EMPIRICAL STUDIES
doi: 10.1111/scs.12244
The multifaceted vigilance – nurses’ experiences of caring encounters with patients suffering from substance use disorder Louice Johansson RN, MNSc (Mental Health Nurse)1 and Lena Wiklund-Gustin RN, PhD (Associate Professor, Professor)2,3 1
M€ alarsjukhuset MSE, Eskilstuna, Sweden, 2School of Health, Care and Social Welfare, M€ alardalen University, V€ aster as, Sweden and Faculty of Health and Society, Narvik University College, Narvik, Norway
3
Scand J Caring Sci; 2016; 30; 303–311 The multifaceted vigilance – nurses’ experiences of caring encounters with patients suffering from substance use disorder
Background: Nursing care is guided by a value base focusing on promoting dignity and health by means of the caring relationship. However, previous research has revealed that negative attitudes towards ‘addicted’ patients, as well as these patients’ behaviour, can give rise to negative emotions such as frustration and disappointment among nurses. This can contribute to a judgmental and controlling attitude towards patients. To preserve order, nursing interventions focusing on creating structure and stability could be applied in a way that challenges caring values. Aims and objectives: This study aimed to describe how nurses’ working in inpatient psychiatric care experience caring encounters with patients suffering from substance use disorder (SUD). Design: This qualitative study is part of a clinical application project focusing on value-based care of patients suffering from SUD. Data were obtained during four
reflective group dialogues with six nurses in a psychiatric hospital. Methods: The transcribed dialogues were subjected to latent qualitative content analysis. Results: The analysis facilitated the organisation of the findings into a coherent pattern. A common thread of meaning was conceptualised as a theme labelled ‘the multifaceted vigilance’, describing how nurses strived to deliver good care, while at the same time being vigilant towards patients’ behaviour as well as their own reactions to it. Within that theme, four categories described experiences related to different challenges nurses face in caring encounters. Conclusion: We suggest that this perhaps unavoidable aspect of caring encounters can be an asset. Thus, if acknowledged and subject to reflection, being vigilant could be understood as a strength enabling nurses to safeguard caring values, and to use their authority to promote patients’ health and alleviate suffering. Keywords: addiction, clinical application research, nursing care, nurse–patient interaction, qualitative content analysis. Submitted 10 September 2015, Accepted 6 April 2015
Introduction In healthcare, there is a demand for evidence-based care, and for implementation of research findings. This demand also characterises the theoretical and ethical foundation of nursing care, which is based on caring science (1). Applying such standards can be challenging, as a caring paradigm sometimes conflicts not only with medical tradition but with traditional views of nursing. Correspondence to: Lena Wiklund-Gustin, School of Health, Care and Social Welfare, M€ alardalen University, Box 883, S-721 23 V€aster as, Sweden. E-mail: [email protected] © 2015 Nordic College of Caring Science
As Mackintosh (2) points out, the nature of the work of nurses may inhibit the caring process as no person can constantly maintain all caring ideals. Within psychiatric nursing, this becomes evident, for example, when patients are involuntarily hospitalised (3) or when a common staff approach is supposed to be adopted (4). Thus, when a small psychiatric hospital was about to reorganise, they wanted to address these challenges. The hospital had an explicit value base, rooted in Eriksson’s theory of caritative caring (5), that they wanted to safeguard during the process. As this was experienced as especially challenging when caring for patients suffering from substance use disorder (SUD), the second author was invited to facilitate the process and contribute to the 303
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development of a value-based nursing care. This article is based on data generated during this process of development, and focus is placed on the caring encounter as this was identified as a key question by the staff at the hospital.
Background The theoretical perspective of this study is in line with the hospitals’ value base, that is Eriksson’s theory of caritative caring (5). From this point of view, caring is considered an interpersonal process directed to alleviate suffering, rather than being problem solving and task oriented. This perspective does not exclude problem solving, but it takes as a point of departure the suffering person, not the problem. From a caring science perspective, the caring encounter is supposed to provide the basis for nursing care, creating a space of togetherness and trust (6). The value of caring encounters has also been demonstrated in different studies in the area of addiction. From the patients’ perspective, caring encounters and supporting caring relationships have been described as essential for recovery (7–10). Recovery is described as a challenging process, especially if the person is using drugs as a means of relieving suffering. Previous research has found that such suffering can be related to experiences of loneliness, guilt and shame, low self-esteem or existential challenges. The drugs are experienced as facilitating social interaction, diminishing self-accusations and increasing self-esteem and euphoria without questioning the meaning of life. Drugs are expected to contribute to an altered mood, and they also contribute to an immediate but temporal sense of control and thus appear as a solution in an otherwise chaotic life, although in the long term, suffering and ill health increase (11–14). As drug dependency contributes to ill health, as well as to social problems such as criminality and deficits in social interactions, healthcare staff have been encouraged to motivate the person to accept treatment for SUD (15). In addition to medical and psychological treatment for SUD, research also suggests that nurses must support the patient in finding other means to deal with suffering and should approach the person in a way that restores dignity and accounts for the patient’s personal resources (8, 13, 16). A positive nurse–patient relationship is also experienced as important when a patient is ambivalent regarding whether to drop out of a programme or not (7). However, previous research has revealed that caring for patients suffering from SUD can raise personal challenges for nurses (17). Patients suffering from addiction are sometimes considered as dangerous and unpredictable by nursing staff (18). Research focusing on the nurses’ perspective also describes how nurses perceive patients’ lack of motivation as a barrier to intervening in
case of problem alcohol use (19). Furthermore, when nurses perceive that patients’ health problems are self-inflicted, their sense of concern for patients is affected (20). From the nurse’s perspective, a lack of understanding and knowledge can create frustration and insecurity as well as experiences of being powerless and giving care to people who are not motivated or susceptible to interventions (21). Research has found that this could contribute to a judgmental and controlling attitude and give rise to conflicts with patients (22, 23). Another consequence of a lack of understanding and knowledge is that nurses might fail to identify caring needs (24) or perceive patients as not being strong enough to manage life on their own (25). Given that the nurse’s approach is important for patients’ recovery, it is important to address challenges associated with caring encounters. This study aims to describe how nurses working in inpatient psychiatric care experiences caring encounters with patients suffering from SUD.
