1 ORIGINAL ARTICLE The woven fabric a metaphor of nursing care: the major subject in nursing education Margareta Asp 1,3 RNT, BNSc and Ingegerd Fagerberg 2,3 RNT, MSocSci, PhD 1 Department of Health Care Pedagogics, University of Gothenburg, Eskilstuna, Sweden, 2 Department of Clinical Neuroscience, Occupational Therapy and Elderly Care Research, Karolinska Institute, Stockholm, and 3 Department of Caring Sciences, Mälardalen University, Eskilstuna, Sweden Scand J Caring Sci; 2002; 16; The woven fabric a metaphor of nursing care: the major subject in nursing education Society s future needs regarding health care present challenges to traditional nursing education. Today, the ambition is to create a nursing role that is appropriate to people s health care needs rather than the needs of the health care system. In nursing education, the major subject nursing care is central. Accordingly, there is a need for a consistent and clear articulation of this subject as well as the nursing profession. The aim of the present study was to interpret and describe the major subject, its content and structure in the nursing programme at Mälardalen University. With a hermeneutic approach an interpretation and application emerged as a metaphor of nursing care the woven fabric. In this structure concepts function as bridges linking theory and practice, whereby it is possible to integrate different aspects of knowledge in order to think, feel and act nursing care. Keywords: nursing education, nursing care, concepts, hermeneutics, field studies. Submitted 16 January 2001, Accepted 11 July 2001 Introduction Curriculum development is a current activity in Swedish universities. As one part of curriculum development within the basic nursing programme at the Department of Caring Sciences, Mälardalen University, a project was conducted in order to clarify the content and structure of the major subject nursing care. In curriculum development it is necessary to pay attention to future needs regarding health care in society and the context in which nurses will perform their profession in the future (1), as well as educational reforms. These aspects influence the major subject s content and structure in the nursing education. In this paper nursing means the nursing profession and nursing care means the major subject in nursing education. Nursing education and nursing care in perspective of health care needs Correspondence to: Margareta Asp, Department of Caring Sciences, Box 325, S Eskilstuna, Sweden. In an analysis of current strategies of European health care reforms, Saltman and Figueras (2) have described demographic and social changes, and health challenges, demanding educational reforms in health care. One important factor throughout Europe is the predicted future pattern of ageing of the population. An increasing number of elderly citizens, with different cultural backgrounds and value systems, will need a greater volume of health care services. The community health care system will expand. The technical development will increase and contribute to health care. Thus, nurses challenge is to fulfil the obligation of combining technical skills and abilities with participation in the patients life-world (3, 4). According to the World Health Organization (WHO) nursing includes planning and delivery of care during illness, rehabilitation and dying. The mission of nursing is described as helping individuals, families and social groups to determine and achieve their physical, mental and social potential, within the environments in which they live and work. This requires nurses to develop and perform skills that prevent ill health and promote and maintain health (5). The predicted future changes in health care create consequences upon what content and which structure the major subject nursing care will have and in which contexts the subject is to be studied. The focus in the nursing curriculum must be health-oriented (1). It is time to change the traditional nursing role, which has the primary focus on the sick individual and which has the primary settings for learning in hospitals and other institutions. Nursing 115
2 116 M. Asp, I. Fagerberg education must also have a community-oriented focus and have the settings for learning in any context where people exist, in patients homes for instance. The key concept underlying the development of nursing education is the need to create a nursing role that is appropriate to people s health care needs, rather than the needs of the health care system. In the resolution World Health Assembly (WHA) 45.5 of the 45th WHA on strengthening nursing and midwifery in support of strategies for health for all in 1992, it was strongly recommended that the nursing programmes should produce generalist nurses able to function in both hospitals and the community. The intention was to indicate the need for a sound, broad-based basic education in nursing with a strong emphasis on primary health care (1). This was also