Looking for someone who can have this assignment done as soon as possible.

Municipal Night Nurses’ Experience of the Meaning

of Caring Christine Gustafsson, Margareta Asp and Ingegerd Fagerberg

Key words: care of older people; caring in nursing; gerontological care; night nursing; phenomenological hermeneutics

The aim of this study was to elucidate municipal night registered nurses’ (RNs) experi- ences of the meaning of caring in nursing. The research context involved all night duty RNs working in municipal care of older people in a medium-sized municipality located in central Sweden. The meaning of caring in nursing was experienced as: caring for by advocacy, superior responsibility in caring, and consultative nursing service. The muni- cipal night RNs’ experience of caring is interpreted as meanings in paradoxes: ‘being close at distance’, the condition of ‘being responsible with insignificant control’, and ‘being interdependently independent’. The RNs’ experience of the meaning of caring involves focusing on the care recipient by advocating their perspectives. The meaning of caring in this context is an endeavour to grasp an overall caring responsibility by responding to vocational and personal demands regarding the issue of being a RN, in guaranteeing ethical, qualitative and competent care for older people.

Introduction Older peoples’ need for care is expected to increase in line with changes in life ex- pectancy and variation in the patterns of diseases over the next 50 years.1–3 There is an increasing prevalence of age-related morbidity and disability in the European popu- lation.4 Older people experiencing multiple functional decline combined with a need for medical care require a mix of services from multiple providers.5 Key contributors to Swedish municipal care are night nurses who provide nursing care and medical ser- vices during the night to large groups of older people in community facilities. Nursing has changed significantly in recent decades, which will continue in the future, with nurses taking on different roles, especially in the long-term care of older people.6 In many western countries care for older people is being transformed from a health care model towards a social care model.7 This study concerns municipal night nurses’ experiences of the meaning of caring in nursing.

Address for correspondence: Christine Gustafsson, Mälardalen University, School of Health Care and Social Welfare, Mälardalen University Eskilstuna, PO Box 325, SE-631 05 Eskilstuna, Sweden. Tel: +46 16 15 3469; Fax: +46 16 15 3740; E-mail: [email protected]

Nursing Ethics 2009 16 (5) © The Author(s), 2009. 10.1177/0969733009106652 Reprints and permissions: http://www.sagepub.co.uk/journalsPermissions.nav

600 C Gustafsson et al.

Nursing Ethics 2009 16 (5)

Caring in nursing The concept of ‘caring in nursing’8 encompasses the caring dimension in municipal nursing practice during the night. Caring is accepted as a central concept in nursing practice.9–11 Van Hooft8 conceptualizes caring in nursing as a virtue. This includes the dynamics between a ‘caring perspective’ and a ‘justice perspective’ that relate to the ethical life of nursing. The caring perspective is an emotional concept that stresses feel- ings of concern and relationships between nurses and care recipients that inspire and motivate caring practice. The justice perspective focuses on the effective performance of professional nursing practice, whether or not motivated by feelings of sympathy or compassion. The dispute between these perspectives is accommodated in moral theory by virtue ethics.12

Care of older people from an international perspective The municipal nursing of older people in Sweden comprises care in special forms of housing, nursing homes and other community-based settings or home care.13–15 Registered nurses’ (RNs) care of older people includes characteristics of both long- term16 and palliative17 care around the clock and is defined as gerontological nursing18 and community nursing.16 RNs’ night care is different from day-time care.19 Today’s RNs’ night-time care of older people often entails administering treatments and under- taking activities also associated with day-time care.13,18 In Sweden, the role of RNs who work in the social care context appears different when compared with the hospital context.

Swedish municipal care for older people Swedish municipal care for older people is regulated by two separate laws. The Social Services Act20 governs care mangers, residential home mangers and care staff (en- rolled nurses and nurses’ aides). The Health and Medical Act21,22 regulates RNs and physicians. RNs may delegate care staff23 to carry out nursing care.21 Care staff are, by definition, on the same organizational level as RNs. This means that RNs do not have any authority regarding the provision of social care, nor are they staff leaders.24,25 In 2006, 4.7% (12 200) of staff working in the municipal care of older and disabled people were RNs.26 No data are available for exclusively night-duty RNs.

To ensure appropriate care, RNs are employed in municipal social care21 and also act as supervisors for care staff.27 These RNs have responsibility for large groups of older people, especially during the evening and at weekends,27,28 and for even larger groups during the night. Care staff provide overnight care while RNs rarely provide bedside care. Unlike night RNs caring for older people in the UK15 and the USA,29 Swedish RNs have a telephone consultation function. Every area of the municipal social care of older people is covered by day/evening duty RNs who are responsible for different caring units. These RNs call the night duty RNs to report any care recipients who will need nursing care or a visit during the night. The night duty RNs work in pairs, and for about 15 minutes they will receive telephone reports from their different areas of nursing responsibility. They then prepare summaries and a schedule for their planned visits. When an RN is required in a central residential home the two nurses normally

Municipal night nurses’ experience of the meaning of caring 601

Nursing Ethics 2009 16 (5)

go together. When a unit on the outskirts of the town requires a RN visit, they split up because they must arrive at any calling unit within 30 minutes. The RNs can have approximately 30–50 telephone consultations during one night and a total of about 15 nursing visits (two or three of these may be visits to care recipients who are at the end of life).

