Journal of Career and Technical Education
SHARED SUCCESS: THE CHALLENGE OF CARING FOR TODAY'S HEALTH OCCUPATIONS EDUCATORS
ABSTRACTThe purpose of this study was to describe faculty perceptions of caring interactions in lived experiences between faculty and their registered nurse (RN) students. Data were collected through semi-structured interviews with three college-based nursing faculty, three-diploma nursing program faculty and three hospital-based nurse educators. This study, using a phenomenological approach, uncovered themes related to the perception of faculty and students' role in caring. The themes discovered were: intuitive discovery, supportive guidance, respect; promoting independence, risk-taking, and shared success. Discussion of the themes indicated potential outcome divergence. Also noted were differences in what students and educators believe to be caring behaviors related to independence and rescue strategies. Health occupations educators, regardless of program design and outcome, are encouraged to use these findings to better understand role perceptions by students.
Caring has been identified as one of the normative values of nursing and health care. In many ways, caring is seen as being at the core of the profession. Although defined in various ways by numerous scholars (Gaut, 1983; Leininger, 1988; Parse, Coyne, & Smith, 1985; Roach, 1984; Watson, 1979), caring is generally recognized as a "mutual human process with identifiable behaviors" (Hanson & Smith, 1996, p. 105). Leininger (1981) suggests that caring be examined by identifying specific activities that are aimed at assisting, supporting, or enabling another person. Watson, whose name is most associated with the concept of caring in nursing, has developed a list of carative factors based upon the caring behaviors that can be observed between nurses and their patients.
The process for experiential learning occurs through a series of critical relationships: the learner to self, the learner to teacher, and the learner to the learning environment (Proudman, 1992). It is through these relationships that an attitude, such as caring, becomes internalized as students feel valued and fully appreciated (Chapman, 1992). In order to better understand the learner-to-teacher relationship involved in the concept of caring, this study examined how nurse educators perceive the experience of caring interactions. Health occupations educator perceptions of caring situations are an important link in promoting the health care goal of creating caring, nurturing students, and ultimately practicing nurses and technicians.
Nursing and other health occupations education has adapted caring as a central concept of its curriculum. The 1990 curriculum revolution in nursing education, initiated by the National League for Nursing, challenged faculty to create a sense of connectedness between themselves and their students (Tanner, 1990). Educators were encouraged to focus less on substance and more on process, embracing the idea that the content of nursing education is actually the interactions that take place between faculty and students rather than information, (Moccia, 1988). Since then, caring as an essential emphasis in nursing education has been related to a reduction in student anxiety and improvement in basic skill and professional value acquisition (Pullen, 2001). Shelton (2003) found that students were more likely to persist throughout their program, regardless of program type, when they perceived a greater level of nurse educator support, which involved a mentoring relationship and direct assistance to facilitate learning.
Yet, the paradox of promoting the concept of caring with nursing students has been that it is a concept that can be learned but not taught (Proudman, 1992; Tanner, 1990). Caring is not something that can be taught in a formal classroom or through traditional classwork (Burnard, 1987). Instead, caring is learned from the daily-lived interactions with others, which impart the real experience of having received care. Indeed, caring is practiced through the provision of opportunities, which involve the student in interactions that require the use of self.
Such an approach to learning has been viewed from the perspective of epistemological theory (Heron, 1981), a theory of knowledge, which has been greatly influenced by the student-centered philosophy of Carl Rogers and the educational philosopher, John Dewey. Epistemologically, caring falls under the experiential knowledge domain that is a type of knowledge characterized as subjective and affective in nature; personal and idiosyncratic; and gained only through direct personal encounters with a subject, person or a thing. Experiential knowledge has been summed up as knowledge through relationship (Burnard, 1987).
To date, much of the research on caring in nursing education has focused on students' perceptions (Beck, 1991, 1992, 1993, 2001; Dillon & Stines, 1996; Hughes, 1992) with very little attention paid to understanding the educators' own perceptions of caring interactions. Such an understanding is important because the learning process occurs through a series of critical relationships: the learner to self, the learner to teacher, and the learner to the learning environment (Proudman, 1992). For health occupation educators to achieve their goal, caring is a normative value. Nurse educators must first be aware of their own conceptualizations of the caring interaction, which then can be role-modeled in the faculty-student interaction. The purpose of this study was to understand health occupation educators' perceptions of caring interactions in lived experiences between themselves and their students.