the intention in the Swedish nursing educational reform in 1993 (6). In order to fulfil these demands, there is a need to develop a curriculum which gives the nursing students professional competence in performing nursing in any context. Fagermoen (7) claims that professional identity is connected with how the nurse conceptualizes what it means to act as and to be a nurse. Accordingly, there is a need for a consistent and clear articulation of the subject nursing care as well as of the nursing profession. Nursing education and nursing care in the perspective of educational reforms Nursing education in Sweden has been subjected to considerable change during the last 30 years. From 1966 it was given at college level. The students were no longer to be regarded as employees in their clinical education, but as students, and the education had a nationwide curriculum. One third of the education involved theoretical studies and two thirds involved practice. Social science and civics was studied as well as medicine. The paradigm was mainly medical biological (8). In 1977 the reform of higher education called for changes in the educational programmes. Nursing care was underlined as the major subject in nursing education, and the education was to be linked to research. The guidelines in the curriculum were nationwide and goal oriented, implying variations between the different colleges. Only students who had a licensed practical nursing degree (LPN) or who had completed their education from college with a supplementary course were admitted. In 1993, another educational reform was carried out, which made it possible for students who had graduated from a 3-year programme at a college of higher education to be accepted as nursing students, even if they did not have an LPN degree. The faculty became responsible for the frame of reference for the curriculum. The only demands from the government was that the nursing students must satisfy five requirements in order to obtain a Diploma in Nursing as a Registered Nurse. The students must have: (a) acquired the appropriate knowledge and skills for the profession, (b) acquired knowledge of professional nursing care, (c) developed abilities of self-reflection, of maintaining an ethical relationship and of creating good relations with patients and their relatives, (d) acquired knowledge of society s influence on man and learnt to initiate and participate in health promotion and preventive work and (e) acquired knowledge of financial aspects of organizations and medical services (9). This latest educational reform has given nursing students an opportunity to obtain a Bachelor of Science degree in several nursing programmes. This means that nursing education has to fulfil two demands: (a) the requirements of the profession leading to a Diploma in Nursing as a Registered Nurse and (b) the criteria for a Bachelor of Science degree. The confrontation between the traditional nursing role in the health care organization and the academic perspective is fraught with conflict and the students experience uncertainty about the nursing perspective in health care (10) and nurses responsibility for performing nursing care (11). The students meet diverging professional attitudes among nurses and develop different professional identities, as Öhlén and Segesten (12) discuss and Fagerberg and Kihlgren confirm (13). In a review, Radsma (14) has found that caring is referred to as an ethic and a science. Despite the traditional view of caring as the essence of nursing, there is little clarity when it comes to understanding the performance of care in nursing. This gap between praxis and the academic world has to be bridged. A possible way to establish this is to study the academic subjects, from literature as well as in the field, in different contexts. By using the concept field studies instead of practice it is possible to think and develop the curriculum without separating theory from practice. It is possible to fulfil nursing education s two demands. In earlier evaluations of the nursing programme at Mälardalen University, students and teachers have mentioned difficulties in describing the subject nursing care, especially in field studies. It was difficult to see the difference between nursing and the subject nursing care. Therefore, it was necessary to clarify nursing care in the curriculum in order to see that everyone involved in education students, teachers and supervising nurses will, irrespective of position in education, recognize the different aspects of nursing care in relation to the whole curriculum. The aim of the present study was to interpret and describe the subject nursing care its content and structure in the nursing programme. Research questions The following questions provided directions for the study: 1 How is the subject nursing care presented in the nursing programme? 2 How can the subject nursing care be described, comprising knowledge from philosophical to empirical levels?
