exceptional nontraditional caring practices of nurses

OR IG INAL ART ICLE

Exceptional nontraditional caring practices of nurses

Olive Yonge1RN, PhD, C. Psych. (Professor) and Anita Molzahn2

RN, PhD (Dean)1Faculty of Nursing, University of Alberta, Edmonton, Alberta, Canada and 2Faculty of Human and Social Development, University of Victoria,

Victoria, British Columbia, Canada

Scand J Caring Sci; 2002; 16; 399–405

Exceptional nontraditional caring practices of nurses

There has been little research that has addressed the

practices of nurses who go beyond the usual scope of

practice to demonstrate caring. In this study, a grounded

theory methodology was used to interview 18 nurses

identified as exceptional caring nurses. The core process

identified was giving and involved gifts (particularly of

time), responsibility and choice, teaching, vulnerability,

preserving dignity, caring with and for coworkers, being

truly present, and always finding a way. Although the

findings of this study are not necessarily generalizable, it is

important to acknowledge that these practices occur and

that they should not automatically be discredited. The

research has implications for the new emerging field

of boundaries in professional relationships.

Keywords: boundaries, caring, gift giving, nurse–patient

relationships

Submitted 2 January 2001, Accepted 21 June 2002

Introduction

One of the most complex areas of investigation for nursing

in the last 20 years has been the area of caring. The caring

roles of nurses have changed, moving primarily from an

emphasis on biological functioning to a focus on the special

relationship between the nurse and patient (1). Currently,

interest in caring includes the nurse–patient relationship,

but also extends to other areas such as politics (2), ethics

(3), culture (4, 5), gender (6) and personality (7).

Incidents have been described in which both patients

and nurses have engaged in exceptional, nontraditional,

caring practices typified by giftgiving and other acts of

kindness whereby these practices have positively influ-

enced patient outcomes, as evidenced by verbal and writ-

ten descriptions. However, these incidents are seldom

identified in the literature. Hence, the purpose of this study

was to describe the process of exceptional, nontraditional

caring practice from nurses’ perspectives.

Review of the literature

Caring is a very complex phenomenon. Morse et al. (8)

reviewed the caring literature and classified caring into

several categories: a human trait, moral ideal, affect,

interpersonal relationship and therapeutic intervention.

They also identify two outcomes of caring: the subjective

experience of the patient and caring as a physical response.

Their thesis was that nurses do not really know what

caring is.

Numerous concepts have been linked with caring:

competence and compassion (9, 10); presence (11, 12);

presence and intention (13); interconnectedness and

detachment (14); coping (15); trust (16); reassurance (17);

risk-taking, advocacy, fearlessness and connectedness (18).

In-depth study of certain concepts such as empathy (19),

altruism (20) and relationships (21) have also yielded

descriptions of caring behaviours.

A number of scholars have described caring as a process

or series of processes. Swanson (22) described the process

of caring as knowing, being with, doing for, enabling and

maintaining belief. Fosbinder (23) described caring as four

processes: translating, getting to know you, establishing

trust and going the extra mile. Wilkes and Wallis (5)

utilized a survey of student nurses to identify eight themes

of caring: compassion, communication, concern, compet-

ence, commitment, confidence, conscience and courage.

Although there is little agreement on a definition of caring,

critical analyses of the concept have been of some help in

identifying various qualities of caring, including holism,

respect and relationship.

The research on caring can be described in terms of the

populations studied [patients, both nurses and patients

(including families), and nursing students]. Rieman (24)

and Brown (25) studied patients’ perceptions of caring and

found that the patient must feel valued to experience

caring. Patients, too, described noncaring interactions in

clinical settings (24). For example, patients stated that

nurses did not recognize their uniqueness because the

Correspondence to:

Olive Yonge, Professor, Faculty of Nursing, University of Alberta,

Edmonton, Alberta, Canada.

E-mail: [email protected]

� 2002 Nordic College of Caring Sciences, Scand J Caring Sci 399� 2002 Nordic College of Caring Sciences, Scand J Caring Sci

nurse did not ‘really listen’ or appeared ‘too busy’.

Morrison (26) found that patients wanted a caring holistic

environment and practitioners with high technical skills.

