about what is right or wrong in her
new environment. Clearly, she feels that there were more appropriate ways
of dealing with the situation, but is not able to say this outright. The phrase
„that was hard‟ could be interpreted in many ways. It may have been hard for
Anne to see what she perceived as being poor practice. She may have found
it hard to observe the laying out procedure for the first time. It may also have
been hard to think that this is what her chosen new career was going to be
like and maybe she had made a mistake in choosing it.
185
Although the student in this next excerpt does not mention explicitly being
„shocked‟, I interpret that she was experiencing feelings of shock by the way
in which she described her story.
Jilly
Jilly was part of my purposive sample although I did not feel that I knew her
very well. She was a very quiet student although when she did offer an
opinion it was usually well thought through and considered. It always seemed
to me that there was a lot more going on inside her head than she was
willing or able to verbalise. When I interviewed her she was in the third year
of the course. She was a single parent and had waited until her daughter had
started school before commencing nurse education. She was fully supported
by her mother in terms of childcare arrangements and when I interviewed her
she was looking forward to qualifying. She saw this time very much as „her
time‟; she had given the last few years to raising her daughter and now it was
time for her to do something for herself. As with the other students, I had
asked her to discuss a time that was emotionally challenging for her. I felt I
got more than I emotionally bargained for:
Jilly: „It is more about what I have seen. There was a man who tried to commit suicide quite a few times and he came on our ward and he had taken (long pause) like a... erm... (pause) power tool to his neck to try and kill himself (laughs nervously) but obviously you couldn‟t see the wound because it was all covered, and... erm... you could just see that he just wanted to die and we tried talking to him but he was just, that was it in his head, he just, he wanted to die. That quite upset me „cause there is nothing you can do, even though you want to try and help there is nothing you can do. You can‟t do anything‟
186
I felt very uncomfortable hearing this story as I found it quite disturbing to
think that someone would take a power tool to their neck. It seemed a very
shocking story and I sensed Jilly‟s discomfort by the way in which she
paused numerous times and laughed nervously. However, I am willing to
accept that because I felt so shocked by the story I may have been imagining
she felt the same way. She uses the term „quite upset‟ to describe how she
felt as if it would have been unacceptable to be any more than a bit upset.
She had wanted to try and help but the situation seemed hopeless. She
reinforces this by saying „...there is nothing you can do. You can‟t do
anything‟. I felt sad for her as her facial expression was one of anxiety; I got
the sense that she really had wanted to help and felt distressed that she was
not able to. I wanted to explore this story further:
Me: „So what happened?‟
Jilly: „We tried talking to him, reassuring him but he just didn‟t really want to communicate with us he was just, “yes” and “no” answers... erm... and then he got sent to another ward and I don‟t know what happened after that. This was an admissions ward. I had general chit chat with him to try and make a bit of a bond at first you know before saying, „Why have you done that?‟ (laughs) Some of the staff nurses were quite direct about it actually, rather than getting to know him first‟
On reading this excerpt I am reminded of Anne‟s words about being
professional and „getting on with the job‟. Maybe the staff nurses in this case
were indeed „being professional‟, trying to get their job done, in the sense
that they are asking this man why he tried to kill himself rather than taking a
more indirect approach. If they can find out why he did it, they can „treat‟ him
and send him home, job done. However, Jilly feels that it is right to „make a
bit of a bond‟ at first rather than get straight to the point. In agreement with
187
what I pre understood about this subject, I suggest that Jilly is trying to make
an emotional „home‟ for this patient, trying to make him more comfortable,
creating an emotional bond which includes „general chit chat‟. However as
she acknowledges previously, there was nothing that could be done for the
man in her view. I wanted to explore the reasons why she thought it
important to go for a more indirect approach:
Me: „So was it important to try to get to know him first?‟
Jilly: „Yeah, definitely‟
Me: „In what way?‟
Jilly: „I suppose it‟s nicer if they know you, they are more likely to open up, rather than you just asking directly and then feel like they have to. It‟s better for the patient I think (long pause) It‟s all in my first year when so many things happened and I put it to the back of my head and then it upset me later on‟
Me: „So you have tried to make this person feel better but he was having none of it – how did that feel?‟
Jilly: „It felt a bit... erm... (pause) kind of sad „cause he didn‟t want, sad for him „cause he didn‟t want to communicate with us and then I suppose I, „cause I am a bit insecure, I thought well maybe you are asking it wrong or saying it wrong, and that‟s why he doesn‟t want to speak to you‟
I was overwhelmed by the explicit sadness in this last excerpt and the way in
which Jilly blames herself for „asking it wrong or saying it wrong‟ as reasons
why the man did not want to talk about what he had done. I sense that Jilly
was isolated from the other nurses who did not want to get to know the
patient in the way that she did. The staff nurses she describes may have felt
that it is an emotionally safer option not to get involved with patients like this
so that they never get to Jilly‟s point of feeling „kind of sad‟. My pre
understanding had included the feeling that providing emotional support is
188
difficult and requires that the nurse perform in some way. Here it is by asking
the „right‟ questions to encourage the patient to talk. Interestingly again Jilly
can only feel „kind of sad‟ as in a previous excerpt when she could only feel
„quite upset‟. It may be that she feels that it is wrong to feel completely sad
and upset, or that her emotions were dulled and she was struggling to
identify exactly how she really felt at that time.
Trying to create an emotional home
I suggest that Jilly was unable to create an emotional home for her own or
the patient‟s emotions. I felt that she was attempting to construct a safe place
for the man by trying to get to know him, using „chit chat‟, as a means of
getting him to open up to her. By doing this she was trying to make him feel
more comfortable and provide emotional support, which in turn would have
helped her. As she was unable to do this, she felt unsettled and sad and was
unable to create a home or in the words of Heidegger (1954/1977) a
„dwelling‟ for herself and the man. If she could have made a home for him
then a more secure way of emotional being could have been revealed to her;
one thing would have led to another. As Heidegger (1954/1977: 325) states
„The way in which you are and I am, the manner in which we humans are on
this earth, is buan, dwelling‟. Dwelling becomes a way of life for us. Applying
Heideggerian thinking in this context, dwelling or creating emotional homes
for ourselves and others is a way in which nurses can „be in the world‟. Life
becomes very unsettling if our way of being cannot be attained. This is
evident in Jilly‟s words: „there is nothing you can do, even though you want to
try and help there is nothing you can do. You can‟t do anything‟. She failed to
create the dual emotional homes and because of this she became
189
emotionally home-less. The anxiety and tension was easily heard in her
voice and she seemed genuinely unsettled that she did not feel able to help.
Heidegger (1954/1977: 326) goes further with his discussion of dwelling by
comparing the word „bauen‟, which he describes as being an older word for
„buan‟, to the Gothic word „wunian‟ which means, „to be at peace, to be
brought to peace, to remain in peace‟. I suggest that there is something
important to be learned from Heidegger here about emotional nurse being.
This is because when we are at home in the literal sense, it could be
suggested that we can relax, live in a more authentic way and be at peace
with ourselves. We may be able to show more of our real selves, either
surrounded by those who love us or by living alone. Creating emotional
homes in the workplace can similarly lead us to a more peaceful place, a
place where we can show more of our own emotional self, being able to
divest some of our own true personality into our relationships with patients.
Jilly wanted to create this peaceful dwelling place for herself and the patient,
where both could feel emotionally at home. She was not sure what to say or
do with the man. I wonder whether just by being her authentic self with him
could have helped more than she could have imagined, and at least she may
have helped herself. Instead, it sounds like she was acting out a part when
she thought she had to say the right thing, but felt she was „asking it wrong
or saying it wrong‟. Creating an emotional home in which we can be our
authentic self can lead us to a more peaceful place, an existence in which we
do not have to act and in which being our real self is good enough. This can
also help us to create emotional homes for our patients in contrast to a
splitting of the relationship and detachment from patients. This has been
190
shown to be a way of being which causes much anxiety to nursing students,
as they are not able to divest any of their personality into their caring
practices (Menzies, 1960).
I suggest that the feelings described by Jilly are similar to those of Andy, a
second year student who was part of my purposive sample and very keen to
talk to me.
Andy
Andy was a very enthusiastic student who, like Anne, seemed to have an
innate caring nature. He seemed to care so much about what he did that at
times I felt concerned that he had an unrealistic expectation of what nursing
was about. I felt that he would not be able to practice nursing in a way that
was acceptable to him and he would become disillusioned very quickly.
Having said that, Andy had been a Health Care Support Worker before
starting his nurse education, so I could have been reassured that he knew
what nursing practice was really like. Andy lived at home with his parents
who were both senior nurses and they were very happy that he had chosen
nursing as a career for himself. Academically, Andy was quite weak although
he was very enthusiastic and tried very hard with his studies. With the
support of his parents and me, he was doing quite well.
Although he did not seem to become disillusioned with nursing practice, on
many occasions he seemed frustrated in relation to the lack of time he had to
deliver the care he wanted to. He also seemed to be resigned to this fact and
I often wondered whether his parents had influenced him by suggesting to
191
him that he would have to accept lack of time as being something nurses
have to accept.
The idea that nurses try to create emotional homes for patients is evidenced
in this next excerpt from him and it seems that time constraints are the
biggest prohibiting factor in this case. It is also interesting to note that he
describes a patient who was physically „homeless‟ within the hospital. We
were talking about the experience of nursing practice and whether he felt
able to provide the emotional support he wanted to. He suggested that some
areas were more conducive to this than others:
Andy: „I think it depends on the area. If you‟ve got a cancer patient on a trauma ward, the amount of patients that are turned over it‟s just, like one man was there for a few months, like a permanent feature, like he didn‟t fit anywhere. I think in a hospice maybe, or in ICU, it depends on the ratio to your patients. If you‟ve got a bay of six patients and you have to do the pills, you just go around doing the tasks, and your work is task-based rather than sitting down, going through your care plans, what you need, what you should be doing really, but „cause you haven‟t got the resources to do it sometimes you just end up doing what you do and the little things get missed or the important things get missed really and it‟s just the little things that get done. They say have you done your venflon scores and it‟s like, “I‟ll do it in a minute”, and you go off and do it and someone buzzes and you say “Yeah, yeah, I‟ll take you to the toilet” and you are rushing them to the toilet, and the next person wants something else, and their fluids have run out or you‟ve got to go to theatre and pick someone up and you are keen to get everything done, but yeah, maybe if you had two patients you could do those things and sit with them and say, “How are you feeling? How‟s your pain been today? Was it worse in the morning?” But you don‟t. If they buzz with pain you give them painkillers and you just write „painkillers given‟ but if you had the time you could maybe sit down and talk about it and say “Where was your pain, is it worse at this time of the day, is it worse when you move?” and then you could maybe get a result out of it but because of the time you can‟t really do that.‟
I feel agitated when I read this excerpt but can fully relate to Andy‟s seeming
resignation that he feels unable to practice in a way he thinks he should. As
192
he states this is the sort of practice that „you should be doing really‟ but there
is a lack of resources so he is unable to fulfil the role. Work is task-based
and rushed, with an emphasis on the completion of scores and charts and
less emphasis on emotional support. In agreement with my pre
understanding, emotional work is not valued as much as the completion of
the tasks. I wondered whether Andy felt guilty about rushing the care he
gave and the fact that he was not able to devote the time to the work he had
to do. Andy can see emotional homelessness in the patients who do not get
asked how they are or about their pain. He wants to „sit down and talk about
it‟ (the idea of „sitting down‟ was identified in an earlier story related by Jan),
thus creating the dual emotional home for himself and the patient, something
he describes as „a result‟. Merely writing „painkillers given‟ leaves both
parties struggling to find an emotional home and a place where his own
emotional being in the world can be uncovered.
Guilt was an emotion explicitly expressed by Jim in this next excerpt, which
reveals very honestly his feelings as a first year student nurse on his first
placement.
Jim
Jim was part of my purposive sample and was a student who did very well in
practice but his theory work was not as good and at the time of writing he
had left the programme due to academic failure. Like Andy, Jim had been a
Health Care Support Worker in an elderly care setting before starting his
nurse education. He often spoke about his family and them being proud of
him going to University but encouraging him to seek help with his work. Jim
193
was always the class joker and there had been times when I had needed to
assist him in refocusing his efforts in class. Rather than be popular with the
other members of the group, I had suggested to him that he needed to apply
more focus to his work. Unfortunately, this was to no avail as he had failed
his first year work and had to leave. I feel sad about this as I feel that this
next excerpt shows such honesty and concern about others‟ feelings. As I
write I can‟t help but think that these are nurses that we need to hold on to,
nurses who can honestly admit how they feel and sense changes in patients‟
emotions too:
Jim: „At the time that this happened it was just a mad rush because there were no doctors on and we were all going mad thinking, „What are we going to do, there are twenty other patients‟ and it was just before tea time so they all wanted their tea and the atmosphere was just a bit like, you know you felt like this one woman needed so much attention that you were snapping with the others who wanted niggly things like their dressing gown tying up. It felt bad afterwards because you didn‟t really mean to snap, it‟s just, (pause) there were more important things going on. It did feel bad to do it „cause even though it was a priority it still felt...these other people even though it was small and completely unimportant that because you shouted at them it would ruin the relationship „cause the next day they might be off with you, and you would feel guilty the next day‟
Jim is referring to a time in practice when there was an emergency involving
one patient. There were only three members of staff on the ward, Jim, a care
assistant and a staff nurse. The emergency involved a patient who was
having a severe gastric bleed and in his words, „there was blood
everywhere‟. I interpret that Jim is trying to cope with the horror of what is
unfolding in front of him by physically trying to help with the gastric bleed. In
addition to this he is trying to cope with his own emotions and the demands
of the other patients on the ward (who could be oblivious to what is going on
194
behind the curtains). He admits that he shouted at some of the other patients
but then worries that he has ruined his relationship with them, which they
may carry over to the next day. This relates to my pre understanding that
emotional support is difficult and requires the nurse to perform. He
recognises that his actions have an effect on the other patients, „it would ruin
the relationship „cause the next day they might be off with you‟. I suggest that
this shows that Jim has a certain amount of sensitivity and can recognise
emotion in others and himself. However, as with the other students, the
emotional home is lacking, as he cannot manage his own emotions whilst
dealing with the demands of the other patients. I feel such sadness and
sympathy for Jim and respect his honesty. On the face of it, shouting at
patients is unprofessional and poor practice. So, why do I think, as I stated
earlier, that this is a student we „need to hold on to‟?
My view of Jim seems rather problematic and it is only by analysing and
interpreting this data that I feel like this. This is another venture into the
hermeneutic circle and leaving with a different understanding of the issues.
As a researcher and a professional, my views and way of thinking about
these issues are changing. This has occurred through talking with Jim who is
now not on the programme; discontinued due to academic failure. I began
this research because I watched a documentary, which showed an image of
a male nurse shouting at a patient. I felt no sympathy or sadness for this
nurse yet I do for Jim. The whole of my understanding has now changed
after examining the parts of Jim‟s story. This relates to the way in which Jim
very sensitively recognises the precious relationship between nurse and
patient. This could be affected by the way in which he may speak to the
195
patient about the „niggly things‟ they may consider as important. He is
showing that things that he may not consider important often are to the
patient. His own self awareness seems to be developing. I feel warmth
towards him that I did not feel before and a sense of loss now that he has left
the programme. I leave the hermeneutic circle again with a different whole of
understanding, relating not only to my own perceptions, but also in relation to
the challenges faced by students in contemporary practice.
Jim openly admits that he shouted at some patients during the night of the
emergency and yet I feel sympathy for him and applaud his honesty, based
on my different understanding of the problems. However, I would not have
had these feelings if I had not talked with him on any meaningful level and
this is something I would never had done if I had not undertaken this
research. I wonder whether anybody had talked to the Panorama staff nurse
to explore his feelings and why he had acted the way he did. It is easy to
judge him without knowing the facts. I now feel very differently about the
trigger which began the process of this work in the first place. My view and
understanding of the issues are different to the ones I started with. It is not
only that I am feeling more compassion towards the students, but also the
need for an outlet, a forum for them to have their say in honest ways, to a
listener who has time to listen, and will not judge them for their way of being.
This involves a return to the Heideggerian concept of the creation of homes,
in this case, emotion homes.
I have discussed Heidegger‟s idea of home and the need in this context for
students to be able to create the dual emotional homes for themselves and
their patients. However, I suggest that we need as academic staff to take a
196
step back and think of creating homes on another level. Heidegger
(1954/1977: 325) continues his discussion of dwelling by saying this:
„To be a human being means to be on this earth as a mortal. It means to dwell. The old word bauen, that says that man is insofar as he dwells, this word bauen, however, also means at the same time to cherish and protect, to preserve and care for, specifically to till the soil, to cultivate the vine. Such building only takes care – it tends the growth that ripens into its fruit of its own accord‟
Creating a „home‟ or dwelling for the students involves care and protection so
that they can bear their own „fruits‟ and transform into caring practitioners. I
suggest that as academic staff we need to take more responsibility for this
rather than expecting it to happen magically whilst out in practice. That is not
to say that we do not care for students already but I am merely asking the
question, does our caring go far enough? My pre understanding before
starting this work was that emotion work is hard work and a lot is expected
from nursing students on an emotional level. On a practical level, I wonder
whether time is really ever given to sharing stories like the ones described
through this research, to encourage the students to be honest about the way
they feel so that their caring natures are cultivated rather than compromised?
Do we ever get to know our students on anything more than an emotionally
superficial level?
These stories leave me feeling sad and I struggle to read them at times
without becoming tearful myself. My sadness relates to Anne‟s story and her
feelings of shock and loss of herself and her usual way of being, which she
perceives as not being acceptable any more. It relates to Jilly, Andy and Jim
who try desperately to create the dual emotional homes both for them and
197
their patients, but are stopped from doing this for various reasons. For Jilly, it
is not her fault that she cannot do this although she seems to blame herself.
Andy is frustrated by the lack of time and resources which he sees as being
the crucial factors. Jim seems like an honest and sensitive student who has
now been removed from the course. I am also feeling emotionally tired and
can relate to the sense of emotional exhaustion felt when undertaking
sensitive research, as described by Dickson-Swift et al (2007). The authors
of this study also acknowledged that researchers can feel emotional
vulnerability linked to the fact that they were learning things about
themselves in the process. Indeed as already discussed, in the case of the
Panorama staff nurse, I have learned to look upon him differently, based
mainly on my learning through discussions with Jim.
I am also sad as I am reminded through these stories of a „hard‟ story of my
own, which I have never forgotten, but try not to think about too much. I
wonder whether Jilly will in the future think of the suicidal man in the same
way as I think about my own story. I will now present this story as what has
happened to me helps me to see and feel more clearly what has happened
to the students. By doing this I am re-entering the hermeneutic circle as I
look at parts of their stories in relation to my original way of thinking, and the
ideas relating to the Heideggerian concept of the creation of emotional
homes. The idea of dual emotional home making in turn fits in with the wider
picture of being a professional. Therefore, it can be seen that the
hermeneutic circle is in operation at many levels here, with many of the
smaller parts leading towards a different whole of understanding.
198
The man with severe burns
As a second year student nurse I was allocated to a four week intensive care
placement. There was a young man in a side room with severe burns. He
had been welding his car but had not removed the petrol tank and the car
had caught fire leaving him with severe full thickness burns to most of his
body. I remember the consultant on the ward saying that it would have been
better if this man had died as his injuries were so horrific. He had brain
damage due to the burns and was on a ventilator, but conscious when I met
him. I was working with a staff nurse on an early shift when two
physiotherapists came in to work with him. He needed physiotherapy to help
ease the contractures which were forming due to the burns. This man was in
severe pain, but seemed to be coping with this until the physiotherapy
started. As soon as they started to move him he began to cry out. His cries
could not be heard because he was ventilated. His face was contorted with
pain and his mouth was wide open, but all that could be heard was the
sound of air passing through the tube in his throat. However, he was clearly
very distressed. I found this sight too horrific to watch. What I found most
distressing was the fact that the physiotherapists did not stop moving him. It
seemed that because they could not actually hear him screaming that it was
acceptable to continue. I remember knowing deep down that this wasn‟t
acceptable, but thinking that it must be alright as they were carrying on as
though nothing was happening. I was frozen to the spot and again felt like
the situation wasn‟t real and I was on the outside, looking in on myself, as an
actor in a film. The staff nurse spoke to the physiotherapists and after that
occasion it was decided that the man would be sedated for all future
199
physiotherapy. This happened twenty years ago and his agonised face and
the sound of the air passing through the tube is still etched in my memory.
Because I have encountered difficult situations like this I can fully relate to
what the students are saying and the harsh reality of being a nursing student.
In the same way I think of Jilly and the suicidal man, I think of myself and my
desire to provide an emotional home for this man with severe burns. I
accepted situations like this, as the students are doing, without giving a
thought to the impact this had on me or more importantly, how having to deal
with shock like this ensured that I detached, and lost some of myself along
the way. If I hadn‟t, how would I have coped? Did I perceive that the
physiotherapists were professionals, getting on with their job? I sometimes
wonder whether I have interpreted my own story in the way it really was.
Maybe I was being over sensitive and in fact, the patient was not in as much
pain as I may have „imagined‟, or remembered. Maybe I have embellished
the story to explain my feelings of shock? However, it is clear from the
literature that burns nurses feel a high amount of stress and a strong sense
of personal vulnerability (Nagy, 1998). It is difficult to watch someone in so
much pain and feel helpless to intervene.
Using the example provided by Anne, I feel saddened that she perceives a
professional as someone who is getting on with the task in hand but does not
interact with the family and offers no explanations to them about the
procedure. She found the experience hard to deal with and as Fran did
earlier, describes herself as being in shock. As before, considering my own
experiences and now the experiences described by Anne, Jilly, Andy and
Jim, I reached the conclusion that exposing student nurses to this kind of
200
experience is inherently problematic without adequate care on our part. The
effect on the student self cannot be underestimated. Certainly, remembering
my story has been difficult, raising uncomfortable feelings in me. However,
by remembering it, I feel more able to experience myself the students‟
feelings of loss and grief about what is observed and experienced in nursing
work. As I remember my story, feelings of emptiness start to develop within
me. I wonder whether these are similar to the feelings of shock described by
Anne earlier. Throughout this thesis I have discussed the need to co-
constitute the data to reach different understandings of the issues. Reading
the transcripts brings my own feelings to the surface and I feel them all over
again. Feelings may be more difficult to explain although these too go
through a co-constitution process. I suggest that Smythe et al (2008: 1396)
summarise the process well;
„We believe a hallmark of phenomenological research is graced moments, when there is a shared sense of belonging to the insight that seems to go beyond what is said, yet is felt and understood as „being true‟. This is different from proffering answers. It is rather a calling-to-consideration‟
Feeling arising from the data, go beyond what is articulated using words
alone. Indeed, there is a shared sense of feeling which goes beyond the
process of co-constitution. It does not need to provide an answer to things. It
is a shared sense of being, one which goes beyond the basics of language,
and is indeed far more powerful than words alone.
Returning to the informants, I knew, as do they, that however „hard‟ or
frustrating we found nursing work, we had to get on with it. I know that I have
201
little control of all that I perceive as being „bad practice‟ which goes on up
and down the country every day. What I do know, at this stage of writing my
thesis, is that I need a way to support and care for students, like these, so
that I can help them not only identify how they feel, but also help them not to
feel that they need to change from the person they are and the nurse they
want to be. A way in which they can stay real to themselves by embracing
their emotion, creating dual emotional homes, but also in their eyes, be
professional.
Becoming Attached
Steve
I will now introduce the next informant, Steve, who returns to the idea that
there is a level or balance of emotion, which needs to be reached when
trying to be professional. He describes the difficulty in maintaining this level
and discusses a situation in which he cried when a patient got the „all clear‟
following a diagnosis of cancer. He describes his behaviour almost like a
guilty secret, and explicitly distinguishes between this behaviour and being a
professional.
When I interviewed Steve he was a third year student nurse, about to
complete his pre registration education. He, like Jenny, was not part of my
purposive sample, but a student who had volunteered to be interviewed. I felt
much more comfortable with him than I had done with Jenny, although I had
some reservations. This was mainly because I hardly knew Steve before I
interviewed him and wondered how well the interview would go. I wasn‟t sure
how freely he would speak to me, having not interacted with him very much
202
beforehand. As with the other interviews, I now feel a little naive that I
thought that the students would not open up to me. I certainly needn‟t have
worried as he spoke unreservedly to me and described his keenness to help
me as much as he could. This could suggest that he had a real felt need to
discuss certain matters. Steve had started nurse education directly from
school and was not originally from England. As with other interviewees, I
asked Steve to describe to me a time in practice that he had found
emotionally challenging in some way. Then, based on my previous
interviews, I raised the question of professionalism and the showing of
emotion. He began by talking about a man who had got the „all clear‟
following a diagnosis of cancer and how this had made him cry. I was
interested to know his feelings about this behaviour:
Me: „So you said you cried when this man got the all clear did you? So what did you think about that, did you feel embarrassed? Did you think it was OK?‟
Steve: (Pause) I thought...(pause)...I didn‟t want anyone knowing I had cried in the sense of, on the Ward but I thought it was Okay „cause I felt ...well it‟s the first and only time it has happened since I started my training and it‟s the first time I think I have ever become... I think it was because I was so close to the patient because I was on the ward for six weeks and he was there for that length of time and every day we talked and I looked after him pretty much every day which normally hasn‟t happened in a lot of places where you have a day or two off from the patient. So I think I got to know him in the end and alright I know you have to have that professional boundary but it is hard to not become attached to certain patients and so yeah I didn‟t want anyone knowing but at the same time it‟s kind of alright to let off a bit of emotion‟
Me: „I think it is incredibly hard. Do you think it‟s unprofessional?‟
Steve: (Long pause) „I didn‟t let him see me get upset and I didn‟t let anyone else see me get upset (pause) and I suppose it depends what situation you‟re in but (pause) probably personally I think it could be a wee bit unprofessional „cause at the end of the day you are in a profession and you must act professionally at all times and especially
203
when really you‟ve got no attachment to somebody I don‟t think you should be letting your emotions show all of the time‟
Me: „But you did have attachment to him‟
Steve: (Interrupts and becomes more animated, wanting to get his point across) „I did but it wasn‟t a personal attachment, officially it wasn‟t a personal attachment, I was, as my role as a student nurse I still had... I knew him and I looked after him but at the end of the day he was a patient‟
Me: „He wasn‟t a member of your family or anything. Is that what you mean?‟
Steve: „Pretty much, yes‟
I found this excerpt from Steve particularly interesting initially due to its
contradictory nature. He started by saying „I think it was because I was so
close to the patient‟ as a way of explaining why he had cried. However he
was keen to point out that this was the first time that this had happened since
he had started his pre registration education. He then goes on to describe
why this behaviour is unprofessional, as he suggests, „especially when really
you‟ve got no attachment to somebody‟. When I challenge him on this and
suggest that he did have an attachment to the patient, he interrupts me, keen
to make his point; „I did but it wasn‟t a personal attachment, officially it
wasn‟t a personal attachment‟ (he emphasised the word „officially‟) It feels to
me that he is saying that any attachment to the patient had to be concealed
and it had to carry on in an „unofficial‟ sense almost like he was doing
something wrong. In agreement with what I already understood about this
issue, I suggest here that Steve is „performing‟ a role. It‟s possible that he
does want to become more emotionally attached to the patient but feels that
he should not do so. Steve, like Fran, asserts that nurses should not be
getting too upset about patients, as they are not personally attached to them,
204
in the way a family member is. I wondered whether I may have got a different
response on this subject from Steve firstly because he was male and
secondly because he had more experience being in his third year. Perhaps
he had learned ways of coping based on the behaviour of others by this
stage.
Barbour (2001) suggests that samples are not always used purposefully
during analysis to explain differences in findings within the sample. Here the
difference seems to be that Steve was even more keen to make the point
that he wasn‟t attached to the patient and that crying is „a wee bit
unprofessional‟. He became animated and much more forceful than either
Fran or Anne when getting his point across. This could be because he had
had more time to become used to this way of thinking, being a third year
student. It could also be because he was male and did not want to be seen
as being „emotional‟. Furedi (2004) explores gender differences when
exploring emotion talk and suggests that masculine self-control and
autonomy are viewed in society as being destructive behaviours. The fact
that men may not want to talk about emotion or be seen to be displaying
emotion, as here in the case of Steve, is viewed as a flaw in the male make
up. He states that in society, „Men who act like women are clearly preferred
to women who act like men‟ (Furedi, 2004: 35). It could be argued that male
nursing students have an even greater challenge to identify and manage the
emotion they feel. On the one hand they may aspire to stay in control but on
the other, society may be seen to be encouraging them otherwise. However,
when contrasting societal culture to that identified within nursing practice,
and there are further incongruences identified.
205
In contrast to Steve, another male student who did not mind admitting that he
had become attached to a patient was Paul.
Paul
Paul was part of my purposive sample and I knew from my relationship with
him as personal tutor that he had a tendency to become tearful when talking
over issues from practice. When I interviewed him he was a second year
student nurse and was extremely happy as his girlfriend had just given birth
to their first daughter and he had become a father for the first time. He had
many years experience of care work prior to starting the course. We had
been talking about the fact that sometimes as nurses our feelings can take
us over and we may become swept away in the process. I asked him
whether he had ever felt like this:
Paul: „Yes. I went to see a lady with early onset Alzheimer‟s disease and there was some talk that she would have to be moved out of sheltered accommodation because she kept getting out in the night and wandering off. The house was very clean and she was dressed very well. She was happy for me to ask her questions and I was writing it all down and my mentor asked me what I thought. I was very attached to this woman, because when we talked she was very lovely and I thought “well she can stay in her own home”. My mentor said that I was letting my own feeling come into the situation and getting in the way of professional duty. I felt very angry; why couldn‟t someone be there with her at night time? I feel very angry about the whole system‟
Paul states quite clearly that he was „very attached‟ to the woman and I
noted that whenever he describes how he felt he uses „very‟; „very attached‟,
„very lovely‟ and „very angry‟. This emphasises the force of his feelings in this
incident and reinforces the point that he felt some fondness for the patient.
However, he is advised by his mentor that his feelings were „getting in the
206
way of professional duty‟ although to him the answer is straightforward and
involves carers coming in at night. He justifies his point clearly in the
following excerpt:
Paul: „Because she may have got worse if she had gone to somewhere else; what was going to happen in a few months time? How was she going to cope? She would have been manageable if more resources could have been put in; people doing night shifts and things like that‟
It could be argued that although his feelings were strong, they were actually
moving him to a place of responsibility and providing the most appropriate
care for the patient. He knows that a change of environment could confuse
this patient even more, therefore the most appropriate way to nurse her is to
keep her at home with more resources. Instead of getting in the way of being
a professional, his emotions were helping him to see other ways of being for
the patient. Emotions here are facilitating his thinking and spurring him into
action. His view may seem unrealistic and impractical to his mentor, but at
least he is standing up for what he believes is best for the patient. This is in
contrast to Andy who can see no answer to the problem of time constraints
and seems resigned to go with the flow. The differences between the two
informants could be due to culture with Paul feeling more able to show and
act on emotion due to a different cultural background in contrast to Andy who
accepts that things will not change:
Andy: „It‟s always been done that way so you have to follow the routine really, and a lot of the time when you‟ve got a lot of deadlines to meet, a lot of the time, you‟ve got to get them done first, and if you don‟t you will get penalised for it, and that‟s why the care you want to give doesn‟t always get given‟
Me: „And how do you feel about that?‟
207
Andy: „You do feel bad about it and you do want more staff, and you want this, and you want that, but you just hope it will change don‟t you, but I don‟t think it ever will do‟
I thought it interesting that Andy, like Fran earlier, starts to talk in second
person. I asked him how he felt about the issues he raised and he seems to
want to disown his feelings. He did not mention a particular patient but talked
about patients in more general terms. I wondered whether not feeling very
attached to someone had led to him feeling more resignation about how
things were, in contrast to Paul.
Another student who at first found it difficult to talk about a particular patient
or time that she felt emotionally challenged was Emily.
A professional face
Emily
Emily is very clear that she would never get upset in front of a patient and
she describes the need to present a „professional face‟. Emily had just
commenced the third year of her pre registration education. She had
volunteered to be part of my research after I had discussed it with a group of
students in class. I knew her quite well as she was the type of student who
stayed behind after classes to talk to me and was very enthusiastic about the
subjects I delivered to the class. Her background was in hairdressing and
beauty and she had a lot of experience in dealing with the public at that level.
She explained to me that her views on being a professional had been
learned in her previous line of work, this is where she got the term
„professional face‟. This was the type of face needed to please the customer
208
who was paying for a service. I asked her, like the others, whether she could
describe a time in practice which had been particularly challenging for her.
She struggled to do this at this time and then began talking about another
member of staff who had been upset, rather than focus on herself:
Emily: „I mean I have seen on my last placement, there was a newly qualified nurse that was absolutely breaking her heart in the corner one day and I am not entirely sure what that was about, I don‟t know if it had just got a bit too much but everybody was aware of it you know, that she was upset and I don‟t know, I don‟t like that. I couldn‟t get upset in work, I just couldn‟t, I don‟t know if that‟s a personal thing or, I just couldn‟t, I would be too worried about drawing attention to myself but then when you go home there‟s nobody to discuss it with really so it‟s a bit of an awkward situation trying to find the time...for me it‟s certainly not something I would do, I don‟t know, I wouldn‟t do it personally, or I‟d certainly try not to do it personally but that said, if somebody came to me upset I would be quite sympathetic even though it‟s not something I would do myself (laughs)‟
I found it interesting that Emily was not able to describe a story of her own
and immediately talked about someone else. However, when examining
what she said, it became clear why she did this. It seems that becoming
upset in front of others is something that for her is unacceptable. She repeats
the phrase, „I just couldn‟t‟ and became quite agitated during this excerpt; it
felt to me that she was very keen to get her point across. Perhaps this was
due to her previous work and the way in which it had been instilled in her that
she should not lose her „professional face‟ in front of the paying public. This
seemed to be an example of her „performing‟ a role which may not relate to
her authentic self, in line with what I had pre understood before starting this
work.