Methods As the study was part of a project striving to improve and develop value-based psychiatric care, the methodological approach was inspired by clinical application research (26). This approach has been described as an alternative to participatory research and has been developed as a means to facilitate the appropriation of caring science (27). The approach is participant oriented, and participants are viewed as co-researchers. This means that knowledge and new understandings are co-created between the researcher and the co-researchers in what has been described as reflective dialogues (28). Knowledge and insights gained during these dialogues can be immediately applied in the research context and contribute to the development of nursing care at the unit. Furthermore, these dialogues contribute research data. Hence, the approach differs from traditional focus group interviews as it is dedicated to influencing the context in which data are generated. Furthermore, the group leader’s role is different from that of a focus group moderator. Lindholm (26) calls the group leader for the scientific researcher and says that this person has a responsibility not only to guarantee scientific stringency but also to provide a theoretical anchor point during the dialogues.
Data collection The participants engaged in four reflective dialogues during a period of 3 months. In these dialogues, the participants and the second author shared and reflected on their experiences of caring for patients suffering from SUD. Each dialogue lasted for approximately 90 minutes. Six Registered Nurses took part in the dialogues. The group © 2015 Nordic College of Caring Science
The multifaceted vigilance consisted of two men and four women, from 24 to 63 years of age. Their experiences of psychiatric nursing varied from 6 months to more than 20 years. Focus was on the different challenges perceived in everyday work with patients suffering from SUD and the nurses’ experiences of interacting with the patients in these situations. The role of the scientific researcher was to pick up threads in the dialogues and give input that encouraged further reflection in relation to theoretical concepts and caring values. The co-researchers’ motives for actions taken with the patients were also explored and reflected on. The scientific researcher facilitated the dialogues by asking questions such as ‘How does this relate to dignity?’ or ‘Is this just a question about patients’ behaviour?’, or ‘Are there other aspects that need to be considered?’. Through this process, new understandings of own attitudes as well as caring were developed while data were generated. As participants were also involved in validating the findings, new understandings and knowledge could be immediately implemented in the context of origin. However, this latter process of application is beyond the scope of this article which focuses not on application but on describing participants’ experiences of caring encounters.
Data analysis The transcribed dialogues were subject to qualitative content analysis. Qualitative content analysis can be either deductive or inductive (29). We used an inductive approach that allows for interpretation on different levels (30, 31). First, the texts were read repeatedly to obtain a sense of the whole. The next step was to divide the texts into meaning units. Considering the context, the meaning units were condensed to develop descriptions of the content and meaning of the text. The condensed meaning units were coded and abstracted into categories. As the categories held nuances, subcategories were formulated to illuminate these nuances within a category. As human experiences are intertwined, mutually exclusive categories are not possible. Rather the goal is to highlight different aspects of the experience in the categories, while the theme expresses the ‘underlying thread of meaning’ (30: 107). The theme is, as is often the case in this kind of research, expressed metaphorically (32–34). The process is exemplified in Table 1. However, this was not a linear process. Subcategories and categories were discussed between the researchers, and also with the coresearchers, and elaborated on until nothing contradicting the categories was found. This provided a way to organise the interpretation in a meaningful pattern. Finally, the findings were presented and discussed with all caregivers – thus not only the participants – on the unit, as a point of departure for change. This procedure contributed to the validation of the result and was also in line with the application research approach. © 2015 Nordic College of Caring Science
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Ethical considerations The project as a whole – which also included interviews with patients – was subject to ethical approval from a regional ethical board. Participants were informed about the overall project as well as this specific study. Participation was voluntary and possible to withdraw at any point, and participants gave their informed consent for the researchers to use recordings from the reflective dialogues for research purposes. Questions about confidentiality were discussed and have been accounted for during the process by not referring neither to specific individuals nor to the unit. No ethical problems were encountered during the process.
Results As illustrated in Table 2, the analysis led to the formation of four categories, and 12 subcategories. In the text, subheadings are used to identify categories, while subcategories are underlined. Quotations are used to illuminate the interpretations. The quotations are linked to different participants by identifiers P1–P6. Reflecting on the categories in relation to each other revealed a common thread of meaning. This is expressed as a common theme ‘the multifaceted vigilance’, reflecting the latent meaning of data.
Balancing between understanding and frustration The importance of staff awareness of patients’ hidden vulnerability was put forth by the group members, as this vulnerability was perceived as a source of suffering. This awareness was linked to a view of the unit as an asylum, protecting patients from their own despair and cravings. Nurses related patients’ vulnerability to shame and lack of self-esteem, and also to difficulties in relating to other people and to setting up boundaries for self and others. Patients were supposed to hide their vulnerability by putting on a facßade in an effort to conceal their vulnerability, and to use special jargon, often perceived as a negative attitude. Therefore, nurses strived to see beneath the facßade and recognise patients’ suffering. This also meant an understanding of patients’ use of drugs as a means to alleviate suffering. The drug becomes some kind of problem-solver, and as long as we talk about them as the problem there is a risk that the patient does not learn how to endure when life is hard (P3). Thus, focusing only on drug reduction was not considered helpful, as long as patients did not learn new skills in how to deal with life. This behaviour gave rise to feelings of frustration for nurses, especially when the patients’ seemingly normal facßade was compared to other patients diagnosed with psychiatric disorders. Therefore,
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Table 1 Example of the process of analysis Meaning unit
Condensed meaning unit
Code
Subcategory
Category
Theme
You know that they are lying. That’s a part of their disorder that not everything they say is true If you have the person’s narrative it becomes something else than just having the fragments you can observe when they are here. . . what was it like before. . . and how it is between episodes
Lying is a part of the disorder
Patients’ lies
Avoid being manipulated
Protecting oneself
The two-tailed vigilance
The narrative facilitates understanding of the whole person
Narratives as means for understanding
Account for patients’ narratives
Safeguard the healthy
Table 2 Overview of the results Subcategory
Category
Theme
Awareness of patients’ hidden vulnerability Understanding drugs as means to alleviate suffering Feelings of frustration Supporting patients to adjust to boundaries Encouraging responsibility Enhancing patients’ motivation Being patient Being attentive to withdrawal symptoms Encouraging patients’ inner strengths and resources Avoiding being manipulated Avoiding being emotionally drained
Balancing between understanding and frustration
The multifaceted vigilance
Being supportive or a guardian of order
Safeguarding the healthy while being observant on problems Protecting oneself while engaging in a caring relationship
nurses could be involved in a struggle between an understanding of the suffering person and their own frustration over what they considered as patients negative behaviours.
Being supportive or a guardian of order As participants perceived the patients as living a life with few boundaries, they recognised a need to support patients to adjust to boundaries on the inpatient unit. This was sometimes two folded as restrictions and rules were perceived as necessary to preserve order on the unit, while at the same time it could obstruct caring by making it rigid and un-creative.