May (27) reviewed selective literature and research on

nurse–patient relationships to find that what ‘ought’ to be

occurring in nurse–patient relationships did not necessarily

occur in practice. In practice, nurses were spending little

time in verbal communication, they used a range of tactics

to avoid communication, and they controlled all interac-

tions (27). Milne and McWilliam (28) found that caring

was interpreted by patients as caring time. Time doing to,

doing for and being with the patient.

Larson (29) used a Q-sort technique to obtain data from

both nurses and patients (n ¼ 57 for both groups). Nurses

ranked listening and offering comfort most highly as caring

behaviours, whereas the patients ranked the competence

of the nurses caring for them the highest. Mayer (30),

replicating this study with oncology patients (n ¼ 54) and

nurses (n ¼ 28), found similar results. Wolf et al. (31)

identified five dimensions of nursing care using the Caring

Behaviours Inventory with 278 nurses and 263 patients:

respectful deference to others, assurance of human pres-

ence, positive connectedness, professional knowledge and

skill, and attentiveness to the other’s experience. Using the

CARE-Q instrument and the CARE-How questionnaire,

von Essen and Sjoden (32) studied the occurrence and

importance of caring behaviour as identified by patients

and staff in psychiatric, medical and surgical care areas.

Patients and nurses differed in their ranking of the

behaviours. In contrast, Harrison (33), using the Profes-

sional Caring Behaviours Instrument to study caring per-

ceptions of 16 nurses and 15 family members in a hospice

setting, found that the rankings were similar for both

groups, raising the possibility of the influence of setting

and speciality on the value placed on caring.

There are incidents when nurses have ‘gone the extra

mile’ or engaged in exceptional nontraditional interac-

tions. Gift giving behaviours are usually viewed as non-

traditional but are not unusual. In Morse’s (34) article on

patients’ gift giving, she wrote that patients gave nurses

gifts if they received excellent nursing care, care that went

beyond basic nursing care. Some patients perceived the

care they received to be a gift and reciprocated by giving a

gift to their nurse or to the staff.

Benner and Wrubel (35) have shown that nurses give

exemplary care to their patients. Morse (36), in an article

on commitment and involvement in nurse–patient rela-

tionships, documented examples of nurses ‘going the extra

mile’ to provide care to their patients. Morse (36) devel-

oped a classification system for these nurses’ behaviours

and classified the first nurse as being in a connected rela-

tionship and the latter one as being in an over-involved

relationship. Kines (37) used a structured self-report

questionnaire to study the risks of caring too much and

becoming over involved with a patient. Kines likened this

relationship to codependency and concluded that code-

pendency is prevalent among practicing nurses. Barker

et al. (38) suggest that nurses do not need to develop new

skills or roles, rather they need to develop new ways of

fulfilling traditional caring acts in our increasingly complex

and technological nursing environment. The intent of this

study was to capture those caring behaviours not previ-

ously documented.

Method

Little is known about the context, consequences, conditions

or causes of exceptional, nontraditional, caring nursing

practices, and so a qualitative method, specifically grounded

theory, was used (39. Grounded theory uses both inductive

and deductive approaches to theory construction (40, 41).

Hypotheses and concepts arise out of the data being col-

lected, rather than being conceived prior to the study, and

thus are ‘grounded’ in the data (42, 43). These hypotheses

are continuously tested against new data to ensure that they

remain grounded and are accurate descriptions and inter-

pretations of the phenomena under study.

Grounded theory assumes the existence of processes

underlying social phenomena, and attempts to discover

and explicitly identify these processes. As a method, it

differs most dramatically from quantitative research

methods in that the steps in the research process generally

occur simultaneously, rather than sequentially. Thus, as

data are collected, concepts and hypotheses emerge from

this data, and the direction of further data collection

is determined by emerging categories (39, 44, 45). This

reflexive process is one of the hallmarks of grounded

theory research.

Data collection

Data were collected using semistructured, longitudinal

interviews. The interviews were approximately

1–1.5 hours in length and began with broad, general

questions, becoming more focused as the data analysis

progressed and the relationships among the concepts

within the data were identified (40). Each of the 18

informants was interviewed at least once, nine were

interviewed a second time, and three were interviewed

three times. All the interviews were audiotaped and tran-

scribed. Immediately after the interviews, field notes were

written focusing on the informant’s nonverbal behaviours

and the environment in which the interview took place.