The RNs’ working conditions are described in terms of being on call to support and direct care staff and, on request, to arrive at a calling unit within 30 minutes. Tasks of planned advanced medical care and contact visits to persons being cared for at the end of their life are also included. For support, the RNs can contact the district physician on call. The RNs can also make referals to the hospital emergency department.

The RNs’ nursing responsibility includes all outpatients enrolled in home care and supporting care staff in assisting old people with alarms. They are also accessible for both planned advanced medical treatments and unplanned nursing needs in the muni- cipal catchment area. Two RNs have nursing responsibility for the night-time care needs of approximately 2700 people.

Rationale Little research has focused on nursing provided at night.30–32 Existing studies have mainly described RNs’ work in hospital settings32 rather than in the municipal, social care context. An expected increase in the need for RNs to care for older people in special forms of housing, nursing homes and other community-based settings or home care suggest the importance of investigating nurses’ caring at night. This is particu- larly important when there is nursing responsibility for large groups of older care reci- pients. When conceptualizing caring as ‘the ethical life of nursing’,8 questions about the meaning of caring in nursing are justified: What is caring in municipal night nursing? How do night RNs who provide nursing and medical services to large groups in the community experience caring? The aim of the present study was to elucidate municipal night RNs’ experiences of the meaning of caring in nursing.

Method Understanding the meaning of people’s lived experiences in new and different ways and explaining them in a better way may open up opportunities for people to live better lives. According to the French philosopher Paul Ricoeur,33 lived experience remains personal but its meaning can be transmitted through the interpretation of narratives. The aim of the interpretation is to reveal the meaning in a text, that is, to interpret the world that is opened in a text. Its meaning is not created by our interpretation; it is already in the world. Through the interpretation of texts we can, however, learn more about world phenomena.

A phenomenological-hermeneutic method, inspired by Ricoeur33,34 and developed by Lindseth and Norberg,35 was used for the text analysis. The aim of this method is to interpret (i.e. to elucidate and understand) the meaning of a phenomenon as it emerges from the text.34 The scientific openness of Gadamer’s philosophical hermeneutics,36 as well as Ricoeur’s33 distancing, questioning and critical approach, influences the inter- pretive process.

602 C Gustafsson et al.

Nursing Ethics 2009 16 (5)

Setting and participants The research context involved all seven night duty nurses working in the municipal care of older people in a medium-sized municipality (90 000 inhabitants) located in central Sweden. All-night RNs in this district also participated in a larger project ex- ploring municipal night nursing. The RNs were all women who were experienced in the profession, having worked for 6–35 years in various nursing contexts. At the time of the data collection for the present study, two participants withdrew owing to illness or termination of employment.

In January 2006, the participants had nursing responsibility for 21 units for older people in sheltered housing. They also had nursing responsibility for 25 special hous- ing units for disabled persons. During collection of the data (January–May 2007) the RNs reported increased nursing responsibility that included all outpatients enrolled in home care, support for care staff assisting older people with alarms, and having to be accessible for unplanned nursing needs in the municipal catchment area.

Data collection The first author (CG) conducted open, tape-recorded interviews with the participants. Follow-up questions varied between the interviewees, depending on the individual narratives.37 The interviews lasted for between 55 and 120 minutes and were conducted in privacy at the local university. The questions were chosen to cover relevant aspects of the participants’ experience of caring in nursing by asking the following opening questions: What does caring mean in municipal night nursing? How do you experience caring in your work?

Ethical considerations Permission for the study was obtained from the staff manager responsible for the RNs in the municipal organization. The study was approved by the Regional Ethics Board in Uppsala (ref. 2004-Ö-437).38 Participating RNs were guaranteed confidentiality and were offered supportive guidance, but none requested this.

The general rules for good research practice concerning honesty, openness, con- sideration of research value and impartiality were respected.39,40 More specifically, the study was also considered appropriate to satisfy the research criteria of risk–benefit assessment,40,41 importance and quality, and protection of individual participants.39,42

Interpretation process and results The process of interpretation of the transcribed interviews was guided by a phenomen- ological-hermeneutic analysis using three phases: naive reading, structural analysis and comprehensive understanding.35 Each interview transcript was read several times in order to grasp its meaning as a whole (naive understanding). A structural analysis was performed and, in a process carried out by the first and second authors, related to the naive understanding in order to elucidate the different parts of the text. Initially the text was split into meaning units defined as a piece of text of any length that expressed a meaning of caring in nursing. The meaning units were condensed and reflected upon to identify similarities, variations and differences, and then used to create subthemes.