209
However, she identifies that „it‟s a bit of an awkward situation‟ not being able
to discuss the day‟s events on returning home. This is a problem in that she
feels that she cannot let her emotions show at work but there is nowhere
else to take them. It seems to me that Emily is almost doing too good a job of
managing her emotions. However, she feels that showing emotion is an
acceptable thing for others to do and states that she would be sympathetic
when someone else was upset. On reflection, I could have probed further
here. I could have challenged the view that it is acceptable for others to get
upset in front of other people, but not for her. However, at the time I was
feeling agitated myself as I could almost feel her „bottled up emotion‟ and her
not having any outlet for it at all. Part of my pre understanding about this
subject is that nursing is emotionally difficult work and ultimately nurses pay
a price for this. This could be in terms of burnout and leaving the profession if
not able to discuss how they feel, although it is easy to see why nurses may
be reluctant to discuss feelings. Exposing perceived weaknesses may seem
like failure, and the desire to keep up a front may be important when wanting
to be perceived as a competent professional (Ekstedt and Fagerberg, 2005).
Well into the interview, Emily did manage to identify a situation, which she
had found emotionally challenging:
Emily: „There was one lady that... erm... she had, she was sort of in her last days really, and she was quite confused and I had gone, I think I had gone to help her with her dinner I think and she had hold of my face but she had hold of both sides of my face and she said, „Please lend me a shilling to go home‟ and that upset me but that was in work and I was a bit choked and I thought “What do I do!” But that was my first placement and the first time I had ever come across anything like that and I think it was just because it was such a sad situation... erm... and that played on my mind for a bit I mean I didn‟t get, I was a bit choked at the time but later on I was fine... erm... but it did play on my mind a bit‟
210
Like Steve, Emily justifies what happened by saying that this had happened
on her first placement and this was the first time she had got upset. She
doesn‟t cry although she becomes „a bit choked‟ and admits that it did stay in
her mind for a while later. Again I suggest that she is managing her emotions
by suppressing them. She insists she was „fine‟ although I do not believe this
as she then goes on to state twice that „it did play on my mind a bit‟. I asked
her how she felt about becoming „choked‟ and she volunteered her thoughts
about the link to showing emotion and being a professional:
Emily: „I don‟t mind people, I haven‟t got a problem with people knowing I am a bit soft, I think I am anyway... erm... but I think that when you are at work you do have a professional face and you do put your professional face on to a certain extent and I think you have to strike a balance between being professional and being human, don‟t you?‟
Me: „Yes. It‟s interesting because as nurses we are meant to be a caring profession and yet there is this idea, you have to be professional and you have to put on a front. I don‟t know how you are meant to balance the two‟
Emily: „I think it‟s important, I think you have to have a boundary, don‟t you? You have to know where the line is and know not to cross it. I mean I am never sure about things like, you know like, you see some nurses who put their arm around the patient and give them a hug and it‟s alright and they will kind of comfort them that way. I mean I am quite happy to get hold of someone‟s hand but then I don‟t know if you are overstepping the mark, personally I don‟t feel comfortable necessarily doing that, not for every patient anyway, you work off the patient don‟t you and take your cue from them I think‟
I thought it was interesting that Emily describes herself as „a bit soft‟ and she
doesn‟t mind people knowing that. What was also fascinating was the phrase
„put your professional face on to a certain extent’. At the start of the
interview she was very keen to suggest that she would never get upset and
there was a need for a „professional face‟. However, towards the end of the
211
interview, she seems to have altered her view very slightly by using this
phrase, „to a certain extent‟. I wondered whether taking part in the interview,
being given the opportunity to talk things through, had actually caused a
small shift in her thinking on the subject. This is part of the reason why I
suggest that returning to informants to check transcripts is not always a
worthwhile endeavour. Their views and feelings have the potential to change
as a product of the interview. Therefore, returning transcripts could carry on
indefinitely. I reflected later that I may have been the first person she had
talked her thoughts through with and so this may have been the first chance
she had been given to consider her own thoughts on this aspect of care.
As with the thoughts of the other informants, Emily recognises the need to
have the boundary or balance between giving enough of ourselves but not
so much as to „overstep the mark‟. As with Fran, although Emily doesn‟t
overtly say it, she describes the need for a balance between being „human‟
and „professional‟. It reminds me of Fran‟s comments about having two „me‟s‟
in that Emily seems to describe the „professional me‟ and the „human me‟.
Joan
Not everyone thought that emotional displays were unprofessional. Both
Joan and Jenny offered a different view. I will begin by introducing Joan who
was a personal student of mine and was in the second half of her first year of
pre registration education when I interviewed her. She had been part of my
purposive sample as she was someone I could get on with and seemed very
keen to talk to me about issues including the reasons she came into nursing.
She had been involved in office work beforehand but had not been fulfilled
212
by this. She lived locally with her partner and had always seemed a very
„common sense‟ hard working sort of student who I thought would be a great
asset to any ward, even if she did not go on to become a trailblazer. She told
me that her mother had died shortly before she began her nursing education.
I felt an affinity towards her, in part because my mother had died half way
through my post registration degree course. She had told me that she had
wanted to make her mother proud of her and I had felt the same way during
my studies.
It is okay to cry
We had got into a discussion about mentors and the importance of having a
supportive mentor, particularly at stressful times on the placement. She
underlined the influence of the mentor at emotionally challenging times:
Joan: „You see the way they deal with it and that sort of influences the way you deal with it, like the first time when you get a bit upset and things, nobody else is, so that sort of sticks in your mind that nobody else was crying so why am I? But then you also see the nurses that do cry every single time and they have been doing the job for twenty or thirty years and they still get upset every time something happens‟ (her emphasis)
I thought this was interesting in terms of telling me how student nurses learn
to behave in the way they do. Similar findings have been described by Smith
(1992) who suggests that other staff members set the emotional tone on a
ward which students can then follow. Here it seems to come from others
such as the mentor who acts as a role model for dealing with this sort of
thing; „Nobody else was crying, so why am I?‟ However, Joan describes
213
other nurses who do cry and believes that it isn‟t healthy to hold back when
wanting to cry:
Me: „......you maybe wanted to cry, what do you do, how do you stop yourself?‟
Joan: „I think if it was getting too much I would have to excuse myself, I think I would just have to say excuse me, and just apologise. I wouldn‟t walk off and I don‟t think I would try and hide it either (pause) but you‟re just normal aren‟t you, in your reactions‟
Me: „So you would just let it happen‟
Joan: „Yeah. I mean I wouldn‟t just cry my eyes out and wipe my snotty nose (laughs) all over, I wouldn‟t do any of that but I certainly wouldn‟t hide my emotions‟
Me: „Why not?‟
Joan: „Because I don‟t think people should. I think people get on better with life if they show their emotions. I think the more people bottle stuff up the more problems they have got and the more isolated they become. I think that families and patients and their families and things probably like a little bit of comfort and emotion‟
In stark contrast to the some of the other informants Joan doesn‟t see any
need to hide her emotions. Even if she began to cry she would not walk
away from the situation. She would apologise but, as crying is normal, she
sees no reason to hide it. She gives a clear rationale in terms of being able
to „get on better with life‟ and describes her view that the suppression of
emotion can lead to isolation. I wondered whether her view had been
influenced by the loss of her mother. Certainly my own experience of loss
encouraged me to view crying as a natural way to behave and not something
that should be hidden. Losing my own mother had led to me feeling more
confident around others who were going through loss; I understood how they
felt on a more meaningful level and crying in that situation was acceptable to
214
me. Feeling personal loss can encourage the need to be seen to be coping,
especially in an environment in which students‟ feelings are not
accommodated (Smith, 1992). What seems significant here is that if „coping‟
is defined as keeping sadness hidden, Joan could be seen as „not coping‟.
However, for Joan, coping can involve the display of tears when necessary.
I was interested to know how Joan perceived the other nurses who behaved
like herself. I was also interested to know, based on my other interviews
whether she thought this was linked to being a professional:
Joan: „I think it‟s nice. I mean I don‟t think anything like they are too soft or anything... erm... just as the ones who don‟t cry, I don‟t think that they are too hard you know, it‟s just people‟s different ways of dealing with it, really‟
Me: „Do you think that is linked with being a professional?‟
Joan: „Erm... yeah, but I wouldn‟t say that a nurse who cries is any less professional than a nurse who doesn‟t cry and in some ways people prefer the nurse who shows more emotion because they don‟t like the nurse who doesn‟t, „cause they are a bit intimidating or frightened by them‟
This comment echoes that of the earlier informant, Anne, who suggests that
from a family‟s perspective, the nurse who shows some emotion conveys the
message, „you are not just looking at it as a job, that you did actually care
about their loved ones‟. Joan goes further by suggesting that the nurse who
doesn‟t show emotion could be perceived as intimidating or even frightening.
She goes on to describe her as an old style matron type:
Joan: „If you‟ve got a nurse that‟s hardened to everything and is, I don‟t know, a bit like how you used to describe a matron, hard faced and everything, I think to patients they are more intimidating than the softer nurse, the one that does cry and cuddle you, yeah, cuddle you and things like that‟
215
Joan has made a distinction here between the „hard‟ and „soft‟ type of nurse;
the soft nurse not only feels the emotion but expresses it by cuddling
patients. The hardened nurse is seen as being more intimidating or even
frightening in Joan‟s opinion. This is in contrast to Emily who did not feel that
she knew what was acceptable when dealing with physical touching. This
could be due to her beauty therapy „upbringing‟ which she still carried with
her. I suggest that as a beauty therapist, spontaneously cuddling clients may
not be viewed as acceptable as it is in nursing work. Emily was being paid to
undertake physical tasks as a beauty therapist, although I suggest that she
may not have the same emotional connection to her clients in this context as
she would as a nurse.
Becoming Hardened
Joan continues her description about becoming hardened, relating it to her
own behaviour although this is more related to coping with issues over time
rather than a type of person such as the hard faced matron:
Joan: „I think I get a bit upset with death and things like that... erm..., I find it hard to see, I think I have become more hardened to it but I think I found it hard to see when I was first on placement and even working in homes... erm, people that hadn‟t had good lives and things like that, people that hadn‟t been brought up the way that I had been brought up, you know people that didn‟t have money and things like that, and I couldn‟t understand why people would be like that and how it could happen and things‟
Me: „You mean why they wouldn‟t have those things in their lives?‟
Joan: „Yeah, it‟s an eye opener to see people in all different situations that you don‟t think exist anymore, you only read about it or see it in a film or things like that‟
Me: „So the harsh reality?‟
216
Joan: „Yeah... erm... death I find hard only because I think it‟s a really sad thing but I am understanding it more, it gets easier the more people you see and the more situations you see it does get easier‟
Me: „How does it get easier?
Joan: „I think it‟s just easier to accept because you have seen it once and you do the last offices and everything and it‟s really really hard and then you do it again and it‟s just as hard but you don‟t cry like you did the first time and you do it again and again and it just gets that little bit easier because you just accept it and you just find it just easier really, to deal with‟
Me: „Okay. Do you think something inside you has changed? You said before that you had become more hardened to it, do you think that‟s something within you?‟
Joan: „Erm... I think it‟s just being exposed. The more you are exposed to, I suppose it‟s the same with anything, the more you see of it, the easier it is to deal with or cope with and that‟s the same with death or anything emotional I would have thought‟
Anne gave a similar perspective on what it was to become hardened. The
term came up in a conversation about how Anne felt she was getting better
at coping with things as time went on:
Me: „So you said that you are getting better at it, how are you getting better at it?‟
Anne: „I think you harden to things the more often they occur so obviously it still affects me but it‟s easier to cope with because you have had the experience of coping with it before rather than it being a whole new thing. Each time is completely different because you have different relationships with everyone and obviously different causes of things but I just think you do find your way of coping and once you have found that way of coping it makes it easier to cope with the situation you are in‟
Me: „Okay. So you said you become hardened to it, what does that mean, ‟cause that sounds like a severe word really, doesn‟t it?‟
Anne: „I just knew because you have coped with it, like the first time I dealt with death, I had never coped with it before like even people close to me I had been fortunate in that way that I had never really lost anyone too close to me so when it happens in the hospital to me they are the people that I am close to because I know them, I am interacting with them, I know their families and the first time it happens
217
it was, well, still now it‟s hard because you don‟t know how to cope with it, you‟re not taught that, it‟s with experience you learn these things and by hardened I think I mean my learning, how I have learned to cope with what‟s happening‟
Anne is using the term „hardened‟, to describe a process of learning and
coping with difficult issues such as death in practice. Joan uses the term to
describe a type of nurse who may be perceived as frightening or intimidating.
Is a side effect of learning to cope, a loss of our natural self, to the extent that
we become the hard-faced matron type described by Joan earlier? Other
researchers such as Randle (2001) would suggest that this is indeed the
case. Students feel their way through this process of coping, as stated by
Anne, „you‟re not taught that, it‟s with experience you learn these things‟ and
this suggests a haphazard way of learning how to cope with these situations
rather than a planned method of support being put in place in a systematic
way.
This finding is similar to some issues described by informants in a study by
Mackintosh (2006). Students in this qualitative study suggested that there
was a need to change in order to cope, but could not clearly identify how this
process would occur. Clearly the influence of the mentor and practice staff is
great in terms of support, and how the student decides what is classed as
professional behaviour. However I tentatively suggest that support for
students needs to go further than that which could potentially be offered by
the mentor. The nature of the support is that which enables us to keep a
sense of who we are as a person, whilst still being able to cope with the
emotional demands placed upon us as a nurse by the nature of the work. I
suggest that this could be more securely grounded within the university
218
setting and be more formally addressed in this setting. It could offer the
potential to encourage students to think about the emotional nature of their
work before they even attended placement for the first time. Without such
guidance, the students‟ method of coping will tend towards the closing down
of emotional vulnerability. The only choice that all but the „strongest‟ will see
will be between allowing themselves to be destroyed by a never-ending wave
of emotions and leaving nursing altogether, or becoming hardened or
detached.
A Pre Understanding I had not yet understood
Throughout this work I have returned to my pre understandings and reflective
stories as a way of strengthening my interpretation of the data. In this way
the reader gets a sense of who I am and where my understandings were
situated before I started the work and during it. Until now, I suggest that my
thoughts on the emotional nature of nursing have not been greatly
challenged. This is worrying as it could suggest that I am not interrogating
the data enough. I stated earlier that my pre understandings of the situation
may change over time and this is to be expected as my learning journey
unfolds. These next excerpts involve a return to Jenny, the informant that I
found most challenging, mainly due to a lack of confidence in myself.
My interest in this next excerpt was around Jenny‟s idea of what it is to be a
professional and how, at the time of my initial reading, I thought that this was
different to mine. This was because of events in my professional life at that
time. I consider this as significant, as it underlines the importance of
reflecting on our own pre understandings of concepts and situations, and
219
giving consideration to how they can have a bearing on the way we view
what informants say. I shall begin by describing the excerpt verbatim and
then go on to discuss it in greater detail:
Jenny: „I mean people say you should be able to set your emotions aside when you come into work but a lot of the time, it‟s not gonna happen. Ninety percent of the time you are not going to be able to say, “Right, nurse hat on, no emotion or no internal emotional turmoil, I‟m just gonna go and do my job” because, you know, humans can‟t do that, it‟s not possible‟
Me: „Why do people say that do you think?‟
Jenny: „I think that a lot of the time people think that if you come to it with a clean slate almost, emotionally, your problems that you are having shouldn‟t be having an impact on your professional practice, and ideally yes, it‟s true, but for me it‟s more important to acknowledge that they may be influencing our practice and to own up to the fact that you know, okay, you had a row last night, so you don‟t want to particularly confront the client because you may be over confrontational‟
Me: „It‟s interesting because some nurses might say that you can‟t have your emotions and be a professional in practice, which I don‟t agree with, but it‟s interesting because you have said a similar thing‟
Jenny: „There‟s a culture of it but there is a culture that your emotions shouldn‟t come into play when you are dealing with somebody else‟s but I don‟t think that‟s practical and I don‟t even think its professional to believe that that‟s possible, you know, why should we professionally believe something that‟s not possible? It doesn‟t make sense‟
On the subject of „being professional‟, at the time of this interview I had, as
part of my work as a pre registration nurse lecturer, been a member of
numerous Professional Suitability panels. These were set up to consider the
professional suitability of various nursing students who had been considered
as doing something „wrong‟ in practice. For example, one student had
falsified a time sheet. All of the evidence is considered before the panel
reaches a decision as to whether the student may remain on the pre
registration nursing programme or not. Therefore, I felt that my view of what
220
it was to be a professional was very much about „right and wrong‟, around
truth and integrity and in one case, violence toward other staff members.
Some of the informants had talked about the tension between showing
emotions and being „professional‟ which is why I brought it up in my interview
with Jenny. Jenny‟s view was the opposite both to that of the other
informants, apart from Joan, and in addition, to my view of what it was to be
a professional, based on my experiences at that time. Jenny is suggesting
that it is unprofessional to think that we can keep our emotions out of our
encounters with clients and goes so far as to say that it isn‟t possible. My first
reflection on this excerpt is as follows:
„Of course dealing with and acknowledging our emotion at work is very important but I wouldn‟t go so far as to say that it is linked with being a professional. Would not acknowledging that our emotions play a part in our work be classed as unprofessional? This isn‟t a way I have thought about this before and seems a bit too far‟
I now look at this interview excerpt in a different way. Firstly, I believe that
many if not all of the students brought up before the professional suitability
panel had emotional problems going on in their personal lives. In every case,
this was a contributing factor to their unprofessional behaviour in practice.
The fact that they had not acknowledged and dealt with their emotional
issues led them at times to deal with situations in destructive and unhealthy
ways. This underlines Jenny‟s point about it being impossible for a nurse‟s
emotions not to have some impact on her professional conduct, and
therefore unprofessional for her not to take these emotions into consideration
in her working life. In all of the cases from that time, acknowledgement of the
221
impact that emotion was having on their work, could have led to a more
constructive outcome for the students concerned. Secondly, I now agree with
Jenny that it is professional behaviour to acknowledge that our emotions will
have an impact on how we act and behave at work and consideration needs
to be given to this. Indeed, this is in line with a pre understanding I already
held which was that the nurse needs to manage her emotions or perform in
some way, in order to do her work. However, my understanding of „being a
professional‟ at the time of the interview had altered my perception and I
could not at that time, see where Jenny was situating her thoughts of
professional behaviour.
As mentioned previously Koch‟s (1996) father died in hospital following a fall;
this had an influence in her study, which sought to understand the
experiences of older people admitted to an acute hospital setting. Similarly,
in this situation my perception of professionalism at the time of the interview,
based on my experiences at that time, had a bearing on how I thought about
this data. However, months later I look upon this data in a different way.
Indeed, by entering the hermeneutic circle, my „bigger picture‟ has changed.
By looking at a small part of this interview, I can now make more sense of
the bigger picture, i.e. what it is to be a professional. My pre understanding
and background as a nurse had been used to contribute to a different
understanding of professional behaviour. Understanding comes from a given
set of pre understandings which we already hold. For example, in my case at
that time I was holding a very narrow view of what „being a professional‟ was
all about. These then changed or were „corrected and modified‟ (Koch, 1995:
832) as new information came to light and I interpreted the world in a
222
different way, through the hermeneutic circle. I now leave the circle again
with a different whole of understanding of the issues relating to emotion and
being a professional.
Earlier in this work I suggested the difficulty in reaching „common themes‟ in
this style of research and cited the work of Paley (2005) who suggests that it
is precisely the things we do not share with others which are the most
fascinating. Jenny‟s view of being a professional is not shared to such an
extent with the others. Joan holds the closest view, but she does not go so
far as Jenny when verbalising how she perceives the issue.
Being aware of emotion as part of being a professional
Awareness of our own physical and emotional self is something I rate as
being very important in nursing practice. At the time of writing, I have
published two „continuing professional development‟ articles aimed at
student or newly qualified nurses relating to self awareness. My interest in
part comes from observing colleagues in practice and in the media. Earlier in
this work I have explained that the trigger for starting this study was watching
the Panorama programme “Undercover Nurse” in which a male nurse shouts
at an elderly male patient in what I perceive to be an uncontrolled manner.
My belief is that if we can identify and understand our emotions, this goes
some way in assisting us to manage them when in practice. This links to my
pre understanding that the „good‟ nurse is emotionally self-aware. Burnard
has written extensively in the nursing literature about self awareness and
describes it as follows (Burnard, 2002: 30 – 31);
223
„Self awareness refers to the gradual and continuous process of noticing and exploring aspects of the self, whether behavioural, psychological or physical, with the intention of developing personal and interpersonal understanding‟
This description takes into account the ongoing journey we take when
exploring our self, and acknowledges different aspects which may be
considered; behavioural, psychological and physical aspects. As Burnard
suggests, there is an intention in mind, that of developing our understanding
of ourselves and others. Indeed, it is only when we begin to understand
ourselves a little better that we can begin to understand others (Burnard,
1997). Awareness of our emotional self is crucial if we are to help others but
our desire to help others may be taken over by unacknowledged emotions.
For example, the angry nurse in the Panorama programme was not
acknowledging his anger with the result that he was unable to manage it in a
different way. This led to his „helping‟ being sabotaged by strong emotions.
Heron (2001: 12) uses the term „emotional competence‟ to describe the
aspect of the self that is needed to help others effectively. Emotional
competence may be described on three levels (Heron, 2001). The first is
„zero level‟, when our helping is sabotaged by our own hidden emotions. We
may present as interfering or oppressive in our helping. The second level is
when our helping is, in the main, uncontaminated by our own stray emotions,
but can slip into „intrusive helping‟ without us realising it. The third level is
when we make this slip less frequently, and we are aware of when this has
happened and can correct our behaviour (Heron, 2001). However, Heron
(2001: 13) suggests that most people work at the second level and believes
that there is a lot of „misshapen compulsive helping around‟. The aim is to
224
recognise any past distress we may have, work through it, and „liberate‟ our
helping from it.
Jenny summed it up in the following way:
Jenny: „…if you don‟t know yourself, you can‟t therapeutically use yourself to help other people. Okay, maybe there are certain scenarios where it isn‟t so important to understand what‟s going on for us, it‟s more important to understand what‟s going on for the client, but at a later date it‟s very useful to reflect on our actions and our opinions and how our emotional state guided our intervention with that client‟
This „summing up‟ tells me a lot about what is going on in Jenny‟s world and
the importance she places on being emotionally self aware. There is a lot
going on in this excerpt; knowing ourselves as nurses is a pre requisite to
caring therapeutically for others. Sometimes, there and then, it is more
important to understand the client than immediately to understand ourselves
although reflection at a later date is beneficial. However, I suggest that we
would need to know and understand ourselves enough, at the actual time of
the intervention, in order that our helping wasn‟t of the oppressive kind,
described by Heron above. It is acknowledged that our emotional state can
guide our interventions with others. Our emotional state can guide us in
different ways when dealing with patients in our care.
Reflective Practice
I believe that reflective practice can be useful and I was keen to pick up on
the statement, „at a later date it‟s very useful to reflect on our actions and our
opinions‟ and to understand what Jenny meant by this and so I asked her
why she thought we should do this. I suggested to her that some may argue
225
that it just comes naturally and we know instinctively how to respond and
behave in an emotional way, as people, with their own values and beliefs, in
a nursing world. This was based on previous research I had undertaken in
which some informants had suggested that refection in a formal sense was
not necessarily a useful activity (Smith & Jack, 2004) She repeated the need
to reflect on some level:
Jenny: „Well, yeah but, you must do it, you must do it, everybody at some level must analyse themselves‟
Me: „What makes you say that?‟
Jenny: „Because I don‟t think it‟s possible to get anywhere without doing it. I mean everybody at some point has thought “Why am I doing this?” haven‟t they?‟
My interpretation of this is that Jenny feels that reflection and analysis of our
actions is needed if we are going to grow and develop as practitioners and
she suggests that everyone at some level must do it. I thought it was
interesting that she assumed that others ask the question, „Why am I doing
this?‟ as I suggest that to cope with the day to day issues of practice outlined
by the other informants, this is the very question that isn‟t asked. Not
analysing practice becomes part of the coping strategy. By not questioning
and detaching from practice, students are more able to survive in terms of
„getting through it‟. This view is similar to the findings of Mackintosh (2006)
who suggests that caring becomes less important when students have to
cope with the reality of practice. This occurs during the socialisation process
and as Mackintosh (2006) suggests, the issue has „major implications for the
nursing profession‟ in that there is a need to discuss ways in which the caring
role of the nurse can be maintained, if indeed it can be maintained at all. I
226
suggest that nurses do want to invest their own emotional selves in their
work as in this way they can remain true to the person they were when they
started their education. They do not have to become someone else or take
on another person‟s way of emotional being. It is not so much a question of
whether or not the caring role can be maintained; moreover it is about how
nurses can be supported to cope, whilst remaining true to themselves.
I suggested to Jenny that even if practitioners do reflect the process doesn‟t
always lead to development and growth. It is worth mentioning that, by this
stage, I was feeling much more involved and enthusiastic about the interview
and the way in which it was unfolding. Here, to my surprise, I felt that I had
found an informant who was agreeing with my own beliefs and my next
question was „from the heart‟, not with my „researcher‟ hat on. Here, I feel I
am „Researcher as Equal‟, really wanting to know and find out what Jenny‟s
thoughts were about the subject. Gone were my thoughts of really needing to
„know more‟ than the informant. I was acting here not as a lecturer or
someone who should know more than the informant. At this stage I felt that I
had let my guard down to a greater extent and could see the potential for my
thoughts and hers to really „fuse‟ to reach a different understanding.
Indeed, following the interview, many months later, I felt I had a different way
of thinking about this student‟s way of being in the world and had learned a
little about myself in the process. My initial background understanding or
„bigger picture‟ was different to the picture provided by the student, which I
viewed by entering the hermeneutic circle. By holding up the student‟s
picture, my „bigger picture‟ has changed as a result. My picture of being in
the world has now altered and is different to the one I saw previously. It is
227
easy to get into a habit of interpreting something in one way. My
interpretation has now changed and this ongoing process is clearly circular in
nature as my bigger picture changes and grows through my engagement
with the smaller parts of it, for example, this part of the student‟s story. In one
sense the process is more like that of a spiral, as different understanding can
go on and on rather than round and round, as in a circular model. A spiral
would suggest that understanding grows and changes in a continual process
with no end, similar to that suggested by Kvale (1996).
Returning to the interview, I was feeling very enthusiastic now and this could
explain why the next question seemed rather incoherent:
Me: „Do you think they are asking the question but maybe not thinking in terms of the solution, in terms of, I mean, maybe they don‟t know what they don‟t know, so they might be questioning it but are they actually thinking then on that next analytical level? Do they ever get to that next level?‟
What I was trying to ask here was that even if nurses sometimes reflect on
their actions, does it often go any further? By mulling over an issue we can
problem-solve it, but do we really learn and grow from it in a meaningful
way? I was quite unprepared for the veracity of the next comment from
Jenny and it took me a little by surprise:
Jenny: (interrupting) „No! No! You have to develop the skills and that takes time and it takes effort. It takes somebody to show you how to do it and I think there is a certain culture of nursing, which doesn‟t allow you to express... erm... that you are disturbed by a client‟s behaviour‟
228
This excerpt suggests that Jenny believes that as nurses, we have to
analyse ourselves and our behaviour. It is something we can learn to do but
we need to be shown, and it takes time and effort. However, here Jenny is
referring to the difficulty in being able to „express‟ disturbance, not
necessarily in the context of being able to analyse in our own consciousness,
not necessarily sharing our thoughts with anyone else. I wondered from this
statement whether Jenny had previously tried to share her feelings with a
member of staff and had been belittled for doing this. It seemed that she may
have been referring to a particular event by the way she said, „disturbed by a
client‟s behaviour‟. On reflection, it could have been useful to probe further
and enquire about this as there may have been a particular incident she
could have discussed. My next question was an attempt to do this, although
Jenny continued to talk in general terms:
Me: „So, do you mean that certain members of staff would not allow you to do that?‟
Jenny: (Nodding) „Yes, they maybe frown on you expressing that you had concerns... erm... in some situations, you know, if you were involved in an incident which involves physical intervention with a client, because they are violent, some people don‟t encourage talking, like, “I was feeling scared „cause I thought he might hit me” would be frowned upon by some people‟
Me: „What do you mean by „frowned upon‟?‟
Jenny: „Some people just see it as part of your job, you know, you take that risk on so you shouldn‟t worry about it (long pause) but it‟s a bit scary‟ (laughs)
The repeated phrase „some people‟ when referring to others in the clinical
area who see being scared as part of the job, one which should not be talked
about, led me to think that there had been a particular incident. I was not
sure that Jenny wanted to discuss it further, so I did not pursue the subject.
229
I was interested in the phrase, „if you don‟t know yourself, you can‟t
therapeutically use yourself to help other people‟ as it implies that our own
emotions can be used purposefully and therapeutically to care for others. I
reflected on the thought that emotions could be viewed as „tools of our trade,‟
almost like Heidegger‟s example of a carpenter, using his hammer, but
without really paying any attention to it. Are there parallels here to the use of
emotions in nursing practice? I will now continue by discussing this idea,
linking my thoughts to Heideggerian philosophy.
Emotional Tools of the Trade
As suggested earlier, Heidegger disagrees with earlier philosophers such as
Husserl and Descartes who believed that we are subjects surrounded by
objects. We are not sitting on one side, like outsiders looking in and
observing the world. Through Dasein, we are in the world as the world is in
us. As suggested by Magee (2000: 258) „We are beings in amongst and
inseparable from a world of being...‟. Heidegger proposed that we are not
beings who consciously think about objects which we use on a daily basis.
Things are so transparent and „normal‟ to us that they do not have to even
pass through our consciousness. We do them without thinking. For example,
when driving a car we are not routinely thinking about changing the gears or
depressing the clutch; we do it routinely without it needing to pass through
our consciousness (Dreyfus, 2000). This everyday coping Heidegger
(1926/1962) describes as „primordial understanding‟. It is only when
something becomes out of the ordinary that we notice it. Using Heidegger‟s
example of a carpenter using a hammer, it is only if the hammer is too heavy
or the head falls off that we notice it at all. Heidegger describes something in
230
this state as „unready to hand‟. We have to problem-solve this issue and it is
only then that we consciously think about what is going on with the hammer
(Dreyfus, 2000). Could the same be said of our emotions when using them in
nursing practice? Of course, there is a considerable difference between
emotions and hammers and the way in which we physically use them. We
can hope to control a hammer in use, but emotions may be perceived as
more out of our control. The following is an excerpt from a novel by Shriver
(2007) that I am reading as I analyse this interview, which I think helps to
summarise this thought. Shriver‟s heroine Irina has just described to her
mother how she fell in love with a man and has just described the
powerlessness she felt. She then goes on to consider the nature of emotion
(Shriver, 2007: 293):
„The question of whether you were responsible for your own feelings – whether emotions were bombardments to which you were helplessly subjected or contrivances with which you were actively complicit – tortured her on a daily basis. Are they something you suffer or something you make? You can control what you do, but can you control what you feel?‟
Do we think about and do we organise our emotions or do we not need to
because they are beyond our control? Do we only notice emotions when they
become „unready to hand‟, that is when we perceive them as a problem, in
this case, falling in love with another man? In this lies a problem in that, do
we actually notice when our emotions become problematic to ourselves or
others in a nursing context? For example, we may behave in an emotionally
inappropriate way with a patient, but do we always notice it? Are our
emotions parts of our nursing tool kit in the way that a pair of scissors and a
231
stethoscope are? Just as we may not know how to use a stethoscope
properly, we may not know how to use our emotions to good effect in our
nursing life. This failure is surely made more likely in an atmosphere which
equates professionalism with the suppression or denial of emotions. The
assumption here would be that we would need to be skilled at using our
emotions in the first place and need to be aware if we were „unskilled‟,
although how could this be measured? We assume that we behave in an
emotionally able way; we know how to use emotions so they do not pass
through our conscious mind, but should they? Firstly, we would need to
perceive and identify our emotions, allowing them to be consciously
considered before they became active at a preconscious level. Heidegger
(1926/1962) suggests that in our day to day coping with the world, we do not
consciously consider what we are doing. We become so „skilled‟ at what we
do that we are not making conscious choices about our behaviour. As stated
by Heidegger (1926/1962: 98):
„....an entity of this kind is not grasped thematically as an occurring Thing, nor is the equipment structure known as such even in the using‟
In other words, we are not „grasping‟ our emotions as happening at the time,
nor are we thinking about them in use. It could be suggested that we become
as nurses so competent at using and managing our emotions that we reach
the stage, as with driving a car, when our competence becomes
unconscious. However, we also run the risk of unconscious incompetence.
Of course, thinking about our actions does have its place (Dreyfus, 1987),
but this is not our starting point according to Heidegger. It is only when
232
something goes wrong that we consciously begin to think about it. This
returns us to the question of whether we always know when something has
gone wrong. It may be only when we rely on maladaptive coping strategies
that we realise something needs to change.
One of the reasons I am attracted to reflexive research is because the
researcher is permitted to be clearly present in the finished research product.
