Critical Appraisal

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You are asked to critically appraise the research using the Critical Review Form Version 2.0 (Letts et al 2007). Attached are the Article to be critically appraisal, Guidelines and the critical review form.
Task 1: Critical Appraisal
Length: 1000-1200 words
Detailed description for each criterion of the Critical Review Form. Critical discussion of the strengths and weaknesses of sampling, data collection and analysis. Critically discusses conclusion and implications of the reviewed study.
Task 2: Phenomenology and qualitative research
Length: 250 words
Describe the phenomenological approach to qualitative research.
Detailed description of phenomenology and detailed comparison to other qualitative approaches. Identifies research problems suitable for a phenomenological study. Identifies research problems suitable for a phenomenological study and basic description of bracketing. Identifies research problems suitable for a phenomenological study and detailed description of bracketing. I have attached the paper (Joanasson et al 2011) you are to review; the Critical Review Form and some Guidelines to help you with the task. Using the form helps you structure your review and cover the most important aspects for describing and appraising a piece of qualitative research.
You are using the critical review tool to guide YOUR evaluation of the quality of the report.
This task shouldn’t require lots of references. References may be included in the relevant question box. In reviewing the paper, give the paper credit where you think it is due but don’t be scared to find fault if you think that some aspect of the study or the report fails to measure up (using the criteria of the CR from). Current references
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EMPIRICAL STUDIES
Corroborating indicates nurses’ ethical values in a geriatric ward
LISE-LOTTE JONASSON, MSc1,4, PER-ERIK LISS, Professor2, BJO¨ RN
WESTERLIND, MD3, & CARINA BERTERO¨ , Professor4
1Department of Nursing Science, School of Health Sciences, University of Jo¨nko¨ping, Sweden, 2Department of Health and
Society, Linko¨ping University, Sweden, 3Department of Geriatrics, County Hospital Ryhov, Jo¨nko¨ping, Sweden, and
4Department of Medical and Health Sciences, Division of Nursing Science, Faculty of Health Sciences, Linko¨pings University,
Sweden
Abstract
The aim of the study was to identify nurses’ ethical values, which become apparent through their behaviour in the
interactions with older patients in caring encounters at a geriatric clinic.
Descriptions of ethics in a caring practice are a problem since they are vague compared with the four principles of
autonomy, beneficence, non-maleficence, and justice.
A Grounded Theory methodology was used. In total, 65 observations and follow-up interviews with 20 nurses were
conducted, and data were analysed by constant comparative analysis.
Three categories were identified: showing consideration, connecting, and caring for. These categories formed
the basis of the core category: ‘‘Corroborating.’’ In corroborating, the focus is on the person in need of integrity and
self-determination; that is, the autonomy principle. A similar concept was earlier described in regard to confirming.
Corroborating deals more with support and interaction. It is not enough to be kind and show consideration (i.e., to benefit
someone); nurses must also connect and care for the older person (i.e., demonstrate non-maleficence) in order to
corroborate that person.
The findings of this study can improve the ethics of nursing care. There is a need for research on development of a high
standard of nursing care to corroborate the older patients in order to maintain their autonomy, beneficence, and nonmaleficence.
The principal of justice was not specifically identified as a visible nursing action. However, all older patients
received treatment, care, and reception in an equivalent manner.
Key words: Ethical values, geriatric wards, grounded theory, nursing ethics, nurses behaviour
(Accepted: 8 August 2011; Published: 14 September 2011)
In a study about satisfaction (Kahn, Hassan, Anwar,
Babar, & Babar, 2007), patients felt that nurses
were good at providing privacy and there were regular
vital sign check-ups. However, the patients were
dissatisfied with the nurses’ behaviour. In other
studies satisfaction depends on the patient’s ability
to participate and being involved concerning their
own care (Ford, Schofield, & Hope, 2003; Larsson,
Sahlsten, Segesten,&Plos, 2011). Different demands
on nurses by patients affected them in their work
situation and make them feel powerless in caring
(Berg, Berntsson, & Danielsson, 2006).
Nurses are dependent on collaborative interaction
(Bischop & Scudder, 1985, 1996), and they should
meet patients and relate to the older patients’ situation.
