The omission of some patterns of knowing in clinical care: A qualitative study.

BACKGROUND: Providing holistic and humanistic care to patients requires a variety of factors. A care solely based on objective knowledge might be unsafe and of low quality. Using the patterns of knowing in an integrated manner and relative to the context of caring is one of the necessities for proving a holistic and efficient nursing care. This study aimed to explore the role of patterns of knowing in the formation of uncaring behaviors.
MATERIALS AND METHODS: The researchers used a qualitative research design for this study. Participants included 19 clinical nurses who attended semi-structured and in-depth interviews. In addition, theoretical and purposeful sampling methods were used in this research. Observation of caring processes in different hospital wards was another method used for collecting data. The data analysis was carried out according to conventional content analysis technique.
RESULTS: The study findings revealed five categories for the theme of "omission of some patterns of knowing" including omission of scientific principles, omission of therapeutic relationship, omission of ethics, omission of social justice, and omission of flexibility.
CONCLUSIONS: The omission of some patterns of knowing creates an ugly image of nursing and a negative outcome of caring as well. Copyright:

Introduction

Caring is considered the essence and central piece of nursing[1] and holistic care requires ethics, emotions, sympathy, empathy, perseverance, reason, wisdom, and knowledge.[2] All nurses use a sort of implicit or explicit theory and thought in order to provide health care.[3] Given the importance of the knowledge required for nursing performance, Carper[4] proposed fundamental patterns of knowing, including empiric knowledge, personal knowledge, ethical knowledge, and aesthetic knowledge.[5] Its work developed and became more inclusive by encompassing emancipatory patterns by Chinn and Kramer.[6] The patterns of knowing pointed out that, each one of the patterns of knowing is considered to be an essential but not complete answer to nursing questions and problems.[5] If the patterns of knowing are used in an isolated manner, we will have a fragmented practice that affects all nursing activities.[7] Knowledge and knowing, while having some similarities, are considered different concepts. Knowing refers to the ways of receiving and understanding one's self and the world around us, but knowledge is something that is shareable with others and transmittable to others in various forms such as practical principles and theories.[6] Caring as centerpiece of nursing is a relationship between nurse and patient accompanied with love, empathy and forgiveness.[8] Nurses' action is called “uncaring” when they do not perceive the patient as a holistic existence. Uncaring is a great obstacle for a nurse for understanding a patient.[9] Inconsideration is a sign of lack of interest in patient, and appears in the form of insensitivity, coldness, and lack of humanity.[10] Uncaring has also be featured with depriving, inadequate care, and ignoring.[11]

The patient's experience is one of the pillars for assessing the quality of care.[12] The quality of nursing care from the patients' viewpoint depends on nurses' communication skills, informing the patient, providing timely support, and extending the support beyond the routine.[13] However, there is evidence that shows a moderate level of patients' satisfaction with quality of nursing care[14]; findings of an observational study indicated that patients' satisfaction improved with the employment of Registered Nurses (RN) staffing.[15] Nursing care, if only based on objective knowledge, might be unsafe, of low quality, and disease-oriented rather than be patient-oriented.[16] The majority of nursing staff in Iran hold a bachelor's degree[17] and have adequate knowledge, however, they fail to provide preventive and desirable care.[18] In fact, providing quality care is not a linear process and based on a protocol or skill.[19] Therefore, having a university degree, long work experience, being an RN, low workload, and working in well-equipped hospitals do not guarantee quality of nursing care and on the contrary, there are many instances of neglecting nursing care protocols and nursing errors.[20]

Different methods of knowing help nurses to meet patients' needs for interacting with their environment.[21] Nurses use different methods of knowing to provide care to terminally ill patients. According to the participants of a phenomenological study, knowing included knowledge of different diseases, knowing through different nursing experiences, and knowing about patients and their family.[22] Another study indicated that empirical knowledge fails to bring health to patients, if not combined with other aspects of knowledge. Thereby, a scientific nursing approach is required to step towards fulfilling health needs of human and beyond the limits of biology.[23] A study indicated that the patterns of knowing in emergency wards could be a tool to analyze critical and complicated conditions. The patterns of knowing help nurses to provide high-quality care services and enrich the relationship between the nurse and patient.[16] This study aimed to explore the role of patterns of knowing in the formation of uncaring behaviors.