Municipal night nurses’ experience of the meaning of caring 603

Nursing Ethics 2009 16 (5)

These subthemes were then grouped into themes by reflection and abstraction35 (Table 1). During this process of structural analysis, the naive understanding was reconsidered and revised.

Table 1 Examples from the structural analysis

Meaning unit Condensed meaning unit

Subtheme Theme

When you enter an old person’s room at a unit, you do not just rush into the room, turn on the light and speak loudly, deliver the injection and then leave. You have to be careful, knock on the door, try to speak to the person in the bed, and ask how he or she is experiencing the problem. I also always take my jacket off before I enter the room.

In caring for the care recipient the nurse is deliberately careful and aware of the care recipient’s well-being and comfort.

The nurse does not just enter a room, turn on the light, do her nursing task and then leave.

Considering care recipients’ perspective

Caring for by advocacy

You kind of try to have your eyes open, to see the person behind the disease, but also to see relatives and the care staff ... to see wider and observe more than just the task you are there for ... to see the whole situation ... it is to see relatives, the care staff ... in this case, they had not succeeded in checking the blood glucose, they did not understand the blood glucose machine ... and this was something I discussed with them afterwards ... I mean it was correct of them to give the man sugar cubes, they understood he had hypoglycemia, they were not sure, but anyway they gave him sugar, and that was good! I mean it is better to do that than to do nothing ... anyway they did handle the situation and it is about giving support and paying tribute to their actions.

It is a nursing process to be open, observant of the whole situation, to see the person behind the disease.

Not to ignore the complex situation.

To observe the care recipient’s comfort, the relative’s situation and care staff’s caring. Trying to figure out the needs for all involved in preparing a caring situation.

Considering situations in wider perspectives

If I observe, for example, medicine that does not work, or if it is care staff who do not understand how to care or, in some way I tell them how I want it to be, or how I think the care recipient would like to be cared for ... that is what I do ... In some way I think I more and more have to stand up for the care recipients to protect them from relatives’ ideas of how the care should be ... actually, nowadays, some relatives have many strange ideas and like to consider themselves as the ones knowing what is best care ... and somewhere there you have to be courageous and tell them that ... NO ...

The care recipient’s well- being, needs and comfort are prioritized ahead of relatives’ or care staff’s requests.

Caring with a prioritized care recipient focus

604 C Gustafsson et al.

Nursing Ethics 2009 16 (5)

Meaning unit Condensed meaning unit

Subtheme Theme

In my work the most important thing is to make sure that the care recipients are given proper care, that I am doing my best every time I make a nursing contribution and that I have courage to act when I observe something wrong or insufficient care.

The main function in nursing is to guarantee care, the recipient’s well-being and doing one’s very best every time when caring for someone.

To have courage to take charge when observing insufficient caring.

Protecting and guarding care recipients’ rights

Table 1 (Continued)

Each interview text was then read again as a whole and related to the naive under- standing and the findings from the structural analysis. It was then reflected upon in discussions with all three authors, resulting in an interpretation of possible meanings of caring in nursing. From the interpretations a comprehensive understanding was formulated, which took into account the authors’ pre-understanding (see ‘Critical considerations’ section).

Naive understanding A naive understanding was formulated linked to the structural analysis, as follows.

Caring is a fundamental stance exercised in nursing activities by RNs, meaning caring advocacy of care recipients in encounters, nursing actions and nursing service. A caring stance means that the care recipients’ rights are considered and given priority ahead of the requests of others. Prioritization in nursing exists in an implicit hierarchy giving caring precedence in the following order: care recipients, relatives and care staff.

Caring in night duty nursing is initiated by other staff or relatives’ cell phone com- munication in informing and consulting the RN. ‘Caring for’ means mediated caring in a triad with care staff (or relatives), that is, this type of caring in nursing means remote caring, being on alert and supporting backup care staff (or relatives) in caring for care recipients. These RNs’ remote caring dimension with superior caring responsibility makes the process of emphasizing and expressing the care recipients’ perspectives easier by advocacy in guarding their needs, well-being and dignity ahead of those of care staff (or relatives). ‘Caring about’ has a preventive dimension in developing confident relationships with care staff and relatives, and caring service mainly implies RNs’ medical services.

Structural analysis In the following sections the meaning of caring is described according to the three themes: caring for by advocacy; superior responsibility in caring about; and con- sultative nursing service (Table 2).

Municipal night nurses’ experience of the meaning of caring 605

Nursing Ethics 2009 16 (5)

Caring for by advocacy

Caring for care recipients, relatives and care staff means attending to persons in need of a RN consultation. This includes both direct caring encounter situations and telephone consultations mediated by care staff or relatives. The primary persons cared for are the care recipients, which means that their perspective is constantly taken into account, although care staff’s or relatives’ problems may be the reason for the consultation.