Sample

A purposeful, or theoretical, sampling method was used;

participants were selected on the basis of their knowledge

of the phenomenon being studied (40, 41). Informants

from two regions in western Canada were invited to

� 2002 Nordic College of Caring Sciences, Scand J Caring Sci

400 O. Yonge, A. Molzahn

participate in the study through word of mouth, adver-

tisements placed in their place of employment, and group

presentations. Also, snowball sampling was used, where

informants introduced the researchers to other nurses who

were known for their exceptional, nontraditional, caring

practices.

The informants in this study were 18 Registered Nurses,

working in a variety of health care centres and community

agencies who had, at some point in their careers, engaged

in exceptional, nontraditional, caring nursing practices.

These practices may or may not have involved spontaneity,

a gift, or occurred when the nurse was on duty, and may or

may not have been viewed by the nurses and/or their

colleagues as positive or negative in nature. The criteria for

the selection of the informants included the ability to ver-

balize their thoughts and feelings, ability to speak English

fluently, and willingness to participate in the study. They

ranged in age from 28 to 66 years. Aside from the diploma

preparation, three of the nurses held baccalaureate degrees

in nursing, one held a Master’s degree, and five had addi-

tional preparation beyond the diploma level.

Data analysis

In grounded theory, it is important that sampling and

analysis occur in tandem, with analysis guiding the data

collection (40). As the data are collected, coding occurs.

The phenomena are identified in the data, categories for

these phenomena are named, and searches for conceptual

links between these categories are sought. As this process

continues, the researcher searches for a core category, that

is, a central category around which the remaining theory

can be pulled together. To assist with the sorting of data, a

computer program called the Ethnograph (46) was used.

Coding was an ongoing process in which data continued to

be collected until the saturation point was reached, that is

until no new or relevant information was found.

Rigour. Rigour was maintained in a number of ways. Field

notes were kept by the researchers to record actions,

interactions and subjective states in the field, as well as

changes in behaviours and attitudes (40, 47). These were

dictated after the interview and transcribed. During

sampling, a range and variation of informants was selected.

A negative case which did not fit into existing categories

was also included to increase validity (40, 47). Having the

interviews audiotaped and then transcribed verbatim

increased reliability. Typed transcripts of data were provi-

ded to those informants who consented to review them, to

verify accuracy. As the study progressed, the analysis of

the data was discussed with selected respondents to assess

accuracy of interpretation. An audit trail was also main-

tained to document decisions, choices and insights (40).

Ethical clearance was obtained from the appropriate

institutional review committees.

The process of giving

For the purposes of the study, the practices have been

called gifts and the process, giving. Initially in the analysis,

concrete material gifts such as books given to clients by the

nurse were categorized as gifts. However, as the analysis

proceeded it became obvious that the concrete gifts were

less important than the gifts of time, presence and

responsibility that truly made a difference to the lives of

the clients and their families.

Gifts. There were many gifts, that is, actual things that

nurses gave or did for their clients. These included: a

nightgown that was cut down the back and had ties; a little

cloth bag with holders for insulin syringes; children’s

drawings; medical equipment to make things easier;

excursions out of the house or hospital; used clothes;

dropping off mail; doing laundry; baking bread; having a

husband change wheels on the Hoyer lift so it would fit

under the bed; reading the Bible; giving a home telephone

number; and having breakfast together.

All of the informants talked about the gift of time. They

gave up their lunch time, time when not scheduled to

work, and time at Christmas. Maggie said that she always

had time for her clients, even on her days off. For example,

one client was very worried about a court appearance and

Maggie accompanied her. Maria visited her clients on her

days off, not because she felt she should, but because she

wanted to. Maggie, Pia and Erin said that to truly listen

took time. Chris, if she worked all night, would call the

unit at lunch time to check on the status of a patient. Maria

also called back to the unit especially if someone was

particularly ill or involved in a traumatic situation. Both

Chris and Erin commented on how much time it took to

listen to family members.

