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How Greek nurses’ personal postoperative experiences influence their behaviour towards patient’s postoperative pain assessment and management

A thesis submitted to The University of Manchester for the degree of Doctor of Philosophy in the Faculty of Faculty of Biology, Medicine and Health

2018

PANAGIOTA GARDELI

School of Nursing, Midwifery and Social Work Table of Contents

List of Figures ...... 1

List of Tables ...... 2

List of Appendices ...... 3

List of Abbreviations ...... 4

Abstract ...... 5

Declaration ...... 6

Acknowledgements ...... 7

The author ...... 8

Introduction...... 9

1 Literature review ...... 11

1.1 Introduction ...... 11

1.2 Search Strategy ...... 11

1.3 History of pain and its definitions ...... 13

1.4 Pain theories ...... 15

1.5 Behavioural aspects of pain ...... 22

1.6 Humanism and pain ...... 24

1.7 Epidemiology of postoperative pain ...... 27

1.8 Nurses at the centre of post-operative pain management ...... 28

1.8.1 Agency, efficacy and control ...... 29

1.8.2 Reasons for nursing stasis ...... 32

1.8.3 The personal pain experience ...... 43

1.8.4 Knowledge and attitudes ...... 47

1.8.4.1 Nursing schools and their curricula ...... 52

1.9 The Greek nursing care system ...... 54

1.9.1 A historical approach ...... 54

1.9.1.1 First period: 1910-1935 ...... 54

1.9.1.2 Post-World War II period ...... 55

1.9.1.3 Third period: 1980-2008 ...... 56

1.9.1.4 Economic Crisis: 2008-today ...... 57

1.9.2 Nurse Education in Greece ...... 59 1.9.2.1 The role of nursing studies curricula in Greece ...... 62

1.9.3 Post surgical pain management in Greece ...... 64

1.10 Theoretical framework and conclusion of literature review ...... 66

2 Methodology ...... 69 2.1 Introduction ...... 69 2.2 Research question and objectives ...... 69 2.3 Quantitative versus Qualitative approaches ...... 70 2.4 Qualitative research methods: key sub-methodologies ...... 72 2.4.1 Ethnography ...... 73 2.4.2 Grounded theory method ...... 74 2.4.3 Case study method ...... 75 2.4.4 Interpretative Phenomenological Approach (IPA) ...... 76 2.4.4.1 Phenomenology...... 77 2.4.4.1.1 Descriptive phenomenology ...... 77 2.4.4.1.2 Interpretive phenomenology ...... 79 2.4.4.1.3 IPA and Phenomenology ...... 81 2.4.4.2 Hermeneutics ...... 82 2.4.4.2.1 The hermeneutic circle ...... 86 2.4.4.2.2 Debating phenomenology and hermeneutics ...... 88 2.4.4.3 Ideography...... 92 2.4.4.4 Interpretative Phenomenological Analysis as a research method ...... 92 2.4.4.5 Interpretative Phenomenology Approach and Human Science ...... 96 2.4.4.6 Reasons for choosing IPA ...... 100 2.5 Conclusion ...... 101

3 Methods...... 103

3.1 Introduction ...... 103

3.2 Sampling ...... 103

3.2.1 Sampling technique ...... 103

3.2.2 Population of interest ...... 104

3.2.3 Sample size ...... 105

3.3 Gaining access ...... 106

3.4 Connection with participant ...... 109

3.5 Data collection ...... 110

3.5.1 Data collection methods ...... 111

3.5.1.1 First phase-Observation ...... 112 3.5.1.2 Second phase-Interview...... 116 3.5.1.2.1 Choice of interview method ...... 116 3.5.1.2.2 Question development in the semi-structured interview...... 117 3.5.1.2.3 Building rapport ...... 119 3.5.1.2.4 Interview/participant dynamics in rapport building ...... 120 3.5.1.2.5 Interview procedures ...... 122 3.5.1.3 Reflective diary ...... 122 3.6 Data analysis ...... 123 3.6.1 Transcription ...... 124 3.6.2 Hermeneutic Cycle ...... 125 3.7 Ethical issues ...... 129 3.7.1 Consent ...... 130 3.7.2 Confidentiality and Anonymity ...... 131 3.7.3 Assessing validity, trustworthiness and quality of the study ...... 132 3.7.3.1 Sensitivity to context...... 133 3.7.3.2 Commitment ...... 135 3.7.3.3 Transparency and coherence ...... 136 3.7.3.4 Impact and importance ...... 137 3.7.4 Methodological rigour of the study ...... 138 3.7.4.1 Credibility...... 138 3.7.4.2 Transferability ...... 139 3.7.4.3 Dependability ...... 139 3.7.4.4 Confirmability...... 139 3.8 Conclusion ...... 139

4 Findings...... 141

4.1 Demographics ...... 141

4.2 Observation findings...... 142

4.2.1 Theme 1: Building beneficial relationships...... 142

4.2.1.1 Subtheme 1: Post-operative patients become partners in their own care...... 143

4.2.1.2 Subtheme 2: Developing proximity with post-operative patients ...... 150

4.2.1.3 Subtheme 3: Developing mutual relationship with post-operative patients ...... 152

4.2.2 Theme 2: Reflection and evaluation of post-operative experience...... 153

4.2.3 Theme 3: Developing interpersonal communication skills for an effective staff and patient relationship ...... 158

4.2.4 Theme 4: Facilitating learning via the participants’ post-operative pain experience...... 163

4.2.5 Theme 5: The exploration of touch in post-operative pain...... 166 4.2.6 Theme 6: Manipulating the environment...... 167

4.2.7 Theme 7: Providing comfort and warmth ...... 168

4.2.8 Conclusion...... 170

4.3 Interview Findings ...... 171

4.3.1 Theme 1: Development of close relationships ...... 171

4.3.1.1 Subtheme 1: Shared decision-making ...... 171

4.3.1.2 Subtheme 2: Post-operative treatment through proximity ...... 176

4.3.1.3 Subtheme 3: Establishing mutual stable relationship ...... 178

4.3.2 Theme 2: Insight and reflection on the post-operative pain experience ...... 179

4.3.3 Theme 3: Enhancing communication skills ...... 184

4.3.4 Theme 4: The participants’ post-operative pain experience – a vehicle for learning ……………………………………………….……………………………….191

4.3.5 Theme 5: Impact of the financial crisis on the quality of nursing care ...... 196

4.3.6 Conclusion...... 198

5 Discussion ...... 200

5.1 Developing therapeutic relationships ...... 200

5.1.1 Partnership...... 202

5.1.2 Intimacy ...... 207

5.1.3 Reciprocity ...... 208

5.2 The role of reflection in the therapeutic approach ...... 209

5.3 The role of interpersonal relationships in holistic person-centered care . 215

5.4 The role of education in therapeutic nursing...... 218

5.4.1 Education Proposal ...... 222

5.5 Limitations of the study ...... 232

5.6 Reflections, implications and conclusion ...... 232

5.6.1 Reflection on the aims of the study ...... 232

5.6.2 Reflection, implications and conclusion ...... 236

References ...... 242

Word count 79.347

List of Figures

Figure 2.1. The three influences of IPA ...... 77

Figure 2.2 Hermeneutic circle/loop ...... 87

Figure 3.1. The participants’journey ...... 112

Figure 3.2. The six steps of IPA analysis ...... 129

Figure 5.1. Muetzel’s model ...... 202

Figure 5.2 Non-directive learning method…………………….…………………………231

List of Tables

Table 1.1. Criteria of literature review search...... 11

Table 1.2. Search terms for literature review ...... 12

Table 3.1. The process of gaining entrance into surgical wards ...... 109

Table 4.1. Participants’ characteristics ...... 141

List of Appendices

Appendix 1 Examples of development themes of data ...... 283

Appendix 2 Consent Form ...... 285

Appendix 3 Translation of ethical approval from Greek scientific council ...... 286

Appendix 4 Ethical approval from Greek scientific council ...... 287

Appendix 5 Observation Schedule ...... 288

Appendix 6 Interview Schedule ...... 290

Appendix 7 Participant information sheet ...... 292

List of Abbreviations

ACC Anterior Cingulate Cortex

ASA American Society of Anesthesiologists

BPS British Pain Society

DRGs Diagnosis Related Groups

IASP International Association for the Study of Pain

ICSTM Integrated Communication Skills Training Model

IPA Interpretative Phenomenological Analysis

NOA Needs-Opportunities-Abilities

SOP Systems of Provision

SPOT Social - Physical Pain Overlap Theory

TEI Technological Educational Institutes

WMA World Medical Association

Abstract

The University of Manchester Panagiota Gardeli Degree Title: Doctor of Philosophy (Ph.D.)

How Greek nurses' personal postoperative experiences influence their behavior towards patient's postoperative assessment and management 2018

Background: Pain is a multi-dimensional experience requiring an interdisciplinary approach. Barriers in pain assessment and management are numerous, varied, and often not clearly identified. In fact, they are challenging and resistant change. In this study, the contribution of human sciences with an aim to understand pain is explored. Humanistic models acknowledge the influence of an individual's personal experiences and concur that these experiences play a vital catalytic role in changing one's attitude and behavior, thus leading to a greater sense of well-being.

Aim: The aim is to explore how the nursing staff's personal postoperative experience influences their behavior in assessing and managing a patient's pain postoperatively in

Greece. Methods: A qualitative Interpretative Phenomenological Analysis (IPA) with an in-depth idiographic design was adopted for this study. Purposive sampling was employed to select 13 nurses who had at least two years’ professional experience in surgical wards and have had a previous personal experience of post-operative pain. Observations and semi- structured interviews were undertaken to collect the data. The current study was conducted in Greece from May 2014 to September 2014. The analysis followed very closely the stages described in detail in IPA.

Results: All the participants had experienced intense post-operative pain which was inadequately assessed and managed. Observation and interview analysis showed that this experience influenced their attitude, beliefs, and behavior. Participants become more sensitive, empathetic, attentive and understanding of their patient's post-operative pain because of their own person experience. Participants were able to assess and manage their patients’ post-operative pain effectively even when they had no previous knowledge of pain assessment tools.

Conclusions: The participants’ personal postoperative experience changed their behavior towards patients’ postoperative pain assessment and management. It became the driving force for them to discern the conflict powers that raised obstacles to apply a person- centered therapeutic approach. The novelty of the current research lies in the fact that it constitutes the first research that has been conducted in Greece combining IPA, Rogers and Lewin's theory.

Declaration

No portion of the work referred to in the thesis has been submitted in support of an application for another degree or qualification of this or any other university or other institute of learning.

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Acknowledgements

With the completion of this study, I would like to thank the people who supported me in this journey.

So, I would like to express my sincerest gratitude to my supervisors, Dr. Clifford Richardson and Dr. Penelope Stanford, who shared their knowledge upon which I have pursued my research activity, actively supported me throughout my research, urging me to dare to undertake research initiatives. I would also like to express my deepest appreciation for all the difficult moments they wholeheartedly offered the necessary support and encouragement to complete this research.

I would also like to thank the participants in this research who shared their experiences with me and contributed to this study in their own unique way.

Next, I would like to thank my colleagues for their invaluable help, patience and professional support.

Finally, I would like to thank my parents Michalis and Zaharoula and my brother Gerasimos as well as my friends David Braund, Georgia Gardeli, Nikos Pappas, Andreas Koukias, Giannis Mylonas, Evdokia Stamou, Andiana Georgadopoulou, Marina Georgakila, Fei Soula and Giorgos Vgenis for their kind words and emotional support.

This study could have been possible without the unconditional help and support of my two associates Mr Demetris Varelides and Mr Costas Catelas.

The author

I am a registered nurse, and I have been working for the last eight years in General Hospitals in Greece. My background is on the Intensive Care Unit of Neonates where I have been working for the previous four years, and also on the Intensive Care Unit of Adults where I have three years of experience. In addition, I have worked in the Emergency Department, Pediatric and Adults Surgical Unit.

At present, I am also working as a laboratory assistant in the Nursing Department of Health and Caring Professions of the Western Greece University of Applied Sciences (ATEI of Western Greece).

I completed my MSc in Nursing in 2009 at the University of Middlesex, London, the

United Kingdom. I became interested in managing post-operative pain during my postgraduate studies where my desire for an in-depth study of the phenomenon was born.

The theoretical approach to postoperative pain in combination with my professional experience led to the realization of this study.

Introduction

During the last decades, researchers' interest in assessing and managing post-operative pain has remained strong. Although science has made considerable advances, the issue of post- operative pain has remained unsolved (Cohen, 1980). Patients still experience severe postoperative pain mainly due to inadequate pain assessment and management which may have both direct and indirect consequences on a patient and the nursing staff (Bucknall et al., 2001).

The current Ph.D. research employed a multifaceted approach to the phenomenon from the nurses' perspective, aiming at an in-depth understanding of their own painful post- operative experience and the impact that this experience had on recognizing, assessing and treating a patient's post-operative pain.

The Literature review provides a historical perspective on pain and its origins. Pain theories and the management of pain have been reviewed throughout the human theory. The 19th and 20th century saw considerable developments in modern pain theories as well as new medicine and procedures. However, several of these developments and theories have not been able to provide effective solutions to post-operative pain management. Social sciences and humanistic theories can provide a framework for considering the phenomenon of pain from an alternative perspective. The discussion in the literature review places nurses at the center of post-operative pain management by exploring their agency, efficacy, and control; the obstacles that emerge in effectively managing post- operatively pain; the impact their professional experience, knowledge, and training has on their behavior in assessing and managing a patient's acute post-operative pain. The review also makes a brief discussion on the Greek health care system, the educational background of the nurses and the role of post-operative pain management in Greece. However, the reader should take into the consideration that most discussion and research has occurred abroad and that calls for more research at a national level especially due to the fact that the country has been going through a financial crisis which has exacerbated the problems inherent in the health care system.

9 The methodology chapter describes the methodological approach selected, interpretive phenomenological approach (IPA), explains the appropriateness of this, and provides a transparent and comprehensive justification. The theories of Gadamer and Carl Rogers are conceptual foundations to this study and therefore introduced in detail as it through them that the research question is explored.

In the methods chapter, the research procedure is presented. The sampling technique, the characteristics of the sample, its size, the way of gaining access to it and the relationship between the researcher and the participants are described in detail. The two phases, observation and interviews, selected by the researcher to collect the data are also presented along with the data analysis procedure and certain ethical and moral research aspects.

The findings chapter is divided into two main sections, the interview, and the observation data. It also provides details on the demographic characteristics of the sample. This chapter highlights the painful postoperative experience of the participants and the impact it had on their behavior in patients' pain assessment and management.

The last chapter is the discussion chapter were the findings of this study are discussed and compared in the light of Carl Rogers and Kurt Lewin’s theories. Based on these findings an education proposal is put forward with to fill the education gaps in post-operative management in the context of a person-cantered therapeutic approach. Finally, overall conclusions and implications for policy makers and future researchers are outlined. The limitations of the study are also mentioned in this chapter.

1 Literature review

1.1 Introduction

In this chapter, the literature associated with acute post-operative pain is presented. It starts with some of the standard definitions of pain and then examines and analyses the theories of pain from a historical point of view. Towards the end of the chapter, a narrative on the Greek health system and the policies of pain management within that system is given to add context to the thesis.

1.2 Search Strategy

With the current Literature Review, the existing literature about the effectiveness of post- operative assessment and management of patients by nurses is explored. The nursing, medical, psychological, social and pedagogical science fields are included in the literature research.

In the following Table (1.1) information about the data basis that was utilized to conduct the research, the search terms, as well as the inclusion and exclusion criteria, are reported. It is pointed out that no restrictions were placed on the search date.

Table 1.1. Criteria of literature review search.

Inclusion Criteria Exclusion criteria

 Literature in English and Greek  Literature not in English and language. Greek language.  Journals, studies, textbooks,  Journals, studies, textbooks, policy documents relevant to post- policy documents not related to operative pain assessment and the assessment and management management and or the broader of acute post-operative pain or for context according to search terms. the purposes of this research.

11 Data Bases

The Literature review was conducted by searching into seven different databases. These included CINAHL Plus, Ovid Medline, BMI, Cochrane Library, Psycho Info, Social Sciences, and Pedagogy.

Search Terms

The following terms were searched and developed in conjunction with each category.

Table 1.2. Search terms for literature review

Acute pain/ pain assessment/ pain management/pain theories/pain strategies/pain history/ pre- post-operative pain/pan relief/pain definitions/ psychological aspects of acute pain/pain behaviourism/ humanism of pain/or classical conditioning of pain/or operant conditioning of pain/or cognitive conditioning of pain/constructivism conditioning of pain/pain management Pain in Greece/painful pre- post-operative experience/ pain measures/pain scales/pain analgesia/painkillers/pain services/psychology pain/physical pain/neuromatrix theory of pain/pain behaviours/pain stimulus/pain knowledge/pain attitudes/education of pain/pain decision-making/pain strategies/communication of pain/ pre- post-operative pain approach/ pre- post-operative care/nurses’ perspectives/barriers to pain management.

Personal pre- post-operative experience/ pre- pain experience of nurses/professional pre- post-operative pain experience/nurses’ knowledge Condition of pre- post-operative pain/nurses’ behaviours of pre- post-operative pain/nurses’ attitudes of pre- post-operative pain/nurses’ empathy of pre-

post-operative pain/pain experience.

Nursing post-operative care/hospital care/day surgery/healthcare/surgical

Context theatre/pre- post-operative nursing care/cultural/social/policy/psychological impact.

Surgical nurses-patients relationship/patient pain information/pain assessment barriers/pain management barriers/knowledge/measure/surgical

Nurses nurses-doctors relationship/surgical nurses-colleagues relationship/ collaboration/habits/personal norms/attitudes/beliefs/professional nurses attitudes/personal post-operative experience.

12 Pain management nursing British Journal of surgery British Journal of anesthesia European Journal of pain Journal of clinical nursing Journal of pain Journals Pain World Health Organisation British pain society International Association of pain Journal of psychology Journal of advanced nursing Journal of consulting psychology Nursing and health sciences

1.3 History of pain and its definitions

The word "pain" was first used in the ancient Greek epic poems like the Iliad and the Odyssey attributed Homer, in 600 B.C where a man uses opium to alleviate his pain and appease the thoughts that torment him. Indeed, even inside restricted societies, such as that of the ancient Greeks, there were contradicting hypotheses regarding the underlying forces impelling pain.

Plato considered pain and enjoyment not as sensations but rather as emotions. He was one of the first thinkers to support the idea of a priori knowledge, according to which our souls are acquainted with the “forms” (or ideas); that is, the true essence of human beings before their birth (Dallenbach, 1939).

On the other hand, Hippocrates (5th century BC) assumed that pain is driven by a deficit or excess of one of the four essential substances ("humors") of the human body (Rey, 1995). Even the scientists of the time admit that pain doesn’t appear to be a mere sensation. Aristotle shares a similar point of view, not classifying pain as one of the five senses, but considered it as a passion of the soul, arising from a sense (Dallenbach, 1939).

More specifically, according to the ancient philosopher, pain is induced when a sense is not in harmony with a person's soul, therefore triggering the person's wish to avoid the source of this feeling. The possibility that the brain may be the center of pain awareness had been assumed by various philosophers and doctors, such as Pythagoras (570– 495 BC), Anaxagoras (500– 428 BC), and Galen (130– 201) in ancient times, and Avicenna (980– 1037) in the medieval times (Merskey, 2005). Aristotle and Hippocrates suggested that the perception of pain is rooted in the heart, rejecting the brain as a focal organ of the sensory

13 perception of pain. Conversely, Galen considered the brain as the focal organ of feelings (Dallenbach, 1939).

Through careful monitoring of patients experiencing different types of agony, he suggested that pain is specific to the sense of touch, and described inflammation as a combination of pain, warmth, redness, and swelling (Rey, 1995).

On the other hand, Avicenna postulated in his famous works Canon of Medicine and Poem of Medicine that agony is an autonomous force that is distinct from the tactile sensation and high temperature, thus being the first advocate of the specificity theory which states that pain is a specific sensation, with its sensory apparatus, independent of touch and other senses (Craig, 2003).

In the 17th century, our understanding of the processes of the brain was fundamentally advanced by René Descartes (1596-1650), who depicted the transmission of pain information through the central and peripheral nervous system to the ventricles of the cerebrum and the pineal organ where pain stimuli were thought to develop the perception of pain (Melzack et al., 1967).

After the Middle Ages, a systematic effort to provide an insight to the components of the nervous system relating to pain enhanced our understanding of the natural world and promoted the development of mechanisms of scientific investigation (Keele, 1957).

Moreover, the scientific progress at the beginning of the 20th century led to the discovery of different types of sensory receptors in the skin, which in turn led to the interpretation of pain as a mere sensation. The pain was thus perceived as a sense arising from the stimulation of free nerve endings. How the theories of pain evolved through the years and how pain is associated with behaviorism will be discussed in the next sub-section.

There are numerous different definitions of pain. The most widely accepted definition of pain is the one used by the International Association for the Study of Pain (IASP). It defines pain as "an unpleasant sensory and emotional experience associated with actual or potential tissue damage or described regarding such damage." This definition recognizes that pain is an emotional as well as a sensory phenomenon.

However, Margo McCaffrey defined pain as “whatever the experiencing person says it is, existing whenever he says it does” (McCaffery, 1968). This definition emphasizes the 14 subjectivity and psychological nature of the patients as reliable indicators of pain (Weiner et al., 2002).

There are several alternative forms of pain classification and definitions. Acute pain is defined as a complex, unpleasant experience with emotional and sensory features that occur in response to trauma (International Association for the Study of Pain, 1994). Postoperative pain is a form of acute pain. The American Society of Anesthesiologists (ASA) defines postoperative pain as the pain present in a surgical patient because of a previous surgical procedure, or a combination of disease-related and procedure-related resources (Chou et al., 2016).

After a tissue trauma, nerve impulses generated from the site of the incision are transmitted to the dorsal horn of the spinal cord which, in return, projects neurons forward towards the cerebral cortex in the brain. According to Lewis (2005), the brain interprets the signal, processes information from experiences, knowledge, and cultural associations to perceive pain. Consequently, the post-operative pain (POP) can generate enormous individual differences in pain perception.

Despite these definitions, barriers continue to exist and to create an ineffective post- operative pain assessment and management (MacIntyre et al., 2010). According to Vervoot (2009), researchers and clinicians should explore factors other than physical ones, such as psychological or social, to identify how they influence the experience of pain. Miaskowski (2004) highlights the need for the development of a multidisciplinary approach to pain assessment and management.

1.4 Pain theories

Several theories have attempted to explain pain conceptualization. The leading five of them are the Specificity Theory (or Labeled Line), Intensive theory, Pattern Theory, Gate Control Theory and the Social - Physical Pain Overlap Theory (SPOT) (Melzack et al., 1994).

The Specificity Theory created by Charles Bellin in 1811, explored the structure of the sensory system. Bellin initially proposed that the brain is not ‘common sensorium,' as

15 recommended by Descartes, which was the acknowledged model of the brain at the time. In contrast, he provided anatomical confirmation that the brain is a heterogeneous structure (Bell et al., 1868).

More precisely he suggested that nerves were distinct sets of neurons with specific capacities and that their bundling merely facilitated signal transmission. Subsequently, Bell proposed that different sensory neurons respond uniquely to different types of stimuli: motor neurons and ‘vital’ neurons that are connected to the psyche rather than the brain (Bell et al., 1868).

Moreover, he distinguished the perception of a stimulus (for example, vision and nociception) from the perceptual experience (sight and pain, separately). This is the fundamental precept of the Specificity Theory which proposes that there is a dedicated fiber that prompts a unique pain pathway to the corresponding center of the brain thus introducing the idea of a dedicated nerve tract (Bell et al., 1868).

Further progress in anatomy, physiology and histology research provided additional data related to pain (Bonica, 2010). Within this framework, Arthur Goldscheider put forward the Intensity Theory, primarily based on experiments showing that continual stimulation of the sense of touch produced pain in patients with syphilis who had degenerating dorsal columns (Goldscheider et al., 1894).

When this stimulus was presented to patients 60–600 times, they experienced pain which was self-reportedly intolerable. Goldscheider created a neurophysiological model to explain that continual sub-threshold stimulation or supra-threshold stimulation produces pain. Also, as opposed to the Specificity Theory, he postulated that intense stimulation of the senses would accumulate within the grey matter of the spinal cord (Rey, 1995).

Expanding on John Paul Nafe's (1934) proposal that distinctive cutaneous qualities are the result of various temporal and spatial patterns of stimulation, and disregarding an extensive collection of findings for receptor fiber specificity, Sinclair and Weddell's (1955) Peripheral Pattern Theory suggested that all cutaneous fiber endings (with the exception of those supplying hair cells) are indistinguishable and that pain is generated by extreme stimulation of these fibers (Bonica, 1990).

In the theories outlined above, pain is recognized as a form of an unbearable response. Intensive Theory takes into consideration the recognition of the pain in the above theories, 16 also suggesting that the biological understanding of pain is associated with the understanding of behavior.

More specifically, for stimuli to be processed in the brain, a complex response in the human body is triggered. This trigger (reaction) can be expressed in many forms, such as changes in heart rate and blood flow, etc. In the same way, painful stimuli also produce a central nervous system response; that can be measured by a component of the peripheral nervous system (Skinner, 1938).

However, considering that different painful stimuli may produce various peripheral responses, the overall response of the human body cannot be measured by this practice. Taking into account that pain responses may, at least partly, depend on other stimuli according to the classical conditioning principles, it may be concluded that if a morbid stimulus is combined several times with a neutral stimulus, the latter will trigger the components dependent upon the complex pain response (Skinner, 1951).

Ronald Melzack and Charles Patrickwall in 1965 proposed a theory that changed and revolutionized the research related to the pain; the theory is known as Gate Control Theory of Pain. This theory was the first groundbreaking effort to unify sensory-cognitive evaluative parameters of pain responses. Ronald Melzack and Charles Patrickwall in (1965) conceptualized a theory that entailed a radical change in patient's understanding of pain.

More specifically, they visualized not just a single signal going from the location of damage to the inhibitory and transmission cells and up the spinal cord to the brain, but also an additional signal going from the location of damage immediately to the brain, where, depending on the condition of the brain, it might induce the transmission of a signal down the spinal cord to regulate inhibitory cell action. This hypothesis offered a physiological clarification of the influence of psychology on pain perception (Melzack et al., 1965).

The Gate Control Theory of Pain furnished corroborating evidence for the specificity and pattern theories (Cardenas et al., 2016). Gate control impacts on how a man perceives pain as sensory pathways intersect so that the mind can control the perceived level of pain, given which pain stimuli are to be disregarded. The brain decides which stimuli are productive to disregard after some time. Consequently, the brain has power over pain sensation and can potentially ignore types of pain that are not deemed valuable (Erpelding et al., 2012).

17 At this point, it is appropriate to introduce the term plasticity. Plasticity is a term used in neuroscience to describe the dynamic functional and anatomical changes in the nervous system after an injury or disease. Plasticity is not only observed in directly damaged neural pathways but also in undamaged pathways of the peripheral and central nervous system, as part of a compensatory reorganization process (Bryck et al., 2012).

As regards postoperative pain, the mechanisms of change are methods through which tissue damage increases the response of the sensory system. As a result, subsequent stimuli have an amplified effect. This phenomenon is known as sensitization and establishes that postoperative pain is not merely a temporary unpleasant experience for the patient, but can have long-term ramifications, which are revealed over time (Mansour et al., 2014).

This reorganization has been demonstrated in imaging studies of the human brain, where gray matter atrophy and a reduced white matter integrity have been observed. It is a reorganization of the cortical circuit, which appears to be specific to particular chronic pain conditions. Therefore, it can be concluded that chronic pain is the result of plastic changes in the cortical circuit having significant implications for learning and memory (Farmer et al., 2012).

According to the literature, the known opiates that were used for the relief of the pain are the earliest proof of the overlap between physical and social pain. It has been found that in non-human mammals the separation distress is reduced. It is characteristic that when morphine is provided, euphoric sentiments are created which in their turn relieve the pain. The same opiate substances at the same time significantly reduce the social distress that is caused when infants leave their mothers.

The common use of the neuron network by physical and social pain can be realized by the fact that the pain of loss can cause stomach problems which in the end can become more painful than the pain caused by this negative social experience. This cause and effect has led scientists to create two subcategories of physical pain: i) a sensory one which causes immediate reactions and ii) an affective one which correlates with an unpleasant or distressing experience (Eisenberger, 2012).

Eisenberg and Lieberman (2004) stated that the social pain, present due to many factors, can lead to social bond breaking and can make one suffer in a similar way to physical pain. Eisenberg and Liebermanformulated the Social - Physical Pain Overlap Theory 18 (SPOT)which suggests that both, social pain and physical injury pain share parts of the same underlying processing system (Eisenberger et al., In Press).

According to the two scientists, the induced social pain, not only affects human brain processes but also shares the same parts of the brain that physical pain does. Notably, both circuits (of physical and social pain) share a more extensive neural alarm system. So, it can be said that physical and social pain overlap. The anterior cingulate cortex (ACC) has a key role in this overlapping. It is known that patients that partially damaged anterior cingulate cortex tend not to be bothered by the pain, (although they do feel it) but they experience social distress which proves that this part of the brain plays a vital role in distressing situations.

However, if the same pain neural circuitry is used, it has consequences. One consequence is that when somebody is sensitive to one type of pain, is at the same grade sensitive to the other kind of pain. This overlap applies to healthy people as well as to chronic patients (Eisenberger, N. I. et al., 2004). High levels of one type of pain imply high levels of another kind of pain. However, in some cases, the opposite behavior is observed.

According to some researchers, it is not very clear which kind of social pain leads to increased or decreased levels of pain. Neuro-imaging techniques have been used to explore the role of the ACC in socially distressing situations. In particular, social rejection of a participant led to increased activity of the ACC and specifically, of the dorsal subdivision (dACC; areas 240 and 320) (Eisenberger et al., 2004). Moreover, they proved that the grade of the social pain depends on whether the patient is in physical pain and the degree of physical pain depends on whether the patient is in social pain (Eisenberger et al., 2004). Extending their previous research Eisenberg and Lieberman (2006) tested two specific assumptions. The first one being whether sensitivity to social rejection could be predicted by the baseline of the sensitivity to physical pain and the second one whether physical pain would be enhanced with the first social distressing situation.

When a virtual ball-tossing game was employed, it was found that the sensitivity to social rejection was related to baseline sensitivity to physical pain and that physical pain was enhanced by social distress. In more detail, the participants played a virtual ball-tossing game with two other individuals and a few seconds before the end of the game they accepted three uncomfortable stimuli which were evaluated by the participants based on a pain rating scale (Eisenberger et al., 2006).

19 It was found that both pain and social distress used common neuro-cognitive pathways. Furthermore, the higher the sensitivity to pain was, the higher was the distress that was caused by social rejection and vice versa (Eisenberger et al., 2006).

This interaction can be very effective for patients with chronic pain. The treatment of physical pain may treat the stress of social pain indirectly since the two kinds of pain share the same neural system. Alternatively, physical pain may be treated by reduced social distress (Eisenberger et al., 2006).

Consequently, according to Eisenberg and Lieberman's theory, physical pain shares the same neural network with pleasure and social pain. The Insula and dACC are activated in every case of social distress making physiological support significant part of pain relief.

At this point, it is worth mentioning that this theory has been applied explicitly to mammals. It has been stated that new-born mammals, which depend on others for their survival they experience pain when separation time arrives. Thus, the social enforcement for survival may in its turn enforce an internal evolutionary mechanism that uses the same neuronal network of physical pain (Lieberman et al., 2008).

So the realization of the way that physical and social pain complement each other may lead to understanding why this happens (Lieberman et al., 2008). One characteristic example is that anxiety disorder may occur either due to physical harm or social rejection. The loss of a beloved person is considered to be another particular example of the intensity of physiological pain which is comparable to the rating scale of physical pain. Moreover, this psychological pain can lead to physical pain such as a migraine. So it is indisputable that these two kinds of pain are connected, but the nerve signals may act in a different way (Lieberman et al., 2008).

Eisenberg and Lieberman (2012) examined the effect of dACC damages on discrete social distress experience and social rejection, using neuroimaging techniques. According to their experiments, in any case, that the patient felt social exclusion, very high activity was seen in the dACC performed. When social support was given to them, then the dACC's activity was significantly reduced.

Additionally to the effect of social detachment on the dACC activity, Eisenberg found out that empathy for a very close friend is another emotion that causes the same activity of 20 dACC and anterior insula. This behavior was explained as mental experience with the sufferer putting themselves in someone else’s position, simulating the same situation in their mind. The sentiment of empathy for another person that is not a close friend does not cause the same reactions. On the other hand, the empathy process moderates the amount of affective pain activation (Meyer et al., 2012).

The above findings may help to realize the direct factors that enhance physical pain, making the treatment of a patient more effective or changing the methods that physiological disorders (e.g., depression) are faced and treated.

Nevertheless, the overlapping nature of the physical-social pain mentioned earlier must be further investigated. It should be noted that in the previous studies of Lieberman, empathy had not been connected to the neural system since during the study of a single emotion, he set limitations as the social context that was provided did not vary. Furthermore, there was no pro-social motivation assessment of the participants.

Morelli et al. (2012) extended the research of Lieberman, by studying the neural response when the participants experienced pain, anxiety, and happiness at the same time and at varying degrees, with the help functional magnetic resonance imaging (MRI) technique. The interesting point was that the observed behavior concerned real word interactions.

Participants during their watch with the MRI were asked to show empathy for different situations if they were in the position of someone else, by presenting them a series of photos. Thus, they were asked to show empathy for pain condition. In the case of empathy for anxiety and happiness conditions, the participants were asked to describe a personal situation followed by photos relating to the described circumstances. Finally, a neutral situation was created by showing pictures with people performing menial tasks (Morelli et al., 2012).

Thus, they (Morelli et al., 2012) found that when a positive emotion rises, then a positive effect appears. In the same manner, when a negative sentiment comes to the surface, an adverse effect appears. Moreover, they found out that when the participant experiences anxiety and happiness, the mentalizing system is activated, while when empathy correlates to pain, the mirror system is activated.

The results of Morelli’s et al. (2012) research showed that there are quite a few neurocognitive elements that affect empathy. Limbic regions such as dACC, AI and VMPFC influence affective congruence that is the consistency between the self-concept of 21 an individual and the related behaviors and responses of others. In addition, mirror and mentalizing systems constitute pathways to sharing emotions with others. Lastly, the septal area is likely to motivate pro-social behavior. As Morelli's et al. (2012) pointed out empathy increases our consideration towards others irrespective of the emotion being experienced and leads to pro-social behavior. Generally speaking, such results can provide new insight into previous studies on empathy and its different components.

In the following sub-sections, the different kinds of conditioning are referred to analyzed.

1.5 Behavioural aspects of pain

Factors that influence the experience of pain include processes of attention, other cognitive processes (memory/learning, thought processing, beliefs, mood), behavioral responses and interactions with the person’s environment (Chung, 2003). According to Leeuw (2007), people who have experienced persistent pain develop a fear of pain. He goes on to say that this may contribute to the development of avoidance responses following pain and injury. Negative affectivity and anxiety sensitivity could contribute to the development of pain- related fear which can lead to behavioral changes.

Such changes can be better appreciated through the theory of Behaviorism. This approach includes stimulus-response behaviors, which are observed through interaction with the environment. Over the years, many theories of Behaviorism have been developed.

John Watson (1913) was the first one who began the behaviorist theory in 1913. He suggested that all aspects of human psychology could be interpreted through the process of classical conditioning, according to Pavlov’s findings. Ivan Pavlov, in his turn, was the pioneer of the classical conditioning theory. Pavlov discovered that it was possible to develop a relationship between a dog and a stimulus, such as food, by producing a reaction to a neutral stimulus, such as a bell ring (Pavlov, 1927).

Therefore, according to the classical conditioning theory, the new behavior is learned through the association process. A new act is generated in a person or an animal through the combination of two stimuli. Classical conditioning is categorized into three steps, before, during and after the stage of a stimulus. The limitation of this theory is that it analyses neither the nature of behavior nor the nurture of a behavior, underestimating in that way the complexity that human behavior appears.

22 Operant conditioning constitutes another type of conditioning which is essential for the comprehension of the overall human behavior, as well as pain behavior. The main focus of operant conditioning is to modify the frequency of the performance of specific behavior (Skinner, 1938). If a given behavior has a positive impact, it is more likely to reoccur, whereas if the positive consequences of a behavior are fragmentary, it is less likely to be performed again (Aall et al., 2000). This theory has its underpinnings on the Law of Effect theory which was initially proposed by Thorndike (1905) and subsequently processed by Skinner as a principle of operant conditioning and then applied to the understanding and treatment of pain through the Gate Control Theory (Melzack et al., 1965) and Fordyce’s theory (Staats et al., 1996).

However, the operant learning model doesn't explain the pain, but mainly focuses on maintaining pain behaviors and avoiding good behaviors, such as activities. As a result, although pain behaviors are initially elicited by sensory input, over time, they may occur as a response to environmental circumstances (Brush, 2014).

Constructivism is a new theory which claims that it can provide an alternative framework based on consciousness studies and hopes to elucidate the complex nature of pain and other emotions (Piaget, 1954). This theory is opposed to the hypothesis that the brain creates an accurate representation of the world based on sensory input (Mandler et al., 1987).

According to constructivism, our brain constructs a subjective experience based on sensory input, memory, and expectations which are shaped according to social and cultural contexts. Thus, the brain produces sensitivity through a complex series of parallel processes, a principle that can be applied directly to matters of emotion and pain (Piaget, 1954).

Moreover, it assumes that the brain is not concerned with the reality itself, but instead with an internal, autonomous representation of the real world, which is being constantly built and revised using sensory information and associative memory circuitry. This subjective reality is constantly undergoing self-organization, as it relies on sensory information, emotions, general knowledge structures and other aspects of knowledge; it is an internal reality which always constructs a point of view based on an individual's self-perception (Freeman et al., 2001).

Furthermore, the constructivist approach states that the experience of an individual is different from the experience of other individuals, as each person creates an empirical reality and lives within this unique reality. Consequently, two patients with identical 23 damage do not experience the same pain, as their personal experiences are not similar. Therefore, to prevent or relieve pain, it is essential that interventions are adapted to the uniqueness of each person (Nakamura et al., 2002).

The constructivist approach appears to avoid strict limitations imposed by the classical sensory neurophysiology of pain, thus defining pain as a phenomenon rooted in consciousness. According to constructivism, pain is a complex physical-conscious experience which is negatively charged as regards emotion. Pain is highly physical, as it is characterized by sensory properties which are typically due to tissue damage (Nakamura et al., 2002).

According to the above behaviorism theories, that have been developed over the years, point to the need for an alternative or a supplementary approach. The humanistic approach, the known as the ‘third force,' constitutes an alternative path to psychology after behaviorism (Maslow, 1968). In the next section, the principles of humanism theory and their relevance to pain are described.

1.6 Humanism and pain

Humanistic models recognize the influence of a person's current experiences on life and admit that these experiences are vital to change, thus leading to a greater sense of well- being. Rogers (1967) shared the belief that individuals have an incentive to understand their potential; that is, the full development of their capabilities. Therefore, these models can be of assistance in perceiving pain and developing new approaches aiming at establishing more humanistic health policies and expanding the meaning of humanism beyond its current use.

Rogers (1961) explored the development of the concept of ‘self' and the values that individuals attach to their experiences that prevent them from fulfilling their full potential in life. These values or ‘conditions of worth' are information registered through the experiences of an individual that he/she perceives as real; this input leads to the formation of the structure of the self (Geller, 1982).

Although these interjections may have a positive influence on a person's self-regard, this is not always the case. For example, in nursing, there are cases of patients who may not ask for help or seek relief from pain because they believe that they are not worth it, as they are not as ill as another person might be. This gap between the real self and the ideal self can

24 become wider if the disease or health of an individual depends on how he/she perceives his/her body (Gambatesa et al., 2013).

Humanistic therapists posit that people are inherently motivated towards development and the degree to which they can fulfill their full potential depends on how their psychological needs have been satisfied (Murphy et al., 2015). The mechanisms of change are characterized as ‘actualizing tendency' or ‘organismic valuing processes.' This self-directed potential for the development of an individual is facilitated by a non-directive system of therapy (Farber, 2010).

In 1967 Rogers had already developed the person-centered approach, which was founded on the idea of the therapy situation. He established three factors which serve as core conditions for personal development within psychological settings: i) maintaining the individual's genuineness through acceptance, ii) empathy and iii) non-directive intervention.

i) Genuineness/Congruence: According to Rogers real involvement is a person's willingness to express through his/her words and behavior the different feelings and attitudes that exist within themselves. Only by providing the actual reality that exists within the person's self will the individual reveal everything that he/she is feeling or thinking, without considering the impact that this may have on the other. For this reason, Rogers suggests that the therapist should focus on their thoughts, feelings, and behaviors and reflect on what they are saying about themselves, the client and the client's situation. Furthermore, genuineness enables the therapist to understand what the person considers best for his/her condition, always with respect and sensitivity. In turn, the term acceptance signifies unconditional warm respect towards an individual; that is, regardless of the person's situation, behavior or feelings. Rogers acknowledges the importance of being able to experience this acceptance in the relationship.

ii) Empathy: Empathy is proposed as the second most crucial factor. Empathy is the ability of a person to continuously have the desire to understand what the person feels or wishes to communicate. Rogers defines empathy not as an understanding which is offered by the other person, but as a profoundly associative understanding. He admits that he had not always been able to establish a relationship of this nature, as the other person may not be able to accept this type of connection. Empathy involves cognitive processes relating to feasibility, expectations, decision-making

25 and interpersonal judgment; aspects that all researchers should bear in mind. Particular attention should be paid when examining whether empathy could be defined as a sense of knowledge of another person's experience (Goubert et al., 2005). Ickes (2009) demonstrated that interpersonal judgment could not be entirely accurate. This also applies to empathy as regards pain. In literature, there are many published works (Chambers, 1998; Redinbaugh et al., 2002) that confirm people's tendency to underestimate other people's pain, while some studies suggest the opposite. According to Rogers (1957), the ability to accurately perceive the pain or discomfort of another person is frequently considered vital to the process of providing adequate care to people who experience pain. So, it is equally important for the observer to be able to distinguish his/her perception of the personal experience of the other individual from his/her emotional response to this (Cano et al., 2004). This idea particularly applies to self-reported feelings, such as unhappiness. If this distinction has been successfully made, it is expected that the intensity of other intense emotions, for example, familiarity and proximity, will increase (Hill, 2007). As a complementary action, it may be appropriate to reveal something personal that is relevant to the specific situation, to establish empathy (Seligman et al., 2006). However, it is crucial that this revelation is to the benefit of the client; the doctor's reaction to a situation relevant to his/her personality should not be mentioned. The objective is to support the person’s experience, not reject or underestimate his/her issues. Although everyone needs to have a sense of achievement, the fact that clients come first should be kept in mind. iii) Non-Directive Intervention: Client-centered therapy aimed at understanding the person, as it is considered that they can be seen through the reflection of their self. It has been suggested that deep understanding and acceptance leads to a more objective self-regard and eventually to a complete acceptance of self. As far as nursing science is concerned, in 1962, a nursing researcher used the term ‘centeredness of the patient' in literature for the first time to describe the communication between the nursing staff and the patient. The nursing staff asks interpersonal questions that encourage patients to reveal how they perceive their world and their experience, the meaning of this experience in everyday life, their emotions and self (Mathews, 1962). Focusing on experience is vital, as a powerful personal experience leads to the acknowledgment of desire, motivation and, consequently, to the change in the person's behavior to achieve their goal. Michel

26 Lobrot, inspired by Kurt Lewin and Carl Roger's theory, developed the NDI theory, which maintains that desire is the driving force that enables an individual to change characteristics of his/her personality that have posed difficulties in the past, thus creating a healthy relationship with other people (Brouzos et al., 2004). This can only be achieved through an experiential process, using a method and a technique that seems vague to external observers but simple at its core, as it relies solely on personal experience. The non-directive intervention involves enabling individuals to be the center of attention in a therapy session without the therapist offering advice or implementing strategies or activities.

To conclude, pain can become very complex, and for this reason, pain management guidance needs to be seen from a humanistic perspective. This may include the identification of the pain type, the symptoms, and causes, the diagnosis and tests, treatment and care, living and managing, support and resources.

1.7 Epidemiology of postoperative pain

Despite advances in the understanding of pain physiology, pharmacology, and assessment there has not been a significant improvement in postoperative pain theory globally even if post-operative pain is considered to be a widespread problem (Wu et al., 2011). Perhaps this is because many reasons make it difficult to provide a more lucid picture.

On a global scale, the prevalence of post-operative pain ranges from 50% to 75% of post- operative patients (Philip et al., 2007).

The Faculty of Pain Medicine of the Royal College of Anaesthetists (Justins, 2008) in the UK concluded that approximately 60% of the patients who undergo surgery experience severe pain post-operatively. Another UK based study reported that 30% of patients experienced pain after surgery (Masigati et al., 2014).

A German study including 70,764 patients from 105 German hospitals concluded that a number of routine minor to medium operations produced surprisingly high levels of pain post-operatively (Gerbershagen et al., 2013).

A Dutch study of 1490 surgical patients showed that 41% of patients experienced moderate to severe pain on the first postoperative day followed by following rates of 30%, 19%, 16% and 14% on the first, second third and fourth day accordingly (Sommer et al., 2008).

27 A study carried out in seven central and southern European countries in 2008, showed that post-operative pain management was insufficient to meet patients' needs either due to a lack of documentation (56% did not have pain recorded), or due to lack of follow up (34% did not have their pain reassessed)or due to absence of written evaluation bids (75%) (Benhamou et al., 2008).

Apfelbaum et al. (2003) conducted a telephone survey with a random sample of 250 US patients and found that almost 70% suffered from moderate to acute post-operative pain. In 2011, the US National Institutes of Health recorded more than 80% of post-operative pain patients, but only less than 50% of them received sufficient relief from pain.

Gan et al. (2014) using a national survey highlighted that postoperative pain is not well managed. More precisely they studied 300 adults who underwent surgery, 86% experienced post-operative pain with 75% reporting moderate or extreme pain. The same group also reported that post-operative pain is still poorly treated. The report emphasizes that large-scale studies are needed to determine whether the currently available therapeutic approaches used during surgery reduce the adverse effects of poor pain relief (Gan, 2017).

Also, 95% of patients experienced various degrees of post-operative pain according to a study conducted in Nigeria (Kolawole et al., 2003).

The data obtained on post-operative pain treatment in a sample of hospitals in seven European countries by the Postoperative Analgesic Therapy Observational Survey reported significant shortfalls in managing pain policies with 62% of the hospitals not offering an acute pain service (Benhamou et al., 2008). As well as this, 34% of the participants complained about the lack of regular staff training programmes while only approximately half of the wards (49%) provided regularly scheduled pain assessment.

To conclude, on a global scale the percentages of patients who experience post-operative pain remain high which may indicate inefficiencies in managing post-operative pain effectively. Therefore, it remains a challenge and calls for further research to obtain more reliable and comparable data to allow for applying a holistic approach to pain management.

1.8 Nurses at the centre of post-operative pain management

The British Pain Society (BPS) in particular, has identified nurses as key members of the pain management team (Lee et al., 2014). Also, the Joint Commission on Accreditation of

28 Healthcare Organizations (2002) emphasized that it is a moral, ethical and professional imperative for nurses to provide pain relief and promote comfort (Innis et al., 2004). Because of their intense, continuously inter-related contact with patients, nurses can quickly gather information on patients and their pain experiences (Ingalill Gimbler- Berglund MSc et al., 2008). Kumar (2002) highlighted that it is a humanitarian and ethical imperative for nurses to provide pain relief. There are many studies which suggest the prioritization of the need of nursing worldwide to enhance post-operative pain management (Gordon, 2002).

