Health Science Journal

Keywords

nurses, definition of nursing, qualitative content analysis, Greece

Introduction

In the nursing literature it has been often noted that the definition of the term “nursing” is not just another word in the dictionary, or just one more paragraph of a nursing text book or of a nursing theory. To the contrary, it is a vital parameter of the social and professional expression of the nursing profession. The way in which nursing care is offered is a reflection of the nurses’ perception of the definition of nursing, which also affects the nurses’ professional identity (Kahn & Steeves 1988, Cook et al 2003). This element is important for the delivery of nursing care. Since care is the essence of nursing, care should be clearly defined in the predominant definition of nursing for each country (Waterman & Waterman 1976, Watson 1996, Kapborg & Bertero 2003). Several authors have tried to describe how nurses perceive the term nursing and their professional identity (Öhlén & Segesten 1998, Onodera & Hatano 1991).

The concept of nursing in Greece, as well as in other countries, is often considered a concept borrowed from the U.S.A. (Hisama 2000, 2001, Pang et al. 2004) because it was there that the scientific dimension of Nursing started to develop in the 20th century (Rogers 1970, Jonson 1974, Watson 1985, McFarlane 1986, Parse 1987, Meleis 1997). Nurse academics knew from early on that in order for nursing to attain an independent scientific and professional entity it should first answer the question “What is nursing?” with a clear definition and a theoretical framework (Reilly 1975, Rafferty 1995, Salvage & Kershaw 1986, Kershaw & Salvage 1990, Silva 1999, Taylor 1997, Gortner 1993, Kikuchi 1997,2003,2004, Edwards & Liaschenko 2003, Sapountzi? Krepia 2004a).

In the 20th century, many nurse theorists all over the world worked on re?defining the nature of nursing and many nursing theories emerged, providing a unique knowledge?base for the practice of nursing and offering definitions for the concept of nursing (Henderson 1969, Rogers 1970, Watson 1985, King 1988).

Henderson (1978) emphasized that different international and national organizations, as well as governments, continue to define nursing in different ways. She also stressed that nurses will continue to discuss about the definition and the dimensions of nursing, as long as the nursing personnel get trained differently and are charged with different responsibilities and roles in the health care system. Henderson (1978) also supported that nurses have a continuing interest in the concept of nursing, because their self?image as nurses is in contrast with the social image of nurses. The reason for this might be that what they do in their daily practice is often different to what they, as well as society, believe they should be doing.

In the U.K. skepticism was expressed about whether there should be an official definition of nursing. More specifically, in 1999 the “United Kingdom Central Council for Nursing, Midwifery, and Health Visiting” (U.K.C.C.) mentioned that it was difficult for someone to reach a common definition of nursing and concluded that: "a definition of nursing would be very restrictive for the profession" (U.K.C.C. 1999). It is also worthwhile to note the fact that the American Nurses Association (A.N.A.) only issued a definition of nursing at the end of the 20th century (Lavi 2003).

Nevertheless, a definition of nursing is necessary in order to form the health policy, to determine the health services, and to develop nursing study programs. Clark & Lang have noted that "…if we cannot define something, we cannot control it, fund it, research it, teach it or introduce it in public policy" (Clark & Lang 1992).

There is however a concurrence among the international nursing community on the importance of the efforts to clarify concepts, such a the concept of nursing, and the factors that influence the social image of nursing in different countries (Bishop & Scudder 1996, Bradshaw 1998, Blais et al. 2002, Kim 1996, Meleis 1997, Casazza 2000, Fawcett 2000).

The term “nursing” in Greece

The definitions of nursing that are found in Greek nursing text books are usually translations of definitions from international literature. The most commonly used definitions of nursing originate from the American Nurses Association (A.N.A. 1995) and the International Council of Nurses (I.C.N. 2003).