When you have rules you can’t see the individual any more, at least if there are rules for everything. Or you see the individual, but it doesn’t count, as they need to adjust (P1). Vigilance was needed to prevent the rules from becoming more important than the patient, transforming them from a helpful tool into rigid routines. Therefore, patients’ active participation in finding their own reasons to keep with the structure was encouraged. When patients participated, it was possible to create links between their personal caring needs and the structure of the ward, making the rules meaningful. By doing so, the rules were understood as a support for the patients, helping them to take responsibility. As one participant said: ‘It is their own responsibility, which they do have. . . if they really want the treatment, to become sober. . . or if they will go on with their drugs’ (P6). Thus, the essence of being supportive was on encouraging responsibility and using boundaries as a means in this effort. When patients failed to take responsibility, it was not perceived as meaningful to ‘keep them safe behind a locked door’ (P4) to prevent relapse. As the patients needed to be able to deal with life outside the unit, too many restrictions were thought of as unhelpful in the long run. Therefore, patients’ active choice was encouraged – to stay on the ward and take responsibility or to leave, as the door was open. This willingness to take responsibility within boundaries was also perceived as facilitating caring relationships and reducing manipulative behaviours, as patients bore liability. This made the nurse’s role more of a support and less of a guardian. Nurses also put forth the importance of enhancing patients’ motivation towards a life without drugs by being present. There are so many who don’t have anywhere to go, anyone. . . What motivates them to stay sober? There must be some meaningful context somewhere (P1). Even if there was a will to be supportive and encourage patients’ motivation and responsibility, there could © 2015 Nordic College of Caring Science
The multifaceted vigilance still be failure. Failure was perceived as a consequence of patients’ lack of motivation and endurance, and of the grim reality in the patients’ ordinary lives, rather than as a consequence of failure in caring. Therefore, being supportive also meant being patient, rather than giving up on patients. Some patients need to come twenty-five times before they become motivated. You must see that the patient is in on it, but sometimes we fail in this (P4).
Safeguarding the healthy while being observant on problems When patients were admitted to the unit, they were often rather ill, and nurses had to be attentive to withdrawal symptoms. Furthermore, patients often demanded quick, medical relief for their agony. This too made it easy to lose the holistic perspective valued by nurses. Thus, they strived to promote health by also encouraging patients’ inner strengths and resources to build on what actually worked well in patients’ lives. This did not mean that problems were avoided – both pros and cons were discussed. Social skills were practiced and developed at the unit, as well as self-care strategies to deal with anxiety and other symptoms. Thus, nurses strived to focus on the future, and not only on the withdrawal period. A joint reflection in regard to the patients’ narrative highlighted patterns that needed attention and gave rise to a new understanding of the current situation, the addictive behaviours as well as the strengths and skills. To narrate is to bring the person to life. It is to help patients to become real persons in their minds eye rather than as hopeless addicts, as losing one’s history is also losing oneself (P2). During this process, the patient also became a person for the nurses who reported that the narratives touched them and created a special interest in the person rather than in treating symptoms.
Protecting oneself while engaging in a caring relationship Even though nurses considered it important to trust patients to facilitate their growth, they strived to avoid being manipulated by patients. These persons live a very special life, they think they need to control others in order to survive. They act like this inside these walls as well, and you need to keep your eyes open (P6). ‘Successful’ manipulation could contribute to inadequate care. When patients were too cooperative, nurses became suspicious. Nurses were also challenged when patients were perceived as pitting staff against each other. Therefore, they were vigilant regarding these kinds of behaviours and kept a distance from the patients using a common approach. Vigilance towards manipulative © 2015 Nordic College of Caring Science
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behaviours also aimed at protecting nurses from being considered na€ıve by their colleagues. To be able to engage in a caring relationship with patients regarded as manipulative, nurses strived to understand manipulative behaviours as part of the addictive personality and as a wish to be appreciated by staff. Paradoxically similar behaviour among nurses was conceptualised as purposeful and good. But there is a difference as we always have a good intention when we manipulate, while an addict is driven by their addiction. It is not the person that is aiming for something good that speaks; it’s the drug and the cravings (P5). Patients were sometimes perceived as demanding and hard to please, having unrealistic expectations. This contributed to nurses’ experiences of frustration, and they claimed that they needed to be watchful to avoid being emotionally drained. Patients’ demands on their attention, as well as their own disappointment felt when patients relapsed, were considered as sources of emotional distress that they strived to avoid. It is so frustrating when they don’t appreciate the care. It’s up to them how they manage their life, but when you have believed in them, and they buy something on the street as soon as they have left the building it feels like I have failed (P3). Nurses also expressed a need to understand and manage their own reactions. However disappointed they were on the patients, the nurses strived to be vigilant regarding their own emotions so as not to reveal them to the patients. Instead, they vented their frustration on each other. This too was challenging, as the need to talk with each other had to be regulated to avoid peers becoming contaminated with negative feelings towards a patient.
The common theme: the multifaceted vigilance Nurses’ experiences of caring encounters with patients suffering from SUD are characterised by a multifaceted vigilance. Thus, nurses can be involved in a struggle between caring ideals, such as developing genuine relations where patients’ health is considered from a holistic perspective, and a reality where patients’ behaviours as well as structures in the organisation call for nursing interventions that challenge the ideals. Therefore, nurses strive to be vigilant not only to patients’ problems and behaviours, but also to their own and their colleagues’ behaviours. Furthermore, they are vigilant towards their own feelings to avoid transmitting them to others, patients as well as peers, and also to protect their own vulnerability.
Discussion This study was undertaken as part of a clinical project in which the application of caring values was in focus.
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Thus, as part of the authors’ theoretical perspective, these values are the focus of the discussion of results. Even though this article is limited to the description of nurses’ experiences of caring encounters with patients suffering from SUD, the results can shed light on caring encounters in general, at least within psychiatric care. Hence, the discussion will focus on the common theme, the multifaceted vigilance, and discuss it mainly on a general level. The findings of this study highlight that caring encounters are indeed challenging. Nurses might struggle to maintain structure on the unit, while at the same time they strive to develop a caring and trustful relationship with patients. Hence, caring encounters can give rise to opposing feelings that evoke vigilance not only towards patients’ behaviour but also towards one’s own as well as one’s colleagues’ reactions. This could be reflected on in relation to the question Mackintosh (2) raised 15 years ago: ‘Is there a place for care within nursing?’ This question reflects a dissonance between caring ideals and the clinical demands on nurses’ everyday work that still appears to be present in today’s psychiatric nursing care. In our results, there was a common theme – the multifaceted vigilance – referring to the need to be vigilant towards one’s own reactions as well as those of one’s colleagues. We do not disregard nurses’ feelings of frustration or their fear of being disappointed or manipulated by patients, nor their fear of being considered na€ıve by colleagues, and we do not consider these feelings as exclusively negative. These kinds of experiences are indeed challenging and might even be painful for the nurse. However, we also acknowledge this awareness of one’s own reactions as a useful and sometimes unavoidable part of caring encounters. Such an awareness can prevent nurses from becoming too naive or blinded by routines and general cultural attitudes and allows them to individualise nursing care (22, 35, 36). As we interpret our results, problems can arise if nurses strive to find a proper solution based on either caring ideals or structure. This is also supported by researchers in other mental health contexts (4, 37). Rather than polarising caring values and issues such as interventions directed to structure as opposites, we will reflect upon the common theme, multifaceted vigilance, as a possibility to what Ricoeur (38) describes as temporal synthesis of the heterogeneous. Such a synthesis makes it possible to embrace two opposite views of reality in a way that facilitates understanding of a multiple and complex reality. Thus, being vigilant could be understood as a strength that enables nurses to safeguard caring values while simultaneously imposing structure and stability on the ward. If so, the supporting structures and rules can be adjusted to patients’ individual needs, and patients’ dignity can be taken into account.