Materials and Methods

The study is a part of a bigger study titled “Process of using patterns of Knowing by nurses in clinical practice” which was carried out from June 2018 to January 2020 in six educational and private hospitals in Tehran. As caring is a reflection of patterns of knowing[24] and encompasses nurse-patient interactions[25] and patterns of knowing depend on personal experiences,[26] this study used a qualitative approach which is rooted in participants' experiences[27] and the purpose of this study is to find behavioral patterns in a specific group.[28] The study started using purposeful sampling and continued with theoretical sampling[28] until data saturation was achieved.[29] Inclusion criteria were as follows: being clinical nurse, holding at least graduate degree, and desire to participate. Eventually, nineteen semi-structured, face-to-face, and in-depth interviews were carried out with 19 nurses in their desired places and time. Approximately, two-third of the participants were working in intensive wards. The reason for this selection was the fact that the nurses who work in the intensive care wards use more scientific principles and therefore were considered to be the key informants for the present study. The first question was as follows: “how do you use your knowledge and thought in providing care to patients?” All interviews were voice-recorded with the permission of the participants. An eight-session observation was conducted through “observer as participant”[30] in medical, urology, burn, emergency, post-Cardiac Care Unit (post-CCU) and Intensive Care Unit (ICU) wards. The researcher took part in answering patients' questions and educating them, obtaining vital signs and medication. Some open questions were asked to complete the observation.[31] Data analysis was carried out according to conventional content analysis manually using a developing scheme for codes in an organized and comprehensive framework, and subcategories and categories were emerged to themes,[3233] [Table 1]. The researcher used several strategies to ensure that the findings are trustworthy.[34] Auditing strategy by the authors,[30] field notes and observations, member checking, supplementary interviews, saving the interviews, notes, and memos, thick description of the context and process of study, reflective thinking, and considering the researcher's bias all were saved to improve credibility, dependability, confirmability, transferability, and authenticity of the findings.[29] Six short additional interviews were conducted via network communications or phone calls. Data collection and analysis were simultaneously done during 20 months for long observation and floating in the data. Two nursing faculty members who were experienced in qualitative studies reviewed the findings, transcriptions of interviews, observations, and coding to obtain credibility via peer checking.

Table 1

Examples of coding and extraction of themes

Qoutation/Observation	Open codes	Sub-categories	Categories	Themes
Participant No. 6: “We don’t have enough time; we don’t do many tasks while we know it should be done. For example, we do not wash hands while we know it is important.”	Neglect of hand washing with excuse of work overload	Negligence in caring	Omission of scientific principles	Removing some patterns of knowing
Observation in the emergency ward: “The novice nurse, who was checking her patients’ blood sugar, she was not cleaning the blood drop from their fingers.”	Neglecting the cleaning of blood drop after checking blood sugar
Participant No. 8: “My colleague injected one gram of a medicine directed and at once, while it should be injected in an hour time period. I cannot describe what the patient went through afterwards…. it was very odd”	Injecting an ampule at once instead of slowly infusion	Error in caring
Observation in the internal ward: “The nurse who was giving medicine put the ready-to-use syringes on the patient’s table without any sterile cover.“	Leaving a ready-to-use syringe without sterile cover

Ethical considerations

This study was approved by the Research Ethics Committee of Iran University of Medical Sciences under the code: IR.IUMS.FMD.REC.1396All. The participants signed a written informed consent letter. The principles of data unanimity and confidentiality were observed and the participants were informed that they could leave the study at any stage.

Results

Finally, 19 Nurses with different characteristics were interviewed [Table 2]. Data analysis indicated that nurses, sometimes affected by contextual conditions such as discriminatory beliefs and undesirable individual characteristics, eliminate one or more patterns of knowing and always aesthetic pattern, most of ethical pattern and to a lesser degree, empirical and individual patterns. The result of such care is to create an ugly image of the nursing profession and this ugliness will be evident to all. Five categories of omission of some patterns of knowing include: (A) Omission of scientific principles, (B) Omission of therapeutic relationship, (C) Omission of social justice, (D) Omission of ethics, and (E) Omission of flexibility, in a hierarchical pattern [Table 3 and Figure 1].