The Hellenic Nurses Association (H.N.A.) has always been adopting definitions from the International Council of Nurses. Providing a national definition of Nursing has never been attempted. This fact, combined with the nursing staff shortage and the lack of a systematic informing of citizens about the nurses’ contribution to the Greek society, does not help the Greek society to comprehend nurses’ exact professional and social role.

This inability to grasp the width of nursing interventions, is characteristically reflected in the definitions of Nursing provided by Greek dictionaries, such as the definition of the “Major Dictionary” of Tegopoulos & Fytrakis (1997) which states: “Nursing is the art or the practice of caring for injured or ill” and the dictionary of Babiniotis (2002) which next to the word “nursing” states: “... the art and the science of pharmacomedical treatment and of care of patients, people with special needs and generally of incapable people according to the instructions of the specialist doctors”.

A careful analysis of these definitions makes it clear that the nursing role, as it is understood by the Greek society (since the lexicographer projects the meaning of the words not only from a scientific point of view, but also in the way they are understood through their use by the public), is limited to offering nursing care to the ill and injured. The first definition there is no mentioning of the nurses’ role in prevention, health promotion, and maintenance of the health status of individuals and groups of people, while the scientific dimension of nursing is totally omitted. In the second and newer definition we observe on one hand an improvement, since it mentions the scientific dimension of nursing, but on the other hand, there is still no mentioning of the role of nursing in prevention, health promotion, and maintenance of health. While, adding the phrase “according to the instructions of the specialist doctors” deprives nursing of any autonomy.

Therefore, the need for a definition of nursing in Greece seems to be imperative for the nurses themselves, as well as for the Greek citizens. The Greek citizens are the users of the nursing services and, without knowing exactly what is the meaning of nursing, they do not know what services can be offered by nurses and what they should expect from them. So, defining the meaning of nursing, as Greek nurses perceive it, will be very beneficial for nursing in Greece.

Aim of the study

The aim of this study was to investigate how nurses in Greece perceive and define the concept “nursing”.

Methodology

Instrument

A questionnaire was developed by the researchers in order to explore how nurses perceive and define “nursing”. This questionnaire was divided into two major parts: (1) the first part included questions for eliciting information about the social, employment, and demographic characteristics, and (2) the second part included items about the participants’ understanding of the perceived social status of nursing in the Greek society. The last question of the instrument was an open?ended question asking the participants to give their own definition of nursing, which reflects their personal understanding of the term nursing, without trying to recall a standardized definition which has been taught to them or which they have read in nursing textbooks or articles.

In this paper we present the results of the analysis of the answers provided to this last open?ended question.

Ethics

The Nursing Department of the Technological Educational Institute of Thessaloniki, acting as an Ethics Committee, approved the protocol of this study and written informed consent was obtained by the participants.

Participants

Our sample consisted of nurses (n=291) working in hospitals in eight major cities situated in northern Greece, as well as of students (n=172) of the Nursing Departments of two Technological Educational Institutes (T.E.I.).

Data collection and data analysis

Written information about the purpose of the study and about confidentiality issues was distributed to all potential participants. They were asked to give their informed consent in order to take part in the study. Then, 1,500 questionnaires were distributed to the hospital nurses and nursing students who agreed to participate in the study. Finally, 1,005 questionnaires were returned to the researchers.

However, not all participants offered a response to the last question of the questionnaire and therefore, we received 603 statements; 385 from nurses and 218 from nursing students. Furthermore, 94 of the nurses’ statements and 46 of the nursing students’ statements were excluded from the analysis because they were not actually answering the question asked. So, we proceeded with analyzing 463 statements (291 from nurses and 172 from nursing students).

Qualitative research uses analytical categories to describe and explain social phenomena. These categories may be derived inductively, that is obtained gradually from the data, or used deductively, either at the beginning or part way through the analysis as a way of approaching the data (Pope et al. 2000).