In this sense, the „physical‟ proximity of the researcher in the text seems to
heighten the sense of responsibility for what is being presented. I am allowed
to show my „.....human side and answer questions and express feelings‟
(Fontana and Frey, 2000: 658). This means that the thought process and
influences on the researcher are clearly visible to the reader. It is these very
influences on the researcher‟s life that can lead the research in different
directions. An example I have previously given is the research presented by
Koch (1996) whose father died following a fall around the time she was
researching the care of older people in an acute hospital setting. This event
in her life meant that she then pursued the subject of falls more explicitly in
her research. It is what we bring with us to the project which can help us to
make choices about the direction of our work, whilst also always recognising
the temporal nature of the process. It is this fluidity and unpredictability that
makes reflexive research so unique. No two research products can be the
same. In addition, the influences on us can affect our interpretation of the
data and this will change at different stages of the project. I raise these
issues here as it was an event which recently occurred in my life which has
encouraged me to think in a different way about the ideas I am now going to
present which are around „being a professional‟.
233
The issue of being a professional was already on my mind, having
uncovered this „theme‟ during my interviews. I had not envisaged that my
work would travel in this „professional‟ direction although this is where the
students led me. I am reminded of the words of Kahn (2000) who discusses
the idea of important data – if it is not important to the informant then it is not
worth pursuing. Evidently, the link between emotion work and being
professional was an important one to the informants and this will now inform
the next part of the discussion. I will begin with some time travel back to the
2009 university Teaching and Learning conference.
The ‘Teaching and Learning’ Conference
As part of my academic role I am required to attend the annual Teaching and
Learning conference held at my university. This provides a forum for the
sharing and discussion of ideas relating to different aspects of education.
One of the key note speakers in the post-lunch lecture introduced the work of
Ron Barnett (2007). Barnett is concerned with the idea of „professional will‟
and how the will to be a professional is formed. „Professional will‟ is
described as something that carries the student through the process of
becoming and developing as a professional. The educator has a crucial role
in this development. This is a challenging task for both student and educator
as professional will needs to be robust and needs to be able to withstand the
traumas of everyday practice.
Barnett (2007) outlines dispositions needed for development of professional
will on the part of the students which include, amongst others, a „will to
engage‟ and a „will to encounter strangeness‟. Part of the developmental
234
process is concern for the nature of the profession and its identity. As I
listened to the lecture I perceived in Barnett‟s ideas some relevance to
nursing practice, and more particularly to my research data. Sitting in the
lecture theatre, I retreated into my own research world and jotted down on
my pad some notes which included the sentence, „the will to engage, our true
self, the authentic self in nursing‟. I reflected later:
„Wouldn‟t it be great if emotional engagement could be seen as being professional rather than un professional, turning it on its head, the will to engage emotionally is seen as the professional way to behave...‟
I wrote this in the context of the students‟ thinking on emotional engagement
and their view (Jenny aside) that the showing of emotion is in some way
unprofessional. To some extent these ideas relate to the previous discussion
on authenticity and the thoughts of Fran and Jan who tried to be themselves
in a challenging environment. I have already discussed the issue of
authenticity and being able to stay true to our own self in nursing practice. It
is not my intention to return to the discussion on authenticity per se although
this idea is inherent in much of my discussion. What interests me here is the
students‟ view of what it is to be a professional in an emotional or non-
emotional sense. I will now take Barnett‟s idea of „will to engage‟ to begin the
discussion of „being a professional‟. As before links to my data, my reflection
and the wider literature will be made. I will begin with a return to the literature
and the work of Dartington (1994).
235
A will to engage
Dartington (1994), a psychoanalytic psychotherapist and ex nurse was asked
to be involved in a project which invited new student nurses to attend a
weekly discussion group to share their feelings about patients. The group
was led by a nurse tutor, with Dartington acting as „group consultant‟ to the
tutors. Dartington did not like the idea of describing the groups as „support
groups‟, preferring to think of them as engaging in more of an exploratory
process around feelings. In her opinion, the danger was that support would
take the form of reassurance rather than an examination of feelings;
examination being a process which by its very nature could be more
challenging. During the process, Dartington observed that the tutors present
seemed uncomfortable listening to the painful stories told by the students.
Gradually, tutor attendance decreased and Dartington felt irritated that they
seemed unable to facilitate exploration of the students‟ feelings, and
recognise the extent of the students‟ distress. It was as if the tutors felt that
they would be held responsible for it. Dartington (1994: 105) summarises the
issue thus:
„What I, the students and tutors were all experiencing at first hand were the unconscious assumptions of the hospital system, which were that attachment should be avoided for fear of being overwhelmed by emotional demands that may threaten competence; and that dependency on colleagues and superiors should be avoided. One should manage stoically, not make demands of others, and be prepared to stifle one‟s individual response‟
It seems that individual emotional engagement is not allowed on the part of
the nurse for fear about what might happen. Dartington (1994: 105)
236
describes patients‟ emotional dependency as the „most dangerous and
contagious of diseases‟. Like all contagious diseases it needs to be
contained. Trying to keep emotion in its “proper place” could be seen to help
everyone and I suggest that this is something that lecturers and practice staff
promote. I will now relate a story from my own teaching experience to explain
my thinking.
‘This is their grief...’
I facilitate many clinical skills sessions relating to care of the dying patient
and the students are encouraged to share their feelings surrounding death
and dying. The groups are generally small with ten to fifteen students present
on average. They are usually first year students, around eight months into
their education. Students often describe how they find it difficult to sit with the
grieving family after a death has occurred, as they do not know what to say
or do and sometimes find it difficult not to cry. There is usually a mix of
opinion although, even at this early stage of their education, the consensus is
that that it is not the nurse‟s grief and therefore they should not be getting
upset. I try to suggest to them that it is not unusual to feel sad, and that this
is a normal way to feel when someone we have nursed has died. Most
students are of the opinion that because the dying patient is not their family
member, then this is not their grief but the family‟s grief. This means that they
should not be getting upset. They have been out on one twelve week
placement by the time this session takes place. Therefore, I conclude that
they are being „taught‟ this way of thinking during their placement, and
perhaps by other lecturing staff within the University setting. Wherever it is
taking place, I suggest that this view is problematic, as I think that it is
237
unreasonable to expect students at this stage not to feel distress when
dealing with death.
Whether issues such as these are discussed privately or in a group situation
i.e. the process isn‟t really the issue to me here. Exactly how we do it, i.e. the
„mechanics‟, can, and I suggest need to be thought through and I will offer
thoughts on this later in the work. The real issue here is that I get a sense
that the students are being encouraged to believe that it is not acceptable to
grieve or feel distress about something that, whichever way we try to
disguise it, is distressing. After one such teaching session I reflected:
„...how can we not grieve when someone we have cared for dies? Is it realistic to expect students not to grieve? What needs to be in place are ways in which we can accept this grief without continually sweeping it under the rug‟
There are benefits to holding the view that feeling or showing grief is not
permissible. Ultimately it serves teaching staff, leaving them free from the
threat of intimacy with students, a state which could be difficult to cope with.
As lecturers we never know what students are going to say or do next,
therefore the safest strategy can be to halt the conversation. There is a
constant need for us as lecturers to perform emotional labour, for example,
surface acting. Surface acting is described by Hochschild (2003) as a display
of emotion that is deemed to be appropriate but not necessarily felt at that
time. This can be useful, although, in itself, it brings stress and has been
shown to be linked to emotional exhaustion (Naring et al, 2006). By surface
acting we are providing a quick fix for both ourselves and the student,
238
although the long term consequences could include burnout, since emotional
exhaustion is linked to this syndrome (Maslach et al, 2001).
General discussion with colleagues over the years I have been teaching,
suggests the need for a „professional boundary‟ to be in place. This is an
aspect of practice which has been mentioned by some of the informants. The
reason for this is because the nurse doesn‟t „know‟ the patient in the same
sense that a family member does, therefore the grief isn‟t the same. At the
end of the shift, the nurse can go home and forget about it. Conversely, the
family member will grieve for their loved one for a long time. However, my
findings show that some nurses do indeed take their grief home with them,
and may find the build-up of emotion difficult to cope with over a long period
of time. The encouragement of this way of being, to suppress emotion, could
be seen to protect students from the dangers of emotional involvement
lurking behind every encounter with a patient. It also could protect lecturing
staff in the sense that they do not have to discuss emotional issues with
students any further. It is accepted that these are things that we „do not really
talk about‟. Subsequently, in order to satisfy ourselves that this is the correct
way to behave, we describe any emotional attachment as „unprofessional‟ or
„different‟ because it is not „our grief‟. However, informal recognition of
students‟ emotional needs is valued by students; see for example „Sister
Kinder‟ in Smith‟s work (1992). Sister Kinder gave time to students following
an emergency, to explore how they were feeling and reassure them that they
had worked well. Interestingly, the students in question believed that how to
manage feelings wasn‟t something that could be formally taught, and talking
about things „like death‟ was something to be done with friends at the end of
239
the shift (Smith, 1992: 104). This echoes a finding of my own, for example
Emily, who stated that she welcomed discussion with her fellow students on
return to university after placement. Certainly, each of us as human beings
manages feelings of grief in different ways. However, I still suggest that
emotion identification and management is something which needs to be
more formally recognised and not something that it is assumed that nurses
will just „get on with‟.
I will now return to the students and their views on what it is to be a
professional in an emotional sense.
‘You must act professionally at all times.....’
A lesson learned from my research suggests that many students see it as
unprofessional to engage emotionally with patients at anything more than a
superficial level. To use the words of Dartington (1994: 105), their „individual
response‟ has been well and truly „stifled‟.
Returning to the data, I am reminded of the words of Steve, who felt a sense
of guilt that he had cried when a patient he had got close to had got an „all
clear‟ result. As he described, „...I know you have to have that professional
boundary but it is hard not to become attached to certain patients ...‟ He goes
a stage further by saying, „I think it could be a wee bit unprofessional „cause
at the end of the day you are in a profession and you must act professionally
at all times and especially when really you‟ve got no attachment to
somebody...‟ Steve found it hard not to become „attached‟. I am reminded of
Smith‟s (1992) work here and her thoughts on „feeling rules‟ relating to death
and dying. Smith (1992) describes stories in which the views of two junior
240
students are not taken seriously by more senior staff. Both students have
insight into the feelings of two patients, but these views are largely ignored.
Smith (1992: 109) describes a „rigid nursing hierarchy‟ which „kept the
feelings associated with death and dying in place by failing to acknowledge
them in the public arena of the ward handovers.....‟
Smith (1992: 110) later reflects on the length of time the two students would
„retain their emotional sensitivity in a hierarchy that neither acknowledged nor
sustained it‟. I wonder too, when I consider Steve who is already feeling torn
about his emotions, feeling tension between attachment and being
„professional‟. Moving away from Steve and his placement back to the
students in the classroom, could it be said that their feelings were kept in
check by failing to acknowledge them in the „public arena‟ of the classroom?
Should the feelings of first year students not be taken seriously due to their
junior status? By this lack of acknowledgment, will some of their „emotional
sensitivity‟ be lost?
There are other examples of the emotional torn-ness which I think are worth
remembering here. Emily justifies the fact that she got a „bit choked‟ when
caring for a dying lady who wanted to go home by saying that it had been her
first placement and the first time she had been in that situation. She
describes the need to have a „professional face‟ and, as other informants
described, the need to have a balance between being „human‟ and being a
„professional‟. Similarly, Anne describes the need to be a „little bit more
professional‟ when dealing with the relatives of someone who had died.
241
Joan describes experienced nurses who do „cry every single time‟ and she
suggests that crying as part of nursing work is normal and not something that
should be hidden. In Joan‟s opinion, this is comforting for the family, as she
suggests that they „....probably like a bit of comfort and emotion‟. Smith and
Gray (2001) undertook a follow up study based on the original seminal work
of Smith (1992) returning to the concept of emotional labour and I suggest
that this is relevant here. As part of the study, the students were asked to
define emotional labour and this question revealed some interesting ideas,
which correspond with Joan‟s thinking, such as making the patient feel „safe‟;
„...you have to get in contact with your emotions and how the patient feels‟,
and psychological care such as, „being more intimate and building up trust
with the patient‟, „holding their hand to make them feel better‟ and „showing
the patient a little bit of love‟ (Smith and Gray 2001: 44). Against this,
emotional involvement is viewed by some as being inappropriate in a
professional relationship, particularly within a medically dominated
environment which still has a focus on cure of the physical problem
(Williams, 2001).
Viewing emotional labour as something basic and an aspect of practice
which does not need development can mean that, „the techniques of nurses‟
emotional labour go unappreciated and are not developed as resources for
the National Health Service (NHS) to draw upon‟ (Smith and Gray, 2001:
231). I would go a stage further than this and return to Dartington (1994: 108)
who suggests that the culture within the hospital setting, „does not encourage
the nurses to be moved by their experiences; attachment is felt as a threat to
the system‟. Whether it is viewed as something too basic to make a fuss
242
about or actually viewed as a threat, findings from my study suggest that the
students feel guilt and discomfort when becoming more intimate with a
patient and even Joan makes the statement, „Nobody else was crying, so
why am I?‟.
Writing in 1994, Dartington suggests that nurses were being encouraged to
be emotional non-thinkers due to the rapid period of professionalization
which was occurring in line with the move to study at degree and
postgraduate level. Whilst this period in time is now over, I suggest that the
culture has not changed. After 2011 there will be no diploma level entry, with
nursing becoming an all degree profession. The NMC (2009) suggest the
following advantage to this move:
„Graduate nurses will be able to deal more readily with increasingly complex care in an increasingly challenging health and social care system. Degree education will provide nurses with the decision-making skills they need to make high-level judgements and enable them to take more responsibility as soon as they start work. It is important that nurses will have these skills as soon as they start practising as registered nurses in order to be able to deliver safe, effective care in the future‟
There seems to be a sense of urgency within this statement with the phrase,
„...enable them to take more responsibility as soon as they start work...‟ They
need to „have these skills as soon as they start practising‟. I suggest that
placing unrealistic expectations onto the shoulders of newly qualified nurses
will do nothing for their confidence, self esteem and belief. It is important to
remember that newly qualified nurses, even those at graduate level, need
support which in turn makes them less likely to leave the profession (Kelly,
1998). Lack of adequate preceptorship on qualification can lead to graduates
243
moving on (Thomka, 2001). Expectations of graduates could be higher, with
others believing that „degree nurses‟ should just be able to get on with the
job from day one. New graduates can experience interpersonal conflicts
(Wheeler et al, 2000) which can leave them feeling stressed and anxious
(Oermann and Garvin, 2002). With the reduction in junior doctors‟ hours
more and more nurses are becoming nurse practitioners, taking on a more
diagnostic role and performing tasks which previously were the remit of
medical staff (Greenhalgh, 1994). Indeed, as Wiseman (2007) suggests, it
can be difficult to see any difference between the NMC (2005) definition of
an advanced nurse practitioner and that of a doctor. In practice, experienced
nurses in these roles can be heard describing themselves as „mini doctors‟
and it could be suggested that the title of nurse is something to be cast off. It
could be argued that nurses are simply using the description of „mini doctor‟
as a means of articulating their „advanced‟ role to the public. However, I
suggest that this does nothing to assist in defining nursing as a distinct
professional group. It would be sad if nursing was viewed as a series of
medical tasks rather than what makes nursing special. If nurses are not able
to describe clearly what they are about, then they will be neither understood
nor appreciated by the public. I suggest that nursing has become something
of an amorphous beast as it tries to encompass „advanced‟ technical roles,
and this, along with the need to meet targets and climb NHS league tables,
could be seen to be pushing the emotional nature of the role further down
the list of priorities. This is something which may have been recognised, for
example, by the Department of Health (DH, 2008) who proposed through the
Darzi recommendations, a „compassion index‟ for nurses. This is a way of
244
scoring the compassion nurses show towards patients and will be measured
in terms of how smiley nurses are towards patients. It would seem that
nothing is above being measured and recorded. It is unclear to me how
compassion could be measured in terms of how „smiley‟ a nurse is although
a „Compassion League Table‟ may indeed become a reality. Whether this is
an agreeable situation or not, the need for such a focus may support the
view that we have moved away from viewing compassion as a core aspect of
nursing practice, and must now regard it as something that needs special
attention. Worryingly for me, when a core aspect of nursing care is offered
such special attention, does it underline how inhuman modern day nursing
practice has become? Of course, it will be up to nursing staff to comply with
the index but thinking about caring and compassion in terms of
measurements and scientific rationality would seem not to be „thinking‟ at all
and in line with Heidegger‟s (1966) view when he suggested that we do not
think enough. Heidegger (1966: 44) makes the following observation:
„All of us, including those who think professionally, as it were, are often enough thought-poor; we all are far too easily thought-less....man today is in flight from thinking...part of this flight is that man will neither see nor admit it. Man today will even flatly deny this flight from thinking‟
Of course, it could be argued that as nurses we are „thinking‟ more than ever
before. By this I mean that we are thinking in a rational scientific mode as we
„develop‟ our roles into areas, some of which were previously occupied by
our medical colleagues. However, I suggest that we are indeed „thought
poor‟ and find it difficult to „see‟ or „admit‟ it. As I suggested earlier, we may
perceive that the style of thinking I refer to could lead to danger as we reflect
245
on emotions, both our own and those we care for. This is because we can‟t
be sure what we might find as we delve into our innermost thoughts and
feelings about situations we encounter.
Reflecting on our own emotions at a deeper level can be challenging and I
propose that this is because as a group we are neither encouraged nor
adequately prepared to do so. Dartington (1994:101) describes this style of
emotional thinking as:
„....the processes of reflection about one‟s work, its efficacy and significance: registering what one observes of the patient‟s emotional state, the capacity to be informed by one‟s imagination and intuition....‟
It is only when we begin to imagine, dream and truly live nursing that it can
become meaningful for us. Our hearts can then become less restless and
more content. On the subject of thinking and reflecting on our work, I suggest
that Heidegger (1966) has some ideas we could consider. He describes two
different kinds of thinking, „calculative‟ and „meditative‟. He distinguishes
between the two in the following way (Heidegger, 1966: 46):
„Calculative thinking computes....races from one prospect to the next....never stops, never collects itself. Calculative thinking is not meditative thinking, not thinking which contemplates the meaning which reigns in everything that is‟
Heidegger (1966) does not seem to suggest that one style of thinking is
superior to the other; both are necessary. However, here I am particularly
interested in his description of meditative thinking as I suggest that this style
of contemplation can assist us in imagining and dreaming of new and
246
creative ways of emotional being. His account of meditative thinking
continues (1966: 47):
„At times it requires greater effort. It demands more practice. It is in need of even more delicate care than any other genuine craft....It is enough if we dwell on what lies close and meditate on what is closest; upon that which concerns us, each one of us, here and now‟
Emotional reflective thinking can demand greater effort from us; it is more
challenging as we delve into emotions that at times it seems may be better
left undisturbed. I suggest that whether we care to admit it or not, we do
indeed feel emotion whilst caring; mine and other data have shown that. The
issue here is that we may try as nurses to suppress it, deem it as
unprofessional, to be locked in a metaphorical box and left unopened. I
propose that it is time to unlock the box and admit, as a „profession‟ that we
do indeed feel and that it is not unprofessional to do so. Indeed, feeling
makes what we do so much more meaningful, both for ourselves and the
patients in our care. To return to Heidegger, let‟s think meditatively, not just
in a calculative style. It is part of being a professional.
Meaning – less nursing practice
Apart from emotional thinking being regarded as unprofessional, as nurses,
we can also be influenced by practical constraints. I suggest that as nurses
we never set out not to feel for others. An American journalist Julia Magnet
(2003) described her experiences as an in-patient in a London hospital and
her thoughts bring to life what I mean by meaning–less nursing practice.
Multiple inadequacies in care-giving, led Magnet to feeling neglected during
her two week stay for an ongoing health problem. She describes what I term
247
„non-feeling‟ care-giving, and provides examples, such as being left in pain,
not being given the correct medication, and being ignored when asking for
help. One experience she described particularly caught my attention. I read
with disbelief (mainly because this article was written as recently as 2003)
her experiences when asking for pillows to support her swollen hand. Her
vein had „tissued‟ which had left her with what she describes as „my Porky
Pig hand‟ (p44). In order to reduce the swelling the hand is elevated on
pillows. Magnet asked numerous nurses for pillows and received replies
such as, „Well, you‟ll have to ask your nurse‟, „We don‟t deal with pillows‟,
„Sorry, the ward is out of pillows‟ and on asking whether a pillow could be
borrowed from elsewhere, „The wards are very jealous of their pillows‟. This
story raises some issues for me. I feel very unsettled to think that none of the
nurses Magnet approached saw the hand and how Magnet felt as the issue;
the focus is on the pillow. I do not suggest that the nurses questioned did not
feel emotion. However, none of them focussed on the hand and considered
other ways to resolve the issue. I wondered why this might have been and
remembered an event from my past. I can relate to how a pillow can become
the issue and overtake the feeling care that nurses want to provide. It was in
fact an issue to do with pillows that led, in part, to me leaving hospital nursing
to pursue a nursing career in the community. I feel that it is worthwhile
mentioning here that this is another example of the valuable nature of
Heideggerian-style phenomenological research. By thinking about my own
past experiences I can understand this event differently. On first reading, it
may seem that the nurses Magnet asked were unfeeling; as if they could not
be bothered to track down some pillows for her swollen hand. However,
248
moving from this whole of initial understanding to the smaller parts of thinking
of my own experiences, has led me to look at this problem in a different way.
By doing this, a different whole of understanding is reached which relates to
lack of resources. It is not necessarily that nurses are unfeeling individuals,
but it can be the case that they are prohibited from doing their job due to
resource constraints.
Pillows in short supply
As a newly qualified staff nurse, working night duty, I received a patient onto
my ward from the emergency department. There were no pillows on the bed
so I went off to search for some in the linen cupboard, to no avail. After
trudging around five different wards, I was still empty handed. I vividly
remember walking back to my ward, across a covered walkway with floor to
ceiling windows, staring out into the night sky. I can still feel and smell the
cold air in that draughty walkway today, as if the event had only just taken
place. I was tired and frustrated that I could not provide the care I wanted to
due to lack of resources. This was just one of many events that had taken
place since I had qualified; lack of time, lack of resources and lack of
adequate support and supervision had left me feeling disillusioned and
unhappy. I felt I had nobody to turn to; it was a hopeless situation as I knew
that any senior member of staff I told would simply say that there was
nothing they could do about it; they were as powerless as I was. I remember
having what I like to term a „thunderbolt‟ moment; these happen sometimes,
when I have reached a turning point in relation to something in my life. At
these times it feels like a voice in my head says, „What are you doing?‟,
„Where is your head at?‟ I knew, standing in that walkway, having a
249
thunderbolt moment, that I needed to get out of hospital nursing as I felt so
often that I was being prohibited from providing the care I wanted to give. It
wasn‟t that I did not care; it was more that I wasn‟t able to express that care
in what ought to have been simple, practical ways.
I naively thought that since I left hospital nursing in 1992 for a career in the
community, things may have changed for the better, at least in terms of
having sufficient pillows to provide adequate care to patients. I note with
dismay that Magnet‟s article was written as recently as 2003. Has anything
really changed over these years? Dartington (1994: 101) states that nurses
are „sometimes valued for the capacity to be passive at work‟; she suggests
that stoicism is appreciated. My feeling is always that nurses are viewed as
coping individuals who get on with things without causing fuss. When there
are no pillows, what better than a folded up bed spread stuffed into a pillow
case? Nurses are problem solvers; maybe we feel that there is not time to
question what goes on. However, this does nothing to change the
environment in which we work. Moreover, when faced with such practical
barriers it is no surprise that we lose the will to be creative, imaginative and
intimate with patients. As Dartington (1994: 101) neatly summarises:
„This is not to say that nurses do not think, but that it is an effort of will to make the space for reflection in a working life dominated by necessity, tradition and obedience‟
The style of Heideggerian meditative thinking does indeed require „effort of
will‟. It is unsurprising that nurses may feel a need simply to „get on with the
job‟ without thinking too much about it.
250
The need for compassion support
Returning to the subject of compassion, I suggest that rather than focusing
our efforts into measuring how much compassion a nurse shows, we could
put more thought into how we support nursing staff both as students and
qualified nurses. If we are to measure anything to do with compassion, it may
be more worthwhile to measure „compassion fatigue‟, a term used to
describe the effects of working with people who are suffering (Sabo, 2006).
Of course, by doing this we run the risk of turning compassion into an „illness‟
but at least in this way the subject could be approached from a more
supportive angle, with recognition of the susceptibility nurses feel when
caring for others. This would seem more palatable than enforcing what could
be viewed as a „smile law‟, which could have the potential to place nurses
under even more pressure than they feel already. I do not believe that
nurses need any more pressure on them to perform tasks, least of all smiling
tasks. Nurses need support, to question practice, to rock the boat, to ask
„Why can‟t I live nursing the way I wanted to?‟ If nurses are able to nurse the
way they want to, the compassion will automatically follow; no need for
Darzi-style enforcement. Nurses need to question assertively, something
which they may find difficult to do. My own experience of teaching
assertiveness suggests that student nurses find it difficult to assert
themselves, usually describing the suggested techniques as sounding „rude‟.
Their ways of coping are usually to ignore problems and „get through‟
uncomfortable placements rather than assert themselves. However, it is
important that nurses do assert themselves as a study by Suzuki et al (2005)
251
found a direct link between low levels of assertiveness and increase in
burnout risk amongst novice nurses.
What is Professional?
I began this discussion by introducing the idea of professional will and
considering what it is to be a professional from a nursing perspective. I have
considered data from my own study but, before going any further, I think it is
worthwhile examining the literature on the subject. I am doing this here as I
believe it to be relevant to this discussion, although I realise that a full debate
on nursing as a profession is outside the remit of this work.
There exist multiple frameworks of criteria suggesting different
characteristics of professions. The notion of what constitutes a professional
seems rather slippery as there are multiple sets of criteria. How emotional
work fits into the different criteria will inform the subsequent discussion.
Nursing as a profession
Nursing has always been a predominately female occupation which evolved
from Victorian society (Wuest, 1994). A study by Kalisch and Kalisch (1983)
examined the image of nurses and suggested that most members of the
general public think that nurses are female and help doctors with their work.
Being written almost thirty years ago, it could be suggested that this
perception has now changed, although it could be argued that we still
subscribe to the male-orientated idea of what it is to be a professional.
Cutcliffe and Wieck (2008) propose that nursing is measuring its own
professional status based on dominant male medical values. Values such as
252
a university-based education; all graduate entry and autonomous practice
are given as examples. It seems that rather than celebrate all that nursing is,
we are measuring it in terms of what it isn‟t, but is misguidedly and
desperately trying to be. By doing this, it seems we are pushing the
emotional nature of nursing further down the value scale until it will soon
have disappeared altogether. Reflecting on other examples of criteria set as
a benchmark to measure „being professional‟ I suggest that as nurses we do
not really fit in. Bilton et al (2002) suggest that public service should be at the
heart of a professional group. I wonder whether we can truly say that we are
of service to the public if we continue to deny emotional needs, both of
ourselves and the patients we care for.
I suggest that it is worthwhile pausing here to consider what patients deem
as public service, in the sense of what a patient values in a nurse. Fosbinder
(1994) proposed a framework of interpersonal competence having
undertaken an ethnographic study involving forty patients and twelve nurses
at an acute care hospital in Southern California. Patients in the study placed
value on interpersonal competence, above the tasks being carried out. Four
main processes emerged which encompassed issues such as explaining
things, being friendly, sharing some personal details, anticipating patients‟
needs and „going the extra mile‟. I think it is worthwhile describing verbatim
what a patient meant by this final phrase (Fosbinder, 1994: 1089):
„.... She got emotional with me...she held my hand. Going by the books is good,...but a gem does more...she took a moment away from being a nurse, thinking about medicine, she was compassionate...There is the little extra smile. You need a human touch. The really good nurses do more than just be „formal‟‟
253
I use this excerpt to give an example of what patients value and what could
be termed public service. A phenomenological study by Carlsson et al (2006)
explored patients‟ violence against carers in a mental health setting.
Situations in which patients received detached and impersonal care had the
potential to become violent. Conversely, when carers were genuine and
authentic, violence was less likely. Carlsson et al (2006: 292) suggest:
„In order for the patients to be able to express their suffering, they need invitations to a caring community where they can feel that the carers are there for their sake and that the carers really want to help. That is, the carers cannot play a part, but have to be able to sincerely convey a feeling of wishing the patient well‟
On this account, rather than following a rule book of how to deal with certain
situations such as an „aggressive patient‟ , investing some of our own
„personal style‟ and being real with patients is more meaningful and
constructive (Carlsson, 2006: 301).
Returning to the discussion of professionalism, a criterion proposed by Bixler
and Bixler (1959) identifies the need for a defined practice and knowledge
base. I suggest that we are further away from this criterion than ever before
and I will now explain why.
Emotional engagement – part of our ‘unique knowledge base’
By trying to make nursing into more of a profession by making it all graduate,
and by taking on more medical tasks, I suggest that nursing has missed an
opportunity. On the face of it, the criterion relating to a defined knowledge
base could be perceived as another dominant male value. However, we do
have a „defined knowledge base‟ and it is this very aspect of practice that we
254
are trying to rid ourselves of. What makes nursing unique is the very thing
nursing is trying to cast off. Intimacy, closeness and fondness for a patient
causes embarrassment, not really worthy of mention or note, something not
really spoken about, a guilty indulgence rather than a celebrated aspect of
what we do and what makes us unique and professional. I suggest we look
at it in another way. Rather than viewing emotional attachment as something
which makes us unprofessional, I suggest that it is this very aspect of
practice which defines us as a profession. This is not to suggest that
technical knowledge and practical skills are not important. However, rather
than measure nursing success in terms of technical knowledge alone, why
can‟t we celebrate our uniqueness in the form of our ability to know the
patient and connect emotionally with him? The two are inextricably linked
anyway. As suggested by Freshwater and Stickley (2004: 93):
„It is not enough to attend merely to the practical procedure without considering the human recipient.... Whilst the rational mind may adequately attend to the necessary technical aspects of nursing procedures, it is not the place of the rational mind to intuitively sense the needs and emotions of the person at the receiving end of care‟
Returning to Barnett‟s (2007) notion of professional will, this will not only
involve the will to engage, but also the will to encounter strangeness. This is
because we are so concerned with detaching as a means of being a
professional that it will indeed be „strange‟ to have the freedom to engage
emotionally to lead more fulfilling professional lives. It will surely feel strange
to not feel guilty when showing emotion and living nursing in a natural rather
than restricted way. I am in agreement with Dartington (1994: 109) who
suggests:
255
„If...we continue to behave as if emotionality in the workplace is best managed by denial, splitting and projection, then we will continue to inhibit the functioning of society‟s humane institutions, and continue to squander the potential thoughtfulness of those who work within them‟
This very thoughtfulness could hold the key to our uniqueness and help us to
be recognised as professionals. However, this view will not be workable if we
continue to subscribe to the dominant medical view of what it is to be a
professional. I suggest that we need to go a stage further and devise our
own nursing definition of professionalism, starting from an empowered
proactive place, rather than reacting to definitions inherited from other
professional groups.
A phenomenological study by Secrest et al (2003) exposed three themes
relating to the student nurse experience of being professional. This American
study included a sample of sixty four student nurses, from different years of
the course. The interrelated themes were „belonging‟, „knowing‟ and
„affirmation‟ and I offer it as an example of the way in which we can begin to
consider our own nursing definition of what it is to be „professional‟. Secrest
et al (2003; 80) state, „Self and others places the ground of professionalism
in nursing as relational, or oriented toward people...this ground gives rise to
the themes...‟
Students valued a feeling of belonging and being part of the team; having
knowledge and affirmation, which came about when interacting with others.
Knowing was not just in relation to having theoretical knowledge as one
student suggested when talking about a patient, „I knew what he needed‟,
which implies something deeper than what the authors describe as
256
„traditional psychomotor skills‟ (Secrest et al, 2003, 81). I suggest that it is
through research and discussion that we can arrive at our own definition of
„being professional‟ without having to resort to other disciplines‟ views, which
seems the equivalent of trying to fit a foot into an ill fitting shoe.
My thoughts on this can be illuminated further by a return to Heideggerian
thinking as I propose that he can assist us in understanding our practice and
ways of being as nurses. I think it is worthwhile here revisiting his thoughts
on death, „everydayness‟ and „covered-upness‟ (Heidegger, 1926/1962).
Heideggerian thinking on death, ‘everydayness’ and ‘covered up-ness’
Heidegger (1926/1962) wrote extensively about death and about his belief
that it is only when we confront and acknowledge the fact that we are going
to die at some point, that we can live authentic lives. He suggests that most
people deny the fact that they are going to die or at least do not think about it
much and because of this we do not live our lives fully. Heidegger,
(1926/1962: 302) suggests, „The falling everydayness of Dasein is
acquainted with death‟s certainty, and yet evades Being–certain.‟
If we evade thoughts of our own mortality we never truly live our lives to the
full. It is easy to take being alive for granted and it is often only when we
watch someone die or we become ill ourselves that we decide we must live a
more full and authentic life. From a nursing perspective this would mean that
we nurse with more passion and energy, investing some of our real self in
what we do.
257
Heidegger (1926/1962: 164) seems rather scathing when he describes how
we live everyday kinds of lives, the kinds which are dictated to us by others;
in his terminology, „the they‟:
„We take pleasure and enjoy ourselves as they [man] take pleasure, we read, see, and judge about literature and art as they see and judge;.........we find „shocking‟ what they find shocking. The “they”, which is nothing definite, and which all are, though not as the sum, prescribes the kind of Being of everydayness.‟
On first reading I thought this seemed rather harsh, as if we are a group of
non-thinking beings who all lead everyday average kinds of lives, dictated by
other people. However, having reflected on these words and the earlier
description about death, I suggest that Heidegger could be telling us
something quite important and something which has relevance to nursing
practice. As I have already suggested I believe that the nursing profession
needs to carve its own definition of professionalism and do its own thing, be
its own person. From this Heideggerian perspective nurses are following
other disciplines such as medicine, or the prevalent culture of nursing, seeing
things as they see them, judging things as they judge them and reading
things as they read them. Kelly (1996) conducted a follow-up study of
English graduate nurses and the recollections of their first year as qualified
nurses in a hospital setting. One of the respondents in Kelly‟s study brings
Heidegger‟s (1926/1962) thinking to life:
„Hospital nursing changes your values... not for the right reasons. I was beginning to think like everybody else. And, I began to go along with things I couldn‟t change‟ (Kelly, 1996: 1066)
258
This way of behaving keeps us in everydayness rather than encouraging us
to be creative and think for ourselves; „I was beginning to think like
everybody else...‟ On an individual level it also stops nurses from being real,
and investing their authentic selves when caring for other. Staying in
everydayness holds us back, rather than encouraging us to reach our true
collective potential as a profession.