Caring for by advocacy means prioritizing care recipients’ perspective, and caring encounters being achieved in a hierarchical fashion. This hierarchy means that care reci- pients’ needs are given precedence, followed by those of relatives. Finally, care staff’s problems and needs must be considered.

Caring for by advocacy is related to respecting care recipients’ basic human rights such as dignity, integrity and autonomy. It also means reflection on care recipients’ problems using a broader perspective (their life situation). Assessments in caring situations imply caring while endeavouring to see the person behind the disease/con- dition. Here, caring means understanding the situation by stopping and reflecting, and using nursing experience to consider the problem combined with the RN’s own life experiences:

... you kind of try to have your eyes open, to see the relatives too; I think you have more ... I believe it is a process of maturing, looking more broadly than just at the problem.

Having concern for the care recipient can often mean leaving direct caring actions to the care staff who are familiar to the care recipient. Experience and knowledge facilitate understanding of care recipients’, relatives’ and care staff’s situations.

Table 2 Subthemes and themes describing municipal night RNs’ experiences of the meaning of caring in nursing

Subtheme Theme

Caring with a prioritized care recipient focus Protecting and guarding care recipients’ rights Considering care recipients’ perspective Considering situations in wider perspectives

Caring for by advocacy

Caring at a distance Co-operating and collaborating with care staff Adopting a superior caring responsibility Prioritizing problems requiring a nurse Being accountable for care staff’s caring Supporting and supervising care staff‘s and relatives’ caring Advising care staff and relatives by confidence and courage guidance

Superior responsibility in caring about

Caring during brief encounters Assessing needs and problems Caring with extensive nursing experience Caring with a range of problems Giving service in advanced medical treatments Giving medical service in advanced medical treatments

Consultative nursing service

606 C Gustafsson et al.

Nursing Ethics 2009 16 (5)

Caring during life’s final stages means contact visits to guarantee care recipients’ well-being, signify accessibility, and offer further contact between relatives and care staff. Caring for aggressive and anxious people with dementia means allowing flexi- bility with the care recipient and striving to attain the best possible treatment for the condition while giving support to care staff in a difficult situation.

Superior responsibility in caring about

Caring about care recipients, relatives and care staff by superior responsibility means adopting vocational accountability by virtue of being a RN. Caring about implies a more remote and distanced caring, excluding direct care and caring encounters. Caring about concerns situations in which RNs’ caring is negotiated, which are triadic with care staff as mediators.

Caring in the current context means responsibility in preparing propitious conditions for night caring by co-operation, collaboration, and supporting and supervising care staff or relatives.

... that you are explicit in terms, they should know that you are there for them, there is a nurse with superior responsibility. If there are any questions or something they would like to discuss they should turn to me through the care staff, because I am seldom at the unit ...

Collaborating with care staff also means managing staff, and sometimes directing how caring is to be employed. In RNs’ adoption of a superior caring responsibility, car ing about may be seen to benefit from RNs rarely participating in bedside care. This facilitates supervision by RNs and sometimes involves care staff in discussions of how to care for care recipients. A superior caring responsibility also includes estimating care staff’s competence in dealing with delegation and instructions.

The focus on care recipients requires, in some cases, teaching care staff to provide competent care. A superior caring responsibility also means having a mandate from care staff concerning decisions, instructions and actions to solve problems that have been raised. Superior accountability and requiring a mandate imply that RNs need confidence and courage in the nursing profession. The authority function also means adopting an overall caring obligation entailing removing responsibility from care staff or relatives by taking charge of a particular problem:

I must be explicit, to inform relatives about the situation, this is what we can offer and what we will do, and there is a kind of response reflecting their understanding about the expected course of events ... in some way I give them a part of me as a professional nurse ... to be there at hand, and in my view, approach to care for the care recipient, and also to care for the staff ...

Caring about also includes a prioritizing dimension, signifying assessment and prioritization of when a face-to-face RN consultation is needed. This is enabled by support from other caring team professionals’ and the organizations’ models of prioritization. Caring about by superior caring responsibility means striving for caring advocacy in facilitating quality and competent night care for older people.

Consultative nursing service

Providing a night nursing service to care recipients, relatives, care staff and clients of a municipal organization means that RNs must be on the alert to respond to acute

Municipal night nurses’ experience of the meaning of caring 607

Nursing Ethics 2009 16 (5)

problems and needs requiring RNs’ skills, competence and authority. The nursing service mainly has the characteristics of medical services, also including planned activities ordered by clients of municipal social care.

... it can be various treatments in private homes, for example, parenteral nutrition via a port-a-cath [a subcutaneous central venous catheter], peritoneal dialysis, or vacuum pumps for leg ulcers.

These nursing tasks mainly involve advanced medical technical treatments neces- sitating the contribution of a RN.

The on-call dimension entails nursing consultations during brief encounters con- cerning the assessment of problems and needs, the use of advanced medical equip- ment, and planning approaches to a broad range of difficulties. These consultations are initiated by care staff observing a problem, leading to arranging a telephone consulta- tion and RNs often giving a prescription and instructions and/or delegation to the care staff in how they are to deal with the situation. When night RNs’ consultations mean encountering a care recipient, relatives or care staff, this consists of intense brief assessments during which the whole situation is taken into consideration.

