psychosocial care in oncology nursing: a study of social knowledge

Psychosocial care in oncology nursing: a study of social

knowledge

DAVEDAVE ROBERTSROBERTS MSc, RMN, RGN

Clinical Nurse Specialist in Mental Health, Department of Psychological Medicine (Barnes Unit),

John Radcliffe Hospital, Oxford OX3 9DU, UK

JANJAN SNOWBALLSNOWBALL BA, MA, SRN, RCNT, RNT

Deputy Head of School, School of Health Care, Oxford Brookes University, Level 4, Academic

Centre, John Radcliffe Hospital, Oxford OX3 9DU, UK

Accepted for publication 2 October 1997

Summary

· A combination of focus group and individual interviews aimed to examine

psychosocial aspects of nursing within a social context and social knowledge

held by two teams of ward-based oncology nurses.

· Five core categories of knowledge emerged: knowledge of how to care,

knowledge of the patient, knowledge of the ward, knowledge of nurses coping,

and knowledge of involvement.

· Involvement or emotional closeness was seen as a necessary, inevitable and

potentially stressful feature of psychosocial care.

· The authors conclude that interpersonal and professional aspects of nursing

must be balanced in order to provide effective psychosocial care.

Keywords: closeness, ethnographic, focus group, involvement, nurse±patient

interaction, psychosocial.

Introduction

Nursing may be viewed as a combination of technical

operations and interpersonal processes which have the

potential to be therapeutic (Peplau, 1952). The shift from

task- to patient-centred care, and to a holistic model for

practice, has been associated with an increasing focus on

the interpersonal aspects of nursing. The nurse must

achieve a level of interpersonal competence, with an

integration of communication, cognitive and behavioural

skills in order to achieve nursing goals (Kasch, 1986).

The resulting nurse±patient relationship has been

shown to involve both verbal and non-verbal interactions

(Bottorff & Morse, 1994; Bottorff & Varcoe, 1995), and

some of these activities may be unique to nursing (Ersser,

1991; Savage, 1995). These psychosocial aspects of care

have become most prominent in oncology nursing

(Germain, 1979; Winters et al., 1994; Wettergren,

1996). In addition to social processes, several studies

have shown how important the social environment is in

the delivery of nursing care (Peterson, 1988; Smith, 1992;

Savage, 1995). The project reported in this article aimed

Correspondence to: Dave Roberts, Clinical Nurse Specialist in MentalHealth, Department of Psychological Medicine (Barnes Unit), JohnRadcliffe Hospital, Oxford OX3 9DU, UK.

Journal of Clinical Nursing 1999; 8: 39±47

Ó 1999 Blackwell Science Ltd 39

to study psychosocial aspects of nursing within their

social context.

PSYCHOSOCIAL ASPECTS OF NURSINGPSYCHOSOCIAL ASPECTS OF NURSING

Ideas about psychosocial aspects of care originated in the

work of Peplau who stated that:

Nursing is an educative instrument, a maturing force,

that aims to promote forward movement of person-

ality in the direction of creative, constructive,

productive, personal, and community living. (1952,

p. 16)

This marked a shift away from needs-based to inter-

actionist models of nursing (Kitson, 1993). Psychosocial

aspects of nursing include the nurse±patient relationship,

and social and cultural knowledge (Gorman et al., 1989),

actions which are speci®c to the psychological state of the

patient, and a focus on the social context of the patient's

life (Wettergren et al., 1996). Peterson de®nes psychoso-

cial nursing behaviours as those which,

¼offer reassurance, support and relevant informa-

tion to patients. (1988, p.86).

Additionally, recent papers in oncology suggest that

psychosocial care covers assessment, identi®cation and

prevention of affective disorders (Maguire, 1995), main-

tenance of hope, management of uncertainty, and sup-

porting the patient's ability to adapt and cope with serious

illness (Haberman, 1988; Winters et al., 1994). Psychoso-

cial aspects of care therefore include nurse±patient

interaction and communication, care which addresses the

psychological state of the patient, and the social context

within which care takes place.

