Documente Academic
Documente Profesional
Documente Cultură
doi: 10.1111/j.1365-2702.2006.01404.x
Correspondence:
Irene Cassidy
University of Limerick
Limerick
Ireland
Telephone: 35361234215
E-mail: irene.cassidy@ul.ie
Introduction
Hospitals are vulnerable to new infections, which result
from changes in both the general population and hospital
2006 Blackwell Publishing Ltd
I Cassidy
Purpose
The purpose of this study was to explore and describe the
meanings of second year student nurses attached to caring for
infectious patients in source isolation within the general
hospital setting.
Methodology
The Gadamerian hermeneutic phenomenological approach
guided this study. Key philosophical concepts within this
approach are prejudgements, dialogue, hermeneutic circle
and fusion of horizons (Koch 1996). Gadamerian hermeneutics acknowledges the prejudgements of the researcher
and conceptualizes the researcher as an active participant in
the interpretation process (Van Post & Eriksson 1999).
Gadamers approach emphasizes the importance of dialogue
so that the existential world is opened and understood (Koch
1999). The notion of change or development of understanding between researcher and participants throughout the
research process is referred to by Gadamer as the hermeneutic
circle (Gadamer 1975, Fleming et al. 2003). The role of
understanding is to show how a fusion of horizons has
occurred (Koch 1996). As the only researcher, the use of a
hermeneutic phenomenological approach made it possible to
engage with participants to create a collective description of
the experience of caring for infectious isolated patients.
Methods
The site selected was a group of general hospitals within a
particular health board region in the Republic of Ireland.
Ethical considerations
Ethical approval was obtained from the local hospital ethics
committee. Permission to undertake the study was also granted
from the director of nursing and principal tutor. Participants
were informed in writing of the study and their right to decline
to participate or withdraw at any time. Potential power
imbalance between researcher and participants was acknowledged. It was left to each individual to make follow-up contact
with the researcher if they wished to take part. This aimed to
protect students so the decision to become involved was truly
theirs. Written informed consent was obtained. Anonymity of
participants was ensured by the use of a coding system. Other
measures such as storing data in a locked press and reporting
the findings so that participants could not be identified by their
individual responses upheld confidentiality.
Trustworthiness
To ensure credibility within a Gadamerian approach, researcher self-awareness is essential (Koch 1999). Throughout the
study, researcher prejudgements were acknowledged using
intuition and a reflective diary. In keeping with beliefs of
hermeneutic phenomenology, validation occurred by asking
the eight participants to check if interview transcripts, data
analysis and interpretation processes accurately reflected their
experiences. An audit trail was retained to ensure that the
research process was open, transparent and justifiable. Anonymous word-for-word excerpts from participants narratives
are included in the report so that other students may recognize
the experiences described. Information on the research setting
and sample are included to assist readers to judge transferability of findings to other contexts.
Findings
Four main themes emerged:
The organization: caring in context;
Barriers and breaking the barriers;
Theory and practice;
Only a student.
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when you hear that some people are in isolation, the first thing that
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comes into your head is what have they can I catch it? Is it
contagious ah? (S-1)
However, for some students, as their knowledge and experience of nursing deepened, they realized that:
if you take the right precautions and wash your hands properly and
do whatever you have to do, you know that youll be OK (S-1).
when we first heard it in first year we were all saying oh yea MRSA,
MRSA but now I think weve become relaxed about it up there, were
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Only a student
Students often felt hard-done-by and their standards of care
belittled when other members of the multidisciplinary team
did not adhere to recommended infection control practice.
One student anticipated the reaction she would receive if
she were to remind a doctor to wash his/her hands before
leaving an isolation room:
if you do say it to a junior doctor or even an older doctor oh theyd
kinda be looking at you going what are you doing telling me what to
do? (S-2).
Being the perfect nurse also makes students stand out and
standing out even if it is because you are doing the right
thing may be uncomfortable. Hence, the importance of
balancing fitting in with being accountable for practice.