Table 2

Participants’ demographics (n=19)

No	Gender	Education	Age	Work Experience	Current Ward	Hospital Type
1	Female	MSN*	41	16 y	CCU**	Public
2	Female	BSN***	37	10 y	Burn	Public
3	Female	MSN	44	20 y	CCU	Public
4	Female	MSN	37	11 y	CCU	Public
5	Female	BSN	35	11 y	Pediatric Cardiology	Public
6	Male	BSN	30	8 y	Urology	Public
7	Female	BSN	34	11 y	Urology	Public
8	Male	PhD****	34	10 y	Kidney Transplant	Public
9	Male	BSN	34	8 y	Emergency	Public
10	Female	BSN	36	10 y	Open Heart ICU *****	Public
11	Female	BSN	54	28 y	Cardiology	Private
12	Female	BSN	46	17 y	Endoscopy	Private
13	Female	BSN	39	16 y	Internal-Surgical	Public
14	Male	BSN	35	12 y	Urology	Public
15	Male	BSN	34	10 y	CCU	Public
16	Male	PhD	30	6 y	Internal ICU	Private
17	Female	MSN	45	22 y	CCU	Public
18	Male	BSN	27	10 m	Internal	Public
19	Female	BSN	23	6 m	CCU	Public

*Master of Science in Nursing, **Cardiac Care Unit, ***Bachelor of Science in Nursing, ****Philosophy Degree, *****Intensive Care Unit

Table 3

Categories and sub-categories of “removing some of the patterns of knowing”

Sub- Categories	Categories	Theme
Negligence in caring	Omission of scientific principles	Removing some patterns of knowing
Error in caring
Referring patients to others	Omission of therapeutic relationship
Caring reluctantly and avoiding
Mechanical care
Discrimination based on social level of patient	Omission of social justice
Discrimination based on patient’s feedback
Discrimination based on others’ commendation
Stigmatization	Omission of ethics
Aggressiveness
Mimicking
Backbite
Sleep induction
Concealing
Pretending
ignoring patient’s right of awareness
Retaliate
Disregarding other ethical principles
Inflexibility in dealing with patient values	Omission of flexibility
Inflexibility in routine enforcement
Inflexibility in communicating with patient

Figure 1

Diagram for omission of patterns of knowing

Omission of scientific principles: The findings of the study indicated that the omission of scientific principles or empiric knowledge leads to unscientific care, including negligence in caring and error in caring. In the below quotations, two instances of omission of scientific principles are given: “We don't have enough time; we don't do many tasks while we know it should be done. For example, we do not wash hands while we know it is important” (Participant 6).

“My colleague injected one gram of a medicine directed and at once, while it should be injected in an hour time period. I cannot describe what the patient went through afterwards…. it was very odd” (Participant 8).

Omission of therapeutic connection: The findings of the study indicated that the omission of therapeutic relationship or refusal to use therapeutic use of self is instantiated with providing care without positive and therapeutic connections. There are three sub-categories in this category including referring patients to others, caring reluctantly and avoiding, and mechanical care. These field notes and quotations are instances of referring patients, avoiding and mechanical care: “A patient companion comes to the nurse and asks: would you please connect the serum bag of my patients?” The nurse points to a nursing assistant by her head (i.e., asks him to do the job). Similarly, the other nurses asked him to do some other things that are not considered part of his responsibility. (Observation in urology ward).

Field Note: “It appears that this nursing assistant is the first person that comes to everyone's mind in this ward to carry out the tasks.”

“There was a patient with positive Tuberculosis (TB) and in isolation room. I noticed that his Blood Sugar (BS) was not checked and nobody has attended him throughout a whole work shift. The poor patient was isolated the whole time” (Participant 7).

“New patient entered the ward. The nurse grabs hospitalization file hastily and without any eye contact: “Do you take aspirin, Plavix, or warfarin?” The old man said: “No” The nurse asked: “Do you have any other problem?” The old man said: “No” The patient wanted to say something: “Madam….”. but the nurse did not let him finish and continued and said:” Purchase a patient's suit and go to room No. 2. “ (Observation in urology ward).

Omission of social justice: The findings indicated that the omission of social justice is a kind of omission of emancipatory pattern. There are three sub-categories in this category, namely, discrimination based on social level of patient, patient's feedback and others' commendation. The following statements are instances of discrimination: “Providing care to such a patient with high socioeconomic class is not easy even if the task is the easiest, I try to keep everything as per the principles and clean” (Participant 5).