The nurses valued their time with clients but did not

worry about having enough time. They noted that they did

not always have time to do extras such as curling a client’s

hair or giving a deep massage. The nurses noted that

everyone has only 24 hours in their day but how that time

is spent affects the outcome of care. The nurses were not

bound by 8- or 12-hour shifts. As professionals, they met a

need whenever it occurred. Lise spent considerable time

on her days off organizing fund raising events for equip-

ment and improving the hospital environment in which

she worked. She organized a garage sale, community

supper and had everyone quilt a square for a quilt that was

later raffled. Christmas was also used by nurses to give

gifts. Both Jane and Trudy would give small gifts such as

bake to their clients.

Responsibility and choice

These nurses were very clear about their roles and

responsibilities and expected their clients to manage

Exceptional caring 401


various situations. Barb, Jesse and Beth talked about

freedom to make decisions and to take responsibility for

actions. Jane’s beliefs regarding responsibility are evident

in the following quote:

I think I told you a story about one lady who was

slothful and that’s why she had these drainy legs, she

wouldn’t go to bed and put her legs up...and I chose

not to do it for her. I chose to make her a lecture and

tell her I wasn’t about to come in and do these basic

things for the rest of her natural life, she had to take

some responsibility for maintaining that. So some-

times it’s almost pathogenic [sic] if you go too far.

Teaching

All of the nurses talked about teaching. Beth explicitly

outlined all the interventions she used to heal the client

and then ensured that she taught the client the same

interventions: imaging, using positive thought, playing

music, using colours, etc. Jesse, like Beth, taught wellness,

wholeness, balance and relaxation. Maria taught some of

her clients to sew; they were frustrated with their jobs and

so she taught them a skill that they could complete and feel

good about.

The nurses saw teaching as happening anytime and

anywhere. Beth carefully outlined a story of how she

taught a client through questioning and reframing in a

manner that allowed him to preserve dignity, while

recognizing that he had acted inappropriately. There was a

recognition on the part of these nurses that a client must

be ready to learn.

Vulnerability

Issues involved in caring for vulnerable populations arose

in the interviews. Maggie discussed her work with First

Nations People. She recognized the importance for some of

them of their Indian Medicine and Indian Spirituality, not

allowed by the traditional system. Thus, she spent a con-

siderable amount of time thinking of how to ‘honour that

part of them and still direct it in a way that there’s some

movement and that would be acceptable to the dominant

medicine society where necessary.

Erin, who worked in palliative care, was adamant that

the patients’ remaining time be good and worthwhile. She

always questioned the care given to each client and asked,

‘could they be more comfortable…without being poked so

often?’ She also acknowledged that each person died in

their own way.

Preserving client dignity

The nurses described a number of examples where they

went to lengths to preserve client dignity. Beth cited an

example from emergency where parents brought in an ill

child but by the time they reached the emergency

department, the child’s condition improved and the par-

ents felt foolish for bringing the child in. She told them,

‘There’s a time warp when you come down the ramp into

the emergency (department) and the child is ill but gets

better in emergency.’ She showed acceptance of their

behaviour and helped them maintain their dignity.

Maggie did not always challenge a client who was in

error. She described a case where a client was doing some

drawings but was confused about some basic facts re-

garding the use of sweet grass. Maggie could quickly see

that the client was incorrect and was making things up.

She accepted the client for who they were and, in this case,

did not challenge her.

To maintain her client’s dignity, Jerri told a number of

‘white lies’. She recalls purchasing creams and things to

help one particular client, passing them off to her as mere

samples. Jerri explains, ‘I know she couldn’t afford it and I

know it would really help.’

Jerri also told another story whereby she saw one of her

clients living in a cold grotty old place and she bought her a

housecoat from a second hand store so the client would be

warmer. She told the white lie that she had the spare

housecoat at home. Using the cover of Christmas, Pia gave

certain clients gifts in the spirit of Christmas that they

needed for healing. One client had a yeast infection, ‘so I

brought her acidophils and thing like that for Christ-

mas…and she was grateful.’

Caring with and for coworkers

The nurses talked about their relationships with coworkers.

Some coworkers were supportive and helped the nurses

provide exceptional care whereas others had to be taught

how to give care. The latter group of coworkers were

mentored or coached by the nurses to give high quality

care. All the nurses were extremely alert to the behaviours

of their coworkers. Kate saw potential in another nurse

to be exceptional and she stressed the word, potential,

because the nurse was still on the ‘border of risk-taking’.