This collaborative interaction (i.e., a caring
relationship) is expressed by Gaut (1983) as ‘‘caring
for’’ and ‘‘caring about.’’ ‘‘Caring for’’ is a one-way
relationship in which the nurse is responsible. ‘‘Caring
about’’ is a quality found in the relationship
between nurse, older patient, and next of kin; that
is, treating them with respect and dignity. A caring
relationship is characterised by promise and
involvement (Hjelm, Hartwig, & Bertero¨ , 2007). In
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Correspondence: Lise-Lotte Jonasson, Department of Nursing Science, School of Health Sciences, University of Jo¨nko¨ping, SE-551 11 Jo¨nko¨ping, Sweden.
Tel: 46 36 101242. Fax: 46 36 101250. E-mail: [email protected]
Int J Qualitative Stud Health Well-being
#2011 L-L. Jonasson et al. This is an Open Access article distributed under the terms of the Creative Commons Attribution-Noncommercial 3.0
Unported License (http://creativecommons.org/licenses/by-nc/3.0/), permitting all non-commercial use, distribution, and reproduction in any medium,
provided the original work is properly cited.
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Citation: Int J Qualitative Stud Health Well-being 2011, 6: 7291 – DOI: 10.3402/qhw.v6i3.7291
a caring relationship, the nurse must have an ethical
responsibility. Ethical responsibility depends on personal
responsibility and this responsibility cannot be
avoided, ignored, or transferred (Clancy & Svensson,
2007).
Individual responsibility is connected with nurses’
behaviour, ethical values, and morals and these are
important aspects that influence their actions, which
in turn influence the quality of care (Schluter,
Winch, Holzhauser, & Hendersson, 2008). Values
represent the basis of ethics as they form the backbone
of how we act, behave, and address different
moral situations (Ka¨lvemark, Ho¨glund, Hansson,
Westerholm, & Arnetz, 2003). Care is both thought
and action*which are interrelated (Tronto, 1993).
Care ethics aim to increase ethical reflection, focusing
on values such as engagement, solidarity, and
moral sensitivity (Vanlaere & Gastmans, 2005). As
explained by Cronqvist, Burns, and Lu¨ tze´n (2004),
caring about someone rests on moral grounds
because moral obligation is inherent in the notion
of caring and assumes personal ability to know what
is morally right in the caring encounter. The nurse’s
attitude, values, self-respect, and so on influence the
choice of a care plan (Gustafsson & Parfitt, 2002),
and choices are made apparent in communication
with the older patient and care plan documentation
(Gunhardsson, Svensson, & Bertero¨ , 2008).
Nurses’ behaviour may have revealed ethical
values that were interpreted by patients, hence the
dissatisfaction (Castledine, 1996). Older patients are
sometimes vulnerable and do not have much to
decide about in caring. It is important to monitor
the nurses’ performance because it affects the older
patient. A nurse’s performance is made apparent
in verbal and non-verbal ways of communicating
(Noddings, 1984; Orlando, 1961, 1972). Important
aspects when caring for older patients are security,
trust, integrity, and personal decision-making (SFS,
1982; National Board of Health and Welfare, 2005),
in order to carry out good health care (SFS, 1982;
ANA, 2001; ICN, 2002). There is also a connection
between the patient’s experience of value, the nurse’s
work, and the ethical environment (McDaniel,
Veledar, LeConte, Peltier, & Maciuba, 2006).
There are different versions of ethics in care,
which complicates the picture of ethical theories in
nursing. Descriptions of ethics in a caring practice
are another problem, since they are vague compared
with the four principles of autonomy, beneficence,
non-maleficence, and justice (Edwards, 2009).
These four principles are central components of
nursing and health care ethics (Beauchamp & Childress,
2001). Again, nurses’ individual ethics depend
upon each person’s upbringing and the atmosphere
of the caring situation (Edwards, 2002; McDaniel,
Veledar, LeConte, Peltier, & Maciuba, 2006).
Authors explain nurses’ actions in different ways,
for example, the caring interaction must be permeated
by a belief in the older patients and their capacity,
and nurses ought to support the patients in realising
their own vitality ambitions (Nordenfelt, 2000). The
nurse’s openness and sensitivity can affect older
patients so that they open up and share difficulties
with the nurse (Eriksson & Na°den, 2002). This
support could consist of the professional’s presence,
touch, and listening; the creation of a base for a
caring relationship (Fredriksson, 1999) and strive to
understand patients perspective (Covington, 2005).