A body of clinical evidence indicates that acute pain can progress into a chronic pain state following surgery or trauma (Perkins et al., 2000). However, effective postoperative pain management may decrease the likelihood of this progression (Storyet al., 2010). Multiple factors have been identified as contributing to poor post-operative pain management; however, the problem still exists.

1.8.1 Agency, efficacy and control

According to Ballard (2011), agency is an individual's conviction that has the ability to successfully perform an action that seems personally meaningful and that action will contribute to accomplishing a task and producing a favorable outcome. This is also known as self-efficacy. Although he suggests that agency accrues with personal experience, he also notes that it can be increased through gaining knowledge, sharing life experiences, collaborating with and devoting oneself to the members of a particular group that the individual is part of.

The notion of self-efficacy is presented in the Social Cognitive Theory (Bandura, 1977) and the Protection Motivation Theory (Rogers, 1975) in a similar way, as a mediator between motivation and behavior.

Based on these theories, the Integrated Communication Skills Training Model (ICSTM), which was introduced by Parle et al. in 1997, posits that healthcare professionals with satisfactory communication skills, high self-efficacy toward the performance of communication tasks, anticipation of meaningful and valuable outcomes and an encouraging workplace, tend to initiate discussion and motivate their patients to express their psycho-social needs.

29 Liu et al. (2007) evaluated the effectiveness of the Integrated Communication Skills Training Program for Nursing staff in Cancer Care (n=129) through a quasi-experimental research design with a nonequivalent control group. This involved intensive learning and practice in the ward, combined with a supportive environment, followed by an evaluation of basic communication skills and self-efficacy in specific nursing communication skills.

According to the findings, positive past experiences led to a significant improvement in the nursing staff general communication skills, estimates of self-efficacy and outcome expectancies. As a result, the nursing staff showed higher motivation to initiate discussion with patients and encourage them to express their psychological needs.

In contrast, accumulated experiences of unsuccessful action or adverse consequences resulted in lower estimates of self-efficacy or negative outcome expectancies. According to Aiken (2001), the inability of nursing staff to provide the necessary care to patients is associated with lower job satisfaction, which aggravates nursing staff' emotional exhaustion (Leiter et al., 2006).

Nevertheless, Liu et al. (2007) findings could not be generalized to other environments, not only because the study was conducted in a single hospital but also because the specific hospital was oncology and not a general hospital.

Self-efficacy and outcome expectancies are two highly correlated notions, as they both reflect the perception of an individual about their personal abilities to correctly perform an action and the outcomes someone anticipates when completing this behavior.

Liu et al. (2007) concluded that there was a positive association of self-efficacy with outcome expectancies, due to the fact that this interaction of the nursing staff with the patients promoted the forging of their self-efficacy and outcome expectancies. In addition, the results found a consistent association of outcome expectancies with perceived encouragement of the nursing staff by their colleagues and supervisors.

In particular, Parle et al. (1997) suggested that the most significant factor which helped create positive outcome expectancies and promoted the effective communication of the nursing staff with the patients regarding their psychological needs was the psychological support provided by the healthcare environment.

As a result, the nursing staff becomes more effortful, active, highly motivated and able to develop their skills further and acquire knowledge. Conversely, healthcare practitioners with inadequate communication skills, less confidence in their abilities, low self-efficacy, 30 the anticipation of negative consequences and lack of encouragement from their colleagues are more likely to manifest distress and avoid challenging tasks to defend themselves (Parle et al., 1997)

As it was stated above, this circumstantial context could either lay the foundation for the manifestation of inaction on the part of the nursing staff (Latane et al., 1981) or produce apathy (bystander effect) (Latane et al., 1968), an extraordinary phenomenon in which the presence of others inhibits helping when confronted with a situation involving for instance, a victim.

These two constructs represent beliefs of the individual. Fishbein and Ajzen (1975) state that the opinions of a person are formed as a result of accumulated personal experiences, immediate observation, knowledge provided by others, and a process of mentally combining these elements to make deductions.

Furthermore, Bandura (1977) notes that apart from the actual experience of effectively dealing with a task, which plays a crucial role in enhancing self-efficacy, self-efficacy is also reinforced through verbal persuasion, namely encouragement to complete a job, and psychological stimulation.

To better understand where the difference between the two constructs lies, it should be noted that a nursing staff's conviction that he/she is able to successfully execute the task required to obtain the desired outcome, for instance, take the appropriate measures to alleviate patients' pain–does not necessarily entail an equally high level of perceived behavioural control. The last one is also subject to contextual hindrances, such as workload and lack of time.

Finally, Stanley and Pollard (2013) used a cross-sectional, correlational design to evaluate the correlation of knowledge and self-efficacy of pain management in pediatric nursing staff (n=25). The results did not find any association between the degree of awareness on the part of the nursing staff regarding pain management and the degree of belief in their abilities to effectively manage pain. However, they reported that in some cases there was a discrepancy between their knowledge regarding pain management and the extent of confidence in their abilities.

The small sample size from only two hospitals as well as the absence of the consideration of nursing staff’ training on pain management and the use of pain tool protocols could not enhance the generalization of the findings to other environments’ nursing staff (Stanley 31 and Pollard, 2013). However, it is worth noting that this excessive self-confidence which does not reflect the actual level of knowledge of the nursing staff may compromise the appropriate care of patients in pain.

1.8.2 Reasons for nursing stasis

Several obstacles to effective post-operative pain management have led to a stasis, in other words, to a condition in which there is minimal action or progress in nurses' development in this field.

To begin with, according to the rational choice theory, individual preferences are influenced by the potential costs and benefits of a decision (Tversky et al., 1986). According to Lankshear (2005), this explains why surveys of nursing staff and literature reviews report that the quality of care provided to the patients is compromised by the shortage of staff and supplies as well as the subsequent increase in the amount of work assigned to each person.

The importance of variables impeding effective pain management in post-operative patients other than nursing staff's individual beliefs, values and attitudes have been emphasized in several studies (Czarnecki et al., 2011; Rejeh et al., 2008).

More specifically, Rejehet al. (2008) conducted a qualitative study to determine how Iranian nursing staff perceive the factors that either impede or facilitate their patients' postoperative pain management by interviewing 26 nursing staff members. According to the study results, nursing staff encountered various barriers during pain management, including their feeling of impotence, the policies, and rules implemented by the healthcare system and hospital authorities, the physicians' persistence in having complete command of their practice, lack of time, communication constraints and disruption of pain-related activities.

Given these obstacles, the nursing staff's decisions and actions revolved around the postoperative comfort of their patients. However, due to the limited sample size, it is not possible to generalize the research findings to another population of nursing staff. As a result, it seems appropriate to consolidate the interview findings by comparing them to the output from observational studies.

32 Apart from individual beliefs, values, and attitudes, behavioral intentions also seem to be strongly influenced by norms. Sociologists acknowledge the power that norms have over personal decisions (Schultz et al., 2007).

Norms are classified into social standards and personal criteria. Both refer to obligations that individuals have to comply with; however, social norms relate to the social pressure that makes a person engage or not in a particular behavior, whereas personal standards are imposed by a personal feeling of duty, which arises from a person's negative emotions if they remain idle.

But how powerful is the influence of social and personal constraints and expectations on nurses' behavior?

Social forces exerted by patients, hospital administration and healthcare professionals often have a powerful impact on nursing staff's intention and behavior (Edwards, 2001). It is worth clarifying the manner in which normative rules are communicated among the members of a specific group of people, the cases where people do not obey to normative pressures and make their own decisions and the factors that enhance the impact of normative influences (Edwards, 2001).

Cialdini (2001) notes that, as a general rule, nursing staff should conform to pain assessment and management patterns to alleviate the patients' pain throughout their rehabilitation, suggesting that the accumulated knowledge shared by a group is often in the interest of both the group as a whole and the individual.

However, Cialdini (2001) points out that obedience to social norms can generate fixed- action patterns; that is, automatic compliance responses which unnecessarily render the careful consideration of the consequences of a decision by the individual during the decision-making process.

The concept of the fixed-action patterns could improve our understanding of the fact that nursing staff blindly follow mechanical patterns of action and fail to adopt new behaviors regarding pain assessment and management in postoperative patients, thus relying on mental shortcuts (Walsh et al., 1994).

Nevertheless, in some instances, group action may not be in favor of the individual. In particular, the notions of group inaction (Latané and Nida, 1981) and bystander effect (Latané and Darley, 1968) have been explored, the latter being an extraordinary 33 phenomenon in which the presence of others inhibits helping on the part of the individual when confronted with a situation involving a victim.

An ethnographic study performed by Crow (1995) in a US hospital set out to explore how social contexts affect decision-making and confirmed the existence of a group where a role was assigned to each member, and the nursing staff, as well as the medical staff, was governed by hierarchical relationships.

According to their findings, the more experienced nursing staff was, the more it became the pivot around which the inexperienced nursing staff revolved to seek help and advice. This is in line with Fishbein and Ajzen’s theory (1975), which suggests that in healthcare settings where senior nursing staff established pain assessment and management as a priority, inexperienced nursing staff would be more likely to follow the health behavior patterns. Considering the above assertions, it is worth discussing whether social norms would be effective enough in eliciting behavioral change on the part of nursing staff towards pain assessment and management.

Berkowitz (2004) states that any effort to shape a person's set of normative beliefs does not lead to sustainable behaviors, and stresses the shortcomings of several theories which focus on norms, leading to ambiguous results. The cross-sectional findings produced by experimental studies demonstrate that normative influences do not create lasting behavioral results, establish possible factors affecting the association of norms with behavior (Cruz, 2000), and specify the type of behaviors that are more likely to bend to normative influences (Bagozzi et al., 2002).

Also, it has been shown that some decision-making behaviors are negatively affected by normative influences, thus creating serious problems for the individual, especially if the nursing social norm is not to assess or manage pain.

According to Ajzen (1988), subjective norms influence the individual to enact a specific behavior or not. Ajzen and Fishbein (1988) introduced the concept of subjective norms and defined them as perceptions about behavior which are shaped by the judgment of important others (e.g., parents, spouse, etc.) regarding the performance of this particular behavior.

Norms, like attitudes, correspond to specific behaviors. The theory of reasoned action was expanded by Ajzen when he introduced the notion of perceived behavioral control (1988) –

34 an individual's confidence in their capability to enact a specific behavior– thus proposing the theory of planned behavior to identify the determinants of non-volitional behavior.

A counter-argument against the theories put forward by Ajzen is Schwartz’s (1977) definition of personal norms as moral beliefs; that is, ethical stances that affect the performance of a particular behaviour and are not influenced by social pressure. Based on this, Schwartz (1977) attempts to shed light on altruistic behaviors, which have been difficult to explain through theories focusing on practical aspects.

He argues that personal norms are self-based standards that derive from the individual’s internalized values, and differentiates them from social norms by locating the sanctions for the performance of behavior inside one's self, to the extent that the action performed deviates from the perception of one's self (Schwartz, 1977).

As it results from the above, a commonly advanced argument is that, apart from the social pressure which motivates a person to bend to normative influences, ethical beliefs must also be taken into consideration when attempting to explain the decision of a person to enact or avoid a specific behavior, also depending on the particular circumstantial settings (Schwartz et al., 1972).

Nevertheless, according to Lipp’s findings (Lipp, 1998), nursing staff were often forced into a submissive role by their medical colleagues, and this conflict seemed to prevent nursing staff from responding to the patient's needs. Also, the nursing staff found it difficult to express their wishes and take autonomous decisions. Leners (1997) notes that nursing staff had to demonstrate aggressive confidence and challenge doctors' authority to respond successfully to the patients' needs. In addition, it has been suggested that nursing staff felt ineffective in their role when they were denied the opportunity to advocate for their patients Glynn et al. (2000).

Another issue worth discussing is that nursing staff norms are not solidified enough; consequently, they don’t seem confident about the correct management of their patients’ pain and show less certainty when in conflict with the medical staff.

This assumption is corroborated by a descriptive qualitative study conducted by Mackintosh-Franklin (2016). Specifically, they explored the association of inadequate management of post-operative pain with nursing staff attitude towards pain and found evidence that nursing staff working in surgical units not only expect patients to experience pain but also consider it an inescapable part of the postoperative process. Based on this

35 evidence, it could be concluded that nursing staff perception of pain as an unavoidable part of the post-operative experience entails a lack of motivation on their part and is a barrier to the effective management of post-operative pain.

Schwartz (1977) originally designed the Norm-Activation Model to predict individual behavior in the context of altruism. This theory proposes that personal norms are determined by two factors: the awareness of the individual that the performance or avoidance of a specific behavior entails certain consequences and the feeling of responsibility that motivates action to prevent these consequences from happening.

The feeling of responsibility is balanced out with the cost that the person estimates they will encumber if they eventually engage in this behavior (Schwartz, 1977). According to Thogersen (2008), altruistic (‘helping') behaviors, especially certain types of pro- environmental behaviors are highly associated with personal moral norms, whereas social norms provide poorer predictive accuracy regarding the behaviors in question.

Cialdini’s Focus Theory of Normative Conduct (1990) proposes a similar model to elucidate the triggering process of social norms by introducing two categories of social norms which serve as the fundamental component for eliciting behavioral change: descriptive norms and injunctive norms. The theory posits that descriptive norms reflect what most people do, without any judgment involved, whereas injunctive norms represent what an individual should do, based on the favorable opinion of the others (Schultz, 2007). As pointed out, descriptive norms often lead directly to end behaviors. From Darnton’s point of view (2008), there is a consensus among theorists regarding the interpretation of social norms as tools which preserve the consistency within a specific group.

It also emerges from Kurt Lewin’s (1951) early work in social psychology that ‘group standards’ contribute to sustaining this connection among the members of the group. Schwartz shares this standpoint by describing social norms as ‘preserving the welfare of the collective’ (Schwartz, 1977).

All the above show that norms seem to create equilibrium between the social and the personal identity. Turner and Tajfel (1979) developed the Social Identity Theory, which sets out to explain how the two identities interact with each other. One of the underlying assumptions of this theory, which purports to predict intergroup behaviors, is that every group of individuals strives to achieve distinctiveness.

36 This distinctiveness is obtained through two processes: 1) the ‘out-group' discrimination, by which individuals identify themselves with a social group and compete with the ‘out- group', and 2) the ‘in-group' favoritism, which means that the members of the ‘in group’ treat others favorably when they are perceived to be a part of the same in group.

In his Self Categorisation Theory, Turner (1987) elaborated on the process of categorization, by which the individual constructs a prototype assembling a set of norms, beliefs and behaviors representative of a specific group. By identifying with this in-group, the individual's identity merges and simultaneously interacts with the identity of the group. Terry (2000) accentuates the interactive nature of the relationship of the two identities which is presented in the Self Categorisation Theory by describing norms as ‘inextricable properties of groups that influence individuals through self-categorization’.

In this setting, Czarnecki’s et al. (2011) study corroborates the findings, as it surveyed one of the largest sample sizes to up to date. They designed a cross-sectional study to assess the perceived barriers to optimal pain management in a 236-bed pediatric hospital. The most significant obstacles established in this study were the inadequate orders before and after procedures, the lack of time to prepare patients before procedures and the doctors' underestimation of the importance of pain management.

In addition, other barriers that were determined included the inability of registered nursing staff to overcome the impediments and their perception of current pain management practices. These variables obstructing efficient post-operative pain management are bound to the healthcare environment and guiding principles which govern healthcare institutions (Czarnecki et al., 2011).

Despite the vital role of nursing staff in pain assessment and management (Francis et al., 2013; Schofield et al., 2003) the outcome is compromised due to the nursing staff's resistance to change their habitual behavior at work along with the situational factors that may affect pain assessment and management.

These factors include the structure of the healthcare system, the increased workload and the performance of many different tasks as well as the intermittent work schedule (Bozimowski, 2012). Taking into account Talbot’s (2007) and Wilson’s (Wilson, 2007) view that when a difficult behavioral choice is presented, people may seem resistant to change or prone to opt for the option that requires the least cognitive load, then how are nursing staff able to reverse such behavior within this setting?

37 Harford (2008) argues that the choice made by an individual is influenced by the range of options offered and the way that these are presented. Accentuation of the expected costs over the benefits arising from a decision or a different presentation of the available choices may modify the decision (Barr et al., 2013; Schilders et al., 2007).

Shoqirat (2015) conducted an explorative cross-sectional study with a qualitative approach to determine Thai nursing staff' experiences of pain assessment. The researchers concluded that nursing staff are aware of the benefits of efficient post-operative pain management and wish to provide comfort to their patients through relief from pain.

More specifically, nursing staff played a pivotal role in assessing and monitoring pain, and the fact that they approached patients’ pain using different methods emphasized their ability to collect information on their patients and rationally combine them with their pre- existing beliefs, which were formed through their own experiences of pain assessment (Shoqirat, 2015).

The resulting well-being of the patients includes earlier mobilization, reduced pulmonary and cardiac complications, reduced risk of deep vein thrombosis, made faster recuperation with less likelihood of developing neuropathic pain and cut healthcare expenses (Trail- Mahan et al., 2013).

Despite the good intentions of each individual, the decision-making process is affected by psychological and contextual limitations (Wilson et al., 2007). As it is mentioned above, environmental factors such as insufficient education, fear of complications related to the administration of analgesic drugs, inadequate pain assessment and shortage of staff may affect the process of pain management (Zoëga et al., 2015). As a result, these variables impose restrictions on people’s ability to calculate the information provided.

According to Darton (2008), this process cannot be considered illogical but rather illustrative of the need to make the optimal decision quickly and easily using the least possible cognitive resources. The implication of economics in the concept of bounded rationality is evident through the need to avoid consideration of each individual piece of evidence and making decisions based on broad options, thus reducing the burden of collecting and calculating all the available information required to opt for an entirely logical choice (Simon, 1955).

38 It has been frequently suggested that nursing staff whose training involved post-operative pain assessment and management under time constraints, do not focus on pain assessment (Davis et al., 2005).

Bolster and Manias (2010) using a qualitative approach based on observation, and semi- structured interviews examined the way that nursing staff interacts with patients during medication activities in an acute care environment with an underlying philosophy of person-centered care. They concluded that, apart from nursing staff characteristics (attributes), clinical context and time constraints also affected the interaction between nursing staff and patients, potentially inhibiting a person-centered approach (Bolster, 2010).

As a result, the nursing staff is deprived of the opportunity to improve their skills and establish a meaningful relationship with their patients, leading to a weak interaction during medication activities (Henderson, 2007). The definition of time limitations included general workload pressures and caring for patients who were acutely unwell.

These findings can be transferred to other contexts because of the holistic approach used by the researchers to capture patients' and nursing staff experiences through semi- structured interviews and observations at different time points.

According to Kahneman’s (2002) ‘judgment heuristics’ theory, the decision-making process is determined by simple, efficient rules which are used to form judgments without much deliberation. These rules of thumb are mental shortcuts which are useful in most circumstances but can lead to systematic deviations from logic.

Also, they can reveal some patterns and personal characteristics involved in the decision- making process, which would otherwise be considered rational. Memorable and traumatic experiences are more likely to affect this process based on how quickly they can be recalled. Thus, a personal experience of post-operative pain may provide the foundation for the explanation of personal patterns involved in the decision-making process of a specific person.

People's estimates are based on a readily available point of reference, which they use to make adjustments. Even if there is no ‘anchor,' people assume one. Given the potential inadequacy of a healthcare system which compromises efficient post-operative assessment and management, could a nursing staff who has experienced a personal post-operative

39 traumatic event such as uncontrolled pain use it as an ‘anchor' to form an estimate about their patient's post-operative pain?

The theory of Judgment Under Uncertainty (1974), proposed by Tversky and Kahneman (1974), emphasizes ‘accessibility' as the basic notion underlying judgment heuristics. The availability of a rule of thumb versus the difficulty of processing the evidence required to make a decision, together with the time constraints and cognitive load, makes it preferable when facing a choice. This idea was seminal in establishing decision-making as both more and less rational and provided insight into understanding behavior.

Moreover, Maio’s (2014) emphasis on the oblique approaches that should be used to modify behavior is rooted in Triandis’s (1997) view that the lack of facilitating circumstantial context confines behavioral choice. Doug McKenzie-Mohr expands on this standpoint by claiming that, in the absence of means which could help these external limitations to behavioral modification to be eliminated, it would not be appropriate to implement interventions as such, due to the sophisticated relationship between interdependent internal and external constraints (Darnton, 2007).

The above assumptions indicate that for effective pain management to be achieved, an integrated method should be used, rather than an analysis into smaller individual elements. Since most social-psychological frameworks focus on the importance of internal, psychological variables affecting behavioral outcomes, external factors have not been sufficiently developed within these theories.

According to Ajzen (1991), social-psychological theories do not provide a concrete definition of psychological factors, but rather present them as being integrated into other variables. Similarly, external moderators of behavior form part of other variables, mainly agency.

Other less distinct factors impeding behaviors, such as cost or facility, are also pointed out in literature. Vlek’s Needs-Opportunities-Abilities (NOA) model regards opportunities as external factors and abilities as internal factors. Given that these barriers cannot be explicitly considered external, but are rather viewed from the aspect of their interdependent relationship with internal variables, as a result of an individual's understanding of the world (Sanne, 2002), it can be assumed that external constraints represent an individual’s perception of the environmental context.

40 Therefore, to eliminate contextual constraints, both environmental settings and how individuals comprehend them should be considered. Our behavior, as social practice, is determined by the interaction of these internal and external variables. Spaagaren and Van Vlietin illustrated this interdependent relationship as a diagram in their Theory of Consumption as Social Practices (Van Vliet et al., 2010).

This theory regards behavior as a result of the interaction between systems of provision (SOP) and the lifestyle associated with a person. The theory does not consider these two variables as distinctly internal or external, but rather as being formed according to the corresponding social practices. The influence of these factors often leads to a situation where they entirely control an individual's behavior, thus creating patterns of predictable behavior, often resulting in mechanically performed activities (Shove, 2003).

A qualitative study was carried out by Rejeh et al. (2009) to determine nursing staff experiences and views on external limitations impacting post-operative pain management through semi-structured interviews. Despite the limitations in sample size and geographic location, the researchers believe that the study findings have significant implications.

The results suggested a self-reported inefficiency in alleviating pain which was due to the lack of healthcare personnel responsible for assessing the results of the pain management methods implemented, depriving nursing staff of authority and rendering them powerless.

Based on these findings, Rejeh (2009) posits that nursing staff's attitude towards pain management, despite the possibility of favorable intentions, is a result of the guiding principles governing healthcare institutions, which regard pain as an anticipated and unavoidable part of the postoperative patient experience.

Dealy’s (2002) opinion supports Rejeh’s (2009) assumptions, suggesting that the healthcare staff's behavior is primarily influenced and constrained by the institution's policy. It is worth adding that throughout literature, the role of analgesics is excessively emphasized by healthcare institutions, whereas the psychological needs of post-operative patients are not deemed important (Kindleberger et al., 2003).

The distinction between internal (subjective) and external (objective) factors, as put forward by Structuration Theory, suggests that structure, defined as the rules and resources whereby the individual is bound, but which only become tangible when reflected in the agent's social activities. It is not a distinct construct, but rather a reflection of an individual's perceptions, and is expressed through their social activities (Giddens, 1984).

41 Therefore, our world does not constitute a clear-cut, objective construct, but is rather reflected in the agent's actions, which are influenced by the meaning the agent accords to the environmental context.

Regarding the opposing intersection of internal and external factors, the above theories acknowledge that our behavior is largely influenced by external variables which lie beyond our command. However, Structuration Theory presents the agent's social activities as a result of the interrelationship between the agent and the world, which promotes and inhibits our actions, thus leading to our constructing both the external world and our self-identity.

According to the above, it is worth wondering whether it is possible for nursing staff to rely on their self-identity and not reproduce the behavioral patterns created by the institution's policy. At this point, one may wonder if the nursing staff who had experienced a personal postoperative traumatic event can enhance their self-identity.

Bandura's Social Cognitive Theory and notion of self-regulation place emphasis on standards being interpreted as psychological constructs, given that the individuals themselves determine them through the observation of others, and focus on behavioral change which can be achieved through the adjustment of our standards and goals (Bandura, 1991).

Could a nursing staff’s distressing postoperative experience be powerful enough to influence their standards and goals, and could it also inspire other nursing staff through observation? Based on Social Cognitive Theory, this plays a vital role since goal-setting is driven by a sense of accomplishment which constitutes a psychological emotion rather than a material reward (Bandura, 1991).

Furthermore, according to Bandura’s theory (1977), an individual's power of command over a task could be developed through the repetition of several smaller tasks. In practice, self-regulation is mostly reflected in self-efficacy. The ability of nursing staff with painful experiences to perform a particular action after estimating the discrepancy between the already existing standard and the target standard plays a crucial role in motivating their behavior.

Lastly, it is worth wondering whether nursing staff's self-efficacy stems from their success in performing a task in which they have accorded a higher standard, or if their self-efficacy contributes to their success in enacting the target behavior. For instance, nursing staff with 42 a traumatic experience and high self-efficacy are continuously motivated to achieve their goals even when they experience failures, whereas individuals with low self-efficacy are more likely to be ‘stuck' in inaction when failing to succeed (Bandura, 1991).

However, despite the significant amount of researches and clinical studies which explore all aspects of pain, the constraints affecting pain management have more or less been identified. For the quality of nursing staff's decision-making process to be improved, it is necessary to acquire a better understanding of the influence of all these organizational barriers on nursing staff's intentions, beliefs, attitudes and finally behavior, which certainly has the most prominent impact on the patients' post-operative pain management.

1.8.3 The personal pain experience

The way that the medical community evaluates the patient's pain and establishes how the patient should be treated exemplifies how the medical community understands pain (Vrancken, 1989). Thus, the therapeutic context of pain management is vastly affected by the attitudes and beliefs of practitioners (Blaxter, 2003; Scott, 1992). McCaffery (1997) underlines that the nursing staff' professional role and decisions when assessing and managing patients' pain is affected by their background.

Holm (1989) and Wessman (1999) expand on this assertion, pointing out another factor that plays a vital role in patient's postoperative pain management and hasn't been sufficiently researched: nursing staff' previous personal, painful experiences.

Only a limited number of studies have explored nursing staff pain experiences, and their implications are significant. In 1987, Holm conducted a quantitative study to demonstrate the effect of nursing staff personal pain experiences on the assessment of their patients' pain (n=134 registered nursing staff). Responses to the Standard Measure of Inferences of Suffering (Chisari et al., 2017) showed that patients’ pain assessment was significantly influenced by the intensity of a nursing staff’s personal pain experience.

Additionally, nursing staff who had experienced intense pain were in general more sympathetic towards patients in pain. These results could not be generalized to other environments since the type of pain (acute or chronic) was not specified. On the other hand, Ketovuori (1987) conducted a quantitative study in 1987, using the Finnish Pain

43 Questionnaire to determine whether nursing staff who worked in surgical departments (whether they had a personal pain experience or not) would describe the pain similarly to patients who had undergone laparotomy, and explore their attitudes towards the use of analgesics (Ketovuori, 1987).

The descriptions provided by both groups of nursing staff did not coincide with the patients' description, resulting in a discrepancy between the intensity of the pain experienced by the patient and the pain that the nursing staff perceived. As a result, mismanagement of analgesics was observed. In this research, there is a negative correlation between the nursing staff's previous experience of pain and the patient's pain.

However, this approach to pain experience would be more profound and comprehensible if employed in a qualitative study where the intensity of pain that nursing staff experienced could be determined, helping us understand the impact that pain probably has had on their attitude towards patients’ pain.

Aziato et al. (2016) conducted a qualitative interpretive study to explore in depth, through individual face-to-face interviews, the pain experiences of 17 nursing staff members who worked in surgical wards. The findings revealed gaps in pain assessment and management practices, as participants claimed that the attention of nursing staff to their intense pain was minimal, a fact which led to an inadequate and ineffective pain management. The severe pain that participants experienced caused them to sleep, nutrition and mood disorders, as well as problems in their collaboration with their colleagues who managed pain poorly, resulting in their withdrawal from social interactions.

According to Aziato (2016), withdrawal from social interactions did not only involve the participants' colleagues but also their patients, resulting in inappropriate communication with them and inability to develop empathetic feelings towards patients in pain. Although this methodological approach enhances our understanding of nursing staff who have experienced pain, there is a need to specify the type of pain, for instance, acute or chronic, or exclude labor pain which is also associated with feelings of happiness and cannot be evaluated to its full extent.

Wessman and McDonald (1999) through a correlational study (n= 177), set out to determine if nursing staff personal pain experiences are linked to their pain management knowledge and their ability to learn more about pain management. Based on their findings,

44 nursing staff becomes more sensitive towards patients' pain because of their painful experience.

However, nursing staff with a painful experience had a low level of pain management knowledge; therefore pain management knowledge was negatively related to their painful experience. Conversely, Pud's (2004)quantitative research found that nursing staff (n=163) with personal past experience of opioid consumption trusted themselves to administer several pain medicines, especially opioids.

This finding is opposed to Wessman's and McDonald's (1999) findings since these researchers suggested that nursing staff with a lower level of knowledge about pain management tend to treat pain less effectively. However, these studies cannot be compared because of their different methodological approach. Considering the above, it can be safely assumed that the authors regard personal pain experiences as a form of pain management education.

Patiraki-Kourbani et al. (2003) and Kiekkas et al. (2015) through their studies in Greek hospitals, evaluated nursing staff painful experiences, as well as their knowledge and attitudes toward patients’ postoperative pain. In particular, Patiraki-Kourbani (2003) conducted a qualitative study on Greek registered nursing staff personal and professional pain experiences and explored how these were related to their pain management knowledge.

The results of this study showed that Greek nursing staff perceive pain as a significant stressful and incapacitating experience, identical to suffering, which affects the cognitive and psychological processes of the individual. Although positive professional experiences of managing pain were common, feelings of inadequacy and frustration were also evident in the case of inadequate pain control for their patients.

In addition to the above, attendance at continuing education programmes positively contributes to expanding pain management knowledge. This may affect the quality of care that the patient receives, as their effective care depends on the psychological situation of the healthcare professionals.

Furthermore, Patiraki-Kourbani (2004) concluded that nursing staff who have had previous personal, painful experience either adopt a pessimistic stance towards the phenomenon of pain or become more motivated towards effective pain management as a result of personal sensitization.

45 However, these results cannot be generalized as the sample size is small. As a consequence, an opportunity to establish significant relationships is missing. In addition, the results are considered limited due to the fact that the type of pain –acute or chronic, medical or surgical– is not specified.

Kiekkas, through a descriptive cross-sectional survey which was carried out in surgical wards of five Greek hospitals, explored predictors of nursing staff’ knowledge and attitudes towards postoperative pain (Kiekkas et al., 2015). Similarly to Patrikaki’s (2004) study, Kiekkas’s survey results highlighted more or less the same serious knowledge deficits and negative attitudes towards patients’ pain assessment and management (Kiekkas et al., 2015).

The findings also revealed that nursing staff who have had a personal postoperative experience become more sensitive towards the pain of others and have a higher motivation to ensure effective pain relief. The Knowledge and Attitudes Survey Regarding Pain (KASRP) tool was used to collect data for his research.

Furthermore, Mrozek and Werner (2001) designed a descriptive exploratory qualitative survey of nursing staff working with elderly residents in 10 long-term care facilities, to identify their attitudes towards pain and their pain assessment and management practices.

They used Dalton’s (1989) questionnaire, which included demographic data and 23 open- end and closed-end questions addressing nursing staff attitudes, pain assessment, and pain management practices.

In contrast to Patiraki-Kourbani et al. (2003), Mrozek and Werner’s (2001) study showed that past personal and care-provider experiences of pain influenced nursing staff attitudes, either positively or negatively. Also, they concluded that previous own pain experiences might improve nursing staff's pain management practices as a result of personal sensitization to pain. This difference may be due to the different methodological approaches that they used or the sample size.

Griffin et al. (2008) explored the pediatric nursing staff's projected responses to children's pain and explored the characteristics that might influence their responses. A survey was mailed to a national random sample of 700 RNs, and 334 nursing staff responded (response rate = 48%).

46 The survey asked for case histories of three hospitalized school-aged children experiencing pain. Contrary to the earlier studies of Patiraki-Kourbani (2003) and Mrozek and Werner (2001), nursing staff members perceived high levels of pain, responded that they would administer doses of analgesia close to the maximum prescribed by physicians and recommended an array of non-pharmacologic methods to treat pain.

Variation in pain perceptions and decisions was not related to key personal and professional characteristics of the nursing staff, including their education level, race/ethnicity, age, years of clinical experience, and participation in continuing education programmes about pain. Findings from this large national study suggest that most nursing staff would make appropriate decisions relating to the treatment of children's pain, perhaps reflecting changes in the attention paid to pain management.

The results of the above studies are pivotal to nursing practice, but further research is required to explore if nursing staff use any defense mechanisms to ensure their psychological balance and what are the processes that make nursing staff with a powerful experience, such as severe postoperative pain, change their behavior towards their patients. On this understanding, it is highlighted that attitudes should not be correlated with knowledge as regards pain assessment and management.

1.8.4 Knowledge and attitudes

Nurses, play one of the major roles in the assessment and acute pain management of severe postoperative pain. However, research in recent years has been increasingly concerned with nursing staff attitudes toward the management and evaluation of postoperative pain (Zhang et al., 2008). Most of the studies are concerned about the impact that nurses' knowledge and previous training have on the assessment and management of patients' acute postoperative pain (Kiekkas et al., 2015).

Dihle et al. (2006) conducted a qualitative descriptive study aiming to investigate nurses' contribution to the assessment and management of acute postoperative pain, through observing and interviewing nurses. The study was carried out in two hospitals (A and B) in Oslo, Norway. The surgical ward in Hospital A had 25 beds and a staff of 23 nurses and five nursing assistants. Hospital B had one surgical ward with 18 beds and another with 30

47 beds. The first one had a team of 17 nurses and three nursing assistants and the second had 22 nurses and six nursing assistants.

The results of their study (Dihle et al., 2006) revealed an inconsistency between what nurses reported in the interviews and how they managed postoperative pain. In particular, although nurses possessed the necessary knowledge for assessing and managing acute postoperative pain, this knowledge did not reflect on their actions when managing the patients' acute postoperative pain. These findings demonstrate the existing gap between nurses' knowledge and actions that lead to ineffective alleviation of postoperative pain.

Lui (2008) performed a cross-sectional study using a quantitative approach, based on questionnaires, to investigate nurses' (n=143) knowledge and attitudes regarding postoperative pain management, as well as the factors that may influence their knowledge and attitudes. To conduct this study, Lui used the NKASRP tool which was developed by Ferell and McCaffery in 1987 and was translated into Chinese for this study. The findings of the study revealed an apparent deficit of knowledge and appropriate behaviors towards pain management.

It is evident that nurses' belief that they are able to manage patients' postoperative pain is contradicted by the results of the study that show that further research is necessary. Another instance of divergence between the attitudes and actions of the nurses is that, although they believe that patients know better the intensity of their pain, they also report that patients often exaggerate their pain. Also, nurses' lack of knowledge about pain relief is affected by misconceptions about the use of analgesic drugs, such as the possibility of addiction, which leads to administering reduced doses of analgesics and, by extension, to an inadequate explanation and management of acute postoperative pain.

Francis's study (2013) corroborates the previous results, suggesting that nurses' personal beliefs have a greater impact on pain management decision-making comparing to the patients' assessment of their pain. More specifically, this study adopts a quantitative approach to determine nurses' (n=31) knowledge and attitudes towards postoperative pain and to identify the pain intensity experience of postoperative patients.

It is worth mentioning again that the ‘Knowledge Attitudes Survey Regarding Pain' tool, which was developed by Ferrell and McCaffery (2008) was used to measure nurses' knowledge about pain management and the McGill Pain Questionnaire (Campbell et al.,

48 2013) was used to measure patients’ pain intensity. The results of this study show that nurses understand that the pain experience is subjective and they also understand that the level of patients' pain corresponds to the pain intensity reported by the patients themselves. Nevertheless, at the same time, patients' reports contradicted nurses' opinions, as they claimed that they experienced medium-intensity pain during the postoperative period. Notwithstanding the small sample size of the study, it is worth noting its significant results, as nurses' attitudes appear to remain consistent over time.

Significantly, Lui (2008) and Francis (2013) identified the lack of continuing education on pain management as a possible cause for this divergence. It is also worth noting the distinction between the concepts of knowledge and education. The main difference between the two notions is that education is provided in formal institutional settings since it is an official learning procedure that includes a predetermined set of rules, regulations and teaching programmes. Conversely, knowledge is not taught but gained through experience; it is therefore derived from particular events, rather than acquired through a teaching process (Wilson-Barnett et al., 1994).

Despite the differences between knowledge and education, studies continue to insist that higher-quality education on the assessment and management of acute postoperative pain would have a positive impact on nurses' knowledge and attitude. For this reason, several studies have set out to investigate whether or not nurses' attitude is improved after the implementation of a postoperative pain management programme (Schreiber et al., 2014).

Schreiber (2014) used a quasi-experimental pre- and post-intervention quantitative design to evaluate the educational intervention which aimed at improving pain control in acute care settings. Three hundred forty-one nurses responded to the Brockopp-Warden Pain Knowledge/Bias Questionnaire (2004), and a pain diary was also used to collect data regarding patients' pain.

The results of this study suggest that despite the implementation of educational interventions, the relationship between the transfer of knowledge and the change of nurses' attitude, which is necessary for the effective management of acute pain, remains unclear. In particular, there was an increased correlation between the documentation provided by nurses and patients' self-reported pain scores after the completion of the educational programme. However, no substantial change was observed in nurses' knowledge about effective pain management. Therefore, despite the abundance of information that nurses

49 received about pain management, a minimal change was observed in nurses' attitudes towards acute postoperative pain management.

Abdalrahim et al. (2011) reached similar conclusions after undertaking a quantitative descriptive study which aimed at exploring nurses’ knowledge of and attitude towards pain in surgical wards before and after the implementation of a postoperative pain management programme for all nurses working in two surgical wards (n=65) at a university hospital in Jordan.

Nurses’ knowledge and attitudes were assessed using a questionnaire developed by Zanolin et al. (2007), and patients were assessed using an instrument for the documentation of pain developed by Ehnfors and Smedby (1993). The study revealed a statistically significant difference in the number of nurses' correct answers before and after the completion of the educational programme. However, the researchers observed that the information that nurses received from the program was not exploited. This, according to the researchers, may be attributed to their persistent traditional thinking and misconceptions about the side effects of pharmacological interventions.

According to Chung (2003), this may contribute to the inadequate control of patients' acute postoperative pain. The fact that nurses are persistent in their beliefs reveals the inability of the educational programme in question to radically change nurses' attitudes rather than merely enhance their knowledge about pain management.

The primary goal of the above research was to teach nurses the latest advances in postoperative pain assessment, treatment, and documentation using recent selected articles and information on the subject. Furthermore, the research programme employed various teaching methods such as role-playing, case methodology, drama theatre and scenario analysis (Chung et al., 2003).

Subsequently, nurses were asked to put what they learned during the educational programme into practice and evaluate the intensity of the patients' pain using scales provided by the instructors. Research assistants visited patients and nurses to ensure the correct implementation of the programme and documentation procedure. It is therefore pointed out the various teaching methods adopted by the instructors (Chung et al., 2003). Thus, the various teaching methods adopted by the instructions are pointed out.

50 At this point, it is also worth being mentioned, how learning principles are applied to nursing education that concerns pain. In that way, it can become clear how individual differences affect the learning process and consequently the change in the nurses' behavior; which is the desired outcome of an education intervention (Chung et al., 2003).

Thus, although the learning context has evolved in various directions over time, researchers opt for the earliest and most radical forms of behavior advanced by Thorndike, Skinner, and Watson, as they principally focus on using external stimuli to elicit specific responses. Instead, researchers within this context could adopt a wide range of educational methods such as role-playing, case methodology, drama theatre, and scenario analysis, to use participants' reflecting practice as a cognitive learning strategy (Chung et al., 2003).

Behaviour is, in essence, a thought process continuously learned and developed by creatively implementing current and pre-existing experiences and reasoning. First, about what happened in a previous situation, second, what might have contributed to the unexpected event, third, whether or not the measures adopted for the management of postoperative pain were appropriate and finally, how this situation may influence future practice (Rostami et al., 2010).

However, researchers in this study did not seem to approach any changes in the attitude of the participants after the implementation of the educational programme, but their attention was rather drawn to the cognitive evaluation of participants by emphasizing the use of forms of control and guidance. This is suggested by the fact that nurses were asked to assess the intensity of the patients' pain by applying what they had learned during the educational programme using scales provided by the instructors. As a result, participants had the opportunity to select the preferred method to assess the patients' pain and decide whether or not they would evaluate without being asked by the researchers. The goal was to determine whether this behavioral change would last after the completion of the research process and become a part of the participants' culture. Consequently, further research should be carried out to establish a rationale for the findings of these studies and at the same time explore the methods used to educate the nursing staff.

Another quantitative descriptive study, in the form of questionnaires, was conducted by McNamara et al. (2012) To assess the effectiveness of an acute pain educational programme in improving nurses' knowledge, skills and attitudes regarding postoperative pain management. This study involved nurses (n=59) who attended an educational 51 programme on acute postoperative pain management and completed validated questionnaires before, immediately after and six weeks after the educational curriculum.

The results of the study demonstrated a significant improvement in nurses' knowledge and attitudes towards postoperative pain assessment after attending the educational programme. Nevertheless, careful observation of the findings reveals a reduction in the improvement rates measured six weeks after the completion of the programme compared to the rates measured immediately after the programme. Based on the previous observations, education cannot induce a change in nurses' attitudes but rather maintain their positive attitude towards pain management.

Taking into consideration the pain, behaviorism, cognitivism and constructivism theories as well as the studies mentioned above one can notice that trainees are taught specific methods of actions based on external, exogenous and environmental factors, by adapting the cognitive structure to particular contexts. Since educational programmes influence the attitudes of professional nurses, it is worth investigating how the study programmes offered at nursing schools affect students' attitude toward pain management.

1.8.4.1 Nursing schools and their curricula

In particular, Al-Khawaldeh et al.(2013) conducted a quantitative descriptive cross- sectional study which was designed to explore the current knowledge and attitudes among students in three national universities in Jordan. The Knowledge and Attitudes Survey Regarding Pain Scale was applied in 240 nursing students for their knowledge and attitudes regarding pain management to be measured.

The results of this study show that students' knowledge about the routes of administration, side-effects, tolerance, and addiction associated with the clinical use of analgesics is insufficient. Although the study used a cross-sectional descriptive design which can only help establish significant links between the variables of a study and cannot provide an explanation, it can be assumed that the educational system is unable to implant a critical approach in the study programmes.

To achieve this, nursing academic programmes should not only offer theoretical knowledge destined to help future professional nursing staff achieve a specific level of performance, as this teaching approach may suppress any form of independent thinking (Von Glasersfeld, 1982).

52 According to constructivism, teachers should aim at providing a learning environment which would facilitate experiential forms of learning and offer sustainable learning experiences (Herman et al., 2009). The results of the research indicate an insufficient number of well-educated pain instructors which, according to Volshall (2012), could reduce the effectiveness of delivering and disseminating critical and accurate knowledge about pain management.

Despite the advantageous sample size of the Al-Khawalde (2013) study, which involved students of three nursing schools, it should be noted that the use of a convenience sample limits the ability to generalize these findings to other populations.

However, Duke's research which was conducted in the same year but thousands of kilometers away from Jordan, in Texas, USA, produced similar results using the same measurement tool of knowledge and attitudes (KASRP) on (n=162) nursing students. The results of Duke's study suggest that, even though all semesters of the study programme included content on pain, no apparent understanding and retention of this knowledge was observed.

These findings substantiate the need to evaluate the methods used to teach pain assessment and management throughout the study programme, taking into account the minimal positive changes in the knowledge of pain management principles that have been observed in the last twenty years.

Therefore, it seems necessary to implement changes in nursing curricula and practice, since, according to the above findings, the knowledge acquired by students regarding pain management does not correspond to the respective content included in the nursing study programmes at present.

Based on the literature review, pain management knowledge can be considered as the result of two distinct factors: i) cognitive knowledge and ii) experiential knowledge (Benner et al., 2002). According to the theory of learning, learning is either reinforced or inhibited by the emotional intensity and quality of our previous experiences; however, the lack of research on pain management necessitates the investigation, through a qualitative phenomenological approach, of nursing staff's emotional intensity and quality associated with previous experiences regarding learning.

53 In short, based on these findings, one could conclude that the impact of nursing staff's painful postoperative experience and their attitude towards pain management on nursing curricula and practice calls for further investigation.

1.9 The Greek nursing care system

Nursing care in Greece has developed in parallel with nursing developments worldwide. This review discusses the evolution of nursing through four periods in the History of Early Modern and Modern Greece. The first period covers the years 1910-1935, which laid the foundation of contemporary healthcare standards, followed by the post-World War II period which includes measures to provide relief to the population, control infectious diseases and expand hospitalization units. The next period covers the years after 1980, when, along with the accession of the country to the European Union, efforts were made to develop a national healthcare system. Finally, we will discuss the period from 2008 up to date, when the country is affected by the economic crisis.

1.9.1 A historical approach

1.9.1.1 First period: 1910-1935

In the 20th century, the modern Greek State was founded, and health services were established, given the poor health status of the country following the War of Independence. The war operations during that period necessitated the education of the nursing staff. In 1875, only 9 years after the foundation of the Nightingale School for Nursing staff, the first school for nursing staff in Greece, the Nursing Seminary ("Nosokomikon Paideftirion") was established, leading to the foundation of "Evaggelismos" in 1881, a hospital oriented towards the education of nursing staff (Lanara V., 1978).

The most critical period for the development of healthcare during the 20th century was under the governance of the country by Eleftherios Venizelos (1909-1932). At that time, the "National Hospitals" and the medical offices for the treatment of tuberculosis were created, laws were adopted, and measures were introduced for the control and prevention of infectious diseases (Lanara V., 1978).

54 Later, the socio-economic situation was largely affected by the fascist dictatorship of Metaxas (1936-1941), who tried to establish a national ideology. During this period, the School for Health Visitors was replaced by the Higher School for Health Visitors and Nursing staff, due to the legal obligation of founding nursing schools in hospitals (Lada- Chatzopoulou, 1978).

The development of the country's healthcare infrastructure during the pre-World War II era and the systematic efforts to prevent the scourge of malaria and other infectious diseases which were the primary causes of mortality accentuated the need for trained professional nursing staff in both care and prevention (Lada-Chatzopoulou, 1978). Therefore, two distinct professional capacities were established: 1) the health visitor, who focused on prevention and 2) the nursing staff, who provided nursing care (Stathopoulos, 2005).

1.9.1.2 Post-World War II period

Greece was suffering from extreme oppression, destitution, and hunger during World War

II (Zavitsanos, 1977). The civil war that followed the country's liberation from Nazi rule was one of the darkest chapters in Greek history. The US-funded Marshall Plan ensured the recovery of the war-torn country (Stathopoulos, 2005). The rapid economic growth contributed to the improvement of the living standards.

