Nursing Students and Nurses' Recommendations Aiming at Improving the Development of the Humanistic Caring Competency.

BACKGROUND: Most nursing education programs prepare their students to embody humanism and caring as it is expected by several regulatory bodies. Ensuring this embodiment in students and nurses remains a challenge because there is a lack of evidence about its progressive development through education and practice.
PURPOSE: This manuscript provides a description of nursing students' and nurses' recommendations that can foster the development of humanistic caring.
METHODS: Interpretive phenomenology was selected as the study's methodological approach. Participants (n = 26) were recruited from a French-Canadian university and an affiliated university hospital. Data was collected through individual interviews. Data analysis consisted of an adaptation of Benner's (1994) phenomenological principles that resulted in a five-stage interpretative process.
RESULTS: The following five themes emerged from the phenomenological analysis of participants' recommendations: 1) pedagogical strategies, 2) educators' approach, 3) considerations in teaching humanistic caring, 4) work overload, and 5) volunteerism and externship.
CONCLUSION: The findings suggest the existence of a challenge when using mannikins in high-fidelity simulations with the intention of developing humanistic caring. The findings also reaffirm the importance of giving concrete and realistic exemplars of humanistic caring to students in order to prevent them from making "communication" synonymous to "humanization of care".

Introduction and background

Humanism, caring, compassion, empathy, and related concepts are all included in most standards of practice (American Nurses Association, 2015), nursing competencies frameworks (Levett-Jones et al., 2017), and vision statements for nursing education (World Health Organisation, 2020). Although these concepts share multiple meanings, they fall under the same “broad umbrella” that comprises the relational dimension of nursing (Létourneau et al., 2017). Therefore, most authors agree that embodying humanism and caring is a requirement for professional competency, and it is this embodiment that leads to humanization of care.

Humanizing nursing care in the modern clinical settings entails a complexity that cannot be solely reduced to “being nice” to patients. This reductionist and stereotypical misconception of the nursing role is a narrative that is still portrayed by various media (Abbas et al., 2020; Finkelman & Kenner, 2013; Gordon & Nelson, 2005; ten Hoeve et al., 2014). In addition, there is evidence that these portrayals influence students’ initial conception of caring (Waterman, 2007) and remain conflictual with newly graduates’ professional identity (Flinkman et al., 2013). In terms of complexity, think about how challenging it might be for certain nurses to make a person feel like they are a human being navigating through health and sickness, rather than conceptualizing them with labels such as “the bleeder in room 51” (Haque & Waytz, 2012; Trifiletti et al., 2014). Even though most nursing schools teach their students this basic humane principle, it appears that the mountains of challenges (i.e., staff shortage, time pressure, work overload, trivialization of humanistic caring) in the clinical settings make it easy for nurses, especially the newly graduated ones, to lose touch with it (Nijboer & van der Cingel, 2019). However, humanizing nursing care is not only about considering patients as human beings: it is being able to establish an authentic and reciprocal relationship with them (Busch et al., 2019), to know what and when to communicate (both verbally and nonverbally) in ways that express concern and empathy, to do a procedure that generates the least amount of suffering and takes into account patients’ existence and preferences, or to be creative in finding ways to respond to and advocate for patients’ priorities and preoccupations (Beltrán-Salazar, 2015; Létourneau et al., 2021a). There is little doubt that these instances of humanized care require nurses to mobilize and combine knowledge, skills, attitudes, and external resources in many instances, a definition of a competency (Tardif, 2006) that illustrate more complexity than “being nice” to patients.

Supporting the development of such competency in nursing students remains challenging, not because evidence about pedagogical strategies is scarce, but rather because there are few recent studies that described the developmental trajectory of humanistic caring in nursing (Haag-Heitman, 1999; Létourneau et al., 2021a; Norman et al., 2008; Paragas, 2019). Therefore, it appears difficult for educators to know which strategy to choose and when it is to be used to foster effectively the development of humanistic caring. In addition to this issue, humanistic caring's development is facilitated and hindered by experiences that are not necessarily depended on these pedagogical strategies (Létourneau, Goudreau, et al., 2020). For instance, humanistic and caring role models in education programs are capital to the development of humanistic caring (Cara et al., 2021; Jack et al., 2017; Logan, 2017) whereas constant devaluation of humanization of care by nurses, colleagues, and managers is on the contrary detrimental (Christiansen et al., 2015; Jones et al., 2016). In this context, studying the development of humanistic caring while taking into consideration those aspects appears relevant to nursing education.

