NELLY_SIMMEN FINAL DISSERTATION 3

An Interpretive Phenomenological Study of the
Meaning of Resource Allocation Experienced by
Nurses Working on a Palliative Care Unit in
Switzerland
By
Nelly Simmen
Submitted for the degree of Master of Science
European Institute of Health and Medical Sciences
University of Surrey
September 2005
© Nelly Simmen 2005
i
Care at the beginning
What lies still is easy to grasp;
What lies far off is easy to anticipate;
What is brittle is easy to shatter;
What is small is easy to disperse.
Yet a tree broader than a man can embrace is born of a tiny shoot;
A dam greater than a river can overflow starts with a clod of earth;
A journey of a thousand miles begins at the spot under one’s feet.
Therefore deal with things before they happen;
Create order before there is confusion.
Tao te jing. Chap.64
Acknowledgements
I would like to thank my clinical nurse colleagues for generously and honestly
sharing their experiences and thoughts with me in the interviews as well as while
discussing the interpretation. I also wish to thank my supervisor Kay de Vries and
Susan Pope for their accompanying and valuable comments on the drafts. My
husband and the research group have been supportive and encouraging. Further,
I thank Pamela Christen and Kathrina Dick for translating and proof reading parts
of my dissertation. Last but not least I thank Sylvia Wilkinson and Judy Locher for
their prompt and efficient help with the finishing touches to the dissertation.
ii
Abstract
An interpretative phenomenological study of the meaning of resource
allocation experienced by nurses working on a palliative care unit in
Switzerland.
Purpose
The purpose of this phenomenological study was to understand
nurses lived experience of resource allocation and to reveal the unarticulated skills
and knowledge embedded in the practice of resource allocation described by a
group of practising nurses working on a palliative care ward in Switzerland.
Background Most often resource allocation is discussed at the macro-level of
politics and budgets. This study has shed light on the resource allocation at the
micro-level of clinical nursing practice. It is, therefore, a new perspective. In the
literature review some articles about priority setting and resource allocation at the
macro-level of politics and strategies were found. However, no evidence was
found regarding the clinical base of resource allocation in daily nursing delivery.
Method
The research process followed the recommendation of van Manen.
Qualitative data were collected from six palliative care nurses by means of open
ended unstructured interviews. Participants were asked to reflect on practices and
incidents that would allow an understanding of resource allocation in their practice.
Findings
Resource allocation is heavily influenced by the nurses’ own
values, knowledge, skills and experiences. Therefore they take on a lot of
responsibility and experience direct consequences. However, their ability to
allocate resources is bound to structures and the resource allocation decisions of
the greater system. Thus they are in a mediator role. This role and the
opportunities and limitations of resource allocation are experienced individually.
These have effects on the nurses’ condition, perception and readiness to meet
needs which has again effects on the individual, the team, the quality of care and
the patients.
Conclusion
This study is a small beginning towards understanding the
experience of resource allocation in daily nursing delivery on a palliative care
ward. Thus it has brought an awareness of important questions that need further
attention.
iii
TABLE OF CONTENTS
1.
INTRODUCTION AND BACKGROUND ........................................................1
1.1.
Significance of the research.......................................................................... 1
1.2.
Purposes of the study ................................................................................... 2
1.3.
Background and assumptions of the researcher ........................................... 3
2.
LITERATURE REVIEW..................................................................................5
3.
METHODOLOGY .................... FEHLER! TEXTMARKE NICHT DEFINIERT.9
4.
METHOD ......................................................................................................12
4.1.
Collecting data or investigating experience as we live it.............................. 13
4.2.
Participants................................................................................................. 14
4.3.
Gaining access ........................................................................................... 14
4.4.
Equipment .................................................................................................. 15
4.5.
Pilot study ................................................................................................... 15
4.6.
Conducting the interviews in the main study ............................................... 16
4.7.
Reflective notes .......................................................................................... 17
4.8.
Ethical concerns ......................................................................................... 17
4.9.
Data collection and interpretation................................................................ 18
4.10. Establishing truth value of the research ...................................................... 19
5.
FINDINGS AND INTERPRETATION ...........................................................21
5.1.
The meaning of the experienced resource allocation .................................. 21
Resource allocation is like...
5.2.
5.1.1.
...building on the foundation of valuing ...................................................... 21
5.1.2.
…being a channel for a good resource flow .............................................. 22
5.1.3.
...using a film library as a treasury of experiences .................................... 22
5.1.4.
…balancing a mobile and juggling with time units..................................... 23
5.1.5.
…experiencing Kairos................................................................................ 24
5.1.6.
…distributing sweets.................................................................................. 25
Different aspects of resource allocation and their correlations .................... 26
5.2.1.
Input:
What did the participants experience as resources?................................. 26
5.2.2.
Processes:
In which way did participants allocate resources?
What processes did participants experience? ........................................... 28
5.2.3.
Influencing factors:
Which factors influenced resource allocation? .......................................... 33
5.2.4.
Outcomes:
Which consequences of resource allocation did the participants
experience- in themselves, in the quality of care and in the patients? ...... 37
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6.
DISCUSSION ...............................................................................................41
6.1.
Objective one:
to understand what it means to these nurses to allocate resources ............ 41
6.2.
Objective two:
to reveal and show the processes, the influencing factors and the outcomes
of resource allocation.................................................................................. 45
6.2.1.
Processes .................................................................................................. 45
6.2.2.
Influencing factors...................................................................................... 48
6.2.3.
Outcomes of resource allocation ............................................................... 50
6.3.
Objective three:
to understand what the criteria, values, and principles involved are ............ 52
6.4.
Objective four:
to highlight the nurses’ unarticulated skills and knowledge needed............. 54
7.
CONCLUSION..............................................................................................58
8.
REFERENCES .............................................................................................64
9.
APPENDICES ..............................................................................................67
9.1.
Interview guide............................................................................................ 67
9.2.
Interview-Leitfaden ..................................................................................... 68
9.3.
Ethical approval .......................................................................................... 69
9.4.
Einverständniserklärung der Ethikkommission ............................................ 69
9.5.
Nurses information sheet ............................................................................ 70
9.6.
Informationsblatt ......................................................................................... 72
9.7.
Consent form .............................................................................................. 74
9.8.
Einverständniserklärung der Pflegenden..................................................... 75
9.9.
Letter of confirmation to participants ........................................................... 76
9.10. Bestätigungsbrief an die Teilnehmenden .................................................... 77
9.11. Letter of non-acceptance ............................................................................ 78
9.12. Absagebrief ................................................................................................ 79
Tables:
Tab 1: Levels of resource allocation decisions………………………………………..5
Tab 2: Methodical structure of interpretative phenomenological
research by van Manen (1990)……………………………………………...…12
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1.
1.1.
Introduction and Background
Significance of the research
Different qualitative studies investigating the quality of nursing care stress
the need to gain more knowledge about how nurses set priorities in the care
delivery (Williams 1998, Hogston 1995, Frei-Rhein and Hantikainen 2001). It has
been suggested that availability of time and other resources, such as number of
staff and their capabilities, availability of equipment, and the philosophy and aims
of the organisation are key elements in resources allocation (Rubenfeld and
Scheffer 1995, Bowers et al. 2001). Therefore a literature search with CINHAL
was undertaken using the keywords: ‘management’, ‘decision making’, ‘priority
setting’, ‘resources’ and ‘resource allocation’. Although some articles about priority
setting and resource allocation in the macro-level of politics and strategies were
found, no evidence was found regarding the clinical base of resource allocation in
daily nursing delivery. In an integrative literature review and meta-analyses Hendry
and Walker (2004) state, that no empirical work on priority setting in clinical
nursing practice appears to have been conducted. This skill is neither well
described nor adequately studied and there is no convincing evidence base to
underpin practice and education.
The present health care environment demands that nurses validate their
influence on patient care. An understanding of the processes involved in resource
allocation is important in relating nursing care to patient outcomes. In addition, an
understanding of these processes contributes not only to nursing science, but will
also influence nursing education and ultimately contribute to the improvement of
patient care.
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Benner (1994) states that much of our intelligent action, sensible as it
usually is, for our situation and goals, is carried out unformulated. If someone asks
us how we are able to walk or ride a bike, we are usually at a loss for an answer.
Such knowledge is often called unarticulated, embedded or tacit knowledge. We
may have knowledge on one level and yet this knowledge is not available to our
linguistic competency. Although resource allocation decisions are made daily by
nurses, they are rarely articulated. It flows from an understanding that is largely
inarticulate. “This understanding is fundamental in two ways: 1. It is always there
whereas we sometimes frame representations and sometimes do not, and 2. the
representations we do make are comprehensible only against the background
provided by this inarticulate understanding.“ (Benner 1994 p.xvi). It is assumed
that resource allocation and priority setting are such unarticulated skills of nurses.
1.2.
Aims of the study
The purpose of this study is to understand the lived experience of resource
allocation and to discover unarticulated skills and knowledge embedded in
practice. I shall explore the experience of resource allocation described by a group
of practising nurses working on a palliative care ward in Switzerland.
The objectives of the study are:
a) To understand what it means for these nurses to allocate resources;
b) To reveal and show the processes, the influencing factors and the outcomes of
resource allocation;
c) To understand what the criteria, values, and principles involved are;
d) To highlight the unarticulated skills and knowledge of these nurses.
2
1.3.
Background and assumptions of the researcher
Because hermeneutics is based on the belief that the researcher's personal
experiences, values and beliefs enrich interpretation, nurse researchers are
encouraged to consider ways in which the understanding they bring to the
research endeavour, their background and their assumptions can be revealed in
their writings.
When working as a nurse and later as a ward manager on a palliative care
ward I experienced the important and demanding task of allocating limited
resources to complex patient care. I especially suffered when I received the advice
to set priorities, which finally meant to omit certain tasks, but no support was
available to evaluate what could be omitted and how to bear the consequences.
Analysing those experiences and seeking to put into place the feelings and
thoughts led to the choice of the research area.
I assume that resource allocation decisions in clinical practice are often
carried out on an unconscious level. Decisions are influenced by the value system
of the society, the profession and the individual. This value system is learned
during the socialisation process and adapted continually during life. Further, I
assume that mutual support is rarely given and the issues are not discussed in
their complexity.
Priority setting is defined as the classifying of problems and concerns into
those that can be delayed until a later time, and the ranking of problems and
concerns, utilising notions of urgency and/or importance in order to establish a
preferential order for nursing actions (Hendry and Walker 2004). This definition
assumes that all the necessary actions may be carried out and that the decisive
3
factor is the nurses’ ability to find the right ranking. In my experience there are high
expectations of what quality of care should be achieved, but the appropriate
resources are not always available. It fellows from that that tasks have to be
omitted or left behind, which has consequences for the quality of care. The dealing
with these situations is left to the individual nurse’s responsibility. Therefore the
scope has been broadened by investigating resource allocation, knowing that
there is an overlapping with priority setting. Further, I hope that thereby the
relationship between the different levels of resource allocation and the
corresponding responsibility will become evident. Moreover, the expression
‘resource allocation’ has a positive and encouraging connotation. Resources can
be used to stimulate and promote change. In our society a lot of valuable
resources are at hand and I want to regard the glass as half full.
4
2.
Literature Review
The following literature review is rather an introduction in the research area,
as it seems that no investigation has been made into resource allocation in clinical
nursing practice. I have chosen to discuss and critique in depth the relevant
literature in the discussion section, as this allows me to show more clearly the
connections between my findings and other research results.
The market economy and health care reforms of recent years, which are
more frequently driven by economical concerns than by quality concerns, inspire
discussion regarding the allocation of resources at both, national and unit level.
Tab 1: Levels of resource allocation decisions.
Area
Level
Duty
Responsibility
Macro-allocation
4
Allocation of the gross national
product
National
government
3
Allocation of resources in
different projects of the health
system
Health minister
2
Allocation of resources within
an institution
Health care
manager
1
Allocation of resources for
different patients
Care team
Micro-allocation
(Illhardt and Piechowiak 1995)
Thus far, the emphasis has been upon examining the provision of
resources in its broadest sense. However, it should not be forgotten that nursing
5
time itself is a particularly precious resource, and that allocation of nursing time is
beset by as many ethical dilemmas as other resources allocation decisions.
Decisions about resource allocation on the macro-level have implications
for the nurses who distribute the resources to the patients and for the quality of
care. It is well recognised that the nature and output of a particular profession is
dependent on factors determined by the wider work setting. (Ferlie et al. 1997,
Huse and Cummings 1985).
On the macro-level resource allocation means decision making about
budgets and money in great amounts, but without understanding consequences
for the individual. On the micro-level the resources are more variable and linked
with individuals and situations. Nurses do not allocate money directly but they
allocate resources like nursing time, skills, knowledge, emotional support, energy,
material and they influence therapy decisions which cannot however be separated
from monetary value (Reay 1999, Illhardt and Piechowiak 1995).
Issues of resource allocations are inextricably linked with the principles of
ethics, in particular with those of justice. Allocation of resources is a complex issue
which is essentially rooted in the fair distribution of benefits and burdens among
clients, and in balancing the benefits of the individual with those of the group.
Direct patient care requires nurses to manage their time and other
resources judiciously and to set priorities in relation to different patients and
different aspects of an individual patient's care. In a large focus group study with
nurses caring for patients with advanced cancer, Tishelman et al. (2004) found
striking evidence of tension between care-giving ideals and limits imposed by the
realities of care giving in today’s health system.
6
The care of terminally ill and dying patients is especially complex and very
demanding, as these patients have multiple needs in different domains (physical,
psychological, social, spiritual needs). Palliative care standards claim to address in
a holistic way all these needs by an interdisciplinary team (SGPMP 2001). Even
with the higher patient/nurse ratio on a palliative care ward than in acute medical
and geriatric wards, palliative care nurses’ time and energy are limited and are
sometimes not sufficient for everything. Therefore resource allocation decisions
have to be made.
The health care reforms in Western European countries of recent years and
the consequent market economy have created a system in which the cheapest
options of care are often desired. Therefore, Hunt (1996) fears that the entire
philosophy on which palliative care services are founded, which is a high quality,
skilled and holistic approach to nursing care is in danger. Although, at present,
those involved in palliative nursing are able to provide such a standard of care, it
could potentially be difficult to maintain this standard with reduced nursing staff.
This view is supported by Radsma (1994), who argues that nurses must be aware
of changes in health care delivery, and should begin to examine caring itself as a
resource. She states that: 'It is in the best interest of nursing to identify the costs
and benefits involved with the presence or absence of care' (Radsma 1994 p.
