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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
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Page 1: Emotional Nurse Being: A Heideggerian Hermeneutical - RCN

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

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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.

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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.

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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

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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

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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

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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.

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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

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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:

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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

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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

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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

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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).

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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.

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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

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(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

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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.

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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

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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.

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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

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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

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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

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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

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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?"

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"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

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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

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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:

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„….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.

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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

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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

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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

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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

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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‟

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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.

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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

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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

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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

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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?

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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‟

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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):

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„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.

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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

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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

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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

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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‟

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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

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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

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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

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„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;

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„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

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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

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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

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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

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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:

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· 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

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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

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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

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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.

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· 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

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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

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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

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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:

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„...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

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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

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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.

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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.

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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.

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· 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

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„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

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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

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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

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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

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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:

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„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

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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

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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

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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

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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.

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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

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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

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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.

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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

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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

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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.

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· 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.

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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

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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‟

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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

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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

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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

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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

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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

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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

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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

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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

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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

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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

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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.

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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

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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.

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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

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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

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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.

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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

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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

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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

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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.

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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)

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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

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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:

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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)

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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

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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

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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‟

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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‟

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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

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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,

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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

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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

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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.

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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

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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

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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

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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

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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

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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.

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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‟

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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

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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...‟

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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

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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

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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

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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‟.

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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

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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‟.

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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.

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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

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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

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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

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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:

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„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:

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„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.

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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,

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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

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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:

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„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,

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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

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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:

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„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

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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

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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

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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

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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‟

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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

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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

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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

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„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

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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

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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

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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.

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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

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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

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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.

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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.

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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

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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

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„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

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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

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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

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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.

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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.

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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...

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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

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(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

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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‟

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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

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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

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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

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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

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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

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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‟

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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

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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

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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‟

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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

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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

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„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:

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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?‟

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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.

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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‟

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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

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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

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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

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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

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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

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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

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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

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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

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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

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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

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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

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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.

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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

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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

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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

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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

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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

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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,

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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.

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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

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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?‟

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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

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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.

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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‟

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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

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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

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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

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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

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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‟

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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?‟

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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

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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

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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

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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

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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

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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

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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);

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„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

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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

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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

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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

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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‟

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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.

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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

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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

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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

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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‟.

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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

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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).

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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)

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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

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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,

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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

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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

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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.

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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

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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

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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

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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

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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

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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

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„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,

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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

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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.

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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)

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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

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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‟‟

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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

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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:

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„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

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„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.

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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)

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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.

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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

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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

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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....‟

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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?

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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.

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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

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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

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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

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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

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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‟

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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).

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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

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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

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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,

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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

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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

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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

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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

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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

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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)

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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‟

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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

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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

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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

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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

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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

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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

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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‟

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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‟

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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”

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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

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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?‟

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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

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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

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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‟

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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.

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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

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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

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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‟

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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

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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

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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

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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‟

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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

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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.

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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

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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

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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

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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

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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

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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

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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

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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

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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

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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

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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

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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

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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.

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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‟

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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

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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

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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,

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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

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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

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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.

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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:

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„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

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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

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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

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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.

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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,

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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

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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

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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

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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

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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

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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

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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

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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.

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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

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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,

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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‟

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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.

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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‟

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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.

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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

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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

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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.

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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

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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

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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.

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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

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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.

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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:

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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.

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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

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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.

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Further Information and contact details

Further information can be obtained by contacting

Kirsten Jack 0161 247 2405

[email protected]

Reference

Salovey P and Mayer JD (1990) Emotional Intelligence Imagination, Cognition and Personality 9 185 – 211

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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.

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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

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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

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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


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