“A patient who keeps insulting us and is always in a bad and uncooperative mood surely gets less service than a patient who behaves politely and respects the nurse's works. Maybe the first patient receives the standard services, but the second one surely receives more and better caring” (Participant 13).

“A patient was one of the relatives of my head nurse; therefore, we permitted his companion to enter the ward, although it was contrary to our ward routine” (Participant 19).

Omission of ethics: The data analysis of the study confirmed that the omission of ethics would also occur along with other omission of the patterns of knowing. There are ten sub-categories in this category including stigmatization, aggressiveness, mimicking, backbiting, sleep induction, concealing, pretending, ignoring the patient's right to be aware, and retaliating and disregarding other ethical principles. The following quotations are examples of these sub-categories: “When a patient is very old, we would say he/she is a real mess. We should somehow get rid of him/ her….” (Participant 14).

“A patient's companion said to the nurse: please disconnect the serum. The nurse disconnected the serum, threw it into the trash bin, while shouting loudly and angrily: is it over? Do you have anything else to say?” (Participant 9).

“The patient said: “Can you take this angiocatheter off my hand?” Male nurse answered: “No, get back to you bed.” When the patient left, the nurse said: “He's crazy (with laughter).”

“Nurses in the rest room were speaking: “The patient of bed No. 7 is crazy; the patient of bed No. 8 is mentally retarded and funny. I don't know what to do with them… (Colleagues confirmed and laughed).” (Observation in surgical ward).

“There was an old lady who wouldn't stop nagging. My colleague administered a cocktail of midazolam and diazepam to her, and as a result, the poor woman was asleep for two days (laughter)” (Participant 6).

“For many times, I've seen that a wrong patient has been prepared for a procedure and the colleagues concealed the fact” (Participant 15).

“For many times, I saw that my colleague did not check the patient's Vital Signs and only filled out the checklist; they might only change the date on a wound dressing without renewing it” (Participant 17).

“I never tell blood pressure numbers to patients, because they do not have enough knowledge about medical events” (Participant 13).

“The paranoid patient was aggressive and tried to hit my colleague. My colleague kicked his leg and told him: do you want to beat me? We injected him a sedative ampule and he fell asleep” (Participant 14).

“In CCU ward, during the night, nurses and physicians would gather around at the station to chat, tell jokes, and laugh. My colleagues don't consider that patients are more sensitive to noises during the night….” (Participant 4).

Omission of flexibility: The omission of flexibility will also occur along with other omissions of patterns of knowing. There are three sub-categories in this category, including inflexibility in dealing with patient values, inflexibility in law enforcement and inflexibility in communication with patients. Three samples of inflexibility are as follows: “We had a patient who was going to have angiography. She was praying before the procedure. My colleague told her: “why do you pray? It cannot help you. The patient became sad and lowered her head.”

The nurse continued: “For many times, some families wanted to visit their patients but I didn't let them enter the ward, because they were likely to ask us many questions and waste our time” (Participant 6).

“Patient No. 2, an old man who underwent sugary yesterday, called. All the four nurses were sitting at the nursing station but none of them answered him. The old man called repeatedly. Finally, staff nurse told: oops! Again, bed no. two! made me crazy! And then, he ordered the nursing students to visit him.” (Observation in internal ward).

Discussion

This study aimed to explore the role of patterns of knowing in the formation of uncaring behaviors. The first sub-category related to the omission of some patterns of knowing was the omission of scientific principles. According to the findings, omission of scientific principles appeared as negligence or error. Negligence in caring is related to misunderstanding the patient or feeling no sympathy and it appears as neglecting patients physically or emotionally.[35] Therefore, omission of scientific principles from clinical care is rooted in the omission of empirical as well as ethical knowledge. Missed nursing care, which is an error or omission of a care, for example, educating the patient,[36] is a serious problem in hospitals all around the world, which leads to a lower-quality care and dissatisfaction in patients.[37]

The findings of the study revealed the omission of therapeutic relationship accompanied by omission of personal knowing. Although the findings of a meta-ethnography indicated that a suitable relationship between nurse and patient improves health and recovery and most importantly, it results in emotional, mental, and social wellness in the patient.[38] According to Carper theory,[5] personal pattern of knowing develops self-awareness and enables nurses to be vigilant to their biases that might hinder the connection between the nurse's real self and the patient and to having an empathetic perception of what happens as well.[39] Watson's theory[8] emphasizes caring as a therapeutic and human-to-human relationship where the nurse influences, affects, and is affected by another person.[40] Therapeutic relationships help the nurse to grasp a better understanding of patient's condition and to improve care and life quality for patients.[41] According to the findings of another study,[42] more than 85% of nurses are not capable of building efficient interpersonal relationships.