NURSE±PATIENT INTERACTIONNURSE±PATIENT INTERACTION

Many ideas about nurse±patient relationships were intro-

duced from the perspective of psychiatric nursing (Peplau,

1964; Ramos, 1992). There are problems, however, in

borrowing concepts from psychotherapy and counselling

since few psychotherapeutic theories have explored links

between the physical and psychological closeness found in

adult nursing relationships (Kitson, 1993). Moreover

studies conducted into nurse±patient interaction in on-

cology settings (McIntosh, 1977; Bond, 1983; James, 1992)

and in both medical and surgical areas (Macleod Clark,

1983; Webster, 1981) have indicated that communication

with patients was often super®cial, routinized and task-

related, effectively blocking communications by patients

which related to emotional aspects of care.

One explanation for this is that registered nurses are

best prepared for and most skilled at the instrumental (i.e.

technical rather than psychosocial) aspects of care, those

aspects for which the system holds them accountable

(Germain, 1979). Nurses may also experience tension

between personal and professional expectations in the

nurse±patient relationship, and this may contribute to

poor communication (May, 1991; Morse, 1991; Ramos,

1992). Smith (1992) and James (1992) identify that

personal emotional investment is required in the form of

emotional labour. This may have more to do with societal

expectations of women's domestic responsibilities than

professional ones, and it is both personally demanding and

occupationally undervalued (Aldridge, 1994).

Bottorff & Morse (1994), however, suggest that most

nurse±patient interaction research has not studied the

unique intimacy and complexity of nursing in context.

Observation-based research suggests that nurses interact

with patients on very personal levels, shifting between a

focus on task and a focus on relationship. This involves

the skilled use of opportunities to integrate physical and

psychological care (Bottorff & Varcoe, 1995). Savage's

ethnographic study (1995), which centred on the idea of

nursing relationships involving a unique degree of close-

ness, highlights characteristics such as the use of touch,

humour and metaphor, and the skilful use of interpersonal

space. Similarly, Ersser's study of the therapeutic dimen-

sions of nursing (1991) revealed spontaneous displays of

emotion by nurses towards patients, which were thera-

peutic in effect.

NURSING WITHIN A SOCIAL CONTEXTNURSING WITHIN A SOCIAL CONTEXT

There is an absence in much of the research of a

consideration of the social, environmental and organiza-

tional contexts of nurse±patient communication (Jarrett &

Payne, 1995; Purkis, 1994; Porter & Ryan, 1996). Wards

form microcultures in which personal ideas, attitudes and

values are modi®ed (Wilkinson, 1991). Nursing practice is

strongly in¯uenced by group dynamics, and patients are

cared for by nurses rather than by a nurse (Peterson, 1988).

However, there is evidence that groups of nurses distance

themselves from patients and this may serve as a means of

avoiding the emotional stress inherent in the nurse±patient

relationship (Flaskerud et al., 1979; Marshall, 1980). Spe-

ci®c causes of stress include uncertainty and responsibility,

relationships with patients, relatives, doctors and other

nurses, and role expectations and con¯icts (Marshall, 1980).

If nurses have protected themselves by avoidance and

distancing, then we must question what has happened as a

result of the closer relationships found in patient-centred

and primary nursing. Some nurses experience closeness to

the patient as enhancing satisfaction and reducing stress

40 D. Roberts and J. Snowball

Ó 1999 Blackwell Science Ltd, Journal of Clinical Nursing, 8, 39±47

(Savage, 1995), although others may feel that closeness

makes them feel vulnerable (Roberts, 1998). Clearly, social

and environmental factors mediate the nurse's personal

experience of emotional closeness with patients and this is

likely to affect the delivery of care.

Methodology

AIMS OF THE STUDYAIMS OF THE STUDY

Knowledge is constructed within a social, as well as a

personal context (Silverman, 1985; Denzin, 1989). This

study aimed to uncover the knowledge held by groups of

nurses, gained through experience of how the ward deals

with psychosocial aspects of care. Oncology wards were

chosen because psychosocial aspects of care are recognized

as being prominent. It was felt that staff would be used to

talking about psychosocial issues and have ideas developed

from their experience of working in this specialism. The

research question: `how do nurses working within oncol-

ogy wards understand and describe their approach to

psychosocial aspects of care?' was generated.