As an answer to Mackintosh’s question, we will argue that there is indeed a place for caring within nursing. However, as researchers as well as clinicians, we need to be aware of the complexity and multiplicity of reality. Many caring theories are by their nature normative (39). Thus, they are intended to guide caring professionals towards what are considered ideals. On the other hand, there are different aspects of reality that comprise a threat to these ideals. For example, in psychiatric care, patients might be cared for against their will; thus, basic values in regard to dignity and autonomy are challenged (3). Furthermore, patients’ mental health problems sometimes call for different interventions to promote stability and structure (40). Being vigilant about our own assumptions as researchers, we are aware that the discussion above could be viewed as normative. However, our intention is not to be judgemental but to suggest an alternative to the neither – or approach to nursing care that appears to generate conflicts among nurses (4). We believe that synthesising the heterogeneous is not an easy task, but it is necessary when implementing caring theories and values. However, synthesising does not mean compromising and giving up caring values. Rather it is a question of maintaining them while simultaneously making use of necessary nursing interventions that might be experienced as restrictive, and while struggling with one’s own feelings of shortcomings. Safeguarding caring values might also challenge traditional structures of power in nursing (41). However, this does not mean that nurses will be powerless; rather it entails a shift from nurses having hierarchical power over patients, to caring encounters in which nurses use their authority to promote health and alleviate suffering (42). Such shifts in power can indeed be challenging. Therefore, further research is needed to study how such changes can be facilitated and implemented.
Methodological considerations In qualitative content analysis, concepts used to describe different aspects of trustworthiness are intertwined and inter-related (30). Instead of validity, reliability and generalisability, other concepts are used. Credibility relates to the ability of participants to shed light on the research question. Participants in this study shared an interest in developing the clinical nursing care. They had wide ranging experiences as nurses and represented different ages and sexes and were able to share their shifting experiences. From the perspective of clinical application research, such a group of committed participants have the ability to contribute with valuable data. Another aspect relating to credibility relates to the selection and condensation of suitable meaning units, and how well categorisations cover data. To avoid bias from the second author’s preunderstanding as a group © 2015 Nordic College of Caring Science
The multifaceted vigilance leader, analysis was first carried out by the first author. Then, the analysis was jointly reflected on, and the authors reached consensus in regard to the final categorisation and interpretation of the data. The participants were then involved as co-researchers, validating the categories and the common theme. This final step in addition to what is common in qualitative content analysis was considered appropriate within clinical application research as part of the co-operation between the scientific researcher and the co-researchers. Trustworthiness in qualitative content analysis is also a question concerning the stability of data over time, labelled dependability (30). This could indeed be challenging if interpreted strictly, as clinical application research deliberately stretches over time to allow for further reflections. Thus, new ‘input’ in data is actually encouraged throughout the process, rather than considered as bias. However, the last reflective dialogue did not contribute with new input and was more focused on reflecting previous sessions. What was notable in this study was that even though nuances and different aspects evolved and were elaborated during the process, there was stability in regard to different aspects of vigilance. The next question to reflect upon in regard to trustworthiness concerns transferability. Is it possible to transfer knowledge developed in a specific context for the purpose of developing that context to other settings? As stated by Lindholm et al. (27), application research involves a changed understanding and contributes to revision of care. In the study context, it contributed to a decision to address patients’ active involvement not only in their care plans but also in daily routines and activities on the ward. This was motivated by a wish to increase patients’ experiences of being valued as a person and accounted for and decrease manipulation. Other readers may come to the same conclusion, but it is also possible that the findings contribute to an understanding of other phenomena, for example in regard to conflicting values, and results in other kinds of revisions of a caring culture. This too could be understood as transferability, as there are no claims that understanding should be implicated in the same way everywhere. Another way to approach transferability is in regard to the theme, ‘the multifaceted vigilance’. As Carpenter (33) concludes, metaphor could illuminate the meaning of experiences. From this perspective, transferability is related to whether this metaphor contributes to the readers’ understanding of nurses’ encounters with patients suffering from SUD and even to the wider context of nurse–patient encounters in psychiatric care. As clinical application research is sparsely described in the literature (28), we will also add to this discussion that the reflective dialogues were not only
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considered as fruitful for generating data for the study reported in this article, but also considered as beneficial at the hospital where the study was conducted. However, we do not think that reflective dialogues are sufficient as means for developing a value-based caring culture, or for the application of caring science in a clinical context. There is still a need for research on how insights gained during these dialogues can be put into action.
Conclusion In this article, a common theme, ‘the multifaceted vigilance’, describes nurses’ experiences of caring encounters with patients suffering from SUD. This vigilance can be experienced as an internal struggle with one’s own reactions and can also be directed towards patients and colleagues. We acknowledge this vigilance as challenging, and sometimes also troublesome for the nurses. Therefore, we suggest that this perhaps unavoidable aspect of caring encounters can be an asset and may make synthesis of the heterogeneous possible. Thus, being vigilant could be understood as a strength that enables nurses to safeguard caring values and use their authority to promote patients’ health and alleviate suffering.
Acknowledgements The authors thank the co-researchers for their valuable participation and Erna Lassenius, PhD, for her comments on the MSc manuscript.
Author contributions This article is based on Louice Johansson’s MSc thesis (43). The thesis was written in Swedish, and the results further reflected on and rewritten in English for the purpose of this article by the authors in cooperation. The second author designed the study, was responsible for data gathering and supervised data analysis. The first author (Louice Johansson) analysed data and wrote the MSc thesis in Swedish.
Ethical approval The study was approved by an ethics committee, 358/ 2009. To avoid identification of the unit, the name of the committee is not stated.
Funding The authors received no external financial support for the research, authorship or publication of this article.