The purpose of this phenomenological study was to describe faculty perceptions of caring interactions in lived experiences between faculty and their registered nurse (RN) students. Data were collected, over a three-month period, through semi-structured interviews with three college-based nursing faculty, three-diploma nursing program faculty and three hospital-based nurse educators.
The study was conducted by asking each of the nine participants to describe a lived experience of caring between a nurse educator and a student, in which caring had been demonstrated. They were asked to share all of their thoughts, perceptions, and feelings until they had nothing more to say about the situation. In an effort to encourage a dialogue centered strictly on the nurse educators' perceptions, the definition of caring was left up to each participant. They were encouraged to relate lived experiences, which they defined for themselves and the students as caring.
Rationale For Qualitative Research Approach
Qualitative inquiry is meant to ask questions about the how or what of a phenomenon (Creswell, 1998). Qualitative research is most suitably used when the phenomenon in question is composed of numerous variables in need of detailed exploration (Creswell, 1998). Caring is a many faceted phenomenon, existing on many planes, and experienced differently in varying situations and by those partaking of disparate roles within those situations. Such a phenomenon is also best explored from playing a natural setting; In this case, the natural setting is the lived experience of nursing faculty and students. Indeed, exploration of phenomena within a natural setting is a hallmark of qualitative enquiry (Creswell, 1998). Although several fine phenomenological studies have been done on student perceptions of faculty/student caring interactions (Beck, 1991; Dillon, & Stines, 1996; Hanson & Smith, 1996), little research exists examining faculty perceptions of the phenomenon of caring interactions between themselves and their students. Since little is known about the topic and no theory yet exists to explain the behavior of participants, qualitative exploration is the natural choice (Creswell, 1998).
Phenomenology as a Tradition of Inquiry
Creswell (1998) defined a phenomenological study as one that describes the meaning of the lived experiences for several individuals about a particular concept (i.e., the phenomenon). It is a qualitative approach to research that is based on the acceptance of a primary tenet which states that the very essence of the experience can best be described from an individual's recounting as opposed to a group's experiences.
The procedural issues involved in using phenomenology require that the investigator follow certain precepts. First, the phenomenological investigator must understand the philosophical perspectives behind the approach, especially the concept of epoch. Epoch refers to the investigator's need to cordon off certain preconceptions , which they might have about a particular phenomenon, and to develop a more general structure, which is derived from people's actual lived experiences.
Secondly, the phenomenological investigator should develop research questions which probe the meanings of individual's lived experiences such that the subject can adequately describe in depth their feelings, thoughts, and beliefs. Third, it is important that subjects of a phenomenological study be carefully selected for their ability to fully describe the phenomenon under investigation, based upon their having had real and lived experiences. Extensive interviewing is needed so that subjects can fully self-reflect and contemplate upon the meanings of their experience. Fourth, phenomenological investigation requires rigorous data analysis that follows a proscribed series of steps: (1) horizontalization, or dividing statements by protocol; (2) clustered meanings, or grouping statement units into phenomenological concepts; (3) textural description, or uniting the units to make a general description of what was experienced; and (4) structural description, or deriving from the units how the phenomenon was experienced (Creswell, 1998). Finally, phenomenological investigators should write their study in such a way that the reader is left with a greater understanding of the quintessence of the experience, or as Polkinghorne (1989) stated "the reader of the report should come away with the feeling that I understand better what it is like for someone to experience that"(p. 36).
Phenomenological investigation is appropriate for this study of faculty-perceived caring interactions because only those faculty who have actually experienced such interactions with their students can describe in-depth the essence of the phenomenon...that is, what caring behaviors look like, feel like, and mean to them as nurse educators. The challenge to the investigator in this study was the epoch of caring, since all three interviewers were nursing faculty and might have possessed (knowingly or unknowingly) certain preconceptions or philosophical perspectives on caring based on their own lived experiences with students. To circumvent this issue several steps were instituted: (1) each interviewer purposely selected faculty recognized by his/her peers as being caring, (2) an interview protocol, reviewed by three nursing faculty, was meticulously developed to focus on open-ended, bias-free questions, (3) intra-interviewer training was held on bias-free interviewing with concurrent practice sessions, and (4) interviewers identified their own pre-conceptions about the notion of caring prior to interviewing subjects.