The purpose of this paper is to provide a description of French-Canadian nursing students’ and nurses’ recommendations aimed at improving the development of humanistic caring among nursing students and nurses. These results are part of larger phenomenological study that had the two following objectives: 1) develop a cognitive learning model of the humanistic caring competency, and 2) identify lived experiences that facilitate and hinder its development. A cognitive learning model is a representation of a competency's developmental stages in which critical milestone (or key learning) are identified for each stage (Tardif, 2006). These findings are reported in other publications (Létourneau, Goudreau, et al., 2020; Létourneau et al., 2021a, 2021b).

Method

The selected methodological approach was Benner’s (1994) interpretive phenomenology. Before being formalized as a qualitative research method (van Manen, 2017), phenomenology was originally a philosophy introduced by Husserl (1913/1950) and Heidegger (1927/2008). Most phenomenological research methods draw on the ideas of at least one of these two philosophers and usually fall under the following schools of thought: descriptive (Husserlian) or interpretive (Heideggerian) phenomenology (O'Reilly & Cara, 2020; Spiegelberg & Schuhmann, 1994). Benner's phenomenology was elaborated through the Heideggerian tradition (Heidegger, 1927/2008), but it also has Taylorian (Taylor, 1985), Dreyfusian (Dreyfus, 1984), and Gadamerian (Gadamer, 1989/2004) underpinnings. Falling under the Heideggerian school of thought, Benner's phenomenology aims at understanding and interpreting human existence (Benner, 1994). At times, this existence is referred to as the phenomenon of “being there”, which is the closest English equivalent to the Dasein, a concept originating from the German writings of Heidegger (1927/2008). For this philosophical phenomenologist, there was a strong relationship between “being there” and “the world” in which this existence takes place, so indissoluble that it gave birth to the hyphenated neologism “Being-in-the-world” (Heidegger, 1927/2008). In simple words, using a Heideggerian phenomenology means to consider experiences as inextricable to their contexts in terms of time, space, history, language, and culture (Benner, 1994). On the practical side, Benner's phenomenology was originally used to uncover the knowledge embedded in the everydayness of nurses’ clinical expertise (Benner, 1994). This embedded knowledge, in the context of this study, pertained to humanistic caring as a competency developing from lived learning experiences in the education program and after graduation in clinical practice.

Ethical considerations

Ethics approval was granted by the review board of the hospital where nurses were recruited (certificate No. FU-8038). This certificate was recognized by the ethical review board of the university where the recruitment of students took place. Written consent was obtained by each participant before they were involved in the study. Participants’ information was safeguarded by using codes and fictitious names in sociodemographic questionnaires, transcripts, and the primary investigator's (PI) journal. In addition, the PI stopped teaching undergraduate courses while the recruitment took place to mitigate student participants feeling pressurized in participating in the study.

Setting

The study took place in a French-Canadian university and an affiliated French-speaking university hospital. Student participants were completing the university's undergraduate nursing education program and nurse participants were graduates from this program. It is a 3-year program that leads to registration as a nurse (or 2-year with an associate degree in nursing). Being based on a competency approach (Goudreau et al., 2009), this program aims at developing eight nursing competencies, one of these being humanistic caring. The education program refers to a competencies framework (Faculté des sciences infirmières de l'Université de Montréal, 2015, p. 13) which defines humanistic caring as follows: “To assimilate a disciplinary perspective to integrate humanistic values ​​into their professional practice centered on accompanying the person and supporting their power to act.” Several pedagogical activities, from the first to the last year of the program, are specifically designed to promote the development of the humanistic caring competency, for instance: simulation laboratory focused on communication skills, students’ written reflections oriented by a humanistic model of nursing, and theoretical and empirical writings about humanistic caring. Using the aforementioned competencies framework, most assignments of the program (including internship evaluation) specifically assess humanistic caring in students. In addition, the program is anchored on a humanistic model of nursing (Cara et al., 2016; Létourneau, Cara, et al., 2020) which students learn, explore, and iteratively critically reflect on over the course of their education.

Recruitment of participants

The PI and a research assistant recruited 18 students and 8 nurses using convenience and snowball sampling methods (Gray et al., 2017; Polit & Beck, 2017). All participants (n = 26) participated until the end of the study. In terms of recruitment strategies, students were invited to participate in the study by sending a letter to their academic email address. The PI and a research assistant also made presentations in few courses to recruit more students. Both the PI and the research assistant were not involved in teaching classes when the study took place. Depending on their progression in the education program, students were recruited in three groups (first-year, second-year, and third-year; see Table 1). According to their clinical experiences, nurses were recruited in three other groups (newly graduated, experienced, and accomplished; see Table 1). Three inclusion criteria (there was no exclusion criteria) were established in the selection of students and nurses: 1) speaking and understanding French, 2) being interested in sharing experiences pertaining to learning the humanistic caring competency, and 3) being a student or a graduate of the same undergraduate program comprising a humanistic caring competency. To be eligible, accomplished nurses also had to self-report that they were recognized as “humanistic caring experts” by peers or patients (Graber & Mitcham, 2004). Participants’ sociodemographic characteristics are presented in Table 1.