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doi: 10.1111/scs.12244
The multifaceted vigilance – nurses’ experiences of caring encounters with patients suffering from substance use disorder Louice Johansson RN, MNSc (Mental Health Nurse)1 and Lena Wiklund-Gustin RN, PhD (Associate Professor, Professor)2,3 1
M€ alarsjukhuset MSE, Eskilstuna, Sweden, 2School of Health, Care and Social Welfare, M€ alardalen University, V€ aster as, Sweden and Faculty of Health and Society, Narvik University College, Narvik, Norway
3
Scand J Caring Sci; 2016; 30; 303–311 The multifaceted vigilance – nurses’ experiences of caring encounters with patients suffering from substance use disorder
Background: Nursing care is guided by a value base focusing on promoting dignity and health by means of the caring relationship. However, previous research has revealed that negative attitudes towards ‘addicted’ patients, as well as these patients’ behaviour, can give rise to negative emotions such as frustration and disappointment among nurses. This can contribute to a judgmental and controlling attitude towards patients. To preserve order, nursing interventions focusing on creating structure and stability could be applied in a way that challenges caring values. Aims and objectives: This study aimed to describe how nurses’ working in inpatient psychiatric care experience caring encounters with patients suffering from substance use disorder (SUD). Design: This qualitative study is part of a clinical application project focusing on value-based care of patients suffering from SUD. Data were obtained during four
reflective group dialogues with six nurses in a psychiatric hospital. Methods: The transcribed dialogues were subjected to latent qualitative content analysis. Results: The analysis facilitated the organisation of the findings into a coherent pattern. A common thread of meaning was conceptualised as a theme labelled ‘the multifaceted vigilance’, describing how nurses strived to deliver good care, while at the same time being vigilant towards patients’ behaviour as well as their own reactions to it. Within that theme, four categories described experiences related to different challenges nurses face in caring encounters. Conclusion: We suggest that this perhaps unavoidable aspect of caring encounters can be an asset. Thus, if acknowledged and subject to reflection, being vigilant could be understood as a strength enabling nurses to safeguard caring values, and to use their authority to promote patients’ health and alleviate suffering. Keywords: addiction, clinical application research, nursing care, nurse–patient interaction, qualitative content analysis. Submitted 10 September 2015, Accepted 6 April 2015
Introduction In healthcare, there is a demand for evidence-based care, and for implementation of research findings. This demand also characterises the theoretical and ethical foundation of nursing care, which is based on caring science (1). Applying such standards can be challenging, as a caring paradigm sometimes conflicts not only with medical tradition but with traditional views of nursing. Correspondence to: Lena Wiklund-Gustin, School of Health, Care and Social Welfare, M€ alardalen University, Box 883, S-721 23 V€aster as, Sweden. E-mail: [email protected] © 2015 Nordic College of Caring Science
As Mackintosh (2) points out, the nature of the work of nurses may inhibit the caring process as no person can constantly maintain all caring ideals. Within psychiatric nursing, this becomes evident, for example, when patients are involuntarily hospitalised (3) or when a common staff approach is supposed to be adopted (4). Thus, when a small psychiatric hospital was about to reorganise, they wanted to address these challenges. The hospital had an explicit value base, rooted in Eriksson’s theory of caritative caring (5), that they wanted to safeguard during the process. As this was experienced as especially challenging when caring for patients suffering from substance use disorder (SUD), the second author was invited to facilitate the process and contribute to the 303
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development of a value-based nursing care. This article is based on data generated during this process of development, and focus is placed on the caring encounter as this was identified as a key question by the staff at the hospital.
Background The theoretical perspective of this study is in line with the hospitals’ value base, that is Eriksson’s theory of caritative caring (5). From this point of view, caring is considered an interpersonal process directed to alleviate suffering, rather than being problem solving and task oriented. This perspective does not exclude problem solving, but it takes as a point of departure the suffering person, not the problem. From a caring science perspective, the caring encounter is supposed to provide the basis for nursing care, creating a space of togetherness and trust (6). The value of caring encounters has also been demonstrated in different studies in the area of addiction. From the patients’ perspective, caring encounters and supporting caring relationships have been described as essential for recovery (7–10). Recovery is described as a challenging process, especially if the person is using drugs as a means of relieving suffering. Previous research has found that such suffering can be related to experiences of loneliness, guilt and shame, low self-esteem or existential challenges. The drugs are experienced as facilitating social interaction, diminishing self-accusations and increasing self-esteem and euphoria without questioning the meaning of life. Drugs are expected to contribute to an altered mood, and they also contribute to an immediate but temporal sense of control and thus appear as a solution in an otherwise chaotic life, although in the long term, suffering and ill health increase (11–14). As drug dependency contributes to ill health, as well as to social problems such as criminality and deficits in social interactions, healthcare staff have been encouraged to motivate the person to accept treatment for SUD (15). In addition to medical and psychological treatment for SUD, research also suggests that nurses must support the patient in finding other means to deal with suffering and should approach the person in a way that restores dignity and accounts for the patient’s personal resources (8, 13, 16). A positive nurse–patient relationship is also experienced as important when a patient is ambivalent regarding whether to drop out of a programme or not (7). However, previous research has revealed that caring for patients suffering from SUD can raise personal challenges for nurses (17). Patients suffering from addiction are sometimes considered as dangerous and unpredictable by nursing staff (18). Research focusing on the nurses’ perspective also describes how nurses perceive patients’ lack of motivation as a barrier to intervening in
case of problem alcohol use (19). Furthermore, when nurses perceive that patients’ health problems are self-inflicted, their sense of concern for patients is affected (20). From the nurse’s perspective, a lack of understanding and knowledge can create frustration and insecurity as well as experiences of being powerless and giving care to people who are not motivated or susceptible to interventions (21). Research has found that this could contribute to a judgmental and controlling attitude and give rise to conflicts with patients (22, 23). Another consequence of a lack of understanding and knowledge is that nurses might fail to identify caring needs (24) or perceive patients as not being strong enough to manage life on their own (25). Given that the nurse’s approach is important for patients’ recovery, it is important to address challenges associated with caring encounters. This study aims to describe how nurses working in inpatient psychiatric care experiences caring encounters with patients suffering from SUD.