Participant Selection Process
Nine nursing education faculty members was purposively selected from two nursing programs and a hospital located in the Midwestern United States. All participants in this study met the following criteria: current licensure as a registered nurse (RN), completion of a minimum of two years in clinical practice, graduate of an accredited nursing program, and recognized by their peers as caring individuals.
Data collection consisted of interviews in which the nine selected subjects were asked to relate a lived experience of caring between a nurse educator and a nursing student. The three interviewers each interviewed three subjects using a semi-structured protocol consisting of four questions. The interviews took place at each of the subject's places of work as this was found to be the most convenient arrangement. The interviews took from 20 to 60 minutes and were all audiotaped and subsequently transcribed. The subjects were all well known to the interviewers, which facilitated a comfortable, open exchange between the interviewer and subject. Anonymity for the subjects was achieved through the use of pseudonyms both in the tapes and the transcripts, as requested when human subjects approval was sought. Only the researcher doing the individual interview knew the name of the subject on any tape.
- The subjects' oral descriptions are read to provide the researchers familiarity with the accounts.
- Phrases or sentences that pertain to the phenomenon are extracted. The meanings of the selected significant statements are clarified while carefully preserving a link to the original descriptions.
- The meanings of the significant statements are organized into clusters or themes. Validation of the clusters is performed by a) referring back to the original descriptions; b) Looking for any information in the original descriptions that is not covered by the identified clusters or themes; c) looking for any cluster or theme which was not represented in the original descriptions, d) examining themes for discrepancies.
- An exhaustive description of the phenomenon is developed and written.
The above steps were followed with the interview data collected for this study. Each of the three interviewers individually reviewed the transcripts of the oral descriptions from their own three interviews. From those transcripts, each researcher gleaned those phrases that were found to be pertinent to the phenomenon of caring between nurse educators and nursing students. The researchers, then, identified their perception of the meaning of each of the selected phrases, followed by the arrangement of the identified meanings into themes. Finally, the interviewers came together and compared their identified themes with the supporting statements.
One researcher identified nine themes: mothering; talking/listening; touch/body language; empathy; sensing/perceiving; promoting independence; being there; guidance/direction; and respect. Another researcher identified four themes: touch; time; personal feelings and openness/expressive/self-confident. The third researcher identified six themes: intuitive discovery; support by words, presence, or active assistance; reassurance; risk-taking; teaching needed skills; and shared success (See Table 1).
Themes Generated by Researchers
Themes Generated By Researchers Researcher A Researcher B Researcher C Mothering Touch Intuitive discovery Talking/listening Time Support by words,
presence, or active
Touch/body language Personal feelings Reassurance Empathy Openness Risk-taking Sensing/perceiving Expressive Teaching needed skills Promoting independence Self-confident Shared success Being there Guidance/direction Respect
The interviewers were able to agree on combining and renaming certain of the themes to create a final six themes: intuitive discovery; supportive guidance; respect; promoting independence; risk-taking; and shared success. From those themes and the rich descriptions that created them, the researchers were able to create an exhaustive description of the phenomenon of nurse educator/student caring interactions.
When examining the transcripts of the interviews with the nine research subjects, several things became readily apparent. First, all of these nurse educators were very concerned with all aspects of caring within the context of their profession and within their personal lives. All told stories of giving of themselves, their time and talents, to meet the challenges presented by the very interpersonal demands inherent in their daily lives and those of their students. Second, while the identified themes were evident throughout most of the caring accounts, the stories themselves represented a wide range of situations. Four of the nine interviews told of clinical situations involving assisting the student in interactions with patients. In several of those cases, the student's difficulties with their clinical assignments sprang from past or present personal issues that needed recognition so that appropriate support could be given. In three of the instances, stories were told about assisting students with personal problems that, while troubling to the students, might easily have been missed since they only indirectly affected the student's clinical performance or academic achievement. In these cases it would have been easy for very busy educators to have assumed these students were merely unprepared due to lack of interest or skill. In two of the accounts the nurse educators dealt with students as they struggled with the classroom part of their educational process. It was also evident that, while the educator had selected a particular story to tell, the sort of caring described occurred often in their professional lives.
