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I am a nurse: nursing students learn the art and science of nursing.

ABSTRACT The purpose of this study was to understand how nursing students make meaning of experiences of being in nurse/patient interactions. The study was conceptualized using Heidegger's philosophy of being. Participants were 28 sophomore nursing students in the first year of clinical experiences with patients. The participants recorded in electronic journals their responses to six open-ended questions concerning their thoughts and feelings about being in nurse/patient interactions. Data were analyzed using an interpretative process true to hermeneutic phenomenology. Five themes were identified: fear of interacting with patients; developing confidence; becoming self-aware; connecting with knowledge; and connecting with patients. Four implications were drawn from the study: nursing students intertwine the art and science of nursing in nurse/patient interactions; nursing education must be restructured to include a balance of the art and science of nursing; reflection and/or journal writing is a valuable way to enhance learning; and each nursing student is developing identity simultaneously as a nurse and as a person.

Key Words Nursing Students--Art of Nursing--"Being" in Nursing--Clinical Experiences--Reflective Writing

I AM A NURSE.

ALTHOUGH for 29 years of my life I defined myself by these words and experienced nursing through multiple roles and in a variety of settings, I never took the time to really think about what being a nurse means to me.

THEN, after nine years as a nurse educator, I conducted a literature review for my dissertation and began to dwell on what it means to say I am a nurse and what it means to be a nurse. * I KNEW that nursing is both an art and a science, and I KNEW that the essence of nursing exists in interactions between nurse and patient. I ALSO KNEW how nursing students learn through both didactic and clinical experiences. What I did NOT KNOW was how nursing students learn the being of nursing.

THIS ARTICLE presents research that explores how nursing students interpret, or make meaning of, experiences of being in their nurse/patient interactions. The meanings of behaviors are explored, not the behaviors themselves.

Terminology Through research and theory in nursing practice, nursing is defined and described as both an art and a science. While the science of nursing is based on the acquisition of skills and knowledge across the curriculum as well as theoretical knowledge of nursing (1,2), Paterson and Zderad describe nursing as "an experience lived between human beings" (3, p. 3). Chinn calls the art of nursing "the art/act of the experience-in-the-moment" (4, p. 24).

The art of nursing develops from the humanness of the nurse and the patient (3,5). Bevis states that it is taught as part of the "hidden curriculum--the curriculum of subtle socialization, of teaching student nurses how to think and feel like nurses" (6, p. 75). Traditionally, the art of nursing is taught in schools of nursing through communication lectures or in behavioral communication skills laboratories (7). However, since the true art of nursing is created in the human realm--the actual interaction of the nurse and the patient--Doane (7) believes that such laboratories do not allow students to truly learn the art of nursing. The essential core, the heart of nursing, is the nurse/patient interaction, in relationship with or being with a patient. And it is in interactions with patients that the nurse experiences nursing (2,8).

In reporting on the research described in this article, it is important to identify the concepts of being and to be. Being is a concept described by Heidegger (1927/1962), and being and to be are used interchangeably. Both concepts are indefinable. That is, being is not an entity to be defined, but can only be discovered from asking about how it was to be from "relatedness backward" (9, p. 277).

The concept of relatedness backward offers a way to understand being. That is, an object is not studied, but looking back at a process is. In other words, the best way to define being is to look at a situation after it has taken place and to focus on the process that occurred. A nurse may not necessarily under stand all aspects of a nurse/patient interaction until she or he looks backward at what took place during the interaction.

It is also likely that there will be differences in the way instructors and students describe the meanings they derive from the same experiences. Therefore, the purpose of this research was to understand how nursing students make meaning of experiences of being from their interactions with patients. A search of the literature describing nursing students in clinical experiences reveals no previous research on this topic in conjunction with the concept of being.

