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ORIGINALS

Care perception among nursing students and professionals*

Rosa Aparecida Pavan Bison,¹ Antonia Regina Ferreira Furegato,² Jair Licio Ferreira Santos^3
1Doctor in Psychiatric Nursing - EERP/USP, ²Titular Professor at Psychiatric Nursing and  Human Sciences Departments- EERP/USP, ³Titular Professor at Social Medicine Department - FMRP/Universidad de Sao Paulo, Brasil

Manuscript received by 29.03.2006
Manuscript accepted by 23.08.2006

Index de Enfermería [Index Enferm] 2007; 56: 30-34

*Maricel Manfredi Award, IX Coloquio Panamericano de Investigación en Enfermería - Lima/Perú - 2004

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Abstract

This study aimed to get to know care perception and the relation between nursing students' and nursing professionals' conceptions, based on Morse's concepts and classifications. We elaborated an instrument about care and its meanings, including statements that were analyzed by jurors and by a performance factor index. The instrument (Care Meaning Evaluation Scale - EESC) is a 5-point ordinal Likert scale with 45 statements, distributed across five categories: human personal characteristic, moral imperative, affection, interpersonal relation and therapeutic intervention. The 171 subjects were undergraduate and specialization students, nursing professionals and teachers. Data were subject to statistical treatment, using non-parametric tests. The greatest differences appeared between students' and teachers' conceptions, between the conceptions of care as a human characteristic (0.094) and as a moral imperative (0.043). Teachers and students reveal approximate positions with respect to categories, as well as specialization students and nurses, with significant differences between the groups (106-112 and 81-66). These results point towards the need for a more fine-tuned articulation between teaching and its application in professional practice.

Introduction

    Health concept has always been related to actions and interventions and, therefore, to care. If the individuals do not receive care, from birth to death, they do not survive. According to the humanistic view, care is crucial to understand the human nature.
    Rogers (1999) states that an empathic way of caring involves genuine interest, engagement, solicitude, and fully concentration on the other one.
    Nursing is one of the few professions sheltering the human suffering to mitigate pains through care. This act is a sole moment to share the human existence.
    To think and to reflect on nursing as the care therapy is the contribution to be extracted from this study, which is only the starting point for the sedimentation of ontological and epistemological processes about the meanings of care and therapeutic act.
    Nursing as a profession was consolidated on a significant way during the last century, transposing the tasks of rendering services, by providing health assistance recognized in the scientific community.
    Since the last century, care has been considered as the landmark in a new nursing paradigm and, despite the relevance for the profession, this issue has not always received the due attention on the part of those who teach it and practice it (Travelbee, 1982, Peplau, 1993, Furegato, 1999, Waldow, 2001, Decher-Brown, 2004).
    Practicing care has been the tonics extracted from the actuation in nursing. Apprehending the meaning of care provides words to explain what we do everyday, also concerning educational practices.
    MORSE's (1990) concepts and classifications were the basis for our research. Her studies contain implicit and explicit definitions related to the perception of care, evidenced through educational techniques allowing the translation of care in 5 ontological classifications: ) as a human personal characteristic; b) as moral or ideal imperative; c) as affection; d) as interpersonal relation; e) as therapeutic action.
    For this reason, we engaged in knowing the nurses´ perceptions about care in the assistance to the human health.

Purpose

    The purpose of this research was to evaluate the perception of care (and its implications) among nursing students (undergraduate and attending specialization courses), nursing professionals and nursing teachers.

Methodology

    Population and sample - the population of this research was constituted by undergraduate and specialization students, nursing professions from 3 institutions in Araras (S.Paulo, Brazil) and teachers at the Centro Universitário Herminio Ometto - UNIARARAS.
    The criterion for inclusion was defined by the subjects´ presence in the setting for data collection.