The following sections will explore each of the six identified themes. For each theme, quotes from the original transcripts will be presented to support the validity of the theme.
Caring, in the nine accounts of lived experience, often started with the educator caring enough to recognize in the student a need for supportive assistance. In describing a situation in which a student was living with an abusive significant other, the nurse educator saw behaviors in the student that could have been interpreted many ways. Intuitively the instructor saw them as signals of needing assistance. This educator related, "...it was just her behavior. It wasn't normal and she was always looking very anxious and very concerned. So I don't know if I drew the short straw to talk to her or whether she and I just talked well together, but we sat down and talked about it. She did tell me, which some student's won't....we just don't know what is going on in the student's minds until we sit down and say, 'What's the matter here?' "
In another account, a nurse instructor was in her office late in the afternoon when a student, for whom she didn't have actual responsibility, came in. She relates that "...she came in and just looked really ghastly, in that she looked like something was really wrong." This instructor discovered that the student had just spent the day with her case management patient while the patient went through the process of dying.
Another subject described a situation in which a student's work had started slipping and then one day she did not show up for her clinical assignment. Missing one day of clinical wouldn't necessarily be seen as terribly out of the ordinary, but this educator put several observations together to intuitively decide the student needed intervention. She called the student at home and got no answer. When confronted later, the student admitted she knew the phone was ringing, but she just didn't have the energy to get up and answer it. Referrals for depression ensued, but the problem wouldn't have been recognized without the persistence of the educator. She described her thought process thus: "she just hung around and I knew she was lonely...I think she was homesick. She had been in clinical for a few weeks and she didn't behave like this ordinarily. So that would have been unusual, unusual behavior....but it wasn't like her not to come."
In another very poignant story an educator told of a student who uncharacteristically appeared reluctant to accept an assignment requiring her to care for patient in the last stages of Alzheimer's disease. After intuitively deciding that there was a problem, the instructor learned from the student that the student's mother had died of Alzheimer's. In describing the discovery of this problem the instructor related the following clue, "...when I made assignments and she saw who she had and she said, 'Oh, I have to take care of him?' but when asked if she wanted to change assignments, she declined. Then when the student was providing care the instructor noted, ..."she was real hesitant and just kind of quiet, withdrawn, not like her usual self."
Another instructor encountered a student who, though verbal about her disappointment with her grade, appeared to have other problems getting in the way of her academic achievement. The instructor related, "...and I could tell she was very distressed during class. I guess the old nurse sort of crept in a little bit here too, the student has ADD and is on Dexedrine and my thought then was...'Oh, do I have a student who is combining drugs?' which truly I believe is a factor in this situation; and I was concerned during the mid-term because I, again, considered drugs were playing a part...."
Alternatively, other nurse educators expressed the knowledge that some students were very good at demonstrating caring behaviors with their patients. That they intuitively noted these talents is evident from the following excepts from their transcripts: "I just thought everything she did was just genuine and it wasn't fake or anything like that...she really did care.... spending time with the patient, sitting down, and not being in a hurry...not waiting for the patient to turn on the call light constantly;" "I think this person was just a very caring and thoughtful person, and wanted to treat patients like she would treat somebody in the family that she really cared about...she was very at ease and natural."
The research team characterized Supportive Guidance, as one of the most prevalently caring behaviors. Described behaviors within this theme ran the gamut from just sitting with the student and listening, to actively intervening, to teaching needed skills or getting the student needed outside help.
One subject described a situation in which a student was seen to understand course content but had a difficult time taking examinations. After struggling throughout the course to achieve high enough scores to pass, she waited after the final exam for the instructors to grade her test, only to find that she had failed. The educator described her support of this student in the following quotes: "Her parents had very high expectations of her doing well, and were supportive, but she was still fearful of telling them she'd failed. So I told her I would sit with her while she talked with her parents; and I think getting over the stumbling block that she was competing with her sister was important. I needed to get her to stop thinking about her sister, and to know that she was a different person and she studied in a different way and she learned in a different way. And not to compare herself to her sister. She didn't even have the same interests as her sister. She was just comparing grades; and we did spend quite a bit of time working with her with test taking strategies and better ways to study, but as a person she was so wounded by the experience that she needed a lot of emotional support and as a faculty member I tried to keep track of her throughout her time at the school; asking how she was doing in other courses, and giving her reassurance as she took their tests."