The 463 statements were typewritten and a content analysis was conducted. Content analysis is designed to classify the words from a text into categories chosen because of their importance (Burns & Grove, 2005). The statements were carefully read by two of the researchers several times in order to familiarize themselves with the data and for achieving a thorough understanding of the material. Then, the two researchers independently made lists of categories according to their codes by classifying the participants’ responses. Next, they met and discussed the categories and necessary adjustments were made in order to form a mutual final list of categories.

Results

Four hundred and sixty three (n=463) participants (291 nurses working in hospitals and 172 nursing students) gave their definition of nursing. The mean age of the sample was 31.36±9.99 years old (minimum age: 18 years old, maximum age: 60 years old).

The content analysis of the participants’ statements resulted into the following six categories: (1) nursing as an occupation or service, (2) nursing as science or art, (3) nursing as offering of care, (4) nursing as physical and psychological support, (5) recipients of nursing, and (6) nursing in relation to prevention and health promotion. The final categories and the codes that derived from the data analysis are illustrated in Figure 1.

Figure 1: Categories and codes of nursing definition

Category 1: Nursing as an occupation or service

Some of the participants characterize nursing exclusively as an occupation. For them it is a way to make a living; it is what they do in their everyday life. They mentioned that this occupation is multidimensional (it includes nursing diagnosis, treatment, nursing care) and that it requires cooperation with other health care professionals.

“Nursing is an occupation…” (206)

Nevertheless, some of the participants support that nursing is a profession which requires in?depth knowledge and many virtues.

“No other occupation combines as many virtues and as much knowledge as nursing!” (70)

However, many of the participants prefer to characterize nursing as a service. For them nursing is more than an occupation or a profession. They do not practice nursing just to make a living. They practice it because they want to offer. For those participants nursing is strongly connected with offering to their fellow?man.

“Nursing is a service that is practiced for the patients’ care and recovery and for better quality of life for the fellow men who suffer from a disease” (129)

In addition, there are cases where nursing is characterized by the same participant as both a profession and a service. Those participants generally recognize nursing as a profession, but they believe that for those who practice it consciously and love their fellow?man it is a service and not just an occupation.

Category 2: Nursing as science or art

Several participants, mostly those who are students, define nursing as a science; a science that aims at patients’ treatment or at their rehabilitation.

“Nursing is a science aiming at rehabilitating the patient physically, psychologically and spiritually” (15)

They also emphasize that it is a science that demands a lot of knowledge. Some of them note that apart from knowledge, this science is also based on experience.

“Nursing is a science based on theory and experience” (45)

Some participants consider nursing a branch of medicine.

“Nursing constitutes the right hand of medicine” (72)

On the other hand, there are those participants that do not consider nursing a science, but an art. For them, nursing is not so much based on the theoretical and practical knowledge that the nursing students acquire during their studies, but on the knowledge, competence, and experience that they obtain while practicing nursing. They stress mostly the necessity for nurses to have specific competencies, technical knowledge, good judgment, and communication skills.

“Nursing is an art that requires specific skills and experience” (272)

Finally, there are cases where nursing is characterized both as science and as art. There are participants who support that nursing demands equally scientific knowledge and technical competencies. For them, both are necessary elements that together form nursing.

Category 3: Nursing as offering of care

The majority of the participant nurses associate nursing with some form of offering to their fellow?man or to the patients. In their answers we frequently find words such as: “offer”, “love”, “help”, “care”, and “nursing care”. They consider nursing primarily as an offering of care and support. They connect it to love towards their fellow?man. They believe that if someone does not love human kind and does not have the wish to help, to care for, to offer, then he/she cannot practice nursing.

“Nursing is those acts that aim at diagnosis, treatment, hospitalization, evaluation and care of the patient” (6)

“Nursing… allows you to love, to care for the fellowman, and to come closer with people” (71)

“Nursing is…an offering to human beings…” (325)

Others clearly state that nursing is care.