3 Woven fabric a metaphor of nursing care 117 Method This study, influenced by Gadamer s philosophy of the hermeneutic process comprising understanding, interpretation and application (15), had several data as the point of departure: 1 Descriptions of all courses in nursing care in the programme (in all eight) and study guides developed from the course descriptions (in all eight). 2 Teachers descriptions of how they considered the theoretical focus in the courses they taught. Teachers descriptions of how they didactically moved between different levels of knowledge in nursing care, from philosophical to empirical levels (in all four). 3 Lists of titles of theses in nursing care which the students defended in spring 1999 (in all 64 theses). Procedure Understanding and interpretation. The first research question focused on data in order to open up and maintain possibilities of understanding. The first researcher read the texts with an open-minded suspension of prejudice in order to understand what the data addressed. In other words, the researcher s own prejudice was brought into play by being put at risk (15: 299). The results from that process of understanding are presented under Result 1. The process of interpretation continued with the second research question and the first researcher focused attention on the texts and projected a preliminary meaning (the frame of interpretation) onto them. In the act of interpretation, the preliminary meaning was revised continuously. This continual process involving new projections constituted the movement of understanding and interpretation (15, 16). Application. The interpretation was discussed with the second researcher and in terms of the significance of application to be understood in the present situation (17) concerning didactical issues and society s need of nurses competence. In the results, the weaving metaphor illustrates this application. Frame of interpretation nursing care The preliminary meaning, understood as the frame of interpretation, was: caring is the essence of nursing care (cf. 17, 18, 19). Caring is seen as a general human phenomenon. People care for each other in the family, as neighbours, etc, and help each other to survive, grow and develop. This general human phenomenon is the origin of nursing care. Some nursing theorists consider that the origin of nursing care is a deep-seated love of life (20 22). When people are unable to remain healthy through this natural caring, because of illness, handicap, side-effects of medical treatments or age-related disability, there is a need for nursing care, by professionals. Nursing care comprises two integrated aspects: the content aspect and the relational aspect in order to maintain health for a person. The content aspect of nursing care means the nurse s intentions to enable people to live their daily life optimally. The relational aspect of nursing care concerns the nurse patient relationship. The science of nursing care is scientific knowledge of this nursing care territory and is described at several levels of knowledge: philosophical, metatheoretical, theoretical, technological and empirical. Results Result 1 The nursing education comprises 120 units (one unit is 1 week of studies). Sixty units represent the major subject, including 10 units representing a thesis in nursing care. The remaining 60 units represent different subsidiary subjects. The documents in the nursing programme, showed that nursing care was considered as a subject set apart from the nursing profession. However, the nursing profession was focused upon in several of the documents. In the descriptions of the courses, nursing care comprised science of nursing care, nursing research and the performance of nursing care. The subject was studied in theory as well as in field studies. The terminology used in the documents to describe the course contents was inconsistent. For example, the terms vårdvetenskap and omvårdnad were used interchangeably and had different meanings in different contexts. Concepts recurring in the documents were also life span and transcultural aspects in relation to the performance of nursing care. According to the faculty, the students studied nursing care at several levels of knowledge, from the philosophical to the empirical levels. All these levels were sometimes studied on the same course. In order to move between different levels of knowledge, the students wrote process papers in order to complement theoretical knowledge with personal knowledge and with experience in field studies. Ethical and aesthetical aspects of nursing care were studied as well. The subjects of students theses showed implicitly how students were thinking about the major subject, nursing care. The titles concerned subject areas as presented in Table 1. The subject areas show that nursing care was considered in relation to living with diseases and with different symptoms, for example, pain and incontinence. In some theses concepts, like eating, activity, transition and adaptation were central. Nursing care in relation to life span and transcultural aspects was also represented. The titles