Over this period, infectious diseases were effectively controlled by exploiting existing measures and infrastructure, and diseases such as malaria, cholera, poliomyelitis, and rabies, etc. were eliminated with the support of international organizations (Lada- Chatzopoulou, 1978). At the same time, the development of health services was governed by a spirit of precaution under significant efforts.

During the war years, nursing as a vocation was considerably improved, given the provision of care for the injured, by volunteers (Lanara V., 1978). At the same time, modern hospital infrastructure began to develop not only in Athens but in all Prefectures of Greece (Papadaki, 1965).

Furthermore, a relevant statute, that set nursing as a regulated profession stipulated that to practice as nursing staff and to use the title of nursing staff, it is required to graduate from an established state school and obtain an authorized admission by the Minister of Health (Lada-Chatzopoulou, 1978). Nursing staff education reflected and followed the needs of Greek society.

55 The statute mentioned above also stated the tasks and obligations of nursing staff and health visitors and classified two types of nursing interventions (Lanara V., 1978): i) nursing actions that did not require a physician's orders and ii) physician-prescribed therapeutic nursing actions.

In addition, the statute foresaw sanctions for practicing nursing illegally. During the post- war period, new government hospitals were founded in many areas of the country. However, the high concentration of healthcare infrastructure in the urban area of Athens and secondarily in Thessaloniki led to a significant flow of patients from the provinces to urban areas (Lada-Chatzopoulou, 1978).

There was a change in the nature of hospital care since specialized hospital departments were developed and new diagnostic procedures and therapeutic practices were established, based on new technological applications. The medical workforce was sufficient in number to meet these needs but unevenly distributed geographically. Nevertheless, a dramatic nursing staff shortage was observed, particularly staff specialized in new technologies and new medical specialties (Lada-Chatzopoulou, 1978).

1.9.1.3 Third period: 1980-2008

In the early 1980s, the most significant reform of the healthcare system was implemented in post-war Greece. The purpose of this reform was to establish a National Health System through an operational integration of the government healthcare infrastructure. This reform went beyond the constitution's requirement that the state should care for the citizens' welfare and established that the state was responsible for providing health services to all citizens (Velonaki, 2006).

Health services were provided equally to every citizen, through an integrated and decentralized national health system, irrespectively of their economic, social or professional status (Rousou, 1993). The unprecedented classification of nursing services as one of the three types of services comprising a hospital’s organization was of particular importance (Papaevagelou, 1998).

This differentiation between administrative structureswas highlighted by the distinction of nursing services from medical services. This was an essential institutional intervention, as it provided nursing staff with administrative autonomy (Papaevagelou, 1998). In addition, 56 a distinction was made between two main types of nursing specialties: i) Community Nursing and ii) Hospital Nursing.

The accession of the country to the European Union led to reforms related to nursing staff’s role and status (Rousou, 1993). These reforms defined nursing as a regulated profession established nursing staff's participation in the planning of nursing services and the decision-making process, and ensured satisfactory working conditions (Moraitis et al., 1995). The change in the government of 1990 was accompanied by a new reform initiative in the field of health services, with the promulgation of a law to enhance nursing services and organizing public health services at a central and regional level (Velonaki, 2006).

The latest reform in the field of nursing was implemented in 1991, having as a goal to develop an integrated primary care system involving the participation of nursing staff in prevention, treatment, and rehabilitation (Moraitis et al., 1995). In the same year, the Code of Ethics for Nursing staff was established, stipulating the scientific independence of nursing staff at practicing their tasks as members of the healthcare team (Rousou, 1993). It is therefore observed that major healthcare reforms were promoted in the 20th century, enhancing the status of the profession of nursing staff, creating however problems that have remained unresolved so far.

1.9.1.4 Economic Crisis: 2008-today

The steady financial growth of the country, exceeding 4% annually, was followed by enormous downsizing of budgets resulting from deficits and a declining rate for health expenditure, which suffered a significant reduction from 2008 onwards which signaled the start of the financial crisis not only at a national but an international level.

Expenditure on health-care in the countries most severely affected was reduced by imposing a series of measures (including wage reductions, low employment rates, increased direct payments by households for specific services and medicines) and consequently the imposition of strict budgetary cuts for hospitals (OECD Health Statistics, 2013).

In the case of Greece, long-existing inherent problems in the functioning of hospitals, including the incomplete implementation of the diagnosis-related groups (DRGs) as well

57 as the shortage mainly of nursing aggravated the operational difficulties during that period (Simou et al., 2014).

Some countries have promoted measures to mitigate the impact of the economic crisis, while others regarded this crisis as an opportunity to introduce structural reforms in their healthcare systems (OECD Health Statistics, 2013). In Greece, the health sector was severely affected by the financial situation, while the two memoranda of understanding (MOU) that Greece has signed since 2010, dictated a series of measures which focused primarily on reducing public expenditure (Kaitelidou et al., 2012).

Oddly enough, the economic crisis catalyzed a quicker implementation of the reforms in the health sector. These included the integration of the sickness funds in a new entity, the National Organisation for the Provision of Healthcare Services, the introduction of a new system for hospital compensation based on diagnosis-related groups (DRGs), invoicing and compensation for pharmaceutical articles, e-Prescription and increased use of generic instead of branded medicinal products, hospital management and improved distribution of hospital beds and clinics (Kyriopoulos et al., 2010).

The reforms focused on re-organizing primary healthcare by founding the National Primary Health Care Network. Thus, a wide range of reforms and policies in the field of health were implemented. Unemployment, vulnerable labor standards and uncertainty had significant adverse effects on the health sector (Kyriakopoulos et al., 2010).

In general, despite the enhanced need for care, nursing staff, mainly due to the crisis mentioned above, is decreasing instead of increasing. The adverse working conditions, low wages, and lack of professional development resulted in high dissatisfaction among nursing staff and fueled their intention of leaving their job (Kalogeropoulou et al., 2013).

In the data recorded in a study by Aiken et al. (2014)involving nine European countries it was noticed that in Greece, one-third of nursing staff were over 50 years old with a professional experience exceeding 20 years. Considering that this personnel is approaching retirement age, the need for replacement by new ones cannot be stressed enough (COM, 2008).

However, the process of recruitment of new personnel came to a halt throughout that period (COM, 2008). According to OECD, Greece in 2012 had 6.2 doctors per 1,000 58 inhabitants; a rate almost double compared to the EU average, placing Greece at the top of the list (OECD, 2014).

In 2011, the lowest per capita rate of nursing staff can be found in Turkey, Mexico and Greece (3.3/1,000 inhabitants), compared to an average of 8.8 nursing staff/1,000 inhabitants in Member States (OECD/European Union, 2014). The nursing staff/doctor ratio was estimated at 0.6 in Greece, whereas the EU average was 2.83 nursing staff/doctor (OECD, 2014).

At the same time, the nursing staff/bed ratio was estimated at 0.67 in Greece, placing the country among the lowest ranks, while the corresponding EU average was calculated at 2.03 nursing staff/bed (OECD, 2014). This implies that Greek hospital institutions have been facing severe understaffing problems as regards nursing personnel.

1.9.2 Nurse Education in Greece

The first attempt to train nurses in Greece took place in 1875, through the founding of "Nosokomiakon Paideftirion," which operated until 1884 (Lanara, 1978). The institutions founded later were, in chronological order, the Nursing School of Evaggelismos (1881), the Hellenic Red Cross Nursing School (1914), the Higher School for Health Visitors and Nurses (1937), the Army School of Nursing (1946), the Higher State School for Nurses in Thessalonica (1951), followed by six more schools in the 1960s (Kourkouta, 1996).

The schools operated according to the Nightingale standards; that is, limited theoretical courses with a strong emphasis on practical work. The inclusion of students was based on strict criteria related to their ethics and manners (Lanara, 1978). Most managers of these schools were members of Christian associations (Sapountzi-Krepia, 2002).

Although the leadership of these schools overemphasized the idea of nurses ministering to patients, they exercised their power in an authoritarian manner. They were excessively interested in the ‘moral standards' of the students and rewarded submissive behavior (Dimitriadou, 2003).

These deeply conservative individuals were critical of any changes, while at the same time, they imposed the ideas they advocated by enforcing rigid school regulations (Dimitriadou, 2003). Until the mid-1970s, the operational needs of Greek hospitals were met by nursing

59 school students under the pretext of training, while the residential nature of the Nursing Schools isolated Nurse Students from society and functioned as a ‘women's ghetto’ (Kokoliou, 1987).

Under the Decree-Law of 1970, the Centres for Higher Technical Studies were founded. Part of them was the School for Healthcare Professionals which included the Department of Nursing, which admitted women exclusively. After the establishment of the KATEs, Nurse education is integrated into the natural vehicle of education: the Ministry of Education (Dimitriadou, 2008). Their founding raised concerns as other schools were opposed to the integration of nursing departments into the Ministry of Education, the absence of boarding institutions and the features of the education that would be provided by the Centres for Higher Technical Studies. In 1983, after the founding of the Technological Educational Institutes (TEI), the Higher Schools for Nurses that were integrated into hospitals or the Ministry of Health were disestablished, and the students and teachers of these schools were incorporated into the nursing departments of the TEIs in the academic year 1984-1985 (Dimitriadou, 2008).

In 2001, TEI (Dimitriadou, 2008) were upgraded. The diplomas obtained from them were recognized as academic qualifications, enabling the graduates to continue their studies and obtain postgraduate qualifications, at the master and doctoral level (Dimitriadou, 2008).

The first department of Nursing in a Greek University was founded in 1979, fulfilling a long-standing demand of the Nursing community who regarded this action as a promotion of the nursing profession (Papamikrouli, 1993). The first Ph.D. in Nursing was awarded by a Greek University in June 1987, while the first two years Master's Programme began in 1993.

Today there are two Nursing departments in Universities and seven departments in TEIs, leaving the nurses' request for unified university education in Nursing unsatisfied (Kourkouta et al., 2012). As a result, the interprofessional disagreements on the level of education for Nurses, which exist even today, inhibit the progress of the profession (Dimitriadou, 2003).

The study programmes in Universities and TEI are similar and aim at providing all necessary knowledge that nurses must acquire, through a large number of courses including basic human sciences, psychosocial, medical and nursing studies (Sapountzi-60 Krepia, 2002). The classes are obligatory and include laboratory skills and clinical practice. Unfortunately, the completion of all recommended courses within a four-year period leads to an overload of the study programmes (Kourkouta et al., 2012).

As opposed to university studies, the curriculum in the TEI departments emphasizes nursing practice, thus focusing on the implementation of practical skills in nursing procedures (Kourkouta et al., 2012). For these purposes, the last semester is wholly dedicated to a supervised clinical trainee programme which is obligatory for all students and requires a six-month rotation in clinics of a state hospital, where students participate in all nursing procedures as full-time junior employees (Dimitriadou, 2003).

The co-existence of three different categories of nursing staff in Greek hospitals complicates matters even further. The categories of nursing staff in Greece are as follows:

1. Registered Nurses, holders of a Nursing Degree awarded by a University, 2. Registered Nurses, holders of a Nursing Degree awarded by a ATEI, and 3. Practical Nurses, high- school graduates (Dimitriadou, 2003).

The latter outnumber the Registered Nurses working in the National Health System. This fragmentation of the nurses' training in three levels certainly doesn't promote the scientific substantiation of education nor contributes to improved quality of the nursing care provided (Dimitriadou, 2003). Continuous education in Nursing is the key to addressing future challenges and, over the last years, one of the main topics of discussion in the field of education. If knowledge cannot be acquired at an undergraduate level, it is worth wondering whether we should seek training options that would both satisfy the need for knowledge and improve the existing level of undergraduate studies (Kourkouta et al., 2012).

The apparent shortcomings of the nursing study programmes in both universities and TEIs require the adoption and implementation of a new, alternative tertiary education system. Such system should emphasize critical reflection and the acquisition of all necessary theoretical knowledge and technical skills, to produce nursing professionals who will be able to provide high-quality nursing care to the patients (Kourkouta et al., 2012).

61 1.9.2.1 The role of nursing studies curricula in Greece

In particular, in Greece, nursing staff are not adequately trained in how to treat pain. This lack of knowledge could be attributed to the fragmentation of the clinical education curricula into three different scales. It can be said that this division hinders the development of an integrated teaching approach to holistic pain management.

This is corroborated by the results of a study performed by Kiekkas et al. (2015) to explore and identify predictions about the knowledge and attitudes of surgical department nursing staff regarding postoperative pain.

Kiekkas et al. (2015) used a quantitative method with a descriptive, cross-sectional approach by using the KASRP tool (n=182) in one academic and four public hospitals in Greece. The results of this study revealed substantial shortcomings in the knowledge and attitude of surgical ward nursing staff concerning postoperative pain.

Although their findings suggest that undergraduate studies could make a significant difference in improving nursing staff knowledge level; the differences in knowledge and attitudes that were identified between the attending registered nursing staff having acquired clinical training during a continuing education programme in the surgical ward and the registered nursing staff who had acquired a higher level of theoretical knowledge during their studies and practical nursing staff were not significant.

At this point, it is worth clarifying that continuing education programmes on pain are very limited in Greece. Therefore, higher scores in the KASRP tool among nursing staff who attend continuing education programmes cannot be directly attributed to the information or skills acquired when attending such plans; on the contrary, they instead reflect a broader personal interest of the nursing staff in keeping up-to-date in terms of pain management based on documented knowledge.

This conforms with the principles of the humanistic learning theory which maintains that learning is a personal act which is necessary for fulfilling the trainee's full potential so that he/she can become independent and self-directed. In this context, curricula and education programmes should be evaluated, and teaching methods should be re-established according to the educational needs and distinct attitudes.

62 It is also necessary for modern learning theories that could satisfy these needs to be identified. In particular, although the learning environment continues to rely on principles that focus on the observation and control of the learning behavior, it is necessary to consider the affective and internal state of the trainees and use individualized motivation systems to encourage learning.

This necessity arises from the correlation of nursing staff' attitudes and characteristics of their personality, as Dihle's (2006) and Hall-Lord's (2006) researches demonstrate. More specifically, they demonstrate that nursing staff personality seems to influence the management of the patient's pain since less empathetic nursing staff often give priority to secondary tasks, such as answering a phone call instead of focusing on relieving the patient's pain (Dihle, 2006). Hall-Lord's (2006) study indicates that nursing staff with emotional stability, kindness, and patience are more likely to adopt a positive attitude towards the management of the patient's pain.

According to Kiekkas et al. (2015), experience may be of greater importance for the improvement of nursing staff' knowledge and attitudes regarding postoperative pain, emphasizing on the need to promote nursing staff' empathy toward patients who experience postoperative pain.

Patiraki et al. (2004) stated that nursing staff personal or professional experience with pain might make them more sensitive towards the pain of others and, by extension, more motivated to relieve the patient's pain. More specifically, they designed a mixed-method survey which adopted a qualitative approach to explore nursing staff's personal and professional pain experience and a quantitative approach to measuring their pain management knowledge using the Greek version of NKASRP.

Their study reveals the intensity of the emotions nursing staff experienced, such as despair, incapability, and psychological damage according to their descriptions, which in turn may suggest that pain is an overwhelming and seemingly uncontrollable experience. Such perspectives may negatively impact nursing staff' motivation and their ability to manage the pain of their patients. That is, nursing staff who have experienced pain may either adopt a pessimistic attitude towards postoperative pain as regards the non-realistic objective intensity of the pain or, conversely, become more motivated to effectively manage pain as a result of their sensitization towards postoperative pain.

63 To address this phenomenon, one might find useful to conduct a phenomenological study to explore how nursing staff's personal postoperative experience affects their behavior towards patients' postoperative pain assessment and management since the factors that may mediate any impact on their behavior are currently unclear.

The main weakness of literature is to bring up the impact of such changes on the nurses as well as to point out the participation of nurses in the development and management of such changes in post-operative pain management practices.

1.9.3 Post surgical pain management in Greece

Although the global nursing community recognizes that nursing staff plays a key role in the therapeutic team as regards the assessment and management of the patient's pain, this role is underestimated in Greece. Only a limited number of studies has been conducted in Greece regarding the assessment and management of pain in patients by nursing staff (Patiraki-Kourbani et al., 2004).

Today, Greek hospitals lack a pain management system. It is typical that neither medical nor nursing personnel working in surgical units use tools to assess postoperative pain in patients. Thus, a set of general rules or procedures that could be followed by healthcare professionals is necessary to be established (Panteli et al., 2007).

Greek hospitals' policies on managing patients' post-operative pain sum up to merely following a standard set of practices which include prescription and administration of analgesics at intervals that are determined by a physician (Panteli et al., 2007).

Besides the fact that until recently no special attention was paid to pain management as part of Greek's hospitals' policy, there are also some major obstacles in the nursing staff's role:

1) Greek legislation doesn't acknowledge the right of the nursing staff to prescribe and administer ‘light' medicines to patients, in urgent situations. Thus, the doctor is generally the primary source of power and control within the healthcare system. Several studies, however, underline the inefficiency of junior doctors as regards pain management, resulting in patients suffering for long periods (Blondal et al., 2009). Furthermore, healthcare professionals neither propose alternative methods of pain management nor encourage communication with the patient (Panteli et al., 2007).

64 2) Organizational and environmental factors that impede as well as inhibit nursing care are present. More precisely, increased workload, shortages of staff and time constraints are some of the main challenges. All the above should be addressed by the nursing staff to effectively assess and manage the patient's pain (Blondal et al., 2009). As a result, negative emotions and lack of trust towards nursing staff and healthcare providers are developed by the patients.

3) Besides, nursing staff in Greece are not adequately trained on how to treat pain due to the fragmentation of both theoretical and clinical educational context into three different scales. As a result, not enough attention is paid to an integrated approach to holistic pain management.

4) The indifference of all up-to-date Greek Ministries of Health to provide models and protocols that would determine the quality of pain-related services constitutes another problem (Tafas et al., 2002).

Currently, in Greece there are 45 pain clinics which constitute part of anesthetic departments in public hospitals, these have a role in post-surgical pain but also deal with chronic pain conditions. Palliative care centers aim to treat and alleviate chronic pain using a team of doctors (anesthesiologists, neurosurgeons, psychiatrists, orthopedists, radiotherapists) and other experts (nursing staff, psychologists, social workers, occupational therapists, physiotherapists).

Significantly, even in this effort to manage chronic pain, the offered services provide focus mainly on medical care, lacking in patient empowerment. As regards the staff employed in Pain Centers, there is a limited number of both permanent and part-time employees. This shortage of staff leads to a failure in creating an interdisciplinary and inter-sectoral team, let alone to establish stable support networks for patients.

The Greek healthcare system has a significant impact on the quality of patients' pain management. The whole clinical team should consider pain management to ensure its optimization (Panteli et al., 2007). Thus, efforts should be channeled for pain management services to receive formal attention and to set their foundation in Greece as well.

65 1.10 Theoretical framework and conclusion of literature review

Through the discussion of the Literature review that was presented in this chapter, the weakness, limitations, and inadequacy of the health care system as regards the effective assessment and management of post-operative pain were indicated. This phenomenon is a global issue as it emerges from the Literature review and demonstrates significant deficiencies in nursing staff education and training worldwide.

Countries with a long tradition in nursing science and with a beneficial and constructive cultural variety in the health care system policies are incapable of covering the needs of post-operative patients. This happens despite their efforts at educational as well as a clinical level to educate the health care professionals with all the required knowledge and to provide them with the necessary equipment to adequately respond, assess and manage post-operative pain.

Through this literature review, it is clear that for decades there has been a traditional angle through which we observe pain as a sensory stimulus that warns us about tissue damage or some illness. This aspect supports that pain is the message that is conveyed through a specific pain path from the nerves on the injury spot, through the spinal cord to the brain. Thus, according to this aspect, the pain that the patient is experiencing must be analog to the tissue damage. This traditional point of view, as it appears from the literature review, is the way through which most people perceive pain resulting in patients turning to biomedical treatment to restore regular tissue functions.

At the same time, a significant part of the research mainly focuses on the study of methods that deal with the biological level and the understanding of the pathophysiology of pain. This perception about the phenomenon of pain appears to have further implications as it is reflected in the nursing staff education and training. This kind of education implies that knowledge is conveyed by giving external stimuli to nursing students. For instance, they are required to be able to recognize and assess the biological needs of the patient and then respond to this stimulus by administering painkillers. So the traditional model of pain perception is dominant.

66 Despite the progress of surgical, medicinal and anesthesia techniques but also of educational methods, this model demonstrates essential limitations. During pain assessment these limitations do not take into full consideration the subjective nature of pain ignoring the profound impact of any social and psychological factors in experiencing pain, since post-operative research demonstrates that pain persists regardless of the treatments that have been designed to correct every single tissue damage and even specialized surgeries cannot appease the pain.

As analyzed in this chapter, pain is a complex phenomenon that equally affects biological mechanisms as well as psychological ones like thoughts, beliefs, and feelings. It also affects social mechanisms like the family, employment and sociopolitical environment.

The studies presented are governed by the biological, psychological and social factory, but they do not provide answers to the numerous questions that arise concerning the biological, psychological and social changes that the patient experiences and how these affect his reactions to pain in the future. More specifically the main weakness of literature is to bring up the impact of such changes on the nurses as well as to point out the participation of nurses in the development and management of such changes in post-operative pain management practices.

Although according to Powell et al. (2009) the quality of post-operative pain management depends on the way that health care system policies recognize pain Bendelow and Williams (1995) regard assessing the environment in which postoperative pain takes place as an essential principle as well. At this point it is vital, to indicate the critical role that the nurses' involvement plays to recognize and establish certain behaviors that can improve their practices in the long run.

As Rejeh (2009) indicated in his study, it is worth wondering at this point whether a nursing staff's painful postoperative experience could act as a catalyst to trigger an internal conflict with the rules imposed by the working environment and possibly lead to a behavior that is consistent with their favorable intentions towards the patient's pain management.

The current Ph.D. thesis aims to explore how Greek nurses' personal post-operative experience influence their behavior towards patient post-operative pain assessment and management.

67 The following chapter presents the methodology through which interpretative phenomenology attempts to provide answers to the research question and helps to achieve the aims of this thesis.

2 Methodology

2.1 Introduction

The following critical discussion outlines the way in which the research process was designed, initially investigating the philosophy of qualitative versus quantitative approaches. The strengths and weaknesses of established methodologies will then be discussed, finally focusing on the benefits of the Interpretative Phenomenological Analysis (IPA) methodology and its application to this study. This discussion involves exploring Husserl's phenomenology and then exploring hermeneutic phenomenology through Heidegger and Gadamer's perspective to decide which approach presents the opportunities to improve the in-depth understanding of nurses' postoperative experience. In addition, this study presents Carl Rogers and Kurt Lewin's theories explaining how a circular approach of this study will bring about a better understanding of it.

2.2 Research question and objectives

Having worked for eight years in the Greek health care system, professional experience has suggested that there are significant differences between the way nursing staff and patients perceive pain. One potential question that could explain these differences lie in the question of whether the nursing staff's perception of pain and consequently their behavior is modified after having undergone a painful post-operative experience themselves. Based on this, the following research question was identified:

“How do Greek nurses' personal post-operative experience influence their behavior towards patient's post-operative pain assessment and management?”

The objectives of my research are as follows:

 To identify nurses who had experience with post-operative pain.   To explore in depth their personal post-operative pain experience.   To investigate how these nurses’ personal post-operative pain experience could influence their beliefs about post-operative pain.   To better understand how their personal post-operative pain experience influences their post-operative pain assessment and management practices.

69  To explore and attach meaning to their post-operative pain experience and their attitude and behavior towards post-operative pain management of their patients.

2.3 Quantitative versus Qualitative approaches

Historically, two paradigms have been applied in the pursuit of knowledge: quantitative and qualitative. These methodologies have been routinely used in different fields as they do not study the same phenomena based on their paradigmatic assumptions.

The quantitative paradigm is based on positivism; a philosophical system that recognizes only that which is capable of logical or mathematical proof (Ragin, 1987). The ontological basis of the quantitative paradigm is that there is only one truth, which is independent of human perception. In other words, the investigator can undertake research without influencing or being influenced by the subject (Sale et al., 2002). The methodology adopted by the quantitative approach is nomothetic (derived from the Greek nomon = law, and thesis = proposition), and depends on the reduction of phenomena to numerical values (Russell et al., 2012).

Regarding data collection, quantitative research demands the random selection of samples from a large study population to prevent bias, commonly using techniques such as randomization, blinding, structured protocols or questionnaires with limited set responses (Goertzen, 2017). This large sample set enables statistical analysis to be applied, resulting in the observation of generalizable casual effects (Neuman et al., 2007). These are then utilized for the recognition and formulation of laws that are universally applicable and immutable in every circumstance. The above characterizes the natural sciences (Gelo et al., 2008). However, when applied to individuals, findings summed up in a numerical form do not adequately depict the reality as participants do not have the opportunity to express their emotions or give further explanations. Therefore, quantitative research answers questions: "what," "how much" or "how many," but fails to explore the "how" and "why" or "in what way" (Saper et al., 2009).

In contrast, the qualitative paradigm is based on interpretivism: the integration of human interest into a study (Altheide et al., 1994; Secker et al., 1995) and constructivism: the notion that realities are generated from multiple mental constructions based on social

70 experiences which are local and specific in nature (Guba et al., 1994). Therefore, the ontological basis of the qualitative paradigm is that multiple truths contribute to one’s construction of reality, as it is based on social constructs, and so is constantly changing (Sale, J. E. M et al., 2002).The qualitative methodology is idiographic (from the Greek idios = “own”,” private, and graphein = "to write", "to describe"). The approach uses naturalistic designs to investigate the behavior of the study population in their natural setting with little-structured context of observations (Gelo, O et al., 2008). The qualitative approach characterizes historical and human sciences, where effects on individuals by specific events are the focus of the research (Creswell et al., 2013).

Alongside the established paradigms described above, a third paradigm has been utilized in many studies in social and health research: Mixed-Method Research (MMR) (Bazeley, 2003). This approach attempts to combine the strengths of both quantitative and qualitative approaches, with the feasibility of this method being based on a number of arguments. For example, King et al. (1994) claim that unified logic is shared between quantitative and qualitative research, so the same rules of inference apply to both. Another stance is that both paradigms are united by a commitment to understand and ultimately improve the human condition through the dissemination of knowledge for practical use (Reichardt et al., 1994). Quantitative and qualitative methods have also been viewed as part of a continuum of research, with the research objective utilizing specific techniques on that spectrum (Casebeer et al., 1997). With regards to nursing, Tashakkori and Teddie argue that the combination of qualitative and quantitative approaches in social and health sciences set the ideal framework to reflect the complexity and multi-dimensional nature of the nursing science (Bazeley et al., 2003). However, the use of MMR has drawn criticism, with some counter-arguing that underlying assumptions behind the quantitative and qualitative paradigms are being overlooked. Since the two methodologies do not study the same phenomena, they cannot be combined in any simple fashion, if at all (Sale, J. E. M et al., 2002).

Ragin (1987) encapsulated fundamental difference between the two types of research when he stated that quantitative researchers work with a small number of variables and in many cases, while qualitative researchers tend to deal with relatively few case studies, each with a lot of variables.

71 In the systematic survey by Osborn and Rodham (2010) a lot of empirical qualitative research with a focus on acute postoperative pain is shown to have adopted both qualitative and quantitative research approaches. According to Tashakkori and Teddie (2003), the combination of qualitative and quantitative methods in social and health sciences accurately reflects the complexity and multi-dimensional nature of nursing science. However, the findings of such studies (combining qualitative and quantitative research) do not adequately depict reality, as noted above.

A qualitative approach includes the study of the ‘phenomena’ in their natural environment (Cresswell, 2003). Therefore, in the present study, the researcher tried to conceptualize and interpret the behavior of the participants who had personal post-operative experience, and how such experience affected their assessment and management of their patients’ pain.

Consequently, qualitative research proved more appropriate for this study as:

 It focuses on experience.   It entails appropriate subjectivity or the truth in a person.   It is used to describe people’s experiences and attach meaning to them.   It is useful for understanding experience, such as pain, care, illness, etc.   It focuses on understanding the whole.   Data is subjective.   Data in qualitative research is usually a matter of words and not numbers.   Data incorporates the perceptions, concepts, and beliefs of both the researcher and the participants.   It is consistent with the holistic philosophy of nursing.

One comes, therefore, to the conclusion that, in order to answer the chosen research question, a qualitative approach is appropriate and necessary, since the aim of the current research is to understand the subjective perceptions of the subject-item, their impressions and how they experienced a painful postoperative condition, together with their consequential attitudes and behaviors.

2.4 Qualitative research methods: key sub-methodologies

Qualitative research can be undertaken through a variety of approaches, notably

ethnography, grounded theory, case-study and phenomenology (Denzin et al., 2000). In 72 this section, these methods are considered and discussed, and the choice of the interpretative phenomenological analysis (IPA) for the current study is explained.

2.4.1 Ethnography

Ethnography originates from social and cultural anthropology. It describes the values, beliefs, and practices of a specific culture of people influenced by their living and working environment, the social structures they are integrated into, and the environment they act in (Hammersley, 1992). Key features of ethnographic research include the exploration of the nature of a particular social phenomenon (as opposed to proving or disproving a hypothesis) and work with ‘unstructured data' (i.e., data not abiding with set analytical categories) — also, small sample sets, and the interpretation of data by focusing on the meanings and functions of human actions (Reeves et al., 2008).

Ethnographic research has been used to explore postoperative pain in the past (Aiken et al., 2014). More specifically, Aziato et al. (2014) used an ethnographic approach to explore the perceptions and responses of Ghanaian surgical nursing staff with regard to their patients’ postoperative pain. They found that there was a gap in the knowledge of the nursing staff, attributed to a gap in the curriculum and time limitations regarding postoperative pain management, the inability to practice what had been learned in a clinical setting and budgetary restrictions, as well as a lack of focus on pain management in training workshops. Consequently, the authors suggested that an expansive and holistic program to enhance postoperative pain management should be developed, and that regular training for practicing nurses should be accompanied by the evaluation of patient care outcomes, so as to ensure that nurses can put into practice what they have been taught (Aziato et al., 2014).

However, this was not a method that the researcher selected in the present study, despite its interesting results, for it entails significant problems of different kinds. One of the main criticisms of this method was the amount of time it took to conduct. Another limitation was that the participants might not act naturally during a short and potentially assessment- oriented study. It was essential for the present study that participants were as accurate a representation as possible of the larger user audience, and also of themselves.

73 2.4.2 Grounded theory method

Grounded theory was developed initially by Barney Glaser and Anselm Strauss in 1967 (Francis, 1968). They argued that an approach was needed to develop contextualized theories, i.e. theories ‘grounded' in acquired data and not in analytical constructs, categories or variables that shaped pre-existing theories. Using this theory as a method provided guidelines on the identification of categories and how to establish links and relationships between them, whereas using grounded theory as a method offers an exploratory framework to help understand the phenomenon being studied (Strauss et al., 1990). Researchers in grounded studies aimed to develop and create a theoretical level of the phenomenon under study, which required a relatively large sample. As a result, individual accounts were used to explain the resulting theoretical requirement (Smith, 2009).

Grounded theory was inductive, not deductive, contradicting the traditional logic- productive research projects. As Glaser and Strauss (1999) have long argued, grounded theory began with a different set of perceptions compared to a traditional quantitative research project. The inductive nature of these methods required tolerance and flexibility in approach. A basic principle of grounded theory was to leave key themes to emerge, rather than being violently applied to prefabricated categories. The traditional research project, by contrast, was theoretically driven by prominent theories in the field (Strauss et al., 1990). Thus, the conventional research project required the researcher to structure in advance each phase of the research process, to verify or to reject these prominent theories. In short, every step had to be necessarily prefabricated (Strauss et al., 1990).

As a method of constant comparison, it required that all parts of the text were systematically compared and contrasted (Corbin et al., 2008). It focused on inductive reasoning to explain the way people found meaning within a specific meaning or civilization.

Grounded theory method consisted of an array of repetitive techniques which aspired to the recognition of categories and terms in a text that in turn connected with official theoretical models (Thornberg, 2012).

Slatyer et al. (2015) followed a grounded theory method to explain the hospital nursing staff's perspective of caring for patients in acute pain. According to their results, when their

74 patients suffered constant, severe pain, the nursing staff faced stressful conditions experiencing an emotional debilitation. The nursing staff's reaction to what they experienced was followed by a psychological process such as building connections, finding alternative ways to comfort and quelling emotional turmoil to resolve distress and exhaustion associated with disempowerment (Slatyer et al., 2015). Using grounded theory to compare the data broached the connection between the nursing staff’s debilitating anxiety and their reaction, recommending some further strategies to deal with this phenomenon.

One limitation of this method was that it produced large amounts of data which the researcher would possibly find difficult to manage and process. In addition, there were no standard rules to follow for the identification of categories, and the presentation of research findings was not straightforward. Finally, this method required a highly skillful researcher, especially when in this type of studies there was ample room for researcher induced bias. Bearing in mind that this research aimed to explore the meaning, process, and essence of nursing staff postoperative experience, grounded theory was not considered appropriate for this study.

2.4.3 Case study method

A case study is a painstaking, complex, in-depth investigation of a complicated specific work, institution, item or system within a period (Borch et al., 2009). The methodology is based on constructivism, allowing a close collaboration between the researcher and participant (Barlett, 2017). That enables participants to detail their views of reality, and researchers to better understand the actions of the participants (Baxter and Jack, 2008).

Researchers often focus their attention on a particular one object of study, aiming at depicting its complexity, the conception of its uniqueness, its permanent structures, the description of its function and its actions that govern it as well as its interaction with other contexts (Stake, 1995).

When the research interest is transferred to a specific, complex and functional situation, then the concept of "case study" is used to characterize the research strategy (Barlett, 2017). The "case" is deliberate, has space-time limits, functional parts, and its own

75 ‘identity.' Cases are usually people, groups, programs, educational institutions or bodies and, more rarely, events and procedures (Stake, 1995).

A case study has been previously utilized in an attempt to understand postoperative pain management. Powell (2009) used an organizational change perspective to explore in detail the organizational challenges faced by acute pain services in improving postoperative pain management.

Case studies have also been conducted comprising documentary review and semi- structured interviews from health care professionals and managers. The findings showed a wide range of challenge interactions such as political, cultural, educational, emotional and technological which should be faced in a fully-realized way at all body levels as well as all medical care systems.

One of the main criticisms was that it would be challenging to draw a definite cause/effect from a case study. As well as this, a case study could possibly lead to researcher-bias in data collection. Finally, it might well have been difficult for the present study to identify and adopt an appropriate case study. For the reasons of theory and practice, the researcher considered it wise not to follow the case study method.

2.4.4 Interpretative Phenomenological Approach (IPA)

Interpretative Phenomenological Approach is an experiential research method which is used to explore the lived experience and how to make sense of it (Smith, 2009). There are three methodological influences upon which IPA relies: phenomenology, hermeneutics, and idiography (Smith et al., 2009), as illustrated in Fig.2.1. Through phenomenology IPA provides the framework to conduct research, through hermeneutics it helps the researcher interpret meanings, and through idiography, it offers a mode to carry out data analysis. This section provides a discussion of IPA, because (particularly given shortcomings elsewhere, discussed above) it was considered the most appropriate methodology for this study. This discussion introduces those three methodological influences and establishes their relation to IPA with a view to showing the positive benefits of this approach.

Figure 2.1. The three influences of IPA (Charlick et al., 2016)

2.4.4.1 Phenomenology

Phenomenology is derived from the Greek word phainómenon "that which appears" and logos, which in this context means "study." A phenomenological approach aims to uncover the description, meaning and essence (not in a reductive sense) of an experience, providing a full and detailed description of an experience rather than a casual explanation of it (Salmon, 2012). Phenomenological approaches to research (descriptive and interpretive) are, in general governed by two philosophies: the Husserlian (Husserl, 1965), which aims to understand the ‘essences’ at the heart of human perception, and the Heideggerian (Heidegger et al., 1962), which views context and preconditioning as vital components of any interpretation. Merleau-Ponty (1962), a French phenomenological philosopher, was strongly influenced by Husserl and Heidegger. He was mainly interested in the constitution of meaning in human experience. Another French philosopher, Jean-Paul Sartre (1956), a key figure in the philosophy of phenomenology, was also influenced by Heidegger's work and maintained that consciousness (being-for-itself) is an activity, not a thing or substance (no-thing) and it should always be distinguished from the world it intends, hence his famous quote ‘existence comes before essence' (1948:26).

2.4.4.1.1 Descriptive phenomenology

The term phenomenology was initially imported by Lambert (1728 – 1777) in the 18th century, and later by Fichte, and by Hegel in 1807 through his work "Phenomenology of

77 Spirit." But it is the German philosopher Edmund Husserl (1970) who is regarded as the father of phenomenology, establishing the approach in his book ‘Ideas: General Introduction to Pure Phenomenology’(Giorgi, 2005). In it, he laid down the foundations for converting phenomenology into a stream of thought and method in human sciences. He developed the notion of the living world, a concept central to an existentially-oriented phenomenology, which aims to describe and analyze how phenomena appear in human experience and existence (Moustakas, 1994).

Husserl emphasized the interaction of the individual with the world that he or she lives in, as the individual is part of it and not something separate from it (Husserl, 1965). Therefore, phenomenology is not concerned with how the individual reacts to external stimuli but instead with the reaction to the individual's perception of what these stimuli mean.

Husserl (1965) derived his method ‘phenomenological reduction' to allow a rigorous study of consciousness after stating that natural sciences readily accepted the reality of nature or the physical world without prior investigation. Phenomenological reduction occurs in three stages: psychological reduction, transcendental reduction and eidetic reduction (Husserl, 1970). Psychological reduction aims to limit the analysis of phenomena based on their appearance in consciousness, without considering their immanence outside of consciousness (Husserl, 1970. It is done by halting (bracketing) judgments about the world (Mabaquiao, 2006), and disputing "a priori" knowledge; where facts are known independent of experience, and studies the question of knowledge before it is acquired (Husserl, 1970).

Schutz (1970) claimed that the first step in this method was the elimination of all preconceived notions. Through the process of bracketing, the validity or objectivity of interpretation is protected against the knowledge and preconceptions of the researcher (Koch, 1996). That can be best achieved by the technique of transcendental reduction which addresses the subject of consciousness and suspends a priori beliefs about it, such as its personality, historical identity, being connected to the body, etc. On using this technique, the researcher has to see beyond or through the singularities of lived experience towards the iconic universal, essence (eidos) that is found on the other side of the substance of lived meaning. These reductions highlight the two aspects of consciousness: the subject and the object of consciousness (Husserl, 1964). The relationship between these

78 two aspects is governed by intentionality, a necessary structure of consciousness (also referred to as ‘phenomenological residue’) which cannot be bracketed (Mabaquiao, 2006). Intentionality has also been described as the ‘necessity for consciousness to exist as consciousness of something other than itself' (Sartre, 1970). An investigation into the nature of intentionality by Husserl is observed in his analysis into the nature and structure of ‘act', which is his preferred term for intentional mental state. Husserl posited any deliberate act is based on the spectrum of Noema (a meaning which is given to an intentional act) and Noesis (which provides meaning to intentional act) (Rassi et al., 2015).

Therefore, phenomenology is primarily concerned with what is perceived by the person. Sensory functions, human perception, and thought are not absent from the world nor regardless of it. The phenomenological method is designed to reveal and describe the structures of the inner meaning of the lived experience (Husserl, 1965).

2.4.4.1.2 Interpretive phenomenology

Interpretive phenomenology was modified and built on Husserl’s theories and developed by phenomenologists such as Heidegger (1962), Merleau-Ponty (1964) and Sartre (1948). Their principle belief was that it was impossible to bracket from preconceptions and approach a phenomenon from a completely blank or neutral perspective since the researcher tended to use their experience to interpret those of others or guide their research question (Koch, 1995). In contrast to Husserl, Heidegger distinguished phenomenology as a metaphysical ontology, which was just one way among many of knowing the world with no specialized access to the truth (Heidegger, 1962). He viewed it as more fundamental than science itself, which differed from Husserl who regarded phenomenology as the foundational/scientific discipline (Benner, 1994). He also moved from the epistemological stance of Husserl to emphasize the ontological foundations of the understanding that is reached through being-in-the-world (Heidegger, 1962); therefore , postulating the central notion of everyday human existence (Annells, 1996).

Heidegger (1962) suggested that consciousness cannot be separated from the world of human existence. He rejected the notion that we are observing subjects isolated from the world of the objects about which we are trying to gain knowledge. Instead, we are beings inseparable from an already existing environment (Heidegger et al., 1962).

79 Therefore, a critical distinction between Heideggerian and Husserlian philosophy is Heidegger's position that presuppositions cannot be suspended because they constitute the possibility of intelligibility of meaning (Ray, 1994). Heidegger’s phenomenology is concerned with understanding and interpreting not merely a description, but the meaning of being; specifically, understanding rather than describing human experiences (Racher, 2003). Heidegger proposed three aspects of being. Beings were always in the world (facticity); beings were always in advance of themselves (existentiality); and beings were distracted by the persistent claims of everyday moods, interests, and companions (forfeiture).

According to Heidegger, taking into consideration a person’s background knowledge is indispensable when confronting any issue (Heidegger, 1996).

Merleau- Ponty’s (1962) theories of perception and the role of the body had a substantial impact on the humanities and social scientists. His holistic approach involved exploring the way people see the word and interact with it, how they perceived the nature of such relationship and how their perception was influenced by cultural-social settings and became contextualized by the existential grounds of the body, time, others and the world (Benner, 1994). The holistic nature of Merleau-Ponty's philosophy defined human experience as a skillful interweaving of consciousness, body, and environment (Moran, 2000). Our consciousness is always specifically directed to objects or events that are meaningful to us thus according to Merleau- Ponty, intentionality is the most essential feature of consciousness. To find meaning in intentionality, one has to step back from the ordinary ways of being and thinking and engage in a new way of suspending presumptions and knowledge trying to understand the uniqueness of a person's world in contrast to Heidegger who emphasized the worldliness of our existence (Sadala and Adorno, 2002).

Sartre (1948) considered himself as a phenomenological psychologist. He was greatly influenced by the phenomenological works of Husserl and Heidegger (Benner, 1994). Sartre (1956) was influenced by Husserl's theory of intentionality (consciousness's relation to phenomena). However, Sartre explored the concept of intentionality disconnected from Husserl's defined structures and concluded that consciousness amounted to nothing other than its ties to objects in the world (Sartre, 1948). For Sartre consciousness was ‘in-the- world.' That was very similar to Heidegger's conception ‘being-in-the-world,' and it was

80 that very conception which Sartre adopted to negate all these structures of consciousness (emotional, cognitive, and social) and turn consciousness into nothingness (Sartre, 1956). Contrary to Heidegger, Sartre maintained that consciousness relied on pre-existing objects. His idea of being-in-the-world involved engulfing consciousness in a world of objects that are, in essence, superfluous (Sartre, 1948). Consciousness is empty and reacting spontaneously with superfluous objects that possess various properties (Sartre, 1956). These reactions are not just subjective ones but the actual experiences of these objects.

The world is not something which holds worldhood but is that which provides worldhood to the objects within it (Sartre, 1956). Heidegger placed emphasis on the worldliness of a person's experience, and Sartre took this further and placed it in the context of personal and social relationships to help persons perceive their experiences as a result of these relationships (Smith et al., 2009).

2.4.4.1.3 IPA and Phenomenology

Husserl's, Heidegger, Merleau-Ponty’s and Sartre’s phenomenology approach offers IPA researchers a guide to explore the lived experience of people.

Husserl’s work has made a significant contribution to the process of methodical and thorough analysis of a person’s lived experience through reflection.

Based on Husserl's principles, Heidegger, Merleau-Ponty, and Sartre focus on existentialism and embodiment contributing towards a more varied and holistic approach to phenomenology (Smith et al., 2009).

Heidegger advocated that human beings are understood as being-in-the-world, both subjects and objects inseparable, subjective, short lasting and definitely ‘in relation to' each other (Smith et al., 2004). He explained that the concept of interpretation was inherent to ‘being-in-the-world.' This interpretation helped IPA researchers uncover and conceptualize the human experience in an environment void of presuppositions. However, this is a challenge for an IPA researcher since they should also be in focus and reflexive of their understanding, personal beliefs, and motives (Smith and Osborn, 2008).

Merleau-Ponty’s (1962) emphasized the notion embodied consciousness. In other words, the body adapts to the intended meaning, therefore acquiring a form of embodied consciousness and stressed that the lived human body relates to a space that is also lived (Merleau-Ponty, 1962). For the IPA researchers, the above calls for an understanding of

81 embodiment and how embodied human beings experience the word. In other words, how a person experiences their bodies in the world and how they experience their world through their bodies (stimuli-response) (Smith et al., 2009).

Finally, Sartre’s existential approach to understanding human existence as understanding the world gives IPA researcher an understanding of how to devise a phenomenological analysis of human experience in the context of personal, social and moral relationships (Smith et al., 2009).

These theories for IPA researchers are of vital importance to balance phenomenological description with insightful interpretation of the lived experience.

2.4.4.2 Hermeneutics

The second most crucial theoretical influence of IPA is hermeneutics (Finlay, 2011). Hermeneutic is a separate philosophy and methodology built on the general principles of phenomenology (Palmer, 1969). It is the science of human interpretation concepts, experiences, based on text and storytelling (Palmer, 1969). The narrative contains the meanings and symbols of the situations as it lives and perceives those who experience them (Jens et al., 2014). Through narratives (interviews and description of observations) and the analysis of their symbols, world and the narrator's existence are revealed as they live in a unique way.

Via narratives, the analyst ‘lives' the world of the narrator, until they become part of it. At this point, the meanings and perceptions of narrator and analyst converge (Ricoeur et al., 1981). This convergence is the product of the hermeneutic phenomenology, the one that reveals the world. The convergence of meanings expands the perception of the listener and the consciousness of the person experiencing them. The situation is interpreted and imprinted uniquely. This methodology increases the sensitivity to the way the analyst see the ‘things' in the world (Dreyfus, 1991).

Hermeneutics is primarily a research tradition based on Heidegger's vision and developed by hermeneutic theorists and philosophers the most important being Schleiermacher and Gadamer.

82 Schleiermacher is the father of modern hermeneutics. In his theory of hermeneutics, he introduces two types of interpretation the grammatical and psychological (Schleiermacher, 1998). The first one aims to determine objective textual meaning as well as the single meanings of words as clearly as possible. The second one seeks to reconstruct the individuality and subjectivity of the author. For Schleiermacher interpretation is not a matter of procedure, it is art. It is the art of understanding which leads hermeneutics to a new direction by drawing a line between speaking and understanding (Schleiermacher, 1998). The above involves immersing in a detailed extensive and holistic analysis to find meaningful insights into the narratives. Notwithstanding the uniqueness of people there is also commonality among them and confirming these two elements becomes crucial to understanding (Schleiermacher, 1998).

Based on what previously discussed, Heidegger (1962) maintain that successful interpretation requires an understanding of lived time and engagement with the world since they are essential characteristics of Heidegger's Dasein or ‘being there.' This type of interpretation is achieved through hermeneutic circle which will be discussed in detail later on.

Gadamer was influenced by both Husserl and Heidegger's work and expanded Heidegger's work. Gadamer (1976) saw the work of hermeneutics not as developing a process of understanding but further clarifying the circumstances in which the understanding itself occurs.