“Nursing is…the care of human beings” (292)

“Nursing is care…” (329)

Category 4: Nursing as physical and psychological support

It is particularly important that several participants note the patients’ need for both physical, as well as psychological support. They identify two dimensions of health: the physical and the psychological; and they support that nurses should take them both under consideration when offering their services. They state that nursing actions must aim at improving the patient’s psychological and spiritual state. They mention that nursing is related to communication. Its objective is to satisfy the patient’s needs and lead to his/her relief.

“Nursing…contributes to maintaining people’s health (physical and psychological)” (3)

“Nursing…aims at rehabilitating the patient physically, psychologically, and spiritually” (15)

“It is the treatment not only of the bodily organs but of the person’s soul as well through genuine communication…” (71)

Category 5: Recipients of nursing

In the participants’ answers we see that the “providers” of nursing care are always nurses, but the “recipients” of nursing care can be different groups of people. In the vast majority of the answers we find words such as: “patient”, “sick”, or “fellow?man”. This indicates that Greek nurses associate nursing with disease, sickness, illness. Even in those cases where they use the word “fellow?man” it is obvious by the rest of the text that they mean the fellow?man who is facing some kind of problem and not a healthy person.

Nevertheless, some participants also mention the patient’s relatives as recipients of nursing care.

“I believe that nursing… has as main aim… the psychological support of the patient and his relatives” (20)

“Nursing… offers care, treatment, comfort and support to patients and relatives” (206)

It is interesting that, even though in Greek hospitals the presence of relatives and friends is particularly noticeable, the majority of the nurses and nursing students who participated in this study did not mention that the services they offer are also directed towards relatives and friends.

Finally, in 4 cases healthy people are mentioned as recipients of nursing.

“…support of a human being, not only of patients, but also of healthy people” (142)

Category 6: Nursing in relation to prevention and health promotion

Only 12 of the nurses and 4 of the nursing students who participated in this study included in their definitions of nursing words such as “prevention”, “health promotion”, “health education”, and “providing information”.

“…as well as providing information about prevention and about maintaining a healthy lifestyle” (20)

“Nursing… is essential for prevention” (72)

“Nursing… aims at health promotion and maintenance of the patients’ health” (309)

It is apparent that the participants did not consider prevention and health promotion activities as an inseparable part of nursing.

Finally, we should mention that four of the nursing students included research in their definitions of nursing.

Discussion

This qualitative study has contributed to the clarification of the concept of “nursing” as perceived by Greek hospital nurses and Greek nursing students living in Thessaloniki and in near by cities in the geographic area of Thessaly and of Macedonia of Greece. Although the findings cannot be generalised, they are helping us to achieve a better understanding of the concept.

The concept of nursing is multidimensional and according to the analysis of the participants’ statements, nursing is perceived to have six components that describe the content of practicing nursing and the relation of nurses with the patient. It is similar to the definitions that have been at times expressed by different nursing associations and organizations (I.C.N. 2003, A.N.A. 1995).

One characteristic of the way that few participants defined nursing, and which seems to differentiate them from the rest, is their reference to patients’ relatives. As Sapountzi et al. (2006) have mentioned the informal care that relatives offer to their patients characterizes the Greek health care system.

Nursing is characterized by some of the participants as an occupation, as a way to make a living. Nursing is also considered a profession that requires in?depth knowledge and many virtues. This is in accordance with the argument of several authors that the characteristics of the profession are its unique body of knowledge and the offering of altruistic services, which is regulated by a code of ethics and requires long?term socialization and autonomous practice (Maloney 1986, Richman 1987, Rutty 1998).

In contemporary Greece, nursing is taught in Institutions of Higher Education (University and Technological Educational Institutions) (Sapountzi?Krepia 2004b) and has achieved a recognized professional status since 1923, by the establishment of the National Graduate Nurses Association. In addition, the professional status of nursing has received formal recognition by the Legislative Decree 683/1948 (Sapountzi? Krepia 2002).