Table 1.

Sociodemographic Characteristics of Participants (n = 26).

Characteristics		Students(n = 18)	Nurses(n = 8)
Progression in program
	First year of education program completed (or in the process of)	3	-
	Second year of education program completed (or in the process of)	9	-
	Reached the end of the third year	6	-
Clinical Experience
	6-18 months (newly graduated nurse)	-	1
	2-4 years (experienced nurses)	-	3
	5 + years (accomplished nurses)	-	4
Gender
	Identified as female	17	7
	Identified as male	1	1
Age
	Mean age (years)	24	30
	20-29 years old	16	2
	30-39 years old	2	6
Ethnic background
	Arabic or Middle Eastern	1	-
	Asian	1	-
	Black or African American	1	1
	Eastern European	1	-
	White	14	7

Data collection

Data collection was initiated in September 2015 and ended in February 2017. To collect data, the PI conducted one semi-structured individual interview with each participant. In other words, 26 interviews were conducted. An interviewing guide was designed with and validated by the PI's supervisors (JG and CC) before being used with participants. Before asking questions to participants, a rather broad definition of the humanistic caring competency was verbally provided. Among the questions that were asked to students and nurses, those related to this paper were: “If you had recommendations to foster the development of humanistic caring, what would they be for nursing schools? and “What about recommendations for clinical settings?” Following each interview, the PI reflected on the participant's shared experiences and wrote down his thoughts in a reflective journal. Each interview was recorded and lasted between 40 and 119 min (average: 63 min). An experienced typist transcribed all interviews and the PI reread the verbatim transcripts to ensure accuracy. Research data was kept safe in a computer that only the PI knew the password in addition to being stored in a lockable filling cabinet.

Data analysis

Data analysis was simultaneous to collection. Initially, the PI imported the verbatim transcripts in ATLAS.ti 8 to support data analysis. Then, the analysis was accomplished by the PI using an adaptation of Benner’s (1994) phenomenological method that was concretized in five iterative stages: 1) lines of inquiry, 2) central concerns and exemplars, 3) shared meanings, 4) final interpretations, and 5) dissemination of the interpretation (Crist & Tanner, 2003). Overall, stages 1 and 2 involved individual analysis, which the PI fulfilled, comprising the naming of meaning units (Benner et al., 2009) and the summarization of central concerns in short interpretive summaries (one per participant). The PI's supervisor (CC), an expert in phenomenology, revised two individual analysis and interpretive summaries before going forward. The third stage comprised interparticipant analysis which attempted to uncover shared meanings among each group, one at a time. These similar meanings were gathered and refined in interpretive group summaries (one per group) by the PI. In a “one group at a time” fashion, his supervisors (JG and CC) familiarized themselves with each interpretive group summary and the corresponding individual interpretive summaries of the same group that the PI had generated. Subsequently, the PI discussed each interpretive group summary with his supervisors (JG and CC). The main purpose of these discussions was for the PI to obtain feedback on his interpretation process, which contributed to the enrichment of his interpretations. In stage 4, the six interpretive group summaries (same groups as those outlined in Table 1) were compared with one another (intergroup analysis) by the PI, attempting to unravel similarities and divergences, hence clarifying the emerging interpreted themes. The last and fifth stage of data analysis ultimately led to the determination of the final themes. This stage involved an in-depth discussion among the research team (DL, JG, and CC) in which clarified themes were disputed and refined. As per Benner’s (1994) recommendation, the PI held a reflective journal in which he recorded his preunderstanding (i.e., preconceptions and assumptions) regarding the studied phenomena in addition to writing down reflective notes systematically throughout the interpretation process. This interpretation process and the demonstration of the study's rigor are thoroughly reported in three other publications (Létourneau, Goudreau, et al., 2020; Létourneau et al., 2021a, 2021b) and are not described in this paper because of space limitation.

