Joan L. Bottorff

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DEVELOPING THEORY USING MIXED METHODS: PATTERNS OF ATTENDING IN NURSING

                The amount of relief and comfort experienced by the sick after the skin has been carefully washed and dried, is one of the commonest observations made at a sick bed.

—Nightingale (1860, p. 93)

Caregiving in nursing is a complex phenomenon. Descriptions of nurse caregiving as a process of interaction began with early theorists (Orlando, 1961; Peplau, 1952; Travelbee, 1966; Wiedenbach, 1964). In response, researchers began to describe, operationalize, and measure nursing interactions. In 1977, Diers and Schmidt classified the rapidly expanding research on nurse–patient interaction (NPI) as: (a) descriptive or correlational studies, (b) studies that measure the indices of nursing using hypothetical interactions, and (c) studies that describe or evaluate nursing interaction using conceptual frameworks and measurement tools from other disciplines (Diers & Schmidt, 1977). Some researchers recognized the problems inherent in using borrowed frameworks and instruments to capture relevant clinical data. To obtain findings more germane to nursing theory and practice, researchers were challenged to design instruments and studies specifically for examining NPIs.

Investigators continued to study those aspects of NPI that were quantifiable using predominately deductive approaches with increasingly sophisticated techniques. However, the results were often discouraging. In general, although some researchers continued to provide indications of the positive effects of various types of NPIs, others reported that NPIs were seriously limited in practice and that nurses lacked effective communication skills (Bottorff & Morse, 1994). Although many factors influence the quality of NPIs in clinical practice, two important limitations of this research must be considered: First, the focus of this research has been on single channels of communication (verbal or nonverbal) despite the fact that a multichannel perspective is necessary to capture the variations in interactions. Second, it is unlikely that insightful accounts of the unique styles of interaction that are characteristic of nursing practice can be obtained using deductive accounts when the context that influences NPIs is ignored, the complexity of encounters is not taken into account, and research is based on communication theories that are derived from contexts that differ from nursing practice in important ways.

Influenced by the acceptance of qualitative research methods, researchers began to explore NPIs using a variety of new approaches. These methods compensated for the limitations of earlier studies in that more comprehensive accounts of the dynamics of the interaction and context are facilitated and a means for obtaining insight from both the patient’s and nurse’s perspective is provided. The result was that in the early 1990s, descriptions of NPIs that are closer to the day-to-day realities of nursing and the identification of previously unrecognized competencies emerged (Estabrooks, 1989; Estabrooks & Morse, 1992; Hunt & Montgomery-Robinson, 1987; Hunt, 1991; McIntosh, 1981; Morse, 1991; Pepler, 1991; Pepler & Lynch, 1991).

Developments in audiovisual technology provided the opportunity to capture rich permanent records of NPIs that could be obtained for subsequent frame-by-frame, and real and slow-time analysis. This made it possible to simultaneously analyze a wide range of verbal and nonverbal behaviors. The use of audiovisual technology along with qualitative research methods enabled a comprehensive approach to the study of NPIs, and the means to study the details of the encounters to advance the development of theory regarding NPIs. The purpose of this chapter is to describe a study that took advantage of these developments to develop a model of NPI and in doing so demonstrate the value of qualitatively driven, mixed-method approaches in theory building in nursing.

THE STUDY OF NURSE–PATIENT INTERACTIONS

The focus of this study was on exploring and describing NPIs that involved touch episodes. Video-ethological methods were used to inductively identify the types of NPIs in which touching behaviors were used (Bottorff, 1994a). Ethology is a method used to identify complex behavioral patterns through systematic observation and description under natural conditions (Morse & Bottorff, 1990), characteristically beginning with an inductive phase. Ethologists often build on this phase to conduct more structured deductive and quantitative investigations. The objectives of this mixed-method study using this approach were to: (a) inductively derive a comprehensive description of NPIs from naturalistic videotaped observations, (b) to verify and extend qualitative descriptions of NPIs by conducting semistructured interviews with patients and nurses using videotaped data to prompt discussion, (c) to develop a detailed coding system based on the qualitative findings to capture significant verbal and nonverbal behaviors in NPIs, (d) to evaluate the use of the coding scheme to determine whether the patterns of NPIs can be identified in different samples of NPIs, and (e) to demonstrate the utility of the identified patterns of NPIs by exploring variations in response to patient state and transitions in patterns of NPIs.