Methods As the study was part of a project striving to improve and develop value-based psychiatric care, the methodological approach was inspired by clinical application research (26). This approach has been described as an alternative to participatory research and has been developed as a means to facilitate the appropriation of caring science (27). The approach is participant oriented, and participants are viewed as co-researchers. This means that knowledge and new understandings are co-created between the researcher and the co-researchers in what has been described as reflective dialogues (28). Knowledge and insights gained during these dialogues can be immediately applied in the research context and contribute to the development of nursing care at the unit. Furthermore, these dialogues contribute research data. Hence, the approach differs from traditional focus group interviews as it is dedicated to influencing the context in which data are generated. Furthermore, the group leader’s role is different from that of a focus group moderator. Lindholm (26) calls the group leader for the scientific researcher and says that this person has a responsibility not only to guarantee scientific stringency but also to provide a theoretical anchor point during the dialogues.
Data collection The participants engaged in four reflective dialogues during a period of 3 months. In these dialogues, the participants and the second author shared and reflected on their experiences of caring for patients suffering from SUD. Each dialogue lasted for approximately 90 minutes. Six Registered Nurses took part in the dialogues. The group © 2015 Nordic College of Caring Science
The multifaceted vigilance consisted of two men and four women, from 24 to 63 years of age. Their experiences of psychiatric nursing varied from 6 months to more than 20 years. Focus was on the different challenges perceived in everyday work with patients suffering from SUD and the nurses’ experiences of interacting with the patients in these situations. The role of the scientific researcher was to pick up threads in the dialogues and give input that encouraged further reflection in relation to theoretical concepts and caring values. The co-researchers’ motives for actions taken with the patients were also explored and reflected on. The scientific researcher facilitated the dialogues by asking questions such as ‘How does this relate to dignity?’ or ‘Is this just a question about patients’ behaviour?’, or ‘Are there other aspects that need to be considered?’. Through this process, new understandings of own attitudes as well as caring were developed while data were generated. As participants were also involved in validating the findings, new understandings and knowledge could be immediately implemented in the context of origin. However, this latter process of application is beyond the scope of this article which focuses not on application but on describing participants’ experiences of caring encounters.
Data analysis The transcribed dialogues were subject to qualitative content analysis. Qualitative content analysis can be either deductive or inductive (29). We used an inductive approach that allows for interpretation on different levels (30, 31). First, the texts were read repeatedly to obtain a sense of the whole. The next step was to divide the texts into meaning units. Considering the context, the meaning units were condensed to develop descriptions of the content and meaning of the text. The condensed meaning units were coded and abstracted into categories. As the categories held nuances, subcategories were formulated to illuminate these nuances within a category. As human experiences are intertwined, mutually exclusive categories are not possible. Rather the goal is to highlight different aspects of the experience in the categories, while the theme expresses the ‘underlying thread of meaning’ (30: 107). The theme is, as is often the case in this kind of research, expressed metaphorically (32–34). The process is exemplified in Table 1. However, this was not a linear process. Subcategories and categories were discussed between the researchers, and also with the coresearchers, and elaborated on until nothing contradicting the categories was found. This provided a way to organise the interpretation in a meaningful pattern. Finally, the findings were presented and discussed with all caregivers – thus not only the participants – on the unit, as a point of departure for change. This procedure contributed to the validation of the result and was also in line with the application research approach. © 2015 Nordic College of Caring Science
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Ethical considerations The project as a whole – which also included interviews with patients – was subject to ethical approval from a regional ethical board. Participants were informed about the overall project as well as this specific study. Participation was voluntary and possible to withdraw at any point, and participants gave their informed consent for the researchers to use recordings from the reflective dialogues for research purposes. Questions about confidentiality were discussed and have been accounted for during the process by not referring neither to specific individuals nor to the unit. No ethical problems were encountered during the process.
Results As illustrated in Table 2, the analysis led to the formation of four categories, and 12 subcategories. In the text, subheadings are used to identify categories, while subcategories are underlined. Quotations are used to illuminate the interpretations. The quotations are linked to different participants by identifiers P1–P6. Reflecting on the categories in relation to each other revealed a common thread of meaning. This is expressed as a common theme ‘the multifaceted vigilance’, reflecting the latent meaning of data.
Balancing between understanding and frustration The importance of staff awareness of patients’ hidden vulnerability was put forth by the group members, as this vulnerability was perceived as a source of suffering. This awareness was linked to a view of the unit as an asylum, protecting patients from their own despair and cravings. Nurses related patients’ vulnerability to shame and lack of self-esteem, and also to difficulties in relating to other people and to setting up boundaries for self and others. Patients were supposed to hide their vulnerability by putting on a facßade in an effort to conceal their vulnerability, and to use special jargon, often perceived as a negative attitude. Therefore, nurses strived to see beneath the facßade and recognise patients’ suffering. This also meant an understanding of patients’ use of drugs as a means to alleviate suffering. The drug becomes some kind of problem-solver, and as long as we talk about them as the problem there is a risk that the patient does not learn how to endure when life is hard (P3). Thus, focusing only on drug reduction was not considered helpful, as long as patients did not learn new skills in how to deal with life. This behaviour gave rise to feelings of frustration for nurses, especially when the patients’ seemingly normal facßade was compared to other patients diagnosed with psychiatric disorders. Therefore,
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Table 1 Example of the process of analysis Meaning unit
Condensed meaning unit
Code
Subcategory
Category
Theme
You know that they are lying. That’s a part of their disorder that not everything they say is true If you have the person’s narrative it becomes something else than just having the fragments you can observe when they are here. . . what was it like before. . . and how it is between episodes
Lying is a part of the disorder
Patients’ lies
Avoid being manipulated
Protecting oneself
The two-tailed vigilance
The narrative facilitates understanding of the whole person
Narratives as means for understanding
Account for patients’ narratives
Safeguard the healthy
Table 2 Overview of the results Subcategory
Category
Theme
Awareness of patients’ hidden vulnerability Understanding drugs as means to alleviate suffering Feelings of frustration Supporting patients to adjust to boundaries Encouraging responsibility Enhancing patients’ motivation Being patient Being attentive to withdrawal symptoms Encouraging patients’ inner strengths and resources Avoiding being manipulated Avoiding being emotionally drained
Balancing between understanding and frustration
The multifaceted vigilance
Being supportive or a guardian of order
Safeguarding the healthy while being observant on problems Protecting oneself while engaging in a caring relationship
nurses could be involved in a struggle between an understanding of the suffering person and their own frustration over what they considered as patients negative behaviours.
Being supportive or a guardian of order As participants perceived the patients as living a life with few boundaries, they recognised a need to support patients to adjust to boundaries on the inpatient unit. This was sometimes two folded as restrictions and rules were perceived as necessary to preserve order on the unit, while at the same time it could obstruct caring by making it rigid and un-creative.