Gadamer, explaining Heidegger, in Truth and Method, notes that "Thanks to the verbal nature of interpretation, every interpretation includes the possibility of a relationship with others" (Gadamer H.-G., 1989; 399). Jung (1964), similarly, argued that the language initially is nothing more than one system of signs or symbols that characterize either real processes or the response to the human soul. The interpretation of the symbols plays an important role from a practical point of view since the symbols are only natural attempts to reconcile and unite opposites within the soul (Gadamer, 1975).

In Gadamer's view (1976), understanding is always more than merely re-creating the meaning of someone else. The questioning opens the possibilities of meaning and therefore what is meaningful is passed on to the person's mind about the subject. Gadamer (1989)

83 believed that understanding and interpretation are linked together, and interpretation is always an evolving process, so a definitive interpretation is probably never possible.

While Gadamer (1998) did not oppose the use of methods that aim to increase analyst's level of understanding, he was categorical in his position that the methods are not entirely objective, separate or value-free. He considered bracketing not only as impossible but attempted to make it absurd.

Koch (1996) described Gadamer's position as one of the supportive prejudices, as a prerequisite of knowledge that determines what is understandable in each case. Such understanding is based on a researcher's historical existence, and every understanding will involve some bias.

The preconceptions and foregrounds that occupy the interpreter's consciousness are not at his disposal (Gadamer, 1998), the interpreter cannot distinguish in advance productive prejudices. However, he/she needs to be fully aware of his/her preconceptions during the process of interpretation or biases so that during analyses the narrative can emerge in each own truth against any preconceived meaning (Smith et al., 2009). The interpreter possesses various conceptions which are compared, contrasted and altered in an attempt to make sense (Smith et al., 2009).

Of course, Gadamer (1977) did not support the option that someone can leave his immediate situation in the present only by adopting a stance. He recognized the undeniable presence of historical consciousness and the positive role that the pre-understanding of it plays to the search of meaning (Gadamer, 1976). In answering the question of how understanding is possible. The answer was described in his Philosophical Hermeneutic where he introduced the use of a hermeneutical form of interpretation (Fleming et al., 2002).

Gadamer (1975) stressed the idea of historical awareness and considered it as a requirement as conducive to knowledge and understanding since according to him consciousness and history closely associated. However, historical awareness came with certain prejudices not in a literal sense but with a meaning synonym to pre-understanding (Fleming, 2002). He maintained that one could not possibly rid of their pre-understandings since they are an inherent part of the sense-making process. Failure to become aware of

84 one's pre-understandings may imply a failure to understand or misunderstand meaning (Gadamer, 1975).

In philosophical terms, experience is knowledge attached to the consciousness of the object and governed by a sense of being in touch with the identifiable reality may that be how the subject perceives external objects and situations or the reality attached to memories and experiences of the consciousness itself (Fleming et al., 2002; McManus Holroyd, 2007).

One of the most critical underpinnings in Gadamer's hermeneutics is the hermeneutic experience. When Gadamer employs the world experience (Erfahrung), he means hermeneutic experience in contrast to experience (Erlebnis) which is, in essence, a lived experience temporal, historical and ever-changing (Gadamer, 1998). The hermeneutic experience offers the opportunity to expand a person's perception so that they can consider things from a different perspective. At this stage, previous experience in its hermeneutic sense is negated which in reality is a negation of past knowledge (Zimmermann, 2012). This curiously enough has a positive effect because a person does not reject prior knowledge but adds to this knowledge by acquiring a new and broader perspective, and that opens up new ways of understanding (Gadamer, 1998).

He considers knowledge as understanding and ultimately self-understanding. True self understanding emerges from experience, and as a person reflects on their past experiences (accumulated through history and tradition), they can learn from them, add new ones and therefore creatively form new knowledge that leads to an objective reality (Gadamer, 1989). Experience is principally based not only on the comparison but also on the assertion of previous knowledge.

Gadamer (1989) viewed human dialogue as a means of highlighting the dialectic nature of experience in his hermeneutics. In his book Truth and Method, he stresses the analogy of hermeneutic experience with conversation. To him, genuine hermeneutic experience occurs at best in personal dialogue.

Gadamer's philosophy is humanistic in nature as it focuses on the concepts of self-control, self-transcendence, and willingness to explore the truth (Zimmermann, 2012).

Gadamer (1990) introduces a triple pattern of understanding based on the three elements of ‘being there’ (Dasein) temporality advocated by Heidegger. The first element is fore- having which implies interpreting narrative or text within an exciting framework of 85 preconceptions. The second element is fore-sight which involves understanding through association with the object of understanding and considering it from a particular perspective. The third element of understanding is fore-conception where understanding is articulated in a meaningful manner to others. These three elements are inherent to the hermeneutic circle which leads to the conclusion that hermeneutics is circular, a never- ending process, as it moves from the whole to the part and back to the whole again (Smith et al., 2009).

2.4.4.2.1 The hermeneutic circle

The hermeneutic circle describes the process of understanding the narrative or text hermeneutically. The concept addresses the idea that understanding the whole is established by understanding the parts the whole consists of. Therefore, neither the whole nor the parts can be fully appreciated without reference to one and other.

Heidegger developed the ‘Hermeneutic circle’ to account for the preconceptions of an object’s being before attempting to understand and interpret it (Heidegger, 1962). Consequently, the circle is not logically a vicious one if it is entered with a prior awareness of the subject’s preconceptions (Mary Converse RN, 2012). The hermeneutic circle can be described as a circle with two poles; one being the object of comprehension and the other being the various parts that the object is composed of. The object taken as a whole is comprehended in terms of how its constituent parts are integrated into the whole, and how they constitute the whole once integrated. Each part is dependent on the location and function with respect to the whole; therefore, changes to the whole will affect the individual parts (Kinsella, 2006). According to Smith (2009) “the hermeneutic circle is perhaps the most resonant idea in hermeneutic theory”.

Gadamer (1975) maintains that altering and developing pre-understanding is carried out through a hermeneutic circle.

His theory pointed out the dynamic relation developed between the whole of life and its parts. Through this meticulous procedure, for the researcher to comprehend the whole, he has to focus on the parts, and by comprehending the parts, he consequently focuses on the whole (Tuohy, 2012). Therefore, processing his pre-understanding, the researcher can comprehend the participant while at the same time the participant’s perceptions will affect the researcher’s comprehension (Harris, 2018).

86 According to Gadamer (1975) this process of the hermeneutic circle never ends since it is cyclical, but it moves back and forth. Moving circularly helps a person establish their interpretation of the phenomena as they shift along the hermeneutic circle, as can be seen in the diagram below.

Figure 2.2 Hermeneutic circle/loop (Harris, 2018)

To elaborate, when one enters the circle they use their own pre-understandings on starting the interpretation of the narrative or text (Gadamer, 1990). During the initial interpretation of its individual parts, one needs to have a range of vision that encompasses everything seen from a particular perspective and knowing the significance of everything (Gadamer, 1960). Acquiring the appropriate horizons, according to Gadamer (1960), means acquiring appropriate points of view. Once this is accomplished, a fusion of horizons and interpretation of the whole is attempted. The next stage in the circle involves the reviewing of personal understanding and the formulation of new horizons leading to new interpretations (Gadamer, 1960).

The significance of the hermeneutic circle to IPA researchers lies in the fact that the circle provides a method to approach qualitative analysis, which in principle tends to follow a repetitive pattern (Smith et al., 2009). The circle serves as an effective tool for deeper interpretation and reflection and provides a holistic analytical interpretation due to the dynamics that develop at different levels in the circle between the parts and the whole

87 (Smith et al., 2009). These come as a significant aid in enhancing our understanding of the research process.

2.4.4.2.2 Debating phenomenology and hermeneutics

Phenomenology is a philosophy that can be chosen as a research method to understand in- depth human phenomena. The primary goal of phenomenological research was to establish a pattern to describe accurately a person’s lived experience in relation to the topic of the study and the research question. However, Crotty (1996) and Paley (1997) were most assertive in their critique of specific fundamental concepts and approaches to Husserl's phenomenological theory (i.e., reduction, bracketing). In 1996, after a review of randomly selected nursing phenomenological research in North America, Crotty triggered a debate questioning its quality, as Crotty and Paley considered this approach less critical, less descriptive and subjective. Apart from the misunderstandings of the basic concepts introduced by Husserl that have arisen, Paley (1997) highlighted the misinterpretations of Heidegger's theory of "being-in-the-world."

Giorgi (2000), Crotty (1996) and Paley (1997) did not separate the scientific from the philosophical aspect of phenomenology. Giorgi (2000) also acknowledged some misplaced applications of the phenomenological theory by researchers and stressed the need for a deeper understanding of theory so that it could be used in practice.

In addition, Giorgi argues that scientific phenomenology has been applied poorly in previous research due to the fact that there have been attempts to make elements of phenomenology a scientific practice instead of a philosophical one (Giorgi, 2000).

According to Crotty (1996), the scientific perspective denies phenomenology. Crotty (1996) and Paley (1997) argue that phenomenological research aims to elucidate the subjective experience of the individuals rather than merely describe the phenomenon.

The necessity of bracketing in previous knowledge and experiences is marked by Giorgi (2000) and others following the philosophy of Husserl, so researchers do not distort the phenomena that are being studied. Although many like Theobald (1997), concur on the necessity of bracketing, they agree with Crotty (1996) and Paley (1997) that distancing of the researcher and their preconceptions is difficult or even impossible to achieve.

88 More precisely, the latter states that the concept of bracketing, according to Husserl's theory, presupposes a lone activity of phenomenological reduction, which has forced Giorgi to adapt bracketing to a broader sense for carrying out research (Paley, 1997).

In his latest book, Paley (2016) does not claim that phenomenologists have misconceptions about their research, but he maintains that the excessive conclusions they draw are may be due to a variety of things that are said when participants are asked about their motives or their decisions.

Paley (2016) attributes to Giorgi's methodology that both his analytical process and the meaning are based on nothing but arbitrary decisions. He supports that interpretation process should be based on an imported descriptive theory and that analysis should not be driven by the data.

On the other hand, Van Manen (1997) considers that all descriptive phenomenological studies seek more profound knowledge other than patterns or similarities of experience, and therefore have an interpretive approach also.

In conclusion, Crotty's (1996) and Paley's (2016) criticism of research motivate researchers to review the methods and complexity of phenomenology as a research approach. This continuing critique of the applications of phenomenological research is essential in the search for new knowledge (Norlyk et al., 2016).

As far as hermeneutics is concerned, Silverman stressed that hermeneutics then is not a method of interpretation, but a study of the nature of understanding, which goes beyond the concept of method (Silverman, 2016). In addition to that, Gadamer argued that the validity of the scientific method is independent of the content of knowledge. The global validity of the scientific method cannot be applied to the experience of truth and understanding (Gadamer, 1998). Pioneer researchers such as Colaizzi (1978), Giorgi (1989), Van Manen (1984), and Diekelmann (1992) have developed research methods that combine phenomenology and hermeneutics. The basic outcome of these methods is to describe and reduce the meaning of an experience, often through the identification of essential themes.

The psychologists Giorgi (1989) and Colazzi (1978) developed similar approaches, inspired strictly by Husserl's' ideas: (a) the original descriptions are divided into units, (b) the units are transformed by the researcher into meanings that are expressed in psychological and phenomenological concepts and (c) these transformations are combined 89 to create a general description of the experience. Although all theories describe the view of an experience through themes, they follow a different approach to validating the results (Pilot, 2005).

Colazzi provides the researcher with a gradual approach based on seven steps when conducting a research survey. He also confirms the results of the study by returning to the participants while encouraging researchers to highlight the participants' views as precisely as possible (Colaizzi, 1978). The latter strays from Gadamer's stance that comprehension relies on pre-understanding, which is necessary for a hermeneutical approach.

Giorgi’s approach relies on bracketing, requiring researchers to set aside their prejudices so that they do not distort the study’s phenomenon. According to Giorgi (1989), the phenomenological perspective recognizes consciousness as a fundamental value that connects the mind with the body and composes the individual. However, this contradicts Gadamer's theory stating that it is unlikely the researcher can set aside prejudices, and that comprehension is feasible through the historical perception, involving prejudices (Gadamer, 1990).

Van Manen’s methodological approach follows Gadamer’s work that knowledge developed by the pre-understanding of the researcher should turn against itself thus exposing its character (Van Manen, 1984).

Diekelmann's work based on hermeneutic phenomenology evolved Gadamer's approach by applying the joint account of data analysis with the intent to highlight and analyze the researchers' pre-understandings. This approach could be considered useful in Gadamer's approach; however, it was utilized by the researchers to explore preconceptions, formed by history and tradition, instead of merely detecting them (Diekelmann, 1992).

There have been various critics of Gadamer’s theory. Habermas criticized Gadamer hermeneutics for being too reliant on tradition (Habermas et al., 1990) while Derrida challenged Gadamer’s hypothesis that understanding implies the willingness or hermeneutical drive to understand the others as well as the universality of hermeneutics.

Even though phenomenology is closely related to Husserl, Heidegger, Gadamer, Sartre, Merleau-Ponty, and Derrida none of them developed research methods most modern 90 qualitative research is based on their theories (Fleming et al, 2003). Husserl introduced an empirical philosophy or as Giorgi defines it, a scientific phenomenological practice (Giorgi, 2002). Similarly, Gadamer (1962) who provided valuable insight into how the researcher can achieve a deeper understanding of the lived experience did not offer a robust methodology. However, he admitted that such deeper understanding required methodological direction through a systematic approach to help the researcher structure the research process (Gadamer, 1975). Van Manen (1997) agreed with Gadamer's views and added that reflection prior to choosing a research method was imperative in finding the most appropriate approach to effective interpretation. In Gadamer's hermeneutics the process of interpretation becomes dialogue, therefore, the process transforms into a dialogical method where a relation between the self and the other is achieved as the interpreter's horizon expand to include the horizon of the other resulting in the fusion of horizons which is, in essence, a dialectical concept (Fleming, 2002).

An amount of nursing research is based on the theories of Husserl and Heidegger while there is growing trend for using Gadamer’s, Merleau-Ponty and Van Manen philosophy (Mak et al., 2003) acknowledging the need for a phenomenological method for the true examination of phenomena free of the effect culture and tradition may have on them (Caelli, 2000).

One has to acknowledge the significant contribution the philosophers mentioned above have made to the development of phenomenology in general and to interpretive hermeneutic phenomenology in particular. Nevertheless, Gadamer's theory was considered to provide the most appropriate framework to apply IPA's principles to this study.

Gadamer's hermeneutics provides plenty of insight into the lived experience and a promising research method. The process itself helps the interpretation and understanding of the phenomena from the subject perspective. It is most appropriate to cases where the researcher has to cope with meanings not easily understood and therefore require effort to interpret. Both experience and understanding of truth are important elements of Gadamer's hermeneutics. Interpretation of hermeneutic experience is more than a mere collection of experiences; it is a learning experience when learning experience occurs, people's consciousness change. Gadamer provides the research with the philosophical principles for extensive interpretation and understanding.

91 2.4.4.3 Ideography

The last significant influence on IPA is idiography. According to Smith (2009), an idiographic approach focuses upon the study of the particular, thereby being devoted to the specific, detailed and in-depth analysis of the participants’ experience. Emphasis is placed on the comprehension of particular empirical phenomena from the perspective of the individuals who experienced them in a specific background (Smith et al., 2007).

The idiographic nature of IPA focusses on the wholeness and uniqueness of the participant’s particular subjective, cognitive situation and exploring their personal perspectives before drawing general conclusions (Smith, 2009). Idiography in its turn, can be applied in studies of individual phenomena and not in the introduction of general laws whether this involves a team or a population (Reid et al., 2005).

That is why the fundamental principle of the idiographic approach lays its foundations on the investigation of every single particular case without proceeding to general statements (Smith, 2009). In particular, since ideography involves effective, in-depth analysis in individual cases, it is of significance to IPA since it enables researchers to focus on the specific rather than the whole throughout the analytical process diverging and converging own experiences.

2.4.4.4 Interpretative Phenomenological Analysis as a research method

To qualitative research, IPA is an approach concerned with exploring thoroughly the human lived experience (Smith et al., 2009). Lived experience is explored by making sense of the participant from a social, cultural and historical perspective of the world (Roberts, 2013). The nature of exploring is interpretive, through dialogue and observation (Pringle et al., 2011). However, one has to consider the researcher's preconceptions as well as how the persons make meaning of their life experiences at the time since qualitative researchers are mainly concerned with meaning, that is, how the persons understand and experience the world, events, and phenomena (Biggarstaff and Thompson, 2008).

Goldsworthy and Coyle recognize that the process is affected by the researcher and their interpretations, even though the goal of the approach is to identify the meaning of subjective perceptions (Golsworthy et al., 2001).

92 Attempts to the interpretive approach occur from a person's perspective (empathic attitude) in combination with the researcher’s understanding of the participants’ experience under investigation (attitude of questioning) (Smith et al., 2009). So interpretation develops in different levels of analysis and proceeds to more in-depth interpretations (Aisbett, 2006). This procedure always evolves into a research data framework instead of a mere theoretical approach adapted to the research data (Smith et al., 2009).

Flowers (1999), underlines the mechanisms of IPA such as the subjective reports of the individuals' experiences and not the objective reality. At the same time, he recognizes a binary dynamic investigative process within which the participant tries to understand his personal world while the researcher attempts to understand the person through their point of view (Smith 2009).

Interpretive phenomenology provides new ways that allow interpreting the process by which people acquire consciousness of the world that surrounds them (Smith and Osborn, 2008). In this type of qualitative research, the researcher is the primary tool for both the collection of data and their analysis (Thomas et al., 2015). The researcher interacts with the research environment, and sensitivities as well as perceptions that directly affect the research (Thomas et al., 2015).

Fade (2004) examines the phenomenological basis of IPA as it focuses on the creation of a relationship of trust in the in-depth recording of the participants' personal experiences and on the other hand, it points out its interpretative character identifying their own beliefs and views.

IPA is confined to a phenomenological orientation (Braun et al., 2006). It is highlighted that qualitative research is based on the interpretative philosophical tradition and has a reconstructive character (Atkinson et al., 1984). The researcher acknowledges beforehand that every social phenomenon that is considered is explained by the ‘participants' (subjects) who have experienced some situations and expressed them through their acts (Roberts, 2013).

Therefore, it is crucial for the researcher to penetrate those situations realizing how this experience has been received, under which social conditions, and finally what the responses are (Smith et al., 2009). Consequently, it can be said that a reconstructional 93 process takes place. The researcher's interpretations of social reality are secondary formulations that are based on the primary ones of the subjects of the survey.

The above assumption is characterized by openness, which aims to consistently document the research object in the way it presents itself (Flick, 2005). Due to the nature of this characteristic, the researcher cannot design their research before studying and understanding how the participants handle the phenomena that are under investigation (Pringle et al., 2011). The researcher should first analyze the reporting systems, and then identify the participants within a framework before making conceptual groups (Charlick et al., 2015).

In all these aspects of the research, the process may be redefined by the research findings, from the contact of the researcher with the participants in the research field. Moreover, for the researcher to see through and understand the aspects of participants' reality without handling it superficially, a communicative relationship should be developed (Smith et al., 2009).

In formulating the research question in IPA, the researcher does not formulate or test any hypothesis prior to the research (Smith & Osborn, 2008). On the contrary, the researcher applies inductive procedures that involve exploring and eliciting to achieve an interpretation of the meaning of lived experiences since research questions formed based on the principles of the interpretive phenomenological approach center on upon people's perceptions of their experiences (Smith et al., 2009). Research questions should be realistic, open, flexible, exploratory and by no means relating to hypothetical constructs (Smith et al., 2009).

According to Smith et al. (2009), ‘the detailed case analysis of individual data is time- consuming, but a study aims to capture in detail the participants' perception as well as understanding it.' Therefore, the use of a small sample size allows expression of the idiographic nature of the method but should be sufficient regarding its size to highlight the similarities and differences between the study cases (Smith, 2015). There are no specific guidelines as to the number of participants in the sample. The decision generally speaking relies on the depth of analysis required in each case, the complexity of the case, the way

94 the researcher decides to compare these cases and the limitations of the study such as deadlines or access issues (Briggerstaff and Thompson, 2008).

Research experience implies that when a purely qualitative method takes place, that the research lacks its right to state generalities that will be valid for the whole population as long as it limits the subjective interventions of the researcher as much as possible. Due to this choice, the interest in qualitative research was a resurgence. The main concern of such research is to maintain its credibility through its adherence to a specific methodology, providing a satisfactory sample of the participants, so their connection to the final interpreter is obvious (Fossey et al., 2002).

Due to the illustrative nature of IPA, data collection is done mainly in the form of loosely framed surveys and interviews, allowing quotes and metaphors to be utilized in the data analysis (Pringle et al., 2011). To emphasize the importance of participants' experience that the IPA delivers, Smith et al. (Smith et al., 2009), suggested that each time new data arises, it should be documented or cited on the interviewed transcripts. Parts of an interview falling under the phenomenological method can improve data analysis comprehension when the comments of the researcher are based on the interpretative part of the study to establish a dialogue between the participant and the researcher.

According to Ricoeur (1970), IPA operates a double hermeneutic in an attempt to make sense of data. On the one hand, empathy hermeneutic is highlighted, while on the other, there is the hermeneutic of doubt. According to Smith (2004) and Larkin et al. (2006) IPA can combine both aspects; meaning that it empathizes with the individual’s experience and also sheds light and attempts a consistent exploration from a person’s different angle. Van der Zalm and Bergum (2000) argued that hermeneutic phenomenology possesses both descriptive and interpretive traits which can be successfully incorporated into the interpretive phenomenological approach.

Critics of the approach maintain that first of all since the method is not descriptive researchers are free to adjust the methodology to suit their needs (Willig, 2008). Secondly, being qualitative in nature demands that the approach is more subjective especially as regards the interpretive analysis rather than objective that is epistemological, particularly since there are not any strict rules governing the method (Smith et al., 2009). As a result,

95 the researcher runs the risk of producing biased reports as far as the results of the study are concerned (Tuffour, 2017).

Nonetheless, IPA offers general guidance on analyzing the qualitative data, but this guidance should be flexible enough to adjust to the specific requirements of each research study.

2.4.4.5 Interpretative Phenomenology Approach and Human Science

Phenomenology is a philosophical approach to the nature of human beings as it emphasizes the subjective experience of the person (Moran, 2000). Attempting to defend the importance of human sciences Gadamer (1975) maintained from the methodological perspective that scientific methods of the natural scientists do not take into account the relationship between the researcher and the object of the research. This type of relationship is crucial in understanding the lived experience which is an essential subject of human sciences. In other words, scientific methods alone cannot provide or promote adequate understanding of lived experience.

Phenomenology later merged with existentialism with philosophers such as Nietzsche and later on with Heidegger (1967) and Sartre (1956). Through people such as Carl Rogers (1965), existential philosophy took a turn into the humanistic approach which maintained that people have an inherent drive for self-actualization. The humanistic approach studies the whole person and the uniqueness of it. It is often referred to as the ‘third wave' after psychoanalysis and behaviorism (Maslow, 1968). Its impact revolves around the fact that it offers new insights into understanding human nature and condition as well as a wider choice of methods of inquiry to study human behavior. The basic assumptions that govern the humanistic approach are that: first of all, people have the power of acting without the constraint of necessity or fate (behavior is not predetermined) (Wertz, 2001). Second, people have an inborn desire to improve themselves and the world. Third, people strive towards self-actualization (growth, fulfillment) and finally, a person's subjective understanding of the world is more important than the objective reality (Aanstoos et al., 2000).

96 Rogers (1965) emphasizes how individuals understand and interpret events and not on behavior, the unconscious and thinking. In other words, he called for the actual study of the self. The humanistic approach is not in favor of scientific methodologies and opts for qualitative research approaches which are more appropriate for in-depth exploration or a person's thoughts and feelings at a personal level.

Carl Rogers was born in 1902, in Chicago, where he was brought up by a devout Christian family. He received a strict Christian education with an aim to enter theology. Nonetheless, he completely changed his orientation, attended psychology courses wishing to respectfully develop an approach to the individual's reliability and freedom (Thorne et al., 2012). This desire of his, made him come into conflict with the theories of behaviorism, which study human behavior and its mechanisms. As a response to stimuli, he creates the humanism trend. His principal notions that have had a major influence on the psychology science are the ancillary relationship developed with the person as well as the creation and bequeathing of knowledge within the educational background (Thorne et al., 2012).

The person-client relationship depends on the fundamental confidence which the therapist has to monitor, penetrating in this way their experience and acceptance thereof (Rogers, 1959). According to Rogers (1961), empathy is the mainspring through which the adaptive outcome of the therapist behavior towards the person can be achieved. To Rogers, the therapist's empathy with the person's feelings requires effective communication skills, which will enhance the person's confidence in the therapist resulting in being able to reveal their truth (Thorne et al., 2012). These include trust, respect to their individuality, the capacity and freedom of making choices which develop their creativity, acceptance by the therapist and the frame (McCormack and McCance, 2017). That leads to the formation of a person who will act responsibly and reinforces his/her ability to adapt effectively to the continually changing system-world that we live in (Rogers, 1961).

Rogers (1961) defined a person self-concept as the building block for personality development. The person strives for balance in three aspects of their lives to achieve self- actualization which is essentially a building tendency to develop positively. Self- actualization evolves around three overlapping elements: self-worth, self-image, and the ideal self. This process increases overlapping between the elements and leads to more satisfaction. Successful self-actualization helps a person remain in balance and relate better

97 to their world. During this process, each personality is unique, and therefore one has to carefully consider the idea of a holistic view of a person (Rogers, 1961). Rogers maintains that people feel, experience and act in ways which are in essence in accordance with their self-image and reflect their self-actualization. Self-image includes the influence of their body image on their inner personality.

Carl Rogers’ contributions to the scientific and clinical work are integrated into the interpretative/hermeneutic approach and evolve on the belief that experience is a person’s ultimate principle, validity and the path to the truth. It can always be controlled in new, original ways.

Along with Carl Rogers, Kurt Lewin has made significant contributions in the areas of applied psychology. Lewin's theory maintained that behavior is the result of the individual and the environment since they both interact to induce behavior (Lewin, 1947).

Kurt Lewin was born and educated in Germany and worked as a professor at Berlin University until 1933 when due to the rise of Nazism he moved to America and worked at Iowa University. After the Second World War, he founded an investigation center at the Technology Institution of Massachusets with the aim to explore all the aspects of behavior and how they could be modified (Lewin, 1947).

Kurt Lewin’s most significant contribution was the development of the three-stage theory of change known as ‘unfreeze,' ‘change,' ‘freeze' (Lewin, 1947).

The first stage involves preparing prior to the change. The necessity to change becomes more imperative depending on how motivated we are to achieve it. The second stage includes the actual change which is, in reality, a process-the process of transition which is, in essence, progress in reaction to change. It is obviously the most challenging stage of the process since people are usually hesitant to change and need to be given time to understand and deal with it. This stage can be made easier by providing some form of support, i.e. counseling or training. The last stage (freezing or refreezing) involves achieving balance after the changes have occurred. In practice, this means that people accept and become comfortable with the changes. At this point, Lewin recommends some kind of reinforcement to help people not only allow but also maintain change. Without making sure that change continues, people may return to their previous behavior or practices.

Kurt Lewin's model can provide insight and a deeper understanding of how to deal with change (Kemmis et al., 1992).

The figure illustrates how Carl Roger’s theories of self-actualization and Kurt Lewin's theories of change have been adopted and incorporated into the interpretative phenomenological approach to empathize with the individual's experience, make meaning of it and gain insight on its impact on their behavior. As well as this, these theories help IPA shape a research framework and methodology.

Fig 2.3. The circular approach developed combining IPA with the theories of Carl Rogers and Kurt Lewin

99 2.4.4.6 Reasons for choosing IPA

IPA as a qualitative approach is concerned with providing a detailed exploration of the personal lived experience as understood by the participants and not based on any pre- existing preconceptions (Smith, 2009). Due to its idiographic nature, it can help the researcher explore in depth each experience especially when these experiences concern complex topics, characterized by intense feelings such as post-operative pain, prior to coming to more generalized conclusions. Therefore, IPA is the most appropriate methodology for exploring how nurses' personal postoperative experience influence behavior towards patients' post-operative pain assessment and management. The phenomenon of post-operative pain can be intangible, difficult to articulate and intricately psycho-somatic a fact which reinforces the need for adopting such an approach since IPA can make a significant contribution to research this phenomenon.

Based on its three underpinnings (phenomenology, hermeneutic, idiography) IPA supports that since persons do not perceive objective reality passively (post-operative pain) but try to interpret and understand their world into some comprehensible form, IPA's aim is to explore in depth how the participants comprehend their experiences mainly through narration and self-reflection (Chapman and Smith, 2002).

Being phenomenological in nature, IPA offers the researcher focus on producing subjective rather than objective narratives (Flowers et al., 1999) as well as the opportunity for reflection, which applies to both the researcher and the participant (Osborn and Smith, 1998). It provides the most fertile ground for understanding the most intimate contemplations of the post-operative pain experience. Being person-oriented, it enables the participants to present their narrative from their own unique perspective without interventions or contortions. What is more, it offers the researcher the ability to put to practice and develop their social and subjectivity skills to the process. The above philosophies are considered, according to IPA, equally significant with the procedure followed during research since familiarization with these philosophies help the researcher to present more elaborate, sound and refined analysis of the data. Its value to a novice researcher lies in the fact that this approach can come of assistance in dealing with unexpected problems and as they become more familiar with the procedure expand their work beyond it. It should be noted that in such procedures, the researcher assumes a dual

100 role that of the participant who tries to make sense of their world and their lived experience and that of the researcher who seeks to understand and assess the participants' experience through narrative and observation.

The design of an IPA research allows for the selection of paradigm that accurately represents the purpose of the research topic (Dush, 2005). It helps the researcher choose the most appropriate methodology to carry out the study that enables the researcher to select the most suitable research design and later on in the research describe the study and its findings in specific ways. A combination of two paradigms, i.e., critical theory and an interpretive paradigm can prove fitting enough if utilized in synergy to help the researcher achieve the aims of the research to the maximum which are, in essence, to explore and interpret the live experience of the participants and its impact.

The small (and yet significant and appropriate) sample size of an IPA study renders it the most appropriate approach for the present study. It enables the researcher to reach a micro- level analysis of individual accounts of the lived experience beyond the single case-study with its inherent drawbacks (set out above). Equally important is its inductive approach to qualitative research, which helps the researcher look for patterns in the data and develop ways to explain them to answer the overall research question that is being addressed.

2.5 Conclusion

This study maintains that qualitative research in general and IPA, in particular, provide a robust but flexible approach to understanding individual experiences. This method of approach draws inspiration from the three key areas of the philosophy underpinning IPA (i.e., phenomenology, hermeneutics, idiography) to form the principles that govern its research methodology. IPA can provide profound, detailed and practical perspectives on the human experience leading to a deeper understanding of a general kind and one that applies to the theory and practice of postoperative pain and its management. For it helps researchers to interpret human experience and attach meanings to it. Therefore, it was considered to be the most appropriate approach in to answer the research question.

101 In the following chapter, the way in which the research process was conducted is discussed in detail as well as the role of the researcher, the process of data collection through observation and interview, the data analysis and also, importantly, ethical and moral issues.

102

3 Methods

3.1 Introduction

This chapter focuses on the methods used to answer the core research question on

“how Greek nurses' personal post-operative experience influences their behavior towards patients' post-operative pain assessment and management."

A two-phase project was developed based on the interpretive phenomenological approach. Phase one utilized observations of nurses during three shifts and phase two used interviews to explore in detail the data from the observation phase. Additionally, there was extensive discussion on essential features of the study. The current study focused on the real world since the framework is realistic and describes the challenges of the research in a therapeutic environment. Finally, the data analysis procedure, as well as ethical and moral issues, are described and analyzed later in the chapter.

3.2 Sampling

3.2.1 Sampling technique

In qualitative research, the goal is to understand a phenomenon in depth, and therefore to focus on a particular group, type of person, or process (Bernard, 2017). The current qualitative study aims to understand better how nurses, who have previously had a painful postoperative experience, care for patients who are in pain.

According to Patton (2005), the validity, meaningfulness, and insights generated from qualitative inquiry have more to do with the information richness of the case selected and the observational/analytical capabilities of the researcher rather than with sample size. Generally, qualitative studies use one of four sampling techniques: purposeful, snowballing, convenience and quota sampling (Bernard, 2017), but perhaps the most important consideration should be the philosophical standpoint that is to be adopted in selecting the most appropriate one (Smith, 2009).

103 Phenomenological inquiries are concerned with the psychological phenomena of lived experience, have only one legitimate source of data informants and these are participants who have lived the reality that is investigated (Sokolowski, 2000).

That means that samples are selected purposively because they can provide an understanding of the specific experience. According to Smith (2009) participants should be chosen on the basis that they can provide access to a particular perspective for the phenomena under study as they represent a perspective rather than a population. When sampling, however, several aspects need to be considered. First, who among the participants has the specific experience and how quickly the researcher can contact them. Second, in what other ways the participants vary from one another and third, how much of that variation can be contained within an analysis of this phenomenon.

It should be noted that the selection of other sampling techniques, such as snowballing, that would allow reaching populations more easily is rejected as a there is little control over the sampling method. Quote sampling was also rejected since the objective of the current research is not the observation of sub-groups or comparison among sub-groups.

It is highlighted that in the current research, the groups were treated as homogeneous as possible according to the research-related factors. The members of the group were not treated as similar so that the researcher could examine in detail and depth the psychological variability group, by analyzing the pattern of convergence and divergence which arose.

3.2.2 Population of interest

The population of interest in this study is nursing staff who work in surgical areas of the Regional University General Hospital of Southwest Greece. The hospital has a capacity of 800 beds and an area of 75,000 square meters, and it is the largest hospital in the region of Peloponnese and one of the largest hospitals in Greece with over 10,000 operations performed, and over 300,000 cases handled each year.

The sample selection was based on inclusion and exclusion criteria, to increase the precision of the study and strength of evidence.

104

Nurses whose only post-operative experience is a cesarean section were rejected because of the positive feelings and emotions of happiness that parents experience on arrival of a baby, which was likely to be a distractor in the exploration of the research question.

3.2.3 Sample size

Morse (2000, 2001) has written that in qualitative research studies, the sample size depends on five things: the scope of the study, the nature of the topic, the quality of the data, the study design, and the use of shadowed data concerning participants speaking about others’ experience as well as their own. Phenomenologists are interested in common features of the lived experience.

105 Although diverse samples might provide a broader range from which to distill the essence of the phenomenon, data from only a number of individuals who have experienced the phenomenon and who can give a detailed account of their experience might suffice to uncover its core elements (Holloway, 2010). Typical sample sizes for phenomenological studies are small and range from 1 to 10 individuals (Starks, 2007). According to Whitehead and Annells (2007), a small sample size usually consists of between eight and fifteen participants, but they assert that it can vary widely.

Brocki and Wearden (2006) explained the importance of using the smallest sample and delved into the phenomenon. However, the literature reports on phenomenological studies based on nurses’ experiences and pain management sample sizes up to 25 participants (Ljusegren, 2011; Subramanian, 2011).

Taking everything into account, the researcher decided that the target sample size was selected to be between eight and fifteen participants or until saturation is reached. Saturation refers to the condition where analysis is undertaken contemporaneously, and no new categories or subcategories emerge (Morse, 1995; Polit, 2001).

3.3 Gaining access

Approaching participants usually required contacting the individuals or groups via gatekeepers or key persons, who control access to participants’ data and records. According to Van Maanen and Knolb (1985), access acquisition in the research sector is of crucial importance, and it must not be taken superficially.

Key persons are an essential factor that will be discussed in this chapter since they are defined as those people who attempt to safeguard the interests of others and so their opinion may have a positive or a negative impact on research (Boman et al., 2000). Holloway and Daymon (2010) highlight the significance of building strong connections with gatekeepers since they have the power and control of access and therefore can deny access even when the rest consent. In this research, junior and senior staff from the multidisciplinary team, mainly nurses, were considered key persons. People, whose duties involve the general management of the hospital, were regarded as gatekeepers.

It should be noted at this point that for the implementation and completion of any research, the formation and maintenance of good and constructive relationships with key-persons is

106 necessary (Waterman et al., 2001). For the current study, in addition to the access granted by the University Ethics Committee, an application was made to the Ethical Committee of the General Hospital to receive the necessary permit. To guarantee this permit, apart from the standard formal procedure that the researcher followed, she also made an effort to get acquainted with the key persons of the surgical wards and at the same time strengthen bonds with people who she had cooperated with in the past. A multi-level approach was required (Bonner and Tolhurst, 2002) and this prompted the principal investigator to build and reinforce trust in relationships with key persons which enabled her to cooperate with them in the research area harmoniously.

According to Smith (2009) when the IPA approach is applied, the researcher is part of the world that is being researched and a pivotal element to the whole procedure. For this reason, it is necessary to give a brief historical background of the current research. The researcher of the present Ph.D. thesis was employed as a full time registered nurse in Greek public hospitals. Initially, she worked as a research collaborator for the Nursery Department of the Technological Institution of Patras.

Due to the financial crisis and the socioeconomic instability in recent years in Greece, the researcher changed work environments either in search of better working conditions and prospects or due to managerial policies on employee scheduling and shift planning. Within nearly eight years as an active, full-time nurse, she has worked in the following areas: Emergency Department, ICU of adults, ICU of neonates, Surgical Clinic and Pediatric surgical clinic. The researcher was not working as a nurse in this hospital when the research took place. However, she was on good terms with several members of the staff, still working in the same positions, since she had cooperated with them in the past. Consequently, access to the key persons was not a difficult task. According to Coghlan and Casey (2001), pre-understanding of the framework by the researcher has a positive impact on the research process. Accordingly, the researcher of the current study, recognized, understood and respected the key persons' attitude towards the internal procedures of the surgical wards which helped her to formulate the study. Finally, the researcher kept a sufficient distance from the surgical wards where the study was conducted to understand the participants' painful post-operative experience in depth (Bonner and Tolhurst 2002).

107 To negotiate access, the researcher arranged via email to meet with the head nurse of the surgical department. The response was immediate, and the meeting was very constructive. Verbal permission was given for the researcher to contact the head nurses of the surgical wards and explain the research procedure. To support the research, the head nurse contacted the surgical ward managers to inform them that she had agreed to the research aims. A formal e-mail was then sent to the head nurses with the participant information sheet attached.

Several meetings were arranged between the researcher and the surgical ward managers to reinforce the study and the participants' requirements. The distinction between the aim of the research and the aim of the health care services was regularly reinforced to ensure that the operation of the ward would not be disturbed by the study and that the service would always be given priority.

Additionally, the researcher pointed out the benefits that the study could bring to the surgical wards making specific reference to the more effective assessment and management of a patient’s pain. The researcher made it clear that the benefits would not be discernible immediately but their effects tend to be long term.

Moreover, to improve access to the surgical wards, the researcher provided the head nurses with a detailed written information sheet which defined the objectives, the nature and the duration of the study as well as the sample taking methods, anonymity and confidentiality issues. The purpose was to increase the likelihood that the surgical ward managers would participate in identifying nurses who fit the inclusion criteria. Parahoo (2006) emphasizes that the key persons must be convinced that the researcher is both able to cope with the study and is also trustworthy. Informal discussions were productive and enabled the development of a trusting relationship with the head nurses, who despite their work obligations and high work, committed themselves to the study. It was evident that the surgical ward managers put a considerable amount of work in promoting the project to their nursing teams and in trying to identify nurses who fit the inclusion criteria.

In conclusion, concerning the environment, policies and the staff, the researcher was able to approach the people who would give her access to nurses who fulfill the criteria set by this research to improve the quality of the scientific data.

108 Table 3.1. The process of gaining entrance into surgical wards

Gaining Access

Formal Access Informal Access

 Formal communication  Followed formal ways of was used through email communication: Personal and and official calls. telephone communication of the Pre  The advantages of research researcher with well-known were highlighted. colleagues. Entry  Issues of anonymity and  Assurance on confidentiality and confidentiality were anonymity issues. Several personal, stressed. unofficial visits of the researcher that did not seem necessary.  The researcher conformed  Redefined cultural practices, values to cultural practices, and norms of surgical clinic. norms, and attitudes of the  Adapted to a language comfortable During surgical ward. and familiar to the interviewees. fieldwork  Addressed them formally.  Needed to obtain permission to tape  Needed to obtain record interviews. permission for tape recordings and interviews.  Sent a formal thank-you  The researcher personally expressed email immediately after her appreciation and thanked them After completing the process. for the collaboration. fieldwork  Verbal appropriate adjusted feedback to maximize the benefit of the study Getting Retained good rapport with  Familiar with the research site made the research site for future it easy to regain access. back needs.

3.4 Connection with participant

The relationship between the researcher and the participant is one of the main challenges that a researcher had to face to develop and maintain a positive atmosphere during the interview and observation (Rubin, 2005). The researcher dedicated time and space to key people (head nurses) of surgical wards to approach nurses who had had a personal, painful experience.

The researcher had left her contact data and the participant information sheet in every ward. The researcher frequently visited the surgical wards to make herself known in all of

109 the hospital wards and made herself available to answer any queries that arose. The researcher introduced the project to the nurses either by sending e-mails to them or by organizing a short presentation in the department with the aid of the head nurse to explain the aim of the present study. The nurses were free to ask questions about the project and read the participant information sheet. The researcher employed a high level of interpersonal skills to establish rapport with participants to urge them to participate in the study on a voluntary basis (DiCicco-Bloom, 2004). There was no coercion from the researcher or senior staff. The researcher was friendly and warm towards the nurses, showed personal concern and respect for their situation and a commitment to embrace the truth of their painful post-operative experiences.

According to Whall (2006) time, place and situation were considered by the researcher in advance to avoid practical complications such as disturbing participants from their job or approaching them at inappropriate moments. Daymon and Hollway (2010) argue that being willing, flexible, and adaptable as a researcher is a good start to create a positive relationship to introduce the details of the project as to why this is done and what the benefits will be. Some openly expressed their will to participate during the presentations and others e-mailed or telephoned to show interest. All the participants were informed that they could withdraw from the study at any point and have their data retracted if they wished.

Once they had expressed their interest before the start of the project all participants gave their written consent.

3.5 Data collection

When undertaking phenomenological studies, thought has to be given to the method of data collection (Oiler, 1982). Phenomenological studies strive to ensure that data are free from preconceived notions, expectations, and frameworks. Polit and Beck (2010) emphasize that the purpose of data collection is to extract information of unique quality and therefore IPA was considered most suitable for this study. IPA mechanisms give participants the opportunity to:

i) freely express themselves about the post-operative experience

ii) develop their ideas and

iii) express their worries and emotions.

110

According to Smith (2009), IPA data collection tends to utilize in-depth interviews, reflective diaries, and observation techniques. He also suggests that other approaches such as participant observations could be used to collect data but under specific circumstances and to discuss with participants about their experience after the observation. Mackey (2005) suggests that pain assessment and management are complex issues that embrace physiological, emotional, cognitive, and social dimensions. With this in mind, it is appropriate for this study to collect in-depth data about the subjective view of nurses’ post- operative pain experiences and their post-operative pain management practices through observation and interviewing. This approach enables the researcher to explore the phenomenon not only from two different perspectives but at two different times, enhancing the creative and reflective aspects of it.

3.5.1 Data collection methods

The interpretative phenomenological approach gives the opportunity to the researcher to use a variety of methods to investigate a phenomenon, in this case, the personal, painful post-operative experience of participants, as a whole and from different viewpoints. In this qualitative study, observation and semi-structured interviews were used as shown in the diagram below. A reflective diary was also employed throughout to help establish links between the two forms of data and to ensure a complete understanding of the issues once time has elapsed.

111

Figure 3.1. The participants’journey

3.5.1.1 First phase-Observation

The observation approach adopted in the present study was based on the principles of hermeneutics as well as ontological phenomenology. More specifically, according to Gadamer (1989), the observation could be compared to watching a theatrical play as he points out the need for active participation by the observer and guards against distancing from presuppositions made during the observation. The role of the researcher was that of a participant observer since according to Gadamer (1989), any effort to understand the phenomenon that is being studied presupposes a need to open ourselves up to the possibility for different interpretation to be attributed to notions than those held previously. In his book Ethics of Play, Gadamer (1989) points out that being open means allowing art to speak to us, to communicate with us, affect us and even to transform our way of thinking. For this reason, Gadamer (1989) considers it necessary to keep ourselves in the game since he considers this to be the only way to protect ourselves from the ‘tyranny’ of our prejudices which can lead to randomly elicited conclusions while interpreting the results. Thus, throughout this process, the researcher's prejudices have to be controlled. By

112 keeping a certain distance, the presuppositions are not tested, and as a result, one does not risk the possibility of being wrong. By being active, the researcher was able to question presuppositions and to suspend their validity. According to Gadamer (1989), this does not imply that we forget our ideas and presuppositions, but we are open to new messages that we must preserve to enhance our understanding. Prolonged involvement as suggested by Lofland (2006) will allow the researcher to gain an in-depth understanding of how the nurses manage postoperative pain.

Several studies employed observation as a means of data collection (Zeitz, 2005; Dihle, 2006; Bolster, 2005; Bandurakada, 2011; Herr, 2011; Manias 2006). According to Manias (2002), observational studies may provide an effective means of describing some of the complex issues that influence pain assessment and management. The researcher was based on previous studies to examine the validity of the research tools to make the research data more robust. During the research study process, the researcher noticed gaps in the information relevant to observation. For example, some researchers did not mention the observation program they followed, a practice which according to Bandurakada (2011) reduced the validity of the study.

On the other hand, studies like those of Bolster (2005), Zeitz (2005) recorded the program in detail. Some of these details included the way they developed their decision-making according to the observation program they followed, the tools they utilized as well as the role they had during the observation of the patients’ post-operating pain. In this study, the researcher used the ideas of Bolster and Zeitz to make it easier for the reader to understand the frequency and the variety of nursing care approaches as well as the interaction among nurses and patients while applying these practices. Besides, the researcher's main tool of observation was the approach of Dihle et al. (2006) whose main focus was the nurses' actions concerning post-operative pain such as pain assessment, treatment to alleviate pain as well as evaluation of the above procedures and the circumstances that affect them. The main reason why the above tools were selected is that they were considered the most suitable for achieving the aims of the present study.

The first phase of the data collection process is an attempt to explore the post-operative management practices of nurses with post-operative experience. The researcher's rationale was to observe the participants' behavior before the interview with the purpose of ensuring 113 that the participants' actions during the observation were not influenced by what was discussed during the interview. Also, the factors which nurses took into account in decision-making, i.e. when administering analgesia to post-operative patients, as well as whether self-reported actions may differ from what occurs in actual clinical practice were identified.

Before the observation, a conceptual method of recording data was created based on the existing literature. According to Gadamer (1960), it is crucial for the researcher to have a clear perception of the research question to be able to recognize whatever is new and anything that is in accordance with his initial understanding. Kvale (1987) maintained that this increases the validity of the research. The researcher attempted during the observation to emphasize the use of appropriate language, i.e., to find the right word to express what she sees and articulate the content of the image to reveal the substance. According to Naden (2010), hermeneutics is inextricably associated with the language and the written word. Gadamer (1960) emphasizes that observation is a wordless process where it finds its true power through writing.

The current hermeneutic observation research aimed at a better understanding of the nursing staff's behavior and how their personal post-operative experience influenced their behavior towards patients' postoperative pain assessment and management.

Since the key to a successful observational study was the quality of the data collected, the researcher adhered to principles which according to Gadamer (1960) had a pivotal role in it.

Firstly, the language which was used for each field note entry was identified. In other words, the use of parentheses, quotation marks, or brackets was defined to reflect the actual field situation in written form.