Methodology Hermeneutic phenomenology was used to uncover how nursing students learn to experience being with patients. Crist and Tanner state that hermeneutic phenomenology should be used as a research methodology "when the research question asks for meaning of a phenomenon with the purpose of understanding the human experience" (10, p. 202).

PARTICIPANTS Participants were sophomores enrolled in an entry-level, two-section nursing fundamentals course at a comprehensive midwestern college. Every other week for four hours, all students engaged in interviews and interactions with patients in a clinical setting. All students were invited to participate in the study; of 117 eligible students, 28 accepted the invitation to participate. Participants ranged in age from 19 to 30; two were male; and the group was primarily Caucasian, with one participant of Hispanic background and one African American.

Participants were instructed to record in electronic journals accessible only to the researcher their thoughts, feelings, and emotions related to being in interactions with patients. Six questions developed by the researcher to guide the journaling activity were based on similar questions developed by the researcher and used by clinical students in a pilot study. Questions were intended to be probing yet sufficiently open ended to elicit student reflections on the day's interactions. They are as follows:

* Describe an interaction you had with a patient today.

* What were your thoughts or emotions while you were in the interaction?

* Describe how you felt about yourself during the interaction.

* Describe how you felt about the patient during the interaction.

* What did I not ask you that you would like to tell me?

* Any other thoughts or feelings you want to share?

DATA ANALYSIS The participants submitted 37 different journal entries describing their interactions with patients. To maintain confidentiality, and because electronic mail messages have names attached, student names were deleted when the journals were printed and code numbers were written on the papers.

In hermeneutic phenomenological research, data are analyzed through an interpretive process. Data collection and analysis occur simultaneously, with the bulk of the analysis taking place toward the end of data collection. Hermeneutics is a circular process used to uncover and identify people's meanings and experiences--in this case, the meaning nursing students experience in being in nurse/patient interactions. The analytic process starts with a priori categories and ends with emerging themes uncovered through interpretive analysis. A priori categories, identified from the literature review, were the science of nursing, the art of nursing, caring, presence, and being.

For this research, journals were first interpreted to understand the entire experience of a participant. Initially each experience was coded in appropriate a priori categories. Entries were reread multiple times, each time to look for similar themes within an individual experience. These similar themes are known as exemplars, or "salient excerpts that characterize specific common themes or meanings across informants. They are parts of stories that have similar meanings within informants' stories" (10, p. 204). The exemplars formed the five themes of how students experience nurse/patient interactions.

Results Five themes of how nursing students make meaning of experiences emerged from the data: 1) fear of interacting with patients, 2) developing confidence, 3) becoming self-aware, 4) connecting with knowledge, and 5) connecting with the patient. Each theme is discussed in detail.

FEAR IN NURSE/PATIENT INTERACTIONS This was the strongest and earliest theme to emerge from the data. The exemplars in this theme revealed how uncomfortable participants were when interacting with patients. Words used by participants to describe how they felt included nervous, scared, afraid, intimidated, frightened, anxious, worried, concerned, and timid. Most of the participants described feeling one or more of these emotions when walking into a patient's room or when interacting with the patient.

One participant described her first day on a neurology floor when she "hesitated by the door" due to feeling "very nervous to talk with my first patient on the floor." Another participant described even deeper feelings of fear and anxiety. She was not just hesitant about entering the patient's room, but found herself "rehearsing what I was going to say because I was nervous that I would say the wrong thing." A third participant described her fear as even more encompassing. Listing all the areas in which she felt emotion, she described herself as "too timid to approach an RN, embarrassed to ask anyone a question, insecure with the patient because I can do so few tasks, and self-conscious [because] the patient thinks I am inept."

DEVELOPING CONFIDENCE This was the second theme that emerged from the participants' experiences in nurse/patient interactions. Often a participant achieved confidence through successful completion of a nursing skill (e.g., a first injection or dressing change). A patient who required complex nursing skills helped a participant experience a one-time boost in confidence. This participant described successful performance of multiple skills with a patient--taking vital signs, giving a bath, providing oral care, catheterizing the bladder, and cleaning the gastrostomy-tube (G-tube) in the patient's stomach and giving medications through the G-tube. After completing all these skills successfully, she wrote, "This experience gave me so much confidence about my ability to give competent care to patients."