RESEARCH DESIGNRESEARCH DESIGN

The phenomenon under study was the socially de®ned

knowledge of ward-based nurses. Social knowledge is a

feature of culture, other features being attitudes, values

and behaviour. The research was therefore conducted

within an ethnographic framework. Ethnography has been

used widely in nursing to study the cultural perspectives

of patients (Leininger, 1987), healthcare settings as

cultures (Germain, 1979), and social processes in nursing

(Ersser, 1991; Savage, 1995). Aamodt (1982) states that

two key assumptions of ethnography, as a philosophical

perspective, are that cultural rules inform social behav-

iour, and that, in studying social behaviour, cultural data

may be abstracted from what people do and from what

they say. A full ethnography, a comprehensive study of a

culture, was both inappropriate, given a narrow focus of

study, and limited by time and resource constraints. An

ethnographic approach was used, i.e. the methods of data

collection and analysis and conceptual framework were

ethnographic (Savage, 1995). Interview was the method

chosen to identify social knowledge expressed in the

language of the culture members, the ward staff.

THE SETTING AND SAMPLETHE SETTING AND SAMPLE

The setting was two medical wards (Ward 1 and Ward 2),

on different hospital sites in the same city, both of which

care primarily for patients with malignant disease. Two

wards were chosen for study to enable comparisons to be

made. Differences between the wards included the nature

of the illnesses and treatments, the age range of patients

(younger on Ward 2), some differences in ward layout

(more single rooms on Ward 2), and the fact that uniforms

are worn by nurses on Ward 1 but not on Ward 2. Fieldwork

was carried out over a period of 6 weeks. Access to both

areas was aided by the researcher having an existing clinical

attachment as a liaison mental health nurse. This is a

specialist area of mental health nursing that provides

consultation services to general adult nurses in a variety of

clinical environments (Roberts, 1997).

The sampling strategy was purposive, selecting partic-

ipants from the wards to maximize the potential for

description and theory development (Field & Morse,

1985). Participants were chosen to represent a breadth of

experience of working on the wards, from 3 months to

7 years, and a range of nursing grades. This achieved a

balance between suf®cient homogeneity to allow open

discussion in the group, and a diversity of views (Morgan,

1988). Demographic criteria were not considered relevant

to sampling in this study as they were less likely than

group dynamics to affect interaction (Stewart & Shamda-

sani, 1990).

DATA COLLECTIONDATA COLLECTION

Interview was chosen as the main mode of data collection

since language is the primary means by which social

knowledge is encoded (Spradley, 1979). The role of

researcher was that of an insider, a participant researcher

with an existing relationship with the sample wards

(Lo¯and & Lo¯and, 1984). This aided the development of

rapport, and facilitated the expression of ideas and

experiences, an important consideration in a time-limited,

interview-based study (Hammersley & Atkinson, 1995).

Focus group interviews were used with a complemen-

tary strategy of individual interviews. Additionally, ward

literature was examined for evidence of formal policies

regarding psychosocial aspects of care. The particular

characteristic of focus groups, in comparison with other

group interviews, is that they stimulate interaction

between participants as well as with the researcher (in

this context, known as the `moderator') and highlight areas

of similarity and agreement and differences and dispute.

They generate a wider range of theoretical material with

an economical use of time and resources. Focus group size

varies between four and 12 participants. Whilst larger

groups have the advantage of representing a wider range of

views they require a higher level of moderator involve-


Psychosocial care in oncology nursing 41

ment (Morgan, 1988). Smaller groups allow participants to

contribute in greater depth from personal experience. The

smallest size of focus group, four members, was therefore

chosen for this study. Homogeneity (through ward team

membership) was higher than in most focus groups, which

meant that only one group was needed in each area. As

group moderator, the researcher maintained a low level of

involvement and a loose structure that favoured the

development of participants' perspectives (Morgan, 1988;

Stewart & Shamdasani, 1990).