In the situation in which the student was facing emotional difficulty caring for a patient with the same devastating illness that she'd experienced with her mother, the nursing instructor chose to provide one-on-one support. She describes her selected behaviors as follows: "And so we sat and basically what I did was to have some empathy for her and let her talk. I asked her what her mom was like prior to getting the Alzheimer's; and we just did a lot of caring...there was no level of an instructor/student; we were both women, talking about a terrible disease. We just did a lot of soul searching, sharing information with no hiding of emotion."
For the instructor confronted with the homesick, depressed student whose clinical performance was slipping. Support came in the following form: "…we had a discussion about what depression was and loneliness and what went on with those problems, and she began to stay after clinical and talk with me. Also we eventually got her to get a little help with sorting all this stuff out. And she settled down and finished her clinical and did a fine job; she needed to have a fair amount of touching, I think. It was very interesting because there was a couple of people in the clinical area, one of them was a custodian and the other was one of the dietary people and we knew everybody because we had been there so long or I knew them all...And I said to the custodian, 'Oh, this young woman's really feeling lonely, I think she needs a hug.' And he just gave her a great big hug and so did the person in dietary. And she started to cry and she said, 'Oh, that's so much better.' So I think that was kind of a turning point for her."
The instructor, through this encounter, that was able to find out from the student that the student was living in an abusive home situation. The faculty was able to give support through first talking about the problem with the student and then providing appropriate referrals. In her words, "we visited and I got her plugged into the places that I thought might be able to help. And she eventually was able to get out of the situation; and ...so basically that was the main thing, to get her out from under and away from him, but she still had to come to school and he knew where she was most of the time, and he was smart enough never to come in. He would always just wait outside."
In supporting the student whose case management patient had died, the instructor took time away from her own busy schedule to sit with the student and listen to all she had to say. The instructor described her actions as, "I listened and she visited a lot. Just her talking about her feelings and all the stuff that just went through her as the death was occurring. How she was helping the family and all of those things. And she credited, not being in such a hurry, rush, I've got to get out of here. Because I think that day, I had about five minutes to get what I was doing done and get going someplace. But I think when I got into it, I decided what I was going to do wasn't as important as this situation."
The accounts of caring interactions were peppered with references to the need to be respectful of students and their needs. In describing their general approach to interactions with students in the clinical area, several nursing instructors emphasized their overall respectful approach within daily, sometimes tense, patient care situations calling for frequent, specific, on-the-spot feedback. Examples of these approaches included, "I believe we all have to be careful. You know it's one thing to be aggressive and to intervene in errors and things like that, but it's another thing to be aggressive so that it sounds like you're just ratcheting at people... Well, I try very hard not to yell at them if I say something like 'Something's not going right,' they know to step back and I'll go ahead and help them finish, then we'll talk about it after we're through; and I don't want to embarrass a student in front of a resident or a patient. That doesn't accomplish anything. All it does is take away their self-esteem."
In dealing with the student who had failed the course, the nurse educator related her approach to giving information, support, and reassurance to both the student and the student's parents. She felt it very important to demonstrate respect to the student through honest, consistent communication: "...the parents wanted to talk to us alone. So we, the Dean of Students was there also, spoke with the parents and we said the same things that we'd said in front of the student. So we were keeping confidentiality. I felt it would be kind of cheating her if we hadn't said the same things in front of her that we said to her parents."
In another instance the nurse educator gave the student respect through the sharing of her personal feelings. When the student was sharing her history with her mother and Alzheimer's disease, the instructor was willing to step outside her professional demeanor to demonstrate her respect and empathy for the student's feelings by sharing her tears. "I remember feeling a little embarrassed...but I remember I shed a few tears and I wasn't sure I should be doing that."
While some of the disclosed situations required much support and nurturing of students by external forces, there were also situations which the nurse educators felt required sparking the students' own internal forces.