Results

Participants shared a great diversity of recommendations that targeted preponderantly the education program. In the first theme, respondents suggested to modify certain pedagogical strategies, for instance increasing the number and the variety of storytelling sessions in addition to enhancing simulations’ realism. In the second theme, participants recommended to cultivate humanism and caring in educators’ approach with students, namely by improving the training offered to nurse preceptors and by strengthening the embodiment of humanism in student-teacher relationships. In the third theme, students and nurses underscored considerations in teaching humanistic caring such as raising awareness about its importance, giving concrete examples of “humanistic verbatims” and “humanistic behaviors”, and taking into account the reality of clinical practice. In the fourth theme, respondents overwhelmingly saw fit to reduce the work overload but accomplished and experiences nurses appeared more hesitant about the applicability of this recommendation. In the fifth and last theme, participants perceived it would be valuable to integrate volunteering experiences in the curriculum (or consider the lasts upon admission) and to make the nursing externship mandatory.

Pedagogical strategies

In the first theme, almost half of the interviewees'’ recommendations, that were voiced by the majority of participants (n = 17)1, involved additions or changes in pedagogical strategies employed in the education program. Patients’ and nurses’ storytelling were recommended the most because participants perceived that this strategy was persuasive and convincing. Participants perceived that there was nothing more “concrete” than hearing from patients themselves about how they were impacted by humanization of care (positive impacts) or dehumanizing practices (negative impacts). On the one hand, nurses’ stories were suggested because they were seen as a way to understand more concretely humanistic caring in daily nursing practice. On the other hand, participants wished that patients from different care settings were invited more often in the classroom to share their stories, from the first to the last year of the baccalaureate, as highlighted in the next excerpt:

Someone [a patient] came to share their experience […] and it touched many students […] With the humanistic caring competency, they [educators] could invite people that had good and bad experiences to educate novices, because when you leave school, you have lots of ideals and then you are struck by the reality which is quite different. I think there should be room to include more storytelling to raise students’ awareness. (Hallay, a second-year student)

In addition, several recommendations aimed at improving sessions in the simulation laboratory, especially those intended to develop students’ communication skills. Some participants suggested modifications to enhance simulations’ realism, for instance by ensuring that the actors playing patients were sufficiently credible. One participant felt that the high-fidelity mannikin used in the laboratory did not allow the establishment of relational reciprocity because she knew it was not a “real person” (i.e., a mannikin does not have feelings and cannot reciprocate authentically with students), limiting her commitment to learning humanistic caring. Therefore, this participant recommended using standardized patients (portrayed by actors and not students) in simulated sessions targeting communication skills development, as highlighted in this verbatim:

Someone who is a professional, as an actor […] and you don’t have a choice but to interact [with them], you know, you cannot laugh and fool around with them, you have to do what you are supposed to do […] at least have this relationship [with them], because with a mannikin, for me, it did not work out so well, nor with students, because after two minutes, you do not even talk about this [the simulation], you just move on to something else, that is my impression. (Jessica, a third-year student)

As for the clinical settings, all participants suggested some form of individual or group reflective practice activities. Among the conditions deemed optimal, participants acknowledged that these reflective practices could be accredited as continuing education activities held during the lunch time to maximize nurses’ participation. The participants provided several examples of content for these activities: thinking about strategies that would make nursing care more humane; discussing about the positive impacts of humanization of care; sharing experiences where humanization of care has happened. It seems that the participants specifically wanted to awaken a desire to humanize care among nurses:

You know, “small” reflective practice activities, this can raise awareness [about humanistic caring] in some of them. I think it can help nurses to rethink their practice, maybe I did not take enough time with this patient, maybe I did not put them at the heart of my care […] It could be a group activity, I mean group reflections […] starting from someone's experience […] It could be accredited teaching sessions. (Emeley, a newly graduated nurse)

Educators’ approach With students

In the second theme, the three groups of students as well as an accomplished nurse (n = 6) wished that educators changed their approach with students. For instance, they suggested to improve the training of nurse preceptors so that they were better prepared to support students’ learning through a humane relationship. If improving the training was not possible, participants stated that schools of nursing could be more rigorous in their recruitment of nurse preceptors, for instance paying attention to their vision about and interests in preceptorship. The following participant advised adjusting nurse preceptors’ preparation because she perceived a contradiction between the message vehiculated by her school of nursing and the one of her nurse preceptor:

To make them [nurse preceptors] understand [that humanistic caring is important]. This is based on my situation because when I spent a lot of time in the room [with a patient] and when I came back, she [nurse preceptor] was not very happy. Maybe tell preceptors to encourage us a little more to see our patients? That way we don't feel that it's contradictory to what the university teaches us. (Laurence, a first-year student)