The ideal nurse is an eager, loving, sympathetic,
and supportive person; the care ability depends on
how helpful the nurse is (Bischop & Scudder, 1985;
Tarlier, 2004). These descriptions of the nurse’s
characteristics lead up to supporting the patient’s
identity by strengthening the patient’s involvement
and participation in their own health, i.e., confirmation
(Gustafsson & Parfitt, 2002).
Study findings indicate the importance of supporting
the patients in their own situation to achieve
their own goals. Nurses need to change roles to
make a patient active even if the patient is in palliative
care (Hjelm et al., 2007). The nurse has to develop
an approach of humility and carefulness when trying
to help patients so that they preserve their activity
and dignity. Nurses must also demonstrate knowledge
as it influences their action in practice (Purkis
& Bjornsdottir, 2006). Concrete caring actions only
have an ethical value in the light of the quality of
the caring attitude of which they are the expression
(Gastman, 1999). Studies of this sort are important
as ethical studies are almost always examined indirectly,
i.e., how nurses’ act are unclear and know
the complex reality of ethical practice (Goethals,
Gastmans, & de Casterle´, 2010).
The study
Aim
The aim of the study was to identify nurses’ ethical
values that become apparent through their behaviour
in the interaction with older patients in caring
encounters at a geriatric clinic.
Design
In order to understand human behaviour a qualitative
approach was used, influenced by symbolic
interactionism. Gestures, attitudes, and the control
of attitudes between people are important components
in symbolic interactionism (Blumer, 1962,
1969, 1986). As this study is based on symbolic
L-L. Jonasson et al.
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Citation: Int J Qualitative Stud Health Well-being 2011; 6: 7291 – DOI: 10.3402/qhw.v6i3.7291
interactionism through which researchers identify
the ethical values visible in nurses’ actions and behaviour,
the methodological approach was Grounded
Theory (GT), using observations and follow-up
interviews (Glaser & Strauss, 1967). The intention
of such a method is to achieve a deeper understanding
of concerns, actions, and behaviours of groups of
individuals through the nurse’s own words and
actions. It is an inductive general method in which
theory is generated (Glaser, 1978; Glaser & Strauss,
1967).
Setting
The setting for this study was a geriatric clinic
in a medium-sized Swedish city. The geriatric clinic
is a stroke and rehabilitation ward with 22 beds.
Geriatrics is a branch of medicine devoted to
prevention, diagnosis, and treatment of disorders
affecting old people (Geriatric Medicine in Sweden,
2009). The average caring time for older patients is
approximately 18 days and, after discharge, they go
home or to another caring facility. The words ‘‘older
patient,’’ as used in this context, define people aged
65 years or above with varying needs of care (WHO,
2008).
Participants and ethical considerations
Approval was obtained from the clinic manager,
the department director, the personnel department,
and the unions involved. While conducting the
study, consideration was given to The Declaration
of Helsinki (World Medical Association Declaration
of Helsinki, 2008), law of research ethics (SFS,
2003:460), which concerns the ethical cornerstones
of empirical research (SFS, 2003:460). Approval for
the study was obtained from the Regional Research
Ethics Committee at Linko¨ping University Hospital,
‘‘Dnr’’.170-06. All older patients were asked if they
agreed to the observations of caring encounters
between themselves and the nurses. All patients
agreed verbally.
The sample population were staff nurses at the
geriatric clinic. Before data collection commenced,
a meeting was held in which the nurses were given
verbal and written information. Written and verbal
informed consent was obtained from all nurses.
A total of 20 nurses participated in the study,
i.e., all invited nurses. The nurses comprised 19
females and 1 male ranging in age from 25 to 62
years, with a median age of 45 years. Twelve of the
nurses were registered nurses and eight were enrolled
nurses. Their experience ranged from 1 year to 40
years, with a median of 19 years. The nurses had
different backgrounds; some had engaged in other
occupations before working as nurses and some were
foreign born.
In the investigated clinic, the competence mainly
concentrated on medical investigations, medical
treatments, and rehabilitation of patients with stroke,
dementia, osteoporoses, and fractures. Older patients
should receive care and rehabilitation suitable for
their needs and they should also have an individual
caring plan. Health care professionals in geriatric
clinics have a holistic view and the interactions with
the patient should appear as teamwork (National
Board of Health and Welfare, 2011).
Observations and follow-up interviews
Empirical data collection took place between
February and May 2008. The researcher was nonparticipant;
that is, was dressed as a health care
professional but did not work as one, although at
times the researcher assisted the health care professionals.