Another participant described her "intimidating experience" with a patient and the physical sensations of first touching his fistula, a surgically created blood vessel used for dialysis. The patient taught the participant how to listen for the flow of blood and how to palpate the pulsation in the fistula, both normal nursing skill assessment activities. She wrote, "During this interaction, I initially felt unknowledgeable and lacked confidence in myself. The patient actually had more medical knowledge than I did." Reflecting on the experience, the participant focused on her recognition of the patient interaction and her connection with the patient. She added, "I felt grateful for his patience and willingness to help me learn. He boosted my confidence by telling me that he wanted to help me become a knowledgeable and experienced nurse."

Developing confidence was especially challenging for participants when interacting with patients who could not communicate verbally. One participant expressed great emotion in her description of caring for a nonverbal patient who also exhibited negative body language. She told how the patient "was glaring at me the whole time I was talking " and "just pointed with her left hand and continued to glare viciously at me" when asked if she needed anything. The participant, trying to learn what the patient wanted, picked up objects or pointed to objects but was unable to get a positive response. "I didn't know what to do," she wrote. "I even questioned if I should be in nursing." Finally she told the nurse assigned to the patient about these interactions, and the nurse laughed, stating that the patient had experienced a stroke and that glaring and pointing for no reason at all could be symptoms of the stroke. The participant wrote that the rest of the day went smoothly and she experienced greater confidence after that day. She wrote that she "got along well with [the patient] and felt more fulfilled than I could have imagined" after the experience. Here, the nurse gave the participant feedback on how to attempt to experience being in interaction with this patient.

BECOMING SELF-AWARE Participants experienced nurse/ patient interactions that resulted in self-awareness. They did so through reflection, finding meaning in who they were as nurses. Four types of reflection helped participants discover self-awareness: reflecting on their thoughts; reflecting on an interaction with a patient; comparing their thoughts to the actions of another nurse; or seeing inner role conflict.

For one participant, reflection on thoughts that led to self-awareness took place while she cared for a patient diagnosed with cancer. While reflecting on her patient, the participant thought about how she will function as a nurse. She wrote, "How would I react if I was diagnosed with cancer? I think I will always react emotionally to all these patients." For another participant, reflection that led to self-awareness took place after she provided care for a patient with Alzheimer's disease. The participant was surprised at how strongly she wanted to provide care for patients who had this disease. She wrote, "I have a strong desire to help those in need no matter what age or level of mental stability. Looking at my patient in a state of mind that she can't control seemed to touch a special place in my heart. My interest and desire to do so much for this patient really surprised me."

Two participants described becoming self-aware by comparing their thoughts to the observed actions of other nurses. One participant described judgmental nurses who were discussing a patient with scabies: "Although some nurses lack the basic need for compassion, I refuse to become one of them." Another participant, who cared for a patient who was a substance abuser, wrote: "Health care providers have biases toward him and his past. I would not want to be one of those people and I would want to know his side."

Two participants wrote of experiencing dissonance in comparing their individual personalities to the characteristics needed to "be" a nurse. The first realized she was still unsure of her role as a nurse and described her inner conflict: "I've realized that even though I consider myself to be a friendly person who cares about helping people, it doesn't mean this personality extends as forcefully into the nursing setting yet."

The second wrote of being "hit on" by a patient who was old enough to be her father. Her initial response to the patient was "a comment about dividing my professional and personal life." The participant wrote about feeling comfortable about how she should respond to this man as a woman, but having no idea how she should respond as a professional nurse. Her self-awareness is apparent as follows: "What I really should have said was, 'this is making me very uncomfortable' or 'I need to take care of you today to make sure you are safe but that is as far as it goes.'" She added that she believed her professional reaction to such patients will come with experience. Both of these participants were becoming aware of how they wanted to "be" as nurses after reflecting back upon their experiences.