Other participants who encountered other types of educators (professors, lecturers, or tutors) that they perceived as having dehumanizing teaching practices urged educational institutions to strengthen the embodiment of humanism in their relationships with students. Again, participants underscored the lack of congruence between their perceptions of their educators’ approach (i.e., dehumanizing) and what these educators were teaching them (i.e., humanistic caring):

I would appreciate if all educators were caring […] We have to find a way that they all embody it because it is not very inspiring when you have teachers who are not [humanistic or caring]. It is as if it did not match in an institution where the approach is caring. I would like to [feel] caring all around me. (Yunan, a second-year student)

Considerations in teaching humanistic caring

In the third theme, participants (n = 10) suggested to 1) raise students’ and nurses’ awareness about the importance of humanization of care, 2) give concrete examples, in the education program, of nurses humanizing care, and 3) take into account the reality of clinical practice while teaching humanization of care. For students and nurses, it was recommended to expose evidence in courses (or clinical settings) about the beneficial effects resulting from humanization of care. Another recommendation was to make sure that humanistic caring was sufficiently assessed in assignments and examinations throughout the education program. Participants felt that this would give students the impression that humanistic caring was “important” to their future practice as nurses, as put forth in the following passage:

[…] But to increase the weighting of the humanistic caring competency in the assessments, this could be helpful to raise students’ awareness […] I think it will also be helpful in cases where nurse preceptors believe that there is no time to humanize care, at least we can tell them that it is part of our evaluation. (Dencia, a first-year student)

Students also suggested emphasizing and encouraging nurses when they humanized care as a means of countering the devaluation of humanization of care that they had witnessed in their internships. Some participants felt that, in order to sustain humanistic caring, humanization of care should be recognized and highlighted. Furthermore, few participants felt that humanistic caring was rather “conceptual” and they encountered issues in translating it into humanization of care. For this reason, they believed it would be valuable for students to provide them with concrete examples of nurses’ “humanistic verbatim” and “humanistic behaviors.”

Several participants also had a growing understanding of the reality of modern clinical practice and how hard it was for them to embody humanistic caring in these settings. Indeed, two participants recommended considering this reality while teaching humanistic caring with the purpose of softening the gap between the theory taught at university and what was practiced in clinical settings, as highlighted in the next excerpt:

I think it would be to make it more real […] Another thing would be, not necessarily to crush down people's optimism, but to remember that in hospital settings, well yes, you will be struggling and in a hurry […] To be more realistic and say well yes, the nurse-patient ratio does not make sense. (Sandrine, a second-year student)

Work overload

In the fourth theme, reducing the work overload was the most mentioned recommendation targeting the clinical settings. All groups of participants (n = 16) alluded to the work overload as a major barrier to humanistic caring, but the recommendations came primarily from second- and third-year students (n = 8). One third-year student highlighted that nurse-patient assignments were mostly revolving around the “physical” dimension of nursing care and suggested taking into account the “relational” dimension when assigning patients:

But I think that we must recognize beyond the physical needs of patients, their psychological needs. I think it's difficult to imagine what the workload will be when assigning patients to nurses, precisely because we assign a number of patients based on their physical needs. Okay yes, maybe this patient just needs “one” dressing change and has no medication to take, but maybe he needs more on the psychological side. (Gina, a third-year student)

Moreover, experienced and accomplished nurses were more aware of the political challenges that arose with the idea of changing the workload in nursing, as if there was a notion of “impossibility” in tackling this everlasting issue. In addition, the following accomplished nurse suggested reducing the work overload, but warned that not all nurses would use the “extra time” for “humanistic caring purposes”:

You know, nurses, they work very hard, but often they are a little disorganized because there are so many things happening at the same time, we really push them to their limits in terms of nurse-patient assignment and “things to do” during a shift. The miracle recipe would be “one nurse per patient,” but that will not happen. But then again, not all nurses would take this time to talk to patients. There are many who would rush to get their “things done” and then be seated at the nursing station. So, I am not sure that this is the solution either. (Marc-André, an accomplished nurse)

Volunteerism and externship

In the fifth theme, few participants (n  =  2) suggested contrastive recommendations, such as 1) incorporating volunteering experiences as part of the curriculum, 2) considering volunteering experiences upon admission to nursing, 3) encouraging nursing students to work as orderlies, or 4) making the nursing externship mandatory. According to a participant, adding volunteering experiences in the education program would evoke students’ interest in focusing on the relational dimension of nursing instead of prioritizing technical procedures:

Mandatory volunteering, or maybe as part of a course […] and to be kind of “forced” to choose a population, to help people, not in a “nursing education context”. You know, to teach kids with learning challenges, to participate in community outreach, to visit people living with homelessness in the streets and just give them dressings [for their wounds]. These volunteering experiences should focus on who we are as an individual vis-à-vis the other. Because our practice as a volunteer is not assessed like it is the case in our internships, we are free to be ourselves. In our internships, there is always someone monitoring us, it is stressful, we do not want to make a medication error. (Felicia, a second-year student)

Another participant saw fit to consider professional experiences in the public sector during the admission process instead of relying solely on the cumulative average. This participant believed that this would signal that the schools of nursing expect its future nurses to be humanistic caring practitioners. For another participant, making the nursing externship mandatory and strongly encouraging students to work as orderlies could increase the chances of interacting with patients, hence, to practice communication skills, as emphasized in the following excerpt:

I think that working as an orderly really taught me a lot because if a patient calls, you have to answer and have no choice but to enter the room […] That way, you are able to intervene, and you feel more at ease and, over time, it gets better […] Could we make the externship mandatory? I think that this would help students feel more comfortable working with patients, because you know, when you start your career, you might feel a little insecure (Marc-André, an accomplished nurse).

Discussion

This study described French-Canadian nursing students’ and nurses’ recommendations aimed at improving the development of humanistic caring as a core competency. Even though the interviewees were invited to share their inputs for both educational and clinical settings, they significantly had more recommendations for the education program. This finding was unexpected because other results from the same study underscored that the development of humanistic caring was considerably circumscribed by experiences lived through their internships or clinical practice (Létourneau, Goudreau, et al., 2020; Létourneau et al., 2021a). To explain this difference, it is possible that students and nurses felt it was more “realistic” to change aspects of the undergraduate program rather than suggesting adjustments for diverse clinical environments. It also appears reasonable to assert that the participants did not think of pedagogical strategies for nurses as much as they did for students because the continuing education policy had been formally implemented by the nursing regulatory body only three years prior to data collection (Ouellet et al., 2011), hence not necessarily being part of the respondents’ professional culture yet.

Another striking finding regarding the pedagogical strategies targeting nurses was the preponderance of various reflective activities. Although the participants only mentioned a handful of educational recommendations for nurses, it almost seemed as if the reflective dimension was indispensable to foster humanistic caring in the clinical settings. The interviewees deemed these activities appropriate because they perceived that nurses did not need more information about “what” humanization of care entailed, but it rather required re-raising their awareness about the “whys” and the “hows” of humanistic caring. In other words, participants alluded to nurses “forgetting” the importance and the added value of humanistic caring for their patients, hence the reason why evoking their desire to humanize care through reflective activities. Based on the participants’ perceptions, such reflection appears more appropriate to seasoned nurses rather than newly graduates because the lasts are less likely to have “forgotten” the significance of humanization of care. The use of reflection in nursing professional development (or continuing education) has been assessed in several studies (Goudreau et al., 2015; Jones et al., 2019; Miraglia & Asselin, 2015; Morony et al., 2018), however, not specifically intended to foster humanistic caring. In Miraglia and Asselin’s (2015) integrative review, only one study out of 25 had reported positive impacts of reflective strategies on nurses’ empathetic response, not to mention that samples in these included publications were rarely midcareer nurses. Otherwise, an ethnographic study found out that patients’ narratives were perceived by nursing, medical, and managerial staff as impactful for stimulating reflection and potentially becoming more empathetic (Jones et al., 2019). Although these narratives were not intended to develop staff's empathy, they incidentally triggered health care providers’ reflection which ultimately led to changing their approach with their patients. Perhaps it would be valuable to integrate patients’ narratives as a triggering part of a formal reflective activity in the clinical settings with nurses, for instance the activity proposed and studied by Goudreau et al. (2015).

Furthermore, the findings of the current study underscored the importance of realism in high-fidelity simulations. Although several mannikins used in nursing education are highly sophisticated, the results suggest that students are not as engaged as they would be with credible standardized patients because expressing humanistic caring to a “plastic” dummy may feel peculiar. There is an ongoing interest in nursing education about high-fidelity simulations and few studies concluded that mannikins could improve students’ empathy (Haley et al., 2017; Levett-Jones et al., 2019) and their communication in mental health settings (Kunst et al., 2016). A pilot preliminary comparative study (Coffey et al., 2016) analyzed healthcare providers’ interactions in a simulation running two different scenarios twice, once with a high-fidelity mannikin and a second time with a simulated patient, and the research team observed that the participants had more verbal interactions with the simulated patients than with the mannikins. In addition, their utterances and behaviors seemed more authentic to what could be expected or observed from healthcare providers with “real” patients. Thus, it seems that this finding is consonant with the above-mentioned perceptions gathered in the present study.