According to the findings, omission of social justice is rooted in the omission of emancipatory pattern. That is, nurses might discriminate between patients with low and high socioeconomic status. The finding of another study also revealed that patients with lower socioeconomic, cultural or education status might be subject to care discrimination.[43] Another study found that patients who experience injustice had a higher significant level of stress and perceived pain as compared to others.[44] Social justice is one of the competencies in healthcare workers that is essential for nursing curricula.[45] The findings showed that nurses discriminate between their patients based on patients' social status. Along with this finding, the results of another study showed that women patients with lower socioeconomic status and immigrants were more discriminated than the others.[46]

Nowadays, scientific and technological developments highlight the need to pay more attention to ethics in nursing care.[47] One of the main categories of the study was the omission of ethics from clinical care. A study[48] indicated some of personal characteristics such as believing in God as a supervisor of man's actions, enable nurses to stand the work and clinical care pressure. However, due to the lack of humanistic and ethical beliefs, some nurses blame bad work condition, lack of motivation, and fatigue for their mistakes and poor performance. Carper[4] argues that ethical pattern indicates the position of ethical codes which dictates what decision is ethical or unethical.[49] In recent decades, science and technology might have negatively affected nursing care and the relationship between nurse and patient[49]. Empathy, sympathy, respecting patients as human beings, along with technical competencies all affect the quality of clinical care. On the contrary, treating patients with indifference and humiliating them are instances of low-quality care,[43] which is in contrast with holistic care. Holistic care encompasses all the aspects of patients, their effects on the treatment process, happiness, and patient's satisfaction.[50] Nurses, who only emphasize body, support a mechanical and technocratic caring. Holistic care is more than a humanistic care and emphasizes integrity of body, brain, and soul as a unit and an energy field.[51] Nurses who care for patients without ethical consideration, do not listen to patients, neglect patients' existential wholeness, and pay no attention to patients' pain, wound care or hygiene.[52] According to the findings of the study, omission of ethics represents nurses' negligence of patients' dignity, existential wholeness, beliefs, emotions, attitudes, and culture.

Omission of flexibility is another main categories of the study. Flexibility is not a pattern of knowing. Rather, it is a core variable and makes interrelationship between the patterns of knowing; Therefore in the situations of the omission of some patterns of knowing, nurses do not apply flexibility and are rigid when dealing with patients' values, law enforcement and communicating with patients, although findings of a study showed flexibility in meeting time leads to satisfaction of patients and their families in ICU.[53]

Aesthetic pattern or art is indeed the essential nature of nursing that creates artistic moments. Such moments are the outcomes of an actual and creative connection between nurses and patients and everything that happens in such a situation is valuable.[54] Therefore omission of each of the discussed patterns is along with omission of aesthetic pattern and results in the creation of an ugly face for nursing. As to limitations, it is notable that the abstract nature of the subject made it hard for nurses to perceive some of the concepts. In such cases, further detailed explanations are provided to clarify the concepts concealed in questions.

Conclusion

The aim of this study was to explore the role of patterns of knowing in the formation of uncaring behaviors. The findings indicated that nurses might eliminate one or more patterns of knowing under the effect of their discriminative beliefs and undesirable characteristics. In such situations, the nurse has no flexibility and eliminates the aesthetic pattern along with the other patterns of knowing. Removing scientific principles, therapeutic use of self, ethical principles, and flexibility as the core variables of this process will lead to uncaring behaviors such as caring errors, avoidance, discrimination, aggressiveness, and inflexibility. Uncaring behaviors are quite visible for others such as patients and colleagues. The findings serve as a theoretical ground for future studies in order to develop questionnaires for measuring the omission of some patterns of knowing.

Financial support and sponsorship

Iran University of Medical Sciences

Conflicts of interest

Nothing to declare.