The researcher listened, watched, and had
conversations with the participants in the study
(Morse & Field, 1996). The researcher accompanied
the nurses on the ward, and 65 different caring
encounters were observed. A follow-up interview
was conducted directly after the observations (Berg,
1995). In the follow-up interviews the nurses
were asked ‘‘Can you tell me what happened in
this caring encounter?’’ The follow-up interviews
(210 min) were conducted in private and away
from the other person involved in the encounter.
These follow-up interviews were tape-recorded and
transcribed verbatim. Transfers, events, information,
social intercourse, and so on were recorded on a
pocket-tape recorder as well as in a notebook as
field notes. This was done immediately after every
observation, verbatim, and as scrupulously as possible
(Patton, 2002). Approximately 85 h of observation
were included, divided into 4-h shifts.
Data analysis
All data, observations, and follow-up interviews
were transcribed and used as a unit. The transcribed
text was analysed using Constant Comparative
Analysis, an inductive analysis method (Glaser, 1978,
1992). The analysis began by openly encoding the
first observation/follow-up interview. The next step
was to capture the substance in the data, to break
it down into identifiable substantive codes that illustrated
the influence of caring situations. The different
codes and interviews were compared to each other
to strengthen their identification. The codes were
labelled with origin words from the data (Glaser 1978;
Glaser & Strauss, 1967). The second observation/
Corroborating indicates nurses’ ethical values
Citation: Int J Qualitative Stud Health Well-being 2011; 6: 7291 – DOI: 10.3402/qhw.v6i3.7291 3
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follow-up interview was analysed and compared with
the first one. All data were processed the same way.
Thereafter, the analysis continued with the aim of
reaching a higher level of abstraction of the material,
thereby allowing identification of categories.
The codes were analysed and similar meanings in
the codes were identified and clustered together into
categories. The categories were labelled with more
abstract concepts. These categories were also compared
with the codes and the other categories. The
gathering of data and analysis continued until a
‘‘saturation point’’ was reached after 65 observations/
follow-up interviews. Nothing new emerged
in the analysis that enabled identification or creation
of new codes or categories. The number of
concepts/behaviour created saturation, not the number
of nurses. The final level reached involved
identifying a theoretical construction*a core
category*that answered possible questions and
explained the phenomenon under study (Glaser,
1978; Glaser & Strauss, 1967). Categories were
related to each other and scrutinised to verify their
relevance. A core category was the major category
found in all data (Glaser, 1978, 1992).
Validity
The findings of GT do not take the form of the
reporting of facts but are a set of probability statements
about the relationship between concepts,
or an integrated set of conceptual hypotheses developed
from empirical data. Validity in GT should be
judged by fit, relevance, workability, and modifiability
(Glaser 1978, 1992; Glaser & Strauss, 1967).
This study is fit as data are linked to their sources
(Berg, 1995; Glaser, 1992).
Conducting observations with follow-up interviews
as confirmation is a triangulation technique
imbedded in GT. This method strengthens the
relevance of the findings in the study (Glaser, 1978,
1992; Glaser & Strauss, 1967). Relevance is when
the findings are recognisable for people. Since data
are derived from empirical data, the findings could
be useful and fulfil requirements for workability
(Berg, 1995; Glaser, 1992; Glaser & Strauss, 1967).
Findings
Three categories were identified during the analysis:
showing consideration, connecting, and caring
for. These categories formed the basis of the core
category: ‘‘Corroborating’’ (see Figure 1). The core
category ‘‘corroborating’’ explains how nurses’ ethical
values are made apparent through their behaviour
in the interaction with the older patient in caring
encounters at a geriatric clinic. All three categories
are related and thus influence each other, but are
separate, aiming to generate the core category. The
core category and categories identified and described
are abstracted to a theoretical level. Some sequences
from observations and quotations from the followup
interviews are provided from the empirical data.
Corroborating
Corroborating means that one person has a responsibility
to promote a relationship, confirming a
person, and making the person feel more secure.
This relationship is based on support and giving
strength; that is, nurses have an obligation to do
good from the account of patient’s own values and
necessity. Consideration and thoughtfulness must be
shown towards the other party. This also involves
having good manners towards someone else. The
nurse is responsible for the other person and care
and treatment must, as far as possible, be designed
and given in consultation with that person.