447). It is essential that nurses caring for the terminally ill begin to identify and
measure care, particularly the hidden aspects of their role. However, the concept
of comparing the 'presence or absence' of care certainly raises many ethical
dilemmas, centred on whether care may morally be withheld in order to evaluate
its worth. In order that nurses may continue to prove, and improve, the quality of
their service, more appropriate outcome measures must be promoted as methods
by which palliative care services may be evaluated.
7
Health care professionals are becoming increasingly aware of and involved
in decisions surrounding resource distribution (Hunt 1996). Several authors
(Benner 1984, Dunlop 1991, Radsma 1994, Frey-Rhein and Hantikainen 2001)
recognise that management is an integral part of the staff nurses’ role, particularly
when numbers of qualified staff decrease. Knowledge on managerial skills,
especially decision making skills, can help with planning, resource distribution and
evaluation of care, can increase efficiency and effectiveness, and help nurses
develop into more effective multidisciplinary team members.
However, nurses require organisational leadership, service support and
sufficient resources to equip themselves with the skills and the resources they
need to administer care. The processes of moving from novice to expert can be
facilitated when clinical decision-making strategies are better understood.
Extracting and defining the knowledge embedded in the practices of nursing is the
challenge for the nursing profession. Banks and Purdy (1995) believe that nurses
are in a unique position to act as advocates within the changing health care
system if armed with such knowledge; the implications for nurses within palliative
care being primarily concerned with quality assurance.
8
3.
Methodology
Benner (1994) has adopted a hermeneutical approach to uncover the
knowledge embedded in clinical nursing practice. The term hermeneutics has
been associated with the theory and practice of interpretation. It is a philosophic
perspective that emphasizes the social and historical nature of inquiry, and argues
that understanding is inseparable from the social interests and standpoints that
one assumes.
This approach of interpretative phenomenology has been chosen for the
present study in order to capture the skilled know-how, the clinical knowledge and
the everyday ethical component of nurses when allocating resources. The
interpretative research can provide the basis for understanding the current
situation as it focuses on everyday experiences in the complex world of human life
and the meaning found within those experiences. It accommodates aspects such
as values, beliefs and feelings and is highly suited to answering “what” and “how”
questions about human issues and concerns, but does not aid in prediction.
The interpretative research tradition emerged in Germany in the late 19th
and early 20th century. Much of the current thinking in the interpretative tradition
stems from the work of Husserl, and his student, Heidegger. There are distinctions
between Husserl and Heidegger's philosophic assumptions, and these distinctions
have implications for the methodology employed. Within the past decade the
Heideggerian tradition of conceptualising and understanding human phenomena
has gained influence in nursing, and it is this perspective of Heideggerian
phenomenology to which this study will refer.
9
Heidegger (1889 - 1976), sought to answer the question of the meaning of
Being. ‘Dasein’ (the human way of being) is best described by our ordinary, pretheoretical understanding of being, which arises in the midst of our practical affairs
- our average everydayness, while we are constantly adapting to our situations.
Heidegger (1962) argued that humans are always living hermeneutically, finding
significance and meaning in their worlds. Dreyfus (1988) states that much of what
we do, does not involve consciousness or awareness, but rather everyday skilful
coping. Drawing from this tradition, interpretative research may be understood as
the study of human experience as it is lived, rather than as it is conceptualised,
which is distinctly different from the natural sciences.
Phenomenology differs from almost every other science in that it attempts
to gain insightful descriptions of the way we experience the world pre-reflectively,
without taxonomising, classifying, or abstracting it. So it does not offer us the
possibility of effective theory with which we can now explain and/or control the
world, but rather it offers the possibility of plausible insights that bring us in more
direct contact with the world. Munhall (1994) states that understanding meaning,
has far greater value than focusing on the behaviour, as meaning influences
behaviour. If we understand the meaning of a behaviour or experience, we might
adapt more easily useful behaviour.
Heidegger rejected the notion that we are observing subjects separated
from the world of objects, which we try to gain knowledge about; rather, we are
beings inseparable from an already existing world. He states that presuppositions
cannot be suspended because they constitute the possibility of intelligibility or
meaning (Ray 1994). Experiences can only be understood in terms of one's
background, or historicity, and the social context of the experience. Therefore,
hermeneutics does not advise the researcher to bracket himself from the inquiry
10
process, either in conversation/interview, or when interpreting texts (Annells 1996).
Gadamer (1976) states that to try to eliminate one's own concepts in interpretation,
is not only impossible, but manifestly absurd. From Gadamer's perspective, a
human being is first and foremost an everyday actor, and this gives the
phenomenologist the necessary ability to interpret wisely.
11
4.
Method
In human science research a certain openness is required that allows for
choosing directions and exploring techniques, procedures and sources that are not
always foreseeable at the outset of a research project. Phenomenology is
regarded more as an approach than a method. Still there is a tradition, a body of
knowledge and insight, a history of thinkers and authors which, taken as an
example, constitute both a source and a methodological ground which will be used
for this research. Van Manen’s (1990) phenomenological approach was used to
guide this study, because his method is open to innovation, and emphasises
dialogue through self-reflection. He developed a methodical structure and stated
that interpretative phenomenology may be seen as a dynamic interplay among six
research activities as I depict here.
Tab2:
Methodical structure of interpretative phenomenological research by van Manen (1990)
investigating
experience as we
live it rather than
as we
conceptualise it
turning to a
phenomenon
which seriously
interests us and
commits us to
the world
balancing the
research context
by considering
parts and whole
describing the
phenomenon
through the art
of writing and
rewriting
reflecting on
essential themes
which characterise
the phenomenon
maintaining a
strong and
orientated
pedagogical
relation to the
phenomenon
Nelly Simmen 2003
12
4.1.
Collecting data or investigating experience as we live it
The world of lived experience is both the source and the object of
phenomenological research. Therefore one needs to search everywhere in the lifeworld for lived experience material that, upon reflective examination, might yield
something of its fundamental nature. To look into other people’s experiences and
their reflections on their experience may be useful to come to an understanding of
the deeper meaning or significance of that experience in the context of the whole
human experience.
As interviewing is a flexible technique that allows obtaining experiential
clinical description and exploration of meaning at a greater depth than other
techniques (Munhall 1994, Silverman 2000), it was considered to be a suitable
method of gaining an understanding of the experience of resource allocation. In
hermeneutic phenomenology interviews are used for very specific purposes. First,
it is used to establish a conversational relation with a partner (the interviewee)
about the meaning of an experience and, secondly, to gather and explore
experiential narrative material. All this serves to develop a rich and deep
understanding of a human phenomenon (Van Manen 1990). The collaborative
quality of the conversations lends itself especially well to the task of reflecting on
the themes of the phenomenon under study. The conversation has a hermeneutic
thrust: it is orientated to sense making and interpreting of the phenomenon that
stimulates the conversation (Benner 1994). Therefore, after obtaining ethical
approval for this present study, interviews were conducted using a phenomenological approach. A tape-recorder was used to assure accuracy in data collection.
To avoid distraction or confusion the interview process was disciplined by the
research question and furthered by some prompting questions (see interview
13
guide in appendix 9.1/9.2). The interviews were afterwards transcribed on a
computer for analysis.
4.2.
Participants
Six nurses from a palliative care ward in Switzerland volunteered to do one
to three interviews. The participants all had a nursing degree and had been
working on the ward for at least one year. As too many volunteers applied to
participate in the study, a selection with the following criteria was used to promote
heterogeneity:
•
experience on the ward
•
age
•
education
•
gender
The number of participants was limited to five persons to gain depth of
understanding. The number of interviews with the participants was established
from the material that was generated and the understanding of the experience as it
unfolded. Succeeding interviews were useful in verifying the transcription and
interpretation of previous interviews with the participants.
4.3.
Gaining access
Ethical approval for this investigation (appendix 9.3/9.4) was obtained
through submission of the proposal to a specifically appointed committee of
persons working in the study institution. These persons include the director of the
central services, the human resource manager, the spiritual counsellor of the
palliative care ward and a research adviser. The purpose of this committee was to
safeguard the protection of the participants and to accompany the research
project. The institution itself is owned and directed by a diaconal order.
14
At a team meeting the nursing team was informed about the research
project and they had the opportunity to ask questions. One main topic concerned
ethical issues (see section 4.8 ethical concerns). The nurses received an
information sheet with the description of the study and its aims (appendix 9.5/9.6),
and a consent form (appendix 9.7/9.8). The nurses were asked to fill in the
consent form if they were willing to volunteer. As more than six nurses agreed to
participate, specific criteria were used to determine which of them will take part. All
volunteers were informed of the final selection (appendix 9.9/9.10 and appendix
9.11/9.12). Convenient dates for both the participant and the researcher were
chosen for the interviews.
4.4.
Equipment
With the permission of the participants, a tape recorder was used to record
the interviews. To avoid data loss by equipment failure, all equipment for the
interviews was tested beforehand and there was a second set of back up
equipment.
4.5.
Pilot study
The interview guide and the question technique were tested with one nurse
who previously worked on the palliative care ward. This pilot study helped me to
get used to the role of researcher and to learn the art of questioning. Through
skilled questioning an atmosphere conductive to collaborative interpretative
conversation should be established. The management of the interview, in terms of
interviewer style and questions asked, was quite a challenge for me.
15
As the data of this pilot study revealed another interesting aspect of
resource allocation I finally decided to include this data with the permission of the
participant.
4.6.
Conducting the interviews in the main study
The interviews took place in a suitable, comfortable, quiet room fit to
enhance conversations. The interview guide, developed and adapted during the
pilot study, was used to ensure that the study focus was maintained. I wanted the
respondents to describe their experiences of resource allocation in their own
words. Therefore I did not provide them with a predetermined definition. The
participants had been instructed that narrative accounts of events, situations,
feelings, and actions were wanted. The interviews lasted for 60 – 90 minutes and
were audiotaped with the permission of the participants. At the end of the
interviews I suggested to the participants that they keep notes between the
interviews of anything, that occurred to them, that they found pertinent and wanted
to bring into the next interview session.
Three participants suggested performing a group interview, which was not
planned at the beginning. As Benner (1994 p. 108 ff) states that the small group
interview is an effective way to set up a familiar communication dialogue, I agreed
to this idea, which has proved to be suitable. The nurses were asked to talk
directly to one another and to respond with similar or dissimilar stories.
I transcribed verbatim the recorded interviews on the audiotapes and
translated them from Swiss-German into Standard German, as Swiss-German is a
spoken language only. Transcripts were made anonymous by deletion of any
references to specific names or locations. As a double-check for accuracy, the
participants had the opportunity to read and comment on the transcription.
16
4.7.
Reflective notes
Although the interpretative process can never be fully explained, Koch
(1996) suggests that interpretative researchers need to convey how insights are
generated. Therefore she recommends that researchers keep a reflective journal
in which they describe and interpret their experiences and the decisions made.
Therefore reflective notes were written at times and some ideas recorded in a
notebook. These notes promoted reflection on the subjects of resource allocation
and of hermeneutics. They are incorporated in the study where appropriate.
4.8.
Ethical concerns
At the team information meeting the main topic concerned ethical issues.
To prevent misunderstandings, all involved needed to understand and agree on
the various stages and activities of the entire study and the dissemination of the
results. There were opportunities to ask questions, discuss issues and state
opinions.
Every nurse received written information with full disclosure of the research
activity (appendix 9.5/9.6). Nurses who wished to volunteer were asked to fill in a
consent form (appendix 9.7/9.8). Because research with a phenomenological
perspective is conducted in an ever-changing field, informed consent is an
ongoing process and renegotiated as unexpected events or consequences occur
(Munhall 1994). Therefore the participants were informed that they could withdraw
from the study at any time. Additionally, they were assured that the tapes would be
locked in a secure cupboard and destroyed one year after the completion of the
dissertation, and that any information used in the research presentation would be
confidential and anonymous. Confidentiality was supported by limiting raw–dataaccess to the researcher and the supervisors. Anonymity of participants is kept by
17
using code numbers on the interview transcripts, thus avoiding personal
identifiable information, and by using pseudonyms in any publication. However, as
the team is small and all team members know each other very well, it is not
possible to assure absolute anonymity and confidentiality. Furthermore, as the
nurses were working in a small, but well-known palliative care unit in Switzerland,
identification of the team was possible. The participants were informed of this ‘risk’
(appendix 9.5/9.6).
4.9.
Data collection and interpretation
I personally facilitated and transcribed verbatim all interviews in German.
After acceptance of the transcript by the interviewee I analysed the data using
interpretative analysis. A selective reading approach was adopted, which means
that the texts were read several times with the question: “What statements seem
essential or revealing about the phenomenon described?” Analysis involved a
prolonged period of reflection on both parts of the data and the whole in order to
extract and define the meaning derived. “The hermeneutic circle” is a metaphor for
describing this analytic movement between the whole and the parts, in which each
gives the other meaning (Van Manen 1990, Benner 1994).
A period followed of living with the data over a number of months and
acknowledging the evolution of the data over time, through conducting further
interviews with participants, through awareness of changes in personal and
professional contexts and through writing and re-writing the report in German. In
phenomenological science writing is not the final step of presenting the results, but
rather the crafting of a text is an essential part of the activity of doing research.
Van Manen (1990) states that we come to know, what we know, in a dialectic
process of constructing a text. Thus, writing creates the reflective, cognitive stance
18
that characterises the theoretical attitude, and may turn into a complex process of
recognising, reflecting, re-writing and re-thinking. This process had to come to an
end recognising that each person’s interpretation of a text will change over time as
the horizon evolves, and that interpretative research represents a temporary view
about a phenomenon. Then the findings and the selected quotes were translated
into English. I attempted to make the quotes readable by, for example, condensing
segments of dialogue, omitting repeated phrases, false starts and comments by
myself, while making every attempt to avoid distortion or misrepresentation of
meaning.
4.10. Establishing truth value of the research
The nature of qualitative analysis is at the heart of much controversy. This
relates, in the main, to dependence on the analyst’s insights and conceptual
capabilities, coupled with ambiguity about the process of knowledge generation. A
suspicion may arise that the data have been shaped, knowingly or otherwise, by
predispositions and bias.
Interpretative phenomenological scholars, according to the Heideggerian
tradition, believe that knowledge is never independent of interpretation. Therefore,
research findings are not considered 'true' or 'valid' (Walters 1995, Koch 1996).
Hence, they state that Heideggerian research should be evaluated not by indices
of objectivity but by indices of convergence, which means the extent to which the
perspectives of the participants, the researchers and other data sources are
merged in the interpretation.