Lightening the work overload was, unsurprisingly, a recommendation voiced by the majority of the respondents. Indeed, it is not the first time that work overload is pointed at as a strong barrier to humanization of care (Beltrán-Salazar, 2014; Busch et al., 2019; Calegari et al., 2015; Chen et al., 2017; Christiansen et al., 2015; de Carli et al., 2018; Guillaumie et al., 2020; Hunter et al., 2018; Nijboer & van der Cingel, 2019; Reis et al., 2016; Roch et al., 2014; Tehraninesha et al., 2019). What the present study may add to the existing literature regarding this recommendation is the development of a “cynical attitude” cooccurring with the acquisition of clinical experience; and the perception that not all nurses would necessarily reinvest the time generated by a lighter workload in humanization of care. The nature of the cynicism that stood out in the present study appears different than the ones reported in the literature. Among previous publications, healthcare practitioners’ cynicism was described as a consequence of various inhibiting factors (i.e., work overload) in the working environments (Sinclair et al., 2016) or emerged out of a belief that the employer did not care about its employees (Mantler et al., 2015). Conversely, the cynicism in the present study seemed to relate more to the perceived possibility of lightening the work overload, a perception that was remarkable in students’ shared experiences, but appeared to fade and transform into an “unattainable” goal several years after graduation (hence the cynical attitude). This attitude is consonant with feelings of “powerlessness” and “resignment” that nurses expressed facing their struggles in humanizing care in previous studies (Cassiano et al., 2015; Guillaumie et al., 2020). The experienced and accomplished nurses in the present study understood that changing the work overload involved exerting political influences towards various stakeholders, an agenda that is usually led by unions. The political actions of these unions may have resulted in few improvements over the past decades, but nurses may feel cynical because they still perceive work overload as a fundamental issue. In the present study, it appears that interviewing both students and nurses most likely allowed the discovery of this particular transformation. On the contrary, the findings also underscored that diminishing the work overload could not guarantee humanization of care, a perception that contrasts heavily with the recommendations of several publications such as increasing ward attendant and nursing staff (Guillaumie et al., 2020), ensuring adequate working conditions (Busch et al., 2019), counting on the public for caring for their loved ones while in the hospital to reduce basic patient care workload (Chen et al., 2017) and focusing on organizational factors such as time constraints, heavy workloads and staffing levels (Christiansen et al., 2015). As previous publications pointed out (Beltrán-Salazar, 2014, 2016; Guillaumie et al., 2020), task-oriented care organizations exhort nurses to accomplish care procedures and other technical tasks as quickly as possible, which may be interiorized to a point of focusing predominantly on these aspects: this is perhaps why the interviewees questioned whether or not nurses would reinvest the “extra time” in humanizing care. When taking the findings of the present study altogether, tackling the work overload may not necessarily be the best strategy because nurses potentially “forgot” the necessity of humanistic caring or they abandoned this professional ideal. If humanizing nursing care is of little significance to nurses, then it seems reasonable to posit that they might not attempt practicing nursing through a humanistic caring lens. What the findings of this study demonstrate is that in order to improve humanization of care, actions must be taken to evoke nurses’ interest in addition to reducing the work overload.