The theme of promoting independence is a concept that is difficult for both faculty and student. The following interaction outlines this dichotomy. "Well, I think it's important that students know that you are generally concerned and I think I am generally concerned about what they are doing in school and their learning; however, its tough not to be seen as a pushover teddy bear, too." This is how one of the nursing instructors expressed the idea that making things easy for students might make them dependent, and, while appearing to be caring, might actually be the worst thing an instructor could do. This instructor was teaching a course in which roughly half the students were failing at midterm. Her feelings, while conflicted, were firm. "When I have given them structured guidance on how to pass and they don't follow it, and I give them support along the way to pass, sometimes I also have to let them fail. Bottom line, the learning belongs to them. I feel I'm really the 'guider', but I really do care enough to let them fail because that may make them come back and learn the next time around and do what they need to do; and I happened to run into one student this morning and she was looking at her grades and she said, 'My, these are poor.' And I said, 'Yes, these are poor grades' And she said, 'I just don't know what it is this semester.' and I said, 'You know, I've really wondered that myself but the best I can come up with is I don't think people are really prepared for class like they should be, like we've talked about. And, sadly enough I think students just need to spend a little more time, and I was trying to politely not say 'Hey, you get what you deserve, you know.' And she said, 'You are absolutely right'." This same instructor dealt with the student upset about her grades, and possibly having difficulty due to drug use. This student often sought assistance by complaining about her grades; however, she rejected all suggestions for changes in study habits. This instructor expressed her confusion and frustration in trying to promote this student's independence. "I've worked with this student and had many other interactions with her and I'm still torn between, is my caring being used as manipulation or is sincerity there on her part?"
Balancing between helping enough but not too much was not the only risk which these nurse educators faced. At times, caring involved putting themselves at risk for professional or personal consequences.
In dealing with the student who had failed her class due to poor test-taking skill, the instructor found herself placed in the position of advising the student's parents about the student's potential for passing the course if she were to decide to retake it. She told of her dilemma, "...it was very difficult because they had certain expectations plus they were paying the bill for her to retake the course…and if it were not possible, in the instructor's opinion, they would support her in not going on, and finding another career that might be more suitable."
Personal safety issues entered into caring given to the student found to be in an abusive home situation. Because the abusive boyfriend would wait outside the school for the student to come out, the student would have become a prisoner or would have had to give up her nursing career if instructors hadn't taken the personal risk required. "The faculty, myself, and some of the other faculty, would sneak her out of the hospital or out of the building so she would not have to confront this abusive individual."
Predictively, the time, energy, and sometimes risk would not have been undertaken by these nurse educators if some element of reciprocity had not been apparent. Caring in most situations created success in which the educators shared.
These nurse educators related stories often ending with expressions of appreciation from their students or with their own feelings of satisfaction with the results of their efforts. One subject remembered just such a warm moment, "...one of the students who was in that clinical group said, 'Oh, I want an appointment. Are you going to be in your office at 2:00?' And I said, 'Yeah, I think so,' and she happened to be one of my advisees so I didn't think too much about it. At 2:00 I had her file out and then all ten members of the clinical group came with a gift certificate. She'd made the appointment to do that. And that was sort of a neat experience."
In the situation in which the student and instructor shared support and information about Alzheimer's disease the instructor remembered the student expressing her appreciation, "...she was very thankful at the end of that session, and told me thanks several times throughout her time in school, and even on the day of graduation she thanked me for the support I had given. This situation appeared to have had positive impact on both parties."
The story told of the student failing the class was laced with references to mutual success. The educator very much felt that the success of her interventions had contributed to the student's success in the course and the school. Some of her quotes include, "She did retake the class and was successful in retaking. She did complete the whole curriculum and was successful in taking her examination after graduation. It was rewarding to see someone so devastated regaining their self-esteem and be successful with just a little support." The instructor also said "…to get her so that she could overcome that and then be successful and have a higher self-esteem to be able to look at you and talk to you, instead of looking down and then to know that she was successful long-term. That was very rewarding, and she did come back and thank us."