Individual interviews were held after a preliminary

analysis of the focus group data. The strategy was to

clarify ideas participants had expressed in the groups,

access individual perspectives and personal experience,

develop and illustrate themes and test the emergent

analysis. This is consistent with what Hammersley &

Atkinson (1995) describe as the research process having a

funnel structure, becoming progressively focused over

time. To aid this process, participants were supplied with

a group interview transcript several days before the

individual interview. They were then asked descriptive

and structural questions, which identi®ed terminology and

the manner and context of their use, and contrast

questions, which clari®ed and quali®ed statements that

the participant had made in the group interview. The

interview style was conversational and informal (Spradley,

1979). Participants were invited to describe speci®c

situations which illustrated their ideas. All interviews

were recorded on audiotape and transcribed by a secretary.

DATA ANALYSISDATA ANALYSIS

The approach taken in this study was that described by

Hammersley & Atkinson (1995), that data collection and

analysis are re¯exive activities, undertaken with a clear

purpose, research questions, and some pre-existing theo-

retical assumptions. Data analysis was performed concur-

rently with data collection. Broad analytic themes were

identi®ed, which had an ad hoc character, in that they

were arbitrary summaries of the data (Denzin, 1989).

These were subsequently revised by re¯ection on the

research assumptions and questions. Highlighted sections

of text were put together in analytic categories with a

software `cut and paste' facility. Their source in the

transcript was identi®ed by a code. A colleague checked

the validity of the categories, and consistency of coding,

with good agreement between the two raters.

FINDINGSFINDINGS

The greatest volume of data was interview transcripts, but

reference was also made to the respective ward philoso-

phies. The following issues were referred to in both

philosophies: open expression of feelings, respect for

individuality, respect for cultural, social, and spiritual

needs, the right to information and partnership in the

planning of care, the need for support, and including the

family and respect for its contribution to care. In addition,

Ward 1 speci®cally mentioned patients' psychological

needs, and recognition of the emotional needs of staff.

Ward 2 stated a commitment to good communication,

trust and friendship, and the need to promote patient

independence. Interview data were organized into ®ve core

categories of social knowledge. These were:

· Knowledge of nursing care,

· Knowledge of patients,

· Knowledge of the ward,

· Knowledge of nurses coping,

· Knowledge of involvement.

KNOWLEDGE OF NURSING CAREKNOWLEDGE OF NURSING CARE

Key therapeutic factors included openness and patient

participation, listening, talking things through, being

available, spending time and respecting individuality. In

both wards participants described psychosocial aspects of

nursing patients as `¼an integral part of their care'. Care

was viewed as taking place within a family context.

Relatives, however, whilst seen as both a source of support

and information, could also be a source of stress. The term

psychosocial was not used by participants. Distinctions

were made between physical and psychological needs and

care, but they were viewed as working hand in hand or as

interrelated:

Yes, because some things about giving information

are just physical aspects of care. That could be just

teaching someone how to do it, although that is sort

of like interrelated so it's sort of like their self worth

that they can do it for themselves and they are

independent, but at the same time it's more of a

physical task¼However, psychological care was provided in a more

informal and spontaneous way than other forms of care:

I don't think you make a conscious decision to

provide psychological care¼You sort of notice it by

talking to patients, how they are reacting to you, how

they are reacting to other members of their family,

other patients, and if they need somebody to listen to

or to talk to¼Talking with patients was felt to enable patients to

express their feelings and disclose fears, and some nurses

felt that this helped to develop a positive attitude and to

stay in control. Openness as both a strategy and philos-



ophy of care was expressed by participants in terms of

open communication, and in patient participation in care

planning and delivery. This was common to both areas,

and was felt necessary for effective patient care:

The majority of them with Hickman lines, they have

to know how to take care of it otherwise we can't

really let them out of the door. They have to know

what to do if something goes wrong or if they have

got a temperature they have to know that they must

call us.

However, implementation of this approach was de-

scribed as needing skill on the part of the nurse in

assessment of how much information the patient is willing

and able to absorb at any particular time:

Or if you have got somebody that's particularly

anxious you wouldn't go into necessarily every side-

effect, or go into it all in-depth whereas you may have

somebody else who may want that information. So

it's assessing what the patients want really.