When you have rules you can’t see the individual any more, at least if there are rules for everything. Or you see the individual, but it doesn’t count, as they need to adjust (P1). Vigilance was needed to prevent the rules from becoming more important than the patient, transforming them from a helpful tool into rigid routines. Therefore, patients’ active participation in finding their own reasons to keep with the structure was encouraged. When patients participated, it was possible to create links between their personal caring needs and the structure of the ward, making the rules meaningful. By doing so, the rules were understood as a support for the patients, helping them to take responsibility. As one participant said: ‘It is their own responsibility, which they do have. . . if they really want the treatment, to become sober. . . or if they will go on with their drugs’ (P6). Thus, the essence of being supportive was on encouraging responsibility and using boundaries as a means in this effort. When patients failed to take responsibility, it was not perceived as meaningful to ‘keep them safe behind a locked door’ (P4) to prevent relapse. As the patients needed to be able to deal with life outside the unit, too many restrictions were thought of as unhelpful in the long run. Therefore, patients’ active choice was encouraged – to stay on the ward and take responsibility or to leave, as the door was open. This willingness to take responsibility within boundaries was also perceived as facilitating caring relationships and reducing manipulative behaviours, as patients bore liability. This made the nurse’s role more of a support and less of a guardian. Nurses also put forth the importance of enhancing patients’ motivation towards a life without drugs by being present. There are so many who don’t have anywhere to go, anyone. . . What motivates them to stay sober? There must be some meaningful context somewhere (P1). Even if there was a will to be supportive and encourage patients’ motivation and responsibility, there could © 2015 Nordic College of Caring Science
The multifaceted vigilance still be failure. Failure was perceived as a consequence of patients’ lack of motivation and endurance, and of the grim reality in the patients’ ordinary lives, rather than as a consequence of failure in caring. Therefore, being supportive also meant being patient, rather than giving up on patients. Some patients need to come twenty-five times before they become motivated. You must see that the patient is in on it, but sometimes we fail in this (P4).
Safeguarding the healthy while being observant on problems When patients were admitted to the unit, they were often rather ill, and nurses had to be attentive to withdrawal symptoms. Furthermore, patients often demanded quick, medical relief for their agony. This too made it easy to lose the holistic perspective valued by nurses. Thus, they strived to promote health by also encouraging patients’ inner strengths and resources to build on what actually worked well in patients’ lives. This did not mean that problems were avoided – both pros and cons were discussed. Social skills were practiced and developed at the unit, as well as self-care strategies to deal with anxiety and other symptoms. Thus, nurses strived to focus on the future, and not only on the withdrawal period. A joint reflection in regard to the patients’ narrative highlighted patterns that needed attention and gave rise to a new understanding of the current situation, the addictive behaviours as well as the strengths and skills. To narrate is to bring the person to life. It is to help patients to become real persons in their minds eye rather than as hopeless addicts, as losing one’s history is also losing oneself (P2). During this process, the patient also became a person for the nurses who reported that the narratives touched them and created a special interest in the person rather than in treating symptoms.
Protecting oneself while engaging in a caring relationship Even though nurses considered it important to trust patients to facilitate their growth, they strived to avoid being manipulated by patients. These persons live a very special life, they think they need to control others in order to survive. They act like this inside these walls as well, and you need to keep your eyes open (P6). ‘Successful’ manipulation could contribute to inadequate care. When patients were too cooperative, nurses became suspicious. Nurses were also challenged when patients were perceived as pitting staff against each other. Therefore, they were vigilant regarding these kinds of behaviours and kept a distance from the patients using a common approach. Vigilance towards manipulative © 2015 Nordic College of Caring Science
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behaviours also aimed at protecting nurses from being considered na€ıve by their colleagues. To be able to engage in a caring relationship with patients regarded as manipulative, nurses strived to understand manipulative behaviours as part of the addictive personality and as a wish to be appreciated by staff. Paradoxically similar behaviour among nurses was conceptualised as purposeful and good. But there is a difference as we always have a good intention when we manipulate, while an addict is driven by their addiction. It is not the person that is aiming for something good that speaks; it’s the drug and the cravings (P5). Patients were sometimes perceived as demanding and hard to please, having unrealistic expectations. This contributed to nurses’ experiences of frustration, and they claimed that they needed to be watchful to avoid being emotionally drained. Patients’ demands on their attention, as well as their own disappointment felt when patients relapsed, were considered as sources of emotional distress that they strived to avoid. It is so frustrating when they don’t appreciate the care. It’s up to them how they manage their life, but when you have believed in them, and they buy something on the street as soon as they have left the building it feels like I have failed (P3). Nurses also expressed a need to understand and manage their own reactions. However disappointed they were on the patients, the nurses strived to be vigilant regarding their own emotions so as not to reveal them to the patients. Instead, they vented their frustration on each other. This too was challenging, as the need to talk with each other had to be regulated to avoid peers becoming contaminated with negative feelings towards a patient.
The common theme: the multifaceted vigilance Nurses’ experiences of caring encounters with patients suffering from SUD are characterised by a multifaceted vigilance. Thus, nurses can be involved in a struggle between caring ideals, such as developing genuine relations where patients’ health is considered from a holistic perspective, and a reality where patients’ behaviours as well as structures in the organisation call for nursing interventions that challenge the ideals. Therefore, nurses strive to be vigilant not only to patients’ problems and behaviours, but also to their own and their colleagues’ behaviours. Furthermore, they are vigilant towards their own feelings to avoid transmitting them to others, patients as well as peers, and also to protect their own vulnerability.
Discussion This study was undertaken as part of a clinical project in which the application of caring values was in focus.
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Thus, as part of the authors’ theoretical perspective, these values are the focus of the discussion of results. Even though this article is limited to the description of nurses’ experiences of caring encounters with patients suffering from SUD, the results can shed light on caring encounters in general, at least within psychiatric care. Hence, the discussion will focus on the common theme, the multifaceted vigilance, and discuss it mainly on a general level. The findings of this study highlight that caring encounters are indeed challenging. Nurses might struggle to maintain structure on the unit, while at the same time they strive to develop a caring and trustful relationship with patients. Hence, caring encounters can give rise to opposing feelings that evoke vigilance not only towards patients’ behaviour but also towards one’s own as well as one’s colleagues’ reactions. This could be reflected on in relation to the question Mackintosh (2) raised 15 years ago: ‘Is there a place for care within nursing?’ This question reflects a dissonance between caring ideals and the clinical demands on nurses’ everyday work that still appears to be present in today’s psychiatric nursing care. In our results, there was a common theme – the multifaceted vigilance – referring to the need to be vigilant towards one’s own reactions as well as those of one’s colleagues. We do not disregard nurses’ feelings of frustration or their fear of being disappointed or manipulated by patients, nor their fear of being considered na€ıve by colleagues, and we do not consider these feelings as exclusively negative. These kinds of experiences are indeed challenging and might even be painful for the nurse. However, we also acknowledge this awareness of one’s own reactions as a useful and sometimes unavoidable part of caring encounters. Such an awareness can prevent nurses from becoming too naive or blinded by routines and general cultural attitudes and allows them to individualise nursing care (22, 35, 36). As we interpret our results, problems can arise if nurses strive to find a proper solution based on either caring ideals or structure. This is also supported by researchers in other mental health contexts (4, 37). Rather than polarising caring values and issues such as interventions directed to structure as opposites, we will reflect upon the common theme, multifaceted vigilance, as a possibility to what Ricoeur (38) describes as temporal synthesis of the heterogeneous. Such a synthesis makes it possible to embrace two opposite views of reality in a way that facilitates understanding of a multiple and complex reality. Thus, being vigilant could be understood as a strength that enables nurses to safeguard caring values while simultaneously imposing structure and stability on the ward. If so, the supporting structures and rules can be adjusted to patients’ individual needs, and patients’ dignity can be taken into account.