Nurses can find it difficult to be creative when they are in constant fear of
failure. In an earlier paper, Kelly (1992) discusses the importance of positive
role modelling as students depend on this as part of their professionalisation.
Castledine (1998) suggests that part of professional development includes
adoption of role model attitudes and behaviours. However, instructors in
practice or in an academic setting can cause confusion if their behaviour is
inconsistent or negative. If a student is only made aware of their
inadequacies they are not going to try something new or take a risk (Kelly,
1992). In addition, the focus of a challenging clinical placement for many
students can merely be to „get the paperwork signed‟ and come through the
placement unscathed. It can be difficult to challenge someone who will be
responsible for deciding the ultimate outcome in terms of passing or failing a
placement (Pearson et al, 2008). I suggest that it is worthwhile remembering
the human cost in terms of the distress and frustration felt by student nurses
and the effect on patients when they witness incongruence and poor
practice. Returning to my data I remember Jan who left her nursing
education due to disappointment and disillusionment with what she
witnessed in practice.
259
Heidegger (1926/1962) proposes that there is a need for phenomenology
because Dasein, or our „being in the world‟ is covered up. It is the job of the
phenomenologist to uncover what is going on in everyday being. He goes so
far as to say that „covered-up-ness is the counter-concept to „phenomenon‟‟
(Heidegger, 1926/1962: 60). He describes how phenomena can be covered
up in two ways. The first is when it is, „undiscovered. It is neither known nor
unknown‟.
He describes the second type of covered-up-ness as „buried over‟. This is
when the phenomenon has been discovered but then covered up again.
Heidegger (1926/1962: 60) states:
„This covering-up can become complete; or rather – and as a rule – what has been discovered earlier may still be visible , though only as a semblance......This covering-up as a „disguising‟ is both the most frequent and the most dangerous, for here the possibilities of deceiving and misleading are especially stubborn‟
I have stated previously that I believe that Heidegger can help us to
understand nursing differently and explore issues which are inherent to
nursing‟s being. Here I propose that the emotional nature of nurses‟ work has
been „discovered‟, indeed this is what makes nursing unique and can help to
define it as a profession in its own right. However, it could be suggested that
it is in fact being disguised, and covered over as suggested in the examples I
have given from the work of Smith (1992), Dartington (1994) and my own
findings discussed earlier. I will go a stage further and say that his thoughts
on „deceiving and misleading‟ are most relevant in that it could be argued
that both nurse lecturers and the wider profession do indeed deceive and
mislead, in a Heideggerian sense, to a greater or lesser extent. This is by
260
suppressing students when they want to discuss how they feel, as discussed
earlier and documented in the work of Dartington (1994) and Freshwater and
Stickley (2004). Indeed, as Freshwater and Stickley (2004: 483) suggest, the
traditional model of education, „suppresses the imagination of the
student....they suffer from educational claustrophobia and lose the capacity
to be autonomous learners and the potential for accountability.‟
I would go a stage further and suggest that students also suffer from
emotional claustrophobia and lose the capacity to feel autonomously and
have accountability for this. However, some writers go so far as to suggest
that emotion work doesn‟t exist. Dingwall and Allen (2001: 64) state that it is
an „occupational myth which has been deployed to legitimate nurses‟
jurisdictional claims‟. They state that the profession is becoming demoralised
because when going into practice, nurses are not „doing the work they are
trained to value‟ (Dingwall & Allen, 2001: 66). The authors suggest that a
little more realism is needed about the nature of nursing to provide a more
sustainable future for the profession. Looking into the past, errors have been
made in thinking that hands on physical care, such as mopping a „fevered
brow‟ was in fact the technical medical prescription of its time (Dingwall and
Allen, 2001). I cannot argue with a lot of what the authors say. There is a
need to carry out the technical tasks in whatever form contemporary practice
requires. As I have stated using my own data and that from others such as
Menzies (1960) and Smith (1992), there can be a focus on performing
fragmented tasks and „getting on with the job‟. Emotion work in practice may
not always be valued and I can see clearly why Dingwall and Allen call for
261
more realism. However, in my view, they are missing the point somewhat
and I will now go on to explain what I mean.
We can choose to look back as far as we like into the history of nursing and
say that emotion work did not occur and even if it did, it wasn‟t valued or
necessary (I do believe that it did occur and is indeed necessary but again,
that isn‟t really the point here). The point is that student nurses (I will link this
debate to student nurses as they are the focus of my work) want to live
emotion work and there is plenty of evidence to support this view. Therefore
if we are going to suggest that there is a need for more realism I suggest the
authors need to be more realistic about the fact that nurses are already doing
emotion work and trying to ignore or suppress it is simply making a bad
situation worse. I will use the work of Menzies (1960) to support my thinking
here and her view is supported by my own data. Menzies (1960) study
explored and tried to account for the high levels of anxiety and stress felt by
nurses in a general teaching hospital. Menzies (1960) decided that the
nature of nursing itself could not account for the high levels of stress and
anxiety felt by nurses in the study; there had to be another reason. She
suggested that the actual techniques used to contain the anxiety were the
real problem. These techniques included „splitting up the nurse-patient
relationship‟, „depersonalisation‟ and „detachment and denial of feelings‟
(Menzies, 1960: 101-102). Taking just one technique, „depersonalisation‟,
results in the following (p114):
„A nurse misses the satisfaction of investing her own personality thoroughly in her work and making a highly personal contribution....The implied disregard of her own needs and capacities is distressing to the nurse, she feels she does not matter....‟
262
This would suggest that ignoring the emotion work that nurses want to give,
whether the organisation views it as valuable or not, is damaging and
ultimately leads to nurses becoming disillusioned and leaving the job, as they
are not allowed to give in the way they want to. To return to Dingwall and
Allen (2001), emotion work may indeed be a „myth‟, in so far as it hasn‟t been
„allowed‟ or truly recognised as going on. Nurses indeed may be dissatisfied
and frustrated. However, the reason for this remains that nurses want to give
emotion work, and failure to allow or recognise this fact is the actual cause of
the dissatisfaction. The issue remains, how do we support nurses in giving
the emotional care they want to give?
263
Chapter Eight
Constituent Three: Experiencing ways of coping
One of the aims of this study was to explore how pre registration nursing
students manage the range of emotions they feel which are related to issues
from practice. As discussed previously many students interviewed have a
tendency to suppress emotions such as sadness, as they do not want to cry
in the practice environment. So in the very short term, sadness is hidden as
the students attempt to maintain a „professional‟ face. However, I was also
interested in longer term emotional management and I wanted to explore
what happens after the event, for example, when the student goes home.
Many issues were revealed. From the data I sensed a real feeling of
loneliness amongst the students, as many did not feel that they could talk
about how they felt to others, even though they identified that this may be
useful as a coping strategy. Students acknowledged that emotional issues
from practice did bother them later, when they went home, with some
students explicitly stating that they cried at home. Various coping techniques
were discussed such as physical activity and the use of „distraction
technique‟. Acceptance that they had done all that they could for patients
during their shift, even if the outcome was upsetting, helped them to cope
with their own feelings. One student discussed the need to be self aware and
to examine their feelings to isolate where their upset was coming from in
order to move forward and deal with it. I will now discuss the informants and
as before relate the data to other work and the thinking of Heidegger.
264
Anne
I have already introduced Anne who is an eighteen year old girl living in halls
of residence. I asked her how she coped with her feelings outside of the
workplace:
Anne: „When I first started, I found it the most difficult thing and I was thinking of packing it all in. Especially with being away from home and not having that support, it did affect me quite a lot. I couldn‟t leave it at the door and I was coming back to the halls with everyone screaming and partying and I was just sitting in my room just trying to switch off from it, but you can‟t.‟
Me: „Okay, so you say at the start you weren‟t able to leave it at the door, can you explain that to me?‟
Anne: (In a very quiet voice) „At the door of the hospital (pause). My first placement was a respiratory ward and there was a lot of elderly people on there and within my third day on the ward someone died. They asked us to come in and watch the doctors do all the things to the body and everything and to me I found that really difficult because, I have always had a thing with death anyway, the unknown and things like that, and just seeing the body, and I knew the lady anyway and it was hard and I remember speaking to one of the nurses and I said „Does this happen often?‟ and she said „Yes but you get used to it‟. I couldn‟t understand what she meant by „you get used to it‟, how can you get used to it, and she said „You just need to leave it at the door‟ and that‟s where I got that from, when you go home you go home to your life and when you are here you are here with this, but it doesn‟t come that easily and you do get more used to it but I don‟t think it ever could become normal if that makes sense because everything that happens is always gonna have some sort of effect but I think you get more used to the idea of bad things happening and how to deal with it but I don‟t think people just leave it at work and that‟s work because it‟s not.‟ (laughs) (her emphasis)
Being away from home and not having the support of her family had affected
Anne to the extent that she contemplated discontinuing the course. She
makes the comparison between herself, going back to the halls and not
being able to switch off and others being more typical students, „screaming
and partying‟. I feel that she has lost herself as a student at this point, being
265
isolated from the others and not doing as other students were doing. I was
interested in the phrase „leave it at the door‟ which was advice given by
another nurse as a coping strategy. She has also been reassured that she
will get used to seeing death. However, Anne questions the advice given as
she doesn‟t think that it is so easy to be able to separate work and home life.
It seems that she knows herself well enough to doubt that „it ever could
become normal‟ and that home life and work life have to merge in some way
as she says, „I don‟t think people just leave it at work and that‟s work
because it‟s not‟. Nursing to Anne seems more of a whole way of being as a
person, rather than something that can be left behind at the end of a shift.
This is not necessarily a good thing, as part of herself as a student has been
lost and she was even having thoughts about discontinuing the course. She
suggests that everything that she lives through at work is going to have an
effect on her in some way and change her way of being. I had this
understanding myself before starting this research, in that I believed that
change of our usual self was necessary for us to survive.
Jilly
I introduced Jilly earlier in the work in relation to the idea of being a
professional. As Anne had mentioned the idea of leaving emotion at the door
at the end of a shift, I brought this idea up when talking with Jilly. I had not
planned to do this, but I had been reflecting on this idea when I interviewed
her and it was on my mind. This is another example of how our past and
current reflection can influence the direction of the research; a way of
working that would be lost if I had decided to adopt a bracketing approach. I
266
suggested to her that we can leave emotion at the door of the workplace
when we go home. Jilly was emphatic in her response:
Jilly: (Interrupting) „I can‟t do that. In my first year I used to get quite, I was quite bad actually in my first year, it was like, it kind of all built up and then you know, it got to me one day when I felt, God! I had all this emotional pressure you know, when you have seen things and no one seems to, unless you are a nurse it‟s quite difficult, you know, if you try to explain to family, they don‟t kind of understand, it‟s like well, „that‟s nursing for you‟, you know and it‟s I think, my friend is another nurse and I speak to her so that helps me a lot, speaking with someone experienced, I can‟t leave it at the door, though. I know a lot of people can but I can‟t, I suppose it‟s my weakness.‟
Me: „I don‟t think it‟s a weakness. I think we do need to acknowledge our emotions and I think that by doing that we work through them and that‟s how we can stay healthy. I mean people sit and say, well I put it in a box, for me, you do need to acknowledge it and yes that is what nursing is.‟
Jilly: „Yeah, even if it‟s just talking to someone about what you have seen or what‟s upset you then, that helps a lot. As well as exercise – I find that if I do that then that helps.‟
I found it sad that Jilly perceives it as weakness that she can‟t leave her
emotions at the door at the end of the shift. She uses the phrase „a lot of
people can‟ and I sensed that she felt pressure to be able to do this. She
seemed frustrated by the fact that she had a lot of pent up feeling but nobody
to talk it through with. Her answer to the problem is talking and I felt relieved
that she did not explicitly state that talking things through was a „weak‟ thing
to do. She continued by giving me an example of a time when she needed to
talk something through and the fact that ignoring issues was not helpful to
her.
Jilly: „On HDU there was a young girl who had been attacked and she was left brain damaged so... erm... bless her, she was only young and I didn‟t really know how to deal with it and it upset me. I was like „Oh my God, that‟s terrible‟. I put it at the back of my mind and then at some point, along with other things that had been upsetting, it caught
267
up with me. I am better now. I mean, in first year I wasn‟t very good. I know now that I need to talk about it there and then rather than ignoring it and letting it get to me at a later date.‟
These thoughts echo those of Joan earlier on in the work, who suggested
that talking things through was more beneficial than keeping emotion inside
which, as a way of being, could lead to isolation. Jilly has learned over the
course of her education that keeping things inside and allowing things to
catch up with her was not beneficial. I was interested in the sentence „I put it
at the back of my mind and then at some point, along with other things that
had been upsetting, it caught up with me‟. I interpreted this statement as
meaning that there was conscious effort on Jilly‟s part to move emotional
issues to another area of her mind. This is not a process that has served her
well though, because she goes on to say that when combined with other
upsetting issues later, it catches up with her. This implies to me that this is an
uncontrolled process, almost as if her emotions take her by surprise. I
suggest that this shows lack of awareness of how Jilly‟s emotions can have
an effect on her; they seem to be controlling her rather than her managing
them, although she closes by saying that she has since altered this
behaviour.
Before starting this work, one of my pre understandings was that nurses
have a level of emotional self awareness, in that they are least able to
identify how they feel, to a greater or lesser degree. However, this pre
understanding has been challenged and in addition, it is not enough to
understand how nursing students identify how they feel, the key question is,
what do they do following this process? It is not enough to be able to say, „I
268
feel anger‟ without then being able to use that anger to move us to a different
place, or take some form of action. Being able to identify our emotions does
not necessarily change anything. As suggested earlier, Paul was able to use
how he felt to instigate a change; his anxieties about a female patient led him
to think in creative ways about how her care could be managed.
Fran
Fran continues the theme of not being able to switch off from the thoughts
going through her head. The overwhelming feelings lead her to cry on her
return home:
Me: „How did you feel?‟
Fran: „Erm... it was, I think my first week on my first placement I cried when I came home after every shift, but I couldn‟t say it was because I was upset. I think I was just so overwhelmed. My mentor was working long days and they said to me, „Have you ever worked them before‟ and I said not and they said, „well do you want to give it a go?‟ She did three back-to-back long days, so I was working 7.30 in the morning to 9.30 and then coming home and doing the same the next day. So I was coming home and I was exhausted and I had so much going through my head and I couldn‟t sleep and I knew I had to get up and I think I just cried every single night‟
Me: „So why do you think you were crying?‟
Fran: „I think it was overwhelming, I think it was like emotional involvement. I‟d never cared for people before and I was feeding them and bed bathing them and it was hard, because everyone else on the ward had been doing it for so long they didn‟t think about it anymore in the same way that I was thinking about it. Like I would be feeding one of the patients in particular, who was like really acutely unwell, and I would be feeding him thinking like „this person is a person‟ they are a person and they‟ve got a wife who comes in every day and sees them and they could be my granddad. But everyone else just thought of him as the man in bed four or something and I was like „It‟s a person actually! „ (laughs) I am feeding a person and they might die and it was just a really strange concept, getting used to the idea that these were really people and I was doing real things to them‟
269
Fran compares herself, seeing the patients as „real people‟ to the other
members of staff, who she perceives as having depersonalised the patients
due to the length of time they had spent in nursing. She uses the phrase „But
everyone else just thought of him as the man in bed four‟ to make this point.
It seems important to her that people are treated as individual people as she
says, „this person is a person‟ they are a person and they‟ve got a wife who
comes in every day and sees them and they could be my granddad‟. She
suggests that the man could be her granddad and I interpret this as meaning
that she would not want a member of her family to be treated in this way.
This makes the experience even more personal to her which could suggest
that she will find the situation even more difficult to cope with. As Diekelmann
(2001) suggests, an interpretive researcher looks further than the text itself to
seek out what the informant did not or could not say. In this way the different
understanding of the situation is reached rather than a reinforcement of what
is disclosed by the informant. As suggested throughout this work, this is
influenced by the researcher‟s historicality and current thoughts and
reflections on the subject. Reflecting on my own experiences, there had been
times when I had felt that patients are very depersonalised and not treated
as though they are „real‟ people with „real‟ families. Personalised care is
advocated by the university, although when the students attend practice, the
reality can be different and leaves the student feeling stressed. Indeed, high
levels of stress from a clinical perspective, amongst nursing students, have
been shown to be related to the theory–practice gap (Evans & Kelly, 2004).
In addition, when nursing students perceive that emotional needs of patients
are not acknowledged, this can also lead to feelings of stress (Lindop, 1999).
270
I acknowledge that depersonalisation is viewed as a form of detachment and
consequently a way of coping with the challenges of dealing with patients.
However, as suggested earlier these ways of working create further anxiety
in the student, who does not then feel that they are able to give enough of
themselves and live nursing in the way they may prefer to (Menzies, 1960). I
was interested to know whether or not Fran had felt supported by the other
staff members in coping with the emotions she felt. It has been shown for
example that confirmation of emotion from others is helpful, and if not
present may lead to the nurse ruminating on emotions later (Sandgren et al,
2006):
Me: „So, you felt supported in the doing of the tasks, the practical point of view. Earlier on you said you had been crying when you went home; did you feel supported from that point of view or did you keep that all inside?‟
Fran: „No. I suppose not on placement. I didn‟t really say, „Oh I‟m feeling really overwhelmed‟ or, „I got really upset because of what has happened to Mr so and so‟ or whatever‟ I sort of kept that for when I got home and probably my boyfriend was regretting supporting my decision to send in my application (laughs) over the first few weeks of that placement, because I would just come home and be like, „well this happened and that happened and what do you think and what would you do?‟ He would be like, „Well I don‟t know I am not on the course!‟ and I‟m like, „well, I‟ve only been on the course for four weeks and I really don‟t know that much more than you do.‟ So, it was, quite hard‟
Fran describes how she kept her emotions inside until she got home where
she explored her feelings with her boyfriend. However, it is not clear whether
or not she was given the opportunity in placement, but did not choose to take
it. Stewart et al (2001) suggest that feelings of fear can prohibit younger
students from asking for support and this may have been the case here.
Using friends, relatives and peers to vent on seems to be a common way of
271
coping, in contrast to using clinical colleagues who we may perceive as
having less time. In addition, we want to appear strong and in control in front
of those who are assessing us. Sandgren et al (2006) suggest that when
ventilating, the listener does not have to be actively listening; it is the process
of getting the emotion out which is important. Therefore, using her boyfriend
in this way may have in fact been helpful to Fran, the fact that he had no
nursing knowledge was not important. However, it seems Fran had a lot of
unanswered questions about the work and overall I sensed a feeling of
frustration from what she said which resulted in her having to speak to her
boyfriend about it. Even though he may not have minded listening to her, she
jokingly states that he may have regretted supporting her in her career
choice and potentially this may have been a concern to her.
Emily
I introduced Emily in a previous chapter. Before starting her nurse education
she was a beauty therapist and has developed a coping strategy through
doing this work, which she has brought into nursing with her. In response to
my question about management of emotion after leaving the placement, she
continues the theme of having to leave emotion at the door. Interestingly, she
talks of it in terms of leaving her own feelings at the door before going into
work, although the cost of doing this is that she is bothered by it later:
Emily: „I mean, from when I started my beauty therapy training the first thing they told us was that when you go into work you go into work and you leave your problems at the door, you come in with a smile on your face and put your professional face on and go into work and people come in, they want to see you happy and smiling and at the time they were paying for a service and that‟s what it is, so you have a professional appearance and you get on with it and I think I have kind of stuck to that and I don‟t know, I think, I am quite good at it I
272
think, I can put on a bit of a front and get on with it and then it bothers me later‟
Me: „So what happens when it bothers you later then?‟
Emily: „I don‟t know. I think sometimes it plays on my mind. I don‟t often get very upset about it. I am quite, I think I can think about things quite sensibly and rationalise it later on and stuff. Sometimes it does bother me. But then you come home and you think (pause) who can I tell? You can‟t tell, you know you can talk hypothetically about hypothetical things, but you know you can‟t sit and say you know, „this poor lady‟, but then when you are at work there is not time to sit and discuss it‟
There seem to be a lot of contradictions here as there were in previous
excerpts I have presented from Emily. She states, „I think sometimes it plays
on my mind‟ then „I don‟t often get very upset...‟ then, „Sometimes it does
bother me‟. I wondered whether this was the first time she had thought about
it and was almost trying to work out how she felt, verbally. It also seems that
emotional nurse being can be contradictory and confusing in nature and it
can be difficult to isolate exactly how it feels.
She returns, as other students have done, to the issue of time and suggests
that there is not enough time at work to discuss issues. This would imply that
she does not talk with her mentor or other members of staff about how she
feels. She highlights issues around confidentiality as being prohibitive when
wanting to discuss things with her mother.
Emily asks the question, „Who can I tell?‟ I wondered whether Emily would
consider personal reflection as a way of exploring how she felt, although I did
not say this at the time. It seemed to me that someone like Emily, who I
consider to be quite a private sort of person, may benefit from writing her
thoughts down rather than talking to others. From a lecturer perspective,
273
maybe I am naive to think that student nurses go home at night and use
reflective practice as a supportive mechanism, although earlier Jenny
explicitly mentioned it. From a personal point of view, I had found reflection
to be very useful for working through events, although my experience with
students suggests otherwise, possibly due to the fact that reflective pieces
are often used for summative assessment. Indeed, when we provide
students with a „mark‟ for their reflection, any therapeutic value may be
altered and this could be viewed as a dilemma of such tasks. If it isn‟t
assessed, the students may not do it, if it is assessed, they write for the
assessment, thereby devaluing the exercise. Emily continued by talking
about the peer support she received when she came into her theory blocks in
university:
Emily: „It‟s nice when we come here because we can all chat about it together, „cause you are sort of away from it, but we all understand what each other has seen and the type of things that have gone on‟
This seemed worrying to me, that she felt she had to wait until the theory
blocks, which may be weeks away from events occurring in practice, before
she was able to get support and understanding from her peer group. I felt
concern about what was happening in between times. However, this is in line
with her storing emotion up consciously, as mentioned earlier. Sandgren et al
(2006) suggest that this sort of behaviour, when emotions are stored, could
be due to a lack of emotional competence on their part. Lack of emotional
competence can also lead to „stashing‟ emotions, which can occur if the
nurse has neither the energy nor the emotional competence to deal with
274
them. I suggest that both Anne and Emily show signs of stashing, which lead
to Anne feeling overloaded, crying alone in her room on returning home.
These events reminded me of my own historicality and my nurse education,
which occurred at a time when the nurse tutors were more visible on the
wards. This practice has died out somewhat, in part due to the distance from
university to placement and increasing student nurse numbers. As a student,
I knew that I would see my personal tutor regularly on the ward where I was
working. Very often, the tutors would work alongside the student or offer a
supportive presence in the placement areas in between the theory blocks.
Therefore, I had the support of my peers, as we all worked within the same
hospital, and also from regular visits by my personal tutor. This enabled me
to ventilate my feelings very close in time to when challenging situations had
arisen. There were times when this was very much appreciated and I will
now relate a story from my own practice to describe why this support was
important.
‘Just stick it up his nose and get some big bogeys!’
My first placement was a mixed medical ward and I was on a late shift.
During handover I was asked to take a nasal swab from a gentleman. I had
no idea what this meant as I had never had to do this before and had never
seen it carried out by anyone else. My only experience of „swabs‟ had been
from the television, during films when nurses during operations had been
asked to „pass a swab‟ to the surgeon. In my mind, taking a nasal swab was
not a simple procedure and I was clueless as to how to proceed. After
handover I approached the junior sister to ask her what I should do. I chose
275
to ask her because she had seemed the least scary in comparison to the
other staff nurses on the shift. I was completely unprepared for what
happened next. She said in a very loud and sarcastic voice, „Get a swab,
take it out of its packet and just stick it up his nose and get some big bogeys!‟
As she was speaking so loudly, other nurses could hear and started
sniggering and looking at me. I was humiliated and upset and felt that there
had been no need for her to speak to me like this.
When I think about Emily‟s phrase „but we all understand what each other
has seen and the type of things that have gone on‟, this incident was a „type
of thing that went on‟ and one which I needed to talk about. Seeing my
personal tutor arrive on the ward the next day was a huge relief and I
remember talking to her about it, which helped me gain some perspective on
the situation and prevented me spending too much time at home, alone and
worrying about my perceived inadequacy as a student nurse. Of course,
what was important here was my ability to be able to do this; to feel
comfortable in telling my personal tutor how I felt. For students who lack the
emotional competence needed to do this, or feel too shy to talk to others, this
would not be helpful. Having the time and space to talk with the personal
tutor seems important and could answer Emily‟s question „...who can I tell?‟
However, student numbers and geographical location of placements may
prohibit personal tutors visiting the practice environment. The hospital in
which I was educated was two minutes away from the School of Nursing, so
travel to and from the hospital was easy for my personal tutor. This is not so
now, with one of my students currently placed over twenty miles away from
the university. Reflecting on my story and on Emily‟s comments has led me
276
to reconsider the importance of the personal tutor and the support offered.
Being able to gain perspective on the humiliation I felt at that time was
valuable to me. Feelings of inadequacy were allayed as I talked through my
feelings. Remembering this helps in my understanding of the students‟ words
and feelings at this time. My personal tutor understood the intricacies of
nursing work and the nature of the nursing world. Moreover, he was visible in
a way that I as a personal tutor cannot be due to time and geographical
constraints. I have entered the hermeneutic circle again, as I move from my
original thinking on the issue of the visibility of the personal tutor to the part
of Emily‟s story. This has led me to a different understanding of the potential
need for the personal tutor to be more visible in practice. I appreciate that
this may not be practical in the real world, although variations on this idea will
be explored later in the work.
Steve
I introduced Steve in an earlier chapter in relation to his feelings of
attachment to a patient who had got an „all clear‟ following a diagnosis of
cancer. After we had finished talking about this patient I asked him how he
usually dealt with emotions he felt that were related to practice, in a day-to-
day sense:
Me: „So, you said that that time you were a bit emotional but usually, how do you manage those sorts of situations, what do you do? Do you go home and bottle it all up, or what? How do you cope with it?‟
Steve: „Erm... (long pause) I talk to people. Like if something‟s really annoyed me during the day I would talk sometimes and last year, although I kind of let it go, I used to actually go running and for some reason that‟s what cleared my head. I mean I won‟t lie, I smoke 20 cigarettes a day but I still managed to run about 2 or 3 miles (laughs) but I do that with everything, you know in my personal life or
277
something annoys me. I maybe go for a walk and might not come back for two or three hours, but that‟s just me. I think I have been like that since I was young and that‟s always been my way of coping or trying to cope with things‟
Me: „That sounds very healthy‟
Steve: „Well, if I could give up the cigarettes it would be a lot more healthy. (laughs)
Me: „One thing at a time, eh?‟
Steve: „Well, that‟s what I have always done. Before I did this, if I had a fall out with my Mum and Dad, I would just walk out the door and just go off and clear my head or go to a friend‟s house and just sit there and he‟d be like, „What‟s wrong?‟ and I would just watch TV but that‟s just something, I have always tended to go walking, I‟d be talking to myself sometimes whilst walking‟
Me: „So that‟s your way of managing the emotional side of it?‟
Steve: „Yeah, always‟
Steve begins the conversation by saying that he would deal with issues by
talking to someone. He then discusses his use of walking as a way to deal
with things and I interpreted this as being his main coping strategy, although
briefly he did some running. He states, „that‟s just me. I think I have been like
that since I was young and that‟s always been my way of coping or trying to
cope with things‟ which implies that this coping strategy is one that he has
brought with him, not something that he has learned by being at university.
As with Emily, previous patterns of behaviour have been transferred into
current ways of working. However, in this case, it could be argued that taking
physical exercise is more conducive to emotional health than stashing
emotions away. Activities such as country walking and attendance at yoga
classes have been shown to be useful coping measures, although not
necessarily the most popular ones (Evans & Kelly, 2004). He mentioned his
smoking habit, although did not explicitly say that smoking helped him to
278
cope. He ends this excerpt by saying that he would sometimes talk to himself
and I interpret this as a way of ventilating. Continuing the theme of talking, I
will now introduce Laura who describes how she used talking as a way of
managing her emotions.
Laura
Laura was just beginning her third year when I interviewed her. She was not
part of my purposive sample but had approached me when she knew of the
research I was undertaking. I had little contact with her before this, apart
from when I had taught her class in the first year of the course. She had
always seemed like a very quiet person and not one who contributed verbally
very much in class. Therefore, I was surprised at how much she seemed to
value the act of talking. Before commencing her nurse education she had
worked in retail and had used a Further Education qualification to gain
access to the course. During the interview, she had told me about an
upsetting incident in practice and, continuing to consider ways of coping, I
asked her whether she had spoken to the nurse concerned at the time about
her sadness about the event:
Laura: „No, I didn‟t say anything. I went home and spoke to my mum about it, obviously no names included, but I did speak to her about it. She‟s doing her nurse training as well and she has experienced this sort of thing as well and we just talk about it‟
Me: „And do you find that helps?‟
Laura: „Definitely, yeah‟
Me: „Do you have any other ways to manage the upset you feel?‟
Laura: „That‟s generally the way I do it. Sometimes it helps to write it down but I don‟t always have time to do that, so I generally discuss it with my mum‟ (laughs)
279
Me: „So, you think that talking about your emotions is a good thing?‟
Laura: „Yeah, „cause you can get to a point where it has been locked up for so long that it‟s got to escape sometime. It‟s got to come out. It‟s better if you discuss it as you go along, rather than letting it all get on top of you and then all of a sudden having a big outburst from all the built up emotion‟
Me: „And has that ever happened to you?‟
Laura: „Actually, yeah! I had an experience on a ward when one of the patients needed cleaning up and I asked the care assistant to give me a hand and she said she would be there in a minute and she was only doing some paperwork and then five minutes passed and I had got everything I needed and I told the patient what I was doing and five minutes passed and she still hadn‟t come so I asked her again, „Will you please come and give me a hand?‟ and she said again, „I will be with you in a minute‟ but another five minutes passed and by this point I was well, I was furious and so frustrated that she wouldn‟t cooperate with me. So I went to my associate mentor and asked him to give me a hand and he said, „No I am busy, you will have to get the support worker‟. At this point I just burst into tears and started ranting about asking her and he just looked at me quite horrified, not knowing what to do at a young girl crying (laughs) and shouting. Unfortunately, it was in the middle of the ward. I wasn‟t particularly shouting I was just basically saying, „I have already asked her‟ and that was the way my frustration blew‟
Me: „So did you feel that your feelings crept up on you?‟
Laura: „Yeah. Yeah they do. If I don‟t speak about it they just all of a sudden get on top of me and then I just cry‟ (laughs)
Me: „Is it getting better?‟
Laura: „Yeah. It‟s something which gets easier and I am learning to control that emotion. Rather than having the outbursts, I will go and take two minutes in the toilet and calm myself down and think, „It‟s not that bad and just calm down‟
Me: „So are you the type of person that says once you go home you leave it at the door of the hospital?‟
Laura: „I certainly don‟t leave it at the door. Sometimes it has got to me so much that I have to go home and think about it and speak about it. I can‟t just let it drop. I need someone to say to me, „Calm down, it‟s not that bad‟. It‟s usually forgotten about then by the next day, because I forget about things quite quickly if I have been allowed to talk about it‟
280
I was very interested in Laura‟s use of the phrase „...if I have been allowed to
talk about it‟. This suggests to me that talking isn‟t something that is always
allowed and referring back to the excerpts from Jenny, she explicitly stated
that talking about issues was frowned upon by other staff members.
However, in the case of Laura, there are things that affect her so much that
she has to speak about them in order to move on. She recognises the
danger of letting things get on top of her and gives an example of when her
emotions built up so much that she had an outburst in front of other people.
She describes this as a time when her „frustration blew‟. As I write this I am
reminded of the very first trigger for me commencing this study. As described
earlier, it involved a male nurse shouting at an older man as part of a
Panorama television programme. Was this nurse feeling the same way as
Laura? Did he have a build-up of emotion which had to be released? Did his
frustration „blow‟ and a patient happened to be in the firing line? Laura
suggests that she is getting better at managing her emotions and seems to
have developed some self-awareness. She seems more able to reason with
her emotions by saying to herself, „it‟s not that bad and just calm down‟.
However, it is not clear where this ability to monitor her feelings has come
from. If she had not begun to develop this ability, could she have developed
into the Panorama staff nurse? She uses her mother almost in the role of
clinical supervisor which, although great for Laura, does not provide a means
for exploration of feelings for the other students. It is clear that Laura felt a
great deal of frustration at the fact that she felt she was being ignored by
other members of staff, who would not help her to do her work. It is important
that nursing students feel that they are being treated with respect, which then
281
contributes to feelings of satisfaction (Randle, 2003). However, this can be
linked to the age of the student (Chesser-Smyth, 2005) and I wondered
whether Laura was being viewed as a „young girl‟ and therefore may have
not been afforded as much respect as a more mature student. Having said
that, for someone who is a younger student, I suggest that she is showing
emotional competence when she states, „I am learning to control that
emotion rather than having the outbursts I will go and take two minutes in the
toilet and calm myself down and think, „It‟s not that bad and just calm down‟‟
She is showing the ability here to identify her emotions, reason with them
and understand how she feels. She understands that what she is feeling is
not „that bad‟ and is able to calm herself down knowing that the feelings will
pass in time. It is not clear where this ability has come from, although it does
seem to have developed with time, as Laura is now in the third year of the
programme. Prior to this she stated, „…they just all of a sudden get on top of
me and then I just cry (laughs)‟ but makes the distinction between that
behaviour and how she copes now.
