Deborah Finfgeld-Connett
30
META-SYNTHESIS OF NURSING PRESENCE1
META-SYNTHESIS OF NURSING PRESENCE
Due, in part, to its spiritual and philosophical underpinnings, nursing presence is a complex concept that is vague and difficult to delineate (Smith, 2001). It is often confused with other concepts such as caring, empathy, therapeutic use of self, support, and nurturance (Gardner, 1992). Adding to this confusion is the finding that presence has been fragmented into numerous types (e.g., Easter, 2000; Osterman & Schwartz-Barcott, 1996), used indiscriminately (Smith, 2001), and combined with other concepts such as caring (e.g., Covington, 2003; Engebretson, 2000; Nelms, 1996). Currently, the concept of presence has unclear boundaries and is poorly defined (Doona, Haggerty, & Chase, 1997; Osterman, 2002).
Despite this lack of clarity, presence is a component of several nursing frameworks (e.g., Humanistic Nursing [Paterson & Zderad, 1988]; Human Science and Human Care [Watson, 1988]; Science of Unitary Human Beings [Rogers, 1990]; Human Becoming [Parse, 1998]), and its significance to nursing has been extolled by numerous scholars (e.g., Chase, 2001; Doona et al., 1997; Engebretson, 2000; Gardner, 1992; Hines, 1992; Osterman, 2002; Osterman & Schwartz-Barcott, 1996). For these reasons and in order to ensure the ongoing emergence of nursing theory and knowledge, it is important that the concept of presence be further clarified.
To accomplish this goal, it has been recommended that substantive findings related to the concept of presence be synthesized (Smith, 2001). Although findings from one synthesis (Fredriksson, 1999) already existed, studies related to the phrase caring presence were included in the data analysis. In addition, several recent works related to presence were not available at the time it was carried out. Thus, a meta-synthesis of qualitative findings related to nursing presence was conducted. These findings are reported in this chapter.
METHODOLOGY
Meta-synthesis methods for this investigation were adapted from Finfgeld (2003). Meta-synthesis is a research method that is used to rigorously study qualitative findings (versus raw data) and results in reconceptualizations of original conclusions (Finfgeld, 2003). Meta-synthesis is restricted to the analysis of qualitative findings; thus, quantitative results were not included in this study.
Based on familiarity with the existing literature related to presence, it was surmised from the outset that coding categories could be saturated based on findings extracted from the nursing literature; thus, data from other disciplines were not included in this investigation. It was also deemed important to limit the sample to findings within nursing because the ultimate goal of this concept development study was to move toward the formulation of nursing-specific theory. This perspective is in keeping with Penrod and Hupcey’s (2005) contention that use of multidisciplinary literature may result in overgeneralization of findings.
The nursing literature was searched using the electronic version of Cumulative Index to Nursing and Allied Health Literature (CINAHL). All available years were reviewed (1982–2005) using the key words presence, concept analysis, qualitative studies, grounded theory, phenomenology, and ethnography. The results were limited to English language publications. Dissertation Abstracts (1861–2005) was searched online using the combined key terms presence and nursing. Books related to nursing presence were located using the Missouri Bibliographic Information User System (MOBIUS), a search engine that links multiple academic libraries throughout the state. In combination, these electronic searches resulted in over 1,300 references, which were individually reviewed for possible inclusion in this study. Reference lists of articles, dissertations, and book chapters were also scanned for relevant documents.
Criteria for inclusion in this study consisted of results from concept analyses and qualitative studies of presence that used established data analysis methods. Use of findings from differing epistemological perspectives (e.g., concept analysis, phenomenology, grounded theory) was deemed as a strength due to their complementary nature (Finfgeld, 2003). Anecdotal discussions of the concept along with qualitative analyses that labeled the concept post hoc were excluded.
Analyses and studies of the phrase caring presence were excluded, because caring has not been fully conceptualized (Brilowski & Wendler, 2005; Smith, 2001), caring and presence are easily confused (Gardner, 1992), and the two constructs require differentiation (Covington, 2002, 2003; Gilje, 1993). It is anticipated that results from this meta-synthesis will help to delineate presence so that it can be better differentiated from concepts such as caring, empathy, therapeutic use of self, support, and nurturance.