In the words of van Manen (1990): “A good phenomenological description is
collected by lived experience and recollects lived experience – is validated by lived
experience and it validates lived experience” (p. 27). If the description is
19
phenomenological powerful, then it acquires a certain transparency, it reawakens
our basic experience and permits to “see” the deeper significance, or meaning, of
the lived experience it describes. Varying the examples is the way in which we
address the phenomenological themes of a phenomenon so that the “invariant”
aspect(s) of the phenomenon itself comes into view. However, quotations can only
reflect a proportion of the evidence available to support a claim and they are taken
out of the context of the interview. Inclusion is driven by the researcher’s choice,
and the word limit of the report dictates how many can be included.
Munhall (1994) states that the most critical, ethical obligation in
phenomenology is to describe the experiences of others as faithfully as possible,
which means to interpret and describe the experience in the most authentic
manner that unfolds. She adds that a good phenomenological study makes
statements we can nod to, recognising it as an experience that we have had or we
could have had.
The aim is therefore to present a study in which, the end product is
presented in an interesting, appealing way, the process of methodological
decisions is clearly presented, and the usefulness and relevance for practice is
shown.
20
5.
Findings and Interpretation
After listening to the interviews and reading the transcripts several times, I
realised that each report about resource allocation was very much shaped by the
individuals’ experiences, their attitudes, their thinking, their way of speaking and
acting. Each participant demonstrated another perspective of the phenomenon of
resource allocation. It occurred to me that each of them owned an inner picture
about their main theme. Therefore, I will at first present their individual meanings
concerning experiences of resource allocation with the help of metaphors.
5.1.
The meaning of the experienced resource allocation
Resource allocation is like…
5.1.1. ...building on the foundation of valuing
To Barbara1 having a valuing attitude towards her patients was
fundamental. With this attitude she was able to construct a trusting relationship
and to build up individualised care. This valuing attitude helped her as a resource.
On the other hand, by allocating resources she expressed her valuing attitude.
Hence she experienced resource allocation and valuing as mutually influencing
processes.
Barbara: One’s attitude towards patients can be a resource. From their feedbacks, I infer
that a valuing attitude increases their well being. If someone has the feeling of not being
taken seriously or of not being held in high esteem, it can increase pain. (2:18) (…) It
seems to me that the attitude must be the basis. I believe that the attitude is really
decisive. (2:25)(…) Being able – even under great pressure – to let people feel that they
are appreciated and that one perceives:“ Hey, here is a person who is in a state of crisis”,
reveals a valuing attitude. After all, most of the hospitalised patients are in one way or the
other in a difficult situation. If one succeeds in showing them that one strives to support
them, it’s a lot already. (3:5) (…) The lady who came to visit the unit today, told me after
approximately two minutes: ”It’s alright. I know that we will come here.” Since the outer
appearance of our unit is not very nice, I asked her what had induced her to say so. She
1
all names are fictitious
21
replied: “I was warmly welcomed at the reception, and they helped me to find the right
place and the right person. Afterwards you, too, greeted me very kindly.” She thus felt
both people’s positive attitude, and it is what may have influenced her decision – probably
more than perfect and beautiful rooms would have. (3:10)
Resource allocation is like…
5.1.2. …being a channel for a good resource flow
Anna experienced herself as a channel for resources to the patient. It was
important to her to create an unhindered resource flow and to constantly be
connected with the source as well. As soon as she found herself missing the
needed resources she tried to get them from team members or from God to
channel them again to patients. Resources could be compared here to energy
being transformed into different manifestations.
Anna: Being able to draw on a divine source is essential to me. Since we so often reach
our absolute limits, I can hardly imagine, how others are able to work on such a ward for a
longer period of time without having the opportunity to contact a superhuman source of
energy. The awareness, deep down inside, to be in God’s hands and backed up means a
lot to me. I very well remember a situation where a patient suffocated. I stood at her
bedside, while my colleague prepared and administered the medicaments. While waiting
for them to have an effect, I beseeched God to give me inner calm and strength to cope
with this unbearable strain. I then felt an intense calm that enabled me to transmit it into a
kind of cycle and to instruct the patient to a more relaxed and calm breathing. The only
thing I did was to stay there, to be calm, and not to keep this calm for myself. And I
noticed that this really helped. (5:18) (…) I hold that I can admit not knowing everything. It
is, therefore, no problem for me to ask colleagues for help. I consider the sharing of
responsibility and the working together as very important. It is, unfortunately, when things
get hectic, that it doesn’t occur to you to call for help. And there must be an atmosphere of
trust within the team for the level of inhibition to drop. (4:22) (…) I’m privileged to have a
family at home, where I can experience a lot of normality and healthiness. Each time, I
move from one world to a completely different one, to one that is demanding too, but to
one that acts as a counterbalance. It helps me to recharge my batteries so that I love
coming to work, moreover to come with “élan”. (2:7)
5.1.3. ...using a film library as a treasury of experiences
Kirsty decided about of resource allocation with the help of memories
connected with similar situations in the past. She described it like seeing many
different film cuts of previous experiences, especially the ones that might be useful
for the situation at hand. From this kind of film library she then chose the most
22
suitable option. Kirsty most often decided on the option with the most promising
effect and the least expense. She could never know ahead what the final
outcomes and side effects would be. But this was exactly the challenge she liked:
to develop intuition through previous experiences and a feeling for appropriate
actions in situations at hand.
Kisty: I have clear ideas of situations. It’s like some kind of images of what is happening
with patients. And I think about possible strategies to make it more complete and
comfortable for them. The process of checking its usefulness with regard to the well being
and other consequences is an enormously quick one. It has to do with experience, one’s
own and that of others I heard of. (6:5) (…) We have an enormous amount of experience
with patients. It’s what I like in this job. You remember somebody you once nursed and
you get an idea of someone. This is useful and nice, although certainly not always fully
applicable. (6:10) (…) An experienced nurse is in a better position to judge a situation.
And this ability to judge can be an important resource. It’s fun to juggle with one’s
experiences and to evaluate the effects it has. Being able to possibly fulfil everybody’s
wishes gives you a sense of satisfaction, even if you have to cut down somewhere. (7:9)
Resource allocation is like…
5.1.4. …balancing a mobile and juggling with time units
The art of handcrafting a mobile is balancing the weights in a multi-layered
construction. Changes on one side need adaptation on the other which is difficult
to balance in a complex whole. The art of resource allocation is similar. On one
side there are one’s own resources and the ones of colleagues (other nurses,
nurse students, auxiliary staff, chaplain, social worker etc.). On the other side are
the needs; different needs of one patient (physical, psychological, social-spiritual
needs), the needs of different patients and the demands of running a unit. These
different needs have to be weighed up and balanced with the resources.
Obviously, this metaphor demonstrates why it is challenging when unexpected
changes occur (changes in the needs: needs of the patients: phone calls,
unexpected visitors and other demands or changes in the availability of resources:
staff shortage, new staff etc.). An adaptation process with decisions and
arrangements is needed which needs additional resources. Bob highlighted this
23
with the following interview excerpts in which he demonstrated how he was
juggling with time units:
Bob: Today, I strove to carry out most of the nursing before the coffee break to manage
the allotted task. Because Ms. B. likes to be nursed before breakfast, I had planned to
start with her. It didn’t come to that, though. Mr. H. called after seven, because he wished
to get up and to ride the bike. As it is with nursing – unpredictable – I had to give him my
attention first and to calm him. It was only after this that I was able to look after Ms. B. as I
had intended. When I had a minute left, I checked, if the trainee needed some support.
Just before nine, I managed to change Mr. H’s dressing. Afterwards we had a thirty
minute break. Then I talked with my trainee and suggested to give Ms. B the enema
immediately after the break, because she would have her music-therapy at eleven, and
we wanted to avoid her being exhausted when the therapist arrived. Meanwhile, I carried
out Mr. X’s oral hygiene. Earlier Mr. P. had told me that he wished to have a bath. I had
promised him to arrange it. In the meantime, however, he had changed his mind.(1:22)
(…) Early in the morning already one has to consider that the physiotherapist, the
counsellor, or the doctor would interrupt for some information. You can’t avoid that, but
sometimes it’s frustrating and tiring. Then there are phone calls, or you have to organise
additional things, such as discharges or transfers. You can’t do anything about it…that’s
the way nursing is. (3:2)
Resource allocation is like…
5.1.5. …experiencing Kairos
There are two Greek words for “time”. One is ‘chronos’, which is time in
general; the general ‘time in which anything is done’. The other word, ‘kairos’, is
the strategic or ‘right time; the opportune point of time at which something should
be done’ (Ethelbert and Bullinger. 1975 p.804)
For Carol the art of resource allocation meant experiencing kairos by using
the available resources and performing the right action in the right moment.
Enthusiastically she described the following situations:
Carol: When Mr. D., whose state of health had deteriorated rather quickly, received his
breakfast, I fortunately happened to be in his room and could watch him from a certain
distance. I was thus able to support him a bit exactly in the right moment and so to avoid a
misfortune, when he was in the danger of soiling himself by spilling. This was great! (2:24)
(…) There was another situation, where I noticed that I was able to make good use of
resources. A patient’s nephew, who stood in the corridor, said he wished his aunt could
die. Since I had been able to build up a relationship to him before, I was able to react
immediately. I thought: “It’s the right moment to ask him how to clothe his aunt after she
will have passed away.” (2:28) (…) The morning had been very busy. Yet I liked it to
establish priorities together with my trainee, to seize such moments, and to make good
use of them. There were probably things I missed, but a few I managed to seize. There is
always more you can do. (4:18)
24
Resource allocation is like…
5.1.6. …distributing sweets
To Sandy, resource allocation meant to add something special to everyday
life by using her individual talents and skills. Non-mundane actions can sweeten
the suffering of palliative care patients who have multi-fold needs in different
areas. Sandy considered these actions as important to apply good holistic quality
care and this gave her a feeling of satisfaction.
Sandy: If the daily load permits, even if its very busy, I am very happy when I can give
sweets - my own special resources! Then it’s fine. But if I do not even have time for this, I
will become discontented after a certain time. (3:4) (…) For me the sweets are something
special, certain extras. To place someone into the air-chair, for example, to sing a song or
to read a story to someone, but also nail-care, a foot bath, to take a patient to the
veranda, to get into a conversation, or to tidy up their room. I like a certain degree of
tidiness, because I’ve the feeling that it’s good for the patients. It gives them a sense of
well being also in their inner world.
Interviewer: Why are these extras so important for you?
They make me feel to realise real palliative care, to emphasise a holistic approach, not to
work at an ordinary medicine unit. I’m convinced that this too belongs to human beings.
Besides personal hygiene, meals, symptom control and suffering, there are other
important aspects in life. That’s why I work on a palliative care ward, it’s my motivation.
Here I can achieve something more, something that I could not, if I worked on a medical
ward. (3:23) (…) Maslow’s pyramid comes to my mind. If the basic needs are provided for,
one can go higher up. On top, there is self-realization, which definitely is a purpose in life
of human beings. Even of our seriously ill patients it is still a goal, or maybe it is especially
important for them. Using the available time exclusively for things on the lowest level is
therefore a pity. According to Palliative Care, these specials are no extravagance, they
should rather be an integral part. However, there is not always enough time. That’s why I
talk of luxury and extras, Moreover, I noticed that it also depends on the nurses’ priorities.
If – after the primary needs are met – there are for once five minutes left for something
special, it is important to seize the opportunity. (4:4)
Summarising: The above-mentioned metaphors and quotes highlighted
each individual’s view of resource allocation. The recurring common factor, like the
essence of the phenomenon, seemed to be the close association of resource
allocation and person. The nurses experienced resources as part of them, flowing
through them and being marked by them. Resource allocation meant they use
themselves, their attitude, experiences, skills, creativity, energy and time to
25
provide care. There may be many different ways to experience resource
allocation, the meaning of which is unique to each person. Nonetheless, there
were agreements and similarities in their experiences, as we will see in the next
chapter.
5.2. Different aspects of resource allocation and their
correlations
As I read each individual report, impressions formed in my mind. In my
imagination I prepared acetates of each impression. By laying these acetates on
top of each other a new and more complete picture appeared. I saw similarities,
overlapping and complementary.
In section 5.2 I will present the whole picture and common work of this
group of interviewees. The different aspects of resource allocation and
interrelations will be presented under the following headings: inputs, processes,
influencing factors, and outcomes.
5.2.1. Input:
What did the participants experience as resources?
The nurses interviewed described numerous personal characteristics, skills
and talents that they consider as resources for the provision of palliative care,
including an ability to provide patients with a feeling of safety and trust, having a
genuine interest in people, being sensitive, creative, curious, patient, empathetic
and courageous, as well as having a sense of humour. These features were
occasionally mentioned explicitly or hypothetically, but more often became evident
through descriptions of concrete situations. Although such descriptions about how
staff members might use themselves therapeutically, were frequently coupled to
statements about how this is hindered by resource limitation. Participants
26
sometimes described situations in which they felt they could not use their
resources because they had been inhibited by varying limitations.
Another characteristic addressed as important was the ability to adapt to
varying needs of individual patients in changing situations. Knowledge and
experience were perceived as prerequisites for developing maturity and for
establishing a repertoire of alternative ways for handling situations. It was
emphasised that clinical experience of palliative care, including reflective practice,
is an important component of quality professional care provision. Besides personal
resources the participants also mentioned the team, the available time, suitable
material and the opportunity to get further education as resources.
They experienced the quantity of these resources as relative - sometimes a
great effect can be achieved with little effort and sometimes a huge amount of
resources is needed for only small results.
Kirsty: Sometimes even tiny things have an effect. Today, I didn’t feel like joking,
unfortunately, but it would be great if one were able to joke, because it relieves….or to say
a prayer or to sing a song. (g, 4:1)
The estimation of the available resources varied depending on what is
expected and what one is used to.
Barbara: When I started working on the palliative care unit, I was impressed by the
discontent of many nurses. Since the unit had been moved to a hospital just before, they
feared an increased pressure and a shortage of time. “It’s like in a regular hospital, now”,
they thought. I, however, had the impression of being in paradise, and I became aware of
how unjust the resources are distributed. I thought: “Here, the conditions for nursing are
really good, while at my former working place – for lack of time and knowledge – similar
patients were simply neglected. (7:13)
Summarising: Different personal characteristics and talents of nurses, time,
space and matter served as resources in the clinical practice. Resources were like
energy appearing in different, interchanging forms, and were used to achieve
effects. Important for apt resource allocation was the quantity, as well as the
27
quality, of resources in relation to the demands. However, the estimation of
quantity, quality and suitability of resource allocation may differ between
individuals.
5.2.2. Processes:
In which way did participants allocate resources?
What processes did participants experience?