James
Another interesting way to cope with emotional issues is provided by James.
James was a third year student when I interviewed him. He was part of the
purposive sample and had been employed as a hospital porter before being
accepted onto the programme. He was a very hard working student and it
always seemed that he felt he had a lot to prove, especially to other
colleagues who knew him in his previous role. He had a very pragmatic
approach to life and issues usually seemed very straightforward to him. I
spent a lot of time trying to discuss the fact that there are many grey areas in
282
nursing, for example, just because a patient knows smoking is detrimental to
physical health does not mean that they will stop. To James, this never made
sense. I think this way of being is summarised in this excerpt relating to
dealing with emotional issues. He uses what he terms „distraction technique‟:
James: „I think it‟s distraction technique sometimes. You can know your own life and know your work life and try not to take it away with you. I think it‟s about knowing you are a nurse and this is your job and just your job and getting on with it that way really. At first it was really hard to handle. I worked on a medical ward once and there was this lady who every time you turned her she would scream in pain even though she was on maximum pain relief and I have never worked on a ward like that before and you would go home and think, “God, could I end up like that?” A patient in pain and you can‟t do anything for her. But as time goes on, you just do the best you can while you are there and when you come away you tend to forget about it and I think as time goes on and you train more you get more used to doing that. You are not necessarily a hard person but you learn you have to do it. You are going to see death on a regular basis and as long as you have done everything you can for the patient, everything in your will and power to do, then you are alright really‟
James, like Laura, has developed coping strategies with time. He seems to
have perfected the art of „leaving it at the door‟ with his „distraction
technique‟, although he did not describe what the technique actually involved
apart from saying „...you tend to forget about it‟. He seems to have resigned
himself to the fact that he can only do so much and as long as he has done
everything in his „will and power‟ then he is „alright really‟. He feels he is not a
hard person, although I suggest that he is becoming hardened to what he
sees and his coping mechanism is to forget about it. I wondered how long he
would be able to continue to forget about it and was also concerned that he
mentioned the lady in extreme pain. I wondered whether this was the first
time he had brought this subject up and whether he wanted me to talk about
283
it and confirm that he could not have done anything more for her. I did not
engage in conversation with him about the particular patient. On reflection, I
think that this was because I knew him as the sort of student who did not like
to mull things over and thought of him as having a hard-headed approach to
things. I wonder now, whether he did in fact want the opportunity to talk and
was inviting me to discuss an issue which maybe had affected him more than
he may have wanted to admit. As suggested earlier, I did not want my
interviews to turn into therapy sessions, but it was difficult at times to know
how far the conversations could or should go. I still feel that the interviews
should not become formal therapeutic encounters because I do not hold a
counselling qualification. However, I suggest that my thinking on this subject
may have shifted slightly. Just by giving a student the opportunity,
uninterrupted time and space to talk, can be therapeutic for them. Indeed, at
times I could almost feel a sense of relief on the part of the student, following
the interview. It may have been that having someone to listen to them was in
itself, enough. This idea will be explored in more detail later in the thesis.
At the time of interviewing James, I had already begun to remember many
stories from my own nursing past and I wonder whether the thought of
hearing another emotion laden story was too much for me to deal with at that
time. In addition to these feelings, I also felt some anger towards James and
I think that this was due to my dislike of his seemingly resigned manner. Of
course, this is my interpretation of his way of being and may have been
influenced by my previous dealings with him. I think I struggled with his
matter-of-fact attitude and this influenced the way I saw him. He describes
someone screaming in pain but relates this back to himself, wondering
284
whether one day he too may end up like that. The focus seems to be on
himself and not on the patient and I know that I felt annoyed by this; this
almost seemed like a selfish approach to take. However, I have to see this
as his coping mechanism. I am not here to judge what the informants are
saying. These feelings underline the difficulties which can be encountered
during qualitative interviews and can lead an interview in a particular
direction. I allowed my feelings towards James to direct the interview. I know
that, if a student approached me today with a story like this one from James,
I would be far more probing and interested. However, at the time of the
interview, I consciously let it go; maybe another tour into the hermeneutic
circle at this point was too daunting for me and I let the opportunity slip by.
Having to reconsider the whole of my initial understanding and then
contemplate the detailed parts of his story in relation to that seemed like a
challenging route to take. I felt that I would have needed to challenge his
attitude, which I considered selfish, and this would have seemed
inappropriate.
However, this event has given me further insight into this whole research
approach, although my thoughts feel challenging. On the one hand, I felt that
I was indeed truly present with James in this interview. Parse (1998: 64)
makes the distinction between „dialogical engagement‟ which is when the
researcher and informant are in „true presence‟, and that of an „interview‟. I
interpret the latter as being a more detached way of interviewing which, if
questioned, I would say I did not subscribe to. I felt truly present with James
as I was gaining „real‟ information about how he felt. He was certainly
opening up to me in what I consider to be a very honest way, although that
285
was where the problem began. I feel that I was a victim of my own research
approach. The very in depth thoughts and feelings that I was so keen to
elicit, did not suit me and because of this, I did not pursue the questioning.
As described earlier, I had a similar experience with Jenny, although for very
different reasons. By the time I interviewed James, I had learned so much
about my own way of being, through undertaking the research. I no longer
felt ashamed of my own emotional nurse being, in that I did not consider
myself or my research to be „soft‟ in any way. On the contrary, I felt so much
more confident by this time and was willing to stand up for my own way of
emotional being. I think that this fuelled my feelings towards James and I
opted out of delving deeper into the discussion, perhaps unconsciously
because I did not want my feelings to show. Conversely, it could be argued
that I was not able to stand up for my own emotional nurse being, as I did not
challenge him further on what I considered to be selfish behaviour on his
part.
To summarise, this highlights issues for researchers to consider when
undertaking interpretive research which hinges on the unseen glue between
informant and researcher. It suggests that, however much researchers can
reflect and attempt to remain aware, moment to moment, of feelings during
interviewing, they can never fully prepare for what may happen during the
exchange. I think that this is highlighted even more when undertaking
research on emotional issues and issues which may arouse feelings which
are only uncovered at that time.
I shall now introduce Eve, whose motivation to become a nurse began whilst
in hospital giving birth to her second baby. She had arrived at the hospital in
286
the nick of time and had to give birth in the Accident and Emergency
Department. Watching what she describes as the „professional way‟ in which
the nurses cared for her, even though she was not in the „right‟ place,
inspired her to commence her nurse education.
Eve
Eve was part of my purposive sample, and was a first year student when I
interviewed her. She echoed the thoughts of James, in that she expressed
the need to remain realistic in order to cope with the emotional demands of
practice. Eve was a mature student, and the sort of person that I always
viewed as a level-headed, calm character, who was not easily flustered. This
was evident in her interview, in that she seemed to have answers for
everything and did not see many insurmountable problems. The contrast with
informants such as Anne, for example, was stark and I wondered whether
this was due to Eve being a more mature student, a mother of two, who had
some life experience before coming into nursing, which seemed to contribute
to her ability to cope. We had been talking about emotional experiences and
she had suggested that often it is the student that the patient confides in if
they have a problem, a finding supported by Smith (1992). Eve stated that
she could not remember the exact detail of the event but could remember
that it was more than she was capable of dealing with on her own:
Eve: „I think, as a student, patients generally do tend to offload onto you more, because you do tend to have more time. Like, I have had patients talk to me about something and I have thought, “Well, hang on a minute. I shouldn‟t really be dealing with that”. I can‟t think what it was now, but I went and spoke to my mentor and she didn‟t know anything about this patient‟s concerns‟
287
She struggled to remember what the issue was and I wondered whether she
had „forgotten‟ it as a way of coping. I asked her how she felt when patients
offloaded their problems on to her and whether the things she saw and dealt
with had any effect on her after she had finished her shift:
Eve; „I think it does sometimes, but you have got to stay, I know it sounds awful, but you have got to stay realistic and remember that you can‟t do everything for everybody. You can do what you can do, like for that woman yes, I managed to help her, but some people, there are some things that you wouldn‟t be able to help, you know? Someone who has lost a loved one, yeah, you can listen and you can do everything you can, but you can‟t bring them back and it does get a bit emotional especially if it‟s a child or something‟
Eve is suggesting that there is only so much a nurse can do for patients, but
seems a little uneasy by saying, „I know it sounds awful‟. This seemed similar
to James‟s comment, „You are not necessarily a hard person‟ as if both
students were trying to justify their comments about only being able to do so
much. I thought it a little sad that she seemed not to value the skill of
listening to someone when they had lost a loved one, as if anything less than
being able to „bring them back‟ was insufficient. She admits that it does „get a
bit emotional‟ but this is as far as she will go. She then began to discuss her
work on an Accident and Emergency placement, in what seemed like very
matter of fact terms:
„.....plus when I think of mental health issues and stuff like that are increasing as well, because people are not listening to people, so they are having to go to the extreme of taking the overdose, self-harming, throwing themselves off a bridge; they are going to that extreme because nobody is listening to them and recognising this patient is, like, cutting their arm or whatever, they have had this a few times. Now surely there is something going on here, when it is continuous, and it doesn‟t look like it‟s been done by accident. If we can get to the bottom of that, then maybe we can stop or prevent anything worse‟
288
In her previous excerpt Eve seemed to suggest that listening was not enough
when someone has died, although here she is blaming lack of listening for
patients self-harming or making suicide attempts. What struck me was the
matter of fact way in which Eve discussed the issues and, on face value, it
did not seem like she was affected by things that she had seen. In fact, it
seemed that she coped by dealing with issues in this way, almost a „taking it
in my stride‟ way of being. This is interesting as she had told me that her
motivation for starting her nurse education had been the way in which the
nurses in the Accident and Emergency Department, although not midwives,
had dealt with her giving birth. They too must have „taken it in their stride‟
and maybe Eve had recognised herself in these nurses.
The nearest she got to discussing emotional support for herself was in the
following excerpts, when she discussed the value of having someone similar
to yourself in the clinical area. She described coping as being easier if she
can find someone to „click with‟:
Eve: „Usually there doesn‟t have to be a mentor, there is usually someone who is close enough to yourself in personality that you think (pause) or the fact that when you have asked them for help they have, say just washing a patient or help getting a patient onto a commode, and they will be the only person that said, “Yeah”, and come straight away, rather than, “I will be there in a minute”, and you think, right from that moment on, you start clicking with that person, more „cause they‟ve been helpful and they don‟t see you as someone, like, in the way‟
Me; „So they help you then work in the way you want to work?‟
Eve; „Yeah. So when something happens and you‟re not too sure they, it might be a HCA, or it might be someone that you need help with a problem with, and they will say, “Well you could have done this, or that”
289
As with Laura earlier, being taken seriously as a student is very important
and in this case, helps Eve to cope with problems encountered. This doesn‟t
even need to be a trained member of staff or a mentor, but needs to be a
person „close enough to yourself in personality‟ or one who‟s „been helpful
and they don‟t see you as someone like, in the way‟. In contrast to Laura,
rather than get upset and frustrated when things did not go her way, Eve
seemed determined to learn from what she encountered, even from „bad
things‟:
Eve; „Yeah, but from all the bad things it teaches you about the type of person you wanna be „cause you think, “Hang on a minute, that‟s not right, I won‟t work like that”, but then you‟ll see something really good and you think, “Yeah that‟s the type of nurse I want to be‟
This excerpt underlines the value of positive role models and a vision of how
nursing could be for the student when they qualify. Indeed, it is important that
students have good role models to emphasise effective practice (Watson &
Harris, 2000). However, it seemed that Eve perceived that she had more
contact with negative role models and a lot of the interview centred on her
criticising other members of staff. At the time of transcribing, I felt frustrated
by this, as I did not feel that it was useful data and I wondered how I could
include it in the analysis. However, now I view this data differently and
wonder whether complaining about others was Eve‟s way of coping with
emotions such as anger and frustration. In a way, I felt she was ventilating to
me and perhaps I was the first person she had been able to do this with. She
was not able to identify the emotions she felt and spoke only in general terms
but it began to seem clear that there was a lot of pent up emotion there, she
290
just did not seem able to identify it. She began by discussing a placement
where she felt there had been a clash of personalities:
„...it was just a clash of personalities... If you were a student you couldn‟t possibly think for yourself! You took the BP cuff off that patient and you should have left it on, and then I would speak to another staff nurse and ask, “Can I take it off?”, and she would be like; “What are you asking me that for?” And the one that was awful was my mentor, and it just made the placement a nightmare and I think it was just a total clash of personalities‟
Eve did not discuss how she dealt with the personality clash, stating that the
event with the BP cuff „just makes you look stupid in front of patients‟. She
became animated and showed obvious frustration when describing how an
older patient was being treated like a child:
Eve: It‟s dreadful. (pause) I hate it. I can‟t stand it. I mean, we had one lady who used to keep getting out of bed and she could fall, she could break something else, but they were like, it was like she was being treated like a little school kid and she was in her eighties. I mean she did have dementia, but it got worse as she was on the ward, and the longer she stayed in the ward, the worse she got, and she was treated like a little child. I mean she was getting told off, so was it any wonder she has gone back to her childhood, „cause everyone‟s telling her off, or was it because, that‟s just part of the dementia? I mean, they take the buzzer off them and they have no way of getting out of the bed and I think; how do you know if they want something?
Even though I explicitly asked her how she felt about what had happened,
she seemed to evade the question and talk about what she did rather than
how she felt:
Me: „And how does that feel?‟
Eve: „I just go in (to the side room) Well, it‟s back to the uncaring thing, sat at the nurse‟s station and just handing out the pills, isn‟t it?‟
291
Eve was scathing and gave many examples of the sort of nurse who is „sat at
the nurse‟s station‟. She is unable to understand why they are coming to
work:
Eve: „At the end of the day, if you are not there to help them, what‟s the point in coming into work? You might as well have stayed at home. It can be manically busy but, I‟m sorry, they were still sat at the nurse‟s station. You get the feeling some of them just come in for the pay cheque. It was left to the HCA‟s and the students to go and see what the patients wanted. I never saw a qualified get up and answer a buzzer‟
The point of including Eve‟s comments in this section is to show that she
needed to vent her frustration and I suggest that this, for her, is a coping
mechanism. I am concerned by her comments for two reasons. The first
relates to the fact that she seems unable to identify how she feels and can
only talk in terms of others‟ poor practice. The second concern relates to the
allegations of poor practice which, as an NMC registrant I needed to follow
up, as with Fran and Jan earlier. However, this is not straightforward as I do
not, and will never know, whether or not Eve is embellishing her answers in
order to provide me with a „good story‟. I felt that I was providing her with a
sounding board, a way to offload how she felt by relating stories which were
critical of others. Another concern here is the fact that she does not suggest
that she was able to approach members of staff to voice her concerns. As
discussed already, this can be difficult for students to do, for fear of then
being victimised by the people responsible for signing their paperwork. It
shows lack of assertiveness skills, although this may be easy to explain in a
first year nurse. What is evident to me is that students like Eve need a place
or a method to vent their frustration and it is not clear that she has a means
292
to do this. I wondered whether the interview was giving her the opportunity
she needed. Eve never addresses her concerns by speaking to the staff
members involved or mentions to them the way she is feeling. It has been
observed that stressors identified in the workplace need to be addressed,
rather than concentrating on our own internal responses (Chang et al, 2007).
Responses such as trying to interpret events in a more positive way or trying
to persuade others to work in new ways, were shown by the authors to be
more beneficial. However, it cannot be assumed that nurses have these
abilities and formal professional development is recommended. Indeed, if
Eve had more constructive strategies available to her to deal with the
problematic issues she faces, she may feel calmer about these situations.
However, as already stated, it is difficult for students to question or try to
change the status quo, when they need to pass the placement and have
their paperwork signed at the end of it.
I will now return to Jenny for further views on emotional coping strategies.
Jenny
I am keen to bring Jenny‟s thoughts in here as, in contrast to the other
informants, Jenny seems to have found what I would consider to be a
constructive way to manage emotions. By this, I mean that Jenny seems to
be actively dealing with her emotions, rather than being acted upon by them.
She explicitly states that she tries to track back and think about what is
causing her to feel the way she does. This is in contrast to Steve, for
example, who copes with issues from the day by walking, but doesn‟t
293
explicitly state that he tries to understand where the emotions are coming
from:
Jenny: „Erm... if I have had a particularly draining day, I like to exercise physically, because I find it helps me put things in place. So, I will hit the gym or I will go out for a walk or I will take a run or something like that... erm... which is, and the other thing I like to do is to ask myself why am I feeling like this? And to try and feed back through the day and pinpoint areas where... erm... where my emotional state has come from, by analysing. That gives me an insight into how I am coping with the stress which is generated at work and maybe an insight into how I can cope better‟
Me: „Okay. So, how do you do that? Is that always easy to pinpoint?‟
Jenny: „It is for me, because I have spent most of my adult life doing it. It was something I was quite interested in from aged sixteen. Last ten years I have spent investigating how things make me feel emotionally... erm... and how I cope with them, what my maladaptive and adaptive coping mechanisms are‟
Me: „So do you want to tell me more about how you have been doing that, then?‟
Jenny: „Erm... it‟s a process of self-analysis really... erm... Also, if you can find other people who you really get on with or that you trust, you can talk with them about how you are handling things and about how they found... erm... how they found ways of coping with things and ways of how they have moved their maladaptive coping mechanisms into adaptive ones, I guess. Earlier on, I used to cope with stressful things by drinking quite a bit... erm... so you would find yourself upset after a hard day at work and you would go home and break out whatever - a can of beer or glass of wine - and you would start to relax yourself, because it‟s really easy to do and there‟s a culture of doing that... erm... So, over time, you come to realise that I am relying on this to relax me, maybe I should find a different way, take a hot bath or something, because linking my drinking with my emotions is not particularly great idea, is it? Let‟s be honest‟ (laughs)
Me: (laughs)
Jenny: „It‟s a case of stepping back from your emotions and saying „ah, I am angry‟, and being honest enough with yourself to say, „I am angry with that client‟, which might not be the most grown up of scenarios to be in, but that‟s acknowledged, that... that‟s why I am angry, because of that today... erm... maybe that shouldn‟t be bothering me, but it is‟
294
Jenny had taken an interest in self-analysis from the age of about sixteen.
Being able to rationalise and examine her emotions and question where they
come from, seems like second nature to her. She talks about maladaptive
coping strategies, such as linking alcohol with her emotions. She shows a
great deal of awareness by questioning this activity, and realising that this is
not healthy behaviour and needs to be changed. She describes the healthy
strategies she takes, such as going to the gym, running, walking or taking a
hot bath. In line with the other extracts from the data, Jenny is using coping
strategies that she has been using for a long time, brought with her from her
past. As before, they are not strategies that seem to have been learned at
university or in practice. Part of her own emotional nurse being incorporates
„investigating how things make me feel emotionally... erm... and how I cope
with them, what my maladaptive and adaptive coping mechanisms are‟. In
contrast to the other students, she views emotions as being something to be
examined, thought about and learned from. She stated in the interview that
she had studied psychology before entering her nurse education and I
wondered whether this could have something to do with her approach to self-
analysis. Although not seeking to make generalisations I considered the
excerpt from Fran, who also began her career in psychology, and I wondered
whether there were any similarities. However, this level of self-analysis was
not evident in Fran‟s case.
According to Jenny, the effects of emotional work in nursing can be
challenging and the nurse needs a high level of self-awareness in order to
cope with them. Unhealthy coping strategies may be adopted, for example,
using alcohol as a means of dealing with the effects of emotional work.
295
Jenny now chooses to use more healthy coping strategies, such as physical
exercise, and continually analyses how she is coping and monitors the
effects her emotions are having on her. This helps her work more effectively
with patients, as she is able to control her emotions when at work.
Looking back at other excerpts from Jenny, she would like the opportunity to
talk with other staff members at work, about the work she does. However, as
she suggests, this is not always seen as being an acceptable thing to do.
Emotional work could lead to the forging of social relationships in the
workplace but, in Jenny‟s experience, this is not always the case. Nursing
can be an emotionally „scary‟ experience. There is a need for nurses to
acknowledge their own emotions when at work; they can‟t be forgotten
about, and need to be managed effectively, so that our helping is supportive.
Concern arising from the data on coping
Having analysed the excerpts presented, I am left with three concerns.
Firstly, although each student has a different way to „cope‟, none of them
makes reference to any formal strategy which has been advised by the
university or by placement. The way in which coping occurs seems vague
and this is in line with previous work; see for example Mackintosh (2006).
Having said that, each individual in life copes in a different way and, as
humans, we do not all deal with stress in the same manner. The students
bring with them strategies learned or developed from past experience. This is
not necessarily problematic, although does seem ad hoc in nature. If there is
any preparation by the university for the emotional nature of nursing it goes
unmentioned in the stories these students had to tell. Of course, this doesn‟t
296
mean there isn‟t such provision, but it seems that any message which may
have been given hasn‟t been getting through. I suggest that this is
problematic as I believe that we do have an obligation to support nursing
students in this way.
Secondly, the emotional issues raised have clearly taken their toll in terms of
Anne, for example, who was thinking of giving up the course; Jan, who
actually did leave; and Emily, who describes how the issues can have an
effect on her later. Emotional nurse being can be challenging, and there
seems to be confusion amongst the informants as to how to cope effectively
and what it is actually acceptable to feel as a nursing student.
My third concern relates to the fact that none of the students interviewed
have described using the mentor or the personal tutor as a means of
support. The management of emotions in the longer term seems to be very
ad hoc from this perspective; Anne, sitting alone and thinking of leaving the
course; Fran, being frustrated and turning to her boyfriend; Emily, using
strategies from beauty therapy; Laura, turning to family members who
happen to be in the same profession, for example. These ways of coping
seem too haphazard, with not one student identifying formal systems of
mentor or tutor support offered by the university or placement areas. The
„formal and systematic training to manage feelings,‟ which was a need
identified by Smith (1992: 139) still does not seem to be in evidence.
Moreover, the „teaching‟ of feeling management and coping strategies is in
itself problematic since, as has been shown through the data, students have
individual ways of coping that they carry with them and, in addition, the
297
coping strategies passed down by teaching staff will vary. Each of us as
lecturers has learned a different way of coping, passed down by other nurses
throughout our education, combined with our own learned or innate ability to
deal with things. It is the passing on of coping strategies which in itself could
be damaging, particularly if it does not „fit‟ with our own way of doing things.
We can begin to feel like failures and think that we are not „doing it right,‟ if
we naturally want to cope in other ways. I suggest that we need to facilitate
exploration, rather than teaching „ways to do it‟. The student can then be
supported and guided as they explore ways of coping and, in this way, the
student has a sense of ownership over their own emotional being and feels
more powerful and in control of their destiny. This is not to say that, as
educators, we do not assist in any way and indeed, the educator has the
potential for growth and exploration during the process as well as the
student. To explicate this way of thinking further, I will return to Heideggerian
thinking, beginning with his thoughts on understanding.
Understanding
Heidegger describes how human beings make sense of the world in terms of
„existentials‟ (Heidegger, 1926/1962). Existentials can be described as a
„meaning pattern that binds human being and the being of the world together‟
(Svenaeus, 2000: 86). These patterns assist us in making sense of our world
and the first is „understanding‟ (Svenaeus, 2000).
In describing understanding Heidegger (1926/1962: 185) states:
„Understanding is the existential Being of Dasein‟s own potentiality-for-Being; and it is so in such a way that this Being discloses in itself what its Being is capable of‟
298
Understanding manifests itself in terms of future possibilities and it does this
through „projection‟ (Heidegger, 1926/1962: 185). Projection, in this sense,
isn‟t towards an arranged plan or to something that has been considered. It
is more in the sense of being „thrown‟ into new possibilities. The students in
this study describe future possibilities of being able to manage their emotions
effectively so they are not seen as unprofessional or weak, although they are
uncertain how and when this will take place. They understand themselves in
terms of what they have failed to be in the past when they, for example, have
let their emotions show too much. Each student arrives as a product of their
emotional experience in the world already. However, on commencing nursing
education they feel that their emotional being needs to change and, through
understanding, they „press forward into possibilities‟ (Heidegger, 1926/1962:
184). What are revealed are new emotional possibilities for being. This is
problematic as, although the students feel the need for emotional change,
they do not suggest a robust way for this to happen. Heidegger (1926/1962:
185) states:
„Projecting has nothing to do with comporting oneself towards a plan that has been thought out, and in accordance with which Dasein arranges its Being‟
The students in this study feel unsure about how they will ever get used to
the emotional nature of nursing and how they can separate their emotions at
placement and their emotions at home. They do not have a strategy to deal
with this, but know that they need to. They try to make sense of their
emotional lifeworld by talking with others, such as peers and family
299
members. Talking in this way is described by Heidegger (1926/1962) as
„discourse‟.
Discourse
Discourse is how we make sense of our world; when we talk with others, our
own existence is revealed to us. Heidegger (1926/1962: 204) states,
„[d]iscoursing or talking is the way in which we articulate „significantly‟ the
intelligibility of Being-in-the world‟. Discourse is the way in which we can
make our lives intelligible. The nurses in this study have a need for discourse
to make sense of emotional nurse being. Through discourse, feelings of calm
may arise and a way of „making sense‟ of events can be revealed. However,
it can be difficult to find others to share our discourse. The data has revealed
issues around confidentiality and the feeling among students that there is no
one there to talk with nor anyone who would understand. However, if we
cannot share discourse with others, we cannot make our lifeworld intelligible.
We need to be heard by others, as Heidegger (1926/1962:206) states,
„[h]earing is constitutive for discourse......hearing constitutes the primary and
authentic way in which Dasein is open for its ownmost potentiality-for-Being‟.
As much as we need to be heard, those who listen become open to their own
personal growth and development. Those who listen can contemplate their
own emotional being, and potential for growth, on both sides, is revealed.
However, the person hearing the talk needs to be receptive to growth. The
data shows that the students have been encouraged to leave emotion
behind when ending the shift. In this way, it could be argued that the listener,
in this case the mentor or staff nurse, tries to impose their own coping
mechanisms onto the student. This is understandable as a well-meaning
300
form of protection for both sides. However, concern shown in this way can
promote dependency and stop the student from developing their own coping
mechanisms. This type of concern is described by Heidegger (1926/1962) as
„leaping in‟ for the other person. By contrast, concern can be shown by
„leaping ahead‟. Concern shown in this way is more empowering to the other
person; rather than „leaping in‟ and taking over, concern facilitates growth in
the other. In the words of Heidegger (1926/1962: 158) this concern, „...helps
the Other to become transparent to himself in his care and to become free
for it‟.
So rather than „leaping in‟ and passing down our own coping strategies,
„leaping ahead‟ encourages the student to explore their own ways of being
and find healthy ways of coping of their own, supported by ourselves. By
facilitating emotional nurse being in a more empowering way, the student
nurse can find for themselves an emotional home or „dwelling‟ in which they
feel safe and in control. To explain this way of thinking further, I will now
introduce the final informant, Carol.
Earlier in this work, I expressed concern about sharing too much of myself
during the interviews. I wanted to maintain a professional distance between
myself and the students, some of whom I would teach in future classes.
However, as I carried out more and more interviews, I became much more
relaxed. I became much less concerned that I would not get enough data
and felt more comfortable in discussing stories from my own practice, if I felt
that they would help the student to make sense of their own emotional being.
It was as if I was trying to say, „Do not worry I have been through it too and I
know how it feels!‟ I felt that learning was taking place on both sides by this
301
time. I hoped that through talking with me, the students were learning about
how they felt, making sense of events and considering their own ways
through painful issues. I too was learning from the students and gauging my
way of being on how they were responding to me during the interview. I was
nearing the end of my interviews and one of my last informants was a first
year student called Carol. Carol was one of my purposive sample and
seemed shy and nervous during the interview. I was struggling to encourage
her to talk to me and decided to share a story from my own practice. She
listened intently and then proceeded to talk about an event from her own
practice. I felt that telling a story to her had acted as a catalyst for her to tell
her own. I was curious to know whether she had found my storytelling useful.
In my mind was Heidegger‟s thinking on discourse and how we can use this
to make sense of events. I also considered the „leaping ahead‟ style of
concern, discussed earlier. This sort of concern helps the student to explore
and express for themselves, their own ways of being. This is in contrast to
me trying to extract information through questioning. Indeed, I suggest that I
was being metaphorically „silent‟ as, this time, I was not purposefully trying to
get information from Carol or questioning her explicitly. Heidegger
(1926/1962: 208) states the following:
„Keeping silent is another essential possibility of discourse....In talking with one another, the person who keeps silent can „make one understand‟ (that is, he can develop an understanding), and he can do so more authentically than the person who is never short of words. Speaking at length about something does not offer the slightest guarantee that thereby understanding is advanced‟
302
By „keeping silent‟ I encouraged Carol to share her feelings and I was
surprised by the depth of her answer. Not only did she talk about story-
sharing on a one to one level, but also on a class-based level:
Me: „Was it useful for me to share my story?‟
Carol: „When you are a first year, like you said, anything can knock you down and I am one of them. I am not confident. If someone does say something, my ego just plummets. When something goes wrong I think, “I want to leave now!” So if someone else has gone through it, then it feels better to know you are not alone. Like even the good stories, the funny ones, it makes you feel like (pause) there‟s hope! So it is useful. If you didn‟t share stories, no one would learn, would they? I mean, some people in the class say, “Oh it wastes too much time”, but these people (teaching staff) have been there, and, you know, you should listen to them and if they have the knowledge, you are gonna need it, so listen to it, and that‟s what a lot of my class mates don‟t understand, I don‟t think‟
By telling my story, rather than intentionally trying to encourage Carol to
speak, Carol had opened up and shared how she had been feeling; „anything
can knock you down‟; „I am one of them, I am not confident‟; „if someone
does say something my ego just plummets‟; „when something goes wrong I
think, “I want to leave now!”‟ Sharing my own emotional being had
encouraged her to do the same and I began to regret not sharing more of
myself, through my own practice stories, in the earlier interviews. I wondered
whether this could have acted as a catalyst for other informants to share
more of themselves, as it may have seemed more acceptable, if I had done
it, too. Her words reinforced the loneliness that I had felt as a student nurse
and was in agreement with my pre understanding that emotional work is hard
and this is not always recognised by others. Her comment; „it feels better to
know you are not alone‟, confirmed my belief that sharing thoughts and
303
feelings about practice is a very powerful tool for uncovering emotional nurse
being and ways to achieve this will be pursued in the final chapter of this
work.
304
Chapter Nine
Implications
Introduction
This chapter will begin by discussing how the concept of emotional nurse
being adds to the existing body of knowledge on emotion work in pre
registration nursing practice. The next section will include a discussion of the
implications of how Heideggerian thinking has influenced this thesis, and
what Heidegger has added to the analysis. There will then follow a
discussion of the Heideggerian concept of Dasein or „being in the world,‟ in
relation to the findings. This helps to situate the discussion of the
implications, as it provides a summary of the phenomenon of emotional
nurse being as found through co-constitution of the data. I will then offer
practical suggestions about how we, as nurse lecturers, can help students to
find their own authentic emotional nurse being. Finally, I will summarise the
current impact this work has had already, on a local, national and
international level.
How this work enhances the existing body of knowledge
It has become clear through the work that the emotional nature of nursing
work remains an important issue, and it is a subject that continues to be
worthy of discussion. It was found to be relevant to the students interviewed
in terms of the effect on themselves, the patients they care for and their
family and peer groups. Formal support mechanisms, such as the personal
tutor role, are not identified as being utilised by the students interviewed.
Students rely mainly on partners, family, friends and other nursing students
305
to support them in this aspect of practice. These findings are in contrast to
earlier work, for example Smith (1992), suggested that nursing students
found most emotional support from the ward manager. Later work found that
lecturing staff took on more of a supportive role in this aspect of practice
(Smith & Gray, 2001). Neither of these avenues of support was being used
by the students in this study.
The use of Heideggerian thinking has enabled exploration of a new term,
„emotional nurse being‟. As we are products of our experiences and we each
bring different ways of being into our lifeworld, this term is multifaceted and
highlights the individual nature of the nursing student. Mackintosh (2006:
960) stated that, „socialisation into nursing may be more complex than early
studies indicate, and subject to much greater degrees of individual variability
than previously identified‟. In this work, the individual variability has been
explored and revealed in greater detail. Through the data, the complexity of
this process has been shown to be related to past ways of coping brought to
the current situation, personal vulnerability, and external support from others.
One of the main reasons for this complex process is that each student is
unique. Each student will bring personal experiences from their past, prior to
the commencement of their nursing education. These will differ from student
to student, and the way in which each student identifies and manages the
emotions related to the past experience will have an effect on the present
way of coping. This relates to the Heideggerian concept of historicality; each
student will bring a unique set of experiences and past ways of being with
them, into their education. Therefore each individual will experience a
different way of being during their nursing education
306
Emotional Nurse Being
There are three ideas which constitute emotional nurse being and these
have been revealed through the data. As mentioned above, there is the need
for the student nurse to identify and use inner resources, for example, their
past ways of coping. Past ways of coping can be used to inform future ways
of emotional nurse being. The past should not be routinely discarded, but
used as a base on which to grow. Secondly there is the need to consider that
students are vulnerable, but that this state can be viewed in a more positive
way. Vulnerability can be viewed as a place for empowerment and strength
to be developed. Thirdly, the amount of external support given to the student
needs to be considered. As stated, this may come from different sources
than previously thought and indeed, use of social networking sites may have
a place in the current time (although this was not explicitly mentioned in my
data). Taken together, these ideas assist the educator in entering the
lifeworld of the student to truly understand the intricacies of their unique
emotional nurse being. Emotional nurse being will be explicated in more
detail later in this chapter.