Jerri demonstrates how nurses in their work setting

supported each other. She explains that it is easy to tell if

somebody is overloaded with work and needs something.

Jerri states that ‘we…maybe go down to (the grocery store)

which is right below us and buy a cake, bring it up and put

the kettle on, and say everybody come on down we are

having cake. We also take it upon us ourselves to say that

today is the day we need some nurturing so we call a little

meeting.

Jerri concluded her story by saying that this same per-

ceptiveness in picking up on concerns of coworkers is also

extended to work with clients. Certain clients were quite

difficult; they did not want to change or do anything for

themselves. The nurses would volunteer to care for these

clients for a few days to give respite to their coworkers.



Truly present

The nurses were truly present with their clients and client

families. They were thoughtful, considerate, empathetic,

decisive and practised holistically. They did not view the

client in isolation from the family, and in turn, the family

was viewed as part of a larger community. For example,

when Beth cared for a child in emergency with croup, she

would tell the mother to get up on the stretcher with the

child to get some rest.

Jesse was very careful to discriminate between what she

believed to be her thoughts and what were the thoughts of

the client. She validated her perceptions using therapeutic

touch, reflexology and physical assessment. She shifted her

thoughts to become conscious of what the client was

experiencing. She stated that she understood what was

really safe for the client. For her to be truly present meant

that she needed to know the client. She knew their bodies,

gave them feedback about their bodies and usually quickly

learned their thoughts. She said, ‘I just look at the person

and – I know’. Clients immediately trusted her and told her

their stories. If she could not manage the client situation,

she referred the client. She recognized her own abilities

and limitations.

There is always a way

The nurse participants were determined to find solutions to

each situation. At times that involved trying to provide

some hope in hopeless situations. Jerri explained that she

cares for a quadropalegic who had heard of an experi-

mental drug from the United States. She then proceeded to

obtain information on the drug for the client, also pur-

chasing a plant to go along with it:

We do things like that all the time…Who knows if it is

going to work or not, but this is something that is

giving him a little ray of hope. I need the idea to go

into his head and there are things that he can do out

there.

The nurses seemed to be undaunted by the situations

presented to them. They had the confidence to find a

solution or to live with uncertainty. Maria noted that there

are so many interventions that can be used, but it is how

you use them that makes the difference. She stated that

nurses have the skills to make it hurt less.

There was also a marked resourcefulness among the

nurses. Maggie was surprised when she challenged the

social services system and obtained a new worker for her

client. She stated that was very unusual for her. Jerri

found that with a particularly difficult client who had no

outside interests, the best gift she could give her was one of

story, using the antics of her pets as the basis of stories.

Another particularly difficult patient, who apparently had

no outside interests, would ask what was new with Molly,

Jerri’s dog.

The nurses realized that there is always a way, but that

the way did not necessarily lie with them. A number of

them commented on their own limitations and noted that

they referred clients to other nurses or professionals.

Discussion

The rich descriptions of these nurses’ exceptional, non-

traditional, caring practices, and the categories related to

the process of giving are consistent with descriptions of

caring from the literature. For instance, ‘preserving dig-

nity’, being ‘present’, teaching, supporting coworkers, and

finding a way are all considered by nursing and caring

theorists to be elements of nursing practice. Some of the

findings do confirm and explicate the statements made by

various scholars about caring. The actual process of giving

is supported in Watson’s work. She stated that the actual

occasion of caring is a field of its own, that is greater than

the occasion itself, and allows for the presence of the geist

or spirit of both (48). This was true for the nurses partici-

pating in this study. They could not discuss the gifts

without the context. Neil (49) noted that caring is more a

way of being than a defined set of behaviours. Beckerman

(14) expanded on this concept by stating that caring means

not being afraid of being oneself, and of giving of com-

petence with the humility of being. This way of being with

clients, coworkers and others is critical. To simply list gifts

is insufficient; the nurses gave to others the essence of

giving.