Instrument and data collection

    For the present study, we opt for a scale measure instrument. According to PASQUALLI (1996), attitude (psychological property) constitutes disposal for action, allowing the verification of an individual's degree of adhesion to a series of statements about the psychological object, through answers registering if he/she agrees, is in doubt or disagrees.
    This instrument was elaborated based on a systematic analysis of 227 writings of students (undergraduate and specialization) focusing care and its meanings. From a great number of affirmative phrases, 50 were selected, grouping 10 in each one of the 5 categories (care: 1- as a human personal characteristic; 2- as moral imperative, 3- as affection, 4- as interpersonal relation and 5- as therapeutic intervention).
    The instrument then was organized in the form of a Likert type ordinal scale.
    In the phase of construction of the instrument, a group of jurors designated the statements and, for the evaluation of the performance index by factor they discarded those presenting index inferior to 80% agreement. For each statement total agreement was considered. In a new evaluation, by another group of jurors, the content of the statements was analyzed as to their understanding and relevancy.
    The final instrument - Care Meaning Evaluation Scale - EESC (EESC) - contains 45 statements, distributed in the 5 categories (according to Morse´s theory), with 9 statements in each one. The questionnaire was answered by the 171 subjects in their respective places of actuation (School of Nursing and hospitals). The subjects answered to all the statements in an average of 15 minutes.
    Ethics - the project was approved by the UNIARARAS Ethics Committee. All had agreed to participate, signing the Informed Consent.
    Analysis - data concerning subjects´ identification allowed the delineation of the analyzed population's social and demographic profile.
    With the results of the questionnaire (EESC) the values of the absolute and percentile frequencies of each subject's answers were figured out, by group and category, and calculated the median values and significance levels. It was used the Kruskal-Wallis test to verify whether or not the frequencies of each group's answers differed excessively from the others.
    Following the indications of SIEGEL (1975), H statistics values were used for a comparison with the chi square critical value, calculated with 2 degrees of freedom (5,99).
    Inside each group, it was searched the identification of the eventual difference between categories. For all the tests, it was admitted the probability of first kind error (standard error) and the value of alpha = 5%.
    The qualitative analysis focused the results encompassing the 5 categories. The reflections were based on the theoretical referential on care.

Results

    The sample of this study was composed by 171 subjects (21 undergraduate students, 99 from specialization, 29 nursing professionals and 22 teachers.

Profile of the citizens

    Mean age: undergraduate students = 29 years; specialization = 31,8; nurses = 34; teachers = 35.
    90.9% of them were women.
    Half of the total of the respondents were single, 77.3% of the teachers were married.
    More than 2/3 of the students came from cities in the region. Almost all the nurses (96%) live in the city of the research and half of the professors (45,5%) live outside the city.
    Therefore, the sample has the city as reference.
    It was found a variation from 2 to 10 Brazilian minimum wages as monthly income, being lesser among the undergraduate students (2), nurses (3,5), specialization (5), and increasing among the teachers (10). This result is compatible with the current Brazilian official statistics data demonstrating the ascension of the economically active people directly proportional to the level of wage and years of study, that is, the more years of study a person has, greater is his/her wage.

Statistical analyses

    In the psychometric statistical analysis, the four groups were compared separately. It was verified, in the distribution of the median values for the 5 categories with the 4 groups, that occurred, in the category of Care as " Moral Imperative", a significant variation from a group to another, more accented in group 1 (undergraduate), with a significance level of 0,43.
    In the other groups, cases with such significant differences were not met. Analyzing the set of categories it is verified in Table 1 that the groups, in their totality, are different, with a significance level of 0,002.
    Comparing all the results, group to group (Table 2), similarities were observed between group 1 and group 4 (undergraduate and teachers), and between groups 2 and 3 (specialization students and nurses). However, results with differences of almost the double of the level of significance between the two sets of groups were found. Therefore, there are significant differences in the intergroup perceptions as to the categories proposed. Greater proximity was observed in the results between the specialization students and the nurses in the 5 categories. There is also proximity as to variables age and years exerting the profession. The students are distinguished in valuating moral aspects and the teachers in exalting human relations categories.

Differences between the groups as to care perception by category

    The application of the EESC in this research pointed out differences among the groups as to care perception in the five categories proposed by Morse (1990). It is observed that the care concept is not fully incorporated by the respondents, which can imply in lack of nurses´ consistent actions while caring.

Care as "human characteristic": Analyzing the results in this category, the statements relative to caregivers' appearance had an excellent index of general performance, with 80% adhesion. On the other hand, in the ones where the percipient internalization of personal care was suggested, it was observed that the attention to personal health, comfort, feeding and physical activity was not a priority as to care perception.
    Silva (2000) argues that the caregivers need to take care of themselves first, because caring only occurs with the transmission of feelings and personal potentialities to the other one.