Procedure and decisions
Several participants described the following procedure: When reading a
patient’s file, information about prescribed times and handicaps were being
collected (actions the primary nurse planned, appointments with therapists,
medication-administration times). Actions which were not bound by time were
subdivided into tasks which were either pressing or important and in tasks which
could be postponed or omitted, when necessary. This gave a rough idea about the
course of events ahead. Plans of resource allocation were often foiled by
unexpected events and needed to be adapted. Therefore the participants stated
that they did not plan any more. They simply liked to have a vague idea about the
course of actions, but remained flexible to adapt to upcoming needs.
Bob: On a palliative care ward it’s impossible to achieve one’s plans one to one despite
very careful planning. There is always a possibility of unexpected incidents, such as a
patient suffering from dyspnoea, or someone being in pain, or, like recently, as Mr. H.
suddenly grew agitated and hung on the bedrails. (4:16)
Prescribed times and tasks provided a certain structure, but might also
produce inflexibility or even stress.
Anna: It happens time and again that – after having been absorbed in nursing a certain
patient – I’m horrified to find that it is ten already, and that by ten I should be doing this
and that. It always produces stress. That’s why I’m often in a dilemma, when there is not
enough time for everything I would like to do. (6:23)
28
Decisions about resource allocation mostly ran automatically on an
unconscious level. Rather challenging situations provoked thought processes on a
more conscious level. These situations of reflection and learning served as
experiences for next similar situations in which less time would be needed to
reflect on a conscious level.
Barbara: You constantly make decisions without much thinking. (2:8)
Kirsty: I had planned the day differently. Most of the time you organise and you
instinctively establish priorities. And I notice how easily – due to the many years of
experience –I can do that. But sometimes, when it gets more difficult, I need a moment for
reflection. Then I become aware that I consciously search for the best way. But usually,
because I’m so experienced, I act instinctively. This ability is also a resource. (4:20)
The participants influenced each other and also tried to match resource
allocation with each other.
Bob: When I notice that a trainee loses a lot of time, for instance, while talking to relatives,
I try to draw her attention to the fact. (4:25)
Sandy: I too try to carry the daily work through as well as possible. I cannot just consider
myself and distribute sweets, while my colleagues have to run around. (4:21)
Endeavour to use sensible and efficient resource allocation
The participants aimed to use resources in a sensible and efficient manner.
They preferred investing resources where they expected the most important and
necessary results that were in harmony with the patient’s needs. Therefore they
found it frustrating if resources were sometimes wasted through inappropriate
therapy or diagnosis, especially if resources were missing in areas where they saw
more urgency.
Kirsty: It happens in hospitals that the nurses burn out, because they have to do things
that make no sense to them, i.e. useless chemotherapies. (5:14)
For efficient and useful resource allocations the participants used their
creativity. Through this, positive results could sometimes be achieved with little
29
resource investment. But when there were not enough resources for the
demanded tasks, they preferred to postpone the task.
Sandy: It’s like throwing a stone into water. Even if it’s a very little one, it will immediately
produce circles, and I think that the extras have a similar effect. (g, 4:21)
Barbara: The lady’s hair in room six badly needs washing, because it has been extremely
dirty for a long time. But even in such a situation it is important to establish priorities and
to consider that it must be done when enough time is available. Otherwise it will go wrong.
(g, 3:15)
Where priorities are set
The participants suggested setting priorities according to the patient’s
needs. Little and inconspicuous actions may be important and trigger great effects.
Further, through adroit resource allocation other resources could be promoted or
released.
Barbara: In my opinion, it is very important to fulfil the nurses’ obligations to the patients.
Since our patients are in very difficult situations, however, meeting this requirement is
extremely demanding. That is why we have to find out the most important or most urgent
task, and to start there, in order to improve the situation a bit. (g, 2:24)
Kirsty: Perhaps something tiny has a great effect. If I think of a patient who is in pain, it’s a
little thing to give him a painkiller, which will improve his situation. Such a thing does not
take much time and I have less stress and more freedom to tackle another problem. (g,
5:4)
The interviewees distributed resources, balanced weights and set priorities
according to available resources and demands. Hereby a hierarchy of needs and
actions developed, arranged by importance and urgency. These hierarchies varied
between individuals and groups as they were influenced by their attitude, values,
knowledge and experience.
Barbara: I believe that the attitude is decisive, it’s the basis. Then comes the care for
physical needs. And there must be room for psychosocial and spiritual needs, which is
important in Palliative Care. These needs are pressing as well, not with regard to time, but
to the importance for the patients. However, they would be listed on quite different
positions in a priority list of nurses. When resources are scarce, the cutting down occurs
there. You can’t leave a person in a bed, dirty with stools, for twenty-four hours. But
leaving a patient in her sorrow for twenty-four hours, without giving them an opportunity to
talk about it, this happens. It is probably related to one’s attitude, to one’s priority setting,
30
but also with the fact that it is easier to clean a bed than to sit down and speak with a
patient when one is in a hurry. A study I made at my previous workplace highlighted the
different priorities of tasks. All visible tasks, that could be noted and charged had a high
prestige. All invisible tasks had a low prestige and one had to defend doing them. For
instance, whenever one hour was available, it was used for extensive body hygiene,
without questioning. But I had to defend myself when I was talking with relatives for ten
minutes because it was considered as luxury. (4:8)
This report showed clearly that inner personal conflicts and also conflicts
within a team could occur if resources were lacking in relation to what the person
considered as needed.
An issue frequently addressed, was the time-consuming nature of some
aspects of nursing. Psychosocial care was described as particularly problematic in
this respect and participants repeatedly spoke of difficulties in negotiating between
time restraints and their ideals about care provision. In those situations one
participant recommended asking the patients for their impression.
Barbara: It’s interesting to hear how patients evaluate my care. Due to one’s ideals one
easily has the impression of not giving enough. This feeling is often not confirmed by the
patient’s feedbacks. They have gathered a lot of experience in hospitals and have
developed different standards about a constant rush, the availability of nurses and being
left on their own when they are in a better state of health. Therefore they are usually easily
satisfied. (6:17)
Saving resources
The participants made no general statements about what tasks could be
omitted to save resources. Depending on the situation something would be
omitted to give time for something else.
Carol: I consider what will be effective, how much time I have, what the patients need, but
also what can be omitted to get time for other tasks. An example: A patient has long nails.
Then I omit to wash the legs, when I know that the situation allows it. Hence the priority
will be to seat the patient on the edge of his bed, to put his legs in a lavender bath, to cut
his nails and put cream on his feet. (6:10)
Most often side-tasks like cleaning, replenishing material, organising and
even personal hygiene may be postponed for a while. If these tasks had to be
31
postponed for too long or were even omitted entirely, negative consequences
occurred.
Sandy: Yesterday, when a patient got a crisis and there was no Nitro-glyzcerin in her
room, I thought: “How awful! Now I need to run to the office to get some:” I was furious
that my colleague did not replace the last one she used. (g, 5:25)
Barbara2: From the beginning at seven a.m. I knew that I would never be able to do all I
should do before four p.m. Clearly I knew that I would allocate my resources in the
morning to my two patients and that I would do all the organisation and writing in the
afternoon.
Interviewer: What exactly was it that you knew you would not have time for and thus omit?
Barbara: All the rest I had to do; the report and the planning for the next day shift, the
organisation for an admission. But there were also things I would have loved to do. One
patient’s nails needed cutting, but I realised that there were more important needs to be
satisfied.
Kirsty: Was this rather your own need than hers?
Barbara: Yes, but when she fell on the floor I realised that it would be important for our
security as well (laughter). (g, 6:16)
Consequences of the lack of resources
When there were not enough resources to enable an adequate resource
allocation, processes became difficult to influence and even more resources were
needed in the end. Problems became like a vicious circle. It would have been
important to break that circle through appropriate resource allocation as soon as
possible. If not, more and more problems arose out of it. Unfortunately stress, lack
of experience and other reasons were frequent hindrances to breaking the vicious
circle. As a result, processes could neither be foreseen nor be evaluated and the
precious reflection in retrospect could not take place anymore. A pity, as such
reflection could have been integrated into the treasury of experiences and be very
helpful in future similar situations.
Barbara: I remember a story. When I started working on the palliative care ward, a
colleague prepared a soup for a patient in the night. The patient ate the soup and slept
afterwards. At my previous workplace I would have told the patient: “I have absolutely no
This quotation is an excerpt of the small group interview I described in chapter 4.6 “Conducting
the interviews in the main study”
2
32
time to prepare a soup, you should sleep now.” Maybe I would have given her a sleeping
pill. Often it happened that one was not able to calm the patients because of one’s own
bustle. Then they got even more agitated, they climbed over the bedrails and dirtied
themselves with stools. The situation escalated and by the end you were forced to invest
your time whether it was available or not. It was partly a lack of knowledge but mainly a
lack of time. When you are under stress you do not have any idea to find out what would
be helpful. (…) I think we did not realise these correlations, even not afterwards, as we did
not have time for reflection. You do not sit down and consider what happened. The day
shift arrives and thinks: “Oh dear, this woman was agitated all night. What shall I do? How
can I sedate her?
Interviewer: To give her medicaments again?
Barbara: Yes, because it is quick and efficient. If you were able to stop and think, you
would find solutions, which would be time-saving in the end and even better for the
patients. I often experienced to be in a vicious circle, which it was difficult to get out of.
(5:11)
Summarising: The participants tried to allocate resources in an efficient and
useful manner with the aim of supporting the quality of life and well being of their
patients. To prevent circles of decline and to support positive processes, they
strove for allocating resources, with the right timing, and where they expected the
most useful and important results. The actual needs of their patients and the
information from the documentation guided their actions. They tried to find a
balance between the different needs and demands of all persons involved and
they influenced each other. In the course of this, adaptations to changes might be
needed. The required thought processes often occurred quickly, automatically and
on an unconscious level. The participants could not state explicitly where they set
priorities and saved resources, because it depended on the individual situation,
the demands, the possibilities and the available resources.
5.2.3. Influencing factors:
Which factors influenced resource allocation?
Resource allocation depended on timing, quantity and quality of resources.
For instance, the ability to intervene at the right moment, the quantity of time
available and the quality of empathy would influence an interaction. Accordingly
positive or negative processes developed as shown in the story with the soup. The
33
participants mentioned different factors which influence the quantity, quality and
timing. They are summarised in the following three groups: correlation between
patient needs and availability of resources, characteristics of nurses, and
structures within the organisation.
Correlation between patient needs and availability of resources
Nurses have the duty to balance the demands and needs of patients with
the available resources. Therefore quantity and quality of resources as well as the
number of needs each patient had, and the number of patients that made up the
nurse's caseload, were significant factors in determining resource allocation.
Barbara: One of yesterday’s situations comes to mind. I did not have a lot of time and was
forced to set priorities. I nursed three patients, moreover I was responsible for the unit
during this day and received a lot of phone calls. One of my patients was in a crisis with
total pain on a psychological and a spiritual level. The second one was new on the ward
and had to decide until today, if she wanted to continue her radiotherapy, and the third
needed a lot of time for body hygiene, but was in a stable situation. I realised - and I
believe this was intuitive- that the lady with total pain had priority. I considered that the
second lady had discussed the problem with several persons already and that her primary
nurse would be there to talk with her in the afternoon. I would have been in a dilemma if
she had to make up her mind immediately. (g, 1:22)
When the opportunity was taken, an excess of resources might by used for
special actions to cover more than just primary needs.
Sandy: One can learn to consciously recognise when you have five minutes spare to
answer not- primary-needs. (5:3)
The nurses’ consciousness, attitudes, conditions, skills and
experiences
Besides time as one important quantitative factor the nurses’ awareness,
attitude, condition, skills and experiences, which are rather qualitative factors,
played an important role in resource allocation. This meant that the quality of care
depended not only on the quantity of the resources.
34
Barbara: In my previous workplace I was in charge of a working group for Palliative Care.
Several members reported that a change in awareness had an effect already. They were
able to achieve more with the same scarce time, because they sensed better what the
patients really needed, and they offered a different kind of care. (7:24) (…) It is not
necessary that patients can talk with nurses for hours at any time. But one has to be
present and to have an inner calm to transmit: “We are available when you need us. We
care about you and we take you seriously. This may happen in a five-minute talk.
However, to discuss difficult and personal issues there must be enough time and trust.
(8:15)
The nurses’ knowledge and experience in quickly analysing correlations
and possible developments had a great influence on their resource allocation.
They needed an ability to grasp completely a complex situation and to assess it
well in its elements. The assessment of situations and the nurses’ following
reaction depended very much on their present condition. Tiredness, insufficient
energy, may lead to a lack of patience and a lower threshold of tolerance.
Sandy: Last night when I started the night shift, I realised that I wasn’t as patient as I
usually am. When I came, one patient immediately got on my nerves. Yeah, I realise I’m in
different shape when working day or night shifts. Sometimes it doesn’t bother me if I have
to look for tights and sometimes it’s a tragedy. (g, 7:2)
Bob: I suppose I’ve an angel’s patience with my patients. This is one of my strengths. But
in the early morning or at night I lack some. When I’m tired or not fully awake, the
threshold of aggression may be a little lower. (8:18)
Structures, organisation, teamwork and working context
The working context influenced resource allocation. Participants mentioned
the advantage of a small unit in allowing a good overview and to get to know each
other, the patients, their relatives and the team members very well. They also
considered the values of the institution, and the attitude towards the staff and their
work as influencing factors. The working context may serve as resource or
inhibition. For instance being appreciated by superiors and the society had a
motivating effect on nurses.
Sandy: One important resource is the fact that our unit belongs to the diaconal order with
its basic principles and atmosphere. The appreciation we and our work receive is not
taken for granted. (6:22)
35
Barbara: When our unit was transferred from the hospital to the trust of deaconesses I
appreciated the attitude of being valued for instance by the personnel of the human
resource department. Being valued motivates me and has an influence on how I treat
other people. (…) The fact that the director values what we are doing strengthens our
conviction that we are doing a good job and enhances our energy even if we do not
consciously realise it all the time.(5:2)
Participants reported that their control over time was often reduced by
interruptions including medical emergencies, physician calls, family visits and
other staff members. The frequent and sporadic nature of these interruptions
made it difficult for nurses to have a stretch of time to devote to the completion of
any one task or sequence of tasks. This created a working environment
characterised by unpredictability and needing a lot more resources.
Kirsty: I had to interrupt the care of the patient several times - phone calls, the socialworker passed by, her children arrived. Not being able to continue and finish a task at
once makes it very laborious and annoying. Finally I used a lot of time and energy by
having to settle her each time so that I could go away and then I had to start again (g, 2:8)
Team working was considered as an important factor in resource allocation.
Through good teamwork individuals may find supplementary resources in the team
and mutual support. They helped balance out resources, gave each other
feedback, learnt from one another and carried the burdens together. They tried to
distribute the workload fairly and invest the individual resources as usefully as
possible, not only in one shift but also across the shifts.