Freshwater and Stickley (2004) suggest a more transformatory approach to
nurse education. My work enhances the existing body of knowledge of
transformatory approaches to education, by sharing my experiences of using
collage and story-sharing. Through the creation of a serene space, we can
share our own stories, so that a safe clearing for the student is found; they
are safe in the knowledge that we as educators have lived a similar
experience to them. Through the data it was shown that listening to the
lecturer telling stories from their own practice can be important to some
307
students. Students need to talk about their feelings and the feeling of being
„allowed‟ to talk is important to them. Through releasement, „permission‟ is
given to talk and both parties have the opportunity to grow and learn. In this
way, they may accept who they are, and their own emotional nurse being is
revealed.
I also suggest that, although this work has been developed with nursing
students, it may have relevance in other contexts. I understand that pre
registration nursing students may have different emotional needs compared
to post registration colleagues. However, I can envisage similar emotional
challenges occurring after qualification and I suggest that my work has
relevance here. Indeed, my work concurs with previous studies which
suggests that socialisation into nursing has been shown to have a negative
effect on emotions amongst student nurses (Menzies, 1950, Smith, 1992,
Mackintosh, 2006). If this effect continues post qualification then my work
could have relevance and application in a post registration context.
From a research perspective, I suggest that this work adds some valuable
thinking. Having reviewed many pieces of work claiming to use a
Heideggerian approach, co-constitution of the data is absent. I suggested
examples earlier, such as Nelms (1996) who invites informants to tell their
stories of living a caring presence. What is missing is Nelms‟s own story so
the data is not fully co-constituted. Another example is a piece by Idczak
(2007) which claims to be grounded in Heideggerian hermeneutics. Idczak
(2007) stated that she never considered what being a nurse had meant to
her. However, even after making this assertion, she omits to tell her own
story of nurse being within the piece. She uses reflective journals to
308
document the experiences of nursing students when dealing with patients.
However the analysis lacks any reference to Heideggerian thinking. Themes
around authenticity and remaining true to the self are evident in the work and
could be illuminated by reference to Heideggerian thought. However, they
remain absent. By not including her story the data is not co-constituted and it
is unclear how a different understanding of the ideas has been reached. In
fact, the work reads like a thematic analysis and I suggest is not a
Heideggerian hermeneutic piece at all. Unless we as qualitative researchers
leave ourselves in our research products, interpretive Heideggerian work will
remain stifled and its benefits not fully understood. In this kind of research,
failure to acknowledge that we understand differently because we have been
there ourselves, leaves half of the understanding absent. If work is claiming
to use Heideggerian hermeneutics as its approach, I suggest that, there
should be explicit reference to Heideggerian work throughout and reference
should be made to the historicality of the author and its bearing on the
interpretation. Apart from stating that she never considered what being a
nurse meant to her, we get no further insight into Idczak‟s (2007) line of
thinking. Therefore, we do not know how she reached her interpretation and
the work is not fully co-constituted. Throughout my own study, I have
acknowledged myself and my past experiences in a very explicit way. This
research goes further than previous work in terms of its honesty and its
commitment to co-constitution of the data. It also shows commitment to the
work of Heidegger, which I suggest is missing from a lot of works claiming to
be Heideggerian in nature. This omission is problematic, as I maintain that
Heidegger can enrich nursing research, by giving insight into the meaning of
309
being. If nurse researchers take the time to read his work, Heidegger can
provide much insight into the challenges faced by nurses in their inter- and
intra-personal work.
I recognise that a potential problem with this approach surrounds the idea of
„thesis as therapy‟. In a recent informal discussion with a more quantitatively
focussed colleague, it was suggested to me that co-constitution of the data is
a way of therapy for the researcher, in that they are being afforded the
opportunity to work through past issues by exploring them on the page.
Indeed, throughout this work, reflecting on my past experiences has had
therapeutic value to me and I regard this as a positive side effect. If through
this work, my emotional self-awareness has grown, and a more meaningful
piece of work has been written, then I suggest that is not a negative thing.
The problem arises when the voice of the researcher drowns out those of the
informants. The researcher‟s reflections are crucial to co-constitution of the
data. However, if the researcher becomes the centre of the narrative then
criticism of this approach is warranted. I make no attempt to hide my
experiences; on the contrary, I suggest that they be valued. Etherington
(2004) kept her own voice out of her PhD thesis and saved her reflexive
writing for later. I have gone a stage further by keeping my voice in this work
and I suggest that this shows my commitment to the approach.
The nature of interpretation
Earlier I suggested that research reflects the time it was written. This takes
on more meaning in interpretive studies, as it is acknowledged that the work
is influenced by the current state of mind of the researcher, and also their
310
historicality and thinking at different times. I accept that I could revisit this
data in ten years time, and think differently about it. In addition, the reader
may already have a different interpretation of the data that I have laid out in
front of them. What I have aimed to do, is to present the influences on myself
which have in turn, influenced the data. In this way, I hope that the credibility
of the study has been maintained. I accept that the recollections of my
stories could indeed be elaborated, based on the influences on me at that
time and in the present. How true they are may not be so important. What
seems more important is the influence they have on the researcher, which
could lead to different interpretations of the data in the present. It is certainly
possible that I have imagined and developed the stories, unconsciously over
time. It is the feeling they generate which is critical to the development of
work using this approach.
Interpretive work is fluid and flexible, and in one sense, never-ending as the
interpretations continue to develop. That is not to say that we dismiss
completely one interpretation, and substitute it for the next. Each exists as a
building block, on the „way‟ to understanding; it could be viewed as a process
without end. Heidegger (1966: 21) summarises what I mean here well:
„I have forsaken an earlier position, not to exchange it for another, but because even the former position was only a pause on the way. What lasts in thinking is the way‟ (my italics)
Having explained how this work enhances and adds to the existing body of
knowledge from both a theoretical and research perspective, I will now
continue by explaining the new concept of emotional nurse being in more
311
detail. This will begin with a discussion of the Heideggerian concept of
Dasein.
Dasein
Previously, I have used the term „emotional nurse being‟, which has its
origins in Heidegger‟s concept of Dasein which is the way in which we „are‟ in
the world. This takes into account that the world and person are inextricably
linked, rather than existing as two separate entities, and also the fact that we
are a product of our past ways of being. In line with my chosen approach, it
was never my intention to define absolutely the phenomenon of emotional
nurse being. This way of being as explored through the data has been
revealed as a multi-faceted phenomenon. However, the constituent parts, as
uncovered through the data, are useful in assisting us as nurse educators in
planning a way forward, and this will be pursued later in this chapter.
I think that it is worthwhile returning to the term Dasein as it was very
important for Heidegger and he used it as his starting point for exploring the
meaning of being. Dasein is the way he used to describe the person in the
world, to explain the fact that people and world are united. Dasein in this way
unites the world and objects in it, rather than objects being viewed as a
group of different entities, as was the view of philosophers such as
Descartes and Husserl, who adhered to the notion of subject/object duality.
The difference in thinking has been explored earlier in this work. As
Heidegger (1926/1962: 330) goes on to state:
„Dasein always understands itself in terms of its existence – in terms of a possibility of itself: to be itself or not itself. Dasein has either
312
chosen these possibilities itself, or got itself into them, or grown up in them already‟
By this, Heidegger is not suggesting that we can decide whether or not to
actually be. For example, we have no control over whether we are born or
die. What he is suggesting is that we have a choice of how to be and we can
choose out of many ways of being (Inwood, 1997). However, what I suggest
he is also saying is that we can „get ourselves‟ into certain ways of being; this
could imply that we have no control over our situation and just slip into ways
of life. Alternatively, it could mean that we deliberately choose to get
ourselves into ways of being if we want to.
What he also suggests is that we may have „grown up in them already‟. We
have no control over how we are brought up or the ways of being which we
witness through our childhood and as we grow into ourselves. Heidegger
(1926/1962: 33) goes on to suggest, „[o]nly the particular Dasein decides its
existence, whether it does so by taking hold or neglecting‟
Thinking about Dasein on an emotional level: in some cases the students
interviewed, in effect, ask the question of whether or not they can follow their
own authentic path or follow the path of the „they‟. Other nurses it would
seem „get themselves‟ into other ways of being which may not necessarily
reflect their true and authentic Dasein, which seems hidden. At times it
seemed that students were not giving their real self much thought, to the
extent that this aspect of their being was being unconsciously sacrificed.
They seemed to go along with the flow and accept events as they were
unfolding. Many students suggested that they had indeed grown up in ways
313
of being and this influenced their emotional Dasein at this time. This did not
necessarily need to be a family upbringing, but could relate to previous
occupations where emotional being was worked out for them and passed on
to them, for example, Emily‟s beauty therapy experiences. As they entered
the nursing world, they experienced further ways of emotional „daseining‟,
(Heidegger uses dasein as a verb as well as a noun) which they were
explicitly or covertly encouraged to adopt. Some students „took hold‟ of the
possibilities for emotional Dasein, whereas others let possibilities slip away
and compromised or neglected their authentic ways of being. This is not a
value judgement of them, in terms of right and wrong. Indeed, doing
emotional Dasein as others do, ensures that the student fits in and perhaps
does not have the same struggle as students who „took hold‟. I am thinking
most notably of Jan, who „took hold‟ of her own emotional Dasein,
challenged the Health Care Assistant and has since left the programme.
What is also evident in this discussion, although not yet explicitly discussed,
is the importance of time. Clearly the issue of time was very important to
Heidegger; his great work was called Being and Time (1926/1962) and very
early on in the work he suggests the following:
„….our treatment of the question of the meaning of Being must enable us to show that the central problematic of all ontology is rooted in the phenomenon of time…‟ (p40)
Therefore, our understanding of the meaning of emotional Dasein is temporal
in nature. This is no surprise given the fact that Heidegger is described as an
existentialist philosopher and with that comes the idea that each one of us is
314
unique, life is context bound and we each have a different relationship to the
world. Heidegger (1926/1962) discusses three aspects of time in terms of our
past, present and future and we can live out the temporal nature of our lives
in authentic or inauthentic ways. Heidegger states that we are a product of
the three dimensions of time, all at the same time. We draw on our past
experiences, whilst projecting ourselves into the future possibilities, and at
the same time we are engrossed in the present. So for Heidegger, we are
never totally in the „here and now‟ of time as we may normally understand it,
and Dasein is always existing in these three dimensions of temporality. As
discussed earlier, Heidegger (1926/1962) states that most of our lives are
lived in inauthentic ways of being and this is not such a bad thing if we want
to fit in with the world and not be seen as too unusual and different. In terms
of temporality, Dostal (1993: 156) interprets what Heidegger means in the
following way:
„For the most part, according to Heidegger, Dasein is inauthentic and fallen, caught up and lost in the present in a way that cuts it off from its authentic future (its “ownmost possibility”) and its past‟
I suggest that this way of thinking has relevance when considering the
students‟ emotional Dasein. Andy was introduced earlier in the discussion of
the students‟ need to find dual emotional homes. I want to return to his
thinking here, as I suggest that he embodies Heideggerian thinking on the
present and future:
„…someone buzzes and you say “Yeah, yeah, I‟ll take you to the toilet” and you are rushing them to the toilet, and the next person wants something else, and their fluids have run out or you‟ve got to go to theatre and pick someone up and you are keen to get everything
315
done, but yeah, maybe if you had two patients you could do those things and sit with them and say, “How are you feeling? How‟s your pain been today? Was it worse in the morning?” But you don‟t. If they buzz with pain you give them painkillers and you just write „painkillers given‟ but if you had the time you could maybe sit down and talk about it and say “Where was your pain, is it worse at this time of the day, is it worse when you move?”, and then you could maybe get a result out of it, but because of the time you can‟t really do that‟
Andy is „lost in the present‟ in this excerpt and cannot see a way that he can
work in another way. His words show resignation to this way of being and
this is due to the amount of patients he has to care for and the lack of time.
What is interesting for a student is that he does not seem to question why
this is the case. He seems to have no drive to change his situation and,
because of this, he is cut off from his future possibilities to change things. Of
course, it could be argued that he is waiting until he is qualified before he
attempts to challenge, but for now he seems resigned to his lot. His past way
of being may have been influenced by his parents, both of whom are nurses,
who may also have influenced his ways of being in the present. He may have
„grown up‟ in these ways of thinking and therefore this may influence his way
of being in the present; this may actually be his authentic way of being.
However, he does offer another way of being in this excerpt, an alternative
way of nursing which he seems to prefer. Because of this, I interpret Andy as
having „fallen‟ from his authentic way of being into accepting the status quo
without much question. Heidegger (1926/1962) suggests that the reason
why Dasein „falls‟ and loses sight of itself is because, in part, it is so
engrossed in the world. Andy and the other students are all engrossed in the
desire to become qualified nurses and, because of this, they lose sight of
316
who they were previously and their usual emotional Dasein is then
compromised. Heidegger (1926/1962: 42) suggests:
„...Dasein simultaneously falls prey to the tradition of which it has more or less explicitly taken hold. This tradition keeps it from providing its own guidance, whether in inquiring or choosing‟
In this way, the students attach themselves to the tradition which is
prevalent, to the extent that they are unable to guide themselves through the
process. Of course, the difficulties that nursing students face when trying to
remain true to their own ways of being must not be underestimated. Talking
from a mental health perspective, Carlsson et al (2006) suggest that care is
still grounded in the biomedical approach and remaining true to our own
„style‟ can be demanding. However, as Carlsson et al (2006: 301) state,
„...supervision according to caring science principles would support carers to
use their own „style‟ better‟. We need to begin by acknowledging that our
own emotional Dasein plays a part in the care we offer, rather than trying to
deny it and this is a state that could be encouraged by educators.
Not all of the students „fall prey‟ to tradition; some do question why things
happen in a certain way. A coping mechanism for them can be to fall back on
previous ways of emotional being, to help them to move forward in the
present and future. Jenny relies heavily on previous strategies, such as self-
analysis, to help her to cope with her current emotional world. This reinforces
the importance of what has already been; past ways of coping are brought
into a present where the students may feel lost.
317
As with authenticity, falling into traditions lain down by others is not
necessarily wrong and in the nursing world it is inevitable that we emotionally
Dasein in this way, in order to fit in and cope with our lives. However,
Heidegger states that this way of being can be problematic, as we start to
behave as everyone else does, think how everyone else does and transform
into the state of „tranquilised familiarity,‟ as discussed earlier.
It could be suggested that a way of emotional nurse being, although maybe
not the easiest way, is to think for ourselves, choose our own paths, so that
we are not compromised and find the joy that can be experienced through
authenticity (Heidegger, 1926/1962). As I have already discussed in this
work, this way of emotional Dasein is one which could set us apart as a
unique profession; one which values emotion and connection with others,
rather than feeling embarrassed by it. This way of being, encourages us to
think creatively, rather than going along with the Dasein of others. This was
evidenced most notably by Jenny, Fran and Jan, who to varying degrees
were attempting to think creatively about how they were going to remain true
to their authentic emotional selves. As with many terms used by Heidegger,
„thinking‟ in this sense does not refer to the actual act of thinking but thinking
in the Heideggerian sense of „a way of being‟. I suggest that Gray (2004) in
his translation of Heidegger‟s set of lectures, “What is Called Thinking”
(Heidegger, 1954), puts it well:
„Thinking…..is a remembering who we are as human beings and where we belong. It is a gathering and focusing of our whole selves on what lies before us and a taking to heart and mind these particular things in order to discover in them their essential nature and truth‟
318
When we think in this way, we return to our authentic way of being and
return to who we really are. It is taking into account the temporal nature of
Dasein, in that we can then focus on our future and take advantage of the
possibilities that lie before us. Fran embodied this way of emotional Dasein
when she said, „that‟s just not me‟. At this point, she was thinking in the
Heideggerian sense of the word, and through this, she returned to her
authentic being. Jan also embodied this way of daseining and because of
this, left the programme. What lay before Jan was not something she
wanted to stay part of, leading her to move on. Jan was very angry and
anxious about what she had seen during her practice placement and it is
interesting to note that anger, uncertainty and anxiety have been described
as some of the psychological effects of vulnerability (Rogers, 1997).
A way of understanding emotional nurse being
Having explored the term emotional nurse being in relation to Heidegger‟s
concept of Dasein, I will now go on to discuss how the findings from the data
have influenced my way of thinking in this area. This begins with the concept
of vulnerability. Through the data it seems clear that feelings of vulnerability,
alongside access to external support and inner resources, greatly influence
emotional nurse being. This is important, as it provides educators with a way
to arrive at a different understanding of the emotional nurse being of
students.
Vulnerability
Daniel (1998) describes a piece of work by the writer Vaclav Havel, who at
the time was a novelist, sent to prison in 1979 for being involved in the
319
Czechoslovakian human rights movement. The text consists of a series of
letters Havel wrote to his wife Olga whilst he was being detained. Some of
the letters are quite moving and written in Heideggerian style. Indeed, in the
introduction to „Letters to Olga‟, reference is made to the debt to Martin
Heidegger owed by Havel based on the language used. On May 29th 1982
Havel was watching a weather report in which the sound cut out, leaving the
presenter helpless and close to tears. He describes feeling a sense of
responsibility for the female presenter stating that it was „an incisive
representation of human vulnerability‟ (Havel, 1983: 323). He suggests that
it is only when we see vulnerability in others that we recognise it in ourselves
and through this state we can recognise our own authenticity (Havel, 1983).
He states the following (Havel, 1983: 324):
„The vulnerability of another person…touches us not only because in it we recognise our own vulnerability, but for reasons infinitely more profound: precisely because we perceive it as such, the “voice of Being” reaches us more powerfully from vulnerability than from anything else: its presence in our longing for Being and in our desire to return to it has suddenly, in a sense, encountered itself as revealed in the vulnerability of another‟
I interpret this as meaning that it is through vulnerability that we can discover
our own our emotional Dasein. However, I suggest that it, like many
Heideggerian ideas, is twofold. It is not only when we recognise it in others
that we see it in ourselves, but also when we discover it in ourselves that we
are more able to see it in others. My thinking is influenced by the data in that
both Fran and Jan felt palpable vulnerability and both of them were then able
to recognise the state in the other person. In contrast, James seemed
numbed to the pain of another, using his distraction technique rather than
320
allowing himself to feel vulnerable and thus recognise vulnerability in
another. I suggest that we as educators have a role to play here, both in the
clinical and university setting. By acknowledging our own vulnerability, we
are then more able to recognise it in the student and perhaps also make it
easier for the student to recognise, acknowledge and share their vulnerability
with us. For example, throughout this work I have acknowledged times when
I felt vulnerable. This in turn, helped me to recognise this state in the
informants. Rather than try to lessen the vulnerability in both ourselves and
the student, I suggest that we acknowledge it and support students through
it. In turn, we as educators can learn from them promoting a two way model
of learning. As Havel (1983) suggests, through doing this, we can reveal our
own authentic being.
Returning to the importance of time in this discussion, it may only be later,
post qualification that we are able to face our vulnerability, as we may be
stronger and more able to cope with the truth at this stage. For example,
through my stories and reflections I am able to recognise my own
vulnerability, a state that I tried to keep hidden when I was a student.
Through this work, I am able to face who I was at that time and the fact that I
felt I had to change my authentic being, just like many of the informants in
this work. However, I suggest that this process is happening far too late.
Rather than encourage nursing students to „be someone else‟ by subscribing
to our ways of being, it seems more sensible to support students in finding
their own personal resources, letting them be who they truly are and
encouraging them to stay true to their own authentic being. For example,
321
Fran was trying to remain true to her authentic self and this could be
encouraged by educators, rather than stifled.
Feeling vulnerable has been associated with feeling under threat and being
in danger of being hurt, either physically or emotionally (Demi & Warren,
1995). In agreement with Spiers (2000) I suggest that vulnerability is usually
presented in the literature as a state of risk when one is open to harm and
danger. What is not so adequately explored is the state of vulnerability as a
positive concept; as a means of growth and empowerment. When our
integrity is challenged in some way, we feel vulnerable although in some
circumstances we can respond in a constructive way and through this,
personal growth may be achieved. Of course, when we are unsupported
during a challenge to our emotional being, we may then feel wounded and
withdraw further into our own world. Alternatively, when challenge prompts
us into action, we can feel more powerful as we see the opportunity for
change (Spiers, 2000). This arises from a vulnerable state, although it is
how we perceive our own vulnerability which decides how we will respond.
This could include how effective we believe our own personal resources are
and also how much support we perceive we can draw on in our external
world, i.e. help from others such as a mentor, personal tutor or friend. Rogers
(1997) presents a model which takes environmental and personal resources
into account when trying to describe a person‟s degree of vulnerability. This
is useful to „measure‟ how vulnerable a person may be. For example, I
suggest that Jenny felt a certain degree of vulnerability; she had some
personal resources to draw on, but little in the way of external support, in that
her colleagues frowned upon talking about feelings. I suggest that Anne had
322
little in the way of personal resources, as she describes going back to her
room crying and berating herself. In addition, she was not able to share her
story with other colleagues as she was sent home, so was unable to talk
about how she felt, and therefore missed out on being nurtured; an important
state for student nurses, described by Jackson et al (2007). Therefore, it
could be suggested that Anne felt more vulnerable than Jenny, as she had
less in the way of both external and internal resources to draw on. Although
Rogers‟s model is useful for exploring the degree of vulnerability
experienced, I suggest that the concept could be explored in a more dynamic
way. This involves the potential for growth and also the recognition of
vulnerability in others, which may be achieved if vulnerability is embraced in
ourselves, rather than viewing it as something wounding or harmful. Each
student nurse showed their vulnerability to a different degree; each had
different amounts of their own personal resources to fall back on and each
had a different type or amount of external support they could access. This
meant that emotional nurse being was different for each student.
Drawing on personal resources
We draw on our personal internal resources in different ways. We can
access resources from our past, such as, coping strategies which may have
worked for us previously. For example, Jenny used ways of self analysis that
she had practiced during her past to help her in the process of dealing with
her present state. However, we may lack, or have very few, personal
resources to draw. Some students needed to be nurtured and developed in
the present time. Nurturing could come from positive role models, for
example. Anne seemed to be unable to find any personal resources within
323
her to help her cope with the death and subsequent experience she lived
through on her placement. Therefore, support from others may be needed to
bolster and develop her personal resources. It has been shown that sending
students away, to have a cup of tea, or sending them home, prohibits them
from talking about their feelings with others actually involved in the same
situation. Support from others, when it occurs, tends to focus on the
procedural elements, rather than on how the student actually feels (Loftus,
1998). My data showed that the students perceived lack of time as being a
major obstacle to them sharing feelings and talking situations through.
Friends, peers and relatives seemed to provide the most emotional support,
sometimes quite some time after the event. I suggest that in time, the
students would develop their „store‟ of inner resources and less external
support may be needed from others. It is the recognition of what is needed
personally which is important here and the ability to recognise that grief
following a death will pass in time and may be short lived. Anne for example,
did not seem able to recognise this.
The process is fraught with difficulty as, alongside dealing with present
feelings, there is a need to protect ourselves from the future, in terms of
mapping out how we will cope with future challenges to our emotional being.
For students, there is also the added pressure of needing to be a success
and pass the course. It is at this point that we may be inclined to detach,
shielding ourselves from harm to our emotional being, rather than embracing
the vulnerability we feel and using it as a growth mechanism and a way of
embracing what it is to be human.
324
External Support
Through the data, it has been shown that being able to express feelings and
ways of being is important for the students in order to move on and grow
from challenges to their vulnerability. Some of the students interviewed
mention being „allowed‟ to talk about situations and that this process is
necessary for them to move on and carry on with their work. However, as
suggested earlier, the opportunities to talk tend to come less from clinical
staff and more from friends and relatives. This could promote feelings of
isolation in the student, in that they have to take their feelings away from the
staff involved in the clinical area and share them outside of work. I support
the suggestion from Loftus (1998) who states that the people most suitably
placed to support the student are those who were involved directly in the
situation. It could be argued that this is problematic, as the clinical staff
themselves may be feeling in need of support and, as suggested earlier,
having to cope with students‟ feelings as well as our own may be too much to
bear. Indeed, the feeling of being responsible for, but not being able to live
up to emotional demands, has been linked to burnout (Ekstedt & Fagerberg,
2005). Conversely, providing clinical staff are not expected to „know it all‟ and
accept that they too are in need of support, the experience could become
one of mutual growth, rather than a one way street which leaves the clinical
staff emotionally drained and feeling that they are not living up to
expectations.
Returning to Heidegger provides an interesting view on the student/teacher
relationship which could be useful here. Heidegger (1954/2004: 15) states
the following:
325
„Teaching is even more difficult than learning. We know that; but we rarely think about it. And why is teaching more difficult than learning? Not because the teacher must have a larger store of information, and have it always ready. Teaching is more difficult than learning because what teaching calls for is this: to let learn‟
Of course it could be argued that what Heidegger is suggesting here is
merely the contemporary view of teaching as we know it, even though this
was written in 1954. The days of treating students as if they are „empty
vessels‟, which we fill with knowledge, are over. Or are they? Through the
data I have shown that clinical staff members are inclined to offer „advice‟ to
students about how they can deal with their emotions; most notably in the
case of Anne, who was encouraged to leave her emotion „at the door‟. This
was advice that both herself and other informants rejected. Rather than
letting students learn their own ways of dealing with personal emotions, we
pass on our ways of coping. This approach may in fact be less healthy than
a transformatory approach, which could be more productive. This is a difficult
task. As caring human beings ourselves, we do not want to see nursing
students upset, and want to lessen their feelings of vulnerability in any way
we can. Watching others in a vulnerable state reminds us of our own
vulnerability and humanness. However, how much does this „attempt to
protect‟ help the student?
To summarise, what I am offering here is a way of considering and
understanding emotional nurse being. Feelings of vulnerability alongside
access to internal and external resources have been shown through the data
to influence emotional nurse being in each case. This way of thinking is
326
important as it can help us to support nursing students and help them retain
their own unique emotional Dasein.
However, offering a way of thinking is only half of the story. At the start of this
work I considered the writing of Menzies (1960) and Smith (1992) who both
wrote important works about emotion work. Both authors suggested that
more attention needs to be paid to the development of this aspect of
practice, with Smith (1992) calling for more formal ways of development. I
shall now continue by offering my own practical way in which we can support
nursing students in this process.
Supporting student nurses
In order for me to explore potential ways to support student nurses, I have to
consider the past. Heidegger (1926/1962) suggests we arrive at our current
understanding based on our historicality, in terms of that which has gone
before. As individuals this will mean that we each arrive at our current
situation in a slightly different way. We value and view ways of being
differently, as we have all arrived in the present via a different route of being
and experience. Rabinow and Sullivan (1987: 14) put it well when they state,
„Understanding is entirely mediated by the procedures that precede it and
accompany it‟. Our understanding of the here and now is mediated by the
procedures that precede it. What has gone on before helps us to understand
where to go next; it shapes our present and future understanding.
When contemplating a way forward, an idea emerged, based on my past
way of being. Thoughts from my childhood started to surface. As with some
of the stories from my nursing practice, these childhood memories returned
327
to me without being forced. I suggest that this process of recall is not
something that can be predicted and there should be no attempt made to try
to prise past thoughts from the unconscious into today‟s thinking as this
would seem more of a forced and artificial process. It is a process which
happens, thoughts occur naturally, at times simply as fragments of our past
life, visions of colour, sound, smell and texture, but they are thoughts all the
same.
Telling emotional stories
My current thinking comprised two elements. The first related to my
childhood and the second was linked to the recent past. I will explain both
elements of my historicality as these inform my way forward.
As a child one of my favourite games was „Fuzzy Felt‟. „Fuzzy Felt‟ was
introduced in the 1950s and is still available to buy today. Essentially it is a
game in which the user makes pictures using felt shapes which can be
attached to a rough fabric board. The shapes can be used to tell stories and
can be removed easily, so that a new story can begin at any time. As I was
able to recall the stale smell of an early morning ward described earlier in the
work, I am now able to recall the feel of the soft felt, the roughness of the
green board and the feeling of excitement as another story was told, through
colour, texture and imagination. Remembering „Fuzzy Felt‟, was inspirational;
just as I told stories using the felt pieces as a child, I considered using the
same methods to facilitate emotional story telling in the present.
The idea to encourage nursing students to tell stories arose from my data
and most notably based on my interview with the informant Carol, who
328
responded to me when I recalled a story from my own past. She had not
been very forthcoming during the research interview and, based on
Heideggerian thinking on discourse, I used my story to encourage her to
share her feelings. Many of the students interviewed, reinforced their need to
talk about how they felt about certain situations, and in some cases, finding
the space or time for this proved difficult. There were many examples such
as Joan, who suggested, „....the more people bottle stuff up the more
problems they have got and the more isolated they become.‟ The time issue
was reinforced by Emily who stated, „...it‟s a bit of an awkward situation trying
to find the time...‟
Therefore, informed by the data, I explored the literature on creative
approaches to nursing education, and found that story telling in a clinical
supervisory relationship had been used by Williams (2000). Moreover,
Williams had used a collage method in which the supervisee was given
magazines and then left alone to cut or tear out images which would help
them to tell their story. The cuttings were then placed onto A1 flip-chart paper
and then the supervisee talked through the representation. Drawing and
painting has also been used as a medium to explore different ways of
knowing related to nursing practice. Cruickshank (1996) divided students into
small groups and asked them to draw reflective stories using felt tip pens.
Warne and McAndrew (2010) used painting in small groups to explore self-
awareness and emotional practice. Therefore, it seems that visual art has
been used with some success to encourage students to reflect on a more
meaningful level than the spoken or written word alone.
329
However, I suggest that these practices could be developed in three ways.
Firstly, none of these examples suggest that the „teacher‟ or „supervisor‟ told
their own story to the individual or group concerned. Maybe influenced by my
chosen research approach, I felt that if only one person in the relationship
tells a story, the data is not fully co-constituted. Indeed, in all three
examples, the students were left alone in the room to carry out the task.
McAndrew and Warne (2010), state that this was so that the students would
not be made to feel self-conscious by presence of the researcher. However,
by not telling our own story through the art, we could be losing an opportunity
to „normalise‟ and show our real relation to the stories of others.
The second issue centres on the fact that the art sessions, apart from the
clinical supervisory session, were carried out in groups. Cruickshank (1996)
acknowledges that in their normal verbal reflective groups, it was often the
same students, usually the male students, who became the spokesperson
for the group. I can see no reason why this pattern would not be repeated in
these visual art exercises. In addition, if it is the case that art brings out more
emotion and the students could feel even more exposed, would it be
appropriate for other students to be present? This seems especially
problematic when often groups are not chosen to reflect complementary
personality types but more usually due to where a student‟s surname sits in
the alphabet.
Whilst I appreciate that one to one sessions may not be feasible, given time
and resource constraints, I suggest that thought needs to be given to the
configuration of groups, and that they should not happen by chance, but by
design. Findings from the work of Smith (1992) and also from my own data,
330
most notably from Emily, suggest that sharing emotion with friends, who
have been through similar situations, is useful. So on balance, group
sessions would seem advantageous, as long as the groups were chosen
carefully, this could be by student self-selection.
Thirdly, if my aim was to attempt to encourage the sharing of emotion I felt
that a collage, put together from magazine cuttings, may fall short. Staying
true to my philosophy that our present day understanding is based on the
context of our past, I wanted to replicate my experiences from the past as a
child, to facilitate the student storytelling in the present day. My feeling was
that if I could give students different textures, colours and shapes and
provide them with a means of sticking them onto card, to make a picture,
then the idea of emotional story collage could become a reality. I scoured
craft shops to find different items. My search yielded coloured feathers, pipe
cleaners, plastic shapes, plastic eyes, coloured stars, glitter and much more.
I bought coloured paper and brightly coloured pens to use to draw outlines,
glue, and scissors to customise the shapes. Looking at and feeling some of
the material was already invoking feeling in me. For example, touching the
soft fluffy feathers left me with feelings of contentment. Looking at the
brightly coloured sticky stars represented happiness to me. I realise that to
others, the materials may represent other feelings. On the subject of colour
McAndrew and Warne (2010) suggest it is up to the student to describe what
a colour represents, not up to us as educationalists to read meaning into
them. In line with my research philosophy, it is the individual student‟s
interpretation of the materials that is important, the way in which they enable
the student to talk about emotional issues, and how this relates to their way
331
of emotional nurse being. It is not about being right or wrong, but about how
the students‟ bigger picture can change through the use of describing how
they feel, facilitated by the use of the materials to create their own picture of
reality.