Secondly, the researcher made a verbatim record of what each person said to distinguish ‘native terms' from ‘observer terms.' It is important to note that the researcher neither generalized nor condensed or abbreviated details, but instead analyzed thoroughly and explained them in as much detail as possible.

In the current research, the observation that took place used an interpretative perspective under which the researcher had to continuously examine her mental state, namely mood thoughts and emotions.

114 According to Heidegger (1997), through mood and emotions, the researcher understand not only themselves, the world and others, but also the way they relate to each other. In this thesis, this ‘inner look’ was considered necessary to enable her to reach a deeper understanding of the emotions and dispositions of nurses during their actions. Heidegger (1997) also emphasized that mood is dependent on what is to be done at that moment, that is, the essence of things rather than the interference and the presence of other people.

The researcher was quiet, discreet and did not rush things during the observation to preserve its interpretative nature. She allowed silence to prevail in the room to concentrate as much as possible on the participant and to distinguish the essence (Nåden, 2010).

According to Naden (2010), speech was a factor that could discourage the researcher from seeing the person and what happened within a general perspective clearly as it distracted his/her attention and did not focus on the prevailing situation. Additionally, the researcher's reduction of internal noise helped to discard what was seen and to integrate into the observational notes.

Observation was performed before the interviews and in the surgical ward where each participant worked. The observation times covered the high activity morning periods (07:00 - 15:00), change of shifts, evening periods (15:00 - 23:00) and quiet night shifts

(23:00-07:00). Some of the observations were made during the weekends. The weekend days were included because the conditions and pressure exerted on the participants are higher during the weekends due to reduced staff numbers. Thus, it was considered an excellent opportunity to evaluate the nursing staff's behavior and reaction to patients' pain management under even higher pressure. Moreover, the decisions to manage or resolve tensions and crises that were created during the weekends were recorded too.

The active role of the researcher during observation helped to establish trust between the researcher and the participants through small actions on behalf of the researcher. These actions such as helping make the beds and transporting the trolley during hospitalization or in an emergency enabled the researcher to be close enough and observe the interaction of the participants with the patients and the health care team. In this manner, she avoided causing embarrassment or inconvenience to patients and nurses (Adler et al., 1994).

115 The notes were taken in written form and in such a way so as not to intimidate the participants. Full descriptions were written away from the research site within an hour from the observation period.

3.5.1.2 Second phase-Interview

Qualitative research frequently relied on interviewing as the primary data collection strategy and was an established method of collecting data about the human experience and more specifically about nurses' personal pain experiences (Aziato et al., 2016). Interviewing people in person was the best way to find out about their thoughts, feelings, and beliefs (Aziato et al., 2016). Information about past activities and events or facts about attitudes and opinions could be gathered through interviews (Whittemore, 2006).

3.5.1.2.1 Choice of interview method

There is a variety of interview strategies available that take many forms with some being very informal while others are more structured. The researcher has the option to choose among unstructured, semi-structured or focus groups (Fontana et al., 2005).

Unstructured interviews were not adopted in the current research because firstly they would be time-consuming as they take a long time to conduct. Secondly, they were not considered to be reliable enough because they were not standardized. Thirdly, there was always the risk of diverting from the topic and leading the discussion away from the goals of the interview. Finally, as a newcomer to IPA, the researcher did not have the required experience to conduct such interviews.

Focus group interviews were also rejected by the researcher even though they allow for multiple opinions to be expressed and intimacy to be established. One reason for the rejection was the sensitivity that was demonstrated by participants in sharing post- operative experiences and their demand to remain anonymous. It would thus be difficult to share their experience through group interviews. Another reason was the difficulty to get all the participants in a group session at the same time and place. In addition, members of the group tend to bias the discussion by being more dominant than others.

Moreover, these interviews require a highly skilled researcher to manage the discussion allowing at the same time unbiased exchange of ideas and information as well as control the nature of the information provided (Dilshad, 2013). Another reason against was that it

116 was not the purpose of the researcher to focus on revealing similarities and differences among the participants. Finally, focus groups could not provide valid information as to how things changed over time (Gibbs, 1997). The nature of the data produced in such interviews made data analysis more difficult. After all, individual interviews were easier to be arranged, controlled and transcripted.

The second phase of data collection was therefore based on semi-structured face-to-face interviews. Such interviews were deemed most appropriate for effective implementation of the research goals due to the fact a lot of qualitative research uses semi-structured interview material (Bolster, 2009; Leegaard, 2008). More specifically, semi-structured interviews aimed to describe and explain the post-operative pain experience of the participant as well as their thoughts and feelings since it is the most appropriate way to collect data of such nature. Another reason in favor of conducting such interviews was that it offered the participants the chance to discuss an issue such as painful post-operative experience in great detail with rich and original expression rendering in this way the data more reliable. Moreover, this type of interview created a more relaxed atmosphere to collect information mainly due to the fact that they were able to have a conversation with the researcher rather than merely complete a survey form. As a consequence, it was easier for the participants to grow feelings of intimacy and trust and thus provide more accurate data. Finally, the semi-structured strategy gave the researcher the ability to analyze and evaluate shared information to understand the participants' post-operative perspectives and experiences. Because the participants were not obliged to follow a specified sequence in responding, there was a more natural flow in the conversation and the sharing of opinions. Although there were an interview schedule and pre-determined areas to cover, in reality, the interviews tended to start using data from the observations which were deemed to be complete once all the observational and interview topics were covered. (Bernard et al., 2002).

3.5.1.2.2 Question development in the semi-structured interview.

As Polit et al. (2010) argued, the semi-structured interview offered flexibility to the researcher to elicit the data from individuals according to the specific research aims. The semi-structured interviews in this study were organized implementing a set of predetermined open-ended questions (Appendix 5).

117 Hesse-Bider (2008) argued that a semi-structured interview with open-ended questions encouraged participants to talk freely about their experiences. As the conversation evolved naturally, the participants provided adequate information (Groth-Marnat, 2009). In-depth interviews allowed the participant to delve into both social and personal matters (Whittemore, 2006).

The use of motives seemed to be very helpful in more complex or abstract questions asked by the researcher. In that way, the participants understood the exact nature and purpose of each question. Finally, these semi-structured interviews enabled the researcher as a novice in this process to improve and maintain good communication with the participants, reduce anxiety and make the process more comfortable. Consequently, the researcher was convinced that scheduled semi-structures interviews were the most appropriate tool for data collection.

Following Smith’s (2009) recommendations, the creation of the program helped the researcher to follow a logical succession of questions. Thus, the initial areas covered by the interview schedule were the elucidation of painful post-operative experience, relationships with nurses and health care providers as well as the clinic's policy on evaluation and management of acute post-operative pain.

It is worth pointing out at this point that the researcher did not directly address the research question but asked questions to identify the broad state of the phenomenon. The most sensitive and emotional questions followed in the middle of the interview. Moreover, the design of open-ended questions was extensively discussed with researchers' supervisors so that the participants could share their own experiences without allowing for researcher's point of view to affect or guide the interview.

According to Smith (2009) developing such schedule was a proper way to prepare the content of an interview to facilitate discussion and set the tone for a loose dialogue that encouraged the participants to talk further.

During the process of designing the schedule, the researcher had to consider any difficulties that could arise during the interview, such as approaching sensitive issues for the participant or the emotions and pain experienced during the post-operative period.

118 Moreover, the preparation of the schedule enabled the researcher to cater for participants who were less talkative requiring a more structured interview.

3.5.1.2.3 Building rapport

The stages of rapport have been described by lots of researchers (Miller et al., 2003) and include apprehension, exploration, cooperation, and participation (Spradley, 1979).

The aim of the first stage which is apprehension was to enhance and support the participant to talk (Bell et al., 2016). Warren (2009) highlights that open-ended questions should reflect the nature of the research and should not be threatening. In addition, Johnson (2002) argues that questions should be clarified whenever needed without leading the participant who should be given time to think on how to respond. During the interview, prompts and process signals were used based on the same words that the participant used to avoid misunderstandings.

The researcher elaborated on the details, achieved clarity, stayed close to the lived experience, acknowledged what the participants said, did not argue or criticize and allowed for silence. Furthermore, the body language didn't convey negative judgments but only interest in what the participants said (nodding, smiling, eye contact) (Rubin, 2005).

However, Starks (2007) noted that the researcher and the participant have to understand each other, mean the same thing and speak a common language. The researcher aimed through an interview to make the participant share as much as possible of his/her knowledge, feelings, thoughts, experiences by using his/her own words (Johnson, 2002).

The stage of exploration contained in-depth interaction. This process was accompanied by learning, listening, testing and a sense of bonding and sharing (Dicicco-Bloom, 2004). According to Tewksbury (2006), at this point, the researcher had the choice to ask more sensitive questions and made the in-depth interview an informative encounter.

The researcher followed Smith's (2009) recommendations clarifying to the participants that there is no predefined agenda but that instead, she is interested in them and their experiences. The researcher specified that there were no right or wrong answers and that the researcher would not talk much during the interview as she was there to listen to as many details as they wished to share with her.

119 The next stage was co-operation; a stage which required a willingness from the participants to share their experience, respond to questions as well as mutual trust and understanding (Spradley, 1979). To accomplish that, the researcher had to dispel uncertainty and doubt, encourage unity and familiarity and make sure that everyone involved shared the same goal. The researcher spent time carefully listening to the participants completing their thoughts without jumping from one topic to another. Once trust and understanding were established, both the researcher and the participants felt more comfortable to share personal information, ask questions and participate more actively, which is the last stage in the rapport process.

At this stage, the participants' active involvement is of a high priority mainly because it is closely related to co-operation (Spradley, 1979). In this way, the participants become observers themselves, and they find it easier to reflect on their experience more accurately and in more detail. Moreover, periods of silence were an opportunity to give space and time to ask the next question.

According to Smith (2009) to obtain quality data, it is vital to built rapport with the participants. It is an essential component of the interview and a way to develop a positive relationship during semi-structured interviews. It involves trust and respect as well as establishing a safe and comfortable environment for sharing personal experiences and attitudes as the participants witnessed them.

3.5.1.2.4 Interview/participant dynamics in rapport building

Another feature that influenced the interview was the rhythm and dynamics that developed during it. More specifically, in the beginning, there were narratives, comprehension concepts and comprehension about the post-operative experience. As soon as the participants familiarized themselves with the process, the interview moved from a general description to specific emotional situations and from the surface to deeper levels of consciousness (Kvale, 1996).

The researcher tried to create interviewer-participant dynamics that were positive, relaxed and mutually respectful (Spradley, 1978). The purpose was to prompt the participants to talk freely, openly and honestly about their experience and to accomplish that they first had

120 to feel comfortable with the researcher, trust her, feel secure about confidential matters and be convinced that the researcher took a real interest in their stories (experience).

The dynamics of the interview that the researcher experienced made her quick to notice when the participant was ready to share their deeper thoughts and feelings, posing minimalist questions such as why? How did you feel? How? Tell me, what you think? etc.

Furthermore, what was observed in some interviews was that for some participants it was challenging to focus and talk about themselves, and they initially preferred to speak generally and impersonally. In these cases, the researcher encouraged the participants to share their own stories about what had happened to them and reminded them repeatedly that the interview was about sharing their own experiences, not other people's experiences (Kvale, 1996).

To understand the reality of the participants and enter their world, the researcher repeated the words and phrases used by the participants to confirm whether what was shared by the participants was fully understood. There were times when the participants themselves made corrections. The researcher sometimes needed to repeat the question she had asked or provide explanations.

Another key feature to interview dynamics was the emphasis the interviewer placed on the participants’ perspective. According to Kvale (1996) emphasizing the participants' perspective meant to consider the participant as an expert but avoid having the participant interview the researcher as well as listening very carefully to their stories while remaining neutral. The primary concern was to minimize the risk that the participants would change their responses to please the researcher or create false impressions instead of describing their perspectives.

In cases when the participant was emotionally charged, the investigator took into account Smith et al., (2009) who stressed the moral responsibility of the researcher over the participant. The researcher had to check the status of the participant to see if he or she was able to continue, wished to change the subject or re-enter it later and even proposed taking some time off before resuming the interview.

121 3.5.1.2.5 Interview procedures

To collect the data for this study, the researcher employed one-hour interviews since most qualitative pain studies used sixty-minute interviews (Aziato et al., 2016) which were considered adequate for the study’s goals.

Smith et al. (2009) recommended individual interviews, given the sensitivity of the subject. The participants were initially asked where they would prefer for the interview to be conducted. Interviews took place in a private office, which was a quiet, safe and comfortable environment away from any external disturbances.

The interviews were digitally recorded with the participants' permission. The interviews were scheduled to take place within a 24-hour period after the third observation and at a convenient time for the participants to achieve the study objectives as they played a key role in providing and maintaining quality-rich data. That would not have been feasible if there had been long gaps between the observation and the interview (Smith et al., 2009).

The interviewer rejected the option to hold the interview immediately after the observation because, according to Wheatley (2006), interviewing time as well as the quality of the data decreases due to the physical and mental fatigue of the participants.

At the end of the interview, the participants did not express any dissatisfaction with the process or mentioned something that put them in a difficult situation. All participants were very talkative and eager to share their emotions and feelings.

3.5.1.3 Reflective diary

The use of the reflective diary by the researcher was considered an appropriate tool as part of the data collection. In this way, a further understanding of the painful post-operative experience of the participant would be achieved.

Other researchers like Bandurakada (2011) used reflective diaries during interviews and observations. Several studies that used observation and interviews have incorporated reflective diaries to establish the primacy of the knowledge and maximize the full learning from both methods (observation and interview).

122 According to Bassot (2012), the researcher recorded any important event immediately, usually after a process, in the reflective diary so that her perception would not be altered in any way. Thus, during the data collection period, the reflective diary was written at least daily, and sometimes multiple entries were recorded in one day, especially during the observation period.

The use of the reflective diary enabled the researcher to put together her opinions, thoughts, and feelings as well as observations of participant behavior and emotions. It was a means to ensure that the researcher reflected on the activities, place, and people and how they related during each observation and interview session.

In addition, the researcher was able to compare and contrast her thoughts with evidence she gathered by using both methods. Most importantly, it helped the researcher analyze data more effectively and in more detail as she could record observations that were not verbally articulated by the participants.

Developing reflexivity allowed the development of dialogue and finally built reliability (Lincoln et al., 1985). As soon as the researcher came to concrete decisions concerning the methodology, she considered it essential to keep notes during and after the observation and interview process (Lincoln et al., 1985). The researcher kept notes on what the world, the phrases and the proposals of each participant meant to her, but at the same time, she tried to record what they meant to the participant as well.

3.6 Data analysis

According to Kvale (2007), data analysis is part of the research process and not an isolated step. Unlike quantitative analysis, qualitative data analysis is not concerned with statistics or numbers, but with the analysis of words, codes, themes and patterns in data (Morse et al., 1995).

There are several analysis techniques described in the phenomenological research literature. Data analysis is a procedure through which the researcher attempts to reduce, organize and give meaning to the data collected by maintaining its wealth (Hammersley, 1992). In particular, IPA focuses the investigator's attention on the more in-depth

123 understanding of participants' postoperative experiences and the meaning to which they attach to the experience they have gone through.

However, the outcome was based on the analyst's thoughts (Smith et al., 2008). The above was accomplished through a set of processes and strategies that will be clarified later in this chapter and consist of a repetitive and inductive hermeneutic cycle, namely the transition from the specific to the general and from the descriptive to the interpretive (Smith, 2004).

In the current research, the initial stage in data analysis involved transcription followed by the application of the hermeneutic cycle steps.

3.6.1 Transcription

The IPA methodology used in this study, according to Smith et al. (2009) required the recording of the data collected, both from observations and interviews. Thus, immediately after the data collection, the selective process of transcription began.

According to Smith et al. (2009), IPA analysis aims to interpret the content of the participants' data and does not require a detailed record of the prosodic aspects. In particular, the investigator did not record the exact length of pauses, sounds such as "eem," hum or other sounds that could be recorded from the environment.

Instead, pauses and punctuation marks were recorded and organized in paragraphs to make the text in the interview as accurate as possible. Initially, the interviewer heard the recording of the interviews once and then proceeded with the transcription word for word in Greek. Moreover, verbal expressions like laughter, hesitation, crying, anger, and any emotional load were transcribed; both during the observation and during the interview. At the end of the transcription, each interview was listened to by the researcher again to ensure the accuracy of the data and to avoid any omissions.

All data and interviews were conducted in Greece, and the interviews were held in the Greek language. Important issues were considered as regards the transcription of data since the researcher is not a native speaker of the English language. The recording and analysis of the data were made by the researcher in Greek, and a professional transcriber had to be hired for translation to English. The researcher considered it necessary, however, to record

124 and analyze the data in Greek so that vital information (Carretta et al., 2015) would not be altered or lost in the translation process.

Moreover, the researcher followed this strategy so that the style and meaning of the words used by the participants were comprehensible. For example, the participants sometimes made use of idiomatic collocations, which were impossible to give the full meaning of in another language with precision. For the above reasons, the texts were translated into English by a professional translator but in collaboration with the researcher to ensure the validity of the study as far as possible. According to Carretta et al. (2015), it would be ideal for the researcher to have a double role, the one of the researcher and the other of the translator which would greatly enforce the validity of the study. This process was a challenge for the researcher who, herself, confirmed the translation with another professional translator and once again, checked the audio recordings which were in Greek, the transcription in Greek and the translation into English.

3.6.2 Hermeneutic Cycle

In this study, the six steps taken were as follows: reading and re-reading, initial noting, developing emergent themes, searching for connections across emergent themes, moving to the next case and looking for patterns across cases.

Step1: Reading and Re-reading

After completing the transcriptions, the first stage of the IPA-based data analysis involved reading and re-reading the text (Smith, 2009). While reading the interview transcriptions, the researcher chose to listen to the interviews at the same time to gain a deeper and more comprehensive understanding of the participants' experiences.

Through this process, the researcher was not led to hasty conclusions but delved into the intense and painful post-operative experiences of the participants as well as the interesting observations that were recorded. Over a period of time, ideas and possible links began to be generated, which included aspects from both the interviews and the observations.

Step 2: Initial noting

Following Smith’s et al. (2009) approach, the researcher at this stage familiarised herself with the text, and this helped her identify specific ways in which the participants thought

125 and expressed their personal post-operative pain experiences. The researcher proceeded to a complete set of detailed notes and commentary on the data and did not separate the text into individual bits of meaning by commenting afterward.

Concurrently, the researcher focused on a more interpretative approach to the data as she tried to understand how and why the participants had these concerns about the procedures followed regarding pain assessment and management, the relationships with colleagues and patients and finally the values and principles that govern them. For a deeper understanding of these concepts, Reid et al. (2005) considered it necessary to examine the language used by the participants, the context of their concerns through the environment in which they live, and the clarification of abstract concepts.

The researcher considered it optimal to use the above analytical procedure in the first phase of detailed analysis to delve into the participant's world and then proceeded to a more in- depth analysis. In particular, the researcher made descriptive comments in the text such as keywords, phrases or explanations that the participant used and had an impact on his/her world. The interpretive cycle provides this possibility, that is, a dynamic relationship between the part and the whole. Thus, according to Larkin et al. (2006), the interpretive cycle follows a circular-spiraling way of thinking rather than a linear one. That allowed the researcher to examine the concepts of words when viewed within the whole of the sentence since the meaning of each word depended on the context and overall phrasing.

As described by Charlick et al. (2016) to understand the given part, we examine the whole and to perceive the whole we focus on the parts. Thus, the researcher kept notes of the things at their nominal value, that is, the painful post-operative experiences of the participants and the effect they had on their behavior towards patient's postoperative pain assessment and management.

Furthermore, there were linguistic comments such as tone of voice, laughter, repetition, and pauses as well as metaphors, similes, analogies and comments that accompany the description with conceptual contexts. The third level of commentary focused on conceptual comments. At this point, the researcher spent a lot of time discussing and analyzing the ideas that emerged.

126 In some cases, the researcher practiced a personal reflection on initial noting on her thoughts and feelings she had because of her professional background. According to Gadamer (1990/1960), this was necessary because of the researcher's pre-understanding of the topic. However, this process was limited to the researcher using herself to understand the participant and not the opposite, as the analysis concerned the participant.

The researcher made notes and comments as to how much the participants have reconciled with reality. According to Reid et al. (2005), this kind of comments can deepen and reinforce the interpretative process. The interpretation that took place in this study resulted strictly from the participants' words and was not influenced by the researcher’s preconceptions.

Step 3: Developing emergent themes

The third stage of the analysis focused on the emergence of themes (Eatough and Smith, 2008). In the previous stage, the researcher made exploratory comments based on field notes, interview transcripts narrowly focusing on the participant's experience. In this stage, she reduced the emergence of details of the data. To prepare the themes from the research data, the researcher started working with it through careful reading which helped her establish connections and understanding of it. In addition, the researcher employed abstraction by creating categories from the complexity of the data and made sure that the emerging themes were explored both from an empirical (the data) and a conceptual (analytical) perspective. The above involved the fragmentation of the narratives, a process, which at times, felt awkward yet necessary for effectively developing emergent themes and sub-themes. Through this process, the researcher tried to find patterns in the data and identify regularities or irregularities to highlight the connection and the relationships among pieces of data, thus formulating a set of themes. Once again we observe how the interpretive cycle is applied, i.e., from the general to the specific and vice versa. Also, the researcher believed that emergent themes evolve from data gathering and synthesis hand in hand with productive reflection and interpretive insights.

Step 4: Searching for connections across emergent themes

The fourth stage, according to Reid et al. (2005) and Smith et al. (2009), includes the search for links between the issues developed at the previous stage. The researcher grouped them based on conceptual similarities.

127 The traditional pen and paper method was used to write comments and topics in the margins, allowing themes and the sub-themes to be grouped. In practice, the researcher placed a large piece of paper where she recorded on the one side of it the issues that represent similar and related perceptions and opposing matters on the other. Such design helped the researcher highlight the most critical aspects of the participants' narratives. According to Smith (2009), the use of various strategies for organizing issues was based on the researcher’s criteria as to how functional, creative, and cost-effective each strategy was in advancing the analysis to a higher level. Specific emergent themes were set aside for later review as they were not relevant to the research question at that point.

Once this process was completed the researcher engaged in reflective scrutiny and retrospective analysis on his analytic work.

Step 5: Moving to the next case

The fifth step involves the researcher's transition to the next participant and the resumption of the process mentioned above. The researcher resumed the process on new data based on the IPA guidelines. That helped the researcher to develop new themes in the next case with its own terms as far as possible by bracketing the ideas that came from the previous analysis. According to Larkin et al., (2006) the emergence of new themes from the subjects that derive from each participant is an essential capability of the mechanism.

Step 6: Looking for patterns across cases

The last step involved searching for patterns across cases examining possible connections and interrelations (Smith, 2007). This process helped the researcher to pinpoint similarities and differences to order, group themes and highlight their most essential features always in accordance with the IPA procedure.

In Fig.3.2 the seven steps of IPA analysis are depicted. Moreover, examples of the development of themes from the data are illustrated in the appendix.

128

Figure 3.2. The six steps of IPA analysis (Charlick et al., 2016).

3.7 Ethical issues

This section describes ethical issues and ethical principles followed by the researcher for the implementation of this study. These issues and principles were following the ones described in the Helsinki Declaration which was approved by the World Medical Association (WMA) (2013) in 1964 and provides the guidelines for ethics in the field of medical research. Such issues and principles involved respect for the individual, their right to self-determination and to making informed decisions regarding participation at any stage of the study, confidentiality of information and the vulnerability of the participants. Finally, the principles described in the Helsinki Declaration take precedence over the interests of science and society and obviously of this research.

In addition to the above guidelines, this study was assessed and approved both by the University of Manchester (reference number 13074) and by the Ethics and Ethics Council of the hospital, where the current research was conducted.

129 3.7.1 Consent

According to Silverman (2000) approval concerns the right of the participants to be clearly and extensively informed by the researcher so that they autonomously and with their own free will decide whether they wish to participate in this study or not.

Therefore, the researcher gave a clear and legible information sheet and consent form at least a week in advance, according to the ethical committee’s requirements. Also, the researcher gave verbal explanations to the participants about the purpose and conditions of the research (Hunn et al., 2009).

Lofland et al. (2006) highlighted that it was important for people to have the right to decide whether or not they wished to be recruited rather than urged and obliged to take part in the research against their will. This may happen because of the apparent higher status the participants think that the researcher probably poses, so Lofland et al. (2006) underline the importance of providing adequate information regarding the scope of this research, its goals and the procedure as clear as possible without using coercive language at any time. This practice was crucial to building fidelity, that is the trust bond that must exist between the researcher and the participants (Parahoo et al., 2006). Therefore, it was important that people understood that choosing not to take part in the research or deciding to take part at a later time or even withdrawing would not affect their relationship with the co-workers, the researcher or the patients (Dimond, 2008).

It was also clearly communicated that they had the right to refuse to answer a question or part of it as well as to exclude any part of their interview they wished, making sure it would not be used in the research (Patton, 2002).

After having completed the data collection, the researcher communicated with the participants to receive their approval and to ask if she could move on to analyze the data. Everyone consented, so no changes or alterations in the data were reported.

Before the beginning of the observations, all the participants signed a consent form. Moreover, before the observation period, the patients were asked by the specific nurse participants for permission to be observed by the researcher while they were performing

130 their usual routine. Both nurses and patients were informed that there was an observer among the caring team.

As far as the interview process was concerned, the researcher reassured the head nurses that the participants would be safe and emotionally protected throughout the interview process. In case intense emotions emerged, the researcher was prepared to avoid reference to particular facts or even to discontinue the interview. This kind of approach was considered necessary to point out to key persons the ethical background on which the research would be conducted. Although the Head nurse might believe that the interview process that is followed during the study would be a harmless procedure, the researcher considered it necessary to dispel any doubts as for the protection of the participants. The researcher reassured the key persons for any potential arguments that this research could sparkle with the hospital institutions and also that any adverse incidence would reveal the system's deficiencies and would help towards improving it. Additionally, the researcher discussed with the participants the time of the interview in order not to cause any problems in patients' care procedure or to other nurses or in the running of the ward.

Another important factor in research was fairness. Everybody had a fair and equal chance of taking part in the research. But it was essential to have a trade-off between societal, research and participant benefit.

3.7.2 Confidentiality and Anonymity

Concerning confidentiality, the researcher protected the nurses’ data as none of the information they provided was miss-quoted or miss-represented. In addition, every effort was made to preserve the nurses’ anonymity as described below in detail.

During the observation, it is evident that due to the nature of the procedure and the limited staff in the surgical wards, it was challenging to maintain full anonymity during monitoring. However, the researcher was as discrete as possible in her role as a participant observer and managed to explain to the participants that according to the invisibility cloak illusion theory (Boothby, 2018) people tend to observe others more than others observe them. In other words, they are less likely to be observed by others more than they observe others themselves which made the participants feel more comfortable to perform their routine as usual without bias.

131 However, the researcher needed to also ask for permission to use anonymized quotes - pseudonyms –since quotes can be used to recognize the interviewees directly. So, the researcher changed some details to safeguard the privacy of the participants (Spradley, 1980). After the data analysis was completed, the participants were provided with a complete transcript of their coded interviews with emergent themes (Flick, 2006). The participants verified whether the codes and themes matched their answers.

The sampling method used also validated the conformability of data (Silverman, 2000). All the data from interviews and observations as well as the field notes were locked in a locker when they were not in use. Access to this locker was allowed only to the researcher. The files would be destroyed twelve months after the completion of this Ph.D.

The researcher was well aware that specific ethical dilemmas could arise during the study with the most common being ‘guilty knowledge,' in which the researcher was privy to confidential information (Chapman, 1999). Another possible dilemma included the ‘dirty hands,' a situation in which the researcher was able to notice instances of unethical or dangerous care (Chapman, 1999). For this reason, all the participants were made well aware on consenting that if the researcher saw anything of this kind, she would report it to their manager and that it could, in turn, lead to disciplinary proceedings. However, such dilemmas did not arise during this study apart from a few persistent inadequacies of the health care system in Greece.

3.7.3 Assessing validity, trustworthiness and quality of the study

Assessing the validity and trustworthiness of a qualitative study is a subject that was extensively discussed (Paley, 1998; Varela, 1996). Qualitative researchers argued that the validity of qualitative research should be assessed by the criteria that governed it. The researcher found it necessary to apply general guidelines commonly found in psychology to evaluate the quality of the current research as it aimed to investigate behavioral change after a painful experience. At the same time, Yardley's stringency criteria offered a variety of ways for determining the quality and also suggested criteria that could be applied regardless of the particular theoretical framework of the qualitative study (Yardley, 2008).

Based on this, the researcher considered that Yardley’s criteria could be applied beyond the field of psychology in nursing research. Smith et al. (2009) analyzed in detail how these

132 criteria could be applied to IPA studies. Yardley (2000) presented four general principles for assessing the quality of the methodology: sensitivity to context, commitment, transparency and coherence, and last but not least impact and importance.

3.7.3.1 Sensitivity to context

Sensitivity to context is Yardley's (2000) first principle for an IPA study. That means that a researcher deliberately selects participants who share a personal and unique experience. The sensitivity, dedication, and empathy of the researcher within the framework provided the impetus and the ease to the participants to express themselves verbally and non- verbally, and to produce fruitful interviews and observations (Camic et al., 2003).

In the current research, the researcher also sought sensitivity to the context at the very early stages of the research process, through the choice of IPA methodology, her rationale for adopting this methodology and the unique characteristics of the sample. According to the IPA methodology, the sample consisted of participants who shared a specific experience (Smith et al., 2009). Besides, accessing them and their working environment (key persons or gatekeepers) could become difficult. For this reason, the researcher examined the above issues in detail to evaluate their role in the progress of the research study and the results of which could constitute an aiding tool for further research.

The sensitivity to context of the present IPA study was also included in both data collection and analysis. More specifically, the researcher's sensitivity to the context was also shown by the interactive nature of the data collection and in the frameworks used for both the interviews and the observations. According to Yardley (2008), holding an interview which implemented ΙΡΑ required skill, sincerity, and devotion so that the quality data collected would highlight the value of the research results. For this reason, the researcher demonstrated empathy and made the participants feel at ease to bring out the truth, and that required a complete understanding of the interview process. It was important for the researcher to understand that the participant was well aware of and fully perceived their post-operative experience and that this process required disciplined attention to the unfolding and rereading of participant's testimonies.

133 The current study presented a large number of extracts from the data collection material to support the study results. According to Smith et al. (2009), the voice of the participants was thus used in the document so that the reader was able to control and evaluate the interpretations given.

According to Malterud (2001), the choice of the investigation, the respective angle and the followed methods were affected by the background and position of the researcher. The perspective of the researcher affected each type of research, qualitative, quantitative and even laboratory experiments (Feldman, 1995).

In the current study, the researcher had to be familiar with previous studies and comprehend the existing theoretical framework that was defined by previous researchers who had already used similar methods or had analyzed related issues to interpret the data more accurately. According to Harding and Gantley (1998), the main aim was to detect and examine ideas and attitudes relevant to contextual studies that could form the observations made and the explanations given. In essence, in the present study, it was considered essential to take into account the history, theories, categories, distinctions, and techniques that were implemented when assessing and managing intense post-operative pain. In-depth understanding of the different point of views and complex meanings enabled the researcher to develop a deep and extensive understanding of the participants' painful post-operative experience without being affected in the interpretation and the analysis of the existing sensitive personal data received. The researcher accepted or rejected theoretical predictions in relevant literature based on the personal post-operative experience of the participants and the truth they expressed through it. When the researcher came across findings that were new to her, she elaborated on rather than merely mentioned them.

According to Camic (2003), the social context of the relationship between the researchers and the participants could prove crucial. For this reason, the researcher considered it necessary for this study to conceive the socio-cultural aspect of the study since it constituted the central element in interpreting the meaning and the function of the phenomenon under study. That was more easily accomplished since the researcher had nursing experience as well as insight into the linguistic and historical influences, the expectations, and the way that the participants work or share their experiences.

134 The social context of the relationship between the researcher and the participants dictated that the researcher took every opportunity during the interview to prompt actively or passively elements of communication that would put relative identities (who I think I am) as well as shared understandings (do you know what I know) into a new speech framework.

3.7.3.2 Commitment

Yardley's second principle was commitment (Yardley, 2000). It called for prolonged commitment, respect and undivided attention by the researcher in every stage of the study. Thus, when collecting the data, the researcher's commitment to the participants meant making them feel comfortable to express themselves while the researcher was focused on them and what they said or did.

According to Yardley (2000), it is imperative for the researcher to realize the necessity of specific skills and strive toward acquiring and implementing them. Despite being a newcomer to the IPA approach, the researcher developed the necessary abilities and applied the skills required to strengthen the validity of this methodology. According to Cohen and Crabtree (2008), effective implementation of interviews and observations, as well as the researcher's commitment to the ideal conduct of the test, was a demonstration of sound validity. Yardley (2000) also stated that the researcher must be careful to maintain the balance between proximity and discretion and be consistent in exploring the person's experience by keeping the evidence and helping the persons go deeper. Validity according to Yardley (2008) was all about the researcher's commitment to collecting and analyzing the data. Having this principle in mind, the researcher examined how sufficient the sample was based on whether the data could provide all the necessary information. For this purpose, the data saturation principle was utilized for this study. The analysis of the results was interpretative rather than descriptive. According to Yardley (2008), commitment to the interpretation during data analysis should ideally cover all the variations and the complexity that were observed and may have to be implemented in different stages of the analysis. In the present interpretative phenomenological analysis, it was a challenge for the researcher who was a newcomer to this approach, to overcome any superficial perceptions and convictions, taking into consideration the insightful exploration of the phenomenon while at the same time combining all relevant theory.

135 In this type of research, Cooper and Stephenson (1996) considered the researcher's intuition and imagination more critical than a standardized data results analysis process. To achieve a multilevel understanding of a research question, the researcher approached the collection of data by applying various methods such as observation and interview to explore the behavior of the participants towards patients as well as their intentions as far as assessment and management of intense post-operative pain were concerned.

3.7.3.3 Transparency and coherence

The third principle of Yardley (2000) was about clarity and coherence. In the current study, the researcher ensured that there was transparency in each stage of the research process. According to Yardley (2008), the quality of the narration constituted an integral part of research quality since it created a reality which was essential to the readers. To improve transparency, the researcher went further to describe in detail the participants' selection process, the interview schedule and data analysis and the method selected. A further step to achieve transparency was for the researcher to ask herself a series of reflective questions providing fundamental answers to when, how and why. The questions included the researcher's philosophical position, the chosen data collection site, and context method and its limitations, her sampling strategy and decisions, challenges and responses before, during and after the process.

As far as coherence concerned, bringing the various elements of any research into coherent textual pattern poses a challenge for researchers. However, according to Yardley (2008) maintaining coherence refers to the degree of adaptation between the research done and the subjective theoretical assumptions of the approach in use. In other words, how closely the research question, the collection of information, the transformation and interpretation of the data and the conceptual and theoretical work fit together in the write-up of the study. In this case, the present study aimed to explore the painful personal post-operative experience of the participants as well as how it affected the assessment and management of the patient's pain. By adopting the interpretative phenomenological analysis of the observation and interview, the researcher provided full data description and analysis consistent with the rest of the study maintaining, therefore, coherence and clarity throughout.

136 Finally, based on Gadamer’s (1989) approach the researcher considered that she constituted an integral part of the world and that her conviction may have been partially affected by the results of the study. She opted for reflection to discuss the motives and the experience that led her to realize the present study or to examine the way the study has been affected by external factors such as pressure or limitations.

It is evident to the researcher during this stage that transparency and coherence would result in a study characterized by clarity and persuasiveness.

3.7.3.4 Impact and importance

Yardley’s fourth and last principle was the impact and importance of research, which was another critical element that had been taken into consideration (Camic et al., 2003; Yardley, 2008). This step examined whether the results of the research were of practical and theoretical use. According to Yardley (2008), it was not enough to develop a sensitive, robust and reliable analysis if the ideas suggested by the researcher did not affect the beliefs or the actions of anybody else.

The importance of the research did not stem from its accurate and complete explanation, but from the fact that a challenging perspective or novel material was presented and new paths of realizing a problem emerged (Cohen and Crabtree, 2008). Some qualitative researchers took into consideration the theoretical and the practical impact of research or in general, the socio-cultural implications of it.

Some others support that qualitative research might not be objective since all the discussion and action following the results could be affected by political and socioeconomic parameters. Novelty is another issue, as already mentioned, that arose from the current qualitative research. That was due to the fact most of the psychological research was still based on already well and widely accepted methods (Camic et al., 2003).

In this work, the researcher sought to provide the reader with something meaningful, interesting and useful to be able to ensure a better quality of patients' post-operative pain assessment and management. The results of the present study are significant not only because they provided a complete and accurate explanation of a particular personal experience such as the personal post-operative experience of nurses, but also because the

137 researcher extracted information and deeper meanings from this empirical material that presented a new perspective which opened up new forms of understanding the topic. Although certain parts of this academic study may appear to be personal or without broad practical applications since they come from a small sample of participants, the knowledge they offer is invaluable since these results may provide solid feedback when applied on practical matters at both academic and clinical level. Consequently, according to Yardley (2008), given that perspectives, ideas, and beliefs are an integral part of our experience, then exploring them can contribute towards changing our way of thinking or our attitude towards the phenomenon under study.

3.7.4 Methodological rigour of the study

According to Morse et al., (Morse et al., 2002) the criteria of methodological rigor were vital to ensure the high quality of the methodology followed by the researcher. Nevertheless, additional tools described by Lincoln and Cuba (1985) were available to the researcher to assess this qualitative study effectively and judge its rigor. They realized the need for gaining a deeper understanding of the phenomena/experience in studies similar to the current one as well as building trust in the study and devised a model that could enhance its trustworthiness (Lincoln and Cuba, 1985).

This model was built around four components: credibility, transferability, dependability, and confirmability.

3.7.4.1 Credibility

Credibility was the first component that had to be utilized to establish trustworthiness. Credibility demanded that the researcher clearly links the study's findings with reality to prove the truth of the research findings (Golafshani, 2003; Thomas and Magilvy, 2011). According to Lincon and Cuda (1985), a study was considered credible when it gave an accurate description or interpretation of human experience that would be immediately recognized by people who also shared the same experience which was exactly what happened with the participants involved in this study. The techniques used in this phase included triangulation of data using different collection methods and multiple theoretical perspectives to analyze the data from as well as member checking which involved sharing with each participant data, interpretations and conclusions allowing them to clarify their intentions, correct mistakes and give extra information if necessary.

138 3.7.4.2 Transferability

The second component was transferability. According to Lincon and Guba (1985), transferability or generalizability was the applicability of the research findings to other groups. Even though transferability adds to the validity of the research, it is essential to know that the current research findings couldn't apply to different contexts, situations, times and populations. However, the post-operative experiences described in this research might help nurses who work in surgical wards to build interventions and deeper understanding towards post-operative pain assessment and management even though the experiences may vary. The comment above could suggest the extent of applicability of this study to practice.

3.7.4.3 Dependability

The third component was dependability. According to Lincon and Guba (1985), dependability was crucial to trustworthiness since it established the research findings as consistent and repeatable. The research aimed to verify the consistency of the findings with the data collected during the observations and interviews. Achieving consistency meant that when other researchers examined the data of this study, they would come up with similar findings, interpretations, and conclusions.

3.7.4.4 Confirmability

The fourth component was confirmability which is the degree to which the outcomes could be confirmed or supported by other researchers (Lincoln and Cuba, 1985). The researcher aimed at ensuring as far as possible the outcomes were the results of the experiences and concepts of the participants as opposed to the qualities of the preferences of the researcher.

3.8 Conclusion

The present chapter provided a detailed description of the methods that were followed in the study, the ways the participants were approached, the role of the researcher, the researcher's relationship with the participants and the way data was collected through interview and observation. Finally, critical ethical issues, as well as the frame that the researcher followed to analyze the data, were discussed. Also, the present chapter illustrated some of the problems encountered during this study. The findings of the data analysis that

139 derived from both observation and interview are presented in detail the chapter that follows. Consequently, an understanding of the effect of the participants' post-operative painful experience on their attitude, beliefs, and practices towards patients' post-operative pain assessment and management, is developed.

140

4 Findings

The sample of this study consisted of thirteen (n=13) participants, slightly bigger than what Smith (2009) suggested but always in accordance with the IPA guidelines. Within a period of three months, the researcher concluded that the data collected from both interviews and observations had reached saturation since they started replicating themselves and further coding was no longer attainable since it was not possible to obtain new information. In the section that follows the demographics, the observation findings and interview findings are presented in detail.

4.1 Demographics

In Table 4.1 the information about specific characteristics of the participants is reported. In total, thirteen people (n=13) took part in the current research. All participants were aged 30 to 67 years. It should be noted that there was no participant between the age range of 18-

30. Also, 12 of the 13 participants were female. Moreover, the number of years of experience in the surgical wards ranged from 3-33 years.

Table 4.1. Participants’ characteristics

141 4.2 Observation findings

As far as observation is concerned, each participant was observed 3 times by the researcher: during the morning, evening and night shifts. The observation was completed when all the study questions had been addressed after 312 hours of observation. Finally, the notes that follow are amalgamated together from individual observations.

Seven major themes were identified from the analysis of field observations. These were as follows:

1) Building beneficial relationships.

2) Reflection and evaluation of the painful post-operative experience.

3) Developing interpersonal communication skills for an effective staff and patient relationship.

4) Facilitating learning via the participants’ post-operative pain experience.

5) Exploring touch in post-operative pain.

6) Manipulating the environment.

7) Providing comfort and warmth.

Throughout the observation period, the participants were found to apply their communication skills to create an atmosphere of trust, support, and empathy. These activities gave them the ability to provide a holistic approach to patients and find solutions to problems that arose.

4.2.1 Theme 1: Building beneficial relationships.

The participants' used nursing activities to establish a relationship with patients from the first contact and throughout their time in the hospital. It was apparent that this produced significant positive changes in their patients' post-operative treatment. Two-way process activities were observed that were based on decision-making, mutual recognition of emotions, trust and deep understanding of each other's knowledge. Moreover, it was observed that the participants had a sincere concern as regards each patient's post-operative individual needs which in turn reinforced their relationship with the patients. It was also demonstrated that for this relationship to be beneficial for both the participants and the patients, the participants had to be self-aware of this unique contribution and it is likely that this contribution came from their previous painful post-operative experience.

142 4.2.1.1 Subtheme 1: Post-operative patients become partners in their own care

Participants utilized an approach to routine nursing tasks which facilitated and enabled the development of a partnership with the patient. By ensuring that the patients were well- informed about their condition, they were encouraged and supported to become actively involved in their own treatment.

To gain a better understanding of the observation data, it would be helpful for the researcher to refer to the Literature Review chapter (1.9.3 Pain management in Greece) where the adverse conditions under which nursing care is performed in Greece are described. According to the policies of the surgical wards, all nurses are responsible for all patients. There is no specific allocation of tasks or patients for each one of the nurses which means that all the nurses working on the same shift become involved with the care and treatment of all the patients. Therefore the holistic approach of each patient is not performed by one nurse, but it is achieved through the cooperation of all nurses. The nurses perform nursing routines such as the measurement of vital signs, preparation of antibiotics and other intravenous medications on shift for all patients. The nurses on shift get to decide between themselves the allocation of tasks that have to be completed during their shift. However, during the morning shift, it is the head nurse who allocates the ‘duties.' The typical pattern is for there to be four nurses in the morning and two nurses in the evening shift covering the needs of 18-23 patients. The results of the observation revealed that the participants started developing a close relationship with the patient and his family from the very beginning of the hospitalization. Within the task allocation process, the participants tended to promote themselves to the ward manager suggesting that they undertook the tasks which required more patient contact such as admitting them before their surgery and receiving them back for theatre. This became apparent by observing that the participants were always willing to have personal contact with the patients instead of working behind a desk or performing other tasks in the back room.

For example,

“when participant 2 was observed, she expressed the wish to deal with the patient upon his arrival rather than record his data on the clinic register. She had already been informed on the phone that a new patient was to arrive from the Emergency Department. She took down some information, assessed it and decided which room was more suitable for the

143 specific patient. She preferred a room close to the nurse desk to have immediate access and supervision. Participant 2 pursued to have face to face contact with the doctor to be informed in detail about the patient's condition and also the care that the patient had received up to that point."

From the observation notes

The specific approach of the participant does not follow the usual routine of the ward during a patients' admission. Normally the doctor briefly informs the nurses on duty about the new arrivals' needs as well as the course of action that will be taken. Following the same routine, the appropriate liquids and medication are prepared according to the doctor's orders, and it is only then that the patient has the chance actually to meet the nursing staff.

In contrast to the usual practices of the clinic, the participants follow procedures in the opposite direction that focuses on the patient.

That is also demonstrated by participant 5

"who introduced herself to the patient and made it clear to him and the family that she would be the person who would be taking care of him for the next hours. The participant initiated a discussion with the patient by asking how he was feeling, how intense the pain was and how the pain had affected his daily routine. She also received input from the family while emphasizing to them the importance of their help at this point in the treatment process. The participant was calm, focused on the patient and seemed to understand the patient's condition and feelings".

From the observation notes

After this first contact with the patient, participants informed patients about the procedures that would follow according to the doctor’s instructions.

Participant 7 “completed all the necessary procedures for each patient including taking blood samples, recording the electrocardiograph, managing the patient's X-Rays according to the doctor's orders and observing vital signs."

From the observation notes

It also consisted of a humane approach which at the same time was social and psychological.

For instance,

144 "participant 2 was keen to learn about the patient's personal interests and preferences, employment, and his family. She also asked about how the patient was feeling at the moment, how his daily routine had been affected by the discomforting symptoms that he was suffering from and if there was anything that she could do for him additionally to the nursing routine. For example, she asked him if he would like to read a magazine that she would provide him with or if he wanted her to turn on the TV set."

From the observation notes

The participants approached the patient’s family members with respect, kindness, warmth and in a friendly way. In addition, the participants, during the observation, were non- judgmental towards the patient or the family.

During this procedure, the participants drew a full picture of the patients' condition which consisted not only of the clinical, physical, and social documentation but also of the spiritual and emotional needs of the patient. It seemed necessary for the participants to get to know each patient as a whole person in their condition and context to devise helping strategies that are likely to work for that person. For example:

“The participants 3 and 6 after the morning schedule of sharing information among the nursing staff, called on the patients personally”.

From the observation notes

Measuring vital signs is usually performed during the morning and afternoon shift by student nurses. The participants insisted on carrying out the routine themselves to have personal contact with the patient and allow them to express and evaluate their condition themselves.

That was confirmed while observing participants 3 and 6 who

“after the morning briefing, checked on their patients asked them how their night was if they had experienced anything strange, something which was also recorded on the patient's chart." The same procedure took place during the evening and night shift" (participant 1 and 9); "Furthermore, all participants received the patients before and after the surgery, and those patients were their priority during their shift. The participants did not pursue to deal with the allocation of tasks, but they preferred to discuss with the patients and develop conversations about what was happening each time"; "Every one or

145 two hours participants 7 and 11 themselves checked on the patients to see how they were and their progress instead of the student nurses".

From the observation notes

It became clear through observation that the constant communication persistently promoted by the participants constitutes an essential element of the close relationship that they create with the patients.

The participants chose to follow their own practice since they approached the patients and did not expect the relatives of the patients to contact them to seek further information and assistance. The participants offered direct and immediate instructions and support to the patients right after the surgery about pain management and what would follow towards their care and relief of pain.