For the faculty involved in helping the student out of the abusive situation, success was very gratifying for all those involved. "This student really wanted the help, and was really willing to go through the process to get out of the situation, and so that made it more successful for all of us, I think." And for the faculty member who chanced to be in the office when the student needed to talk about her first patient death, gratification came from just being in the right place to provide the needed support. "I was glad I was there. I was glad I was in the office and I heard someone come in."
In reviewing the literature, numerous studies have been done on student's perceptions of a caring faculty interaction (Beck, 1991; Dillon & Stines, 1996; Hanson & Smith, 1996; Roach, 1984). Most of these studies emphasized the importance of faculty understanding the student's perspectives on what constituted caring behaviors. (Beck, 1991; Dillon & Stines, 1996) While previous research has been useful for understanding the student's perspectives, there is no published research on understanding faculty's perceptions of the caring interaction.
While the dearth of study of the perspective of the faculty member is distressing, it is interesting to note that the results of the Dillon and Stines (1996) and Beck (1991) studies mirror the results of this study. The Dillon and Stines study discovered that nursing students found caring from faculty to consist of sharing and giving of self, respecting the student as a unique individual, and role-modeling caring behaviors. These themes and their associated quotes demonstrate a striking resemblance to this study's findings. Students in the Dillon and Stines study wanted faculty members to take extra time, help them one-on-one, follow through after discovering problems, touch the student, express sensitivity, perceptiveness, and understanding, and express emotions openly through laughter and tears. Faculty in this study expressed many of the same sentiments. They certainly demonstrated perceptiveness through those behaviors characterized as intuitive discovery, supportive guidance, respect, and risk-taking behaviors, and gave to the students in our study what the students in the Dillon and Stines study desired within caring situations.
The findings of the Beck (1991) study were very similar to those of Dillon and Stines (1996). She found three themes that characterized the findings within her data. These were attentive presence, sharing of selves, and consequences. Most striking is the resemblance of data statements from Beck's study with those of the Dillon and Stines study and with the present research. Beck (1991) lists, among others, "the behaviors of gave of her time, listened to me, sensed my need, shared in my joy, allowed me to express my feelings, empathetic, supportive, reinforced my value as a person, stopping and asking how things were going and moment of sharing" (Beck, p. 20). These statements tend to reflect the themes of this study with the possible exceptions of risk-taking and promoting independence.
This study demonstrated a progression of themes. The health occupation educator must recognize the student in need. That the subjects of this study seem to have become very adept at this intuitive discovery would tend to indicate that instructors are seeking ways to provide needed caring within the academic setting. They know that nursing school is a very stressful time in the lives of students at fragile life stages, and they want those students to be successful.
Once the situation was recognized, the faculty members had to select among a variety of supportive options. The educators/subjects in the study often selected to start with supportive guidance characterized by listening, talking with the student, taking needed time, and providing needed interventions. An alternative was promoting independence of student behaviors. Some tension existed over how much to assist the student and when to let go and allow the student to take needed consequences.
Respect for the student was evident throughout. Faculty were often able to recognize behaviors as reflective of the need for help because they respected the students' abilities and their previous efforts to succeed, and knew that those efforts would have been continued if possible. Respect was also demonstrated in the desire to give feedback in as confidential and gentle a manner as possible.
Risk-taking by faculty may be seen as more unusual and, perhaps, as the ultimate expression of the desire to give of oneself in a caring relationship. One would hope that nurse educators would not be called on frequently to take risks in providing caring to students; however, in the situations described by subjects, the faculty took professional and personal risks almost without thought for themselves. This, to them, was just another needed step that they could provide and willingly did provide for the good of their students.
The most rewarding and joyful of the themes is shared success. While it is to be assumed that many caring behaviors go unsung, the students in this study knowingly or unknowingly provided warm remembrances for their instructors. The more overt of these rewards came in the form of thank you's, often delivered multiple times. But even without those expressions of gratitude, the students "paid their faculty back" (Beck, 1991) by turning failing or borderline behaviors into success. Nursing education is a demanding profession, full of stresses and long hours, and though students may not realize it, they may help encourage caring behaviors from faculty by reciprocating.