The nurses in the study talked about the importance of

knowing the clients, as do Tanner et al. (50); they discussed

preservation of human dignity as does Watson (48, 51);

and they viewed caring as the condition for facilitating

trust, as do Baker and Diekelman (16). Beckerman (14)

stated that caring is both interconnectedness and detach-

edness. There are times that caring means being hard and

doing what others do not want, as was noted in the find-

ings related to responsibility and freedom. Jensen et al. (18)

described caring as risk-taking, advocacy, fearlessness and

connectedness. All of these descriptors can be directly

found in the present findings, with the exception of con-

nectedness. This latter descriptor was implied by the par-

ticipants but was not clearly articulated using that specific

word. Rather the nurses used language such as being

‘totally present’ and ‘involved’. This finding is related in a

theoretical article written by Osterman and Schwartz-

Barcott (12) on presence. Fealy (7) described caring as not

just a series of acts, but a way of acting which is both

totally contextually dependent and value bound.

Hawthorne and Yurkovich (52) stated that caring is

based on trust and loyalty and involves reciprocity. The

findings do not support this claim. The nurses wanted

feedback but the feedback did not have to be at the level

of reciprocity. Nor did they want loyalty. They had an

internal locus of control and were governed by their own



standards. Even if a client was rude to them, they would

still care for them in an expert manner. Swanson (22) also

stated that there was no expectation of reciprocity in car-

ing.

Obtaining the patient’s perspective, Fosbinder (23)

identified four processes of caring: translating, getting to

know you, establishing trust and going the extra mile. The

latter process was reserved for the nurse that did more. The

nurses in this study went beyond going the extra mile and

simply doing more. Although ‘extras’ were part of their

practices, they were not limited to giving more energy,

thought, time, clothing or food. They gave holistic care,

that was driven by the situation.

Implications for nursing

This study has implications for nurses. Administrators need

to understand that these nurses manage themselves and

report high levels of job satisfaction. However, they will

question policies and rules. Some of their practices may

seem to be unorthodox. As they believe in advocacy for

clients, there is always the potential for interdisciplinary

conflicts. An administrator with a rigid vision of nursing

will be challenged by these nurses. Educators cannot teach

students this level of caring. Students are not traditionally

confident, mature and able to articulate a developed phi-

losophy of nursing. The very experience of being a student

involves learning policies and rules and not breaking

or rewriting them. There are also policy implications in

relation to exceptional caring practices. With increasing

concerns regarding potential abuse of clients, many pro-

fessional associations and hospitals have developed policies

governing nurse–client relationships. Some of these poli-

cies and guidelines address boundaries, which participants

in this study crossed. For instance, ‘giving personal gifts…to clients is strongly discouraged’; ‘accepting personal

gifts… from clients is strongly discouraged’ (53). In par-

ticular, some of the ‘yellow lights’ such as spending free

time with clients, frequently thinking of clients when

away from work, frequently planning other clients’ care

around the client’s need, and feeling irritation if someone

or something in the system creates a barrier to client’s

progress were all commonly reported by the nurses in this

study.

The findings of this study cannot be generalized to other

populations. However, the theory may prove to be useful

in other settings/situations. No attempt was made to elicit

the experiences of clients in this study. Also, no attempt

was made to analyse data in relation to gender, educa-

tional preparation, or culture. As is the case with much

qualitative research, there are often hypotheses that are

generated and research questions that arise. Given that the

participants were from two geographical areas of the

country, it would be useful to replicate the study in other

areas to validate, expand and elaborate on the findings. It

would also be useful to examine narratives or critical

incidents from other studies of nursing practice to identify

whether the same factors emerge.

Conclusion

The 18 participants in this study crossed the boundaries of

standard nurse–client care in one form or another. The

process of ‘giving’ by the nurses embodied several forms,

such as teaching, ‘preserving dignity’, caring for cowork-

ers, being ‘present’, and finding a way, amongst others.

Therefore, the findings in this study are wholly consistent

with the descriptions of caring from the literature.

Acknowledgements

This project was funded through a research grant from the

Alberta Foundation For Nursing Research. As well it was

funded indirectly through staffing from the Alberta

Foundation for Medical Research Women in Engineering,

Science, and Technology Work Programme.

The authors would like to acknowledge the invaluable

assistance of Nasir Khan, Jillian Lemenymer B.Sc. N., Lyle

Thomas B.Sc., Sharon Wilson R.N. M.Ed. M.N. and Mary

Haase, doctoral student in the Faculty of Nursing.

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