For example, participant 10,

“paid special attention to the whole post-operative procedure by informing the patients about the analgesia that they had already taken during the surgery and also about the doctors’ orders for post-operative pain management. The patient expressed his needs and feelings to the participant who in turn informed the doctor and the final analgesia plan was drawn”.

From the observation notes

Moreover, the participants demonstrated a sincere interest in the patients' recovery since although the health care system in Greece is doctor-centered and according to the law they are not required to perform so, they confirmed the medication prescriptions and any potential allergic reaction to certain medicines that might have been recorded in the patients' medical history. Their will to act in such a way is guided by a strong sense of responsibility towards their patients and deep respect for their work. For instance participant 3:

"..when the patients had just come out of the surgery room and complained about intense pain, the nurse checked on their post-operative bulletin that accompanied them in order to be informed about the medication that had been administered to them not only during the operation but also in the resuscitation room"; "The participant studied the patients' medical history very carefully and asked him once again if there was an analgesic which could provoke side effects like vomiting, dizziness or nausea…".

146 From the observation notes

The participants made themselves available to the patients by standing next to them, giving explanations and trying to schedule the next step of pain management. During the observation, a sense of empathy was witnessed on the participants' part that seemed to make the patients feel free to express their feelings about their pain. In turn, this gave the participants the opportunity to realize how the patients might react to painful procedures. The participants identified the patients' feelings and helped them assess their condition.

In some cases when the patients continued to be in intense pain, they occasionally became anxious and even inpatient with the participants. The observation suggested that this negative behavior on the patients' behalf towards the participants did not affect their desire to work closely with these patients. On the contrary, the participants' humane, close and professional reaction towards the patients reinforced it.

The participants accepted the patients as they were to help them meet their expectations. They allowed the patients to behave as they wished without necessarily expecting them to be polite and cooperative. The participants overcame such possible obstacles and approached the patients by introducing themselves and calling them by their first name. The immediate response of the participants to assess the patients' condition, to call for the doctor and to stand by the patients while at the same time giving them explanations, led to the participants' reduction of stress and finally to the treatment completion through their consent. Enhancement of trust became feasible through participants' attendance next to the patients throughout any intense feelings they were experiencing. The participants took the time to deal with the patients personally instead of directing them to the doctors. For example, participant 5

"...discussed and explained to the patient who was in intense pain and was very upset about the reasons why the next dose of painkillers was delayed. The patient insisted on having analgesics administered and wanted extra information about his condition. The participant called for the doctor to speak directly to the patient and answer all his questions. While on the phone, the participant reported to the doctor the vital signs of the patients such as blood pressure, pulse, and temperature. She also described his posture in bed which indicated that he was suffering changes in his mood too. Then the participant informed the patient that the doctor was on his way and the patient felt relieved".

147

"Participant 12 explained to the patient that she was personally responsible for answering any of his calls and helping him with his needs".

From the observation notes

Such approach helped the patients become aware of their condition, recognize how the existing care plan functioned for them and adopted an active role towards the decisions taken by the participants as far as their postoperative pain was concerned.

The participants did not receive proper directions by the head nurse, but they formed their own evaluation of the patients' condition. The participants seemed to empathize, sympathize and understand in depth the patients' conditions. In addition, they were found to be expressive of their feelings to the patients. During the observation, participants were warm and friendly by using humor to build rapport with the patients and their families. However, beyond the rapport, the participants were able to develop a trusting relationship. They actually stepped into the personal space of the patient and got engaged in important conversations to reach the core of what was considered important for the patients themselves. The participants succeeded in penetrating the patients' world by dedicating time to them, understanding their state of mind and how current functional limitations imposed by their condition affected them in their everyday routine. In this way, they managed to promote empathy and mutual trust. For instance, participant 5

“asked about and observed the difficulties of a patient who had undergone orthopedic surgery. These included immobility and their subsequent effect on his sleep and mood”.

From the observation notes

These conversations clearly constitute the ideal opportunity for the participants to point out that they really value the sincere feedback received from their patients. This practice on behalf of the participants clearly set the foundations for the patients to openly express themselves regarding what they liked or not about the services provided. After these interactions, the participants suggested a treatment plan for the patient by providing them with any required information and setting short-term goals. Moreover, the participants made sure to inform their patients that their actions had a particular impact on their health. For instance, participant 1

148

"…informed the patient about the immediate benefits he would have if he got up from the bed and gradually walked in the corridor. He suggested that this should be done after taking painkillers, so as not to be in pain and pointed out that it is up to the patient to make an effort for it. The participants talked to the patients regularly throughout their post- operative care period. Finally, they reset the targets they set with the patient depending on his needs and wishes overtime”.

From the observation notes

As a result, they identified the holistic needs of the patient and this in turn, made decision- making feasible. During the observation, the participants seemed to care about the patients in a way that demonstrated understanding for each patient as an individual human being.

Caring conversations that developed between participants and patients helped to establish a relationship every time a participant approached a patient for any reason, whether it was about administering medication, performing a procedure or asking a specific question. All cases were opportunities for the participants to create a sense of security, belonging, continuity, purpose, achievement, and significance. The participants seemed confident to be dealing effectively with the patients' needs.

The participants were not trying to solve problems. Instead, they aimed to understand, be with the patient and explore the situation so that both the participants and the patients reached a deeper understanding.

This understanding led to awareness, acceptance of their condition and treatment, as well as facilitated decision-making on critical issues.

The participants were observed to be looking out for opportunities to encourage their patients to exercise their own freedom of choice. Overall, close cooperation between the participants and the patients created an atmosphere of security, freedom and mutual respect. The outcome was to empower the patients within a supportive, personalized care plan, and enhance a close relationship.

149 4.2.1.2 Subtheme 2: Developing proximity with post-operative patients

While the shared decision-making and mutual recognition of feelings and trust is one part of the process, being friendly and showing sincere concern through care, compassion and openness are undoubtedly the other. The participants maintained a relationship that encouraged the expression of feelings by the patient. Through observation, it became clear that the constant attendance of participants next to the patients improved the sense of proximity in their relationship, regardless of the reasons for the participants' presence or the limited time available. Participants were observed to be showing compassion through concern, consideration, and care for the patients who were in acute post-operative pain and were taken over by intense feelings of fear and worry. The participants invested time in approaching patients to help them feel safe and eventually foster an environment where the patients could express their feelings.

For instance, participants 6 and 10 were the ones who initiated the discussion with the patients by saying something like

"Where do you feel pain? How intense is it? Do you feel any pressure? Could you please describe it in your own words?"

From the observation notes

As a result, the patients appeared to feel secure and familiar enough with them to express their inner feelings. Additionally, sincere communication was shown to facilitate the completion of various post-surgical procedures, such as wound cleaning. At the same time, it improved the assessment of post-operative pain as the participants tried to identify the real source of patients’ pain before administering analgesics. The participants did not detach themselves from the patient by just carrying out doctors’ orders, as is the usual practice in the clinic.

Following this pattern, they did their best to respond effectively to post-operative patient’s pain assessment and management during the first days after the surgery. Once again, the participants seized the opportunity to spend time with the patient despite the excessive workload they had been assigned with.

150 The participants showed the patients that they were vulnerable as well by divulging that they had also been in their situation, were also afraid of the unknown and were deeply stressed too. The patients realized that there was a human side in the participants and that they could truly understand how they felt. It is interesting to note that although the participants expressed their vulnerability to the patients, they tried not to allow this to interfere with the objectivity in their work whatsoever. They assessed the patients' pain based on their own words and understanding of their feelings and helped the patients evaluate it themselves.

Actually, it was observed that both verbal and non-verbal communication proved the participants' sincere intention to break the ice with patients they did not know to make them feel less hesitant, trustful and more secure towards opening up and expressing their feelings. The physical touch between the participants and the patients was observed to have a positive impact on patients as it reduced their anxiety and made them calmer. At the same time, it proved that they felt familiar with each other. The aspect of physical touch is analyzed extensively in one of the following themes (5.Exploring touch in post-operative pain),

During the observation,

“The participants go inside the room, they smile, they greet everyone and introduce themselves, and in an attempt to create a friendly atmosphere they may even tell a general joke. After that, the participants focus on the patient, retain eye contact, stand or sit exactly next to the patient, talk to them in a lower pitched but straightforward voice and with a vocabulary which is comprehensible by the patient. All that contributes to establishing close contact with the patient" (participant 3and 7) “The participant was the one who initiated the discussion with the patient by saying something like: “How are we doing today? Are we feeling better?”, this way involving herself with the patient (participant 12).

From the observation notes

Familiarity can adopt several forms according to the psychological, physical, spiritual and even social needs of the patient and forms a stable contact basis. It is this proximity that helps the patient have an insight into his real feelings, a process which is promoted by the participant through respect, recognition, and compassion.

151

4.2.1.3 Subtheme 3: Developing mutual relationship with post-operative patients

The developing nurse-patient relationship reflected the belief of mutual benefit for the nurse as well as for the patient. The participants on most occasions spoke about their personal experiences to patients especially to those of similar age because they appeared to empathize with them and understand their anxiety, distress, fear of the unknown and everything the patients were about to experience post-operatively. Self-disclosure of post- operative personal experience and beliefs provided solid ground towards establishing mutual benefits. The above is the fundamental process of sharing feelings and emotions which has a comforting effect for both sides, and that became obvious through careful observation.

On occasions when there was nothing else for the participants to do, they preferred to show their support by standing beside the patients trying to keep them calm and lend a sympathetic ear. This process was found to have a reciprocal benefit for both sides since the psychological pressure that both felt was significantly reduced. The moments they shared and the calmness that followed indicated the depth of the relationship. However, it was clear that the participants tried to keep a balance between their own and the patients' priorities during this interaction. It was also observed that through this experience the participants were able to adjust their behavior to cater to the individual needs of each post- operative patient.

The process of sharing their feelings with the patients came to be beneficial for both as the participants reflected on their experience especially through dialogue and saw things under a different perspective and depth. As a result, they gradually improved their support and understanding by further enhancing mutual trust and feeling of safety.

During the observations, the participants' demeanor was considered an essential element of their approach. They appeared to exude calmness, enthusiasm, and liveliness when associating with patients. They received positive feedback when they coordinated a purposeful action which as a result encouraged them to use their time and follow the same approach to other patients.

152 Narrating goes beyond merely telling a story. It includes the reason for telling that story to be understood. Participants through willingly sharing personal accounts of post-operative experiences achieved mutual benefit for themselves and the patients.

The participants were observed to encourage their patients to narrate their stories in their own words and speak about themselves. After the patients' narration, the participants reiterated their stories in their own words. So the exchange was not antagonistic in any way since the patients realized that the participants had perceived their interaction like one of their own experiences. It was an open and sincere dialogue that challenged both involved sides and not a monotonous or uninteresting monologue. Observation proved that this practice promoted balance and illuminated the patients' perspective, including not only the meaning of a single encounter but also the depth of communication which aimed to make the patients profoundly introspective by paying attention to their physical feelings, thoughts, and emotions.

It was only then that the nurse-patient relationship was performed in an unconditional positive manner and yielded mutual benefits.

4.2.2 Theme 2: Reflection and evaluation of post-operative experience.

Even if the distinct proximity reflects the belief that the nurse-patient relationship has mutual benefits for both parties, the nurse needs to balance her own and patients’ priorities within the relationship. The observations show that the participants must have insights into themselves before they can apply intimacy safely and effectively. The participants in this way develop a psychological closeness towards the patient.

For instance, participant 8 expresses their true feelings to the patient in the following way: "Mrs. A you know, when I was in a similar situation, I was in pain, stressed and I was afraid of the unknown, so I know how it feels."

From the observation notes

The participants developed their understanding and recognized the way that their painful post-operative experience affected their attitudes and beliefs. That was achieved by expressing specific details of their post-operative experience and thus assisting their

153 patients. The participants did not hide their feelings in the presence of patients, and they were able to work through the patients' post-operative pain by being emotionally open.

The observations showed that the participants exposed themselves to the patients by sharing their personal post-operative experience, which simultaneously gave them a chance to expose themselves to the patients while being in the process of co-creating a close relationship with them.

For instance, participant 1 told the patient:

"I do feel you Mr "B," I have also been operated on the belly, and I can understand how much it hurts… I remember how difficult it was to stand up... I couldn't sleep or eat… It was a lesson for me to see my weaknesses and through a different perspective appreciate things that in the past I used to take for granted".

From the observation notes

The participants proved to be dynamic human beings whose attitudes, beliefs, theories, and practices were continually evolving. The participants were observed to be referring to their patients by their actual names and not by the type of the surgery that they had. That clearly demonstrated that human nature prevailed over technical rationality. In other words, the patients were treated as persons not merely as objects.

To achieve that, the participants adapted their sense of identity through being in relation with themselves, the patient and the other members of the health care team instead of adopting one forged by their environment.

Throughout the observations, the participants' decision-making activities provoked arguments between them and other nurses or doctors. The atmosphere was intense, and the cooperation was sometimes difficult between the nurses. The reason was the empathy that the participants showed to their patients which in turn created negative feelings among the other nurses working in the ward.

For instance:

"..Participant 6 spent 20 minutes with the patient to assess and manage his pain which made the participant run out of time to prepare the fluids which she asked another nurse to do. The reply from the other nurse was that she should learn to manage her time according to the things that she had to do and not spend so much time with the patients. The 154 participant explained to her how important the communication with the patient was and pointed out that she was responsible for clarifying the details about the patient's condition and that assessing and managing the patient's pain was her main priority. Finally, the participant prepared the fluids on her own, obviously looking stressed and disappointed..." From the observation notes

When the participants were not able to relax due to their workload, they usually felt disappointed, disconnected or even exhausted at the end of their shift. They followed their personal routine in an unsupportive environment which took its toll on them. However, it became clear that the participants protected and prevented themselves from a possible burnout by being involved and engaged with the patients, a practice which evoked a true empathetic insight towards the patients. In this way, the mutual benefit between the nurse and the patient was further enhanced.

It was revealed from the data that the participants were self-aware, and trying not to be influenced by the health care system culture. For instance, they remained focused on their target which was to assess and manage the patients’ post-operative pain. The participants were also not affected by the barriers of the health care system, the habitual behavior of other nurses or poor collaboration with the doctors. Τhe participants took strength from the positive feedback that they got from their patients. It was observed that one way for participants to discover themselves was through their relationship with patients and other members of the health care team which in turn allowed them to become more aware of themselves. In this way, the participants saw themselves mirrored in other people. The observation revealed that all the participants were, on the one hand, liked and accepted by their patients, while on the other they were often treated with suspicion and doubt by their colleagues. The relationships between participants, patients, and colleagues are analyzed in detail in theme 3 (Developing interpersonal communication skills for an effective staff and patient relationship).

For instance,

"participant 10 received positive comments from the patients who emphasized how simple, direct and humane she was"; "participants 3 and 5 were asked by their patients when their next shift was and if they were going to be on leave during their hospitalization"; "her colleagues criticized participant 5 for the time she spent with patients, and she was advised 155 to follow the pace of the ward. The participant did not argue but said that this was the way she worked".

From the observation notes

Τhe participants evaluate themselves as dynamic and worthy beings whose presence made a difference through intentional engagement while being simultaneously aware that they are re-inventing themselves. It was observed that to understand and help other people; the participants need to be self-aware.

For example,

"Participant 5 pointed out that only the patients themselves knew how they experienced pain and no one else. The participant's role was to be able to understand what the patients were experiencing to help them as effectively as possible. She said that she had had a painful operation herself and it was only when she openly expressed the acute pain she was going through, the other nurses could understand how she was feeling".

From the observation notes

The participants tried to reflect on their previous post-operative experience and were self- aware to maximize their effectiveness when working with their patients. They developed self-efficacy, were confident, positive and empowered to help the patients overcome any obstacles and ultimately manage their pain.

For example,

“Participant 1 carefully listened to the patient’s concern about whether he would be able to call for a nurse in case he needed help during the night. The participant tried to find out the reason why the patient was so worried about it only to find that he was hesitant because he was afraid that this would be disturbing for the nursing staff. The participant shared the patient’s concern and said that during his hospitalization, he didn’t call for the nurses for the very same reason although he did know that the nurses were there for him round the clock. After the participant understood the patient’s worry, he assured him that asking one of the nurses for help would not be a nuisance to them”.

From the observation notes

156 The observation revealed that the participants developed self-knowledge through being reflective of their own lived post-operative experience and felt good with themselves; this was a fact which enhanced their self-esteem.

The participants placed emphasis on the patients' needs, particularly in the doctor-patient relationship which was often especially tricky since the hierarchical relationships in the clinical area were strict and tended not to allow for variations. It was also observed that the participants made their practice more personal by expressing their concerns and deliberations as they recounted their personal post-operative experience. For instance,

"Participant 8 expressed her concerns to the doctor as regards the analgesia that the doctor had prescribed. She mentioned that in her experience there were quite a few side effects of the Pethidine and they would face unpleasant feelings additional to those that the patient was experiencing because of the orthopedic surgery he had had; she also recommended a physiotherapy plan if the doctor approved, of course".

From the observation notes

Also, participants with apparent high self-esteem and positive self-image reflected in their professional self, even if the social environment within the ward did not fully appreciate their qualities, deprived them of their autonomy and provided them with negative feedback. The participants did not necessarily adopt norms, values, and rules which characterized them as members of a collective nursing group.

The participants demonstrated high self-esteem through effective interpersonal skills, got involved and were willing to cope with health care system problems. During the observations, it was clear that the participants felt prepared to deal with the intimacy involved in their nursing care role. The participants had the chance to express themselves and their own painful post-operative experience in a unique way from within and from beyond the self. That created new means of aesthetic expression which were personal and undoubtedly subjective. The participants also developed aesthetic expressions as they were open, authentic and dedicated to their counterpart. They offered their presence wholeheartedly, they avoided isolation, and they experienced mutuality and harmony.

157 Ultimately, reflective practice appeared to be a useful tool for the participants to deepen their understanding of themselves after their personal post-operative experience and adapt their practices to help their patients deal with their condition.

4.2.3 Theme 3: Developing interpersonal communication skills for an effective staff

and patient relationship.

Depending on the type of communication required between I) participant-doctor, II) participant-nurse, and III) participant-patient/family, a variety of approaches, interpersonal skills and interactions were adopted to find mutually acceptable solutions. As this study took place in a university hospital, the participants did not behave formally or competitively which can often become an obstacle to developing healthier working relationships among colleagues and physicians.

I) Participant-Doctor

During the observation, the existence of a doctor-centered health care system was recognized. More specifically, doctors were the ones who decided what the most critical task such as pain assessment and management was and how it should be managed. For instance:

“Participant 12 was observed taking orders from the doctor to give a specific painkiller when the patient was in pain in addition to the normal administration of analgesics”; “Participant 9 expressed to the doctor her concern about whether there was irrational use of analgesics since she felt that in many cases they were not necessary. She based her concern on the fact that she spent a lot of time with the patients and quite often she recognized anxiety and fear instead of pain that the patients claimed to be experiencing”.

From the observation notes

However, in most cases where the participants disagreed with the doctors' methods, the doctors' arguments were medically rather than holistically based as far as the patients' personality and needs are concerned. Nevertheless, it was difficult for the participants to assert their professional knowledge within this arena. This fact made the participants feel rather frustrated and aloof. There were even occasions when the relationship between the

158 participants and the doctors was intense because of the doctors' apparent indifference. However, the participants were observed to be acting professionally throughout and were decisive in overcoming the obstacles towards achieving their end-goal which was to relieve the patients from their pain. The participants followed a more direct approach in their exchanges with the doctors. On most occasions, it appeared that it was more helpful for the participants to ask the doctors the right questions to get a specific answer. For example, Participants 1 and 4 asked questions such as

"How much should we reduce the analgesic dose for that patient?" "Will we change the number to four or five painkillers per day?"Are you going to prescribe the same tranquilizers as those that the patient used to take at home?"

From the observation notes

The participants once again proved to be sensitive and empathized towards the patients’ post-operative pain. They also supported their beliefs without negotiating the patients’ right to pain-free procedures.

For example,

“Participant 6 insisted that the doctor should use a local anesthetic to clean his wound because, as he claimed, this procedure was painful for him”.

From the observation notes

On the other hand, there were some exceptions when some participants had developed a good relationship with the doctors, and that allowed for quicker and like-minded decisions. Doctors respected and wanted to have nurses with an opinion about patients’ post-operative condition including their intuitive skills and knowledge as they realized the obvious benefits for the patient.

II) Participant-Nurse

The nurses demonstrated disbelief about the way that the participants behaved and acted towards the patients. The participants did not follow the routine of their clinic and clung to their approach towards their post-operative pain assessment and management as they were convinced that they had taken the right decision. Overall, the participants were not static as

159 they reflected their personal, painful postoperative experience and developed awareness of their practice, attitudes, and beliefs towards the patients.

On one occasion one of the participants was transferred to another clinic as she allegedly did not conform to the standard clinical practices. However, the participant was reassigned to her post mainly due to staff shortage. When such difficulties in the communication between the participants and the other nurses became obvious or caused frustration, a solution had to be found. That was mainly achieved by appreciative dialogue. For instance,

“When the other nurses talked about how difficult it was for them to effectively manage post-operative pain under such stressful circumstances and constantly complained, participant 3 became interested to find out exactly what the problem was”.

From the observation notes

By applying appreciative questioning, that is asking the right questions; the participants adjusted their way of engaging by using a problem-solving language to an inquiring and at the same time learning one.

The participants asked questions like

"How do you feel about what is happening in the clinic or your relationship with the doctors? "What should be different?", and "Is there something we could do as a team the way we all would like it to be?".

From the observation notes

The participants used some form of appreciative inquiry and supported the care environment in their own way. They were open and tried to find new ways of working in collaboration that could have a positive impact for all. This process required the strength to share and the ability take a risk using different approaches, but they knew that they could get much better results in this way than seeking out and solving problems. However, collaboration and communication with the other nurses were often tricky and rigid as they insisted that there was nothing else to do to make things better. Although the participants were cautious to defend their approaches, at the same time, they worked hard to enhance collaborative engagement with other nurses.

For instance, participant 4 and 5

160 "explained to the other nurses, the reasons and the benefits that their own more humane way to treat post-operative patients had the positive feedback they received by both the patients and their families. They pointed out that, once again, the found meaning in their work and that they feel capable of carrying whatever task might be required for the patients benefit. However, the participants expressed genuine understanding for the nurses who did not wish to follow their ways".

From the observation notes

The other nurses were generally negative towards the participants, which constituted a barrier to a more holistic approach for post-operative patients within the health care team.

On the other hand, the relationships were entirely different between the participants and the younger nurses of the clinic. The participants set the example for the younger nurses due to the acceptance participants were earning from the patients as well as the respect of some doctors. The participants were open to sharing the knowledge that they had gained from their post-operative experience.

For example,

"Participants 7 and 13 spent a lot of time explaining to young nurses that all actions that they would follow during the care of the patient should and would be taken for his benefit. They gave simple examples, like measuring vital signs, which, as they pointed out, constituted ideal opportunities for them to communicate with the patients. Quite often, the younger nurses escorted the participants to observe how they interacted with the patients and built a constructive and beneficial relationship with them".

From the observation notes

In cases where the participants’ colleagues expressed difficulty in handling a patient’s condition the participants encouraged them to be more supportive and communicative, something which was not always appreciated as they did not appear willing to adopt a new approach.

III) Participant-Patient/Family

The participants engaged the patients in a more elaborate conversation rather than listen to a descriptive story from the patient. The participants paid careful attention to the patients' stories despite the unique experiences that they may have had themselves. The participants 161 did not interrupt the patients to tell them their own story or to show them that they had been in a more serious condition. The conversation assisted the participants to see the truth from the patient's perspective. That was evident from the type of questions that participants 1, 4 and 9 used, for instance

"What makes you do or say that? How are you feeling? What does that mean to you?". From the observation notes

The outcome was that this reflective process gave the participants a chance to develop not only as human beings through personal reflection but most importantly to develop a collective meaning of nurse-self. This form of communication was deeply emotional, and the observations noted expressions of emotions like tears and laughter which indicated that the participants were personally involved and the whole process increased learning.

Quite often, the family was used by the participants as an intermediary to avoid significant interference that might become uncontrollable. The participants clarified some critical points in the patient's treatment to the family and asked it to inform them in case the patient's condition changed. That happened mainly because of the lack of nursing staff in the ward since there were only three nurses to cover the needs of 28 patients in the morning shift and only two in the evening and night shift. For example, participants 6 and 10

"asked the patient's family to observe his body temperature or feelings of dizziness or possible vomiting."

From the observation notes

However, the participants emphasized that the family should give space to the patients and make them feel calm and free to express themselves instead of taking initiatives without their permission.

For instance, participant 1

"asked the family to let the patient relax and sleep, instead of bothering them with stressful questions and allowed only one person in the ward for each patient."

From the observation notes

162

The overall feeling throughout the observation was that there was more of a sense of connectedness with the patients’ world and less of a need to patronize them. The participants themselves appeared to assume responsibility for the choices they had made.

4.2.4 Theme 4: Facilitating learning via the participants’ post-operative pain

experience.

A variety of participants with different educational backgrounds provided the object for the observations. They were all able to adequately provide detailed explanations and helped the patients understand what they were going through to enhance their ability to make informed decisions about themselves. For instance participants 2,5,8,9 and 13

"informed the patients about the side effects that certain painkillers or antibiotics had, so as soon as the patients knew, they were able to report any side effects and make shared decisions with the participants about their medical treatment."

From the observation notes

Observing the participants' constant and persistent efforts to inform the patients was a permanent component of their daily routine. The participants were observed to be imparting knowledge or skills to the postoperative patients. For instance,

"participant 12 explained to the patient once again the reason why he had to have a colostomy, and after that, she showed him how to change and clean the area. However, this was not enough for the participant. She listened to the patient's questions and problems carefully, they discussed how he felt and they demonstrated understanding for the embracement he felt about the new condition";

From the observation notes

The participants delved into the cognitive approach of learning since they did not only confine themselves to helping people learn new facts about post-operative pain or their surgical condition, but they also promoted the process of learning through sharing and

163 debating with every patient. In addition, they expressed a deep understanding of pre and post-operative experience and hospitalization processes. For instance, participant 6 quoted

“I fully understand what you are going through; the intense pain, the stress, the fear of what will happen and if the doctors and the nurses take an interest in my case ... I had the same thoughts when I was hospitalized”.

From the observation notes

The participants shared pre and post-operative information with the patients so they understood their health condition and realized that their surgery would cause a degree of pain. They had honest discussions about the severity of the pain and the strategies which could be followed after the surgery. The participants shared their post-operative experience, looking confident and sure about everything they explained and taught to the patients.

For instance, participant 3

"…tomorrow morning before surgery you are not allowed to eat or drink anything, and liquids will be given intravenously. Immediately after surgery, the pain will not be as intense as you will be given painkillers during surgery. The pain is expected to become more intense in the abdominal area in the next few hours as the effects of the narcosis wear out. Because of the narcosis, you may feel dizzy or even like vomiting. You may not eat anything then. I remember, when I woke up from nausea the dizziness was very intense, I could not understand exactly where I was ... I think I was at a loss for words ... and I was quite anxious. At this stage, I will be next to you, no need to worry. The doctor will have already prescribed painkillers that we will administer depending on the intensity of the pain you experience… You will guide us on this".

From the observation notes

Participants expressed that by sharing information, they maximized the patients' ability to self-care and adapted to their stress or feeling of helplessness, before the surgery. They reduced the patients' fears and enhanced their independence to make decisions about any changes in their way of therapy which could be beneficial for their health.

164 For instance,

"participant 1 was observed to be spending more time with some patients, for instance, those with a permanent tracheotomy, to be explaining everything about it, teaching them how to treat it by adopting teaching methods to cover the individual's needs. He also provided them with solutions about the way they could speak and communicate with others since this was one of their major fears. All in all, he was quite supportive and helped the patients and their families adapt to the new situation and adjust it to their previous daily life. The participants spent time listening to patients, asked them about how they felt, what they were afraid of and what their opinion about themselves was. One of the patients expressed rejection towards all the options that were available to him, and he insisted that he would keep his distance from the people close to him. The participant understood that the patient felt awkward for his condition and considered himself handicapped and that's why he wanted to avoid contact. The participant was able to convince him that by the time he would be ready to leave the hospital, he would have been able to cater for his own needs, feel strong again and become more sociable".

From the observation notes

Each patient was approached differently by the participant and depending on their personality the participant adopted different learning styles. When the patients expressed difficulty in managing their pain, the participants provided them with instructions about how to apply breathing techniques and correct positioning. The participants re-approached the patients when it became clear that they were ready and able to learn and expressed their desire to do so.

For example,

"Participant 5 dedicated time and space to his patient during the morning shift to accept his condition (leg amputation) assuring him that whenever he wished she would be there for him to answer all his questions about his rehabilitation plan and complete recovery. During the night shift on the same day and while the participant was administering antibiotics to the same patient, he asks her if she had time to spare for some conversation. At this point, it must be reminded that the shift lasts eight hours and according to the law the next one cannot be in less than twelve hours for the same nurse. However, this was not the case here due to staff shortages which meant that a nurse completed one shift and

165 returned for the next one after only eight hours. The participant promised that she would return after attending to all the patients' immediate needs. The participant kept her promise and returned; she listened to the patient's worries and explained that he would not be alone in this. She also informed him that in the period after his hospitalization he would have to return at regular intervals to be examined by the doctors. She also told him about the rehabilitation centers that would help him as soon as he left the hospital"

From the observation notes

On no occasion the participants made the patients feel guilty or responsible for their condition. In particular, when the patients were ready to leave the hospital, the participants gave them a lot of advice to help them familiarize themselves with the new situation, i.e., in case of amputation, or deal with any difficulties that might arise after their hospitalization. The participants spent time teaching the patients how to take care of themselves when they returned home knowing that the problem would not disappear as soon as the patient left the hospital. This way, the participants cared and helped their patients grow and mature to develop a holistic approach to their post-operative condition.

One can conclude that the two of the essential components of learning are listening and reflecting on the patient's words and reactions. It is clear that for this learning to be effective, the drive must derive from the learner. In practice, the participant evaluates the situation and helps his patient explore his concerns and utilize the information when they feel ready. This process appeared to help the patients make use of and enhance their strengths and knowledge through self-evaluation.

4.2.5 Theme 5: The exploration of touch in post-operative pain.

The transference of feelings through touch between participants and post-operative patients became apparent in their non-verbal communication. During observation, participants gradually performed extensive touching and patting on the hands, the shoulders and even the head of the patients to express their empathy and relieve them of their stress and agony. For example:

“Participant 3 sat right next to the patient. She introduced herself to the patient, and her tone of voice was soothing but cheerful"; "Participant 10 initiated a discussion with the patient. She used the patient's first name several times in their conversation. She touched

166 the patient, usually on their hands and their head, while talking to them. She had eye contact with patients during their conversation. The participant was calm, focused on the patients and seemed to understand their condition"; "Participant 11 touched the area around the patient's wound for some time".

From the observation notes

Through this observation, it became clear that two different functions identified the whole procedure.

I) Instrumental touch

Participants were observed to be using instrumental touch as a deliberate physical contact which was part of a procedure such as performing an aseptic technique or supporting the patient to walk again or to lift them into more comfortable positions. Also, participants touched patients when they performed wound dressing changes. It was evident that the nature of their profession allowed participants the privilege of close body contact at the very beginning of their relationship with a patient.

II) Expressive touch

There were some instances when participants reacted more spontaneously and effectively as far as touch is concerned. Participants used hand-holding when it naturally occurred, and they described how they felt.

Participants hugged patients who were feeling unhappy or touched them lightly on the arm to reassure them, conveying their inner feelings and reactions in this way. They communicated comfort, warmth, security, acceptance, and care which were welcomed by the patients.

4.2.6 Theme 6: Manipulating the environment.

The participants made effective use of resources available to create a relaxing atmosphere and make the patients feel at home by letting natural sunlight and fresh air in during the day or by dimming the lights in the evening. They used air fresheners or offered them hot milk with honey – the participant seemed to be aware if patients were accustomed to drinking something as part of their usual evening routine – however, the participant knew if the patient used to take sedatives to sleep and informed the doctor accordingly while at

167 the same time brought into consideration what the patient was allowed to consume or not.

Finally, they stretched bed sheets, and they plumped patients' pillows.

During the night shift, several patients claimed that they were in pain and needed analgesics. Participants understood from their own post-operative experience that their pain was, in essence, a reflection of their anxiety, fear, and sleeplessness. Many patients reported that they were in a lot of pain, but when the participant diverted their attention through dialogue, they stop complaining about being in pain. In those cases, participants tried to relax the patients prior to administering sedatives, hypnotic or anti-anxiety medication. Participants approached the patients, told them a joke and made them laugh or even started a general conversation. Nurses tried to create a relaxing atmosphere. In some cases, participants looked at the patients' file to find out if they took sedatives at home to sleep. If that was the case, she informed the doctor to prescribe the same medication.

Equipment checking was one of the tasks involved in the participants' daily routine and at the beginning of their shift. If everything was in order, they prepared the emergency trolley. However, since there was not enough equipment for each patient, quite often, they had to share it with the rest of the staff. It seemed that the participants have become accustomed to this lack of medical equipment and left certain pieces in one or two rooms where the participants' condition demanded intensive care.

The participants appeared to be flexible and resourceful when they have to come up with solutions to overcome common problems during their shift.

4.2.7 Theme 7: Providing comfort and warmth.

The participants encouraged the patients to stand up, sit on a chair next to their bed or have a walk according to their condition, thus gradually making them more mobile. Participants supported and encouraged the patients especially during their first post-operative days. For example:

"The participants encouraged patients many times in their shift to get out of bed and have a short walk in the ward. For those patients whose condition did not allow them to walk, the participants made sure to adjust and ensure a comfortable position for them on their bed."

From the observation notes

168 The participants understood and demonstrated empathy for patients' condition since they recognized that all these were painful procedures. Accordingly, they took prophylactic pain relief measures before activity to minimize the patient's pain. Since the participants were sincerely interested in reducing the patients' feeling of post-operative pain, they assisted them to stand up and walk after they have been given painkillers. The participants' empathy was quite obvious when the patients' reactions to pain became more intense. In this case, they did not pressure the patients to continue any painful activity that was required. When patients seemed to be feeling calmer and more relaxed, the participants proceeded to re- evaluate the patients' pain and acted accordingly.

The participants made efforts to make their patients feel being cared for by another human being and gave them enough information to help them handle their emotions more effectively.

In the following example, the case is presented in descriptive language to demonstrate the incident as it happened. According to it, a patient who had had orthopedic surgery felt very uncomfortable, complained that he was in pain, moaned, breathed heavily and sweated profusely. The participant recorded indications of his vital signs, put some pillows under his leg, removed his bandages and observed inflammation in the wound.

"Participant 9 after assessing the patient's condition, called the doctor, explained the situation and asked him to come over for further assessment and treatment. While waiting for the doctor, the participant stayed close to the patient, she applied ice packs and tried to keep him calm. Ten minutes later, there was no sign of the doctor, and when the participant called him again, he claimed that to him it did not sound like an emergency, but still, he would come a little later. On arrival, he didn't take into much consideration the participant's remarks for prophylactic pain relief, he just prescribed some antibiotics and left. He was too busy for a detailed explanation. The participant had to address another doctor who was available at the time".

From the observation notes

The participants provided ample comfort and warmth to their post-operative patients, a practice that has been identified as a key function in the nursing profession. All in all, the participants treated patients in a purely humane way.

169 4.2.8 Conclusion

The observation findings clearly demonstrate first of all the relationship participants with post-operative experience developed with patients, doctors, and colleagues. Secondly, the reflection practice that the participants pursued to deal with patients' post-operative pain. Third, the ways communication skills were adopted and enhanced by the participants. Fourth, the teaching methods the participants applied to their patients. Fifth, the variety of participant-patient connections through verbal and non-verbal approaches. Last but not least, the provision of comfort, warmth, and security to patients through the creation of a functional working environment. The results of the participants' interviews will be introduced in the following sub-section.

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4.3 Interview Findings

The interviews followed the three periods of observations and the interview data were classified in the following five major themes:

1) Development of close relationships.

2) Insights and reflection on post-operative pain.

3) Enhancement of communication skills.

4) The participants’ post-operative pain experience – a vehicle towards learning.

5) Impact of the economic crisis on the quality of nursing care.

4.3.1 Theme 1: Development of close relationships

4.3.1.1 Subtheme 1: Shared decision-making

It was apparent that the participants wanted to build rapport, develop trusting partnerships and make shared decision-making a real possibility.

Participants were open, warm and friendly and had the strong will to step into the patients' world and engage themselves in critical conversations that were meaningful to the patients. To do so, the participants expressed their desire to take an active part in pre- and post- operative preparation procedures and develop advanced communication skills that would enable them to engage in useful conversations thus establishing a sense of partnership.

"..Apart from the nursing care, I try to approach the patient I received from the unit and see with my own eyes the new case. Also, during the process, I try to detect each patient’s particularities according to the report. Approaching the patient is important for me, but it isn’t limited to nursing care…". (participant 1)

"..I feel the need to communicate with the patients and further help them when needed..." (participant 2)

Participants recognized that caring for post-operative patients’ physical needs was one of nursing’s basic concerns. However, they emphasized the challenge to see beyond physical care as well as beyond the strict categorization of man as a bio-psycho-social being. The

171 participants were able to focus on the person’s unique existence and share the situation. For example, by considering how the patient's world changed as his or her bodily functions changed during post-operative pain, and how they experienced the world, the participants were aware that things usually are taken for granted such as hospital noises, touching, bathing, feeding, sleep or meal schedules, quite often had very different meanings for individual patients depending on the particular person's world.

"One could clearly see the pain reflected on my face since my characteristics were altered. For example, I closed my eyes, gritted my teeth. I was talked to and did not respond. I kept repeating "I was in pain!"'- "Most of the patients that are in pain say it and ask for painkillers. (participant 2)

"I determine it by checking their clinical profile, their look, and their words. Also, I can understand it by the expression on their face, or when they say they are in pain and have difficulty in moving or lying down." (participant 6)

"They've got an expression of discomfort, they may sweat, and they may have facial spasms. They definitely cannot sit on their bed or a chair comfortably and easily; you can see it, they ask something from you, they usually look for you with their eyes." (participant 11)

"First of all, you monitor the frequency in which he is asking you for painkillers and to what extent he is covered by the medication the doctor has prescribed. Then, it's a step-by- step course depending on each day, which can be completely different. Would that improve it though? I don't know; it's a communication, an interaction with each person individually. I don't know, you monitor and improve communication every day" (participant 11)

Participants tried to understand patients' pre- and post-operative pain experience. Some patients overtly showed their pain while some others did not, so it was a challenge on behalf of the participants to assess and manage pain appropriately. The participants' believed that they were mostly successful in identifying the patients' experiences by making links between their own experiences and it was this which enhanced their ability to meet the patients' needs.

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“…there are however some other patients that do not communicate their pain. They are kind of passive, so we have to approach them and create the circumstances to ask them and try to find out about how they feel. Post-operatively, we have to check on them frequently and ask “how is everything?” or “how are you feeling today?” which facilitates a conversation, where they might let us know what is going on. But if we are not friendly and spark a conversation, these types of patients might not say a word. Many such patients believe it is normal to be in pain post-operatively and therefore do not verbalize it! Honestly!" (participant 2)

"…A patient might endure the pain while another might have undergone minor surgery and tell us he is in a lot of pain; the intensity and extent of the pain are experienced individually. The doctors and nursing staff must take that into serious account when assessing whether a patient is in pain…" (participant 1)

The participants respected the patients' views, and values closely cooperated with them, provided them with relevant information and facilitated them in participating in decision- making regarding their condition. The participants underlined how important the process of negotiation was to form a legitimate basis for decision-making, the outcome relied on how successfully communication had been established. However, it was person-centeredness that constituted the central element of how participants were able to facilitate participation in shared decision making.

"It is of vital importance to take into account the patients' medical record. When the patient mentions something, the nursing staff or the doctors do not overlook it! ….. That is what I also try to do myself because I am aware of the pain and how it feels to be in it! When it comes to a major operation, the patients' personal suggestions should be seriously taken into account!" (participant 3)

According to the participants' words, their painful post-operative experience made them appreciate the importance of establishing partnerships between nurses and patients. They recalled that in their own cases when they felt that their opinion did not matter to the nurses and doctors, they felt at risk and insecure.

173 “I have to mention I was a little bit disappointed and angry with the doctors, especially with the anesthesiologist… Despite having informed them that the drug had caused hallucinations, they kept on using it! This fact made me really nervous because they did not take into account my previous medical record, which I had specifically insisted on.” (participant 8)

"I asked the nursing staff why they hadn't taken into consideration the fact that I told them about Pethidine. They merely answered that they thought I was exaggerating and that's why they went on with administering the specific drug. That, in addition to the pain I was already experiencing, caused anger, which of course aggravated the pain! The vomiting went on for a day, which was the worst thing in my whole experience." (participant 6)

The participants were motivated by their personal post-operative experience to work harder, to establish an emotional connection and attach importance to things that mattered to patients through being responsible, applying new practices and improvising by using a variety of approaches.

"The fact is that we develop a kind of personal contact with the patients, which of course leads to more direct treatment, at least as far as I am concerned. My experience had a positive effect on me since I always strive to establish a connection with my patients." (participant 7).

The participants' goal was to help the patients understand that their needs were recognized and they were not considered a nuisance so they considered ways in which they could help the patients participate in their post-operative pain management. For instance,

"I am trying to guess what patients want to do to defend their wishes and protect patients' by helping them express their own opinion of their condition. In this way, decisions regarding the patients are reaffirmed and possibly reviewed. Therefore, the patient's decision is truly self-determined, rather than merely imposed by others". (participant 1)

"Most of the times, I try to start a conversation with the patients and tell them to hang in there. But if the patient is really restless and painful, then I administer painkillers." There are so many of these patients! Even their escorts request painkillers or tranquilizers to 174 calm the patients down and help them get some sleep. I do not administer drugs right from the start. I inform the patient about the situation and the options we have, and according to their desire, I check with the doctor. I also tell them to be patient and wait for a while in case the pain subsides. But if I understand that a patient is in unbearable pain, I give them painkillers. That is where I call the doctor if I realize that there is nothing that could be done from my part such as change his posture, create a relaxing atmosphere or make him calmer through conversation."(participant 4)

The participants empowered the patients to plan their own care with the help of nurses, showed understanding, allowed them to be in control and employed a variety of services to achieve the desired outcome for the patient. Thus, treatment was planned according to the patients' needs and wishes. Their personal post-operative experience was instrumental in the process, and it is clearly illustrated in the following example.

"I wanted to make my own decisions and take action. I share my feelings of pain mostly with the nursing staff.” (participant 2)

"Personally, my husband was by my side when I had surgery. I don't think that it's necessary for the family and friends to support the patient; sometimes things get worse this way. The patient needs a quiet environment to help ease the pain; they need to sleep more comfortably and have a more relaxed position. I believe that during the first twenty-four hours, even your family can be a nuisance. Personally, I felt nauseous, and I was irritated because there were too many people around. The fact that I am a member of nursing staff myself played an important role because, based on my experience, I am trying to understand patients' feelings and thoughts and discuss all the options they have." (participant 12)

It is important to note that participants consistently made a conscious effort to show their more empathetic side, notwithstanding the difficulties that they often faced.

"What I do as a profession, I try to do best. I always tell myself that it could be a person close to me lying on that hospital bed or me and so I am very attentive towards patients' needs. But their behavior is sometimes rude and entirely out of hand, I would add". (participant 5)

175 “The most important thing is that the human factor is of more importance than the system itself. For instance, the system is sometimes inefficient or inadequate when providing medicine is considered to be the standard approach to pain management. We need to be closer to the patients” (participant 3)

According to the participants, mutuality was attempted throughout the postoperative care period. It is this which enabled both the participant and the patient to grow into their relationship and learn from each other.

4.3.1.2 Subtheme 2: Post-operative treatment through proximity

The participants recognized the necessity of establishing a close relationship with the patients to have a better outcome in their treatment, as they wondered how the nursing staff could assess and manage post-operative pain especially when patients avoided expressing their real feelings.

The participants directed their attention towards the patients, by being present, open to listening and willing to act. This kind of relationship was based on the participants' ability to receive as well as give. Care, attentive understanding and support of the patients’ post- operative experience were established in many ways. According to the participants’ words:

"...when I've got time, as frequently as I can, I go back to a patient to break the ice and help them loosen up a little. If I do not this, I cannot understand how they feel to relieve their pain" (participant 1)

The particular approach through which participants introduced themselves reflected their values, beliefs and the effects they had in their effort to keep their patients safe and relaxed from the very beginning of their hospitalization.

"Hello, my name is … and I will be here for you this morning looking after you, so if there is something you need, or I can do for you, you can call me. Also, I explain to my patients that at a specified time I will treat their wounds or give them painkillers or antibiotics. Based on my experience, I understand that if patients are informed about the routine procedures, they stay calm, they can express their thoughts, worries, their queries or

176 concerns and this helps reduce their feelings of isolation as they know that I will come back for them". (participant 11)

The close relationship that the participants built with their patients was based on communication which in turn created a comfortable relationship and set the scene for trust to be developed between the patient and the participant. That is illustrated in the actual words of participant 3:

"...this is very effective in post-operative pain assessment and management procedures as we closely observe patients and get to be by their side, while forming better and authentic cooperation..." (participant 3)

The participants did not address patients according to their professional status and did not give formal or technical responses. Their responses were authentic and heartfelt. Consequently, their conversations enhanced the creation of a caring relationship promoting an appreciative dialogue which aimed at establishing feelings of security and continuity. The participants invested time and effort to approach patients properly, to make them feel safe and familiar with their situation and their new surroundings. When the participants were asked why they performed all the previous actions, they stated that:

“…These are important to me... I understand... because of my post-operative experience… The importance in patient’s psychology is to make them feel safe and calm before and after the surgery... also, I touch patients when they are in need to make them realize that nurses are there for them”. (participant 2)

The participants focused on their own emotions as well as on patients' inner feelings, a fact which revealed that personal and professional empathy was present and helped towards the creation of a trustful relationship. The participants also mentioned that touching was comforting and beneficial, as sometimes patients did not want to start a conversation and felt calmer in that way. In their own words:

"Patients feel relieved and relaxed when, for example, I touch their hand. I can feel that their whole attitude altered positively. They feel they can trust me. I do look in their faces, their eyes, or probably their grimaces. I might even say a few words of comfort and pat 177 them on the back. It all depends on the patient. If I notice anyone who is worried and stressed, I try to comfort and reassure them. In general, I communicate up to the point that I notice is well accepted. Some people might misunderstand what I am just saying, but I strongly believe, as I have been in the same position, it is the right thing to do to comfort a patient". (participant 7)

The empathy that participants developed during their interaction with their patients helped both of them to become and remain companions during the patients’ intense post-operative experience. The trusting relationship that the participants built with their patients enabled them to effectively perform the evaluation and implementation of acute post-operative management procedures. These procedures required a more holistic approach, seen through the unique existence of each patient and the subjectivity of each case rather than exclusively through the physical care perspective. The participants pointed out that each patient had experienced changes in their body, their mood and their perception of the world due to the acute post-operative pain they had experienced and this is something that needs careful consideration when devising such procedures.