Corroborating indicates nurses’ ethical values that
are apparent through their behaviour in the interaction
in caring encounters. In corroborating, the
focus is on the person who needs integrity and selfdetermination;
that is, it involves application of the
autonomy principle. Corroboration places a responsibility
on the nurse to promote another person’s
well-being (beneficence) and health through support
and giving strength. As with caring encounters, the
foundation is based on a corroborative relationship.
The actions in caring encounters are both verbal
and physical. Corroborating means being sensitive to
another person’s gestures, listening to the person,
and trying to understand his/her thoughts. It also
means giving priority to the person’s needs in the
situation, a form of benefit. Corroborating means
to act in such a way that time is given to the older
person, aiming to maintain the person’s self-control
Showing
consideration
Connecting
Caring for
Figure 1. The three categories: showing consideration, connecting,
and caring for are related to and affect each other. These
categories generate the core category ‘‘Corroborating.’’
L-L. Jonasson et al.
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Citation: Int J Qualitative Stud Health Well-being 2011; 6: 7291 – DOI: 10.3402/qhw.v6i3.7291
and strength. This is done to benefit the person.
This means paying attention to the other person’s
condition and encouraging them in order to motivate
them. Encouragement is central to corroborating.
Encouragement can be expressed verbally
through words or physically through a pleasant
demeanour. Corroboration is based on experience
and knowledge about the patient as a person, and
on paying attention to reactions in different caring
situations (beneficence, non-maleficence). It is also
about having good intentions and creating something
good.
Corroborating includes the categories of showing
consideration, connecting, and caring for. To be
considerate is to be present in the caring situation,
show respect, and involve another person in a trusting
relationship. In connecting there is communication
between two individuals to create participation. The
connecting function is related to someone else and
it deals with information, instructions, guidance, or
small talk. Caring for means to carry out a task in a
caring encounter using competence and knowledge
regarding the issue to be solved, and also to make the
task safe and secure for the person who is being cared
for*demonstrating non-maleficence.
Corroborating verbalised by one nurse:
You must have focus and get through . . . consider
gestures. . . , what the patient says, what is most
important for the patient, and help the patient
with that. Give time to the patient and listen and
encourage.
Showing consideration
Showing consideration concerns opening up the
situation, through suitable actions such as showing
respect and infusing confidence in another person in
a caring encounter. Showing consideration, which
could be done both verbally and physically, invites
both parties to participate. Verbal invitation takes
place through words and questions. Physical invitation
happens through eye contact and nearness as
well as by showing trust in the older patient and
his/her capacity. These actions promote the wellbeing
(beneficence) of the person, and if the nurse
considers this person in a holistic way, makes contact
and shows concern for the person throughout the
caring process, mutual respect will be fostered.
There is a desire to do well for (benefit) as well as
perform acts of kindness. Showing consideration
means having an open mind and being helpful, being
‘‘here and now,’’ having a sense of caring about
another person. Time is an important element in this
caring encounter, as the amount of time dedicated to
the patient gives an indication of that person’s value.
These actions, which are connected with showing
consideration, are made apparent when caring about
older patients in caring encounters. On the other
hand, showing a lack of consideration includes having
an arrogant attitude that manifests itself in nurses not
talking directly to the patient but to each other over
the patient’s head or talking about ward-related
tasks, displaying irritation, or laughing at the patient.
Sometimes nurses find themselves in a dilemma of
whether to follow ward routines or act according to
the older patients’ wishes, i.e., respecting the older
patients’ autonomy. A sequence to illustrate data
from an observation:
[T]he patient answers very quietly, I will not
get out of bed, I am tired, I will stay I [in]
bed. The nurse responds, ‘‘It will be nice to get
out of bed, and you will go home to your man
today’’*in a way to relieve the atmosphere.
Another nurse joins the effort to convince the
patient. The patient still refuses, but the nurses
are determined.
Nurses use different strategies such as negotiation,
verbal explanation/argument, or ignoring the older
person’s protests. This was expressed in a follow-up
interview:
She . . . the patient didn’t want to get out of bed,
uhm . . . and I knew that she had a clear intellect,
uhm . . . it was a little bit unpleasant to get her up
against her will . . . get her up so early . . . uhm . . .
if I had this caring encounter in her own home so
of course she had to decide by herself . . . I will stay
in bed for 1 hour more . . . Now we had the
routines of the ward to take into consideration . . .
and certain other things so we took no notice of
her . . . and that was not a good feeling.