Another area of skill described was availability; delib-

erately making time available for the patient. This could

be done informally, being with the patient in the course of

routine nursing care, or time and space could be set aside:

It's the little things. You can say to someone, I have

got X, Y and Z to do, but if you give them time by

spending the time, or just arranging the ¯owers, they

appreciate that you might not have time to sit on the

bed and talk to them. but if you are a nurse that can

make time to arrange someone's ¯owers¼it's mak-

ing them aware that when the time is right and you

have got the time you will be able to sit down with

them.

In response to questions about mental health issues,

most participants felt they were not quali®ed to distin-

guish between normal and abnormal reactions to illness,

and between low mood and clinical depression, feeling

these issues were not really addressed on their wards:

When somebody isn't coping maybe we are not so

good at supporting or maybe picking up on it,

because you think that it is abnormal for them to be

feeling that depressed and that low or having

problems, because so many other people cope.

Psychological aspects of care were based on knowledge

of the speciality, and con®dence in basic nursing skills:

¼when you know that the physical care that you give

is the best you can give, then you can move onto

psychological care, helping patients with their emo-

tions, and you know you don't have to worry about

whether you bathed that patient properly or whether

I did that blood pressure properly.

KNOWLEDGE OF PATIENTSKNOWLEDGE OF PATIENTS

Nurses described how individual patients, and patients

generally, experience the healthcare system, primarily how

they react to illness and treatment:

¼and at certain stages of their treatment as well, you

notice. If they come back after maybe four admissions

they could be quieter than they have been before.

Maybe it's because they have had more side-effects or

they don't think they are getting any better.

Patients were also described as actively seeking infor-

mation from each other about illnesses, treatment and

hospital routine:

The patients know that, yes, Fred is having [treat-

ment], `how far is he through his [treatment]?'¼`oh

that's the worst part of the [treatment] and I know

that you are busy'; they know.

KNOWLEDGE OF THE WARDKNOWLEDGE OF THE WARD

Numerous organizational and environmental factors were

reported which had an impact on nursing care. References

were made on Ward 2 to stress as an intrinsic feature of

the ward. This was partly because of the younger age of

patients, but also having more single rooms which made

nursing individual patients more intensive, and also the

absence of a separate staff of®ce. Nurses on Ward 1

expressed frustration at the lack of time and resources.

They reported that often they were called away whilst

with a patient by phone calls or by other patients. Not

only did this compromise care, but it was an additional

stress:

Often somebody is having a really in-depth conver-

sation with you and you are listening and you really

want to be there, but half of you is thinking `my

goodness, that infusion in the next room will be

®nishing soon and the next drug has got to be

up'¼your other patients have a lot of physical and

emotional needs as well and you almost feel torn

three ways.

KNOWLEDGE OF NURSES COPINGKNOWLEDGE OF NURSES COPING

Nurses learned to cope with the stresses of interpersonal

aspects of nursing (e.g. working with distressed patients,

hostility, treatment failure). Individual coping methods

included learning from others, self awareness, having

con®dence in their own abilities, and recognizing limita-

tions and signs of stress:

¼experience and just day to day living with being a

nurse. Seeing how other people cope with it and just



your own personality. How you are. That's how you

cope.

Team coping methods emphasized the importance of

taking time to talk with colleagues and share feelings.

Regular team meetings were felt to be important in both

wards. Nurses also `looked out for' each other, trying to

identify when colleagues were having problems coping,

offering support and giving permission to withdraw from

dif®cult situations. Whilst these strategies were valued in

both areas, there were clearly problems with teamwork on

Ward 2:

It gets to a certain point when you feel that

everybody around you is starting to get burnt out and

then who gives you the support?

KNOWLEDGE OF INVOLVEMENTKNOWLEDGE OF INVOLVEMENT

Participants described developing special relationships

with patients, whereby they became close or emotionally

involved. This occurred by a process described by one

nurse as bonding, and it was considered an inevitable

consequence of the extended periods of time spent

together, in emotionally intimate circumstances. On Ward

2, it was also described in terms of friendship:

You just know so much more about somebody as if it

is a friend that you wouldn't know on a general ward.