Four linguistic concept analyses and 14 qualitative studies of presence were included in this study (see Table 30.1). Investigations were not excluded based on quality, since universally accepted and empirically reliable criteria for evaluating qualitative studies for use in meta-syntheses do not exist (Sandelowski & Barroso, 2003). In addition, valuable data can be inadvertently excluded based on unnecessary restrictions (Sandelowski, Docherty, & Emden, 1997). The qualitative studies included in this investigation reflect the perspectives of staff (primarily nursing staff), patients, and significant others.
TABLE 30.1
Publications Included in Meta-Synthesis
AUTHOR(S)/YEAR | TYPE OF INVESTIGATION | DATA SOURCES |
Benner (1984) | Qualitative | Nurses |
Cavendish et al. (2003) | Qualitative | Nurses |
Doona, Haggerty, and Chase (1997) | Qualitative | Nurses |
Duis-Nittsche (2002) | Qualitative | Nurses, patients |
Easter (2000) | Concept analysis | Literature |
Fuller (1991) | Qualitative | Nurses |
Gilje (1992) | Concept analysis | Literature |
Gilje (1993) | Qualitative | Patients |
Hemsley and Glass (1999) | Qualitative | Nurses |
Hines (1992) | Concept analysis | Literature |
MacKinnon, McIntyre, and Quance (2005) | Qualitative | Patients |
McKivergin and Daubenmire (1994) | Concept analysis | Literature |
Miller and Douglas (1998) | Qualitative | Nurses |
Mohnkern (1992) | Qualitative | Nurses |
Osterman (2002) | Qualitative | Nurses, patients |
Pettigrew (1988) | Qualitative | Family |
Savenstedt, Zingmark, and Sandman (2004) | Qualitative | RNs, nursing staff |
Wilson (1986) | Qualitative | Staff, documents, film |
Identical data analysis methods were used for findings from all studies, regardless of their epistemological origins (e.g., concept analysis, phenomenology, grounded theory, etc.). Each reference was carefully studied and findings were highlighted. After reading only a few documents, in vivo and metaphorical codes emerged, which provided a beginning structure for data analysis. In keeping with methods suggested by Finfgeld (2003) and grounded theory strategies (Strauss & Corbin, 1998), the initial coding structure was shaped by Walker and Avant’s (2005) broad process categories (i.e., antecedents, attributes, and consequences). Outside of offering a structure for coding, Walker and Avant’s (2005) methods were not used to conduct this investigation.
Ongoing analysis of the findings was accomplished using an electronic matrix; codes and categories were added, combined, and deleted. Substantive categories and codes that were saturated were subsequently synthesized and translated to create a model. Links among constructs were explicated with the assistance of written memos and diagrams, and a new interpretation of nursing presence was formulated.
FINDINGS
Nursing presence is an interpersonal process that is characterized by sensitivity, holism, intimacy, vulnerability, and adaptation to unique circumstances. Potential recipients demonstrate a need for and openness to presence, and nurses are willing to enact it. To engage in presence, nurses must possess personal and professional maturity, and their nursing care must be based on moral principles of commitment and respect for individual differences. They must also practice within an environment that is conducive to presence.
Presence results in enhanced mental well-being for nurses and patients and improved physical well-being for recipients. In keeping with the nature of a process, the outcomes of nursing presence go on to influence its enactment in the future. These findings are illustrated in Figure 30.1 and are discussed in detail throughout the remainder of this article.
Attributes
Presence consists of a process that is enacted in moments or over days, weeks, and years (Fuller, 1991; Gilje, 1993; Hines, 1992; Mohnkern, 1992; Miller & Douglas, 1998; Wilson, 1986). Given extended periods of time, a rhythmic pattern of presencing develops between the nurse and patient (Easter, 2000; Gilje, 1993; Miller & Douglas, 1998; Osterman, 2002). This process is characterized by interpersonal sensitivity (Doona, Chase, & Haggerty, 1999; Duis-Nittsche, 2002; Gilje, 1993; Hemsley & Glass, 1999; MacKinnon, McIntyre, & Quance, 2005; Pettigrew, 1988) and is holistically focused on each individual’s physical, psychological, and spiritual well-being (Doona et al., 1999; Duis-Nittsche, 2002; McKivergin & Daubenmire, 1994).