4 118 M. Asp, I. Fagerberg Table 1 Theses in nursing care Subject areas n ¼ 64 Nursing care in relation to persons with diseases 14 The nurse patient relationship and information 14 Nursing care in relation to persons with different symptoms 10 Documentation of nursing care 6 Patients suffering 6 Nursing care at the beginning and at the end of life 6 Confirmation in nursing care 2 Ethical or philosophical aspects of nursing care 2 Transcultural nursing 2 The nursing profession 2 showed that the students discussed different levels of knowledge in their theses: from philosophical aspects of human existence to empirical issues like documentation in nursing care. Concepts like suffering, comfort, integrity and confirmation were central in some theses concerning the nurse patient relationship, from the metatheoretical to the empirical level. Data were analysed with the perspective of nursing theories or with the perspective of concepts at theoretical or metatheoretical level. Some theses concerned the nursing profession and not the subject nursing care. A conclusion from this step of understanding data, in the research process, is that concepts in nursing care are central when it comes to describing the major subject. These concepts concern both caring and nursing. The concepts from nursing represent intentions that nurses have an autonomous responsibility to enable people to live their daily life optimally. The concepts of caring are not specific to the nursing profession. The major subject is studied at different levels of knowledge, from metatheory to empirical data in field studies. In the process of further interpretation a metaphor (Fig. 1) emerged, a structure of nursing care. The metaphor of the woven fabric The metaphor of the woven fabric (Fig. 1) makes it possible to think multidimensionally when the subject nursing care is to be planned in the nursing programme. The Figure 1 The structure of nursing care. structure of nursing care, symbolized by the woven fabric, is to be regarded at different levels of knowledge, from the philosophical to the empirical (Table 2). The substance comprises theories and concepts in nursing care, from the ontological to the empirical level. The research comprises knowledge of nursing research at different levels, from epistemology to empirical data. The woven fabric (Fig. 1) has two colours. The light-grey one represents concepts concerning the relational aspect, and the darker grey represents concepts concerning the content aspect of nursing care. The features of the fabric symbolize different themes, focused upon every level in the nursing programme. These themes are life span, transcultural aspects, gender and research methods. The colour of the fabric is successively deepened. This implies that the subject has a different focus in the different years of the programme. Nursing care, 1 20 units, has its focus on the continuum of health/ill health and on suffering without relation to disease, but related to the themes: life span, transcultural and gender aspects. These units are studied in the first year of the programme. The major subject is separated into three courses. The first course comprises philosophical and metatheoretical levels concerning the relation between language and world, the history of nursing ideas and the meaning of the following fundamental concepts: human, Table 2 Levels of knowledge in nursing care Substance Research Philosophical level Ontology Epistemology Metatheoretical level Fundamental concepts Theory of science Theoretical level Concepts concerning the content aspect and the relational aspect Qualitative and quantitative method theory Technological level Technology concerning the content aspect and the relational aspect Qualitative and quantitative methods Empirical level The territory of nursing care which also is the field of research
5 Woven fabric a metaphor of nursing care 119 health, nursing care and environment. The second course looks at nursing research methods and covers the nature of knowledge and an overview of the research process and ethics in nursing research. The third course offers knowledge of nursing care from the theoretical to the empirical level. This course contains field studies where theoretical, technological and practical knowledge can be learned and linked together by means of the concepts concerning content and relational aspects of nursing care. The nursing process is studied, with emphasis on needs assessment. In literary courses the students can study the content and relation aspects separately, but in field studies these aspects are integrated in nursing actions, which have health-promoting characteristics at this level. Nursing care, units, is focused on the continuum of health/ill health and on the suffering of persons with diseases, and related to the same themes as in the first year. These units are studied in the second year of the programme and are separated into three courses. The first course has a philosophical and metatheoretical level, concerning holistic views of human nature. The fundamental concepts are analysed from the starting-point of holism. Concepts like patient and suffering are studied. The second course focuses on nursing research. Here, the students obtain increased knowledge about epistemology and theory of science as well as practising the research process. The third course concerns concepts at the theoretical level involving content and relational aspects in nursing care when a person suffers from a disease. Students obtain increased knowledge about the nursing process as a whole and they learn nursing skills related to theoretical concepts in field studies in contexts where patients are. Nursing care, units, is focused on the continuum of health/unhealth and on suffering when the person is unable to protect her integrity and autonomy. These units are studied in the third year. The studies focus on nursing care for individuals in different contexts: elderly care, community care and psychiatric care. The knowledge of nursing care is deepened with a higher degree of problematization and analyses and health care situations