Bob: I delegate some tasks, when I think they could be done by the evening shift - I mean
not extensive body hygiene or a big dressing change, but smaller tasks like a mouth
inspection, a mobilisation, or brushing teeth. I aim to perform the time-intensive tasks in
the morning so that the evening shift will not get into trouble and that the tasks are fairly
distributed. (3:27)
Summarizing:
Different factors
influenced
nurses’ clinical resource
allocation. It was primarily governed by the needs and expectations of patients and
the quantity and quality of the available resources. How nurses managed resource
allocation was influenced by their knowledge, skills, attitudes and conditions. And
36
these interactions took place in a context that influences resource allocation by
values and structures. All these factors influenced thinking, evaluating, balancing
out, priority setting and therefore resource allocation, even if it happened mostly
on the unconscious level.
5.2.4. Outcomes:
Which consequences of resource allocation did the participants
experience- in themselves, in the quality of care and in the patients?
Consequences for nurses
Resource allocation was closely related to the nurses, their competences
and main duties. They used themselves therapeutically as resources and
influenced resource allocation through personal characteristics. Therefore nurses
experienced direct consequences of resource allocation. When they achieved their
goals with adroit resource allocation they experienced satisfaction and well being.
Several participants expressed their joy about their ability to juggle well, to keep
the mobile in balance and to experience ‘kairos’. These positive consequences
and results served to improve the motivation and well being of the nurses. This is
important, especially on a palliative care ward.
Kirsty: It’s a pleasure to juggle well with different options for actions from the treasure-box
of experiences and to see the results. It provides me with good feelings if I can do justice
to every body even if I have to take short cuts somewhere. (6.22) (…) Knowing that you
are doing a good job is good for my morale. I consider that the nurse’s creativity serves
both parties, the patient’s and mine. (3.22)
When the participants did not have enough resources to meet the patients’
needs and to achieve quality care, there were negative consequences like stress,
frustration, anger, unhappiness or a feeling of guilt, which could influence the
whole team.
Bob: If somebody calls already at seven o’clock: “Come and help!“ that’s stressing. When
I come back, sometimes I do not know anymore where I left my previous work. I lose the
37
thread.(4.3) (…) If a patient is confused and I am supposed to explain again and again I
get nervous inside, especially if I should do a lot of other things. (4.18)
Barbara: I remember very well at my previous work place, that I often thought in the
evening: “I worked the whole day like a horse and just the same I did not do the
essentials.” This is linked with an extremely unsatisfied feeling and I had the impression of
investing a huge amount to only half-do my job. (…) There was the expectation to do
justice to a lot of persons, but you never got a chance to achieve this goal. Besides the
patients there are relatives as well, there are students and auxiliary staff you have to
watch for, and last but not least you should not forget to care for yourself. This leads to an
inner conflict. I feel angry that this is expected from me and other nurses. (…) If one is
under pressure one gets aggressive. I remember that we walked through the six patients’
rooms with closed eyes and thought: “Hopefully nobody will call.” If somebody needed the
bedpan one got angry and thought: “Oh, again!!!”. This produces a guilty feeling. I believe
my colleagues felt the same. There was discontent, unhappiness and later on conflicts in
the team. (7.14)
Nurses often tried to hide their negative feelings in order not to trigger
negative developments.
Bob: I can hide my feelings quite well and the patients do not notice that I am furious.
Anna: It’s important that the patients feel your stress and rush as little as possible, as
otherwise they get nervous and anxious and then they need more attention, which means
more resources.
The participants reported that they tended to accuse themselves, even if it
was the context that hindered adroit resource allocation.
Barbara: Kirsty, you had an extremely difficult situation during your night shift. You
probably can’t resolve such a situation alone. Just the same one feels that one hasn’t
done enough. That’s crazy and one has to watch not to tear oneself of a strip. Sometimes
I consider what I would say to a friend. I am harsh with myself and grumble: “You should
have done differently, this was not sufficient and that did not turn out well.” To a friend I
would say: “You did great! You did you best in this situation.” One has to take care in
these situations not to get unhappy or even ill. (4.12)
Insufficient resource allocation as a permanent state can be frustrating and
even lead to a burnout.
Kirsty: To push limits hurts. Expecting too much produces anger and bad feelings. If this
goes on for a long time there is a risk of burnout. (2.6)
Barbara: If somebody is continually under stress and a burnout is developing, I can
imagine that this person loses the valuing attitude. (…) A burn-out is often experienced by
persons with a good attitude so I assume that a change occurs in their attitude because
they have nothing more to give. (8.24)
38
Unfortunately, a shortage of resources over a longer period caused a lack
of the personal resources in nurses needed for the initiation of any changes.
Barbara: We wanted to defend ourselves and at the same time noticed that we were so
exhausted that we couldn’t defend ourselves. We had no energy ourselves left to battle for
change. (7.16)
Consequences on the quality of care
The quantity and quality of resources, and the efficiency of resource
allocation managed by the nurses had either favourable or negative effects on the
quality of care. When tasks had to be postponed or omitted over a longer period of
time the quality of care suffered.
Sandy: Maybe it is because of lack of time or because it mounts up. Sometimes the
quality of care suffers. The things we should do have to be left for the next shift. Then the
tiny things I consider as important and valuable fall aside. After a few such days or nights I
feel frustrated and unhappy. (5.7)
Consequences for patients
Participants told that it was relevant for patients if poor resource allocation
occurred over only a short or over a longer period of time.
Barbara: If patients generally feel well cared for they cope with the odd time when one
reacts impatiently or even aggressively. (5,19)
The following excerpt showed what consequences poor resource allocation
may have for patients.
Barbara: In acute hospitals I often experienced situations in which several patients
needed urgently something from me and I did not have enough resources to give. I
experienced this as extremely burdensome. A situation which comes in my mind again
and again was with a young AIDS-Patient. He lay in his vomit for more then an hour,
because other more urgent tasks had to be performed, I mean infusions who risked
getting blocked, patients with severe pain and blood pressure problems, where a triage
was needed. Both of us found this awful. (…) Whenever the public hears that nurses do
not have enough time people probably think of luxury things like not having time to wash
hair every second day or stuff like that. I am sure it’s underestimated that often very
important things are missed or too late. I would not have believed it either, but I
experienced it. (6.3)
39
Consequences of omissions could be either obvious or hidden. Hidden
consequences needed the commitment and ability of the nurses and the
organisation to uncover the causes and correlations.
Barbara: It’s awful if somebody needs to go to the toilet and has to wait for fifteen minutes.
Especially for older people it is difficult to wait for such a long time and perhaps they wet
themselves. This is very bad and has a lot of negative consequences although it is not
obvious. (…) We worked very hard for patients so that they would not be suffering too
much, but just the same there where adverse effects. If patients do not say when they are
in pain or need to go to the toilet for fear of disturbing the busy nurses it’s not good. (4.7)
(…) Patients feel that they can’t talk about what is depressing them when nurses are in a
rush. Confidence and quietness is needed. Here as well there are adverse consequences.
(5.2)
Summarizing: The consequences of resource allocation for nurses, quality
of care and patients were closely related. They hindered or stimulated each other
in positive or negative directions. The consequences and correlations were not
always obvious and not common knowledge. Resource allocation was heavily
influenced by the nurses’ own values, knowledge, skills and experiences.
Therefore, they took on a lot of responsibility and experienced direct consequences. However, their ability to allocate resources was bound to structures and
the resource allocation decisions of the greater system. Thus they were in a
mediator role. This position together with the opportunities and limitations of
resource allocation were experienced individually. These had effects on the
nurses’ condition, perception and readiness to meet needs, resulting again in
effects on the team, the quality of care and the patients.
40
6.
Discussion
This interpretative phenomenological study sought to understand the lived
experience of resource allocation of a group of nurses working in a palliative care
ward in Switzerland and to reveal the un-verbalised experiences, skills and
knowledge embedded in their clinical nursing practice. In this chapter follows a
discussion of the results in relation to relevant literature organised by the
questions of the study.
6.1.
Objective one: to understand what it means to these
nurses to allocate resources
The following individual meanings of the lived experience revealed by the
data were very impressing.
Resource allocation is like:
-
building on the foundation of valuing
-
being a channel for a good resource flow
-
using a film library as a treasury of experiences
-
balancing a mobile and juggling with time units
-
experiencing kairos
-
distributing sweets
Van Manen (1990) explained that the meaning or essence of a
phenomenon is never simple or one-dimensional. That is why the meaning of an
experience can never be grasped in a single definition. It can only be
communicated textually. Phenomenological themes may be understood as the
structures of experience. Themes are the means to get at a notion, as themes give
shape to the shapeless. They fix or express the ineffable essence of the notion in
a temporary and exemplary form, but they remain always a reduction of a notion.
41
Grasping and formulating a thematic understanding is not a rule-bound process
but a free act of “seeing” meaning. It consists of being sensitive to the way the
experiences reveal themselves and speak to us (van Manen 1990).
The individual meanings were closely related with the individuals, their
thinking, talking, and acting. Ricoeur (1992) suggested that when one is telling a
story one also presents one’s identity, and this identity is used when acting, as
portrayed in the narrative. The essence of these experiences showed that nurses
experience resource allocation closely related with themselves. They shape
resource allocation and use themselves as resources. They experience positive
feelings if they achieve their goals and feel frustration if they are lacking the
resources to achieve their idea of quality care. Similar results could be seen in
Fagerberg’ (2004) phenomenological study. Her aim was to understand the
meaning of 16 registered nurses’ narratives of their work experience in different
clinical settings in Sweden five years after graduation. The findings of her study
showed that the nurses used their personal characteristics to communicate and
break down barriers which, together with conscious use of self in influencing their
own and their staff’s possible actions, served to reach their goals. The nurses’
individual attributes seemed to be closely related to their experiences of the
professional role. However, since the number of nurses participating in the study
was small, it is important to re-contextualise the results when transferring them to
other contexts.
The participants of my study expressed their satisfaction, if they were able
to use their relationships with the patients, together with their skills and their
experiences, to contribute to the well being of their patients. They considered this
as an important and meaningful work. In the study by Fagerberg (2004) the nurses
42
expressed a wish to work closely with the patients to care for them holistically and
to provide them with the feeling of security. A study by Luker at al (2000)
highlighted the centrality of ‘knowing the patient’. They interviewed 62 members of
district nursing teams in the northwest of England. An adaptation of the critical
incident technique was used to determine factors which contributed or detracted
from high quality care for a number of key areas including palliative care. Factors
that enabled the formation of positive relationships were given prominence in the
description of ideal care. Getting to know patients helped nurses to acknowledge
the individuality of patients and the uniqueness of their needs, to interpret
concerns, to anticipate patients’ needs and it also added to job satisfaction.
Radwin (1996) suggested that “knowing the patient” can inform decision-making
and may be a factor that facilitates the achievement of positive patient outcomes.
Benner and Wurbel (1989) asserted that interpersonal aspects of care, leading to
the feeling of being cared for and about, are the essence of caring and that the
provision of quality care is hindered by the absence of close social relationships
between patients and staff. May (1991) underpined that involvement is a
prerequisite of getting to know the patients and an essential characteristic of good
working relationships. Henderson (2001) claimed that emotional involvement by
nurses may contribute to the quality of care because the majority perceive
emotional engagement as a requirement of excellence in nursing practice.
One participant considered a valuing attitude for patients as an important
resource and a basis for quality care. May (1995) and Jones (1999) supported this
view and stated that the basic need to be valued and respected is covered by
caring actions and attitudes built on trusting and connected relationships.
The close relationship of resource allocation and nurse, the close
relationship and involvement with patients, and the personal commitment might be
43
the reasons why nurses tend to accuse themselves and try to compensate for
resource deficiencies in a system even if they risk a burn-out. Bowers et al. (2001)
conducted an investigation into how nurses manage time and work in two long
term care facilities in the Midwestern region of the United States. Both nursing
homes of 100 and 150 beds had reputations as ‘good homes’ and staffing levels
were well above the state-mandated minimum. In 1995 and 1996, interviews and
participant observation were used to examine how 18 licensed nurses performed
their day-to-day work. Grounded dimensional analysis provided the framework for
data analysis. They found that nurses developed compensation strategies to keep
up or catch up on a lack of time. Although these strategies allowed nurses to
complete tasks for which they were accountable, they had to omit tasks they
considered as “should do work” and there were adverse outcomes for nurses and
residents. The consequence of this is that nurses attempted to compensate by
working harder. This compensation led to even more stress. Conqvist et al. (2001)
made a descriptive exploratory study to investigate the nurses’ experiences of
stress in intensive care units. They interviewed 36 registered nurses from 10
intensive care units in Sweden. Their study highlighted the nurses’ sensitivity
towards the patient’s vulnerability and dependency. They found that feelings of
stress arose when nurses were forced to make priorities that were contradictory to
their nursing care principles and resulted in the basic nursing care being left
undone. Benner and Wrubel (1989) described this as „illegitimate“ stress and
claimed that it is destructive because it hinders care giving practices that are
congruent with good care. However, further studies are required to explore
whether or not and to what extent the findings of Bowers et al.’s (2001) and
Conquist et al.’s study (2001) are transferable to a palliative care context.
44
6.2.
Objective two:
to reveal and show the processes, the influencing factors
and the outcomes of resource allocation
6.2.1. Processes
The participants tried to allocate resources in an efficient and useful
manner with the aim of supporting the quality of life and well being of their
patients. The actual needs of their patients and the information from the patients’
files guided their actions. In order to prevent negative developments and to
support positive ones, the participants strove to allocate resources as early as
possible and where they expected the most useful and important results. They
addressed not only needs on the physical but also on the psychosocial and
spiritual level. They called some of their actions luxury, extras or sweets, because
sufficient resources were not always available for these. Those actions should
bring colour and joy in the grey and sorrowful daily life of palliative care patients.
They did not have to be spectacular or costly. The aim was to stimulate positive
feelings and developments in patients as well as in nurses. In the previously
mentioned study by Luker et al. (2000) an essential component of high quality care
was having time to provide more than the physical aspects of patient care. This
created a climate in which nurses could respond best to individuals’ needs.
For these extras the nurses used their individual talents and creativity.
Thereby they demonstrated what was important for a holistic care in accordance
with their own and the patients’ values. Hence they had to get to know their
patients and their preferences by building up a relationship of mutual confidence.
Mok and Chiu (2004) explored aspects of nurse-patient relationships in the context
of palliative care. They interviewed 10 hospice nurses and 10 terminally ill patients
by means of open-ended unstructured interviews. Van Manen’s (1990) reflective
45
approach was used to interpret the data. Mok and Chiu (2004) concluded in their
study that trust, the achievement of goals of patients and nurses, caring and
reciprocity are important elements of nurse-patient relationships in palliative care.