Connecting
To connect means to relate together; to be relating
to someone. Connecting is a relationship created
through the caring situation. Connecting is central
to the interaction in caring encounters as the associated
actions open up collaboration. These actions
serve to benefit someone. Connecting serves as a
link between the people involved in the encounter.
Questions are asked and actions are performed in
order to assess the situation in the caring encounter.
The older patient is at the centre of attention and
has autonomy. Connecting could also entail small
talk or questions, aiming to create a good atmosphere
where both individuals meet in a dialogue.
Corroborating indicates nurses’ ethical values
Citation: Int J Qualitative Stud Health Well-being 2011; 6: 7291 – DOI: 10.3402/qhw.v6i3.7291 5
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Connecting is often the starting point of a special
task. Information provided by the nurse prepares the
older patient who receives notice before any actions
are carried out.
Connecting could also mean a flow of information
from one person to another. In connecting, one
person invites another person. This person is free to
choose options that often concern small decisions.
Connecting could also be about guidance, where
one person is in need of advice to solve a problem.
These actions benefit the patient. Connecting
also appears in a physical sense in approaching
and contacting. Communication is richer in longer
caring encounters. Connecting could be associated
with caring for and task orientation and is common
in short caring encounters where mostly just one
person talks. There is less connecting when several
nurses are involved in the caring situation and in
acute situations. Ethical values become apparent in
connecting as described from the observation and
follow-up in the next interview:
Do you wash your face yourself? [Nurse gives
the older patient washcloth and soap and towel.]
Yes . . . now you will wash yourself calmly and
peacefully. Call me with this bell . . . [The older
patient does not see. The nurse repeats her last
remark, then the patient sees the button she
should push to get help.] You have a dress and
socks behind you. Call us then we’ll come.
Nurses use different strategies as stated in the
follow-up interview:
This information is important, well very
important, so you don’t just do it: for us it is
natural . . . tell them that now I am doing this
because . . . especially patients who have had a
stroke, it is different due to a stopper or a bleeding
or . . . naturally, often when you have had a stroke
you have difficulties putting things together and
the memory is affected, you need to talk about
the same thing all over again and they do not
remember. All the time repeat and repeat.
Caring for
Caring for is a well-defined responsibility for nurses.
It concerns competence, skill, and knowledge regarding
different tasks. It includes medical-technical
tasks, physical caring, taking into care, and specific
caring; it is about non-maleficence. Often these are
routine tasks in divided caring situations where
there is a larger focus on tasks; divided situations
could be interrupted by a telephone ringing, other
caring staff entering the situation, and so on. Even
when several nurses work together with the same
older patient in a caring encounter, focus is on the
task in the encounter, as the nurses interact with
their colleagues rather than the patient. Caring tasks
are focused upon both by experienced and inexperienced
nurses. Focusing on caring tasks is a sort of
corroboration. It deals with carrying out tasks safely
and creates confidence between the different people
in the caring encounter, i.e., it demonstrates nonmaleficence.
Focus is still on the older patient’s state
of health. These actions often start with connecting
and then involve performance of caring, conducting
a test, control, and so on. Focusing on caring
tasks entails less verbal activity. There is a clear focus
on caring tasks, particularly in acute situations or
when there are communication difficulties. In these
situations of care for the older patients, focus is
on carrying out the task correctly so as not to harm
the person and perhaps save a life. An example from
an observation:
Nurse goes to a lonely man and says hello and the
older man’s name. The man does not answer.
You will change your drip now . . . The nurse
disconnects the old drip and hangs up the new
one, then unscrews the peg and puts a new peg on
the drip and flushes with sodium-chloride, and
then ‘‘increases the flow’’ . . .The nurse says the
infusion is going in well . . . The nurse says nothing
to the patient, there is no reaction from the patient
. . . The nurse leaves.
Nurse’s explanation on acting with a focus on duty:
Well it became more one-sided and more focused
. . . on the task we were performing . . . not so
much talk. Yes, it was a more serious caring
encounter . . . in this case it was about an infusion
with great amount of additives and so . . . I was
very focused on what to do . . . so it was not a
personal meeting . . . with the patient . . . the
patient was so tired and exhausted that he was
not easy to communicate with . . . I was there to
take action.