You ®nd out so much information about them and

their families.

Considerable emotional investment was required of the

nurses on Ward 2, and demands could be great. Nurses

referred to staff `burning out', and one nurse said she was

leaving because she could no longer cope with it. One of

the problems, felt most acutely on this ward, where

patients were younger, but also mentioned on Ward 1, was

the problem of identi®cation; feeling closer as a result of

being a similar age. As one participant commented, `¼you

can put yourself in [their] position'. Emotional closeness

was referred to as over-involvement if it involved a loss of

professional objectivity:

Too close¼you feel you are becoming too involved

in some ways, especially perhaps after the patient has

died and there are still those ties afterwards and you

are very much a link for those people and where does

your role end really?

This again was reported more on Ward 2, but it

occurred in both areas. Neither ward had clear written

guidelines on involvement with patients. The issue of

managing personal and professional boundaries was de-

scribed as `maintaining a distance' or a `®ne line on which

you tread'. One participant cited a nursing model, Peplau,

as the basis of her professional relationship with patients.

Most had learned from experience:

Because it spills over into your personal life you know

you will have a bad day at work, and you would be

miserable when you are at home, and that spills into

your relationship with friends, partner or what have

you, and in the end it's destructive, and you do learn,

and I think you learn the hard way, that, no, work has

to stay behind when you leave.

Two of the nurses on Ward 2 referred to the absence of

uniforms as a sign that barriers between nurses and

patients had been broken down.

Discussion

Psychosocial aspects of care were described as prominent

in both wards, and this is consistent with statements made

in both ward philosophies. There is also evidence of a

signi®cant and often sophisticated integration of physical

and psychological aspects of care. Many of these features

were related to the length of time nurses and patients

spent together, often over extended or repeated admis-

sions, associated with a degree of closeness and involve-

ment between nurse and patient. It is likely that these are

features not only of oncology wards, but also other medical

wards dealing with chronic illness.

Descriptions of psychological care from both wards

largely fell into consistent categories and there did not

appear to be signi®cant differences in practice. These

®ndings give further evidence of nurses' use of subtle and

informal interactions with patients. An example is the

subcategory of àvailability' of the nurse to the patient,

similar to the concepts of `being with' (Swanson, 1994),

àttending' (Bottorff & Morse, 1994; Bottorff & Varcoe,

1995) and àvailability' described by Ersser (1991).

Many of the skills described by participants in this

study were neither systematically applied nor formally

taught,

¼they are just basic skills that you can learn, and you

learn as you go along in nursing.

Nurses also reported learning psychosocial skills from

experience in Smith's (1992) study of emotional labour.

Con®dence in the performance of psychological care was

based on knowledge of physical nursing care, and

knowledge of the patient and their social circumstances.

It was not based on a systematic assessment of the

patient's psychosocial needs. In two previous studies in

oncology settings (Germain, 1979; Dennison, 1995),

assessment skills were also found to be lacking. The

exception in this study was assessing a patient's need for

information, where skills were well developed. This is not



surprising, as giving information in oncology care is so

well recognized as to be considered a speci®c form of

therapy, called psychoeducational care (Devine & West-

lake, 1995).

INVOLVEMENTINVOLVEMENT

One of the striking ®ndings from this study was that

involvement with patients was perceived by nurses to be

an inevitable and essential characteristic of psychosocial

care. The process by which this occurred, described by

one participant as bonding, was considered to be like

getting to know a friend. Similarly, in a study by Ramos

(1992), respondents described bonds developing between

nurses and patients which were modi®ed social relation-

ships; modi®ed in the sense of being more purposeful and

skilled. Comparing nurse±patient relationships with

friendships is problematic. It encourages identi®cation

with the patient, and this will make emotional demands on

the nurse. This posed particular problems for staff on

Ward 2, where friendship between nurses and patients was

a stated aim of the ward philosophy of care.