As an answer to Mackintosh’s question, we will argue that there is indeed a place for caring within nursing. However, as researchers as well as clinicians, we need to be aware of the complexity and multiplicity of reality. Many caring theories are by their nature normative (39). Thus, they are intended to guide caring professionals towards what are considered ideals. On the other hand, there are different aspects of reality that comprise a threat to these ideals. For example, in psychiatric care, patients might be cared for against their will; thus, basic values in regard to dignity and autonomy are challenged (3). Furthermore, patients’ mental health problems sometimes call for different interventions to promote stability and structure (40). Being vigilant about our own assumptions as researchers, we are aware that the discussion above could be viewed as normative. However, our intention is not to be judgemental but to suggest an alternative to the neither – or approach to nursing care that appears to generate conflicts among nurses (4). We believe that synthesising the heterogeneous is not an easy task, but it is necessary when implementing caring theories and values. However, synthesising does not mean compromising and giving up caring values. Rather it is a question of maintaining them while simultaneously making use of necessary nursing interventions that might be experienced as restrictive, and while struggling with one’s own feelings of shortcomings. Safeguarding caring values might also challenge traditional structures of power in nursing (41). However, this does not mean that nurses will be powerless; rather it entails a shift from nurses having hierarchical power over patients, to caring encounters in which nurses use their authority to promote health and alleviate suffering (42). Such shifts in power can indeed be challenging. Therefore, further research is needed to study how such changes can be facilitated and implemented.
Methodological considerations In qualitative content analysis, concepts used to describe different aspects of trustworthiness are intertwined and inter-related (30). Instead of validity, reliability and generalisability, other concepts are used. Credibility relates to the ability of participants to shed light on the research question. Participants in this study shared an interest in developing the clinical nursing care. They had wide ranging experiences as nurses and represented different ages and sexes and were able to share their shifting experiences. From the perspective of clinical application research, such a group of committed participants have the ability to contribute with valuable data. Another aspect relating to credibility relates to the selection and condensation of suitable meaning units, and how well categorisations cover data. To avoid bias from the second author’s preunderstanding as a group © 2015 Nordic College of Caring Science
The multifaceted vigilance leader, analysis was first carried out by the first author. Then, the analysis was jointly reflected on, and the authors reached consensus in regard to the final categorisation and interpretation of the data. The participants were then involved as co-researchers, validating the categories and the common theme. This final step in addition to what is common in qualitative content analysis was considered appropriate within clinical application research as part of the co-operation between the scientific researcher and the co-researchers. Trustworthiness in qualitative content analysis is also a question concerning the stability of data over time, labelled dependability (30). This could indeed be challenging if interpreted strictly, as clinical application research deliberately stretches over time to allow for further reflections. Thus, new ‘input’ in data is actually encouraged throughout the process, rather than considered as bias. However, the last reflective dialogue did not contribute with new input and was more focused on reflecting previous sessions. What was notable in this study was that even though nuances and different aspects evolved and were elaborated during the process, there was stability in regard to different aspects of vigilance. The next question to reflect upon in regard to trustworthiness concerns transferability. Is it possible to transfer knowledge developed in a specific context for the purpose of developing that context to other settings? As stated by Lindholm et al. (27), application research involves a changed understanding and contributes to revision of care. In the study context, it contributed to a decision to address patients’ active involvement not only in their care plans but also in daily routines and activities on the ward. This was motivated by a wish to increase patients’ experiences of being valued as a person and accounted for and decrease manipulation. Other readers may come to the same conclusion, but it is also possible that the findings contribute to an understanding of other phenomena, for example in regard to conflicting values, and results in other kinds of revisions of a caring culture. This too could be understood as transferability, as there are no claims that understanding should be implicated in the same way everywhere. Another way to approach transferability is in regard to the theme, ‘the multifaceted vigilance’. As Carpenter (33) concludes, metaphor could illuminate the meaning of experiences. From this perspective, transferability is related to whether this metaphor contributes to the readers’ understanding of nurses’ encounters with patients suffering from SUD and even to the wider context of nurse–patient encounters in psychiatric care. As clinical application research is sparsely described in the literature (28), we will also add to this discussion that the reflective dialogues were not only
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considered as fruitful for generating data for the study reported in this article, but also considered as beneficial at the hospital where the study was conducted. However, we do not think that reflective dialogues are sufficient as means for developing a value-based caring culture, or for the application of caring science in a clinical context. There is still a need for research on how insights gained during these dialogues can be put into action.
Conclusion In this article, a common theme, ‘the multifaceted vigilance’, describes nurses’ experiences of caring encounters with patients suffering from SUD. This vigilance can be experienced as an internal struggle with one’s own reactions and can also be directed towards patients and colleagues. We acknowledge this vigilance as challenging, and sometimes also troublesome for the nurses. Therefore, we suggest that this perhaps unavoidable aspect of caring encounters can be an asset and may make synthesis of the heterogeneous possible. Thus, being vigilant could be understood as a strength that enables nurses to safeguard caring values and use their authority to promote patients’ health and alleviate suffering.
Acknowledgements The authors thank the co-researchers for their valuable participation and Erna Lassenius, PhD, for her comments on the MSc manuscript.
Author contributions This article is based on Louice Johansson’s MSc thesis (43). The thesis was written in Swedish, and the results further reflected on and rewritten in English for the purpose of this article by the authors in cooperation. The second author designed the study, was responsible for data gathering and supervised data analysis. The first author (Louice Johansson) analysed data and wrote the MSc thesis in Swedish.
Ethical approval The study was approved by an ethics committee, 358/ 2009. To avoid identification of the unit, the name of the committee is not stated.
Funding The authors received no external financial support for the research, authorship or publication of this article.
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