Such relationships not only improved patient’s physical and emotional state, but
also facilitated the adjustment to their illness, eased pain and could lead to good
death experiences. Besides, nurses derived satisfaction and were enriched
through such relationships, which can be seen as burnout-prophylaxis. It must be
taken in consideration that this study was conducted in Hong Kong, China, as a
context with its culture, religion and philosophy influences the findings.
The participants tried to find a balance between the different needs and
demands of all persons involved. In the course of this, adaptations to changes
might be needed. The required thought processes often occurred quickly,
automatically and on an unconscious level. Benner (1984) described expert
nurses as having the ability to juggle and integrate multiple patient requests and
care needs. She argued that, with experience, a nurse’s ability to make judgements about priorities in patient care improves, often to the point at which nurses
are no longer aware that they are making these judgements, and are unable to
describe how they are really doing it. Bowers et al. (2001) discovered in their study
that the time management strategies derived almost exclusively from participant
observation. In the interviews, nurses, who explained the origins and effects of
time restriction and unpredictability, were unable to verbalise how they managed
with these constraints. The question arises how much these findings are related to
these nurses in the two nursing homes or if similar results would be found
elsewhere.
To illustrate their experiences the participants in my study frequently
reported situations of resource deficiency and boundaries. The reason might be
46
that resource allocation normally happened on an unconscious level. Reflecting
and reasoning on a conscious level occurred more often in difficult and challenging
situations. Thompsen et al. (2004) pointed out that nurses need to be better able
to recognise the decisions they make and to understand the uncertainties
associated with them. They need to be given the skills to construct questions and
to search for the best available evidence with which to answer the questions. This
suggests that more professional judgement courses should be offered.
The participants made no general statements about which tasks could be
omitted to save resources and where they set priorities. It depended on the
situations; the demands, the available resources and the apparent possibilities. If
the demands exceeded the resources, a hierarchy of needs and tasks developed.
Bowers et al. (2001) stated that the level of importance may in part be determined
by the nurse’s estimation of likely consequences of leaving the nursing action
undone. In line with Barbara’s quotation on p.30 they highlighted in their study that
the priority assigned to tasks increased with the visibility of patient’s needs and the
probability that adverse consequences could result if a nurse did not attend to the
needs and also partly, because the visibility of patient’s needs made adverse
consequences more likely for nurses and the organisation. While highly visible
physical problems were considered emergencies and given the highest priority,
conditions such as constipation and routine infections, which were not apparent,
were described as non-emergencies. Although, in the long run, such conditions
could have adverse consequences for patients, these consequences were not
likely to be traced to a particular nurse’s inattentiveness. Besides, despite nurses’
protestation that establishing and maintaining relationships with residents were
their most important and rewarding task, such emotional work was often assigned
the lowest priority. Nurses explained that because emotional work required a lot of
47
time, had few immediate consequences for the nurse or the facility and was nearly
invisible in its results, that it was one of the first things to be postponed. Bowers et
al. (2001) stated that narrowing the scope of work to technical, visible and urgent
tasks for which nurses could be held directly accountable meant that nurses were
less likely to perform the surveillance, preventative and follow-up work. I conclude
that this hinders the nurses in preventing problems escalating and thereafter
demanding a lot of resources. In addition, Tovey and Adams (1999) as well as
Bowers et al. (2001) stated that narrow scope of work means increased frustration
and lower morale for nurses.
6.2.2. Influencing factors
The present study found different factors influencing resource allocation,
which were summarised in three groups: Firstly, the balance between the patients’
needs and the quantity as well as the quality of the available resources. Secondly,
the handling of this balance shaped by the nurses’ attitudes, skills, experiences
and conditions. Thirdly, the context in which the nurses were working with its
structures and values. All these factors influenced resource allocation, but this
happened mostly on the unconscious level. Hendry and Walker (2004) established
in a selective, descriptive literature review what was currently known about priority
setting in nursing, including how nurses set priorities and what factors influenced
this. However, only English language papers were considered and no statement
was found about how many papers were included. In this literature review of the
years 1982 - 2002 similar factors were identified that may impact on priority
setting: the expertise of the nurse, the patients’ condition, the availability of
resources, ward organisation, philosophies, models of care, the nurse-patient
relationship, and the cognitive strategy used by the nurse to set priorities. They
admitted that this was not an exhaustive list, and neither was there any indication
48
of the extent of their effect on determining priorities. Their preliminary model of
priority setting could be a basis for further research in this important area.
Fagerberg (2004) revealed in her study that the organisation of work greatly
influenced the nurses’ situation, the quality of care they could provide, and their
own job satisfaction. A decrease in staff due to financial cutbacks and changing
from patient-centred care to a more task-orientated system affected their chances
of maintaining a holistic view of patients. This in turn, implied a conflict between
the organisation and the nurse’s feelings concerning their professional
responsibility. She stated that the nurses sometimes feel caught in the middle of
having to solve the problem of providing the best possible care with limited
resources and deal with the frustration when they did not have the resources to do
so. Williams’ (1998) grounded theory study explored and described the delivery of
quality nursing care from the perspective of nurses. Ten registered nurses from an
acute-care public hospital in Perth, Western Australia, were interviewed.
Transcripts of 12 additional interviews conducted by postgraduate students were
used for comparison and clarification of categories at the end of the data analysis.
Her subjects identified insufficient time as a significant barrier to providing care
they considered therapeutically effective. Therapeutic effectiveness was facilitated
by the development of positive relationships between nurses and patients, nurse’s
positive attributes and competent practices, as well as a functional nursing team.
Under conditions of varying time availability nurses moved through a process of
“selective focusing”. While ample time allowed nurses to look at patients
holistically, more limited time reduced nurses’ ability to focus on needs not directly
related to physical condition and safety, and insufficient time caused them to shift
in “self focusing”, a “personal preservation strategy” in which nurses did not
involve themselves with patients and tended to deliver low quality nursing care. It
49
was in these situations, Williams reported, that job stress and dissatisfaction
increased. This process of selective focusing has not previously been identified in
the literature. Therefore, more research for confirmation of its existence is needed.
However, the results highlighted that the power or the resources directed towards
nurses coming from both society and institution management, influenced the
nurses’ and patients well being.
The importance of team work was highlighted by the participants of this
study. They stated that through good and efficient collaboration the team-members
could support each other and balance out their resources. They learnt from each
other and carried the burdens together. A growing body of evidence shows the
importance of interpersonal relationships to the nurses’ job satisfaction. Adams
and Bond. (2000) demonstrated in their research that the cohesiveness of the
ward nursing staff was the most important working relationship for nurses, with the
most significant impact on their job satisfaction. Yet its development required the
following resources: staff stability, a sufficient core of permanent staff and support.
They also found that the quality of ward facilities and of services provided to the
ward by other departments affected the nurses’ ability to do their work. Fagerberg
(2004) stated, that the work context is important for the development of nurses’
skills and identity as professionals, but the work context and organisation can also
hinder their professional development.
6.2.3. Outcomes of resource allocation
The findings of my study uncovered that the consequences of resource
allocation for nurses, quality of care and patients are closely related. They hinder
or stimulate each other in positive or negative directions. These correlations are
not always obvious and known. The nurses know or suspect certain correlations
50
and consequences, the patients and their family are affected by them, but they’re
often unknown to the institution management and the public.
My study revealed that nurses know or suspect the hidden consequences
of insufficient resource allocation and suffer with patients when they are not able to
provide the care they consider important. In a multi-centre research initiated by
two universities and three health care facilities in two Swedish cities Tishelman et
al. (2004) aimed to explore how clinical staff reasoned about care provision for
patients with advanced cancer. They analysed 20 focus group discussions. Each
group was composed of staff from the same unit. This may be a methodical
limitation as taboos or blind spots might have been omitted by the group. With the
aim of knowledge-exchange an initial analysis based on grounded theory was
complemented, carried out by a team consisting of senior nurse researchers,
clinical experts and nursing instructors. This process, combining different
knowledge and experiences allowed them to build a broader knowledge base and
enhance validation. The findings of Tishelman et al. (2004) emphasised the
complexity of care giving for patients with advanced cancer and the tension
between care-giving ideals and limits imposed by the realities. Psychological care
was described as particularly problematic in this respect, and participants
repeatedly spoke of difficulties in negotiating between time restraints and their
ideals about care provision. They stated that cost containing measures leading to
use of less-educated staff for task believed to be ‘simple’, and more educated staff
for ‘more complex’ tasks, come into question as the complexity of even simple
care-giving situations were illuminated. The question arises how much the
Swedish health care system impacted on these findings.
In a qualitative study by Attree (2001) using grounded theory, data were
collected by semistructured interviews from a purposive sample of 34 acute
51
medical patients and 7 relatives in Great Britain. In her study patients and relatives
believed that “good quality care” was based on a caring relationship. They
described this care as patient-focused and related to their needs, individualised,
and “provided humanistically”. Receiving “Good Quality Care” was experienced
positively and gave patients a feeling of being genuinely cared for and about,
which facilitated the development of trust and confidence. Patients in Otte’s (1996)
study reported that communication breakdown, leading to a lack of patients’
confidence, was the effect of pressure on staff time. In Attree’s study (2001)
patients’ suggestion for improving the quality of care included more staff, spending
their time with patients, and improved communication together with information
sharing.
6.3.
Objective three:
to understand what the criteria, values, and principles
involved are
The participants reported that the estimation of the quantity and quality of
resources and their appropriate allocation varies, as it is influenced by
assumptions and values of individuals, teams and a movement like Palliative Care.
Several times the participants mentioned that the palliative care ‘philosophy’3 with
its values helps them when allocating resources. It is the basis on which they
decided not only to care for cleanliness of the body, but also for the psychosocial
and spiritual well being. But it was emphasised that sufficient resources must be
available to translate these values into action. Hendry and Walker (2004) claimed
that the personal philosophy subscribed to by the nurse, the philosophy of the
ward where the nurse works, those of the organisations that employ nurses and
Within clinical nursing, the term "philosophy" may be used in an everyday sense, to refer to an
ideal statement of values, beliefs and aims that relate to what nurses and nursing are trying to
achieve in a particular clinical area.
3
52
regulate nursing, and the prevailing philosophy held by the profession and society
as a whole, will inevitably have an influence on practitioners. Adams et al. (1998)
found varying underlying dimensions in nursing care systems and stated that the
organisation of patient care within health care settings depends on what is valued.
These values and structures influence the quantity and quality of resources at the
nurses’ disposal, the guidelines how and where to invest them and the freedom
and limitation for nurses.
One participant expressed that there may exist a continuum with ordinary
work and luxury or “sweets” at its ends. Where on the continuum the tasks are
allotted depends on the philosophy and the available resources. Bowers et al.
(2001) revealed in their study the difference between “must do work” and “should
do work”. “Must do work” included those things that were rigidly scheduled and for
which nurses were held directly accountable, e.g. medication administration,
treatments and paperwork. “Should do work”, however, encompassed the less
tangible psychosocial aspect of the nurses’ job, i.e. talking with and getting to
know patients. As time pressure increased, more and more “must do work” shifted
to become “should do work”. Because it was in large measure the “should do
work” that made the nurses’ job meaningful, when time constraints restricted the
ability to do this work, then job dissatisfaction soared. Constant time pressure
engendered severe frustration related both to the inherent unpleasantness of
feeling rushed and to nurses’ awareness of what they have lost, including their
failure to provide good quality care. Bowers et al. (2001) concluded that if the
public policy choice is that the “must do work” is sufficient, then the decision
should be made explicit and the quality expectations revised. Fagerberg (2004)
supported this view with the statement that the provision of adequate resources for
nurses’ professional and personal development is needed to ensure high quality
53
patient care. She raised the political question: What price is to be paid for not
providing patients with the best possible care? One can add: What price is to be
paid for not providing nurses with sufficient resources?
6.4.
Objective four:
to highlight the nurses’ unarticulated skills and
knowledge needed
The results of my study demonstrated that nurses used (had to use)
themselves, their personality, their creativity, their skills and knowledge to allocate
resources. They needed experience and intuition to perceive the needs of their
patients, to figure out the most suitable actions, to see possible developments, to
balance and to invest resources in useful ways. Besides, participants mentioned
their planning, organisation, delegation and team-working skills. Especially
important were flexibility and adaptability as changes and interruptions could occur
at any time. They needed an ability to grasp completely complex situations and to
assess them well in their elements. In addition they needed the ability to be totally
present with patients in their situations without forgetting what happened
elsewhere in the ward. The nursing literature shows that the caring process
implies relating with the patient and that it is a nurse’s personal qualities and skills
which constitute excellence in nursing care. (May 1995, Benner 1984, Jones 1999,
Luker 2000, Fagerberg 2004). Mok and Chui (2004) concluded in their study that
the nurses’ personal qualities and skills, which were imbedded in the nurse-patient
relationships, constituted excellence in nursing care and that nurses derived
satisfaction from these relationships. Fagerberg (2004) found that self-confidence
relied on the nurses’ knowledge, intuition and reflection to think up new
alternatives. Relying on their knowledge and intuition was something nurses could
also do in relation to other staff and was usually connected to their use of self and
54
how they thought and acted. Practitioners in the study of Tishelman et al. (2004)
discussed the organisation of care, different forms of relationships between
patients, family members and professionals, and theoretical and experiential
knowledge as equally important aspects in dealing with concrete situations in daily
practice.
The participants of my study emphasised the importance of experience.
The treasury of experiences served to discern correlations, interactions and
possible consequences. It made them think more globally and take on
responsibility. They could sense inconspicuous signs and take prophylactic steps
which often resulted in resource saving. However it is always difficult to prove that
problems have been prevented. When problems are prevented, the knowledge
required for this prevention is taken for granted and becomes invisible, yet patient
outcomes are positively influenced. Bowers et al. (2001) stated that the invisible
nature of problem prevention might be the reason why there is so little research
linking the contributions of nurses to patient outcomes.
The participants stated that they love using their creativity to find new ways
to meet their patients’ individual needs, to provide patients with “sweets” and to
make sure that patients are provided with the best possible care. In doing so they
expressed the art of nursing. Fagerberg (2004) claimed that this art of nursing can
be, in some instances, understood as creating ways to assure patient safety
during times of financial cutbacks, when lack of staff or inadequately prepared staff
might otherwise jeopardize patient safety. This means that insufficient resources of
the organisation are compensated by the nurses’ individual resource of creativity.
One participant emphasised that the treasury of experiences may grow
through reflection and exchange of experiences between practitioners. Tishelman
55
et al. (2004) highlighted the importance of reflective practice, use of self and
ethical reasoning. Therefore time for personal and group reflection is important to
secure. The opportunity to pursue and test out creative ideas that would improve
care is important. This thinking time should be seen as a necessity, not a luxury.