Capturing Routine Nurse–Patient Interactions

Data Collection

First, videotaped data of NPIs were collected. To maximize observations of various types of interactions involving touch, patients who required a high proportion of nurse–patient contact (e.g., patients who experienced pain and nausea) were invited to participate. The convenience sample included 8 cancer patients (three females, five males) and 32 nurses who were assigned to provide care (Bottorff, 1994b). Informed consent was obtained from all participants who were told that the observations would focus on verbal and nonverbal behaviors of nurses without emphasizing the researchers’ interest in touch.

Videotaping was done in a private room on an active treatment oncology ward. The cameras ran continuously at slow speed for 72 hours for each patient. Taping was only discontinued for brief periods at the request of patients (usually to provide privacy during particular caretaking activities) or when staff members who did not wish to be involved in the study entered the room. A total of 1,085 interactional units delineated by the entry and exit of the nurse (average duration 1.9 min) were collected. Tape-recorded unstructured interviews with patients and selected nurses were conducted to complement the videotaped, observational data. One nurse who cared for each patient was selected to be interviewed to explore segments of the videotape in which he or she appeared to elicit perceptions of the interaction and, specifically, the purpose of the nurse–patient touch and the perceived effect of the touch. Following completing of the videotaping, eight nurses were interviewed. With the exception of the first two patients who were part of a pilot study and were not interviewed, the remaining six patients participated in a similar interview 3 to 10 days after each was videotaped.

Data Analysis

Data analysis of the videotapes began with the development of an ethogram, which is a detailed textual description of the behavior patterns under study were identified qualitatively (Eibl-Eibesfeldt, 1989; Martin & Bateson, 1986). Videotaped interactions were played and replayed to observe major behavior clusters in interactions involving touch. The researchers assumed an inquiring attitude toward the data in order to delineate distinct interactional segments, asking themselves questions such as, “What is going on here?”, “How does this interaction differ from that interaction?”, and “What are the characteristics of this interaction?” Intensive examination of the videotaped interactions enabled other instances of similar interaction patterns to be located. Specific recurring behavioral patterns were then delineated by continuing to compare and contrast interactional segments. For example, it was noted that NPIs differed by the amount of nurse–patient proximity, the degree to which the nurse focused on a patient and caretaking tasks, and the way in which patients participated in the interactions. Units of interaction that shared particular characteristics were grouped and the properties of each group were listed and described. In addition to the characteristics of behavior, the descriptions included interpretations of the functions, conditions, and consequences of each behavior and variations in techniques.

Four patterns of behavior, referred to as “types of attending” were identified as the structural units of NPI (Bottorff & Morse, 1994). These patterns were doing more, doing for, doing with, and doing tasks. The types of attending used by a nurse could change several times during a single interaction simulated by a patient’s behavior. Factors influencing type of attending were the perceived needs of the patient, the nature of the task, time constraints, and the sensitivity of the nurse. With the exception of doing for, the types of attending were not task specific. The characteristics of each type of attending were distinct in terms of focus, eye gaze, intent, nurse–patient relationship, time/task ratio, nature of the dialogue, tone of voice, and type of touch (see Table 26.1). Although nurses and patients were not asked to comment on the types of attending during interviews, data from these interviews provided some support for this classification and insight into these types of attending from the perspective of both patients and nurses. Transcripts of verbal interactions captured on videotapes were used to demonstrate how the characteristics of each type of attending were played out in everyday interactions between nurses and patients. Although these examples are limited to the extent that they emphasize the verbal interaction and underplay the contribution of nonverbal behaviors, they provide helpful exemplars. Five types of touch were also identified and described: comforting touch, connecting touch, working touch, orienting touch, and social touch (Bottorff, 1993).