As suggested earlier I wanted to truly share the experience of storytelling
with the student and it is with this in mind that I suggest that the lecturer
shares their own story too. I realise that this may seem problematic, and I
have already had experience of story-sharing when carrying out my
research. My dilemma at that time centred on how much I felt able to
disclose of myself during the interviews. However, my thinking on this matter
has changed. As stated by Heidegger (1954/1977: 356):
„If the relation between the teacher and the learners is genuine, therefore, there is never a place in it for the authority of the know-it-all or the authoritative sway of the official‟
I am not suggesting by this excerpt that myself or any of my colleagues act in
a „know-it-all‟ manner; in fact, on the contrary, I suggest that many of us are
humble in our approach to teaching and learning. However, I suggest that
this is not the same as sharing something of ourselves in order to achieve
the „genuine‟ relation between the two. This is not an approach to be
measured in terms of objectives or a piece of work to be marked, as
reflective pieces often are. The aim here is much more important than
something for which a mark is given. I suggest that if the relationship is
genuine then transformation in the student can occur and they can find their
own emotional nurse being. This is in contrast to having one given to them
332
by well-meaning others. Discussing the subject of „student-teacher
connection‟ Gillespie (2005: 212) states:
„....student-teacher connection creates a space which, in its effect, is transforming. Within this space, students are affirmed in who they are in the present, become aware of their potential, and are supported in personal and professional growth...‟
I would go a stage further than Gillespie and suggest that connection in this
way also affirms students in their past and supports them in who they can
become in the future. As stated earlier Heidegger (1926/1962) describes the
potential for us to become lost in the present, and connecting with students
could help them to find the emotional home that many of my informants
seemed to be searching for. Part of my way of thinking about emotional
nurse being suggests that students need to embrace their vulnerability and
view it in a constructive way. I also suggest that, through the sharing of
stories, we too as lecturers reflect on our own vulnerability; in this way we
can recognise it more easily in our students. Earlier in the work, I asked the
question of whether we as lecturers care enough for students. Sharing
stories in this way helps provide a clearing for students and an implicit
caring, where the nature of their own true being can be revealed. Dreyfus
and Rubin (1991: 339) discuss what they term „later Heidegger‟, that is a
discussion of Division II of Being and Time and some of his later work. They
discuss Heidegger‟s thinking about technology and his use of the term
„Gelassenheit‟, which they describe as, „a serene openness to a possible
change in our understanding of being‟. It is this „serene openness‟ which I
suggest can be revealed, during the process of sharing stories, in which
333
emotion is exposed, through the texture, colour and pattern of an original
collage. True to Heideggerian style, thinking at a creative level, in relation to
this open space needs a special name, and he uses the term „releasement‟
for this state. Anderson and Freund (1966: 25) summarise the term by
saying, „Releasement is a defining characteristic of man‟s true nature
involving openness and, through it, direct and immediate reference beyond
man to Being‟. Through releasement I suggest that the true nature of both
the student and the lecturer may be revealed, so that they can make an
emotional connection, and their authentic emotional nurse being is exposed.
Chinn (1994: 21) talks of the use of art in nursing in the following way:
„Turning to art as a way of „seeing‟ the present meaning and experience of nursing, we also begin to remember that which has been lost and to truly comprehend the wisdom of our knowing and doing‟
Through this method we can find „that which has been lost‟, in terms of our
authentic selves, and when found, use it to inform our future being.
Finding a space for connection has been shown to be important for the
student. During a study utilising an interpretive descriptive approach,
Gillespie (2002: 573) found:
„The inherent qualities of the connected relationship (caring, knowing, trusting, respecting and mutuality) and the connected teacher‟s way of being and teaching, resulted in an environment in which students were affirmed and supported in recognising and growing towards their potential as a person, learner and nurse‟
The findings of my research suggest a need for this emotional connection
space, where emotional nurse being can be found and exposed, enabling
334
the student to move forward. The data revealed that students have a desire
to talk through their feelings and if they are allowed to do this, they can come
to terms with their emotions more easily. This way of „being with‟ the student
provides the external support and forum for vulnerability to be revealed, in
order for them to grow as people, learners and nurses. Working in this way
supports the development of their own internal resources, so that future
emotional challenges can be met authentically, so that their true emotional
self is not compromised. It is important that the goal is empowerment of, not
sympathy with, the student. Of course, we can feel sorry for students, but I
agree with Clare (1993) who suggests that using techniques such as
explaining or justifying to students, can merely serve to empower the
lecturer, not the student. Sharing stories helps keep the relationship more
egalitarian, so that the lecturer is not seen as expert, but as someone who
can listen, affirm and above all be kind and caring towards the student. In
summary, the lecturer is being a „Skin Horse‟, the toy I described much
earlier in this work. In The Tale of the Velveteen Rabbit, the Skin Horse is
called upon to describe what it is to be „real‟. He can do this, as he has lived
longer than the other toys in the nursery. He is described in the following way
(Williams, 1922/1991: 4):
„He was wise, for he had seen a long succession of mechanical toys arrive to boast and swagger, and by-and-by break their mainsprings and pass away... For nursery magic is very strange and wonderful, and only those playthings that are old and wise and experienced like the Skin Horse understand all about it‟
I suggest as lecturers we are indeed similar to Skin Horses. We have seen
ways of thinking come and go; we have seen multiple changes in nursing
335
education; developed curricula based on the current trend and then watched
as everything returns to how it was initially. We have the potential to be „old
and wise and experienced‟, like Skin Horses, and use this way of being to
nurture student nurses in their emotional development. This is not the same
as being an expert. We do not have all of the answers; indeed how could we
know the answer to another‟s true emotional self? What we can be is the
faithful friend, someone who is always returned to when the going gets
tough.
Of course, I realise that there may be some in the profession who would
disagree with my way of thinking, and prefer to keep the student/lecturer
relationship less intimate. However, problems related to the issue of
emotional nurse being, although not necessarily described in my terms, are
well documented. For example, within this work I have referred to the
seminal study by Menzies (1960). This work is fifty years old, suggesting that
the problems relating to emotion work are nothing new, and yet still not
adequately addressed. Latterly, the subject has taken on particular relevance
in light of the recently published report High Quality Care For All which stated
that improvements in care would come if the NHS was more patient-centred
(Darzi, 2008). Part of the report described the views of patients who voiced
such concerns as: the feeling of being neglected or ignored; being treated
like an object and not as a person; and the feeling of not being listened to. It
is suggested in the report that nurses will be instrumental in achieving Lord
Darzi‟s aims, which relate to the need to tailor care to the needs and wants of
each individual. Achieving these aims will place further emotional demands
on the nursing workforce and I believe could have implications for student
336
nurse education. In addition, there have been concerns about inadequacies
in pre registration nursing education which have been highlighted by the
Nursing and Midwifery Council (NMC, 2006) and other writers such as
Freshwater and Stickley (2004). One of the NMC skills clusters; a set of
competencies viewed as a priority area to be included in pre registration
curricula, is „care and compassion‟. The NMC are recognising the need to
value the emotional nature of nursing within pre registration nursing
education and this also falls in line with Lord Darzi‟s report. This view is
strengthened by the new Standards for Pre-Registration Nursing Education
(NMC, 2010) which highlights communication and interpersonal skills as
being a discrete domain. It would seem that the case has never been so
strong to emphasise the emotional nature of nursing work. Nurses will not be
able to communicate effectively if they are not able to identify their own
emotional self and manage their emotions effectively. So I suggest that the
emotional nature of nursing is still something that we need to consider and
secure innovative ways to explore. Doing this also gives us the opportunity to
explore what it is to be a professional, another aspect of the work which was
uncovered during the interviews. Although exploring the emotional nature of
professionalism is outside the remit of this thesis, the opportunity to explore
what this means to the student could continue using the same methods.
Story-sharing through collage is not costly in monetary terms, and is
something that I have already started to use to good effect within my
teaching practice. Indeed, this way of working has facilitated the students in
their identification of emotions in ways in which I have not seen in written or
verbal pieces. One poignant example of this was a student who, after putting
337
together a very intricate collage, set about scribbling „himself‟ out of the
picture, using a pen. I was interested, although a little shocked, to see him do
this. He told me that this was his way of showing his feeling that he should
not have been there, during the incident he was describing, and that he had
felt like a „spare part‟. This saddened him greatly and he felt let down during
the experience, in which he felt worthless and in the way. What has been
interesting is that the students who have tried to put a collage together of an
incident from practice, have thought that it would be an „easy‟ thing to do.
However, once they have started, the emotion that has been revealed has
sometimes come as a shock. In some cases, students have felt better after
they have created their collage, and haven‟t felt quite as sad or upset as they
did when putting their story to one side in their mind. As revealed through my
data, these stories have a habit of catching up with the students, leaving
them in a distressed state.
I too have shared my own stories during these occasions and they have led
to a place of connectivity with the students; a calm place, where emotional
nurse being on both sides has been revealed and accepted. Simply sitting
together, talking, cutting and sticking shapes onto card, seems like the most
straightforward way of being and yet, so much is revealed in that clearing.
The very nature of deciding on which colour to use, what sort of texture
displays the emotion felt and where everything should sit on the card,
provides time and space for feelings to be reconsidered and relived. Indeed,
students I have shared stories with, have given me fresh insight into the
emotional issues inherent within them, and have helped me to look at the
issues with fresh eyes.
338
As with my chosen research approach, story-sharing in this way assists both
parties to reach a new whole of understanding, almost like returning to the
hermeneutic circle. We each begin the story with a current understanding of
the situation. We talk through the issues within each story; this is based on
our current emotional nurse being, so will take into account how vulnerable
we feel, and to what extent we have used both external and internal support
structures. Through talking and the collage work, we are left with a different
whole of understanding. This may be a very subtle shift in our feeling and
thinking, and may not even be consciously felt at that time. Furthermore,
when I say „talking‟, this does not always mean „talking‟ in the usual sense of
the word. Returning to the thoughts of Heidegger (1926/1962: 208) „talking‟
in this way can be more about being quiet:
„Keeping silent is another essential possibility of discourse....In talking with one another, the person who keeps silent can „make one understand‟ (that is, he can develop an understanding), and he can do so more authentically than the person who is never short of words‟
This way of talking, in that the student is present, with someone who has
been through similar ways of being, helps the student not only to describe
(again, not necessarily by talking) but to normalise their feelings. Returning
to the data I am reminded of Joan‟s words, „nobody else was crying, so why
am I?‟ This process provides them with the opportunity to become more
familiar with their own emotional selves. They can express what they could
not, or would not express at the time. In time, this could help them to predict
more accurately how certain situations will leave them feeling. This could
339
also help them to manage future situations better, so that they are not
surrounded by as many feelings of shock when things occur.
Heidegger (1966: 53) talks about „meditative thinking‟, which I suggest has
relevance here, in the following way:
„Meditative thinking demands of us not to cling one-sidedly to a single idea, nor to run down a one-track course of ideas. Meditative thinking demands of us that we engage ourselves with what at first sight does not go together at all‟
I suggest that as nurse educationalists, we tend to favour the „one-track
course of ideas‟, which culminates in written pieces of reflection, which at
times are even summatively marked. Reflection in this way is often „managed
by teachers‟ to such an extent that any meaningful change in the student
cannot occur (Clare, 1993: 284). I concede that initially, the idea of sharing
stories in this way may seem strange and require a shift in the usual way of
thinking. However, if emotional exploration and growth are to occur, whilst
meeting contemporary political and professional demands, transformatory
approaches such as these need to be considered. Ekebergh (2005)
suggests that as nurse educators we are at risk of adhering to certain
methods of teaching, which may provide us with structure and a systematic
way of working. However, we do not necessarily critically reflect on the
meaning of these practices and how other methods could be adopted. Other
authors advocate a transformatory approach to nursing education,
suggesting that if we ignore the development of emotions then the heart of
health and social care practice is denied (Freshwater & Stickley, 2004).
Freshwater and Stickley (2004) suggest an emotionally intelligent curriculum,
340
and others suggest that emotional intelligence is a prerequisite for
recruitment (Cadman & Brewer, 2001). I submit that the approach I have
offered would assist in the development of emotional intelligence, in that it
encourages emotional self-awareness and self-regulation. These are two of
the personal competencies, suggested by Goleman (1998) in his popular
model of Emotional Intelligence.
In this chapter so far, I have discussed Heidegger‟s important concept of
Dasein and how it has influenced a way of thinking about emotional nurse
being, based on my research findings. I have also considered a practical way
forward in terms of how, as lecturers, we can connect with students so that
they can reveal their own being, in a non-threatening environment. This is
underpinned by the data which suggests that the students had a desire to
talk over how they feel. Instrumental to my views throughout this thesis, has
been the work of Martin Heidegger and it is now my intention to discuss what
his thinking has added to this work.
The influence of Martin Heidegger
It was with some trepidation that I embarked on a thesis underpinned by
Heideggerian philosophy. There were many reasons for my concern, not
least of all the strange terminology often used in his work. As stated by
Anderson and Freund (1966: 13):
„It is true that Heidegger is notorious for the use of coined words and phrases, and in many of his writings this in itself makes a grasp of his goal difficult‟
341
Being in total agreement with this statement, it could be hard to describe why
anyone would pursue a piece of work based on his thinking. Indeed, it is not
just Heidegger‟s strange terminology and invented words that hinder the
endeavour. At times, even when speaking more directly, his thinking can be
difficult to follow, and the reader could be forgiven for giving up. In addition to
these practical reasons for not pursuing Heideggerian work, is a more
emotive one. It is well documented that Heidegger was a Nazi sympathiser
(Inwood, 1997), a fact that in itself, could be very off-putting. So what is the
appeal of Heideggerian work to someone pursuing a piece of research, and
what does he actually add to the enterprise?
Heidegger as teacher
As stated earlier, Heidegger was first and foremost a teacher, and this is
obvious in his style of writing. One of the first pieces of Heideggerian
research I read was by Nelms (1996). She states that her findings:
„...help to answer the Heideggerian question of what a marginalized cultural practice like the profession of nursing can teach a levelling technological society about the meaning of being‟
I felt inspired by the phrase, „the meaning of being‟ and wanted to know more
about the „Heideggerian question‟. Could it be the case that nursing could
teach society about what it means to be, and furthermore, what could
Heidegger teach me about the meaning of emotional being? Beginning with
his great work Being and Time, (Heidegger, 1926/1962) it soon became clear
to me, that Heidegger could teach me a lot about „nurse being‟. I could relate
to many of the practices he suggests we all live out, a lot of the time.
342
In what I have termed „Constituent One: Threat to the authentic self‟, his
thinking on authenticity, conscience and resoluteness taught me a lot about
the practices of student nurses, in terms of why they behave as they do, and
assisted me in my understanding of their ways of emotional being. It helped
me to answer some questions about why we do not, as student nurses,
behave „as ourselves‟ a lot of the time, but how through conscience and
resoluteness, we can return to a more authentic way of being. I found myself
nodding as I read his work, in agreement at his words, as I felt it helped to
explain my data well. I felt that my data was illuminated by his thinking, and
developed by it. In addition, on a more personal note, it helped me to
understand much more about my own emotional self, and why I behaved as I
did, as a student nurse, twenty years ago. Using his thinking has helped me
lay some old ghosts to rest, such as The Man in the Green Pyjamas. My
heart still feels sad when I think of him, but I feel that I have grieved some
more for him, through this research. Heidegger, in one sense, has helped me
to work through this grief, by helping me to consider why I behaved and felt
the way I did at that time. As explained earlier, what I had not thought about,
until this research journey, was how much this story reminded me of my own
father. Thinking about how this story affected me, I suggest, has implications
for nurse educators when thinking about the emotional ways of student nurse
being. I shall now go on to explain my thinking here. When undertaking
Heideggerian style research, Diekelmann (2001: 57) suggests:
„The researcher does not stop at what the participants say, but goes behind the text and asks what the participants could not or did not say‟
343
I suggest that when student nurses reflect on incidents, they too may not be
able to, or not want to say, what is going on behind their own personal „text‟.
Just as, for me, thinking about this poor man opened up a huge part of my
own personal life, as educators, we simply do not know what is lurking
behind the reflective stories told by students. It is not as simple as asking a
student to „tell a reflective story‟. We need to be mindful of what lurks
beneath and behind stories, and consider ways to provide the serene and
tranquil place, where new ways of being can be slowly and carefully
uncovered.
The idea of Heidegger as teacher, with me as student, did not stop there.
Later in the work I considered the students‟ need to be „emotionally
professional‟. It was then that I delved into Heidegger‟s later work, on
dwelling and home making. This helped me to make sense of the anxiety
some of the informants felt, when they did not seem able to find emotion
homes, for either themselves or their patients. This was influenced by the
implicit and at times explicit need, to be seen to be „professional‟. Heidegger
helped me here to consider a different perspective on professionalism and to
think in a more liberated way about the nursing profession. This was through
his thoughts on different ways of thinking: „meditative thinking‟ and
„calculative thinking‟. I felt supported by him, in the sense that I felt I had a
certain „backing‟, almost as if he was on my side when I made the assertion
that, as nurses, we need to think in a different way about what makes us
special. We do become „attached‟ to patients, we feel for them, but this does
not make us unprofessional. Without reading Heidegger‟s work, I am not
sure that I would have felt confident in making this assertion.
344
Application beyond my research
There is also another important level of application, in terms of what
Heidegger has added to this work and this relates to me as a person, on both
a personal and professional level. It is now very clear to me that there is
more than one way of thinking about research. Of course, it is obvious that
there are both quantitative and qualitative approaches, but what I mean goes
further than that. Heidegger makes the distinction between calculative and
meditative thinking. Playing devil‟s advocate, he presents a view of
meditative thinking as follows (Heidegger, 1966: 46):
„Yet you may protest: mere meditative thinking finds itself floating unaware above reality. It loses touch. It is worthless for dealing with current business. It profits nothing in carrying out practical affairs‟
I suggest that this excerpt in part, describes my way of viewing my own
research, at the beginning of the journey. As I stated earlier, I tended to
describe my work as „airy fairy‟, almost feeling I had to make excuses for it.
Through my research journey there has been such a dramatic shift that I find
both exciting and inspirational. I am now in a position to better argue the
case for the more meditative styles of work, for example, qualitative work
pursued by other colleagues, not just my own. What is inspiring to me is that
the development in my thinking goes beyond my own work, and extends to
that of others, undertaking qualitative research. I am not suggesting that this
style of research is more important or significant than the more calculative
styles (by calculative styles, I am suggesting research which leans toward
the quantitative paradigm). However, when challenged, I now think of the
following words from Heidegger (1966: 46); „Calculative thinking is not
345
meditative thinking, not thinking which contemplates the meaning which
reigns in everything that is‟ (my italics). It is this very meaning that is so
important to nursing work and research needs to be developed to find this
meaning behind what is explicit. It is not just about finding out the
„everything‟, e.g. the facts, but the meaning behind the facts. I suggest that
this meaning cannot be reached via merely analysing factual data. There will
always be some important qualitative „truths‟ which quantitative data cannot
hope to reveal. This is crucial if we are going to get under the skin of the
important but elusive soul, which lies within the practice of nursing and binds
all of nursing work together.
Heidegger as researcher
Heidegger did not write a research approach for nurse researchers. Although
as stated earlier, much of his thinking has influenced interpretive approaches
to qualitative research. However, he did suggest that understanding could
only be gained through the context of our pre understandings. We will all
arrive at our current situation with a different set of pre understandings and
these cannot be ignored or bracketed out. This is to the extent that they
actually assist us in making sense of our current world and way of being.
This is important to nurse researchers for two reasons. Firstly, being
„allowed‟ to acknowledge our pre understandings and bring them with us, into
the research situation, assists us in understanding the stories we hear. This
is particularly important when carrying out research, for example, with other
nurses or patients. The fact that we have been in comparable situations
ourselves, helps us to understand the other, in a way we could not do if we
had somehow to ignore our own personal history. The possibilities for a
346
different understanding of the issues are vast. For example, because I had
„been there‟ with the „Man in the Green Pyjamas‟, I was able to understand
Fran‟s distress on a level I would not have been able to achieve, had I not
been through this situation. I felt almost as if I was stepping inside her,
looking through her eyes and feeling how she felt at that time. This opens up
a whole new way of being for the researcher, as they become immersed in
the lifeworld of another, reaching different levels of understanding and
knowing.
Through this way of being, the data becomes co-constituted, a joint creation
of researcher and informant. However, this is presented as „real‟ at that time.
It is accepted that the reader may interpret the data in a different way, based
on their own past and pre understanding of the event. In this way, the
research product is always alive, moving and open to new interpretations. It
is presented as „truth‟, subscribing to the belief that truth is not made, but
found. It seems that there could be a no more fitting approach for research
which deals with human emotion and feeling. Even the researcher and
informant may look at the joint text in the future, and see the events in a new
way. When we reflect on events, we often view them in a different way to the
one we did previously.
If I had not discovered Heidegger‟s work, initially through the writing of Koch
(1995), I purport that I may not have embarked on this journey at all. Being
able to work in this way has been a liberating experience, far removed from
my positivist research upbringing.
347
Conclusion
This study has demonstrated emotional nurse being as being dependent on
many factors. I have attempted to capture these in the previously proposed
model, which encompasses issues such as vulnerability, internal resources
and external support. This model very much works along a continuum of
time, which I have illuminated using Heideggerian thinking on temporality,
taken mainly from his work, Being and Time (Heidegger, 1926/1962).
Every research endeavour reflects the time at which it was written and as I
write, the nursing profession in England is about to become all-graduate. I
cannot predict what this will mean for nurses, and the nature of nursing work.
My fear is that the emotional nature of nursing may become more and more
marginalised, in favour of more academic curricula. Conversely, as
mentioned earlier, the NMC (2010) and particular political drivers seem set to
keep emotion central to the nurse/patient relationship. However, this aim
could be set to be merely rhetoric if we as educationists do not secure ways
in which student nurses can identify and manage their emotions.
Furthermore, I suggest that student nurses need to explore for themselves,
the nature of their unique emotional nurse being.
These thoughts return me to the beginning of this work, and my initial aims
and motivation. I felt moved to start this study after watching the Panorama
television programme “Undercover Nurse”. The programme uncovered
abuse and neglect of the older patients in a hospital in the south of the
country. The focus of my inquiry centred on the way nurses identify and
348
manage their emotions in practice. These aims continued to form the basis of
the aims of this study. These were:
1. To analyse the emotions felt by student nurses in practice
2. To analyse how student nurses identify and manage their
emotions
3. To analyse the effect of emotion work on student nurses‟ lives
4. To offer suggestions of how the findings impact on the delivery of
patient-centred nursing and the preparation of student nurses
5. To contribute to the growing body of knowledge of nurses use of
emotion in their relationship with patients.
I tentatively suggest that I have met my aims, although I acknowledge that
due to the nature of the work, it is an ongoing process. This relates
particularly to the fifth aim, in that our understanding of emotion work grows
as more research is published.
Limitations of the work
The bigger issues, in terms of the discourse of emotion at this time, could
have influenced me and the students and could have been explored further.
Taking this influence even further would have led to a more contextual
analysis. However, placing more focus on culture and the wider context may
have prohibited my focus on the individual lifeworld of the students
interviewed. Therefore, not focussing on the wider cultural issues could be
349
viewed as strength of the work, in that it has allowed me to focus in greater
depth on the individual.
I have concentrated this study on adult branch nursing students. I am aware
that if I had widened the study to include other branches such as mental
health, child and learning disability, then a different picture may have
emerged. However, as before, what is viewed as a limitation could also be
viewed as a strength in that, by using adult branch informants, I have been
able to concentrate rather than dilute the work. In addition, I am not sure that
I could have fully co-constituted the data in the same way that I have, other
than by using adult branch students. I may not have been able to relate to
other branches of student as easily as I have using the adult branch group.
I acknowledge that exploration of these issues may have developed the
analysis further, although they could inform ideas for future research.
The impact of this work so far with ideas for future research
I have raised many issues within this work, and I suspect that some of these
could inform a whole thesis alone. Parts of the work have already been
shared on an international level, at the Nurse Education Today/Nurse
Education in Practice Conference in Sydney, Australia in 2010. Discussion
with colleagues there raised interesting debate around attrition, and the
effect that unpreparedness for the emotional nature of nursing could have on
attrition rates (Gillespie, personal communication, 2010). It would certainly be
interesting to explore the model of emotional nurse being in relation to
attrition.
350
On a national level, there has been a recent request by a neighbouring trust
to facilitate a study day on the emotional aspects of practice with post
registration nurses. Interestingly, this was an aspect of practice identified by
them as being one in which they felt they had developmental needs. Future
research could explore emotional nurse being amongst post registration
nurses. This would be particularly interesting in light of the changes ahead
within the NHS in the UK following the election of the Coalition Government.
On a local level
At the time of writing I am closely involved with the rewriting of the BSc
(Hons) Nursing curriculum in readiness for the all-degree preparation of
nurses in the United Kingdom. It is here that I suggest that this work has had
a large impact. I agree with Carlsson et al (2006) who suggest that, in caring
situations, encouraging the development of the carer‟s own personal style is
preferable to following a set of rules. From my own experience there is
pressure from academic team members to populate timetables with session
content such as „dealing with difficult patients‟. Often accused of „blue sky‟
thinking, I am undeterred in my argument for a more coherent set of
principles which underpin the whole curriculum. For example, if the whole
curriculum philosophy was based on authenticity, trust and sharing, I suggest
that sessions like these would not need to be delivered. As educators, I
suggest that at times we restrict practice as the student feels that they are
unable to deal with certain situations as they haven‟t had that „session‟ yet
which „tells them how to do it‟. This serves to disempower them, rather than
enable them to develop their own authentic ways of emotional being. If we
present emotion work as task-centred by delivering „content‟ in prescribed
351
sessions, we cannot be surprised when students deliver care in inauthentic,
prescribed ways. Although I am arguing a move away from the prescriptive
approach, the caring philosophy described by Mayeroff (1971) could be used
as an influence. A move to a more creative, learner-centred curriculum, in
which the learner has more freedom to be authentic and real, could be
beneficial to all concerned. Future research to explore how learning could be
made more meaningful, against the backdrop of political and professional
body demands, would be an interesting mission.
352
References
Alavi C and Cattoni J (1995) Good nurse, bad nurse.... Journal of Advanced Nursing 21, 344 – 349
Allen D, Benner P and Diekelmann NL (1986) Three paradigms for nursing research: methodological implications In Chinn PL (Ed) Nursing Research Methodology: Issues and Implications Rockville Aspen Publishers
Annells M (1996) Hermeneutic phenomenology: philosophical perspectives and current use in nursing research Journal of Advanced Nursing 23, 4, 705 – 713
Anderson JM and Freund EH (1966) Introduction In Heidegger M (1966) Discourse on Thinking New York Harper and Row
Andrews CA, Ironside PM, Nosek C, Sims SL, Swenson MM, Yeomans C, Young PK and Diekelmann N (2001) Enacting Narrative Pedagogy. The Lived Experiences of Students and Teachers Nursing and Health Care Perspectives 22, 5, 252 - 259
Barbour RS (2001) Checklists for improving rigour in qualitative research: a case of the tail wagging the dog? British Medical Journal 322, 1115 – 1117
Barnett R (2007) A Will to Learn: Being a Student in an Age of Uncertainty Maidenhead McGraw-Hill/ OU Press
Beck CT (1992) The lived experience of postpartum depression: A phenomenological study Nursing Research 41, 3, 705 – 713
Beech I (1999) Bracketing in Phenomenological Research Nurse Researcher
6, 3, 35 - 50
Benner P (1984) From Novice to Expert: Excellence and Power in Clinical Nursing Practice California Addison Wesley
353
Bilton T, Bonnett K and Jones P et al (2002) Introductory Sociology 4th Ed Basingstoke Palgrave
Bixler GK and Bixler RW (1959) The professional status of nursing American Journal of Nursing 59, 8, 1142 - 1146
Bond M (1986) Stress and Self Awareness: A Guide for Nurses London Heinemann
Boyle J (1994) Styles of Ethnography In Morse J (Ed) Critical Issues in Qualitative Research Methods London Sage
Brannen J (1988) The study of sensitive subjects Sociological Review 36, 552 – 563
Buber M (1958) I and Thou Edinburgh T and T Clark
Burnard P (2002) Learning Human Skills Oxford Butterworth Heinemann
Cadman C and Brewer J (2001) Emotional Intelligence: A vital prerequisite for recruitment in nursing Journal of Nursing Management 9, 321 - 324
Caelli K (2001) Engaging with phenomenology: Is it more of a challenge than it needs to be? Qualitative Health Research 11, 2, 273 – 81
CarlssonG, Dahlberg K, Ekebergh M and Dahlberg H (2006) Patients longing for authentic personal care: A phenomenological study of violent encounters in psychiatric settings Issues in Mental Health Nursing 27, 287 - 305
Castledine G (1998) Nursing professionalism: Is it declining? British Journal of Nursing 7, 352
Chang ML, Bidewell JW, Huntington AD, Daly J, Johnson A, Wilson H, Lambert VA and Lambert CE (2007) A survey of role stress and health in
354
Australian and New Zealand hospital nurses International Journal of Nursing Studies 44, 1354 - 1362
Chesser-Smyth PA (2005) The lived experiences of general student nurses on their first clinical placement: A phenomenological study Nurse Education in Practice 5, 320 – 327
Chinn PL (1994) Developing a method for aesthetic knowing in nursing in Chinn PL and Watson J (Eds) Art and Aesthetics in Nursing New York National League for Nursing
Clare J (1993) Change the curriculum – or transform the conditions of practice? Nurse Education Today 13, 282 - 286
Clarke K and Iphofen R (2006) Issues in phenomenological research: the combined use of pain diaries and interviewing Nurse Researcher 13, 3, 62 - 74
Cohen MZ (1987) A Historical Overview of the Phenomenological Movement Image: Journal of Nursing Scholarship 19, 1, 31 - 34
Cohen MZ (2000) Introduction. In Cohen MZ, Kahn DL and Steeves RH (Eds) Hermeneutic Phenomenological Research: A Practical Guide for Nurse Researchers Thousand Oaks Sage
Cohen MZ and Omery A (1994) Schools of phenomenology: implications for research In Morse JM (Ed) Critical Issues in Qualitative Research Methods
Thousand Oaks Sage
Colbourne l and Sque M (2005) The culture of cancer and the therapeutic impact of qualitative research interviews Journal of Research in Nursing 10, 5, 551 – 567
Conroy SA and Dobson S (2005) Mood and Narrative Entwinement: Some Implications for Educational Practice Qualitative Health Research 15, 7, 975 – 990
355
Corben V (1999) Misusing phenomenology in nursing research: identifying the issues Nurse Researcher 6, 3, 52 – 66
Corbin JM and Strauss AC (2008) Basics of Qualitative Research 3rd Ed California Sage
Cutcliffe JR and Wieck KL (2008) Salvation or damnation: deconstructing nursing‟s aspirations to professional status Journal of Nursing Management 16, 499 - 507
Crotty M (1996) Phenomenology and Nursing Research Melbourne Churchill Livingstone
Crotty M (1998) The Foundations of Social Research: Meaning and Perspective in the Research Process London Sage
Cruickshank D (1996) The „art‟ of reflection: using drawing to uncover knowledge development in student nurses Nurse Education Today 16, 127 - 130
Dahlberg K, Dahlberg H and Nystrom M (2008) Reflective Lifeworld Research 2nd ed Sweden Studentlitteratur
Daniel LE (1998) Vulnerability as a Key to Authenticity Image: Journal of Nursing Scholarship 30, 2, 191 - 192
Darbyshire P, Diekelman J and Diekelman N (1999) Reading Heidegger and interpretive phenomenology: a response to the work of Michael Crotty Nursing Inquiry 6, 1, 17 - 25
Dartington A (1994) Where angels fear to tread in Obholzer A and Zagier Roberts V (Eds) The Unconscious at Work London Routledge
356
Davis F. (1975) Professional socialization as subjective experience: the process of doctrinal conversion among student nurses In Cox C and Mead A (Eds) A Sociology of Medical Practice London Collier Macmillan
Debesay J, Naden D and Slettebo A (2008) How do we close the hermeneutic circle? A Gadamerian approach to justification in interpretation in qualitative studies Nursing Inquiry 15, 1, 57 – 66
Demi AS and Warren NA (1995) issues in conducting research with vulnerable families Western Journal of Nursing Research 17, 188 - 202
Department of Health (2008) High Quality Care for All London The Stationery Office
Devereux G (1967) From anxiety to method in the behavioural sciences In Reason P and Rowan J (eds) Human Inquiry – A Sourcebook of New Paradigm Research Chichester Wiley
Dickson – Swift V, James EL, Kippen S and Liamputtong P (2007) Doing sensitive research: what challenges do qualitative researchers face? Qualitative Research 7, 3, 327 - 353
Diekelman NL and Allen DG (1989) A Hermeneutic Analysis of the NLN Criteria for the Appraisal of Baccalaureate Programs In Diekelman NL, Allen D, and Tanner C (Eds) The NLN criteria for appraisal of baccalaureate programs: A critical hermeneutic analysis. New York National League for Nursing
Diekelmann NL (2001) Narrative pedagogy: Heideggerian hermeneutical analyses of lived experiences of students, teachers and clinicians Advances in Nursing Science 23, 3, 53 - 71
Dingwall R and Allen D (2001) The implications of healthcare reforms for the profession of nursing Nursing Inquiry 8, 2, 64-74
357
Dostal RJ (1993) Time and phenomenology in Husserl and Heidegger In Guignon CB (Ed) The Cambridge Companion to Heidegger Cambridge Cambridge University Press
Draucker C (1999) The critique of Heideggerian hermeneutical nursing research Journal of Advanced Nursing 30, 2, 360 – 373
Dreyfus HL and Rubin J (1991) Apendix: Kierkegaard, Division II, and Later Heidegger in Dreyfus H (Ed) Being-in-the-world. A commentary on Heidegger‟s Being and Time, Division I New Baskerville MIP Press
Dreyfus HL (2000) Husserl, Heidegger and Modern Existentialism in Magee M (Ed) The Great Philosophers Oxford OU Press
Duncombe J and Jessop J (2002) “Doing Rapport” and the ethics of “faking friendship” In Mauthner M, Birch M, Jessop J and Miller T (Eds) Ethics in Qualitative Research London Sage
Ekebergh M (2005) Are you in control of the method or is the method in control of you? Nurse Educator 30, 6, 259 - 262
Ekstedt M and Fagerberg I (2005) Lived experiences of the time preceding burnout Journal of Advanced Nursing 49, 1, 59 - 67
Etherington K (2004) Becoming a Reflexive Researcher; Using Our Selves in Research London Jessica Kingsley
Finlay L (2002) „Outing the Researcher; The Provenance, Process and Practice of Reflexivity Qualitative Health Research 12, 4, 531-545
Finlay L (2003) Through the looking glass: intersubjectivity and hermeneutic reflection in Finlay L and Gough B (Eds) Reflexivity. A Practical Guide for Researchers in Health and Social Sciences Oxford Blackwell Science
358
Fleming V, Gaidys U and Robb Y (2003) Hermeneutic Research in Nursing: Developing a Gadamerian-based Research Method Nursing Inquiry 10, 2, 113 - 120
Fontana A and Frey JH (2000) „The interview: From structured interviews to negotiated text‟ In Denzin NK and Lincoln YS (eds) Handbook of Qualitative Research 2nd Ed Thousand Oaks Sage
Fosbinder D (1994) Patient perceptions of nursing care: an emerging theory of interpersonal competence Journal of Advanced Nursing 20, 1085 – 1093
Frede D (1993) The question of being: Heidegger‟s project In Guignon C (Ed) The Cambridge Companion to Heidegger Cambridge Cambridge University Press
Freshwater D (2000) Crosscurrents: against cultural narration in nursing Journal of Advanced Nursing 32, 2, 481 - 484
Freshwater D (2002) Therapeutic Nursing London Sage
Freshwater D (2003) Counselling skills for nurses, midwives and health visitors Buckingham OU Press
Freshwater D and Stickley T (2004) The heart of the art: emotional intelligence in nurse education Nursing Inquiry 11, 2, 91 – 98
Furedi F (2004) Therapy culture. Creating vulnerability in an uncertain age London Routledge
Gadamer HG (1960/1989) Truth and Method London Sheed and Ward
Gadamer HG (1976) Philosophical Hermeneutics London University of California Press
359
Gair S (2002) In the thick of it: A reflective tale from an Australian social worker/qualitative researcher Qualitative Health Research 12 1 130 – 139
Geanollos R (1998) Hermeneutic philosophy. Part II: a nursing research example of the hermeneutic imperative to address forestructures/pre-understandings Nursing Inquiry 5, 4, 238 – 247
Gillespie M (2002) Student-teacher connection in clinical nursing education Journal of Advanced Nursing 37, 6, 566 - 576
Gillespie M (2005) Student-teacher connection: a place of possibility Journal of Advanced Nursing 52, 2, 211 - 219
Giorgi A (1997) The theory, practice and evaluation of the phenomenological method as a qualitative research procedure Journal of Phenomenological Psychology 28, 2, 235 – 260
Glaser BG and Strauss A (1967) A Discovery of Grounded Theory London Sociology Press
Goleman D (1998) Working with Emotional Intelligence London Bloomsbury
Gough B (2003) Shifting researcher positions during a group interview study: a reflexive analysis and re-view. In Finlay L and Gough B (Eds) Reflexivity. A Practical Guide for Researchers in Health and Social Sciences Oxford Blackwell Science
Gray JG (2004) Introduction In Heidegger M What is called thinking? (J
Glenn Gray translation) New York Harper Perennial
Gray DE (2005) Doing Research in the Real World London Sage
Greenhalgh and Company (1994) The Interface Between Junior Doctors and
Nurses. A Research Study for the Department of Health Macclesfield
Greenhalgh and Co.