Discussion
Corroborating could seem similar to the concept of
confirming (Gustafsson & Parfitt, 2002; Randers,
Olson, & Mattiasson, 2002). However, corroborating
involves more than confirmation, it is support
by means of strengthening evidence in caring, and
this explanation related to ethical values in caring
encounters has not been mentioned before in the
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Citation: Int J Qualitative Stud Health Well-being 2011; 6: 7291 – DOI: 10.3402/qhw.v6i3.7291
literature. Nurses motivate older patients through
encouragement. Unlike the obstacles encountered
by Stabell and Na°den (2006), nurses can take action,
verbally and physically, in order to encourage. All
depends on the nurses’ decision-making (SFS,
1982:763) and ability to notice the older patients’
need of rehabilitation so that they maintain their
integrity and self-determination; that is, corroborating
is to benefit the older patient. Nurses promote
the relationship with the older person, and caring
is based on respect for self-determination and privacy.
There is also mutuality in the relationship,
and the different persons involved exchange information,
creating participation. This supportive attitude
guarantees security in the caring relationship for the
older person.
The concept corroborating includes showing consideration,
connecting, and caring for are findings
in our study. Compare these findings with Na°den
and Eriksson (2004), who discussed invitation and
confirmation. There are similarities between these
two mentioned studies, but there are also some
differences. In this study caring for is one aspect of
a nurse’s practical performance. Thus it is related
to carrying out a task in a caring encounter using
competence and knowledge regarding the issue to
be solved, and also to making the task safe and
secure for the person who is being cared for. Caring
for is a one-way relationship in which the nurse is
responsible for the older patient. This becomes
apparent when the older patient has communication
difficulties. Caring for entails a reduced amount of
verbal activity. Carrying out the duty safely and
securely for the older patient is one aspect of ethical
values. Caring for is about non-maleficence, it is a
central component of nursing and health care ethics
(McDaniel et al., 2006; SFS, 1982:763). The ethical
values in caring encounters are more than showing
consideration and connecting. The concept of
corroborating includes caring for, which is one
aspect of ethical values (The National Board of
Health and Welfare, 2005). The nurse must reflect
on how to corroborate the older patient as a unique
person with unique needs. Focusing on caring
tasks is associated with years in the occupation
and developing skills*from a novice to an expert
(Benner, 1984).
Time is an important element that characterises
respect for the older patients, as it makes them feel
that they have value. In our study it is corroborating
because time given to the patients supports their
strength and autonomy. Corroborating includes
more than the findings in the study by McDaniel
et al. (2006), stating that more time helps in
developing a caring relationship. Corroborating is a
foundation for creating a caring relationship, as
suggested in a study by Hjelm et al. (2007). Nurses
can corroborate older patients by paying attention to
their reactions, being sensitive in different caring
situations, and showing interest in actions beneficial
to the older patient.
The nurse shows consideration through action by
being ‘‘here and now.’’ They are present in the caring
encounter*socially, physically. and psychologically.
Older patients should feel that they are at the centre
of attention (Cortis & Kendrick, 2003; Orlando,
1961; Teeri, Leino-Kilpi, &Va¨lima¨ki, 2006). To be
considerate of someone in need of caring could be
compared with the concepts of ‘‘caring about’’
(Bertero¨ , 1999) and ‘‘being.’’ The latter includes
the subcategories ‘‘being there’’ and ‘‘being with’’
(Kapborg & Bertero¨ , 2003). In the present study,
showing consideration includes being present in the
caring situation, showing respect, involving another
person, and creating a trusting relationship. Nurses’
ethical responsibility is to be considerate (Clancy &
Svensson, 2007). When the actions mentioned above
become apparent, the older patient will trust the
nurse and consideration is demonstrated.
To show respect is an important aspect, as
mentioned by both the older patients and their next
of kin in another study (Jonasson, Liss,Westerlind, &
Bertero¨ , 2010). As nurses must find a structure in
the ward, there are discussions about ways to show
respect (Cameron, 2004). Nurses sometimes show
disrespect both verbally and physically. These actions
could create moral distress; therefore it is necessary
to find support from the team around the older
patient and their next of kin (Ulrich, Hamric, &
Grady, 2010). In the present study some of the
nurses found themselves in a dilemma of having to
choose between routines in the ward and acting
according to the older patients’ wishes. Different
strategies were used, for instance, verbal explanation
and ignoring the patient. Similar findings were found
by Slettebo and Haugen Bunch (2004), which raises
some questions. What is more important, following
the patient’s wishes or the ward routines? Are actions
different when the patient is in his/her own home
compared to a hospital? An answer could be that it
ought to be the nurses’ main goal to benefit patients
and focus on the best for them. As stated in the study
by Lindh, Severinsson, and Berg (2009), attention
must be given to the institutional and professional
processes that influence morals in caring situations.