4.3.1.3 Subtheme 3: Establishing mutual stable relationship

Reciprocity is another significant element that was observed in the relationship between the participants and the patients. According to the participants' views, the sharing of inner feelings and thoughts through an account of their personal, painful post-operative experience had a healing impact on both of them. It was something more than telling a story. The intention with which a story was narrated, the patients' perception of the story and the derived meaning led to common decision-making and internal change. According to this, the participant was asked to express her feelings and thoughts about the action taken and quoted that:

“..under specific circumstances where patients suffer from intense pain, get angry, feel depressed, restless, anxious or don’t pay carefully attention, I prefer to share my personal post-operative experience in order to become more credible and warm towards the patient, since they know that I have been in a similar situation.” (participant 3)

178 Participants identified that this was potentially close to the professional limits but explained that it was a personal decision and that they carefully controlled the situation as it was a technique to make the patients trust them. For instance:

"… it is nice to know that someone has gone through a similar situation and knows how much it hurts because when you are in pain, nobody sympathizes with you". (participant 7)

The participants were self-aware of the impact that their experience had on them, and as a result, they engaged with their patients by providing care, wisdom, and knowledge. The sincere revelation of their personal, painful post-operative experience led to a mutual healing process where the participant could be self-aware, and the patients' post-operative stress could be reduced. At the same time, they both benefited through the creation of a close and intimate relationship. It is worth being noted that the participants were not compelled to follow this specific behavior by their superiors or established processes since they were self-motivated to help in their patients' healing process and had to adapt to each particular situation. They retained control over whatever was being shared with the patients and used it whenever they believed it would function beneficially for the patients. On the contrary, they maintained control over whatever was being shared with the patients and used it whenever they thought it would work beneficially for the patients.

4.3.2 Theme 2: Insight and reflection on the post-operative pain experience.

The way in which the participants saw themselves after their own painful post-operative experience had apparently changed. In their own words, this change did not only affect the image they used to have of themselves but also the way through which they had constructed their personal world, that is the way they exercised their profession, interacted and cooperated with their colleagues. In the examples that will be described later in this theme, the participants expressed that the painful post-operative experience they had was the driving force that made them reflect, increased their self-awareness and understanding of their behavior towards patients and ultimately led to their personal development.

Participant 6 emphasized a behavior that had been the norm in the surgical ward where she used to work for years.

179 "I used to tell my patients for twenty years "You have just been operated on, what you expect, you are supposed to be in pain," but there came the moment it blew up in my face." Also, another statement: "I used to follow the protocol of the clinic, I wanted to finish my job which had to do with completing the allocation of tasks and administering painkillers according to doctors' orders. That's all… that was my job. I am not proud about my approach" (Participant 2) and "I didn't spend time listening to the patients or explain the whole procedure to them either pre-operatively or post-operatively. That was a mistake" (Participant 9)

The above statement suggested that the previous practice had been habitual, regulation led and lacked emotional involvement with the patient, limiting the participants to a mere completion of regular procedures. As the participants evaluated the way they used to work, they expressed surprise and criticism concerning their professional image, the quality of care, the practices and the information they provided to post-operative patients. Their hospitalization, both pre-operatively and post-operatively, gave the participants the opportunity to have first-person experience of the way that they treated post-operative patients and had now become more aware of the repercussions of their previous approach. Furthermore, lack of adequate information pre-operatively led the participants to find out as much as they could about their condition since without the knowledge and the commitment of the health care providers they felt somewhat insecure, isolated and helpless.

For example,

"Neither the physician nor the other nursing staff informed me about anything. I was alone on this. The only information I found was through the Internet search - I should have asked the staff for answers. I could not imagine that my surgery would be so painful, I did not expect that.” (participant 6)

"I knew certain things because of my profession. Also, I had read books, and I had watched some videos and documentaries on this subject". (participant 9)

"A verbal preparation and a complete briefing on how we would deal with this would have been useful. It would also have been useful to be informed of what would happen post-

180 operatively, what I would have to deal with, the severity of the pain and its gradual course after the second or third day." (participant 1)

The care that the participants received during their hospitalization was mainly based on caring for their physical needs pre-operatively and post-operatively and less on briefing and teaching the patient to prepare and accept the new post-operative situation.

It became evident from the participants' quotes that nursing care focused around the completion of their duties and their routine which was followed in their clinic and did not adapt it to meet the specific needs of each patient. On the contrary, it was expected that the participant, who was now a patient, would adapt to the health care system and not vice versa.

"After my surgery, I felt that they treated me like a protocol, they just gave me Pethidine, and that was it. There wasn't any special provision; for example, administering a different drug later, etc." (participant 10)

"I asked the nursing staff why they hadn't taken into consideration the fact that I had told them about my oversensitivity to Pethidine. They merely answered that they thought I was exaggerating and that's why they went on with giving me the specific drug. That, in addition to the pain I was already experiencing, caused anger which of course worsened the pain! The vomiting went on for a day, which was the worst thing in my whole experience." (participant 8)

“Right after the operation, because the pain was unbearable, I was administered Pethidine. Not only did this medication, not relieve the pain but it made it worse!” (participant 2)

"…due to the fact that I had undergone surgery in the past, I had experienced intense negative symptoms, like nausea and vomiting, from the use of Pethidine as a painkiller and sedative drug and therefore specifically requested not to be administered this medicine. Despite that, they seriously questioned my judgment (participant 3)

According to the participants, nursing care during the assessment and management of post- operative pain was generally dictated by doctors who emphasized managing the 181 participants' post-operative pain with painkillers. As a result, the participants expressed dissatisfaction with the fact that despite their complaints and suggestions they were frequently ignored and decisions were taken for them, not with them.

"The staff didn't do anything else besides administering drugs to manage my pain." (participant 4)

"The painkiller didn't work immediately, but afterward it made things a little better. The staff didn't try anything else apart from painkillers." (Participant 1)

"Of course doctors had already administered intravenous painkillers, which didn't work for me!" (participant 2)

"I asked for, and they administered an intravenous injection. The next painkiller was in syrup form, and I couldn't swallow it; it was of little help. I was still in pain, and I asked for another, but they didn't give me one, because it was too early for a second one." (participant 6)

"Besides intravenous and intramuscular medication, as well as epidural analgesia via an epidural catheter, the use of which had to be announced to the anesthesiologist, there was nothing else for the nursing staff to do to relieve my pain." (participant 9)

"The staff didn't try any other method to manage the pain. They came and asked me if I was in pain and I replied positively. Then they said they would administer Pethidine and I agreed; in the course of the first twenty-four hours they told me that if I were still in pain, they would administer another one." (participant 10)

The above statements imply that the nursing staff acted according to protocol and relied on their existing know-how to manage post-operative pain instead of adopting a more holistic approach based on the patients' needs.

By reliving the painful post-operative experience they had in the past, the participants became more self-aware, which made them organize their professional practice in ways to ensure that they can assist with as many patients who live through a similar situation. That is illustrated in the following words:

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“I handle it in a completely different way than before. Now I am more persistent…and I want to relieve their pain.” (participant 6)

“I’ve always had a strong opinion on pain management, but my experience reinforced it. I’ve never believed that anyone should be in pain as long as something could be done to make it bearable.” (participant 10)

“The most valuable thing, especially when practicing health professions, is that you find yourself on the other side; the patient’s side. Therefore, you can relate more to them by taking a more cooperative stance. The best and most powerful experience is that I have found myself on the patient's side; I have learned to have empathy and not to speak always from a position of power about things I've never experienced." (participant 1)

Through their painful post-operative experience, participants developed a positive sense of individual and professional self which meant that they felt good and became more positive about themselves and others as well. Findings from the interviews, which will be presented in the following themes, showed that the participants’ post-operative experience helped them develop a new professional self which was based on empathy and deep understanding towards the patients.

"I could empathize with patients and understand their anxiety, distress, fear of the unknown and everything they were about to experience because they hadn't been hospitalized before and had only experienced familiar situations in the hospital while escorting a relative." (participant1)

"...I don't support the view that nowadays a patient, after surgery, should be expected to feel pain even to a certain extent. I have been in that position as a patient, so intense pain made me suffer a lot and also made me feel anger because nurses take the pain for granted…"(participant12)

This painful post-operative experience offered the participants’ food for thought which became a stimulus for self-discovery that led to the development of their knowledge and practice.

183 4.3.3 Theme 3: Enhancing communication skills

I) Doctor - Participant

According to the participants' words, nursing care of post-operative pain was based on a medically-centered culture rather than a person-centered one. According to the participants, it was a challenge for them to maintain their new values, attitudes, and empathy towards post-operative patients (person-centered) which were values they developed after their own painful post-operative experience. The participants were efficient as regards the doctors' instructions since the Greek health care system did not give them the autonomy to administer painkillers and this was something that they made clear in the interviews. In their own words:

“The nursing staff does not have the autonomy to administer painkillers." (participant 1)

"It's dangerous if there aren't any written instructions. In case of any complications, the nursing staff would have to prove that they didn't act on their own and that they had administered the right drug. Here we only follow the written instructions of the doctor, with the patient's and the doctor's name on it." (participant 13)

"Only after a doctor’s order can we administer painkillers." (participant 4)

"Because of the nature of the system, we have to cooperate with the doctors and follow their orders because if something goes wrong, they tend to blame us! That is why we are cautious. For example, we request "please, do prescribe the drugs that have to be given to the patient” and only when this is completed, can we go on and administer what the doctors have ordered.” (participant 3)

When doctors had the last say in the decision-making process, the participants felt powerless, angry, disappointed and frustrated about the way that communication took place and about the doctors' approach towards post-operative patients. However, due to the circumstances, it was also challenging for them to find ways around the rigid procedures. For example:

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"There are doctors whose communication and cooperation level with us is excellent. However, there are two or three doctors that are, if I might say, too set in their ways!” (participant 9)

“There have been cases when the doctors were rather indifferent towards patients' pain management; although you explained, they wouldn’t put it on the schedule.” (participant 11)

“… it is a kind of disturbance if you call the doctor many times a day and complain that the patient is still in pain despite the systematic painkillers we have administered!...” (participant 9)

Despite these adversities, their postoperative pain experience appeared to have shielded them from criticisms received and they continued to strive to give patient-centered care. The way they achieved this derived from developing effective communication skills, a positive approach and did everything in their power to deal effectively with the patients’ post-operative pain.

“I have found that asking appreciative questions and encouraging dialogue about hopes, values and emotions are invaluable ways to make things better that is by building on the best of what already exists, and in this way make the change.” (participant 1)

"You didn't wait for them to talk to you about painkillers; you asked: "Should I give Paracetamol, Pethidine or what and in what dosage?" (participant 9)

“When you posed the question a little differently, they would give you a specific answer. Or they would be a little more concerned about the general situation of the patient” (participant 11)

Their personal experience filled communication gaps, and as a result, it renewed and enhanced the participants' assertiveness.

185 “However, based on my personal experience I do my best to persuade doctors to accept my descriptions of patients’ condition. But if this doesn’t work, I may contact another doctor, until I am convinced about the quality of analgesia.” (participant 1)

The participants demonstrated remarkable internal locus control over the management of the patients' post-operative needs. The level of conscious self-choices and decisions were determined by the participants themselves rather than an external control system such as a doctor-centered one prevalent in a Greek clinical environment.

"As I believe, all problems have a solution as long as we try to find one, of course. We do have the necessary personal and professional knowledge to fully comprehend the patient's problems, which would make our approach more appropriate and therefore useful." (participant 3)

The participants were not exhausted by the feelings of disappointment and pressure imposed on them. On the contrary, they pushed for further involvement in the care of the patients and for building a closer doctor-nurse relationship.

II) Participant – Nurse

The participants did not have difficulty only in their cooperation with the doctors but also with their nursing colleagues. They considered this mainly to be due to a lack of meaningful nursing leadership from the nursing hierarchy. In Greece the ward-based nursing hierarchy tends to follow the following format; Head Nurse of the ward, Head Nurse's assistant and finally nurses who are ranked according to their years of service in the health care system. However, during the nursing care practice the roles of the nurses, apart from the Head Nurse, are not strictly enforced and all nurses are responsible for all patients. This practice can lead to limited communication and the creation of friction among participants and colleagues. According to the participants' claims, the allocation of tasks is performed by the Head Nurse during the morning shift, but it is mostly based on communication among colleagues. In general, therefore, the Greek system insists on a task allocation rather than a primary nurse care model.

186 “I think it depends a lot on the Head Nurse and her assistant when they see how tasks are allocated; there isn’t much complaining. Yet, the leadership is not usually good, so there’s a lot of arguing.” (participant 11)

"…this, of course, begins every morning, with the available means of course, and proper cooperation between the members of our team. If there is no cooperation, the results will not be good enough and will have a negative impact on our team and our patients, because when there is no proper communication, pain is not handled accordingly." (participant 3)

The participants, however, did not seem to be genuinely discouraged by the existing situation. On the contrary, they stated their desire to remain true to their values bearing in mind their own personal, painful post-operative experience. The participants were fully aware of the deficiencies of the healthcare system, and at every opportunity, they tried to engineer ways to make amends through their own approach.

"Yes, many times my personal experience helped me not to lose myself again. That's why I am trying not to be so much affected by the whole situation. I tell myself that it's just eight hours… I'm going to work, help patients and then leave... I hope I will never become like those people I am blaming today: indifferent. Laughter is my defense, and I remain positive with the people who come in here." (participant 8)

"My personal post-operative experience helped me become more sensitive and emotional. Since I went through my own painful experience, I have changed my perspective completely. I have even urged the nursing staff to make an effort to see things through it. Of course, I never put pressure on anybody, but only tried to make them understand how I felt to convey my experience to our post-operative patients. Also, I take every opportunity to listen to my colleagues' difficulties and concerns about their adopting my approach" (participant 2)

However, some colleagues were unwilling, so the participants did not insist any further.

"Concerning the rest of the staff though, there is difficulty sometimes to communicate! What I do when this happens is that I pay no attention at all. I ignore them and go on with what I have to do." (participant 4)

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"I think there is a professional relationship with the other members of the team. Cooperation is vital for a good outcome for all of us."(participant 1)

Communication is central to the participants' skill set and enabled them to overcome most obstacles. The way they attempted to succeed in this was through being open to sharing the feelings they experienced post-operatively as well as the impact they had on them. They aimed to make colleagues respond to the new ways of cooperation they had invented and to be more supportive of achieving a positive result for all. Nonetheless, the participants demonstrated understanding when their suggestions could not be put into practice by the other nurses.

III) Participant – Patient/Family

Participants built a relationship with the patients and their families which would have an impact on managing effectively post-operative pain. The participants pointed out that the presence of the family members during their hospitalization, which was typical in the Greek culture, in practice was assistive to their approach.

“In Greece, for example, the institution of the family is vital, and family ties are strong. When someone is hospitalized, their relatives stand by them." (participant 5)

“I believe it is a strong attribute of our culture.”(participant 4)

The participants demonstrated understanding towards the constant presence of relatives since they recognized through their own experience that the family covered the nursing care gaps such as the emotional support and the security they provided to the patient. For example:

“My family supported me. They were trying to support me and stand by my side.” (participant 11)

“I shared my feelings with my own people. My people helped me during this difficult time."(participant 9)

188 “It only has to do with psychological factors. The fact that a patient sees their spouse or children strengthens them.” (participant 2)

“My experience has taught me that if the post-operative pain is managed effectively, the patient can function much better, their body reacts more favorably, they comply with the doctor’s orders, they cooperate with the hospital staff and their recovery is faster.” (participant 5)

“Any problem can be solved if addressed properly.” (participant 12)

“From my experience, I would like to have a family member nearby; this is the reason why I allow patients to have a person as a guest in the clinic. First and foremost for sentimental reasons and secondly for safety ones… So for both these reasons, having people by your side in such difficult situations is very important. Actually, they were my transmitters! My daughter was constantly by my side. She was the one who informed the nursing staff when I was in pain,” (participant 7)

Nevertheless, the participants were aware of the drawbacks of such relationship, since based on their own experience, the relatives usually tried to take control of the situation, on occasions, did not allow personal time and space for the patient and occasionally misinformed the nurses about the patients' condition.

"I remember my family nagging the staff, asking for painkillers and asking doctors too many questions. At every opportunity, they asked a lot of questions and notified the staff whenever they noticed something or when I was in pain. That happened because there were excessively concerned of course. I have also noticed the same behavior with other patients' relatives, but sometimes, I think they make a situation worse instead of making it better because they tend to be too supportive. That also happens when two or more escorts, on separate occasions, ask a professional for information about the same patient." (participant 1)

"Strong family ties help the nursing staff come closer to the patient and treat them like their own family. Like my family, they were next to me when I underwent surgery.

189 However, there was no need for them to annoy the staff and ask for painkillers." (participant 5)

It could be said that the presence of family members occasionally made the patient feel uncomfortable:

“Yes, my mother and brother were constantly by my side. Well, my mother did not help me that much I would say. When I was in pain, she kept telling me not to shout, and she thought that I was exaggerating. My brother was a bit more helpful and had a more positive attitude. (participant 4)

“In my case, my son who is a dentist seemed more concerned and asked if I was all right, and how I was feeling, which made me nervous. He was scared! Unfortunately yes! Seeing me in bed made him feel bad. So, it would have been better off if he wasn't there. (participant 2)

Despite these nuisances, the participants expressed their strong will to connect to the family environment of the patient, to acquire a personal relationship, to provide the family with information about the patient’s needs during their hospitalization and so willingness to prove useful in any way. For instance:

“Greek people have in general a certain attitude concerning illness; sometimes they cross the line and suffocate you. So I think this attitude contributes a lot to this behavior. Because of that, I am trying to inform the family members and set boundaries" (participant 1)

"The patient needs a quiet environment to help ease the pain; they need to sleep more comfortably, and have a more relaxed position. I believe that during the first twenty-four hours, even your family is a nuisance, I know that from my post-operative experience. That's why I try to make it clear to the family what the patient needs". (participant 2)

"I can use family members as transmitters; I tell them to call me if they notice changes in the patients' mood or temperature… Strong family ties do help the nursing staff come closer to the patient” (participant 5)

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The participants, having been patients themselves and having experienced their own painful post-operative situation recognized the advantages and disadvantages of the Greek family attitudes. As a result, they highlighted the positive elements in their relationship with the patients’ relatives and at the same time tried to cope with any negative ones.

4.3.4 Theme 4: The participants’ post-operative pain experience – a vehicle for

learning

In the previous subtheme, we saw that the participants, irrespective of their educational background, rejected the usual nursing care practices which were based on a limited number of skills deriving from a theoretical background. The participants discussed their education and knowledge about post-operative pain assessment and management and commented on the contribution of their nurse training.

“…I think that the information and the little knowledge the school (Nursing School) offer you, does not help you adopt a professional attitude...” (participant 1)

More specifically, the participants expressed that they were not aware of the pain assessment scales and in some cases, they did not know anything at all about them.

“… I have never seen the doctors or anyone else use them either…” (participant 8)

“...unfortunately I have only heard of pain assessment tools...” (participant 1)

"I am aware of these scales, but that is all..." (participant 2)

“I have never heard anything about pain assessment tools…” (participant 8)

Although the participants had no adequate professional base or the educational background as far as assessing and managing patients' pain, they rejected these scales based on their own personal post-operative experience. Their analysis accounted for the acknowledgment of the subjectivity of pain as well as the difficulty to be assessed using a scale. In their words, they explained

191 “… I mentioned it before and will say it again and again… pain is subjective and cannot be measured or estimated with the use of a scale...” (participant3)

“…subjectivity means that each case is unique and pain intensity differs among ages, gender and type of surgery” (participant 1)

"…they [these tools] seem a little silly to me…I don't think anything is missing from pain management…" (participant 11)

"...they would come in handy and might help the nursing staff conclude in the case of a cancer patient who is in pain. That is when the Pain Assessment scales are primarily used and not in ordinary cases" (participant 3)

So bearing in mind the participants comments about the lack of understanding of pain assessment management (especially management tools) in post-operative patients’ pain, one might wonder what it was that influenced their behavior and reflections. In other words, what were the influences of the participants’ personal experiences that contributed to their beliefs about pain assessment and management? It was clear from their comments that pain could not be placed into a rigid theoretical framework. Their capability to be empathetic superseded any theoretical knowledge. “…how is it possible to measure human pain… if it is strong or moderate? You have to be personally aware, which means that you need to have been in pain yourself to understand how it feels…” (participant 2)

"…A patient might endure the pain while another might have undergone a small surgery and tells us he is in a lot of pain; the intensity and extent of the pain are experienced individually. The doctors and nursing staff must take that into serious account when assessing whether a patient suffers…" (participant 1)

".. I am sensitive as a person to all expressions of pain, and despite what we have been taught in programs, it's completely insane for a person to deny another's pain, I can often see what kind of logic prevails. I have experienced this; the nurse tries to reassure me that I'm not in pain, although I feel discomfort etc. I believe this part has intrigued me... I think we become wiser through our experiences... I am one of those who put themselves in this position - that's why I have chosen nursing because I’m very sensitive to human pain - but

192 I think that your receptors work better when you’ve experienced pain than when you approach it theoretically.” (participant 11)

"Well, there was some basic help to understand the patients' pain better, but mainly I got the largest amount of help from my own pain experience." (participant 3)

“..My experience helped me manage and form a different attitude towards the patients’ pain in the first place...” (participant 6)

“Any problem can be solved if addressed properly.” (participant 12)

“My personal experience guides me when managing a patient’s pain; it has made me understand their psychological state much better, even if the surgery was for a different reason.” (participant 8)

The influence of their painful post-operative experience was holistic since it changed their behavior and in turn, their personality. The data showed that the painful personal post- operative experience of the participants led them to self-reflection and since then they have used it as a benchmark to assess and manage the patients' post-operative pain.

"One could see the pain reflected on my face since my characteristics were altered. For example, I closed my eyes, gritted my teeth. I was talked to but did not respond. I kept repeating "I am in pain!"'- "Most of the patients experienced the same things" (participant 2)

"I determined it by checking their clinical profile, their look, and their words. Also, I can understand it by the expression on their face, or when they say they are in pain and have difficulty in moving or lying down." (participant 6)

193 "…there are however some other patients that do not communicate their pain. They are kind of passive, so we have to ask them and try to find out how they feel. Post-operatively, we have to check on them frequently, asking "how is everything?" or "how are you feeling today?" which facilitates a conversation and they might let us know what is going on. But if we do not spark a conversation, these types of patients might not say a word. Many such patients believe it is normal to be in pain post-operatively and therefore they do not verbalize it! Honestly!" (participant 2)

Having had a painful post-operative experience seemed to increase their emotional intelligence when dealing with patients in the same situation. For this reason, they proceeded to assess both verbal and non-verbal expressions of the patient and encouraged him to express his thoughts, concerns, and worries.

"As I believe, all problems have a solution as long as we try to find one, of course. We do have the necessary scientific and professional point of knowledge to put to use to fully comprehend the patient's problems of pain, which would make our attitude more appropriate and therefore more useful." (participant 3)

The lack of pre-operative information had adverse effects on the patients' physical and emotional state. It made the participants recognize the need for and the importance of providing pre-operative information during their patients’ care. They decided to discuss with patients more, understand their fear of the unknown and help them become more prepared.

“I could empathize with patients and understand their anxiety, distress, fear of the unknown and everything they were about to experience because they hadn't been hospitalized before or had only experienced similar situations as visitors." (participant1)

More specifically, the participants revealed that the process of informing patients pre and post-operatively was a conscious choice that aimed to enable the patients to understand their health condition post-operatively. They attributed the reason why they chose to follow this new strategy to having been affected by their own painful post-operatively experience. They argued that in this way, they empowered the patients’ ability to care for themselves and become more independent.

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"…having experienced the fear and the agony of what follows after the surgery and whether there will be one of the staff there for me… to listen to me and help me adapt to my new condition, I choose to have sincere conversations with the patients, to explain that after the surgery they will be in pain, but at the same time I will be there to listen to them, help them out and show them how they can adapt to their new condition…" (participant 1)

“…they (the patients) themselves know how much pain they are suffering, how they feel, but also what is best for them…what is required from us is to dedicate time to find that out…” (participant 3)

What must be pointed out in this subtheme is that the participants persisted in dedicating time to patients and taught them how to handle pain, explaining how they could feel better through the application of specific breathing techniques or the adoption of an appropriate posture. However, they did not stop there. They gave advice, supported and encouraged the patients to accept and familiarize themselves with the new irreversible condition that they would have to deal with in their everyday life. In their own words:

"…today I choose to be right next to the patient, to show him how to breathe or how to sit up in bed to ease the pain…some small techniques can make all the difference and make the patient feel better…" (participant 8)

“…it is shocking when, for example, somebody loses a limb…there is a lot that he or she has to deal with… it is not only the healing of the wounds but also to learn to live with it… to do as much as possible as he or she used to… I am here to help them with that, to listen to them and to provide solutions to the problems they will have to deal with when they leave hospital… they must be prepared as well as possible…” (participant 7)

The interviews indicated that the participants had a holistic approach towards the patients' needs and they set long-term targets since they didn't just rely on carrying out the usual nursing practices. Their role was to listen, to explore the patients' wishes and help them return to their daily routine.

195 4.3.5 Theme 5: Impact of the financial crisis on the quality of nursing care

External factors can affect the behavior of many professionals. Lack of staff and supplies due to the financial crisis, as well as excessive workload and lack of time, played an essential role in reducing the quality of services provided to patients. The participants made it clear that the Greek financial crisis had a significant impact on their ability to treat patients in the way that they had hoped for.

"The crisis has adversely affected the Greek health care system. For instance, the quality of services provided has decreased due to the lack of supplies on the one hand -because suppliers don't provide material- while, on the other, the staff is more reluctant to use supplies. The crisis has affected very much the way I work because we economize on everything; we bring pens with us from home and toilet paper." (participant 10)

"There is a severe lack of staff and healthcare material, and that has certainly had a negative impact; when hospitals face such shortages, the consequences can be devastating."(participant 6)

“The national health care system is almost non-existent due to the crisis. Some years ago the level was much better.” (participant 11)

"It has affected the system, to a great extent." (participant 1)

"The Public health care system, at least in the hospitals I have worked for and from my experience, is ineffective." (participant 4)

“Hospitals are seriously understaffed!” (participant 2)

"The crisis has affected our system considerably; the situation is terrible in this hospital. Things have changed a lot during the last five years. There aren't even enough wheelchairs for the patients or stretcher bearers to carry the patients who are to be examined; only their family accompanies them. Also, food isn't like what it used to be. In general, food consists mostly of soups or meat soups with just traces of meat inside. The situation is unacceptable. There are no gauzes, or even syringes at times, or serums." (participant 8)

196

The participants pointed out another parameter they encountered daily partly due to the side effects of the financial turmoil. That was the patients' indignant, resentful and at times aggressive behavior.

"There are a number of changes we have undergone. It is true that the nursing staff numbers have declined, but so have the medical supplies and consumables. Also, there is a significant change in patients' attitude. Both patients and their escorts can be resentful and aggressive." (participant 9)

"The crisis has influenced the system in many ways. First of all, patients tend to be more indignant even when the nursing staff tries to communicate in an honest and friendly tone. To make matters worse, patients or their relatives are informed that they need to pay for the medication most of the times. That does not happen in our hospital, though" (participant 7)

Moreover, according to the participants’ claims, the financial crisis and salary reductions have affected the values and the morale of health professionals and in effect the quantity and the quality of care they provide to patients.

“I have heard colleagues say that we will only provide what we get paid for, which of course implies the minimum of effort! I have also heard similar comments from doctors!” (participant 4)

The participants expressed negative feelings due to work overload and the various tasks that each one had to undertake on top of the persistent problem of inadequate staffing.

“I can’t be in two or three different places at the same time… it is impossible for me to do my job properly”. (participant 8)

“The lack of staff is a factor which makes things a lot more difficult than they already are!” (participant 7)

The previously mentioned working conditions can paint a clear picture of the pressures they experienced in their working environment daily. Nevertheless, the way the 197 participants perceived their relationship with the others was not limited to their professional role and did not constitute a restrictive factor towards the effective, holistic, human-centered management of the patients’ post-operative pain.

"Although it hasn't affected my way of thinking and the way I work, it has had an effect on how I fully implement my duties. The things I have to work with affect the results because I don't have the material I need anymore so I cannot work properly". (participant 1)

"Of course, my own pain experience helps me manage those difficulties." (participant 2)

“It helps me manage my anger and find ways to deal with the financial situation.” (participant 6)

Despite the adverse working conditions, the participants chose to put their beliefs and values in practice. They did not hesitate, and as a result, the quality of their services remained high.

4.3.6 Conclusion

The findings of the interview portrayed in detail the intensity of the feelings that the participants had to go through during their own post-operative experience. Fear, pain, and agony prevailed. However, it was shown that this painful experience led the participants to a person-centered approach based on mutual understanding, empathy, and trust. The participants paid great attention to the creation of an authentic, quality relationship with the patients. The effectiveness of this relationship was due to the communication skills of the participants as well as the mutual trust and understanding that developed between them. The humanistic approach appeared to be the result of the participants' personal painful post-operative experience which helped them avoid adopting superficial, expected or predetermined roles. All the above seemed to have contributed to a much more effective acute post-operative pain assessment and management. Moreover, through self-reflection on the quality of the nursing care they provided to patients before their post-operative experience in the past, they were led to acquiring the necessary knowledge for themselves and their patients. Finally, they did not allow the adverse climate in the working

198 environment or the effects of the financial crisis to affect the quality of their services to the patients.

The discussion of this thesis will be presented in the following chapter.

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5 Discussion

The following discussion presents an overview of the findings of the interpretative phenomenological study and addresses its original aims. Through this discussion, it becomes clear that the present study makes an original contribution to what we know so far regarding assessment and management of post-operative pain of the patient. The aim of this study was to explore how Greek nurses' personal post-operative experiences influence their behaviour toward the patient's post-operative assessment and management. In the literature review chapter of the present thesis, the barriers to post-operative pain assessment and management that emerge are numerous, varied, and often not clearly identified. They, in turn, result in having a negative impact on meeting the needs of the patient effectively. At the same time, the current PhD research explores the contribution of human sciences to understanding post-operative pain. Humanistic models recognise the influence of a person's current experiences on their day to day life and acknowledge that these experiences can significantly influence one's attitude and behaviour, thus leading to a greater sense of well-being.

The following discussion evolves in the light of Carl Rogers and Kurt Lewin theories, pointing out the significant influence of the painful post-operative experience on individual nurses' behaviour towards patients in post-operative pain. As well as this, it considers the impact of the participants' post-operative experience on their relationship with doctors and colleagues and the way that they deal with the inability of the system. At the end of this chapter, an additional discussion on how this study could contribute to the training of nurses is cited.

5.1 Developing therapeutic relationships

Nurses who have undergone a painful post-operative experience demonstrated that the experience alone could significantly change the manner they treat a post-operative patient even if this particular manner had been the norm for decades. Furthermore, they clearly stated that it became possible to build and maintain a therapeutic relationship with the patient. It was evident therefore that through this novel humanistic approach and interaction with the patient they were able to help and encourage the patient to achieve a

200 more positive sense of being well. The unconditional positive attitude of the nurses towards their patients, an idea introduced by Rogers (1951) when discussing therapeutic relationships in terms of psychotherapy, constitutes an important starting point for the development of effective therapeutic relationships (Attree, 2001).

The therapeutic approach in question proved to be based on mutual understanding and trust as well as empathy, care and compassion (Brownhill et al., 2013; Porr et al., 2012). Although, these characteristics may have been considered as traditional concepts as far as nursing care is concerned (Richardson et al., 2016), the data revealed that the participants had neither experienced them as patients nor had they put them into practice in their relationship with their patients prior to their own post-surgical experience. It was this experience that triggered the development and maintenance of a new system of values, attitudes and beliefs. This system was reflected in the nurse-patient relationship, a therapeutic relationship to be precise which fostered the effective assessment and management of the post-operative pain of the patient.

The effect of a painful post-operative experience of the participants on the way they interact with their patients could be described through Muetzel’s model (Fig. 5.1) according to which the participants adopted three overlapping concepts partnership intimacy and reciprocity to build the therapeutic relationship (Muetzel, 1988). These concepts will be examined in detail as soon as a clarification of these terms is provided. To begin with, a partnership can be defined as a two-way process between the nurse and the patient in which they make decisions after reaching a consensus, share feelings, knowledge and expertise and above all trust each other (McCloughen et al., 2011). Secondly, intimacy is perceived as a very close personal relationship where both parties feel unique (Shattell et al., 2007; Williams et al., 2010; Zyblock, 2010). Finally, reciprocity is the concept in which both parties can benefit when each person allows something to the other (McMahon et al., 1998). A functional therapeutic relationship requires that nurses realise the benefits that can derive from an effective patient's care (Brown Wilson, 2009; Shattell et al., 2007).

201

Figure 5.1. Muetzel’s model (Muetzel, 1988)

5.1.1 Partnership

From the first moment, the participants met the patient and their family the application of nursing care was evident. Gradually, a partnership was built as they often came into contact to reach an expanded view. In other words, as the situation was reviewed, the nurse-patient relationship developed and deepened new opportunities in understanding the patient's condition occurred (Bidmead et al., 2005). However, this allegedly idyllic situation was overturned by data which proved that participants as patients did not feel that the health care providers took their desires and peculiarities into consideration during their hospitalisation. Heidegger supports that when maintaining the authenticity of a person was not a priority in the care practice then it was possible to get the impression that problems were merely solved or needs were met on behalf of others (Heidegger, 1927; McCormack

202 et al., 2016). He defines this practice as ‘defective solitude’ because one party takes over the dominant role and the other the dependent one (Heidegger, 1927; McCormack et al., 2016). The realisation of such a negative experience had a positive impact on the way in which the participants treated the patient. In particular, before any nursing practice, the participants collected information regarding the clinical, physical and social condition as well as the spiritual an emotional needs of the patient in order to have a clear picture of how the patient perceived himself in these contexts. The fact that the participants focused on the beliefs and values of patients showed the holistic and human approach adopted by the participants, an approach based on the individual needs of the patient and how they perceived their condition. Understanding the patients' values and beliefs could lead to a nursing care practice that treated the patient as a special and unique person (McCance et al., 2009; McCormack et al., 2016). According to the participants, it was not sufficient to take into account the beliefs, values, opinions and experiences of a person but also comprehend them in depth for they not only provided action guidelines but guidance and counselling tailored to the individual needs of the patient.

What emerged from the data in the present study was that the participants' behaviour was shaped based on their own post-operative experience. This experience also defined their choices as their understanding of the patients' needs became more effective which enabled them to incorporate personalised information into a care plan. Martinsen (2006) argued that it was the responsibility of health care professionals to treat every contact with another person as unique, considering at the same time factors such as the concept of individual relationships, emotional engagement, knowledge and ability to make decisions as necessary requirements in order to define our 'being in the word' (Heidegger, 1927).

In this context, the participants saw nursing from the perspective of the human condition by delving into a person's unique being and how this person experienced their condition. In this way, they refrained from regarding a person as a bio-psycho-social organism. This approach according to Paterson and Zderad (1976) constituted a primary concern and weakness of nursing science as it focused only on the care of the patient's needs. As stated by Straughair (2012), the nursing practice that promoted such a humanistic approach was based on the belief that a patient’s interest as well as their value and dignity had a paramount role and acted accordingly. Based on the above belief, the patient was not treated as a series of problems for each of which a solution had to be found. For instance,

203 in the surgical departments' standard routine where the doctor prescribed painkillers and the nurse simply administered them.

On the contrary, the participants regarded the patient in its entirety. Having, therefore, approached the patient holistically, gathered the evaluation data, analysed it in the light of the theory above and based principally on their past experiences, the participants were able to understand in depth what the patient was experiencing during their hospitalisation. As a result, the participants now considered the patient's problem as an integral part of their, post-operative experience, rather than independently.

According to Twycross (1978) attention should also be paid to factors that regulated the pain limits when under stress, fear or fatigue as the pain limits of a person vary depending on their mood or morale. The participants in question during their post-operative experience realised that their stress and fears made them more demanding when coping with their own post-operative pain. Besides, the feeling of loss of control exacerbated their stress and agony. That explained why a big part of the nursing care provided by the participants revolved around interventions that assisted in alleviating the feelings of the patient. These interventions emerged from the participants' behavioural patterns demonstrating the care measures taken to initially help patients understand the effect of medicine and the goals of the treatment. Then there was a discussion on the patient's fears and misconceptions relating to pre and post-operative experience. As well as this, the patients were encouraged in active involvement in the decision-making process. The ability of the patient to gain control of their care was consistent with the current existential philosophy which declared faith in freedom, personal choice and responsibility (McMahon, 1991).

According to Rogers (1961), a truly humanistic approach to the therapeutic process required a firm belief in the development of a person. Besides, according to Paterson and Zderad (1976), the therapist should see nursing as an opportunity in achieving the desired development.

The data revealed that the participants who had a personal, painful post-operative experience also had the opportunity to acknowledge the importance of having the ability to take an active part in decisions concerning their treatment as they themselves experienced 204 negative emotions by not having their opinion heard as patients. McCormack and McCance (2006), stressed the importance of giving the nurse the opportunity to experience first-hand the development of a responsible choice so that they were able to recognise the value of their patients' responsible choices more readily. For this reason, the participants sought opportunities to encourage the patient to exercise their freedom of choice. In this manner, the participants through a humanistic approach created essential freedom and security where each patient had the ability to participate as much as possible in the decision-making process of their treatment. To attain this Brown Wilson Zderad (2009) highlighted that the nurse must waive their instrumental role considering at the same time ways to help the patient take part in their own health care plan.

In this research, it was demonstrated that the participants followed an intuitive understanding of the patient's post-operative pain based on their own painful post-operative experience to successfully respond to the individuality of the patient revealing all their complexities. Their goal was to explore the condition the patient was in. According to Roger's (1961) humanistic approach, both participants and patients aimed to acquire a deeper understanding of each patient's condition so that they can find a common solution or mutually accept a situation rather than solve the problem. According to Schon (1983), problem-oriented nurses may have a reduced perception of the patient's overall condition, although they were still able to respond to complex situations. This according to Shon (1983) indicated that these nurses were selective in dealing with patients' problems based mostly on their professional knowledge ignoring, on the one hand, the data and on the other blaming the patients themselves considering them as problematic. It was also proved that the post-operative experience of the participants helped in cases where they could not or did not know what else to do to manage the acute post-operative pain of the patient. This experience contributed to their understanding that it was helpful for the patient to feel someone stand by them showing understanding, compassion and empathy. According to Schon (1983), this could not have been achieved by using a resolution-oriented method or by merely decomposing problems as the nurse would feel helpless in situations they did not know how to respond. Roger's (1961) quotes that the humanitarian approach was less restrictive, thus adding another positive element to what had already been developed. The goal of this proposed relationship was to assist the other recognise and develop a mechanism which on some occasions would let them free to determine their fate by developing their own strategies and on other occasions would support them in times of

205 weakness (Rogers, 1961). Therefore, the concept of authenticity, which is consistent with the philosophies of personality, appeared to be of utmost importance (Gadamer, 1975; Heidegger et al., 1962).

Summing up the findings of the research we would conclude that an effective therapeutic relationship between the nurse and the patient was achieved by the active involvement of its members in it. It was also achieved by taking a certain distance to create space so that the patients could express themselves and accept the new situation especially during periods of vulnerability for instance during recovery. It became clear from the data that the participants did not face their painful post-operative experience in a piecemeal way that was of little importance to them. On the contrary, they considered it to be a basic internal mechanism through which they were encouraged to focus on sustaining and revealing the patients' genuineness (Rogers, 1961). This was achieved by making the patient able to exercise autonomous action by reducing those factors, external or internal, that limited the full development of the patient's potential.

In the present study, it was further demonstrated that the participants influenced by their personal experience defended the unique self-being of each patient as it manifested itself. In other words, they helped the patient by providing them with all the necessary information to clarify their own values so that the decisions that would be made were truly self-defined rather than merely a decision determined by others. At this point, Rogers (1951) through the humanistic approach promoted the concept of the defence of self-being which according to Gadow (1980) deferred from either merely admitting to the patients' decisions (or simply protecting the right of patients' to do whatever they desired).

It was now evident that an essential element of communication in the context of a partnership was the pursuit of continuous discussion by the participants to inform the patient about the pre and post-operative course, offer advice, as well as encourage them to express what they consider best for themselves. This could be accomplished by granting them control and by allowing them to have a say in the decision-making care plan, a plan governed by principles that promote personal-centeredness and responsible choices. It became clear that learning from each other as equals demanded to grow in each other's capacity. In that respect, the participants built such an effective partnership with their

206 patients that allowed its further development and nurtured an effective therapeutic relationship.

5.1.2 Intimacy

Intimacy, like partnership, is a two-way process (Muetzel, 1988). Slater (2006) described it as the relationship between the person and the caregiver that ensured the valuation of the individual's personal decisions. Such a partnership is based on mutual trust which is created as a result of intimacy (McMahon et al., 1998). As it is apparent from the findings during their first meeting, both the patient and the nurse carried their aspirations and their goals. For instance, the patient was deemed to need help and the nurse expected to be of assistance. However, according to Rogers (1951), each of them was a unique entity which brought all its traits in the foreground. In the current research, therefore, it emerged from the data that the participants entered this relationship having undergone a painful post- operative experience while carrying certain beliefs about the treatment of the patient.

Nevertheless, it was not proven that the participants scheduled a relationship which, contrary to common belief, was based on various preconceptions deriving from the participants' painful experience. What happened, in reality, was that they both freely decided the kind of relationship they would have as well as how to deal with things as they happened. At this point, Rogers (1951) added that these kinds of meetings were not planned, but they were based on free will, openness and the freedom to express different views to determine the needs and the extent of assistance required. The expectation built for this kind of relationship according to Paterson and Zderd (1976) was one that generated feelings such as stress, fear, hope, satisfaction, impatience and hostility.

The humanistic approach exercised by the participants was based on kindness and compassion and emerged as the starting point of the relationship. Developing intimacy required respect for the patient's personality in health care routines (Richardson, 2016). In this context, the participants did not impose on the patients the application of biomedicine as a benchmark for categorising the patients and their needs as part of their health care practices. As Rogers (1951) claimed such approach should start with respect to the personality of the person and be based on their strengths; something that was core to being person-centred. Therefore, in the context of this therapeutic relationship, the recognition of

207 the other created a bond of professional intimacy (Richardson et al., 2015). Hannah (2014) emphasised the element of kindness that should exist in any healthcare provider-patient relationship. Besides, as McMurray (1995) claimed we have a choice as to how we connect with others. He argued that this was a choice that we could all make and the way we truly connected with others was a matter of personal decision.

A bilateral relationship resulted from the fact that the participant was at their patient and their family members' disposal. This, in turn, enhanced trust which was a way of creating an open, positive and helping relationship. This approach influenced the patient's views on health issues and their behaviour during their painful experience.

The fact that the participants offered the patients the opportunity to express their feelings, thoughts, concerns and desires highlighted their empathy and profound understanding towards their post-operative patients and the intimacy that existed it their relationship. From the data of both the observation and the interview, we could conclude that the intimacy developed by the participants stemmed from their authenticity, openness and willingness to provide information regarding their own post-operative experience as well as the way they approached the patient based on frankness and understanding.

5.1.3 Reciprocity

According to Muetzel (1988), a balanced and deep relationship between the nurse and the patient must be based on reciprocity, a concept where both the patient and the nurse benefited from it.

The data showed that despite the painful post-operative ordeal experienced by the participants, it had, on the whole, a positive impact on the patient's post-operative pain assessment and management. The positive way in which the participants focused on the various activities that concerned the care and management of the patient's acute post- operative pain showed that their stamina levels were amplified rather than depleted. McCormack and McCane (2017) pointed out that the vitality, that is, the positive stamina that a person possessed was a form of energy that a person could harness and coordinate a deliberate action plan. The participants did not feel exhaustion, or abandoned their desire

208 to respond to the needs of the patient readily and certainly did not apply themselves to the routine of the department because of the health care system obstacles.

All the above showed that activities carried out with positivism and determination led to a renewal of energy and over time added an increased sense of vitality. According to Ryan and Deci (2008), this kind of vitality had a significantly positive impact while negative energy often led to inadequate post-operative care and possibly to negative consequences. Ryan and Deci (2008) through their contact with patients the participants experienced positive emotions such as warmth, appreciation and enthusiasm as they were rewarded for the effective role they played in relieving their patients from the post-operative pain during a potentially stressful and painful period for them. It was, therefore, revealed that the painful post-operative experience helped the participants realise the benefits that emerged from such humanistic approach which they then applied in their relationship with the patients and played an instrumental role in increasing the self-confidence of the participants' actions and as a consequence, in improving their level of professionalism. In other words, the positive emotions experienced by the participants as a result of this vitality strengthened reciprocity which according to Meier (2013) was in turn reinforced by activities that met basic human needs such as human connection, capacity and autonomy.

According to Sherwood (2000), the strengthening of reciprocity improved the therapeutic relationship between the nurse-patient and their family members that was necessary for the provision of holistic care. Thus, the practices followed by nurses after their post-operative experience appeared to take advantage of every contact with the patient by spending more time on the patient. This was evidenced to have a positive impact on the effective evaluation and treatment of the patient’s post-operative pain. Last but not least, any improvement in the balance between effort and rewards was conducive to the strengthening of reciprocity, an approach which was of vital importance to the achievement of successful therapeutic care (Li et al., 2013).

5.2 The role of reflection in the therapeutic approach

In order to achieve a mutually beneficial therapeutic relationship, the participants must reflect into themselves in order to balance both parties' priorities and apply intimacy safely and effectively.

209 In the field of humanist psychology, it was worth quoting Carl Rogers (1961) theories on person-centered therapeutic relationships so that the reader understood how the self- reflection process was achieved and how it affected the participants' attitudes and behaviour in developing an effective therapeutic relationship. Carl Rogers quoted the three selves: the organismic self, the ideal self and the self-concept (Rogers, 1959). The organismic self is the true self which grows and matures with us and is aware of its needs from its environment and its relationships (Rogers, 1959).

Secondly, the ideal self is how we see ourselves and what we would like to be affecting consequently the degree we value ourselves, and finally, the self-concept which is a set of ideas and beliefs that we hold about ourselves (Rogers, 1991).

As far as the self-concept is concerned, it is influenced by external factors such as other people's attitudes, values and experiences (Burns, 1979).

The need to feel loved and accepted as our concept of self-development through experiences and interactions with others leads to the organismic self or the real self be neglected in favour of our self-concept (Rogers, 1959).

However, routine and mundane tasks in the nursing practice often led to losing the concept of "I" or "self" and therefore the reflective consciousness (Morgan et al., 2012).

According to the findings of the present study habitual behaviour tended to deprecate the cognitive load with an adverse effect on task completion and decision-making in the context of the humanistic approach. It was also observed that the participants shunned emotional involvement in their communication with the patient and resorted to mere completion of regular procedures without isolating any personal feelings that emerged.

Roger maintained that while the self-concept was influenced predominantly by external factors, the organismic self was influenced by internal ones such as our values, resulting in an inconsistency in ideas and feelings (Rogers, 1961). Burns (1982) argued that the concept strived to keep things consistent, set the framework for the interpretation of experiences and delivered a set of expectations. Failure to maintain consistency created a degree of dissonance and discomfort encouraging the person to work towards maintaining harmony and comfort (McMahon and Pearson, 1998).

It was often these factors that led a person to engage in reflection. According to Arygris and Shon (1974) when this kind of reflection was incorporated into the nursing practice, it

210 helped the nurse to review any incongruities between the practitioners' actual behaviour (theory-in-use) and their perceived behaviour (espoused theory).