Discussion
Implementation of isolation precautions varies depending on
available resources (Gould 2000). Accessibility and design of
rooms, provision of equipment and approaches to care
delivery frequently placed students in the situation of
adjusting their care of isolated patients to the context of the
hospital environment.
The small space within some single rooms often meant that
students faced the choice of closing the door and adhering to
recommended isolation precautions or leaving it open for
patient comfort. Prieto and Clark (1999) reported similar
findings. Moreover, lack of individual or non-functioning
equipment frequently resulted in students using the same
sphygmomanometers on isolated and non-isolated patients.
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acknowledge and build on the important role that supernumerary students provide in ameliorating negative consequences of source isolation.
Providing patients with information about their illness and
associated infection control measures is vital (Myatt &
Langley 2003). Education decreases anxiety, depression and
increases self-esteem and sense of control (Gammon 1998,
Rees et al. 2000, Ward 2000). However, competing demands
and emphasis on physical care reduced the priority given to
education. Consequently, students generally handled it
through personal, unstructured and covert approaches.
Visitor education presented greater challenges as students
experienced it as largely unstructured, unplanned and anxiety
provoking. White (2003) highlights the importance of having
guidelines for visitors to infectious patients. Nurses should
consider using the nursing process and care plans when
dealing with information giving (Greenwood 1998). Integrating written and verbal education into care plans would meet
patients needs and help students gain knowledge and
confidence in patient and visitor education. Local guidelines
or standards for isolation practice could provide guidance for
staff and student nurses.
Students look to model behaviours and demeanour of
nurses they encounter in clinical practice (Jackson & Mannix
2001). Courtenay (1998) highlights the powerful influence of
effective rolemodelling on clinical learning about infection
control issues. Students were beginning to discern effective
and ineffective models of practice. Ineffective role models
demonstrated complacency towards isolation or were considered to have insufficient up-to-date knowledge of isolation.
Du Toit (1995) calls this the selection of antimodels.
Effective supervisory support from Registered Nurses has a
major influence on student learning in clinical practice
(Ohrling & Hallberg 2000, Jackson & Mannix 2001,
Lofmark & Wikblad 2001, Spouse 2001, Lee et al. 2002).
Effective role models were nurses who taught students the
right way of going about caring for isolated patients. While
organizational and staffing constraints may impact on staff
nurses ability to be effective role models, using every
available opportunity to link infection control theory to
patient care helps make learning meaningful contributing to a
sense of student satisfaction.
Fitting in and beginning to think as staff nurses were
important to students experience of caring for isolated
patients. Fitting in and learning to get on with work without
questioning have been discussed elsewhere (Bassett 1993,
Nolan 1998). On one hand, students were trying to be true to
their own beliefs and values of good isolation care. On the
other hand, they were trying to blend in with the staff nurse
role, adjust to the business of wards and nursing routines.
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Limitations
Hermeneutic phenomenology recognizes multiple realities of
an experience (Morse & Field 1996). This study was
undertaken at one research site in the Republic of Ireland.
Findings must be considered as a contribution to widening
the understanding of caring for patients in source isolation.
Gaining experiences of students; at different stages of
education, on undergraduate degree programmes in general
nursing and those in different cultural settings could add to
the depth and breadth of knowledge on students perceptions
of caring for this client group.
Conclusion
Nursing patients in source isolation is influenced by the
context within which such care is provided. Caring
experiences and student nursepatient relationships are
dramatically altered by the uniqueness of imposed physical,
psychological, social and emotional barriers. Balancing care
to meet individual needs while preventing spread of
infection had significant meaning for students and explicates the challenges of integrating the art and science of
nursing. Application of theory to practice is vital for
personal and professional development of student nurses
and needs to be recognized and nurtured within clinical
practice.
Acknowledgements
This paper is based on my dissertation as part fulfilment of an
MSc in Nursing though the Royal College of Nursing and the
University of Manchester. Therefore, I would like to thank
my supervisor Conal Hamill for his guidance and support. I
would also like to thank An Bord Altranais for their
monetary support.
Contributions
The study design, data collection, data analysis and manuscript preparation were undertaken by IC.
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