... I have more demands on me when I enter a caring situation where I do not know anybody ... I have to do my assessment in 10 minutes and give the impression of not being stressed, of having a genuine interest in how they are (relatives and care staff) and the care recipient’s condition. Rapidly, I have to create a picture, give some kind of sense of community, make them feel confident ... it starts when I enter the door. I have a nurse’s role in encountering relatives, you always have two paths or ... more ... you have to sense which to choose ...

A consultative nursing service implies a requirement for confident RNs with extensive nursing experience. Basically, night nursing care is an interdependent phenomenon. The initial stage is observation of a problem by care staff leading to a RN consultation and the RN’s assessment and decisions concerning confidence in care staff to take further action.

... you have to trust the care staff because you do not have time ... you cannot be everywhere.

In this way, caring in nursing means a state of contradiction, existing in an inter- dependent independency, including both RNs’ and care staff’s independence in caring actions as well as dependency on communication, competence and attention to an identified problem.

Comprehensive understanding and reflection Comprehensive understanding is based on the naive reading, the themes and sub- themes, the authors’ pre-understanding, reflections related to the context of the study, the research question and the literature.

Municipal night RNs’ experiences of caring in nursing are interpreted as paradoxes: ‘being close at a distance’ and the conditions of ‘being responsible with insignificant

608 C Gustafsson et al.

Nursing Ethics 2009 16 (5)

control’ and ‘being interdependently independent’. The themes emerging from the structural analysis seem to be connected and intertwined with each other, illustrating the complexity of the phenomenon under study.

It could be suggested that caring may be considered to comprise RNs’ all-nursing activities. On the other hand, the participant RNs experience caring as a fundamental and basic stance in night nursing. Conversely, caring is often associated with and described in terms of relationships and encountering the care recipient.10,43–45 However, that these RNs seldom physically meet care recipients does not mean a lack of caring. The philosopher Marcel46 discusses the concept of being co-present. Marcel explains that encounters can also occur at thought level. An encounter is not merely to cross someone’s path, it is also to be near to or with them. Municipal RNs’ night caring may also occur at thought level. This means thought while near to or with the care reci- pient. Consequently, the caring stance is important despite the lack of a meeting that could be discussed in terms of nursing ethics. The caring stance can also be viewed in relation to the work of Marcel,46,47 who examined ‘being’ and ‘having’ in a variety of contexts. When applied in the study context, the RNs’ caring stance means caring is more important than having a caring attitude. The RNs thereby think and narrate caring with the care recipient as a natural focus taking precedence over the problems of both relatives and care staff. This means that, in caring, the RNs strive ‘to be close at distance’ because by their actions they deliberately advocate the care recipients’ needs, well-being and dignity. The needs, well-being and dignity of relatives and care staff, are considered at a subordinate level. This deliberate focus on care recipients emerges as caring advocacy.

Advocacy is a central concept in nursing ethics48 and also in gerontological nurs- ing.13,18 Caring advocacy is also in line with a caring science approach, which emphasizes the patient’s perspective.10,43,44 In the present study, caring advocacy was stated to be a feature for protecting care recipients’ dignity, well-being and caring needs, as also noted in the literature.48,49 If their condition seldom permits care recipients to consult RNs this is mitigated by the triad formed by care staff (or relatives) being mediators in the communication process between RNs and care recipients. This means that despite the night duty RNs’ distance from the care recipients, it is easy to advocate for this group, in spite of the fact that they are mainly frail older people not capable of involve- ment. Similar situations have been discussed50 when studying telecare, which also has emphasis on the importance of having experienced care staff as intermediaries in the communication process.

Van Hooft8 considers the concept of caring in nursing connected to moral theory by virtue ethics, which is neither merely an interpersonal emotion nor just a professional practice; it is the ethical foundation of nursing. A RN who demonstrates phronesis (an Aristotelian concept meaning ‘practical wisdom’) will feel caringly, think caringly and thereby act virtuously.8 In the results presented in this article RNs deal with medi- ated care carried out by care staff, which seems to call for a nursing quality of clinical wisdom43,51,52 or phronesis.53 The concept of clinical wisdom is complex, being related to advocacy in preserving care recipients’ dignity. There is also a stated need for skills of sensitivity, patience, trust, compassion, ethical discernment and clinical competence in the care of older people.43,52,54,55

Night RNs are consequently dependent on care staff and relatives to guarantee good nursing care for older people; that is, they are responsible but have insignificant control. They want to give, and are responsible for, good quality care21,56 that they do

Municipal night nurses’ experience of the meaning of caring 609

Nursing Ethics 2009 16 (5)

not administer themselves and over which they have insignificant control. This leads to a high risk of work-related stress28,57 and can be a reason for moving away from caring for older people.58,59