Over-involvement was reported as more of a problem

on Ward 2. Emotional demands on nurses can be managed

if they have a clear professional framework, and assess the

patient's needs within this. Otherwise, the nurse is unsure

whether their role is a personal or professional one. This is

illustrated by one participant's question `¼where does

your role end really?' Role ambiguity may contribute to a

lack of job satisfaction and burnout (Duquette et al.,

1994), and there was evidence of nurses experiencing

burnout on Ward 2. This was also in¯uenced by

environmental factors. There was no separate ward of®ce

for staff, and nurses did not wear uniforms. Both of these

features were outward signs that `¼the barriers have been

broken down' between nurses and patients. As a conse-

quence of having no separate of®ce, nurses felt exposed to

patients' demands even when they were having a break or

discussing clinical issues.

The decision not to wear uniforms on Ward 2 had

involved patients, and it was popular amongst both

patients and staff. However, some staff expressed reser-

vations, in that it represented a level of openness with

which they felt uncomfortable. In contrast, nurses on

Ward 1 were clear about the role of the uniform,

¼it does make it obvious that you are the profes-

sional and they are the patient.

Uniforms have a symbolic role in representing the

professional function of the nurse as separate from the

personal (Holland, 1993; Savage, 1995). The important

issue is not whether uniforms should be worn, but that

if they are not worn, how professional authority is

represented in relationships between nurses and pa-

tients.

ACHIEVING A BALANCEACHIEVING A BALANCE

Patient-centred nursing requires a commitment on the

part of the nurse of both self and values. However, an

emphasis on interpersonal aspects of care may make

excessive emotional demands on both nurse and patient

(May, 1991; Ramos, 1992). Closeness must be balanced

with organizational demands for the effective use of

professional knowledge and skill. In Ramos' study (1992)

the most effective level of involvement was mediated by a

process of understanding, an assessment of the patient's

needs requiring a degree of emotional objectivity.

Participants frequently associated interpersonal factors

with stress, expressed as patient and family hostility, the

experience of patients' loss, and the emotional cost of

involvement. This suggests that the psychosocial aspects

of care are the most stressful. In previous studies

(Flaskerud et al., 1979; Marshall, 1980), avoidance behav-

iour has been identi®ed as a means by which nurses

protect themselves against the stress of emotional involve-

ment and other occupational demands. This study, using

neither the patient's perspective nor observational data

collection methods, could not identify avoidance. How-

ever, the potential for emotional depth in an interaction

was frequently inhibited by lack of time, resources,

con®dence or skill. This may lead to a sense of detachment

from the patient's problems, and inhibit the development

of therapeutic levels of involvement.

This study supports previous ®ndings that involvement

with patients should achieve a balance between the

interpersonal and the professional. Closeness represents

the optimum state of nurse±patient involvement, as it was

associated in both this study and Savage's (1995) with a

range of therapeutic nursing activities. As closeness can

place emotional demands on the nurse, it should also be

accompanied by adequate support. Nurses who break

down the barriers between nurse and patient will need to

balance this with clarity of role and the necessary

knowledge and skills, otherwise relationships with patients

are in danger of becoming either excessively personalized

(over-involved) or depersonalized (avoidant). Personal

over-involvement is associated with a loss of professional

objectivity and burnout, and avoidance is associated with

emotional distance from the patient. The optimum level of

involvement is closeness associated with understanding of

the individual patient's psychosocial needs, based on

assessment (see Fig. 1).



Conclusions

Psychosocial aspects of nursing are central to practice.

They should continue to be emphasized, but placed within

a clear professional framework and incorporated more

fully into educational programmes. The social knowledge

of this sample of ward nurses included a complex interplay

of interpersonal, professional, institutional and environ-

mental factors. Environmental factors had an impact on

the social process of care by in¯uencing relationships

between patients and staff and in their capacity to produce

additional stresses. Working patterns had a reciprocal

relationship with psychosocial care, to the extent where

they enhanced or compromised nurse coping behaviours.

Wards are complex social environments which have a

profound effect on patient care and they would bene®t

from further study.

Acknowledgements

Mr Roberts thanks the Newby Trust and the Barbers

Company for their ®nancial support of this project.

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