Care as "moral imperative": The most significant differences found among the results of the groups refer to the statements of ethics-moral order, involving feelings of solidarity, compassion and idealization.
    Care as a compassion act points that, while 76.3% of the students are in agreement as to its signification, only 18.2% of the professors have such an opinion, with 68,1% disagreement index. This result is repeated in the statement referring that care involves the ideal to serve, with 95% agreement index among the undergraduate students, 80% among the ones from specialization, 72.4% among the nurses and 64% among the teachers.
    Interestingly 41% of the professors have doubts as to affirming that care is above any price. In the same way, taking care of the other one as a matter of solidarity is positively significant for 90% of the students, in contraposition to 54.7% of the teachers. The answers of the specialization students (74,7%) are next to the nurses´ ones (62,1%).
    As to exerting the profession, 50% of subjects in all the groups consider nursing a difficult profession. However, it is appreciated by the totality of the respondent subjects.
    As Volich mentions (2000), therapist derives from "I care", being the therapist (thêrapêuo) the one who shares the ill's experience of suffering, understanding him/her, assisting and staying with him/her, being interested in his/her whole life, using knowledge and technical resources in the art of caring.
    The absence of valuation of the ethical-moral aspects, which certainly intervenes with caring, can disqualify care as a type of therapeutic action, making the act of nursing a product of exchanges, diminishing the enormous importance of this therapeutics.
    According to Mayeroff (1990) and in Rogerian studies (Rogers, 2001) it is observed that the respect with the other one is favorable for the development of the real meaning of lour lives, our potentialities and growth.

Care as "affection": Analyzing the results in this category, significant differences among the groups were not observed. The adhesion indices represent almost a consensus and it can be concluded that the affection and its adjectives are component of the representation of studied groups´ conceptions, proving its incorporation in the attitudes while caring.
    By means of the affection one develops his/her capacity to visualize and to understand the extension of everyone's values, making the events significant. Admitting that education is a cultural element, in close relation with individuals´ behavior, one understands that it is possible to transmit affective care values through education.

Care as "interpersonal relation" and as "therapeutic intervention": Despite the absence of significant differences in the results among groups, some differences in relation to this category were registered, mainly between the groups of teachers and students, and specialization students and nurses.
    The interactive process is an integrator element among people, in their social environment. The therapeutic interactions form a set of professional actions (care) having as goal the maintenance of human health, equilibrium reestablishment, pain relief and cure. Based on such a humanist presupposition, the nursing teacher has to privilege the teaching of concepts and techniques to reach such goals.
    The teacher is the conductor of all the educative process. Therefore, the results of this research are preoccupying.

Comparison of results in the groups' totality, related to the studied characteristics

    The present inquiry pointed significant differences in the percentages of acceptances and disagreement, mainly with reference to care as affection and as moral imperative between the groups of undergraduate students and teachers, compared with the groups of specialization and nurses, as it can be observed in Table 3.
    The results of this study showed that despite the well development of care concept and perceptions, their application in nursing situations is below the expectations in all the groups studied. Based on her studies, Morse (1998) affirms that the more abstract it is the concept, more complex and changeable is the identification of its attributes. The meanings stabilize through the uses and processes of social interaction.
    In Table 3 it is observed that the percentages of the questions on affection are the ones that present the greatest similarity, although the low percentages gotten referred to the importance of nurses´ feelings.
    The results of care as interpersonal relation point the highest values of acceptance, corroborating findings in literature. The greatest frequencies refer to care as therapeutic intervention, indicating the professional care in the level of its conceptual meaning.
    When the main objective of nursing (care) is materialized, the nurse establishes a relation of proximity with the one being assisted, favoring the expression of positive feelings in the process of overcoming illness and suffering. Thus, the teachers must take into account the vital concepts of education and nursing practices.

Conclusion

    We showed situations extracted from nurses´ daily life to present to the respondents, who expressed their concepts, based on their reality. This way the results allow reflections and generalizations as to the similarities among the groups.
    The results of the EESC pointed out discrepancies related to care concept among groups and categories investigated. As to the groups the greatest differences concern students and teachers´ conceptions. As to the categories, the frequencies between students and teachers are close, as well as between specialization students and nurses. Significant differences among the groups are observed, which reaffirms the data found in literature and corroborates the need for more studies on this issue.
    It was not the pretension of this study to be definitive. The intention was to analyze a sample of views of people involved in caring. In our reality we reflect about the existing matters.
    It is important to adapt nursing knowledge to nurses´ actions beneath the lights in this new era which, according to Toffler (1990), will be the time to inter and transpersonal relationships.
    Concluding, the results of this study suggest that it is necessary to reflect seriously on the education of undergraduate nurses and those already exerting the profession.

References

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