CONNECTING WITH KNOWLEDGE Another theme that emerged from the data analysis was the a priori category pertaining to the science of nursing--the skills, knowledge, and content of nursing. Participants wrote of how they connected with the knowledge of nursing, the knowledge needed to be a nurse. Two subthemes of knowledge emerged: connecting with classroom knowledge and connecting with the performance of nursing skills.

Some participants connected both skills of nursing and classroom knowledge in the same patient interaction. One participant wrote about observing a nurse and participating in performing skills herself. The nurse inserted an intravenous catheter into the arm of a 300-pound Navy veteran and the participant used a smaller needle and syringe to inject medication into the patient's abdomen. She wrote of being pleased with the success of her injection and reflected on the patient's reactions to both procedures. She wrote, "When I gave him the injection, his reaction made me wonder if I was doing something wrong because subcutaneous injections don't hurt that much. Then I began to ponder the issue of pain tolerance across age, gender, and culture. He probably hated needles."

CONNECTING WITH PATIENTS The participants wrote story after story about connecting in various ways with their patients. One of the more dramatic examples concerned a patient who had difficulty talking due to a stroke. The participant understood that the patient was upset during her morning care. Through patience and a willingness to spend time with the patient, the participant was able to make a connection with her. She learned that the sponge used to clean the patient's teeth was not "minty" enough and she wrote, "Although the conversation took a while because of my difficulty understanding her, I finally understood how it meant a lot to her if I would clean her mouth thoroughly. After I finished with her teeth she expressed how she felt much better and how she could taste the mint. Through her facial expression I was able to see how much she appreciated my time in trying to understand her and thoroughly cleaning her teeth and mouth. I felt I was making a difference in this patient's life even though it was very minor compared to the difficulties she was going through with her stroke."

Implications for Nursing Education The purpose of this research was to understand how nursing students learn to experience being in nursing. Four implications can be derived from the themes emerging from the data.

First, clinical experiences provide excellent opportunities for students to learn the art and science of nursing. By intertwining the art and science of nursing, the clinical experiences described by participants in this study allowed students to experience being in nurse/patient interactions. Participants identified important connections between the art and science of nursing, supporting the notion that experiences with patients provide the best learning opportunities for becoming a nurse (3,7).

Second, nursing education must be restructured to include a balance between the art and science of nursing. If nursing students learn from the intertwining of the art and science of nursing, then curricular structure must parallel how nursing students learn. Traditionally, in addition to having a heavy science focus in the curriculum, nursing programs require science courses as prerequisites. The use of behavioral objectives to measure outcomes of the educational process further reflects a focus on science (6). The result is that the education of nursing students becomes an applied science that borrows from medicine and the biological and physical sciences.

Doane (7) notes that science is the technical doing of nursing and that nurses should open up to feeling and the being of nursing. To educate nurses who balance the art and science of nursing and strengthen nursing as a humanistic profession, the strong science focus within nursing education must shift to include a balance with the arts. Paterson and Zderad noted that "science may provide the nurse with knowledge on which to base her (his) decision, but it remains for the arts and humanities to direct the nurse toward examination of value underlying her practice" (3, p. 87).

Watson has stated that nursing is a balance of the masculine and feminine (11). One might describe the science of objective knowledge as masculine and the feeling and sacred caring in nursing as feminine. It is possible that a shift from science courses to arts and humanities courses as prerequisites in the general education curricula of the nursing major would open the door to other perspectives.

A third implication is that reflection, through journal writing, is a valuable way to enhance learning and must be an integral part of nursing education. Reflecting back through through the process of journal writing allows for understanding the experience and leads to learning, particularly to a focus on the intertwining of the art and science of nursing (12). Journal writing should be part of all postclinical experiences, and students should be given open-ended questions to guide their journaling activities.