The difference between caring for and caring about stands out in the findings. Caring for means a care recipient focus despite the RNs’ remote function. This can be considered as an individual characteristic founded in self-knowledge by a process of vocational maturity and incorporated into these RNs’ being and their meaning of caring. Ricoeur33,60 acknowledges that the self is not a simple subjective entity. It is in some part a social construct, and an important source of such a construction of the self is the role we occupy in society. This van Hooft12 exemplifies as especially clear in the case of the nursing profession. For the RNs, caring is not just a matter of doing the job effectively by looking after sick people, it is also a matter of having a compassionate and benevolent attitude towards them. The care recipients and the RNs are, in many ways, dependent on the care staff (or relatives) owing to decisions that have to be made about if and when RNs are to be consulted. This is the situation of being interdependently independent. The RNs are independent in the execution of their professional practice, making their own self-governing assessments and decisions. At the same time they are dependent on the skills of care staff and/or relatives to observe problems and also to perform the RNs’ instructions and delegated care. It is also illustrated in the findings that the night duty RNs seldom participate in bedside nursing, which is instead exer- cised by relatives or care staff. The RNs’ caring thus often means also caring for relatives and care staff. This has been brought about by Swedish national and political reforms in the care of older people.61

One perspective on caring in night nursing revealed in this study relates caring to an organization that mainly requires RNs’ medical services. Conversely, caring in nursing means striving to grasp an overall caring responsibility by responding to the vocational and personal demands of being a RN,8 and in guaranteeing quality, ethical and competent night-time care for older people.

Critical considerations This was a small study undertaken in Sweden. The intention was to obtain a better under standing of the meaning of caring in municipal night nursing. The interpretation process was an ongoing dialectical movement between the whole and parts of the text, between nearness to and distance from the text, with the purpose of validating what the text is revealing. This was completed by all the authors being involved in different parts of the analysis. The parallel reading made it possible to approach the relational uniqueness that is always there in everyday (night) nursing practice. Ricoeur33 argues that there is always more than one way of understanding a text, but this does not mean that all interpretations are equal. The results of these analyses should be judged taking into account the authors’ pre-understandings. None of the authors have experience of municipal night care for older people, however, all three are experienced RNs and educators, and have knowledge and interest in caring. To these authors, the results represent a most useful and credible understanding of these RNs’ experiences of the meaning of caring in night nursing.

There has been emphasis on describing the interpretation procedure in a way that provides possibilities for the reader to follow the interpretation from the raw material

610 C Gustafsson et al.

Nursing Ethics 2009 16 (5)

to the comprehensive understanding. Transferring the findings to other contexts there- fore presupposes a recontextualization of the results to the actual context.35,62 Results obtained using this method may be considered credible if RNs recognize descriptions or interpretations comparable with their own.35,62 This allows results to be transferred to other comparable situations.

Conclusion and applications This study was an exploration of caring in nursing by municipal night RNs that reveals both ethical dimensions and problems. Although the organization mainly requires RNs’ medical services, the RNs experience that caring in nursing means striving to grasp an overall caring responsibility connected to the RN profession. This involves striving to offer quality, ethical and sufficient caring to older people during the night. This entails understanding that caring is the ethical foundation of nursing. In considering the context, it is important to understand that the care recipients are older people and some times their relatives and also care staff, which is necessary for preparing propitious conditions for the care of these older people. This indicates the presence of dimensions of family nursing.63,64 The findings consequently point to the necessity to implement further studies observing municipal night RNs caring for relatives and care staff in addition to the elderly people in their care. The results of this study can be applied to increase understanding of RNs’ ethical reasoning when having responsibility for large groups of frail older people in need of care.

Acknowledgements The authors would like to express their sincere thanks to all the night nurses who participated in this study. We also wish to thank Mälardalen University School of Health Care and Social Welfare, the foundations of the Swedish Order of St John for their financial support, and Tamarind Translations for linguistic revision.

Conflict of interest statement The authors declare that there is no conflict of interest.

Christine Gustafsson, Mälardalen University Eskilstuna, Sweden. Margareta Asp and Ingegerd Fagerberg, Mälardalen University Vasteras, Sweden.

References 1 Davies E, Higginson IJ. Better palliative care for older people. Denmark: WHO Europe; 2004. 2 Socialstyrelsen. (National Board of Health and Welfare.) Folkhälsorapport 2005. (Public health

report 2005.) Stockholm: och EpC, 2005. 3 World Health Organization. Current and future long-term care needs. 2002. Retrieved 29 May,

2009, from: www.who.int/chp/knowledge/publications/ltc_needs.pdf 4 Blackman T. Defining responsibility for care: approaches to the care of older people in six

European countries. Int J Soc Welfare 2000; 9: 181–90. 5 Meinow B. Capturing health in the elderly population: complex health problems, mortality, and the

allocation of home-help services [Doctoral dissertation]. Stockholm: Stockholm University, 2008.