For situations of limited resources and reflection during working hours, participants
brought up concerns about the “privatisation” of reflection, referring to transfer of
the reflective process from the working place to their homes during private time,
which was seen as a risk factor for a variety of stress and burnout-related
reactions. Gerrish (2000) stated that lack of staff will result in lack of time for
sharing and learning from experiences. In conclusion the possibility for reflection,
ideally within the team, is important to develop the treasury of experiences which
was seen as a great resource.
The main findings in my study highlighted how much the nurses, as whole
persons with their thinking and their emotions, were involved in resource
allocation. On one side they used themselves as resources, on the other side they
felt the consequences of resource allocation as whole human beings. The nurses
must be able to bear the tensions, such as balancing needs and resources, the
stress between ideal and reality, and between their own and others’ priorities.
They must be able to manage emotions to prevent negative developments or learn
to use them constructively. Analysis of the literature on emotional intelligence and
emotional labour by McQueen (2004) suggested that the demands of nursing draw
on the skills of emotional intelligence to meet the needs of direct patient care and
co-operative negotiations with the multidisciplinary team. Emotional intelligence
involves verbal and non-verbal assessment and expression of emotions, control of
emotions and the use of them in solving problems. The interpretation of emotional
expression by the patients and the intelligent response in the application of
56
appropriate professional skills, such as emotional work, empathy and counselling
skills, can result in patients’ emotional states being modified and anxiety being
ameliorated.
The results of my study and the literature discussion highlighted the
complexity of resource allocation with its inputs, processes, influencing factors,
outcomes and the sophisticated skills used in this important area of daily clinical
nursing.
57
7.
Conclusion
The main findings of this phenomenological study concerning resource
allocation experienced by nurses working on a palliative care ward highlighted the
close relationship between resource allocation and the individual nurse. This study
is a small beginning to understand those experiences. Thus, it has brought an
awareness of important questions which need our attention.
Because of the close relationship between resource allocation and the
nurse it is difficult to distinguish between lack of resources in the organisation and
lack of competency of a nurse. More investigation in this area could help to clarify
situations and responsibilities. Furthermore, it could support mutual understanding
and information exchange between decision-makers on macro- and micro-levels.
My study found that nurses aim at investing resources in a sensible and
useful manner. The participants demonstrated useful knowledge, skills and
experiences. Therefore, it is intelligent to integrate nurses’ knowledge and
experiences of clinical practice in decisions about resource allocation on the
micro-levels as well as on the macro-levels. And it is sensible to delegate
decisions on the lowest possible level of hierarchy.
Nurses tried to stimulate positive developments and to avoid vicious circles.
For that they need sufficient resources to intervene early enough. I postulate that
having “governer c’est prévoir”4 as a motto would help for a sustainable use of
resources. However, it is difficult to prove that problems have been prevented and
how many resources have been saved by this. Nevertheless, this would be an
4
to govern is to foresee or foresight is the key to good management
58
important area to investigate as potentially many precious resources could be
saved and invested in a more useful manner.
It is decisive that sufficient resources are available and nurses can use
them for the right actions, at the right moment, in the right quality. In addition, it is
crucial which consequences are highlighted, honoured or sanctioned by an
organisation: whether only the obvious or also the hidden consequences are
considered. Investigations into hidden causes and correlations would be important
to enhance quality of care. Furthermore, the development of an open minded
culture allowing the discussion of issues normally hidden, and a positive handling
of failure and errors are needed. Without the ability to discuss, decide and carry
the consequences together on a conscious level the individual nurse is left alone
with the responsibility and her bad feelings. This highlights the importance of
reflection, also within groups, and that thinking time is a necessity, not a luxury.
Resource allocation is influenced by different factors and more knowledge
about the extent of their effects is needed. This knowledge could enhance the
ability to manage different situations, especially those of resource insufficiencies.
The
interactions
between
nurses
and
patients
are
imbedded
in
organisations. An organisation influences resource allocation by its values,
structures and by the quality and quantity of resources which are at nurses’
disposal. Therefore it would be important to know how the influencing factors of
organisations shape the experience of nurses. Pursuing this study in different
nursing settings could answer this question.
59
The results of my study showed that the philosophy5, with its differences in
resource allocation, varies between individuals, teams and organisations and that
in the course of time adaptations of the philosophy occurs. Discussing the values
and their influence on organisation and work would surely be important for all
persons involved.
Participants stated that they take resource allocation decisions mostly
automatically on an unconscious level, if things run smoothly. Only in challenging
situations did they reflect on a conscious level. Finding ways to make the
processes explicit and to learn from skilled nurses could help other nurses,
especially trainees. Reflecting and discussing issues of resource allocation,
deciding and carrying the consequences together, could support individual nurses
in handling their responsibility. Attree (2001) suggested that improving the quality
and effectiveness of staff-patient interaction may be achievable through changes
in health care professionals’ attitudes, values, knowledge and skills. Achievement
of these objectives requires time and commitment, as well as changes in
individual, professional and organisational values to one where interpersonal
aspects of caring are perceived as essential attributes of quality care and not as
optional extras. This demonstrates the importance of the whole system (the micro
and macro-level) to take on responsibility and to see correlations.
My study showed the danger of nurses accusing themselves or burning out
in attempt to compensate for a lack of resources in the system. Nurses are
sensitive towards the patients’ vulnerability and dependency, and this is of
significant moral importance. The following questions arise: In which situations are
5Within
clinical nursing, the term "philosophy" may be used in an everyday sense, to refer to an
ideal statement of values, beliefs and aims that relate to what nurses and nursing are trying to
achieve in a particular clinical area.
60
nurses at risk of compensating for a lack of resources in the system? What are the
influencing factors? What do nurses need to handle these situations? What is
needed from the organisations?
The participants of my study reported that their control over time was often
reduced by interruptions including medical emergencies, physician calls, family
visits and other staff members. The frequent and sporadic nature of these
interruptions made it difficult for nurses to have a stretch of time to devote to the
completion of any one task or sequence of tasks. This created a working
environment characterised by unpredictability and needing a lot more resources.
The following questions arise: How effective would resource allocation be if nurses
were interrupted less? What measures are needed to reduce interruption? What
change in the cost / benefit scale would occur?
Participants stated that they try to hide stress or negative feelings to avoid
negative developments. It would be important to know if they are successful in this
attempt or what other solutions could be better. These investigations may even
find solutions to reduce stress and negative feelings.
This study found that the outcomes of resource allocation for nurses, for the
quality of care and for the patients are interwoven. The three areas support or
restrain each other in positive or negative directions. However, correlations and
developments are not always obvious. A lack of resources means that priorities
have to be set and certain tasks are to be postponed or omitted. The
consequences may not be immediately visible, but may lead to suffering in
patients, affect quality of care and the nurses. Nurses are therefore in a key role to
investigate in these areas and to highlight correlations for decision makers and the
public. Provision of adequate resources and support for nurses’ professional and
61
personal development is needed to ensure high quality care, and these are
political issues. Clarifying and discussing these issues could enhance conscious
decision-making at the micro-level of clinical practice as well as at the macro-level
of policy making.
Appraisal of the study
Most often resource allocation is discussed on the macro-level of politics
and budgets. This study has shed light on resource allocation on the micro-level of
clinical nursing practice on a palliative care ward. It emphasised the complexity
and multi-faceted nature of the challenges in care giving.
Furthermore, investigations in this area are often led by questions
concerning priority setting and decision-making. An investigation in resource
allocation is, therefore, a new perspective which has highlighted other important
aspects. However, the results are similar to those studies investigating nurses’
experiences in general. Much more, this interpretative phenomenological study
reminded us of what we already know, but continually pass through in day-to-day
living.
The participants had been very open and honest in their statements. They
reported examples which other nurses would probably try to hide from superiors.
Through this openness they provided valuable insight into their experiences.
Methodological considerations
Working on the palliative care ward as a nurse, I have a long clinical
experience in palliative care and I am familiar with the participants. It is therefore
possible that details may have been omitted during interviews, because of a tacit
understanding between the interviewer and the participants. However, in
62
accordance with Benner (1994), clinical experience may serve as a preunderstanding that is beneficial for the interpretation of the information.
Interpreting data without co-assessment is a delicate matter. To test the
credibility of the interpretations and to counteract possible research biases, I
asked the participants to read my interpretation and to discuss issues with me.
However, it must be taken into account that different findings may have been
reported by another researcher. Ricoeur (1976) held the opinion that an
interpretation is only one of several possible ones.
Using a phenomenological approach to research demanded much time and
thought. Therefore this study lasted over a long period of time. In the process it
was difficult to maintain the orientation towards the research project besides the
challenging daily business and other appealing issues in life. However, this slow
maturation might have added value.
63
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66
9.
9.1.
Appendices
Interview guide
(r.= resource allocation)
Important, main questions
What do you consider are resources which you, as nurse, allocate?
What does it mean for you to allocate resources? How do you experience r.?
What are your feelings and thoughts while allocating resources?
Are there times when r. is difficult for you? If yes, what do you experience in these
situations?
Which knowledge and skills are involved in r.?
What processes are going on?
What are the results of your efforts at r.?
How do you make resource allocation decisions?
Which factors influence your r.?
How conscious are you about your r.?
Additional possible questions
Focus on management, processes and outcomes:
There may be persons you consider as role models in r.. What behaviour do they
demonstrate?
How are you supported? (From whom)
What are your impressions when observing colleagues?
What consequences of r. do you experience, observe?
What do you consider as good / bad investment of resources?
What do you consider as a good / bad results?
Focus on feelings and behaviour:
How do you feel when you have enough / not enough resources?
What experiences do you remember well?
What are the responses or reactions
• of patients, next of kins?
• of yourself
• of colleagues?
• of superiors?
Focus on ethical questions and values involved?
Which values are involved in r.?
Do you experience conflicts? If yes, what types of conflict?
How do you deal with them?
What do you consider important in nursing? What can be omitted? (priorities)
What are the most important needs of patients? How would you rank these needs,
that is from the most important to the least important.
67
9.2.
Interview-Leitfaden
(R= Ressourcenzuteilung)
Hauptsächliche, wichtige Fragen
Was bezeichnest Du als Ressourcen, die Du als Pflegefachperson zuteilst?
Was bedeutet es für Dich Resourcen zuzuteilen? Welche Erfahrungen machst Du
dabei?
Welche Gefühle und Gedanken hast Du bei der R.?
Gibt es Momente in denen Du Schwierigkeiten hast bei der R.? Falls ja, was
erlebst Du dann?
Welches Wissen, welche Fähigkeiten werden gebraucht bei der R.?
Welche Prozesse laufen bei der R. ab?
Welche Resultate Deiner R. stellst Du fest?
Wie entscheidest Du bezüglich R.?
Welche Faktoren beeinflussen Deine R.?
Wie bewusst bist Du Dir bezüglich R.?
Zusätzliche, mögliche Fragen
Management, Prozesse, Resultate:
Es gibt vielleicht Personen, die Du als Vorbild einschätzt bezüglich R. Wie
verhalten sich diese Personen?
Wie wirst Du unterstützt? (von wem?)
Welche Eindrücke hast Du, wenn Du Kolleginnen beobachtest bei der R.?
Welche Konsequenzen der R. erfährst bzw. beobachtest Du?
Was beurteilst Du als gute / schlechte Investition von Ressourcen?
Was als gute / schlechte Resultate?
Gefühle, Haltung und Verhalten:
Wie geht es Dir, wenn Du genügend bzw. zuwenig Ressourcen hast?
An welche Erfahrungen erinnerst Du Dich besonders gut?
Wie reagieren oder antworten:
• PatientInnen bzw. Angehörige?
• Du selber?
• KollegInnen?
• Vorgesetzte?
Ethische Fragen, Werte
Welche Werte sind einbezogen?
Erlebst Du Konflikte? Wenn Ja, welche Art von Konflikten? Wie gehst Du damit
um?
Was betrachtest Du als wichtig in der Pflege? Was kann weggelassen werden?
Welche Bedürfnisse der Patientinnen betrachtest Du als priortär? Wie würdest Du
diese einordnen von den wichtigsten zu den unwichtigsten?
68
9.3.
Ethical approval
Title of the study
An interpretative phenomenological study of the meaning of resource allocation
experienced by nurses working on a palliative care unit in Switzerland.
Researcher
Nelly Simmen
Student in the Msc Advanced Clinical Practice Program, European Institute of
Health and Medical Sciences, University of Surrey, Guildford
We……………………………………………………………*agree/do not agree
to allow Nelly Simmen to perform a research study on resource allocation as
described in her proposal and allow the nurses of our institution, the Palliative
Care ward of Diakonissenhaus Bern, to participate in this study.
9.4.
Einverständniserklärung der Ethikkommission
Titel der Forschungsstudie
Interpretative Phänomenologische Studie in die Bedeutung von
Ressourcenzuteilung wie sie Pflegefachpersonen erleben, die auf einer Station für
Palliative Therapie in der Schweiz arbeiten.
Untersucherin
Nelly Simmen
Studentin in einem Masterprogramm für Pflegeexpertinnen am European Institute
of Health and Medical Sciences, University of Surrey, Guildford
Wir........................................................................................................geben Nelly
Simmen die Erlaubnis im Rahmen des von ihr beschriebenen Proposals eine
Untersuchung durchzuführen, in der sie Pflegende, der Station für Palliative
Therapie des Diakonissenhauses Bern, befragt.
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9.5.
Nurses information sheet
Date: September 2003
Introduction
This information sheet is to inform you as the nurses of the Palliative Care ward
about the planed research study so that you are able to decide whether or not you
would like to participate.
Title of the study
An interpretative phenomenological study of the meaning of resource allocation
experienced by nurses working on a palliative care unit in Switzerland.
Researcher
Nelly Simmen
Student in the Msc Advanced Clinical Practice Program, European Institute of
Health and Medical Sciences, University of Surrey, Guildford
The aim and purpose of the study
I ,the researcher, shall explore the experience of resource allocation described by
some nurses working on the palliative care ward. The study’s purpose is to
highlight unarticulated skills and knowledge embedded in practice.
The goals are:
e) To understand what it means for you as nurses to allocate resources;
f) To reveal and show the processes, the influencing factors and the results of
resource allocation decisions;
g) To understand what criteria, values, and principles are involved;
To highlight unarticulated skills and knowledge of your nursing practice that are
seldom talked about.
Methode
Since I am dealing with a research area where very few studies have been
conducted, I have chosen the qualitative research methodology of interpretative
phenomenology. This method is suitable when one starts gaining information in a
new research area and it helps reveal hidden knowledge and skills.