The final implication is that the traditional nursing student is developing identity simultaneously as a nurse and as a person. Simply stated, the traditional nursing student is a college student for whom two different types of learning are taking place. Faculty must not lose sight of the fact that as they guide students to develop knowledge of nursing, they are also guiding their personal identity development.

Final Thoughts As the nursing student learns the art and science of nursing through interactions with patients, the nursing instructor serves as guide. Palmer stated, "Good teachers possess a capacity for connectedness. They are able to weave a complex web of connections among themselves, their subjects, and their students so that students can learn to weave a world for themselves" (13, p. 11). Gendron compared the intertwining of the art and science of nursing to creating a tapestry (14). In weaving, the warp consists of bare strings set in a loom. The weft consists of threads that are woven across the warp to create a pattern, or, in the case of tapestries, an image.

In nursing, the warp is the science--the foundation of knowledge in nursing care. And the weft is the art--the authentic interaction of nurse and patient. As nurse educators teach nursing, the art and science of nursing intertwine to create a tapestry. What a beautiful analogy to use for teaching nursing students about nurse/patient interactions and to encourage students to experience being in caring for their patients.

References

(1.) Donahue, R (1985). Nursing: The finest art. St. Louis, MO: Mosby.

(2.) O'Brien, M. E. (2001). The nurse's calling: A Christian spirituality of caring for the sick. Mahwah, NJ: Paulist Press.

(3.) Paterson, J. G., & Zderad, L.T. (1976). Humanistic nursing. New York: John Wiley & Sons.

(4.) Chinn, R L. (1994). Developing a method for aesthetic knowing in nursing. In R L. Chinn & J. Watson (Eds.), Art and aesthetics in nursing (pp. 19-40). New York: National League for Nursing.

(5.) Osterman, P., & Schwartz-Barcott, D. (1996). Presence: Four ways of being there. Nursing Forum, 31, 23-30.

(6.) Bevis, E. O. (1989). Nursing curriculum as professional education: Some underlying theoretical models. In E. O. Bevis & J. Watson (Eds.), Toward a caring curriculum: A new pedagogy for nursing (pp. 67-106). New York: National League for Nursing.

(7.) Doane, G.A.H. (2002). Beyond behavioral skills to human involved processes: Relational nursing practice and interpretive pedagogy. Journal of Nursing Education, 41, 400-404.

(8.) Chinn, P. L., & Watson, J, (Eds.). (1994). Art and aesthetics in nursing. New York: National League for Nursing.

(9.) Heidegger, M. (1962). Being and time (MacQuarrie & E. Robinson, Trans.). San Francisco: Harper & Row. (Original work published 1927)

(10.) Crist, J. D., & Tanner, C.A. (2003). Interpretation/analysis methods in hermeneutic interpretive phenomenology. Nursing Research, 3, 202-206.

(11.) Watson, J. (2001). Postmodern nursing and beyond. Philadelphia: Churchill Livingstone.

(12.) Brown, S. C., & Gillis, M.A. (1999). Using reflective thinking to develop personal professional philosophies. Journal of Nursing Education, 38, 171-174.

(13.) Palmer, P.J. (1998). The courage to teach. San Francisco: Jossey-Bass.

(14.) Gendron, D. (1994). The tapestry of care. Advances in Nursing Science, 17, 25-30.

Sue Easter Idczak, PhD, RN, is an associate professor at Lourdes College School of Nursing, Sylvania, Ohio. She was affiliated with the Medical College of Ohio, Toledo, as an assistant professor during the preparation of this article. Contact Dr. Idczak at sidczak@lourdes.edu.
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Author:Idczak, Sue Easter
Publication:Nursing Education Perspectives
Geographic Code:1USA
Date:Mar 1, 2007
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