To the knowledge of the authors, the impacts of prelicensure clinical extern programs on humanistic caring (or related concepts such as empathy and compassion) have rarely been reported. Indeed, the outcomes mostly revolve around students benefits such as confidence and clinical skills (Rugs et al., 2020), interprofessional collaboration (Ruth-Sahd, 2016), professionalism, job satisfaction, and sense of belonging (Cantrell et al., 2005), transition into the professional nurse role (Cantrell & Browne, 2005) in addition to recruitment and retention (Cantrell & Browne, 2006; Friday et al., 2015; Remle et al., 2014). However, two studies (Massé, 2016; Oja, 2013) reported a development of communication skills in externs who completed their program. Although humanistic caring cannot be solely reduced to communication skills (Létourneau et al., 2021a), the findings of the present study corroborate the perception that externships may support this development. As mentioned by the participants, a humanistic and caring approach in educators was recommended and this holds true to externship experiences as well. Indeed, externs are usually paired with a nursing preceptor and completing an externship is not a requirement to licensure (Kilpatrick & Frunchak, 2006). If externships are to become mandatory the same way internships are in most education programs, attention must be paid to select (or support) inspiring role modeling preceptors that make learning possible through a humane relationship (Bengtsson & Carlson, 2015; Bonnier et al., 2013; Cara et al., 2021; Quek & Shorey, 2018). As for volunteering experiences, there is little evidence pertaining to humanistic caring. For instance, Fiore-Lopez (2015) observed that non-school related volunteering experiences were positively correlated to novice nurses’ caring behaviors, but these encouraging outcomes disappeared when volunteering was made mandatory. The author thus concluded that it would be preferable to encourage volunteerism rather than making it mandatory in the undergraduate program, a recommendation that contradicts the findings of the current study. Compared to other experiences already built into nursing education programs, volunteerism usually involves a free will and a freedom that allows the person to choose the population with whom they will get involved. This is perhaps an aspect that would allow the volunteer to focus their efforts primarily on the relational level with diverse populations (i.e., persons experiencing homelessness), which could in turn be potentially beneficial to the development of students’ humanistic caring. Service learning is one of the pedagogical strategies that could be used to encourage and evoke students’ desire to engage in volunteerism, a strategy which also demonstrated the possibility of fostering caring and compassion towards different populations (Brown & Bright, 2017; Chrisman-Khawam et al., 2017; Jarrell et al., 2014). Indeed, few authors (Brown & Schmidt, 2016; Dombrowsky et al., 2019) posited that service learning could heighten the willingness of students to volunteer in the future, an avenue that could be considered in nursing education programs.

Limitations

One of the limitations that was not already reported in three other publications (Létourneau, Goudreau, et al., 2020; Létourneau et al., 2021a, 2021b) pertains to the interpretation process of respondents’ recommendations. Participants voiced a great diversity of recommendations that were interpreted and their similarities were regrouped in the five themes presented earlier. Although the authors attempted to follow diligently the principles of Benner’s (1994) phenomenological analysis as rigorously as possible, it would be unreasonable to affirm that all of the recommendations’ subtilities could be integrated in the five aforementioned themes. The present authors are nonetheless positive that these subtilities would not change the global meaning of the themes presented in this manuscript.

Conclusion

The aim of this manuscript was to provide a description of French-Canadian nursing students’ and nurses’ recommendations that could foster the development of humanistic caring. Five salient themes emerged from the phenomenological analysis, shedding light on areas of improvement that could potentially cultivate humanistic caring in nursing students and nurses. Majority of the recommendations targeted changes in the education program in terms of pedagogical strategies, educators’ approach, ways of teaching humanistic caring, and additions of volunteerism and externship experiences. One of the implications for nursing education concern the non-human nature of high-fidelity mannikins in regard to humanistic caring and participants preferring and recommending standardized patients instead. In the minds of the respondents, the mannikins’ nature, despite being able to speak and mimic certain human features, limit considerably the establishment of a genuine and reciprocal relationship. It is most likely an aspect that nurse educators must bear in mind when using high-fidelity simulations to specifically develop humanistic caring. Another implication for nursing education is that it could be relevant to use service learning in the program to increase students’ willingness in volunteering, instead of making the last mandatory.

The most salient suggestion being applicable to the clinical settings corresponds to the reduction of work overload, a finding that was highlighted in a considerable number of studies pertaining to humanistic caring (Beltrán-Salazar, 2014; Busch et al., 2019; Calegari et al., 2015; Chen et al., 2017; Christiansen et al., 2015; de Carli et al., 2018; Guillaumie et al., 2020; Hunter et al., 2018; Nijboer & van der Cingel, 2019; Reis et al., 2016; Roch et al., 2014; Tehraninesha et al., 2019). In this study, second- and third-year students voiced their concerns about the work overload and seasoned nurses (experienced and accomplished) were not convinced that this recommendation could be realistically put into action. Other results of the same study (Létourneau et al., 2021a) underscored that students practice humanistic caring mostly through lengthy nurse-patient conversations and that it takes several years after graduation before being able to integrate a humanistic caring approach in “all” nursing care (not only pertaining to the nurse-patient communication). This is perhaps why the recommendation came primarily from students rather than nurses, because the lasts conceptualize humanistic caring as an approach (i.e., “being”) that tints all care, rather than being solely a “thing” (i.e., “doing”) similar to a technical procedure. Although communication can convey humanism and caring to patients, it is “one” of the many possible roads leading to humanization of care. Based on the findings of this study, it appears relevant to provide students concrete and realistic exemplars of what humanistic caring can be in contemporary nursing practice. There is little doubt that making the workload more reasonable would support nurses in being humanistic and caring practitioners, but the results also suggested that it could be appropriate to rekindle their desire to humanize care through reflective practice activities.