are studied with more complexity. Concepts concerning content and relational aspects are studied in these contexts as well as in relation to administration, leadership and quality assurance. The theses in nursing care are also written within these units. The warp in the woven fabric has four-twined threads, symbolizing the nature of the knowledge the students develop and integrate during the course. There are various types of knowledge: aesthetical, ethical, personal and scientific. The aim is to didactically plan the course so that the students can become conscious of these types of knowledge, integrate them in themselves and develop an attitude to think, feel and act nursing care. By studying different aspects of knowledge in relation to the concepts in nursing care this integration can be made possible. The students study scientific knowledge related to specific concepts and reflect on their personal knowledge of these concepts. In field studies the students learn practical knowledge based on health workers experiences and related to concepts. Ethical and aesthetical aspects are also considered and related to the meaning of the concepts. Discussion The results of the act of interpretation are in accordance with the WHO directives for nursing education. The increasing number of elderly citizens must be considered (2), and in the presented results the students begin and finish the programme with community-oriented studies, including nursing care for elderly people according to future demands of health care (2). Another directive from WHO is that health promotion should be a major part of study hours because health promotion is a point of departure in the nursing profession (1). In the presented results from the study, health is focused at every level of nursing care in the programme. A third directive is that education must enable the students to be aware of the mission of the nursing profession in any context (1). Nursing care, presented in the results as a structure related to concepts, is studied in different contexts. By means of concepts it is possible to establish links between the academic world and praxis, which has been a challenge and a concern in nursing education for many years. Many researchers hold the opinion that a major goal for professional nursing education is to integrate the performance of nursing care with a well-defined theory base in the curriculum (23). When it comes to linking theory and performance it has been successful to use concepts in teaching basic nursing skills. Concepts are mental pictures which guide human perceptions, and concepts can therefore function as bridges linking theory and performance. This means that the focus will be upon people s need for nursing care rather than on the health care system, in line with Salvage s standpoint (1). Studying concepts according to the relational and especially the content aspects of nursing care enables the students to be aware of the intentions of nursing care in any context and in co-operation with other health care professions (24). By studying concepts, it is also possible to enable the students to integrate different aspects of knowledge used in the nursing profession (25). Caring, or the relational aspect, as the core of the nursing, is described from the philosophical to the empirical level. The content aspect, the intention of nursing care, is described from the theoretical to the empirical level. Studying both these aspects is a way to incorporate caring as a nursing value in the socialization of nurses, a need elucidated by Radsma (14). Nursing care is one subject among others (for example human biology, medical science, social sciences and civics) in nursing education. Nursing involves knowledge from all
6 120 M. Asp, I. Fagerberg these subjects. The presented structure of nursing care makes it possible to understand the differences between nursing and the subject nursing care. The profession is in this way based on theory, which is a demand from the Swedish government. According to the results presented here, most demands from the government in order to obtain a Diploma in Nursing as Registered Nurse can be fulfilled by studying nursing care. The students can achieve knowledge of professional nursing care and they can develop abilities of self-reflection and of maintaining an ethical relationship (9), using different bodies of knowledge, studied in the proposed way. Students will be able to create good relations with patients and their relatives (9) when the relationship aspect is studied. The demands of knowledge concerning society s influence on man, financial aspects of organizations and medical services (9) is fulfilled within the subsidiary subjects and is not presented in this article. With the presented structure of nursing care, integrating theory in field studies, and with the thesis in nursing care, together with the subsidiary subjects, the requirements of the profession and the criteria for a Bachelor of Science degree can be fulfilled. The strategy of intertwining different aspects of knowledge in education is a way to develop the nurses competence to think, feel and act nursing care. The knowledge can be integrated as a habit in the lived body as Merleau- Ponty (26) would say and is a way to bridge the gap between the mind and the body, a heritage from Descartes. This view of separating mind and body may be one reason why there is a gap between theory and practice in education exists. One present demand is to develop the curriculum in order to eliminate this dualism in the future. The major subject, nursing care, comprises science of nursing