Pilot study
A pilot study will be conducted in order to test the interview questions, get
acquainted with my role as researcher and get accustomed to the recording
equipment I will be using. The sample for the pilot study will consist of one or two
nurses who worked on the palliative care unit.
Main study
For the main study I am asking you as nurses presently working on the palliative
care unit and with at least one year of working experience on the unit to volunteer.
I ask you to fill out a form stating your willingness to participate in the research. I
hope to find four to eight volunteers among the staff for the interviews. You will be
informed that you have the right not to answer individual questions or to stop
participating in the study without having to state any reason or to fear any negative
consequences. The interviews will be conducted in a quiet, suitable and common
agreed upon place where both parties can be at ease. It is expected that the same
participants will take part in two or three interviews to be able to achieve greater
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depth, to take up what was said in a previous interview, and to be able to develop
a common understanding.
As participant you will be asked to write down any thoughts you have in between
interviews that are related to the topic and that you would want to mention in the
next interview. I, as researcher, will take notes during the interviews of any
observations made and I will keep a filed diary. These will be used in the
descriptive and interpretive process. The interviews will be recorded on tape,
translated from Swiss German into Standard German and transcribed for the
analysis. The participants will then be able to read these transcriptions and give
feedback. Only after this step is made the data will be used for the interpretative
analysis.
Confidentiality
As participant you will be granted confidentiality and the data will be extinguished
one year after the termination of the dissertation. If citations from the interviews
are used in the dissertation or in publications, these will be anonymous. It is
anticipated that only a few persons will have access to the data: my supporting
supervisors Kay de Vries from the European Institute of Health and Medical
Science in Great Britain, and Susan Pope, Doctor of Philosophy and teacher at the
Lindenhof School of Nursing in Switzerland, and the person/persons I engage to
help with the transcriptions and translations.
Limitations to confidentiality
There are some limits in the assurance of confidentiality. The results of the study
will be discussed in team meetings. The personnel of the palliative care unit know
each other well and are able to identify each other easily. In addition, the
dissertation will be read by superiors of the institution. These superiors have
promised that the participants of the study will not have to fear any negative
consequences. Finally, because our unit is one of very few such palliative car units
in Switzerland, it may be relatively easy to identify the team as a whole in case the
study is published.
I expect that the study will contribute to the recognition of resource allocation and
its challenges and will further the awareness of the processes involved therewith.
It is hoped that the understanding of the processes involved in resource allocation,
the decisions taken, the values involved and the knowledge and skills employed
will encourage discussions about this important topic and help decide what its
main aims are in everyday work, how these aims can be achieved and what
changes might be anticipated. It is finally hoped that this study will help to make
transparent and encourage discussion about an area of nursing that has long
remained unconscious and hidden.
You are most welcome to state any further questions and I am most willing to try
and answer them. Contact me on the ward or under…
031 337 70 13
[email protected]
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9.6.
Informationsblatt
Datum: September 2003
Einleitung
Dieses Informationsblatt dient als Grundlage, damit Ihr als Pflegefachpersonen der
Station für Palliative Therapie genügend Informationen habt, um frei zu
entscheiden, ob Ihr in dieser Studie mitmachen wollt oder nicht.
Titel der Forschungsstudie
Interpretative Phänomenologische Studie zur Bedeutung von Ressourcenzuteilung
wie sie Pflegefachpersonen erleben, die auf einer Station für Palliative Therapie in
der Schweiz arbeiten.
Untersucherin
Nelly Simmen
Studentin in einem Masterprogramm für Pflegeexpertinnen am European Institute
of Health and Medical Sciences, University of Surrey, Guildford
Ziele der Studie:
Als Forscherin hoffe ich durch diese Studie Wissen und Fähigkeiten im
Zusammenhang mit Ressourcenzuteilung, die in der Praxis auf der Station für
Palliative Therapie gebraucht werden, aufzeigen zu können.
Teilziele
a) Verstehen, was es für Euch als Pflegefachpersonen bedeutet Ressourcen
zuzuteilen.
b) Aufwand, Prozesse, beeinflussenden Faktoren und Resultate aufdecken.
c) Verstehen welche Kriterien, Werte und Prinzipien angewendet werden
d) Darstellen von Fähigkeiten und Wissen über die selten gesprochen wird
Methode
Da es sich um ein Gebiet handelt in dem bis jetzt wenig Forschung betreiben
wurde, wähle ich den qualitativen Forschungsansatz der Interpretativen
Phänomenolgie. Dieser Ansatz eignet sich gut um ein neues Gebiet auszuloten
und verborgenes Wissen beziehungsweise Fähigkeiten aufzudecken.
Pilotstudie
Zuerst werde ich eine Pilotstudie durchführen, um den Interview-Leitfaden zu
testen, mich in die Rolle als Forscherin einzuleben und die Handhabung der
Technik zu üben. Diese Pilotstudie werde ich mit ein bis zwei Pflegenden führen,
die früher einmal für die Station für Palliative Therapie gearbeitet haben.
Hauptstudie
Für die Hauptstudie bitte ich Euch, Pflegefachpersonen, die seit mindestens einem
Jahr auf der Abteilung arbeiten, sich für die Beteiligung an der Studie bereit zu
erklären in dem Ihr eine Einverständniserklärung ausfüllt. Ich hoffe auf diese
Weise mit vier bis acht Pflegefachpersonen ein bis drei Interviews durchführen zu
können.
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Als Teilnehmende habt Ihr das Recht, einzelne Fragen nicht zu beantworten oder
Euch jederzeit ohne Angabe von Gründen aus der Untersuchung zurückzuziehen.
Sollte dies der Fall sein, so hat das keinerlei negative Konsequenzen für Euch.
Die Interviews finden an einem gemeinsam festgelegten, dafür geeigneten,
ruhigen Ort statt, an dem sich beide wohl fühlen. Wahrscheinlich wird mit
derselben Person zwei bis drei Interviews durchgeführt, um das Gebiet in die Tiefe
ausloten und den Faden aus vorhergehenden Interviews aufnehmen, sowie ein
gemeinsames Verständnis entwickeln zu können.
Die Teilnehmenden werden gebeten sich Notizen zu machen, falls zwischen den
Interviews Gedanken zum Thema auftauchen und sie diese aufschreiben mögen.
Ich selber werde mir als Forscherin auch Notizen machen, um die Übersicht zu
behalten, Beobachtungen und eigene Gedanken aufzuschreiben. Diese Daten
werden in den beschreibenden und interpretativen Prozess einbezogen. Die
Interviews werden auf ein Tonband aufgenommen und danach von
Schweizerdeutsch auf Hochdeutsch übersetzt und für die Analyse in elektronische
Form transkribiert. Nachher haben die Interviewten die Gelegenheit ihre Daten zu
lesen und mir Rückmeldungen zu geben. Erst danach werden die Daten für die
interpretative Analyse weiter verwendet.
Vertraulichkeit
Den Teilnehmenden versichere ich, dass die gesammelten Daten vertraulich
behandelt und ein Jahr nach der Dissertation vernichtet werden. Sollten Zitate in
der Dissertation oder in Publikationen verwendet werden, so sind diese anonym
und lassen keine Rückschlüsse zu. Es ist vorgesehen, dass nur folgende
Personen Zugang haben zu den Daten: die Supervisorinnen Kay de Vries vom
European Institute of Health and Medical Science in Grossbritanien und Susan
Pope, Doktor of Philosophy und Lehrerin an der Lindenhof Pflegeschule in der
Schweiz. Bei Bedarf werde ich Personen zuziehen, die mir bei der Übersetzung
oder der Transkription helfen werden.
Limitation der Vertraulichkeit
Es ist geplant die Ergebnisse der Studie während einer Teamsitzung zu
besprechen. Die Vertraulichkeit ist insoweit limitiert, dass die Pflegenden der
Abteilung sich gut kennen und einander relativ leicht identifizieren können.
Ausserdem wird die Arbeit innerhalb der Institution, auch von Vorgesetzten,
gelesen werden. Diese Vorgesetzten versprechen, dass die Teilnehmenden der
Studie keinerlei Konsequenzen für sich zu befürchten haben. Da es sich um eine
der wenigen Stationen für Palliative Therapie in der Schweiz handelt, ist es auch
relativ einfach das Team zu identifizieren, falls die Arbeit veröffentlicht wird.
Erwartungen
Ich erwarte, dass diese Studie dazu beiträgt das Bewusstsein über
Ressourcenzuteilung und die damit verbundenen Herausforderungen zu erhöhen.
Das Verständnis für Prozesse, Entscheidungen, Werte, diesbezügliches Wissen
und Fähigkeiten, und wird helfen über dieses Thema zu sprechen und zu
entscheiden was gewollt ist und falls erwünscht Veränderungen einzuleiten. Ich
hoffe damit beizutragen, über einen relevanten Teil der Arbeit von Pflegenden zu
sprechen, der häufig unbewusst und verborgen geschieht.
Falls noch weitere Fragen vorhanden sind, bin ich gerne bereit diese zu
beantworten, sofern ich dazu in der Lage bin. Ich bin erreichbar im Büro auf der
Abteilung oder unter: 031 337 70 13
[email protected]
73
9.7.
Consent form
Title of the study
An interpretative phenomenological study of the meaning of resource allocation
experienced by nurses working on a palliative care unit in Switzerland.
Researcher
Nelly Simmen
Student in the Msc Advanced Clinical Practice Program, European Institute of
Health and Medical Sciences, University of Surrey, Guildford
1. I confirm that I have read and understood the information sheet, dated 10th
May 2003, for the above study, and have had the opportunity to ask questions.
2. I understand that my participation is voluntary and that I am free to withdraw at
any time, without giving a reason.
3. I agree to take part in the above study.
4. I allow the interviews to be tape-recorded
5. I agree that the data from the interviews may be translated and
used for analysis.
6. I allow the use of the data in the dissertation and for publication provided
confidentiality is maintained.
__________________
Name of Participant:
__________________
Name of Researcher:
_____________
Date:
_____________
Date:
_____________________
Signature:
_____________________
Signature:
74
9.8.
Einverständniserklärung der Pflegenden
Titel der Forschungsstudie
Interpretative Phänomenologische Studie zur Bedeutung von Ressourcenzuteilung
wie sie Pflegefachpersonen erleben, die auf einer Station für Palliative Therapie in
der Schweiz arbeiten.
Untersucherin
Nelly Simmen
Studentin in einem Masterprogramm für Pflegeexpertinnen am European Institute
of Health and Medical Sciences, University of Surrey, Guildford
1. Ich bestätige, dass ich das Informationsblatt zu oben erwähnten Studie
gelesen und verstanden habe.
2. Ich bestätige, dass ich Gelegenheit hatte Fragen zu stellen.
3. Ich weiss, dass meine Teilnahme an der Studie auf freiwilliger Basis beruht
und ich mich jederzeit zurückziehen kann ohne Angabe von Gründen.
4. Ich erkläre mich bereit zur Teilnahme an dieser Studie.
5. Ich gebe die Erlaubnis die Interviews aufzuzeichnen.
6. Ich erlaube die Übersetzung der Interviews und die Analyse der Daten.
7. Ich gebe die Erlaubnis Angaben von mir unter Wahrung der Anonymität
in der Dissertation und in Veröffentlichungen zu verwenden.
__________________
_____________
_____________________
Name der Teilnehmenden
Datum
Unterschrift
__________________
_____________
_____________________
Name der Untersuchenden
Datum
Unterschrift
75
9.9.
Letter of confirmation to participants
[Letter to nurses who have agreed to participate in the study]
Title of the study
An interpretative phenomenological study of the meaning of resource allocation
experienced by nurses working on a palliative care unit in Switzerland.
Researcher
Nelly Simmen
Student in the Msc Advanced Clinical Practice Program, European Institute of
Health and Medical Sciences, University of Surrey, Guildford
Dear………………………
I am writing to thank you for agreeing to participate in the above study and to
confirm that your interview will take place:
On ………………………………………………………………………………………
Time ……………………………………………………………………………………
Venue…………………………………………………………………………………...
………………………………………………………………………………………………
……………………………………………………………………………………..
I look forward to meeting you. If there are any difficulties please do not hesitate to
contact me.
Nelly Simmen
Telephone: 031 337 70 13
Email: [email protected]
76
9.10. Bestätigungsbrief an die Teilnehmenden
Titel der Forschungsstudie
Interpretative Phänomenologische Studie zur Bedeutung von Ressourcenzuteilung
wie sie Pflegefachpersonen erleben, die auf einer Station für Palliative Therapie in
der Schweiz arbeiten.
Untersucherin
Nelly Simmen
Studentin in einem Masterprogramm für Pflegeexpertinnen am European Institute
of Health and Medical Sciences, University of Surrey, Guildford
Liebe(r)
Herzlichen Dank für Deine Bereitschaft in der obengenannten Studie
mitzumachen. Mit diesem Brief bestätige ich Dir den Interview-Termin für den
Datum...............
Zeit....................
Ort.....................
In Vorfreude auf das erste Interview mit Dir grüsse
ich Dich herzlich
Nelly Simmen
031 337 70 13
[email protected]
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9.11. Letter of non-acceptance
Title of the study
An interpretative phenomenological study in the meaning of resource allocation
experienced by nurses working on a palliative care unit in Switzerland.
Researcher
Nelly Simmen
Student in the Msc Advanced Clinical Practice Program, European Institute of
Health and Medical Sciences, University of Surrey, Guildford
Dear .....
As more volunteers applied for the study as are needed I used a method with
criteria to select the number of participants needed while at the same time giving
each applicant equal chance to take part. Although you name was not chosen, I do
want to thank you sincerely for your application and wish you all the best for the
futur.
With kind regards
Nelly Simmen
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9.12. Absagebrief
Titel der Forschungsstudie
Interpretative Phänomenologische Studie zur Bedeutung von Ressourcenzuteilung
wie sie Pflegefachpersonen erleben, die auf einer Station für Palliative Therapie in
der Schweiz arbeiten.
Untersucherin
Nelly Simmen
Studentin in einem Masterprogramm für Pflegeexpertinnen am European Institute
of Health and Medical Sciences, University of Surrey, Guildford
Liebe(r)....
Es haben sich mehr Personen für diese Untersuchung bereit erklärt als ich in der
Lage bin einzubeziehen. Aus diesem Grund musste ich ein Auswahlverfahren
anhand von Kriterien anwenden. Dabei hat sich herausgestellt, dass ich Dich
leider nicht in die Studie einbeziehen kann.
Ich möchte Dir aber ganz herzlich danken für Deine Bereitschaft in der Studie
mitzumachen und wünsche Dir alles Gute.
Mit lieben Grüssen
Nelly Simmen
79