Furthermore, some of the participants used the Greek word “leitourgima” in their definitions of nursing in order to characterize it as a “service”. In Greece, the term “leitourgima” means “the total duties of the ‘leitourgos’ who is a person engaged in a service that is beneficial for the society” (Tegopoulos & Fytrakis 1997). We have to mention that in Greece, in social speeches many government officers and professors use the term “leitourgima” when referring to nursing as an honor for the nursing profession, while the term is also used sometimes by lay?people to honor nursing, even thought the nursing profession has not yet achieved a high social status in the Greek society.

Nursing is also described by the participants as a science. Nursing was appointed a scientific status in Greece much later than in the U.S.A. and in other European countries. By the establishment of the Nursing Department of the University of Athens in 1979, nursing has attained the status of a science (Sapountzi?Krepia 2002). Furthermore, since 2001, the Technological Educational Institutions of the country, which educate the majority of the nursing students, have been classified to the higher education. In addition, during the last decades a lot of nursing studies have been conducted and nursing has its own empirical data and a unique body of knowledge. It is therefore apparent why the participants perceive nursing as a science. However, since nursing is an applied science, many participants consider it also an art.

Nursing is also characterized by the participants as offering of care to the fellow?man. This can be attributed to the roots of Greek nursing through its historical development (Sapountzi?Krepia 2002, Sapountzi? Krepia 2004b). It is characteristic that the participants when they refer to nursing as offering often use words such as “love”, “help”, “offer”. This can be attributed to the influence of the Christian virtues in the content of nursing practice (Lanara 1976). However, nursing is also characterized just by the word “care” and here comes up Burnard’s (1997) argument “…we might want to say that if a person is engaged in nursing, then they will have cared. If they have not cared, then they have been engaged in something, but that ‘something’ is not nursing. To nurse then is to care”.

The participants also consider nursing to be physical and psychological support. Human beings have physical and psychological needs and by fulfilling those needs nurses treat their patients as whole persons; this is true nursing and has a positive effect on the patients’ well?being (Morisson 1997, Ley 1988, Nichols 1993).

Very few participants mentioned “prevention”, “health promotion”, and “health education” as a part of nursing, while on the other hand most of the participants referred to patients as recipients of nursing care. This practically means that nurses either do not recognize that they have a role in prevention or that their daily nursing practice in the hospital ignores every other nursing intervention apart from those that demand technical competences and are about patient treatment.

However, among the participants there were nursing students who in their studies take courses on health education, illness prevention, and health promotion. This puts a crucial question mark on the contribution that nursing education makes on the students’ understanding of the full spectrum of nursing science and practice.

An additional reason for this is probably the etymology of the Greek word for nursing, “nosileftiki”. This word derives from the word “nosos” which means “disease”. It influences the expected role of a nurse and thus nurses understand their role in relation to desease and patients rather than healthy people (Sapountzi?Krepia 2002). Nevertheless, much research is needed on this topic in order to clarify this particular issue.

Based on the findings of the present study the deriving definition of nursing is as following:

Nusing is a science and art as well as an ocupation and a sevice. Is also an offering of care including the provision of physical and psychological support to patients and their relatives. Nursing is also provided to healthy people through activities of prevention and health promotion.

Limitations of the study

One of the limitations of the study is the issue of representation. The questionnaire including the statement of the subjects about nursing distributed to nurses working in hospitals situated in Thessaloniki, in cities of east and northern Macedonia of Greece and in one city of Thessaly as well as to student nurses of two Technological Educational Institutions and not all over Greece and thus the finding did not represent the views of nurses and nurses students all over Greece.

Conclusion

The present study is the first one in Greece searching this particular issue of the definition of nursing in Greece. We therefore believe that the findings can help nurses for broadening their understanding of the concept of nursing through the derived definition.

Acknowledgement

The project No 224 is co?funded by the European Social Fund & National Resources?EPEAEK II, ARCHIMIDIS II

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