360
Greenwood J (1993) The apparent desensitization of student nurses during their professional socialization: a cognitive perspective Journal of Advanced Nursing 18, 1471 - 1479
Guignon CB (1993) The Cambridge Companion to Heidegger Cambridge Cambridge University Press
Gullickson C (1993) My death nearing its future: A Heideggerian hermeneutic analysis of the lived experience of persons with chronic illness Journal of Advanced Nursing 18, 1386 – 1392
Havel V (1983) Letters to Olga (Trans Paul Wilson) London Faber and Faber
Heidegger M (1926/1962) Being and Time (J Macquarrie and E Robinson translation) New York Harper and Row
Heidegger M (1954/1977) Basic Writings New York Harper and Row
Heidegger M (1952/2004) What is Called Thinking? ( J Glenn Gray translation) New York Harper Perennial
Heidegger M (1959/1971) On the Way to Language New York Harper and Row
Heidegger M (1966) Discourse on Thinking New York Harper and Row
Heron J (2001) Helping the Client. A Creative Practical Guide London Sage
Holloway I and Wheeler S (1996) Qualitative Research for Nurses Oxford Blackwell Science
Holroyd AEM (2007) Interpretive Hermeneutic Phenomenology: Clarifying Understanding The Indo-Pacific Journal of Phenomenology 7, 2, 1 - 12
361
Hochschild AR (2003) The managed heart: Commercialisation of human feeling 2nd Ed Berkeley University of California Press
Hubbard G, Backett-Milburn K and Kemmer D (2001) Working with emotions: Issues for the researcher in fieldwork and team work International Journal of Social Research Methodology 4 2 119 – 137
Husserl E (1913/1970) Logical Investigations (JN Findlay translation) New York Humanities Press
Idczak SE (2007) I am a nurse: Nursing students learn the art and science of nursing Nurse Education Perspectives 28, 2, 66 - 71
Inwood M (1997) Heidegger: A Very Short Introduction Oxford Oxford University Press
Jackson D, Firtko A and Edenborough M (2007) Personal resilience as a strategy for surviving and thriving in the face of workplace adversity: a literature review Journal of Advanced Nursing 60, 1, 1 - 9
James T and Whittaker D (1998) Researching hidden worlds: dilemmas for nurse researchers. In Smith P (Ed) Nursing Research. Setting New Agendas London Arnold
Janesick VJ (2000) The choreography of qualitative research design In Denzin NL and Lincoln YS (Eds) Handbook of Qualitative Research
Thousand Oaks Sage
Johnson ME (1998) Being mentally ill: A phenomenological inquiry Archives of Psychiatric Nursing 12, 4, 195 - 201
Kahn DL (2000) How to Conduct Research In Cohen MZ, Kahn DL and Steeves RH (Eds) Hermeneutic Phenomenological Research A Practical Guide for Nurse Researchers London Sage
362
Kalisch BJ and Kalisch PA (1983) Improving the image of nursing The American Journal of Nursing 1, 48 - 52
Kelly B (1992) The Professional Self-Concepts of Nursing Undergraduates and Their Perceptions of Influential Forces Journal of Nursing Education 31, 3, 121 - 125
Kelly B (1996) Hospital nursing: „It‟s a battle!‟ A follow up study of English graduate nurses Journal of Advanced Nursing 24, 1063 – 1069
Kelly B (1998) Preserving moral integrity: a follow up study with new graduate nurses Journal of Advanced Nursing 28, 5, 1134 - 1145
Koch T (1994) Establishing rigour in qualitative research: the decision trail Journal of Advanced Nursing 19, 976 – 986
Koch T (1995) Interpretive approaches in nursing research: the influence of Husserl and Heidegger Journal of Advanced Nursing 21, 827 – 836
Koch T (1996) Implementation of a hermeneutic inquiry in nursing: philosophy, rigour and representation Journal of Advanced Nursing 24, 174 – 184
Koch T (1999) An interpretive research process: revisiting phenomenological and hermeneutical approaches Nurse Researcher 6, 3, 20 – 34
Koch T and Harrington A (1998) Reconceptualizing rigour: The case for reflexivity Journal of Advanced Nursing 28, 4, 882 - 890
Koch T (1998) Story telling: Is it really research? Journal of Advanced Nursing 28, 6, 1182 – 1190
Kvale S (1996) Interviews. An Introduction to Qualitative Research Interviewing Thousand Oaks, California Sage Publications
363
Lindop E (1999) A comparative study of stress between pre and post project 2000 students Journal of Advanced Nursing 29, 4, 967 - 973
Loftus LA (1998) Student nurses‟ lived experience of the sudden death of their patients Journal of Advanced Nursing 27, 641 - 648
Lopez Nahas V (1998) Humour: a phenomenological study within the context of clinical education Nurse Education Today 18, 663 – 672
Mackintosh C (2006) Caring: The socialisation of pre registration student nurses: A longitudinal qualitative descriptive study International Journal of Nursing Studies 43, 953 – 962
Magee B (2000) The Great Philosophers Oxford OU Press
Magnet J (2003) What‟s wrong with nursing? Prospect 93, 40 - 45
Maslach C, Schaufeli WB and Leiter MP (2001) Job burnout Annual Review of Psychology 52, 397 – 422
Mayer JD, Salovey P and Caruso D (2004) Emotional intelligence: Theory, findings and implications Psychological Inquiry 15, 197 – 215
Mayeroff M (1971) On Caring New York Harper Perennial
McCracken G (1988) The Long Interview Qualitative Research Methods Series 13 Newbury Park, California Sage Publications
McQueen ACH (2004) Emotional intelligence in nursing work Journal of Advanced Nursing 47, 1, 101 - 108
Menzies I (1960) A Case Study in the Functioning of Social Systems as a Defence Against Anxiety London Tavistock
364
Morrison P (1994) Understanding Patients London Balliere Tindall
Morse JM (1991) Qualitative Research: A Contemporary Dialogue London Sage
Morse JM (1994) Designing funded qualitative research in Denzin NR and Lincoln YS Handbook of Qualitative Research London Sage
Moustakas C (1994) Phenomenological Research Methods London Sage
Murray BL (2003) Qualitative research interviews: therapeutic benefits for the participants Journal of Psychiatric and Mental Health Nursing 10, 2, 231 - 238
Nagy S (1998) A comparison of the effects of patients pain on nurses working in burns and neonatal intensive care units Journal of Advanced Nursing 27, 335 - 340
Naring G, Briet M and Brouwers A (2006) Beyond demand-control: Emotional labour and symptoms of burnout in teachers Work and Stress 20, 4, 303 – 315
Nelms T (1996) Living a Caring Presence in Nursing. A Heideggerian Hermeneutical Analysis Journal of Advanced Nursing 24, 2, 368 – 374
NMC (2006) Advance Information Regarding Essential Skills Clusters for Pre-Registration Nursing Programmes October 2006 London NMC
NMC (2005) Implementation of a Framework for the Standard for Post Registration Nursing – Decision. Agendum27.1 December 2005/c/05/160 London NMC
NMC (2008) The Code. Standards of Conduct, Performance and Ethics for Nurses and Midwives London NMC
365
NMC (2009) NMC Review of Pre Registration Nursing Education Frequently Asked Questions London NMC
NMC (2010) Standards for pre-registration nursing education London NMC
Oermann MH and Garvin F (2002) Stresses and challenges for new graduates in hospitals Nurse Education Today 22, 225 – 230
Oiler C (1982) The Phenomenological Approach in Nursing Research Nursing Research 31, 3, 178 - 181
Omery A (1983) Phenomenology: A method for nursing research Advances in Nursing Science 5, 2, 49 - 63
Paley J (1997) Husserl, phenomenology and nursing Journal of Advanced Nursing 26, 180 - 186
Paley J (1998) Misinterpreting phenomenology: Heidegger, ontology and nursing research Journal of Advanced Nursing 27, 4, 817 - 824
Paley J (2005) Phenomenology as rhetoric Nursing Inquiry 12, 2, 106 – 116
Parse RR (1998) The Human Becoming School of Thought. A Perspective for Nurses and Other Health Professionals Thousand Oaks Sage
Paterson BL (1994) A Framework to Identify Reactivity in Qualitative Research Western Journal of Nursing Research 16, 3, 310 – 316
Patton MQ (1990) Qualitative Evaluation and Research Methods Newbury Park CA Sage
366
Pearson PH, Steven A and Howe A (2008) Patient Safety in Health Care Professional Education: Examining the Learning Experience Universities of Newcastle, East Anglia, Edinburgh, Manchester and Surrey DH
Priest H (2004) An approach to the phenomenological analysis of data Nurse Researcher 10, 2, 50 – 63
Rabinow P and Sullivan WM (1987) Interpretive Social Science. A Second Look London University of California Press, Ltd
Ray M (1994) The richness of phenomenology: philosophic, theoretic and methodological concerns. In Morse JM (Ed) Critical Issues in Qualitative Research Methods Thousand Oaks Sage
Randle J (2001) Past Caring? The Influence of Technology Nurse Education in Practice 1, 157 - 165
Randle J (2002) Transformative Learning: Enabling Therapeutic Nursing in Freshwater D (Ed) Therapeutic Nursing London Sage
Randle J (2003) Changes in self-esteem during a 3-year pre registration Diploma in Higher Education (Nursing) programme Journal of Clinical Nursing 12, 142 - 143
Reed J (1994) Phenomenology without phenomena: a discussion of the use of phenomenology to examine expertise in long-term care of elderly patients
Journal of Advanced Nursing 19, 2, 336 – 341
Rogers AC (1997) Vulnerability, health and health care Journal of Advanced Nursing 26, 65 - 72
Rose JF (1990) Psychologic health of women: A phenomenologic study of womens inner strength Advances in Nursing Science 12, 2, 56 – 70
367
Rowan M (1997) Qualitative Research Articles: Information for Authors and Peer reviewers Canadian Medical Association Journal 157, 1442 - 1446
Rytterstrom P, Cedersund E and Arman M (2009) Care and caring culture as experienced by nurses working in different care environments: A phenomenological–hermeneutic study International Journal of Nursing Studies 46, 5, 689 - 698
Sabo BM (2006) Compassion fatigue and nursing work: Can we accurately capture the consequences of caring work? International Journal of Nursing Practice 12, 136 - 142
Sandelowski M (1986) The problem of rigor in qualitative research Advances in Nursing Science 8, 3, 27 – 37
Sandelowski M (1995) Sample Size in Qualitative Research Research in Nursing and Health 18, 179 – 183
Sandgren A, Thulesius H, Fridlund B and Petersson K (2006) Striving for emotional survival in palliative cancer nursing Qualitative Health Research
16, 1, 79 - 96
Schutz A (1967) The Phenomenology of the Social World London Heinemann Educational
Secrest JA, Norwood BR and Keatley BM (2003) “I was actually a nurse” The
meaning of professionalism for Baccalaureate nursing students Journal of
Nursing Education 42, 2, 77 – 82
Seidman IE (1998) Interviewing as Qualitative Research: a Guide for Researchers in Education and the Social Sciences New York Teachers College Press
Shriver L (2007) The Post Birthday World London Harper
368
Smith A and Jack K (2005) Reflective Practice. A Meaningful Task for Students Nursing Standard 19, 26, 33 - 37
Smith JA, Flowers P and Larkin M (2009) Interpretive Phenomenological Analysis. Theory, Method and Research London Sage
Smith P (1992) The Emotional Labour of Nursing London Palgrave Macmillan
Smith P and Gray B (2001) Emotional Labour of Nursing revisited: Caring and Learning 2000 Nurse Education in Practice 1, 42 – 49
Smith P and Lorentzon M (2005) Is emotional labour ethical? Nursing Ethics 12, 6, 638 – 642
Smythe EA, Ironside PA, Sims SL, Swenson MM and Spence DG (2008) Doing Heideggerian hermeneutic research: A discussion paper International Journal of Nursing Studies 45, 1389 - 1397
Spiegelberg H (1984) The Phenomenological Movement. A Historical Introduction The Hague Martinus Nijhoff
Spiers J (2000) New perspectives on vulnerability using emic and etic approaches Journal of Advanced Nursing 31, 3, 715 - 721
Steeves RH (2000) Sampling In Cohen MZ, Kahn DL and Steeves RH (Eds) Hermeneutic Phenomenological Research: A Practical Guide for Nurse Researchers Thousand Oaks Sage
Stewart L, Mort P and McVeigh C (2001) Barriers and gateways: a study of nursing students‟ utilisation of learning support resources Nurse Education Today 21, 209 - 217
369
Suzuki E, Kanoya Y, Kitaoka-Higashiguchi K and Sato C (2005) Workplace environment, assertiveness and burnout risk among novice nurses in university hospitals Journal of Japanese Society of Nursing Research 27 85 – 90
Svenaeus F (2001) The Hermeneutics of Medicine and the Phenomenology of Health: Steps towards a Philosophy of Medical Practice London Springer
Thomka LA (2001) Graduate nurses‟ experiences of interactions with professional nursing staff during transition to the professional role Journal of Continuing Education in Nursing 32, 1, 15 – 20
Thompson JL (1990) Hermeneutic Enquiry In Moody LE (Ed) Advancing Nursing Science through Research Newbury Park Sage
Van Manen M (1990) Researching Lived Experience: Human Science for an Action Sensitive Pedagogy Ontario Althouse Press
Wall C, Glenn S, Mitchinson S, and Poole H (2004) Using reflective diary to develop bracketing skills during a phenomenological investigation Nurse Researcher 11, 4, 20 - 29
Walsh K (1996) Philosophical hermeneutics and the project of Hans Georg Gadamer: implications for nursing research Nursing Inquiry 3, 231 – 237
Walters AJ (1995) A Heideggerian hermeneutic study of the practice of critical care nurses Journal of Advanced Nursing 21, 492 – 497
Warne T and McAndrew S (2010) Portraying an abstract landscape: Using painting to develop self awareness and sensitive practice in Warne T and McAndrew (Eds) Creative Approaches to Health and Social Care Education London Palgrave Macmillan
Warne T and McAndrew S (2010) Re-searching for therapy: the ethics of using what we are skilled in Journal of Psychiatric and Mental Health Nursing 17, 503 - 509
370
Watson HE and Harris B (2000) Supporting students in practice placements in Scotland Glasgow Glasgow Caledonian University and National Board for Nursing, Midwifery and Health Visiting for Scotland
Wheeler HH, Cross V and Anthony D (2000) Limitations, frustrations and opportunities: a follow-up study of nursing graduates from the University of Birmingham, England Journal of Advanced Nursing 32, 4, 842 – 856
Whitehead L (2004) Enhancing the quality of hermeneutic research: a decision trail Journal of Advanced Nursing 45, 5, 512 - 518
Williams M (1922/1991) The Classic Tale of the Velveteen Rabbit or, How Toys Become Real Ontario Running Press
Williams B (2000) Collage work as a medium for guided reflection in the clinical supervision relationship Nurse Education Today 20, 273 – 278
Williams A (2001) A study of practising nurses‟ perceptions and experiences of intimacy within the nurse-patient relationship Journal of Advanced Nursing 35, 2, 188 - 196
Wiseman H (2007) Advanced nursing practice – the influences and accountabilities British Journal of Nursing 16, 3, 167 – 173
Wuest J (1994) Professionalism and the evaluation of nursing as a discipline: A feminist perspective Journal of Professional Nursing 10, 357 – 367
371
Appendix One: Example Consent Form
Consent Form (STUDENT)
Manchester Metropolitan University
Title of Project: ‘Emotional Intelligence in Pre Registration Nursing Practice’ (Working Title)
Name of Researcher: Kirsten Jack
This form is designed for you to use to help decide whether or not you would like to take part in the study. Please fill it in after reading the information sheet provided.
Please initial box:
Initial
1. I have read the information sheet dated 21/5/07 (Version 2) describing the study
2. I have had the opportunity to consider the information, ask questions and have had these answered satisfactorily
3. I understand that I can refuse to take part if I wish, without giving a reason and my refusal will not affect my progress on the Dip HE/BSc/BSc (Hons) Nursing programme
4. I understand that I can withdraw from the study at any time without giving a reason and my withdrawal will not affect my progress on the Dip HE/BSc/BSc (Hons) Nursing programme
5. I know that I can ask the researcher for further information about the study at any time
6. I understand that all information I give will be confidential and it will not be possible to identify any of the respondents in the study report
7. I understand that quotations from the study can be used in the final report and in other publications.
8. I understand that quotations used will be anonymous and I will not be identifiable in any report or publication
9. I agree to take part in the above study
Name/Date:
Signature:
Name of person taking consent /Date:
Signature:
372
Appendix Two
Information sheet to accompany Consent Form (student) Version 2 Date 21/5/07
Study Title: ‘Emotional Intelligence in Pre Registration Nurse Education’1 (Working Title)
Please read the following before completing the consent form.
I would like to invite you to take parting a research study. Before you decide you need to understand why the research is being done and what it would involve for you. Please take time to read the following information carefully. Talk to others about the study if you wish.
What is the Purpose of the Study?
The purpose of this study is to provide an analysis of „emotional intelligence‟ and explore its value with respect to emotional work within nursing practice.
The specific aims of the study are as follows:
1. To analyse the concept of „emotional intelligence‟ and its relationship to nursing practice 2. To explore the ways in which „emotional intelligence‟ could be promoted in nursing students 3. To contribute to the growing body of knowledge of nurses use of emotion in their relationship
with patients
The term „emotional intelligence‟ may be described as
„the ability to monitor one‟s own and others‟ feelings and emotions, to discriminate among them and to use this information to guide one‟s thinking and actions‟
(Salovey and Mayer, 1990 p 189)
Your role in the study
Your role in this study will involve you describing your experiences as a nursing student. The researcher will want to talk to you about what it has been like for you to become a nurse, particularly the emotional side of your work. The researcher will be interested in the interpersonal relationships you may have formed with patients during your education, and how you understood patients‟ emotional needs.
1 The focus of the work has always been to investigate emotion work amongst pre registration nursing
students. The concept of emotional intelligence was used as a means of explicating the nature of the
work to the participants in the early stages of the study. This was before the emergence of the term
‘emotional nurse being’, which was developed by the researcher toward the latter stages of the study.
373
Why you have been invited
The researcher is interested to hear about your experiences as a student nurse in terms of development of their emotional skills.
Do you have to take part?
It is up to you and you have two weeks to decide whether you wish to participate. I will describe the study and go through this information sheet, which I will then give to you to keep. I will then ask you to sign a consent form to show that you have agreed to take part. You are free to withdraw at any time without giving a reason. This will not affect your relationship with the University or with the researcher in any way.
Procedure and time requirement
Over the next two years you will be invited to participate in a focus group (discussion group with other student nurses) and a semi structured interview (a one to one talk with the researcher based on a set of prompts relating to the subject matter). You will be invited to take part in approximately 1 interview and 1 focus group, each lasting a maximum of one hour. These will be arranged at mutually convenient times and negotiated with you so that disruption to your schedule will be minimal. During the focus group, you will be invited with other student nurses, to discuss your thoughts and feelings about the development of your emotional skills in practice. This discussion will be taped so that the researcher can listen and reflect on your ideas later. The interview will involve only yourself and the researcher. The researcher will have a set of topic areas to guide the discussion. However this will act as a prompt only. You will be free to discuss areas related to the subject which you may feel are important.
Expenses and Payments
There will be no monetary payment for expenses or participation in this study.
Benefits, Risks and Discomforts
It may be that having an opportunity to take time out and discuss and reflect on emotional issues from practice, is a therapeutic experience for you. However, due to the nature of the subject matter, there may be times that you feel uncomfortable. For example, it could be that remembering an experience makes you tearful or angry. Please be assured that no pressure will be placed on you to carry on with a discussion of any subject about which you are uncomfortable, or that you find distressing. You can withdraw from the study at any time, without giving a reason. The researcher cannot promise that this study will help you personally, but your valuable thoughts and experiences could be used to inform and develop the delivery of education to pre registration nursing students.
Confidentiality
Confidentiality will be maintained at all times and you will not be identifiable from conversations which take place during the focus group or during the interviews. For example, during the writing up phase of the project, the context of the conversation can be changed so that a future reader of the work will not be able to recognise you in any way. During the course of this research study if I believe that patient care is being compromised due to bad practice or patients are at risk, I have a responsibility as an NMC registrant to report this to the most appropriate person. This will be the senior nursing manager of the Trust concerned
374
unless advised otherwise in line with the Trusts local arrangements. I will report verbally in the first instance and then my concerns will be put in writing to the manager concerned.
How will my data be kept confidential?
All written summaries of the information the researcher receives from you will be password protected on a home and University computer to which others have no access. All tapes and written field notes will be kept in a locked drawer at the University in the researcher‟s office. Data will not be identifiable when it is in transit e.g. in the researchers car as it will not have your name or base attached to it. The data collected will be kept for ten years. When it is destroyed it will be disposed of securely via confidential waste. The audio tapes will be destroyed on completion of the study. Confidentiality will be maintained at all times and you will not be identifiable from conversations which take place during the focus group or during the interviews. For example, during the writing up phase of the project, the context of the conversation can be changed so that a future reader of the work will not be able to recognise you in any way.
NB Limited confidentiality due to the nature of the study
Based on your comments during a focus group or interview, if I believe that patient care is being compromised due to bad practice or patients are being put at risk, I have a responsibility as an NMC registrant to report this to the most appropriate person. This will be the Senior Nursing Manager of the Trust concerned unless advised otherwise in line with the Trusts local arrangements. I will report verbally in the first instance and then my concerns will be put in writing to the manager concerned.
What will happen to the results?
The results of the research are being used to inform the development of nurse education. Results may be published in peer reviewed journals and a copy of the thesis which summarises the research will be available in the University library. You will not be identifiable in any publication unless you have given your explicit consent.
Who is organising and funding the research?
The research is part of an educational (PhD) project being undertaken by the researcher. The educational programme is being funded by the University as part of the researcher‟s professional development.
Who has reviewed the study?
The research proposal has been looked at by the Research Ethics Committee to protect your safety, rights, well being and dignity. This study has been reviewed and given favourable opinion by the Faculty Research Ethics Committee.
Complaints
If you have a concern about any aspect of this study you should speak to the researcher who will do her best to answer your question. She can be contacted on 0161 247 2405. If you remain unhappy and wish to complain formally you can do this by contacting Dr Maureen Deacon on 0161 247 2531.
375
Further Information and contact details
Further information can be obtained by contacting
Kirsten Jack 0161 247 2405
k.jack@mmu.ac.uk
Reference
Salovey P and Mayer JD (1990) Emotional Intelligence Imagination, Cognition and Personality 9 185 – 211
376
Appendix Three
Part of a Transcript: ‘Fran’
Me: OK, thanks. You mentioned earlier that there are some stories that you have found difficult. Is there a story, happy or difficult, that you think you might never forget that you could share with me?
Fran: There are a few that jump out at me straight away (long pause) erm, I think one of them is when I was on ICU there was a lady who was coming towards the end of her life and the decision was made to withdraw treatment and this had happened the week before with another patient I was looking after, but they hadn‟t managed to withdraw treatment before he had had a cardiac arrest and so that was really a very different situation and that was really upsetting and quite shocking. He had not been for resuscitation but he arrested in front of us and they had not managed to withdraw the treatment and so the family were actually in the room that they take people to, to talk about withdrawing treatment, and they were sat in the room as he was arresting so we had to run and get them and it was all really emotionally charged. The following week they decided to withdraw treatment on a lady who I was looking after, and so I was really apprehensive after what had happened last week and I had completely gone to pieces about it, but it was just an entirely different situation and it was still obviously very upsetting because we did withdraw treatment and within a few hours she did die, but it just felt so different and I just couldn‟t understand it at all, someone had died but I felt completely different about it, the family were there and involved in the decision and it was just a really positive experience, and it seems so bizarre that my patient dying could be positive but I suppose it was because the family were given some control over the situation and they were allowed to stay with her and we turned all the monitors off so that they wouldn‟t be distracted looking at the monitors wondering when she was going to go, and they could come and go, different members of the family could come in, you know they were like, she had adopted children and been a foster carer so there were loads of them coming and going and we just let them get on with it. It was just like, obviously it was upsetting, but it was just such a different situation and it was just really a nice situation to be allowed to give that to her, and for me it made a massive difference after what had happened the week before, to actually be able to know that it was coming and to know that she was dying and to be able to see the family being given a chance to say goodbye and actually, when she died being involved in looking after her after she had died and taking away all the tubes which we hadn‟t been allowed to do with the patient before which, it seems silly, but it was so important to me, but he had to go for a post mortem, and weren‟t allowed to take anything out so he still looked like he was suffering even though he had died (voice wavering a little). Whereas with this lady we were allowed to take everything away and get her all cleaned up, and it was just really peaceful and nice.
Me: A more positive experience…
Fran: It was and I come into university after every placement and say “oh someone died on my placement” and people had died when I had been on placement but not people that I had been involved with looking after, so I‟d thought “well I‟ve got that to come” and “what‟s it going to be like”, so when I went on ICU and there were people dying all over the place (laughs) I thought it was going to be really negative and I am just going to be really upset, but when that happened I started to realise that it doesn‟t have to be, and it definitely made a big difference.
377
Me: Mmmm, yeah, so you were able to comfort the relatives and family?
Fran: Yeah, and I felt really really nervous cause I hadn‟t been used to breaking bad news and things but they said, “Come in with us when we talk to them about the idea of withdrawing treatment” and the family were like, you feel awful cause the family were concerned for me, and they were like “I hope this isn‟t your first day and they have just brought you in here”, and I was like “Don‟t worry about me!” (laughs) but they were like, you know, yeah, it was really good cause I didn‟t think I would have the confidence to actually talk to them and say “Is there anything you need?” and, but, I just thought what would I want people to say to me if I was doing this, so I just kept popping round saying, “Are you alright?”, and they‟d say, “Well actually I am glad you‟ve put your head around the curtains cause we were just wondering, is she still with us?”, cause we had turned the monitors off, and we could see elsewhere what was going on but they were just sat with her talking, so we could reassure them and say, “Yes, but it won‟t be long now so if you want to get the rest of the family in”….so it was really good…
Me: So you felt able to support them emotionally….that sounds very positive…..have you ever felt unable to support someone in that way?
Fran: Erm, there was a situation in my second year were I was putting myself out there but it wasn‟t doing any good, because no one else on the team was, so I was literally the only person who was there for the patient. It was a lady who was admitted to a ward I was on, and she had never been in hospital before and she was really nervous and I went to do her admission and showed her around the ward and she told me she had never been in hospital before, and she also told me that she had been suffering with depression and she had been having suicidal thoughts and so that was quite a lot for me to suddenly take on because obviously when you are doing patients admissions you are their first contact with the ward. So I reassured her that I would pass that on to other people and she should approach people if she felt like she was having trouble when she was in, because her condition, she had a skin condition which was linked to her emotional state because she felt really ashamed of the way her skin looked and the way that people saw her and, when she went out shopping and it was obviously like, the two were affecting each other and every day that I went on that week she was like, “Oh I am really glad to see you, I had a bad night last night”, and she would always want to talk to me, but nobody else wanted to give her the time of day, nobody was bothered about her…
Me: Why not?
Fran: Well when I passed on the information, that she was depressed and that she had been thinking and having these suicidal thoughts, one of the staff on the ward said to me, “Well, she should just do it then!” (gasps). That was their idea, they just didn‟t have time for people who had mental health issues, even though more people they could possibly know have mental health issues but the fact that someone had been brave enough to come forward and say “I do, and it might be an issue whilst I am in here”, they just didn‟t want to know. I think there was just a real stigma with people…
Me: What was that like for you?
Fran: I felt really shocked because I couldn‟t believe that people could be like that and it seems naïve but you can‟t believe that someone would come into a caring profession who don‟t really care…..erm…and I didn‟t really know what to do about it because I still wanted to be there for her but there was only so much I could do. I obviously wasn‟t there all the time
378
and if she was really distressed whilst I wasn‟t on shift, is she going to feel like she can approach someone else because I had made sure that she knew I didn‟t have any, that I wasn‟t going to judge her and she could just come and tell me things, but I didn‟t know if anyone else on the other shifts would be doing that so would she be able to come forward? And if she wasn‟t able to come forward, what was she going to do? So I came on shift one day on the early and it was handed over from the night staff to the early staff that she had approached the night staff like on their shift and gave them her medicine cabinet keys cause she was self medicating and said “I feel like you need to take these off me because I am feeling really low tonight and I don‟t want to do anything I will regret”, and their attitude to that was hilarious and that they should have just left her with the keys and let her get on with it and how melodramatic, and they just didn‟t have time for people like that and I found out that they had had a patient on the ward, I think it was a year or two before who had committed suicide on the ward and had actually passed away like as a result of that and so they seemed to all have this idea that people who do that and how dare they come on here and do that, it gives us a bad name on the ward which was just like “Can you hear yourselves talking!” (laughs), no wonder the ward has a bad name! It was really hard because I felt really responsible and at the same time I didn‟t know how much I could actually do. I was only at the beginning of my second year so I was still really new to the idea of challenging people about things, like, you shouldn‟t have this view of people with mental health problems, I just didn‟t know where to go with it so I thought well I will just do what I can for her and that‟s the best I can do.
Me: Were you tempted to join in? It must have been hard to be on your own and not join with the culture
Fran: I just didn‟t want to because I thought, “That‟s just not me”. If I do become like that then obviously I have completely lost who I was who came into my training, because I just ….couldn‟t look at myself if I suddenly became that sort of person who thinks it‟s funny that someone had mental health problems so…..I just thought, “No”.
Me: You must have felt sad
Fran: I was very sad yes, it definitely was sad. I felt angry with myself because I thought, well really, if you really want to be true to yourself, you should say to them “What? I can‟t believe you just said that!”, but I just wasn‟t at a stage when I felt I could do that, so I thought the next best thing I can do, is just carry on and still be there for the patient, and just get on with it myself.
Me: The patient must have valued you …..
Fran: Well she came back which was really lovely, she got discharged off the ward and her mental health problems still hadn‟t been addressed at all but her skin problems had improved so she got discharged home and she actually came back when I was on one of my final shifts on the ward to say thank you for everything that you have done and she had had a new haircut and she was feeling really good in herself and so that was really really nice for her to have remembered what you did for her whilst she was in
Me: So how did you feel about that?
Fran: I felt really relieved to see her because I wasn‟t sure which way it would go when she had been discharged, I thought she may just think well that was such an awful experience, being in hospital, with her mental health problems, I didn‟t know how stable she was but for her to come back in and be feeling quite positive cause her skin was under control and
379
she.....like her confidence had been boosted so she had got this new haircut so it was really nice. It felt like well even if I have just done something to make her feel like a worthwhile person then that‟s been worth it
Me: Good. Is there anything we have not talked about that you wanted to tell me?
Fran: Erm, I don‟t think so, no
Me: We have covered quite a lot of ground
Fran: Yes definitely!
Me: Thank you very much
top related