Municipal night nurses’ experience of the meaning of caring 611

Nursing Ethics 2009 16 (5)

6 Tschudin V. How nursing ethics as a subject changes: an analysis of the first 11 years of publication of the journal Nursing Ethics. Nurs Ethics 2006; 13: 65–85.

7 Angus J, Nay R. The paradox of the Aged Care Act 1997: the marginalisation of nursing dis- course. Nurs Inquiry 2003; 10: 130–38.

8 Van Hooft S. Caring and ethics in nursing. In: Tschudin V ed. Approaches to ethics: nursing beyond boundaries: London: Butterworth-Heinemann, 2003: 1–12.

9 Benner P, Wrubel J. The primacy of caring: stress and coping in health and illness. Menlo Park, CA: Addison-Wesley, 1989.

10 Watson J. Love and caring: ethics of face and hand – an invitation to return to the heart and soul of nursing and our deep humanity. Nurs Adm Q 2003; 27: 197–202.

11 Eriksson K. Understanding the world of the patient: the suffering human being – the new clinical paradigm from nursing to caring. Adv Nurs Pract Q 1997; 3: 8–13.

12 van Hooft S. Understanding virtue ethics. Stocksfield: Acumen, 2006. 13 Caffrey RA. Independent community care – gerontological nursing. J Gerontol Nurs 2005; 31(8):

12–17. 14 Murashima S, Asahara K. The effectiveness of the around-the-clock in-home care system: did it prevent the instutionalization of frail elderly? Public Health Nurs 2003; 20: 13–24.

15 Wheatly F. Heat of the night. Nurs Stand 2004; 18(47): 24. 16 Caffrey RA. Community care gerontologic nursing: the independent nurse’s role. J Gerontol

Nurs 2005; 31(7): 18–25. 17 Johnston B, Smith L. Nurses’ and patients’ perceptions of expert palliative nursing care. J Adv

Nurs 2006; 54: 700–709. 18 Eliopoulos C. Gerontological nursing, sixth edition. Philadelphia, PA: Lippincott Williams &

Wilkins, 2005. 19 Campell A-M, Nilsson K, Pilhammar Andersson E. Night duty as an opportunity for learning.

J Adv Nurs 2008; 62: 346–53. 20 SFS 2001:453. Social tjänstlagen. (Social Services Act.) Stockholm: Sveriges Riksdag, Rikstrycket,

2001 (in Swedish). 21 SFS 1982:763. Hälso- och sjukvårdslagen. (Health and Medical Act.) Stockholm: Sveriges Riksdag,

Rikstrycket, 1982 (in Swedish). 22 SFS 1998:531. Lag om yrkesverksamhet på hälso- och sjukvårdens område. (Regulation of work in the

health and medical domain.) Stockholm: Sveriges Riksdag, Rikstrycket, 1998 (in Swedish). 23 SOSFS 1997:14. Socialstyrelsen föreskrifter och allmänna råd. Delegering av arbetsuppgifter inom

hälso- och sjukvård och tandvård. (Delegation of responsibilities in health and dental care.) Stockholm: Socialstyrelsen (National Board of Health and Welfare), 1997 (in Swedish).

24 Karlsson I. Förväntningar och realitet för sjuksköterskor verksamma på äldreboenden. (Expectations and reality for nurses working in residential homes for elderly people.) [Doctoral dissertation.] Stockholm: Karolinska Institutet, 2007 (in Swedish).

25 Karlsson I, Ekman S-L, Fagerberg I. A difficult mission to work as a nurse in a residential care home: some registered nurses’ experiences of their work. Scand J Caring Sci 2009; 23: 265–73.

26 SALAR. (Swedish Association of Local Authorities and Regions.) Care of the elderly in Sweden today, 2006. Stockholm: Sveriges Kommuner och Landsting, 2007.

27 Kihlgren AL, Fagerberg I, Skovdahl K, Kihlgren M. Referrals from home care to emergency hospital care: basis for decision. J Clin Nurs 2003; 12(1): 28–36.

28 Juthberg C. Samvetstress hos vårdpersonal i den kommunala äldreomsorgens särskilda boenden. (Stress of conscience among care workers in municipal residential care for the elderly.) [Doctoral dissertation] Umeå: Umeå University, 2008 (in Swedish; English summary).

29 Tucker N, Smith L. All through the night. Geriatr Nurs 1987; 8: 256–57. 30 Duxbury J. Night nurses: why are they undervalued? Nurs Stand 1994; 9(11): 33–36. 31 Meredith R. Improving the quality of care provided at night. Prof Nurse 2000; 15: 502–505. 32 Oléni M, Johansson P, Fridlund B. Nursing care at night: an evaluation using the Nursing Care

Instrument. J Adv Nurs 2004; 47: 25–32. 33 Ricoeur P. Interpretation theory: discourse and the surplus of meaning. Forth Worth, TX: Christian

University Press, 1976. 34 Ricoeur P. Hermeneutics and the human sciences. New York: Cambridge University Press, 1981.