care, nursing research and nursing care as it is performed. The science of nursing care is scientific knowledge of the nursing care territory, which comprises the content and relational aspects in order to maintain health for the person. Further research is needed, especially to develop theories of these concepts from the patient s lifeworld perspective. Methodological considerations The validity problem of hermeneutics centres on what grounds interpretations shall be chosen or excluded. In this context two criteria are useful (16). The first criterion is a principle by which interpretations can be rejected: if an interpretation leaves an essential part of the information unexplained, this interpretation cannot be accepted as a valid description of the reality which the data are referring to (16: 170). The second criterion is: if an interpretation is to be accepted as a valid description of the reality that the data are referring to, it must be the only one that gives a complete and reasonable explanation of the information available (16: 170). These two criteria have guided the act of interpretation. The first researcher collected different kinds of information in order to validate the interpretation, according to the first criterion. In the act of interpretation, the researcher created an interpretation which met the second criterion. The application of the interpretation, the metaphor, could have been described in another way, but in this research process the application was formed in line with the needs of health care and the external demands on nursing education. References 1 Salvage J. Nursing in action. In Strengthening Nursing and Midwifery to Support Health for All. WHO Regional Publications, European Series, no. 48. Copenhagen: World Health Organization, Saltman RB, Figueras J. European health care reform. Analysis of Current Stategies. WHO Regional Publications, European Series, no. 72. Copenhagen: World Health Organization, Nagle LM. A matter of extinction or distinction. West J Nurs Res 1999; 1: Lindeman C. The future of nursing education. J Nurs Educ 2000; 1: Salvage J, Heijnen S. Nursing in Europe: A Resource for Better Health. WHO Regional Publications, European Series, no. 74. Copenhagen: World Health Organization, Ds 1992:34. EU Direktiv Avseende Sjuksköterskeutbildning Och Barnmorskeutbildning (EU Directive Concerning Education in Nursing and Midwifery). Stockholm: The State Department of Education, Fagermoen MS. The Meaning of Nurses Work: A Descriptive Study of Values Fundamental to Professional Identity in Nursing. Dissertation Publicasjonsserie 7. Oslo: Oslo University, Institutt for Sykepleievitenskap, Lindberg-Sand Å. Det Sitter I Väggarna (It exists in the walls). In Carlsson B, ed. Kulturella föreställningar i vård och vårdutbildning (Cultural idéas in Health Care and Health Care Education) Kalmar: Kalmar läns vårdhögskola (University college of nursing), Fagerberg I. Nursing Students Narrated, Lived Experiences of Caring, Education and the Transition into Nursing, Focusing on Care of the Elderly. Dissertation, Stockholm: Department of Clinical Neuroscience and Family Medicine, Division of Geriatric Medicine, and Center of Caring Sciences South, Karolinska Institute, Linder K. Perspektiv i sjuksköterskeutbildning. Hur en grupp studerandes uppfattning av sjuksköterskans yrke förändras under tre år av utbildning (Perspectives in the Nursing Programme. How a Group of Students Conceptions of the Nurse Profession Change During Three Years of Studies) Lund Studies in Education 9, Doctoral Dissertation, Lund University, Department of Education: University Press, Lindberg-Sand Å. Spindeln i klistret. Den kliniska praktikens betydelse för utveckling av yrkeskompetens som sjuksköterska (The Spider in the Glue the Impact of Clinical Training on the Development of Professional Nursing Competence. An Ethnografic Phenomenografic Study. Sweden: Lund University, Department of Education, 1996.
7 Woven fabric a metaphor of nursing care Öhlén J, Segesten K. The professional identity of the nurse: concept analysis and development. J Adv Nurs 1998; 28: Fagerberg I, Kihlgren M. Experiencing a nurse identity: the meaning of identity to Swedish registered nurses two years after graduation. J Adv Nurs 2001; 37: Radsma J. Caring and nursing: a dilemma. J Adv Nurs 1994; 20: Gadamer H-G. Truth and Metod, 2nd rev. edn. New York: The Continuum Publishing Co., Ödman PJ. Interpreting the past. Qualitative Studies Education 1992; 5: Eriksson K. Nursing: the caring practice being there (Gaut DA ed.) In The Presence of Caring in Nursing. New York: National League for Nursing Press, 1992: Watson J. Nursing: The Philosophy and Science of Caring. Colorado: Colorado Associated University Press, Svenson BE. The concept of Biophile per se and within caring sciences. Socialmedicinsk Tidskrift 1997; 2 3: Svenson BE. Prerequisites for care of self and others and the concept of Biofile in light of neuroscience and brain research. Interdisciplinaria 1992; 11: Lanara VA. Heroism as a Nursing Value: A Philosophical Perspective. Athens: Sisterhood Evniki, Eriksson K. Vårdandets Idé (the Idéa of Caring). Stockholm: Liber Education, Smith BE. Linking theory and practice in teaching basic nursing skills. J Nurs Educ 1992; 31: Svenson BE. Identification and elucidation of fields of research within health and social training courses of medium length. Interdisciplinaria 1990; 9: Chinn P, Kramer K. Theory and Nursing, a Systematic Approach. 4th rev. edn. St Louis: Mosby Year Book Inc., Merleau-Ponty M. The Phenomenology of Perception. London: Routledge and Keagan Paul Ltd., 1962.