Some behaviors that educators viewed as caring (i.e., supportive guidance, intuitive discovery) appeared to similar to what students have identified as caring behaviors in earlier studies (pre-sensing, sharing, supporting [Beck, 2001]). In addition, the fact that educators viewed promoting independence as a caring behavior seemed consistent with Lofmark and Wikbald (2001), who found that responsibility and independence were viewed as facilitating behaviors in students' clinical learning. However, nurse educators clearly had their own unique perspectives on what constituted caring interactions with students. Educators tended to view caring interactions as reciprocal behaviors and not one-dimensional relationships viewed in terms of what the nurse educators contributed to the interaction. Implications of this divergent perspective are that both nurse educators and students should be made aware of these conceptual differences so that clarification can be made early in the relationship. That is, students need to understand that nurse educators view caring as a two-way street requiring active participation in a genuine, committed manner. Similarly, nurse educators would benefit from understanding that their view of caring is somewhat divergent from the students' view, since students see caring primarily from an egocentric position.
Another area of divergence between educators' perceptions and students' expectations might arise in terms of promoting independence. While both students and educators seem to value this as a part of the caring interaction, educators emphasized that this sometime meant that they deliberately chose not to rescue the student and instead allowed for the possibility of failure. To students, this behavior is likely not perceived as caring and indeed, our educators recognized that some tension existed over how much to assist the student and when to let go and allow the student to take needed consequences.
Risk-taking by nurse educators may be seen as more unusual and, perhaps, as the ultimate expression of the desire to give of oneself in a caring relationship. One would hope that nurse educators would not be called on frequently to take risks in providing caring to students; however, in the situations described by these educators, they took professional and personal risks almost without thought for themselves. This, to them, was just another needed step that they could provide and willingly did provide for the good of their students.
IMPLICATIONS/RECOMMENDATIONS FOR FUTURE RESEARCH
Leininger (1981) warned that without specific teaching and practice opportunities of caring in nursing schools, faculty could not ensure that their graduates would know and practice care later on. For health occupations education to achieve the goal of promoting caring as a normative value, role-modeled in the faculty-student interaction, faculty must first be aware of their own conceptualizations of the caring interaction. Thus, this study approached caring from a unique philosophical basis--epistemology--grounded in the belief that there are different perspectives, or ways of knowing (e.g., faculty knowing versus student knowing) that exist relative to the caring interaction. It is for this reason that the work in nursing can encompass all areas of health occupations education.
Findings of this study contribute evidence that phenomenological research is an appropriate method of generating nursing knowledge. In addition, the results of this study have significant implications for all health occupation educators. Clearly, faculty has their own unique perspectives on what constitutes a caring interaction with students. While many of the behaviors identified by faculty in this study are consistent with those identified by students in previous research, the findings of this study identify differences between students and faculty. For example, faculty discussed caring as an interaction which required reciprocal behaviors while students emphasized interactions which appear to be more one-dimensional in terms of viewing only what the faculty contributed to the interaction. Implications of this divergent perspective are that both faculty and students should be made aware of these conceptual differences so that clarification can be made early in the relationship. That is, students need to understand that faculty view caring as a two-way street requiring students to participate in a genuine, committed manner. Similarly, faculty would benefit from understanding that their view of caring is somewhat divergent from the students' egocentric position.
This study's findings also have significant implications for school administrators interested in promoting a curriculum change toward more caring interactions by their health occupation faculty. The change process begins with the identification of a problem. By first having faculty self-reflect their own caring behaviors, a strong foundation is laid for initiating the transformation of caring. For only when we truly recognize our own epistemological basis for the concept of caring can we consciously pursue those behaviors and evaluate our own strengths and weaknesses as necessary for personal growth.
On-going research is needed to compare the perceptual differences in caring behaviors between students and faculty. Further research is also needed to document the outcomes of student-perceived caring interactions and faculty-perceived caring interactions in order to validate perceptions with actual performance outcomes. Health occupation educators need to match their teaching of caring with their actions and provide curricula that enable students to form meaningful human connections. Knowing how both groups perceive caring will help to maintain the necessary faculty-student connectedness that evolves, ultimately, into a nurse-patient connectedness.
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THE AUTHORPatricia Coyle-Rogers, PhD, MSN, RN, BC, Purdue University School of Nursing, Johnson Hall of Nursing, 502 North University Street, West Lafayette, IN 47907. Phone: 1-765-494-4030. E-mail: email@example.com.