612 C Gustafsson et al.

Nursing Ethics 2009 16 (5)

35 Lindseth A, Norberg A. A phenomenological hermeneutical method for researching lived experience. Scand J Car Sci 2004; 18: 145–53.

36 Gadamer H-G. Truth and method, second edition. New York: Crossroad, 1989. 37 Kvale S. Interviews: an introduction to qualitative research interviews. Thousand Oaks, CA: SAGE,

1996. 38 SFS 2003:460. Lag om etikprövning av forskning som avser människor. (Act concerning the ethical

review of research involving humans.) Stockholm: Sveriges Riksdag, Rikstrycket, 2003 (in Swedish).

39 Gustafsson B, Hermerén G, Petersson B. Good research practice – what is it? Views, guidelines and examples. Stockholm: Vetenskapsrådet (Swedish Research Council), 2006.

40 Polit D, Tatano Beck C. Nursing research: generating and assessing evidence for nursing practice. Philadelphia, PA: Wolters Kluwer Lippincott Williams & Wilkins, 2008.

41 LoBiondo-Wood G, Haber J. Nursing research: methods and critical appraisal for evidence-based practice. St Louis, MO: Mosby Elsevier, 2006.

42 Patton MQ. Qualitative research and evaluation methods, third edition. Thousand Oaks, CA: SAGE, 2002.

43 Benner P, Hooper-Kyriakidis P, Stannard D. Clinical wisdom and interventions in critical care. Philadelphia, PA: Saunders, 1999.

44 Bäck-Pettersson S. Caring in research and practice – some nursing aspects. Gothenburg: Göteborg University, Sahlgrenska Academy, 2006.

45 Tschudin V. Ethics in nursing: the caring relationship. Oxford: Butterworth-Heinemann, 1992. 46 Marcel G. Creative fidelity. New York: Fordham University Press, 1964. 47 Treanor B. Gabriel (-Honoré) Marcel. In: Zalta EN ed. The Stanford encyclopedia of philosophy,

2008. Retrieved 29 May, 2009, from: http://plato.stanford.edu/entries/marcel/ 48 Fry S, Johnstone M-J. Ethics in nursing practice. Oxford: International Council of Nurses,

Blackwell, 2002. 49 Anderberg P, Lepp M, Berglund A-L, Segesten S. Preserving dignity in caring for older adults: a concept analysis. J Adv Nurs 2007; 59: 635–43.

50 Savenstedt S, Zingmark K, Sandman PO. Being present in a distant room: aspects of teleconsultations with older people in a nursing home. Qual Health Res 2004; 14: 1046–57.

51 Benner P. The wisdom of our practice. Am J Nurs 2000; 100(10): 99–101,103,105. 52 Uhrenfeldt L, Hall EOC. Clinical wisdom among proficient nurses. Nurs Ethics 2007; 14:

387–98. 53 Aristotle. Den Nikomachiska Etiken. (The Nicomachean ethics.) (Swedish trans Ringbom M.)

Stockholm: Natur och Kultur, 1967. 54 Erlen JA. The frail elderly: a matter of caring. Orthop Nurs 2007; 26: 379–82. 55 Haggerty L, Grace P. Clinical wisdom: the essential foundation of ‘good’ nursing care. J Prof

Nurs 2008; 24: 235–40. 56 Juthberg C, Eriksson S, Norberg A, Sundin K. Stress of conscience and perceptions of conscience in relation to burnout among care-providers for older people. J Clin Nurs 2008; 17: 1897–906.

57 Karasek R, Thorell T. Healthy work: stress, productivity, and the reconstruction of working life. New York: Basic Books, 1990.

58 Fläckman B, Sørlie V, Kihlgren M. Unmet expectations: why nursing home staff leave care work. Int J Older People Nurs 2008; 3: 55–62.

59 Secrest J, Iorio DH, Martz W. The meaning of work for nursing assistants who stay in long- term care. J Clin Nurs 2005; 14(suppl 2): 90–97.

60 Ricoeur P. Oneself as another. Chicago, IL: University of Chicago Press, 1994. 61 Socialstyrelsen. (National Board of Health and Welfare.) Vård och omsorg om äldre: Lägesrapport.

(Care of the elderly: progress report.) Stockholm: Socialstyrelsen, 2006 (in Swedish). 62 Sandelowski M. Focus on qualitative methods. The use of quotes in qualitative research. Res

Nurs Health 1994; 17: 479–82. 63 Wright LM, Leahey M. Nurses and families: a guide to family assessment and intervention, third edition. Philadelphia, PA: Davis, 2000.

64 Lilly ML. Gerontological family nursing. In: Harmin Hanson SM, Gelday-Duff V, Rowe Kaakinen J eds. Family health care nursing. Philadelphia, PA: Davis, 2005: 375–92.

Reproduced with permission of the copyright owner. Further reproduction prohibited without permission.