It is important that nurses work in a supportive
culture (Jakobsen & So¨ rlie, 2010), so that they can
give corroborating care. This supporting culture
should influence all nurses and other professionals
to have a similar corroborating approach in caring
encounters with older patients.
Corroborating indicates nurses’ ethical values
Citation: Int J Qualitative Stud Health Well-being 2011; 6: 7291 – DOI: 10.3402/qhw.v6i3.7291 7
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Connecting with someone means to create a
relationship between the nurse and the older patient.
A nurse must be considerate; that is, display both
verbal and physical actions before connecting. In a
study by Cortis and Kendrick (2003), the nurses
invited the patient to interact by asking questions; but
in our study, invitation came from consideration.
Being considerate makes ethical values apparent
through actions that are not only verbal. Connecting
serves as a link between the individuals involved in
the encounter. A relationship is created between the
nurse and the older patient in the caring encounter.
The nurse’s outlook is revealed in connecting. Special
situations ought to focus on connecting; that is,
in caring encounters including several nurses or in
acute situations. In these situations ethical values
become apparent. The focus is still on the older
patient’s well-being (beneficial). It is then important
that the nurse is corroborative, uses experience from
previous encounters, and interacts with the patient.
If the nurse is trustworthy, the patient will trust
him/her. The patient interprets the nurse’s verbal
and physical actions. For instance, a nurse creates
trustworthiness if she says ‘‘I am coming back’’ and
then does exactly that as found by Sellman (2006).
Hopefully, the findings of this study can improve
the ethics of nursing care, which are unclear according
to Edwards (2009). The study by Suhonen, Stolt,
Launis, and Leino-Kilpi (2010) mentions that there
is a need for research on development of a high
standard of nursing care to corroborate the older
patients in order to maintain their autonomy, beneficence,
and non-maleficence. According to ethical
values, nurses have a responsibility to maintain their
level of competence, to plan and deliver quality care,
perform tasks safely, and evaluate the services they
provide (ICN, 2002). Perhaps this study could give
some guidance in right direction. The principal of
justice is not specifically identified as a visible nursing
action in this study. However, it was noticed that
patients were received and cared for in an equivalent
manner.
Conclusion
Corroborating indicates nurses’ ethical values that
are apparent through their behaviour in the interaction
with the older patient in caring encounters.
In corroborating, the focus is on the patients so
that they can maintain their autonomy. Corroboration
places a special responsibility on the nurse to
benefit the older patient through support and giving
strength. This study presents the ethical values
apparent as a corroborative relationship. Corroborating
means being sensitive to the older patient’s
gestures, dedicating time, listening, and trying to
understand thought. These actions serve to benefit
the patient. In corroborating, giving encouragement
in order to motivate is central. This can be
expressed verbally but also physically through a
pleasant demeanour. Further, corroboration is based
on beneficence and non-maleficence facilitated
through the nurse’s experience and knowledge about
the older patient as a unique person. Corroborating
includes the elements of showing consideration,
connecting, and caring for; that is, creating a trusting
relationship and using competence and knowledge in
caring for the older person.Nurses with corroborating
behaviour in the caring encounter with the older
patient guarantee good, safe, and secure care, which
is in accordance with laws and professional codes.
Study limitations and strengths
One limitation could be that making direct observations
could be affected subjectively by the researcher/
observer making ‘‘private’’ interpretations. Using
follow-up interviews is a way to triangulate data/
interpretations. There was no time delay between
the observations and follow-up interviews, which
may strengthen the validity of the observations in
the study. The nurses recalled the caring situation
immediately and clarified what had happened from
their point of view. Thus the risk of incorrect underor
over-interpretation was reduced (Berg, 1995).
Another limitation is that the researcher/observer
has limited experiences doing observations and
follow-up interviews. This limitation rectified with
reflections and supervision is one technique to assure
quality (Berg, 1995) that has been used by the
researchers in this study.
Conflict of interest and funding
The authors declare no potential conflicts of interest
with respect to the authorship and/or publication of
this article. This study was supported by the Medical
Research Council of Southeast Sweden, Linko¨ping
and Department of Medical and Health Sciences,
Faculty of Health Sciences, Linko¨ping University,
Sweden.
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