A MODEL OF NURSE–PATIENT INTERACTIONS

The four types of attending identified from the videotaped interactions provide a model for describing the interactional context of the touch events (Bottorff & Morse, 1994). Each is described below.

Doing More

The first pattern of behavior, doing more (making contact), was a type of attending in which the nurse “did something” beyond what is usually required to complete care. It was characterized by an engaged relationship between a patient and nurse, and was used when the nurse was making contact or trying to “reach out” to the patient. The nurse might have been physically closer or have taken more time than was usually required, although attending interactions of this type may be brief. This type of attending could occur with or without a task and was characterized by an intense focus on the patient. The nurse’s attention often provided the patient with an opportunity to confide in the nurse. Videotaped observations indicated that this type of attending was also characterized by concerned acknowledgment of patient concerns and symptoms, and an attempt to understand a patient’s experience in order to provide more care. It was frequently, but not always, associated with patient distress or discomfort.

As nurses were providing care, working touch occurred frequently in all four types of attending. However, in doing more, the tone of the interaction was different. It was more intimate, and more focused on the patient, as evidenced by the use of comforting, connecting, and orienting touch along with working touch. The following excerpt from one interaction provides an example of a doing more type of attending.

Interview data about similar interactions with patients fit with a doing more type of attending. These data underlined the importance of focusing on the patient as well as the factors that influenced engagement with patients.

The engaged interaction that was characteristic of doing more was often referred to by nurses as being “close” to patients. Nurses identified the following factors that influenced how close they were able to get to patients: how well they knew the patient, how comfortable the patient was with them, the intimacy of the nursing procedure that they provided, their workload, whether the patient had any immediate family to support them, and the level of patient distress. Interview data with patients provided evidence that patients recognized and appreciated this type of personalized care.

Doing For

The second type of attending, doing for, was evident when the nurse was primarily occupied in responding to patient requests and needs that were not treatment-related. It was characterized by a personalized approach to assistance. It often involved extras, such as organizing the patient’s room so that things were in easy reach. However, the time a nurse spent with the patient was limited to that necessary to complete a task. These activities sometimes led to interactions in which a pleasant, considerate nurse attempted to understand a patient’s personal experience of illness, but these interactions were not part of doing for. Doing for attending was characterized by the use of working and connecting touch, although comforting and orienting touch occurred in rare instances.

The following excerpt reflects the type of interaction that was characteristic of doing for:

In the interviews, nurses talked about trying to be “more personable and friendly” by doing “a lot of little things” for patients. They tried to keep the patients’ surroundings neat and uncluttered, put things within easy reach, helped them find comfortable positions, assisted with their grooming, provided extras such as colourful quilts, rubbed their legs or back, or just took time to chat. Nurses explained that during these interactions they tried to give patients as much control as possible, a point that some nurses believed was very important considering that much of the time patients had very little control over the care they were receiving. Patients appreciated the friendly way nurses did things for them and the time, no matter how short, that nurses spent “just chatting.”

Doing With

The third type of attending, doing with, was evident when nurses focused equally on the task and patient. This type of attending was characterized by a willingness to work cooperatively with patients. For example, the nurse may have actively engaged a patient by seeking or attending to his or her opinions, thoughts, and perceptions. The nurse often used eye gaze to focus on the patient and reinforce interest in the patient; however, the gaze might have been broken to attend to activities or tasks. In this type of interaction the patient was alert and able to cooperate. The nurse was friendly and used a tone of voice that was conversational. In this type of attending, working touch predominated, although orienting touch was most likely of all the other touches to be used along with working touches. Connecting touches occurred less often than orienting touch and comforting touch was seldom used.

In the following excerpt, the patient had requested a hot pack for abdominal discomfort and the nurse returned with the hot pack and a sphygmomanometer:

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