In the current study after their painful post-operative experience, the participants reported a change not only in their self-image but also in the way the exercised their profession and interacted with others. It was their post-operative ordeal that provided a motive for them to reflect, increased their self-awareness and empathy and contributed to their personal development.

In therapeutic agreements, the notion of self was of paramount importance since when patients were physically or psychologically upset the most arresting change reported occurring was a change in self-concept (Dawason, 1998).

Fiere (1972) supported that, in such therapeutic agreements the goal is to bring the authentic self to the surface. The authentic self could be found in true desires, emotions and original thoughts (Rogers, 1961). To manifest itself, a person needed to become a responsible human being aware of their identity (Rogers, 1961). According to Heidegger (1972) as soon as the authentic self became independent, it could then become responsible for being-in-the-word. Furthermore, Rogers (1961) argued that the desire to be our true selves required the most profound responsibility.

In a therapeutic agreement both the organismic and authentic self needed to emerge in order to achieve the materialisation of the authentic self of the person-patient (Rogers et al., 1991). It was the role of the nurse to achieve that by surpassing their self-concept and image. This process involved the ability to monitor their inner world, their thoughts and emotions as they arose (self-awareness) and a heightened sense of self-awareness (self- consciousness) (Rogers, 1959).

The most essential skill in developing self-awareness and self-consciousness was self- reflection. It was the most effective way to rediscover the "I" in habitual behaviour (Menzies-Lyth, 1988). Self-reflection assisted the practitioner in amending their identity especially in relation to themselves, the patient and others rather than in relation to their surroundings (Freshwater, 2002). The practitioner needed to realise that self-reflection made them realise the loss of self which became apparent with physical and psychological consequences such as extreme tiredness, dissatisfaction and loss of motive (Rogers, 1959).

211 The absence of reflection after or during the condition does not constitute deliberate practice (Rogers, 1959).

During appraisal of their previous practices, the participants expressed surprise and dissatisfaction for the image of professionalism they conveyed and the quality of care they provided to post-operative patients. This appraisal helped the participants realise the importance of intentional action in order to alter their behaviour.

When this action was internal, it aimed at influencing the actions or behaviour of the patient. However, it was not always intentional because care plans did not involve mental processing by definition. In other words, self-reflection did not take place.

This was verified by the participants' comments who had in the past embraced the way the surgical department operated without questioning its routines which meant that they unintentionally followed reparative procedures when dealing with acute post-operative pain. These practices resulted from the data and came to the participants' attention only when they were treated as patients themselves.

Through their understanding of their personal experiences and beliefs, they pictured their previous practice towards post-operative patients and realised that nursing care was based more on meeting physical needs and less on providing information and psychological support to the patient during their post-operative condition. Therefore, it became apparent that care centred around their duties and routine not adapted to the patient's needs. That made the participants, being patients themselves, realise that they were the ones who had to acclimatise to the health care system, not the system to them. Such understanding stemmed from the ability of the participants to reflect not only what they had learned from their post- operative experience (cognitive dimensions), but also on the feelings and motivations associated with the experience (affective dimensions) and what they did to accomplish that (behavioural dimension).

This reflection led to a fully self-regulated individual. Bandura (1991) stressed the role of self-regulation (the ability to act in one's long-term best interest, consistent with one's deepest values (Stosny, 2011) and self-influence (the ability to have control or influence our beliefs and expectations) as motivating factors in resolute decision-making. In addition, the practice of reflection offered the practitioner the chance of self-observation and monitoring of self-efficacy (commonly known as confidence) assigning the self a

212 central role in the process of creative, self-ruling and responsible practice. Such essential skills (self-awareness, self-consciousness and self-efficacy) could lead to effective therapeutic nurse-patient relationships (Muetzel, 1988).

Above all, only by knowing self as caring could one understand in another what was understood in oneself (Freshwater, 2002).

Resolute decision-making requires positive self-esteem (Mutzel, 1988) which was critical to the nurses' autonomy in assessing and managing post-operative pain. However, it was reported that the medical-central system did not provide nurses such autonomy and that led to lowering self-esteem and subsequently the efficacy of the nurse. As soon as the nurse acknowledged the importance of self-esteem to relationships, they tried hard to build or strengthen both their own self-esteem and that of their patients. The participants improved their own self-esteem by being with patients which allowed them to become aware of themselves through the variety of different experience including as Taylor (1988) suggested self-likeness (when people saw themselves mirrored in other people). Through self-reflection of their previous painful post-operative experience, the participants were able to develop self-knowledge and consequently see themselves mirrored in all the people whom they interacted with receiving love and trust from their patients and scepticism from their colleagues as the data suggested.

However, such scepticism did not discourage the participants to build a close therapeutic relationship with the patient or made them hide behind their professional mask. John Dewey notes that we do not learn from the experience but from reflecting on the experience (Dewey, 1933). According to Rogers (Rogers, 1961) in order to begin to understand, empathise and help the other person the therapists needed to be aware of themselves through self-reflection that is by evaluating their feelings, behaviour and cognition (thinking) thus improving achievement and performance and reaching their full potential. This potential was characterised by intentional or unintentional practices (Freshwater, 2002). In other words, the participants' experience affected their attitudes and beliefs and contributed to assisting their patients by sharing their experiences and creating a close relationship. Recollecting their acute post-operative experience made the participants reflect upon themselves becoming more aware of themselves as professionals or patients and enabled them to review their routines and practices and guide them to a new course of action and self-improvement.

213 Muetzel (1988) supported that the ability of the nurse to participate in a therapeutic relationship depends on her development not only as a person but also as a professional. According to Freshwater (2002), the practice of therapeutic nursing should become an essential component of routine nursing practice and provide the basis for all nursing practices especially when it came to therapeutic relationships.

Barton (2000) argued that reflection and reflective practice enabled nurses to express their knowledge freely and minimise the theory-practice gap, knowledge which was based on personal experience. A reflection of the participants' personal responses influenced by their acute post-operative experience helped them to understand the problems associated with health care system practices. Their knowledge was conducive in enabling the therapeutic use of self and according to Carper (1978) necessary to establish a connection and remain connected with each patients' condition.

Nursing care could be adversely affected when there was a lack of reflection on action especially when negative feelings towards others were present (Johns, 1993).

The ability to self-reflect and be self-aware could expand consciousness and assist in pattern recognition (Rogers, 1961). The ability to perceive existing or emerging patterns was one of the most essential skills in decision making as well as understanding and demonstrating empathy to others (Freshwater, 2002).

As people matured emotionally their characteristics, qualities and abilities to define themselves shifted towards what Newman called a choice point (Bateman et al., 2014). In other words, as consciousness developed choices become more intentional, and self- awareness was heightened (Freshwater, 2002). In this manner, the participants of the current research heightened their self-awareness and self-consciousness to a point where a change in the way they assessed and managed post-operative pain was imperative, and that could be accomplished by making responsible choices not based on standard routine practices.

When self-consciousness extended beyond physical boundaries one could be describing transcendence, during which one reinforced their connectedness with other human beings and felt less obliged to conform to prescribed rules and regulations (Freshwater, 2002). Every human being possessed the quality of self-transcendence (a process of personal 214 transformation), and its experience could help patients deal with suffering and assisted nurses in offering a holistic approach (Haugan et al., 2012). Current research proved that the participants’ post-operative condition constituted such experience which could become the driving force for change. This change called for new rules and new rules called for caring which was paramount to nursing and required the highest form of self-awareness that was of acceptance, compassion and empathy (Newman, 1994).

Finally, from the data, we understand that the participants acknowledged the value in helping the patients develop new patterns of connection. They also acknowledged the fact that a heightened consciousness allowed them to form a healing environment which facilitated self-transcendence and developed a reflective practice, which was in its purest form, thinking about or reflect on one's actions that is, what one did and what happened and decide from that what one would do the next time differently.

It could be seen that reflective practice had immense benefits in developing self-awareness which in turn were crucial in developing a deeper understanding of others and thus promote active involvement in work processes. In addition, it improved the participants’ ability to be alert and quick to notice other people’s patterns.

5.3 The role of interpersonal relationships in holistic person-centered care

When one discusses the concept of a person-centred approach, one tends to consider the nurse-patient/family relationship. Nevertheless, the principles that govern such relationship also apply to the relationship nurses have with their colleagues. What that implies is that nurses should devote time and effort to building positive relationships not only with the patients but also with the other members of the healthcare team. That should not prove extremely challenging since the standards of respect and value that apply to patients also apply to their colleagues.

In the current study, the absence of such relationships was mainly due to their environment for instance high workload, staff conflict, lack of time, support and autonomy, as well as existing practices and stereotypical relationships. As a consequence, after their own post- operative experience, it was a challenge for the participants to maintain their new values,

215 attitudes and empathetic behaviour and establish effective communication in a hectic health care environment where staff were frequently stressed.

Effective relationships require effective communication. Effective communication requires high interpersonal skills as well as awareness of self and others (Brooks et al., 1993). However, the knowledge of communication the nurse acquires is through clinical practice from colleagues and head nurses who themselves possess only too often inadequate communication skills training (Bramhall, 2014).

Under such circumstances, interpersonal relationships can become difficult although it is evident that performance in health care also depends on the ability of the nursing staff to effectively interact not only with their colleagues but also with their managers (Shelton and Darling, 2001). As well as this, such relationships at work have a positive impact on both the nurse and their environment as they can improve not only performance but also individual attitudes to job commitment and engagement (Rickard et al., 2012).

Effective communication minimises the possibility of making mistakes and can successfully manage conflicts, misunderstandings and confusions among colleagues at the workplace (Bramhall, 2014). In this study, the participants realised the problem of ineffective communication as soon as they decided to remain true to their values, challenge existing practices and apply a more humanistic and authentic approach to their patients. As a result, they had to get along without full support from their co-workers in their effort to establish positive communication with the patients and provide holistic care. The participants realised the benefits that derived from effective interpersonal communication and set about to achieve this by being open, share their own post-operative experience and the effect it had on them. Also, by developing appreciative dialogue and by careful listening. According to McCormack and McCance (2017), openness, patience and optimism can help nurses establish better communication with colleagues and therefore more positive interpersonal relationships.

Obakpolo (Obakpolo, 2015) argues that there are four contributing factors towards building effective interpersonal relationships and communication. Firstly, openness; that is the extent to which individuals are willing to share feelings and thoughts with their colleagues. Secondly, trust; that is the extent to which individuals believe their colleagues 216 are truthful and encouraging. Thirdly, owing which refers to the degree of responsibility that someone can assume every time problems arise. Finally, the risk of experiment, which is the risk that one is willing to take for adopting a new approach or practice instead of following an existing or approved one. The participants in this study appeared to have taken into consideration all the above factors after their own post-operative experience realising that effective communication among colleagues should be based on a person- centred approach and had a noticeable impact on the patients.

During appreciative dialogue, the nurse employs a range of communication skills in order to keep the dialogue focused and disengage their colleagues from their present stance (Rowean, 2001). Bramhall (2014) acknowledges specific communication skills to keep the conversation focused and engage the listeners actively. One of this skills is to empathise, that is to express empathy to the other person's feelings. Another skill is to listen carefully and pay close attention to crucial verbal and non-verbal signals. Besides, employing pauses and silence gives the listener the necessary time to process information and become more actively involved in the conversation. Sometimes, a small word or gesture or even a simple nodding can be enough to progress the discussion. Another essential skill is reflection, which in practice means reflecting back to the other to ensure that understanding takes place and important points are highlighted. Last but not least, a skill that can have a severe impact on successful communication is active and empathetic listening which implies a continuing effort to achieve an understanding of the other's awareness (Stewart, 1983).

The participants, through dialogue, were willing to elaborate on their experience and justify their choices. They focused on the present and the derived benefits from these choices. They were also eager to acknowledge their colleagues' different point of view and engage them in reflection to find out their reality and the reasons for keeping to their existing practices. Above all, in the context of a meaningful dialogue, they agreed to disagree to promote acceptance and a peaceful relationship.

According to Gadamer, an individual who listens is basically open. Successful listening implies speaking the same language in linguistic terms. Since language itself is a tool or a way that people use to represent and engineer their reality (world), an awareness of linguisticality can help a listener stay focused on the present and discover, during the course of the conversation, the intentions or attitudes of the speaker.

217 The openness and active engagement of the participants in true and empathetic dialogue through active listening was a successful way to reveal attitudes concerns or questions from their colleagues.

In conclusion, it is necessary to overcome any communication barriers and strive for a person-centered nursing framework within the care environment. Achieving this requires, working interpersonal relationships, willingness and ability to share, taking risks, compromising, being supportive and above all fostering authentic relations among all the persons involved in the clinical environment. One ought to always bear in mind that problematic interpersonal communication and relationships often have negative consequences not only for the nursing staff but also for the patients.

5.4 The role of education in therapeutic nursing

Three decades ago Watson (Watson, 1985) argued that advanced knowledge of health and nursing was crucial to enhancing the practical skills of nurses. Such notion is still supported in our days as many studies claimed that the more educated the nurse was, the more effectively they could respond to the patients' needs (Abdalrahim et al., 2011). Despite the participants' higher degree levels, they had a superficial theoretical background regarding pain assessment and management and as the data revealed they were inadequately informed about pain assessment scales. Their post-operative experience gave them the ability and skills to assess and manage patients' post-operative pain effectively, rejecting these scales. Besides, it enabled participants to teach patients and shared knowledge with them.

Bearing in mind the lack of theoretical background in post-operative pain assessment management, one wonders what influenced the participants' behaviour. It was evident from the data that first, post-operative pain could not be placed into a rigid theoretical framework and therefore it was difficult to assess using a scale. Secondly, participants' experience heightened their self-awareness and self-confidence enough to implement an effective care plan without using scales as they expressed a solid understanding of a patient's pre and post-operative condition. In particular, the participants employed cognitive learning to reflect on their experience, justify and explain their thinking,

218 encouraged discussion about what was being taught and improved patients' understanding or recall.

On the whole, teaching a patient according to the cognitive learning process gave the patient the ability to process information through perception which in turn influenced behaviour and helped the patient understand and accept not only their current condition but also the importance of their involvement in a therapeutic plan (Mutzuel, 1988). The current study showed that most of the teaching aimed at helping patients to make more independent and responsible decisions about their health. However, to effectively accomplish that according to Rogers the learning process had to be carried out in a meaningful way for the patients (Rogers, 1994). Watson (Watson, 1985) additionally, supported that this type of teaching required skillfulness teaching just because it took much effort to process information and put it into a practical perspective.

According to Delhs (2006), there was a discrepancy between proposed care plans and their implementation. In other words, nurses did not always take an active approach to post- operative pain management. Also, Bendall (1975) proved that this discrepancy could be found among patients who may acquire the knowledge to make more independent and responsible decisions about their health but may not turn this knowledge into a change of behaviour. In the current study, however, there was a close correlation between the words of the participants and their actual behaviour. In that respect, the participants managed to successfully share their new knowledge in a meaningful way, and that had an impact on patients' behaviour.

The participants were convinced that teaching was not only about acquiring information but also converting it into knowledge. They were also convinced that the best way to accomplish that was to help the patients find the most effective way for them to learn. Nevertheless, according to McMahon (1991) on occasions, it was up to the professional to decide when it was appropriate to share their knowledge and that depended on how the professional believed the individual would manage this knowledge. In this study, the participants did not expect the patients to process information without questioning. On the contrary, they aimed at sharing information and discuss its impact. In this case, according to Rogers (1974) teaching was perfectly acceptable. As well as this, the participants did not take advantage of their status to influence the patient's behaviour or argue with them when

219 the conditions for learning were not optimal. Otherwise, according to Rogers (1974), such attempts tended to have a short-term effect.

Carl Rogers (Rogers, 1961) believes that people learned effectively when the incentive came from the people themselves. In that respect, the participants in the current study acknowledged their lack of knowledge concerning the pre and post-operative period and tried to make amends. Roger maintained that the motive for the learner was internal even when the stimuli were external (Rogers, 1961). In addition, he stressed the need for personal involvement in the learning process as far as the emotional and cognitive aspects were concerned.

The participants' behaviour after their post-operative experience turned to spend time with patients in order to help them adapt to their condition, but they regarded the patient's willingness to absorb knowledge a key learning factor as it had been for them during their post-operative period. Roger believed that the facilitator had the ability to help the learner evolve (Rogers, 1961). Nevertheless, a personal commitment was a requirement for the success of this effort.

According to Burnard (1985) and Bound et al. (1985), individuals learned not only from their current but also from their past experiences. Based on that premise the participants of this study shaped their new behaviour strategy after their own acute post-operative experience. This new behaviour strategy enabled them to give the patients the means to care for themselves and become more independent. Participants quoted that this was attainable by sharing information with the patient helping them in this way to adapt to their new condition, deal with their stress pre-operatively and empower them to take an active role in the therapeutic care plan.

Participants were convinced that sharing information with the patients had a positive therapeutic effect, for instance, it could primarily reduce their anxiety, or help them come to terms with their new condition, notwithstanding the current conditions as this course of action proved advantageous in the participants' case. However, Benner (1984) expressed the opinion that one had to decide on the optimal circumstances to share information to avoid having an adverse impact.

220 These particular experiential learning methods were based on learning through experience or through reflection on doing (Gadamer, 1976; Rogers, 1961; Freire, 1972). Although the participants had a more conventional background and were not entirely familiar with this method of learning they had the willingness and flexibility to reflect on their personal post- operative experience to learn and use this knowledge to help the patients to take an active role in learning.

During the learning process, one needs to consider the importance of not only the learner's experience but also the wealth of experience the participant could bring to this debate (Gadamer, 1976; Rogers, 1994; Taylor, 1014).

According to Rogers (Rogers, 1994), the goal for the facilitators was to improve their self- awareness and skills and adjust their experiential learning methods to cater to individual needs. This could be best accomplished through the tutorial teaching method which according to Watson (1985) was most common in clinical practice compared to the didactive teaching where the learner played a passive role. The primary goal of the tutorial method was to make learning more interactive, focus on patient's perspective and help them develop self-directed, reflective skills (Rogers, 1994). In this context, the participants considered post-operative pain as subjective and unique and therefore difficult to access and manage by using the existing pain scales.

They maintained that only through hands-on experience and reflection could they understand and empathise with the patient and consequently use this knowledge in experiential learning process thus, making tutorials more effective.

Watson (1985) regarded this type of interpersonal learning process as crucial in every nurse-patient therapeutic relationship. In such relationship teaching and learning goals were set in a new perspective and each of them became a teacher and a learner at the same time (Rogers and Freiberg, 1994). In other words, both of them had the opportunity to share knowledge and reflect on their experience. In this study, both the participants and the patients shared their personal, painful post-operative experience, had the opportunity to develop their understanding of the situation through reflection and discussion, conceptualise it and plan a course of action.

221 The participants’ behaviour (to share their personal post-operative experience) followed the implementation of what they themselves had learned during their post-operative experience.

Kolb's experiential learning cycle provided additional insight into the course of effective learning followed since he refined the concept of reflection, already developed by Rogers, adding an extra stage, called ‘Abstract Conceptualization' where learning involved using logic and ideas, rather than feelings to understand problems or situations.

In the current study, the participants created an emotional, friendly and supportive learning environment where they could work together with their patients in order to share their thoughts, feelings and views during their post-operative treatment. The participants' personal, painful experience gave them the means to recognise the learning needs, set the learning framework and determine when the patient was mature enough to learn. However, we should bear in mind according to Rogers (Rogers, 1969) that teachers should build a learning environment which gives the learner the freedom to learn and express themselves but at the same time sets the framework within which the learner is free to operate.

Negative emotions such as stress, mainly due to lack of information, the participants experienced provided a motive for them to develop learning methods to share knowledge with the patients and help them change attitude and behaviour. This change demanded considerable effort and dedication to the cause (McMahon and Pearson, 1991) and this was mainly due to peoples' reluctance to change (loss of face, loss of control, excess uncertainty, concerns about competence).

Finally, the knowledge the participants shared with the patients helped them not only to alleviate their negative emotions but also enable them to operate on their own devices. Consequently, the participants were able to perceive the significance of experiential teaching and the creation of a therapeutic relationship in an environment not so favourable to this new approach.

5.4.1 Education Proposal

Despite the developments in the field of nursing science, training nurses to effectively meet the patients' needs to assess and manage post-operative pain from a therapeutic perspective

222 has been proved inadequate. One possible reason, according to Freire (1972), was that during training, learners did not realise that they were biased by existing conditions that made them behave and react in a particular way in their current practice. Thus, the therapeutic approach should be taught and applied during their academic studies and follow the nursing students throughout their carrier (Richardson, 2018). Successful instruction of therapeutic approach needs to move away from the "monologue approach" where there is no interactivity with the learner and be taught through a student-centered approach (Rogers, 1961). The above implies that the teacher remains non-directive but an equal partner in the process (Lobrot, 1992). In this way, the facilitator can develop a genuine and transparent dialogue where kindness, compassion and empathy emerge and can be further explored (Rishardson (2018). This offers the learner the opportunity to rise above the standard practice, make more autonomous decisions, act with honesty and communicate more clearly (Adamson, 2014). It also favours critical reflection which is an extension of critical thinking and key to enabling learners to develop greater self-awareness (Rogers, 1951). It becomes evident that educators have a responsibility to carefully build a critical pedagogy framework that is to design a nursing curriculum which will provide nurses with the necessary knowledge, inspire them to act therapeutically and prepare them to meet the difficulties of modern nursing practice.

The revised Muetzel's model that is proposed by Richardson (2018) and Percy et al. (2018) is an attractive modern pedagogical approach, according to which the educational experience focuses on partnership, intimacy and reciprocity. It prepares the ground for a real dialogue and according to Richardson (2018) encourages more profound learning and consequently leads to creating caring, compassionate and empathetic professionals.

At the same time, it helps the learner develop his critical thinking, reasoning and problem- solving skills (Rogers, 1969) which are key factors in professional nursing practice. Therefore, it is imperative that curricula be designed following the principles that govern person-centred learning frameworks (Rogers, 1994; McCormack, 2017).

The non-directive teaching model places the student in the centre aiming at creating an atmosphere of empathetic communication in which the students can perceive and develop self-direction (Williams and Stickley, 2010; Joyce et al., 2014). The model best applies to small encounter groups where the students are given every opportunity to express thoughts and views in a warm and responsive environment, to be heard and understood without

223 prejudice and be allowed to develop their own ideas and creativity (Rogers, 1994). Effective conversation means attentive listening and understanding each other despite the differences in their experiences as the primary goal is meaning rather than truth (Bohn, 1985). During attentive listening of personal post-operative experiences, the students are encouraged to reflect further by asking questions aimed at forming a holistic perspective rather than engaging in analysis.

At this point, an interpretive approach to listening can be of benefit both to the listener and the speaker in several ways (Stewart, 1983). First of all, it introduces two elements: the psychological, which refers to what is in them and the communicative, which refers to what happens between them. The second benefit is that this approach can teach perception checking, i.e. mirroring, repetition and reformulation in order to maintain focus without having to guess what the speaker means. Another significant benefit is that emphasises the productive and creative quality of conversation (Stewart, 1983).

The intensity of human experience during reflective discussion surfaces not only the unique self but also the collective self (Sedikides et al., 2011). At this stage, members of the encounter group become deeply emotional releasing their feelings openly, and this enhances learning (Brookfiled, 1990). In such courses, a warm and responsive environment is developed where instruction is based upon human relation rather than subject matter since the model is non-directive and person-centred (Rogers, 1994). As such, it creates positive and unconditional human relations where the focus is on ‘we' instead of ‘you' (Rogers, 1994).

The teaching methodology calls for extensive discussion, exploration and integration that can lead to new ways of exploring a problem, developing insight, planning and decision- making and consequently integration in contrast to the existing models of learning (Rogers, 1994). At this point, it should be noted that the closer the learning resources relate to the encounter members' life experiences the more they are motivated to achieve personal integration and honest self-evaluation (Joyce, Weil & Calhoun, 2009).

Rogers (1951) argued that self-esteem was pertinent to all persons and necessary for developing a healthy sense of self. According to Freshwater, self-esteem was a learned ability which student nurses could develop when they found themselves in an environment 224 surrounded by complete confidence and respect (Freshwater, 2006). During reflection, nursing students were more aware of any pressure or intimidation exercised by the professional nurses in a clinical environment (Freshwater, 2006).

Since the teaching model is non-directive and person-centred, the educational aim is to develop independent learners and foster subjectivity throughout the entire learning process (Brookes & Grundy, 1988). This is achieved by providing fertile ground for structuring, reflecting on, and enhancing their study proposal.

The aforementioned teaching model is extremely interactive lending itself to establishing several learning aims in a pragmatic setting (Mc Gaghie, 1999). A primary concern of this model is to help nursing students to acquire a deeper understanding of themselves in order to learn to assess themselves and consequently develop a strong personal identity. This is an essential stage in learning how to care and value others in a relationship as well as in developing a professional identity (Moola, 2017). To accomplish this, Rogers argued that a person should feel fully accepted, without judgment, but with kindness, understanding and sympathy in order to face themselves and build the courage to abandon their inhibitions and confront their true self. Wagner (Wagner, 2000) argued that the science of nursing implied connecting the true-self with their professional-self. According to most theoretical definitions and practices of caring, the self was considered an essential element in creative and versatile therapeutic relationships (Moola, 2017).

In order to develop appropriate caring practices, nursing students in for instance encounter groups should be given time to conceptualise the notion of caring from their point of view. Simultaneously, they are encouraged to consolidate their beliefs and values as well as their willingness and commitment to respond adeptly to the patients' needs whenever needed forming a sound therapeutic relationship (Freswater, 2006). Forming encounter groups constitutes a strong proposition and the element of knowing themselves should be an integral part of any study curricula since this study showed that this element emerged from nurses' personal and professional experiences.

The role of the educator

Joyce, Weil and Calhoun (2009) emphasised the fact that the teachers respected and allowed the students to participate actively so that, according to Dewey (Dewey, 1983), they could build knowledge on their own, develop their own rationale and creatively 225 channel their own educational decisions. To accomplish this, the teachers needed to build knowledge around student experiences and not on set references to techniques and academic material. More specifically, teaching propositions should be following each student's needs in order to help them ultimately make personal progress in learning (Brookes & Grundy, 1988). The teachers themselves ought to create a setting of empathetic communication, encourage students to evolve the learning process and urge them to shape their own (Rogers, 1961). In this context, the teacher is advised to urge students to develop abilities such as establishing their learning objectives, choosing the right learning material and method, set and record their learning progress and assess its effect.

Any changes in the student curricula should be considered under the social and political nursing spectrum since this is the only way for the students to define their self as persons and nurses in order to develop a healthy sense of self. Developing such self enabled the students to accept changes as opportunities for improvement and adopt a more forethoughtful attitude. The teacher should foster encouragement, validation and support rather than simple instruction to engage their students in a more active, self-directed learning involvement (Joyce, Weil & Calhoun, 2009). However, this teaching method demands that the teacher be aware of each student's traits, their abilities, inner world and learning requirements (Joyce, Weil & Calhoun, 2009). This is necessary in order to attain a mutual relationship from which the student can reap the full benefits of this teaching method and therefore reach their full potential. The values that govern such relationships are fairness, sincerity and trust.

Non-directive teaching proposals thoroughly explain the educational procedures, the role of the instructor and the benefits for the students to prepare graduate nurses who act in a person-centred manner (McCormack, 2017). After all, the principal educational aim lies in shaping a fully functioning person that is one who is in touch with their personal and intimate emotions and wishes (Rogers, 1969).

The implementation of such an education proposal consists of four phases:

Phase One: Forming encounter groups

The creation of personal development encounter groups among nursing students aiming at producing good listeners, physically and mentally present and attentive to every member of 226 the group so that whatever occurs within the group is strongly suggested. As a result, every member of the encounter group can effectively assess themselves and others. This is a prerequisite to the development of a person who acts with empathy and insight.

Training within these personal development encounter groups is conducted in the presence of a leader who is drawn from various health care professional groups (doctor, nurse, or psychologist). The techniques employed within the encounter groups include role-playing, repetition, questioning, reformulation and proposition.

1) Role-playing

This technique allows the person to assume the role of another and mirror their attitudes and behaviours. It can take place in groups of two each attempting to present and evaluate conditions authentically.

2) Repetition

The technique of repetition is employed by the leader who repeats each person's words to backchannel the person and help them consolidate his utterances and feelings.

3) Questioning

The technique of questioning involves questions by the leader and every other member of the encounter group in order to make what is being stated and shared apparent not only to those who listen but also to those who speak.

4) Reformulation

The leader briefly but precisely reiterates what the members of the encounter group stated and shared.

5) Propositions

Propositions are made by the leader and are exclusively based on each member of the encounter group's wishes.

Phase Two: Sharing post-operative experience from people who underwent surgery.

During the proposed training sessions, nurses or people who have undergone surgery are welcome to share with the members of the encounter group their post-operative experience, the effect it had on assessment and management of patients' post-operative pain and on their relationship with them and the health care providers. The guests reflect on their feelings of how they felt as patients, their fears and concerns and the problems

227 they possibly had to resolve usually due to inefficiencies of health care system or due to the nurses' approach.

Encounter groups

On completion of sharing post-operative experience, it is recommended that the nursing students share the feelings that arose during the narration, their inner thoughts, concerns and queries. It is also suggested that the nursing students share moments of identification with a guest's post-operative experience as well as share, if any, their own post-operative experiences or one of a person close to them.

The role of leader

The role of the leader in this process is recommended to be non-directive. Instead, they listen and empathise. They encourage nursing students to express their emotions without exercising judgment or label feelings and convictions as positive or negative, good or bad. In addition to this, the leader highlights and discusses all the issues that concerned the students.

Phase three: Nursing students’ clinical practice in surgical wards.

In order to have an objective picture of what takes place in the surgical wards, nursing students visit hospitals in small groups escorted by a supervisor. This procedure has a dual benefit because they have the opportunity to see how they interact not only with the patients but also with the health care providers and the working environment.

a) Interaction with patients

It is suggested that each nursing student, under the presence of the supervisor, is responsible for one patient during the clinical practice session. In order to respond effectively to the needs of the patient, the students should be fully informed of the patient's condition and medical record before he or she proceeds to administer any form of medication or apply any other form of treatment, always with the presence of the supervisor. Through this procedure, they gain knowledge or apply the knowledge they have already acquired. As soon as nursing students have a complete picture of the patient's condition they are encouraged to meet the patient, make acquaintances and commit themselves to the patient's needs during their shift. As the nursing student comes closer to

228 the patient, they have the ability to discuss, listen, understand and feel how the patient experiences their post-operative condition. As well as this, the nursing students are able to understand and collect information on the patient's condition not only from verbal communication but also from their facial expressions, gestures and posture. This type of approach should be encouraged every time the nursing students meet the patient as part of the standard nursing care procedure such as administering medication, liquids and measuring and assessing vital signs. In this way, the students can not only assess the effect of medication on patient's post-operative pain but also develop a close relationship with the patient based on trust, intimacy and reciprocity.

a) Interaction with health care providers and the working environment

The students are encouraged to observe the procedures and the protocols followed by nurses and health care providers as well as the nursing practices in surgical wards. Such procedures include morning nursing staff briefing, preparation of medication administration as well as problems that may arise and usual ways of resolving them. They are additionally encouraged to observe how the nursing staff interacts with them and how they themselves respond and react to the stimuli of the environment in the surgical ward.

The role of leader

The leader is present, supervises nursing students and monitors their action to secure that protocols are followed, and nursing practices are adequately implemented since the leader bears full responsibility for their students' performance. The leader should encourage the students to create communication channels between themselves and the patients and be open to listening and sharing their own experiences. Another essential quality of the leader is to facilitate procedures and grant the necessary autonomy to the students so that they can cope with different challenges based on their own judgment and rationale. Last but not least, the leader should be positive towards the students and encourage initiative, original and creative thinking and responding to situations.

Encounter groups

At this point, students should share how they felt when they found themselves in the clinical environment and when they came in contact with the patient. Additionally, this procedure lends itself to emerging thoughts and emotions the students experienced when

229 coping with challenges and how they resolve them. What can also possibly emerge is an identification of the students' own experiences with the patients' experiences. Encounter groups give students the opportunity to observe whether the patients undergo similar feelings during the post-operative experience and assess whether the way the post- operative pain is managed makes meaningful difference. Positive feelings emerging from the students' contact with the patient as well as from successful assessment and management of post-operative pain should be emphasised.

On the other hand, negative feelings should be analysed when performance is less than satisfactory or when goals are not met to establish obstacles and limitations. Also, the nursing students should be encouraged to share their impressions and feelings on the manner the surgical wards are run and on the attitudes and behaviour of the nursing staff towards them. Their impressions and feelings should also include their views on the conceptual differences between the theoretical and the practical framework that govern surgical wards. Finally, nursing students should be given the opportunity to recommend a therapeutic care plan for the patient they were in charge of, fully justify the reasons that led them to devise such plan and outline possible differences of their plan compared to standardised ones.

Phase four: Post-operative pain as the main discussion topic within existing encounter groups.

Introducing post-operative pain as the main discussion topic within existing encounter groups (phase one) is strongly recommended. The primary aim of such encounter group discussions is to listen and share every person’s feelings relating to the post-operative pain phenomenon, their connection with the patient and the environment as well as their convictions and motives relating to the assessment and management of the phenomenon.

Therefore, the researcher believes that continuous involvement in encounter groups could help students develop into good listeners, physically and mentally present and attentive to every member of the group and whatever occurs within the group and enable them to utilise these skills in their relationship with their post-operative patients and other nurses. This, as a consequence, leads to a more effective assessment of self and others. The latter is a requirement for developing the person and acting with empathy.

230 Similarly to phase one, encounter groups take place in the presence of a leader who is drawn from various health care professional groups and follow the same techniques procedures described in detail in phase one.

The ultimate purpose of non-directive person-centred teaching model in this proposal is to prepare caring and empathetic nurses who can apply a holistic therapeutic approach to post-operative patients rather than focus on technical practices. In this approach, the caring experience involves mutual interaction which can be unpredictable and therefore exclusive, and as such, it demands that the nurse adjust to it and responds accordingly (Schon, 1987).

The figure 5.2 that follows illustrates the above described non-directive teaching process and its impact on nursing care students.

Figure 5.2 Non-directive learning method

231 5.5 Limitations of the study

This section presents the limitations of this study. First of all, the sample size was small, and it could not assume that there would be comparable and transferable findings from other similar environments or participants. Nevertheless, the methodology used by the researcher explored the identification in the experiences shared by nurses who had a painful post-operative experience, a fact which indicated the possibility of broader applications. For this reason, the results of this study allowed the reader to look at the results based on his/her own personal or professional experience. At the end of the day, the researcher adopted a different approach to the participants during the interview and observation developing through the experience which she gained from the implementation of the present study as well as from Carl Rogers' theory and the way he referred to the person.

The researcher discovered IPA while forming the aims of this research and trying to find an approach to answer them. Nevertheless, an obstacle in collecting and analysing the data was that the researcher was a novice to the IPA process since research based on phenomenology tries to explain the lived experience and in order to do that the researcher needed to do justice to the phenomenon of this research. The researcher had to repeat the hermeneutic circle in order to provide a deeper understanding of the participants' experiences and add a phenomenological sensibility to the study.

Another significant limitation of this study focused on the time management practices of the researcher from the beginning to the completion of this dissertation — the frequent rotation of hospitals and clinical objects as well as the personal difficulties that occurred intensified the deadlines. Finally, another limiting factor in conducting this research is that the researcher was not a native speaker of the English language, which posed difficulties in clarity. Nevertheless, the researcher did their best to overcome them.

5.6 Reflections, implications and conclusion

5.6.1 Reflection on the aims of the study

Reflective practice, at this stage, aimed to make clear to the reader how this research study was constructed and that such construction originated in the various choices,

232 presuppositions, experiences and decisions the researcher undertook during the process to achieve the goals of this study. The goals concerned exploring how a nurse's personal, painful post-operative experience might influence their beliefs, their post-operative pain management practice and their behaviour towards post-operative pain management of their patients.

In particular, I initially focused my attention on studying the literature on post-operative pain, its effect on the patients and the way it was assessed and managed by the nurses in order to answer the research question. It was my conviction that focusing on such literature would be the most consistent way to achieve the aims of this research. However, over time, I gained a deeper understanding of the research method and began to question this approach as it proved inadequate to answer the research question. The primary objective was to explore and corroborate the change of behaviour in assessing and managing patient's post-operative pain rather than one more study which described a post-operative experience and the factors that inhibit its effective assessment and management. As a result, I found myself at a point where I had more questions than answers.

To cover these “grey areas” I resolved that I had to look at the phenomenon from a distance so that I could perceive it more holistically. At the same time, using both academic and professional experience as well as my thoughts and concerns that emerged after each discussion I had with supervisors I was led to approach and study other sciences without conforming to specific guidelines or rules. More specifically, by recording my thoughts on whether and how this change could be achieved not only in the behaviour of nurses but also in their beliefs and attitudes, I found myself wanting to learn more about how behaviour is shaped in order to understand, explore and interpret the mechanisms by which change occurred. For this reason, my interest focused on exploring the theories on behaviourism where I understood their evolution over time from the classical conditioning theory to operant conditioning to social cognitivism to constructivism and finally to humanistic theory. So observing the sequence of views that these theories profess and examine them in relation to pain theories, I recognised their parallel course and connection that was proportional to their evolution throughout time.

IPA as a contemporary qualitative methodology attracted my attention while I was trying to find a method to implement my research question. I found the interpretive nature of IPA 233 extremely appealing in that it gave me the opportunity to broaden my current perspective of understanding and at the same time challenge my pre-existing ways of knowing and understanding only to make me wise enough to realize that in hermeneutics there are no absolute truths and understanding and knowledge is an ever-changing process. Employing Gadamer's theory in my interpretive hermeneutic inquiry helped me realise that understanding has a principle connection with language and it was only through dialogue that we can comprehend the value of learning through experience.

Becoming acquainted with humanistic models helped me recognise the influence experiences had on a person's life since these models maintained that these experiences were vital to change and led to a greater sense of well being. Humanistic therapists postulated that individuals possessed an innate motive to self-improvement and to what extent they improved relies on the extent their psychological needs were met (Rogers, ...)

Having read the literature, I saw how IPA as a research method and Roger's theories complemented each other despite their differences. Both IPA and Rogers focus on exploring what a person understands to be true (perceived reality) rather than what is actually true within a given context. Examining this context from both IPA's and Roger's perspective led to a more productive analysis of the data and the achievement of the aims of this study.

Self-improvement implies change. Change is marked by the need to fulfil a person's full potential and unavoidably influences behaviour (actualising tendency). This tendency motivates a person to fulfil their potential, but it is the organismic valuing process that triggers this tendency (Rogers, ...). The fulfilment of such potential is more easily achieved through a non-directive system of learning. At this point, I felt that my "acquaintance" with Carl Rogers theories was instrumental in the course my research would take as I realised that a whole new word would unfold in front of me in my attempt to achieve a deeper understanding of the data, to see beyond what was being done and what was being said and to give prominence to the more profound truth of the participants' experience.

The three parameters that characterised Rogers' person-centred practice that is empathy, non-directive intervention and maintaining the individual's authenticity through acceptance motivated me to change my approach towards the way I viewed the effect of acute post- operative pain and follow a course that I had initially not planned to take. That was the 234 main reason why I reconsidered predetermined ways which up until that moment, I believed would help me meet the goals of this study.

More specifically, when I reviewed my research proposal I found that a human science combined with a qualitative approach, which was a combination of existential and phenomenological concepts, would lead to a deeper understanding of the human experience and not to the symptom itself since it perceived the human being holistically emphasizing on the participants own perspective to the lived experience.

Education and training of nurses on the assessment and management of post-operative pain was another perspective of the humanistic approach that broadened my perception. Studying the literature, I realised that a large number of qualitative and quantitative studies available advocated change in the way nurses perceive and resolve a patient's post- operative pain through repeated training sessions. However, these training sessions did not prove to be successful enough as nurses' behaviour had not shown signs of significant change as reported in the relevant literature.

My awareness of the study of the humanistic approach helped me identify that the educational methods or techniques employed in the above training sessions were based on earlier didactical concepts.

These concepts stipulated that learning was achieved "from the outside to the inside". In other words, the knowledge shared by the teacher, i.e. instruction on how to assess and manage post-operative, was expected to be absorbed and applied effortlessly by the student. By studying the humanist approach, nevertheless, I found that change in behaviour could not be accomplished in this manner and the question that arose was how a person could change by adopting and consolidating a new mode of behaviour. Roger argued that such a change in behaviour could be accomplished "from inside to the outside", in other words, when there was an inner desire to change. According to Rogers, at this point, a person's experiences were vital to this.

As far as the educational aspect was concerned, the current proposal was based on humanistic-non-directive teaching of nurses and emerged from the reflection of participants’ experiences during this study based on Roger’s person-centred approach and my views, thoughts, experiences and feelings.

235 As far as the technical part of the research process I followed in order to achieve the objective of this study I had to identify nurses who had experience of post-operative pain and were willing to share it. Initially, operational and technical issues arose, such as what was the most appropriate way to approach the participants.

I did not have difficulty in integrating into the clinical environment as my previous professional experience in the surgical departments helped me to identify with it and the multifaceted understanding of the prevailing pace.

Upon completion of this study, I described it as unique and intense as well as challenging and conceptually demanding. As a novice to IPA, I felt secure and confident to follow IPA's step by step guide to the analysis process.

Coming across unexpected responses during the participants' accounts of the lived experience gave me the chance to explore phenomena not previously thought of, which is probably one of the most critical aspects of the interviewing, enabling me to explore the participants lived painful post-operative experience more holistically.

The aims of this study were achieved primarily by providing ample information on how the participants experienced post-operative pain and the effect it had on their beliefs, practices and behaviour.

In conclusion, the role of self-reflection during this study as well as rapport and guidance from the supervisors led me to views, decisions and paths that I had not foreseen when I started this doctorate thesis.

5.6.2 Reflection, implications and conclusion

Upon completion of my study I found it useful to present a reflection of the knowledge and understanding I gained during my thesis as well as thoughts on this thesis implications, and finally, it is only fair that I conclude with some.

Before I started my decorate studies my first contact with the phenomenon of post- operative pain during my post-graduate studies at the University of Middlesex London. This encounter revealed the gap that existed both in the curriculum of my Bachelor's studies in Greece as well as in clinical practice in the surgical wards were I worked as a

236 student nurse. Upon my return to Greece, I was soon employed as a nurse in a public hospital where I began to observe the way the Greek health care system operated, particularly the surgical departments and the health care providers. There, I noticed the deficiencies in the training of the staff and the techniques they followed. For instance, lack of pain scales and even worse lack of nurses' autonomy intensified the presence of the medically-centred system. Nevertheless, it was not long before I realised that despite all these problems exacerbated by the recent financial crisis a number of nurses had adopted a unique, subjective yet effective treatment practice to deal with post-operative patients without having undergone any specialised training.

My professional and personal background stimulated my curiosity to delve into issues such as post-operative pain and the role of the nurse in the care process. Reading the literature on the post-operative pain and get in contact with colleagues made me wonder what the element that can have such an impact on the behaviour of nurses was as current training did not seem to play a conducive role. I found that ‘breaking the habit' may demand an ‘emotional stir-up'. So a desire was born to explore whether there was a connection between nurses' previous personal post-operative experiences and their behaviour towards patients who have the same experiences. When I started my doctorate, my ambition was to contribute to nursing science and to obtain adequate qualifications to enter the nursing academic community. However, the scope of my research offered me more than knowledge into research techniques and academic skills as it proved to be a challenge for me as a person and researcher.

Reading the broader literature and listening to the participants of the research I was able to define my own norms, values, attitudes, preconceptions and behaviour as well as their impact on my working practices. There were times, especially in the beginning of my professional carrier that I became engaged in reviewing myself and my practices as there were quite a few time when I felt anger or frustration due to my compliance with the policies and practices of the department I worked in. However, I found comfort in Roger's theories realising my ability to challenge this compliance in several ways. Of course, I was aware that a change in conformity, particularly in dire times, cannot occur in a short period of time. Nevertheless, I understood that health care should embrace a more therapeutic and humanistic approach. This approach to me meant providing the best quality of care to patients (person-centered) and at the same time having effective cooperation with

237 colleagues despite any individual differences in patient approaches. This was achieved by seeking to have a closer relationship with both the staff and the patients, listen without prejudice, accept their diversity and difficulties in making small or significant changes and always adhere to the principles of a person-centred philosophy.

Apart from my professional approach as a nurse, this research also influences my teaching practice by giving priority to the development of a therapeutic nursing approach with the active participation of students. All the information in the literature collected for this study was invaluable to me in order to improve the content and the process of my teaching along with the feedback I received from my students. Through my thesis, I discovered that evolving is achieved by being open and self-reflective as well as learning through the experiences of others, students and colleagues.

This study showed that the results were consistent with Carl Roger's person-centred theory. One may wonder how the study findings can inspire a person-centred approach in clinical nursing and nursing education in Greece. The findings reveal the urgent need to redefine the structure and content of nursing, especially in Greece so that the patient becomes the focal point of post-operative pain assessment and management rather than the passive recipient.

Although I do not work in a surgical department at present, the knowledge I gained from this study found application in the neonatal unit. For instance, since I became more conscious of the difficulties that parents face I proposed the forming parent encounter groups in order to help them learn how to experience and overcome difficulties which may otherwise adversely affect their parental experience.

This research identified how participants changed their previous behaviour towards post- operative pain evaluation and management because they dealt with their own personal painful post-operative experience single-handed without the appropriate educational background or the support of the system. It also showed that participants were able to analyse and continually evaluate their work so that they could formulate new, creative solutions to problems concerning patients. One might think that the cultivation of such skills posed a significant challenge for them. However, nurses were able to cope under a therapeutic perspective due to their personal post-operative experience. Other issues that

238 emerged concerned the question of how to build an environment that supports therapeutic practice and at the same time be useful and beneficial for the patients and the system itself. The Greek national health care system must recognise the importance of pain management for both nurses and patients. The elimination of adverse conditions under which the nurses on the one hand and the support from the health care system on the other can relieve them from the restrictions imposed on them by the current conditions and practices followed to address the patient's post-operative pain. Besides, strategies involving the establishment of pain scales in surgical departments should be implemented in order to help professionals recognise the importance and value of post-operative pain assessment. Therapeutic nursing practice was for the participants the means to use their creativity to intervene positively and help the patient deal with their condition. This research indicated that pain management should be considered from a more holistic perspective rather than in isolation. Such a holistic approach could prove useful for improving health care practice and minimising patient stress as a result of surgical operations.

Therapeutic nursing practice demands solid knowledge and skills as well as the ability and willingness to learn during working life. One of the most effective techniques to achieve this is self-reflection on experiences that come in our path. An accumulation of reflected experiences help the nurse grow as a professional and individual as well as contribute to enriching nursing knowledge; however, this might imply significant changes in the behaviour, which cannot be easily achieved and therefore calls for substantial support and assistance both during the learning phase and the reflective one. For training facilitators, this implies involvement in clinical practice, development of various teaching techniques, the ability to apply critical reasoning on text and narrative in the contexts of a person- centered learning approach. Becoming proficient in reflective practice does not happen overnight, but it can tremendously improve the lives of both nurses who endeavour to it and patients who benefit from it. Sadly, a significant number of nurses do not exhibit the willingness to adopt such practices or even recognise their value. This may be due to pressure from their working environment, regular working routine or problems in delegating authority.

Another area that needs addressing as far as nurse training is concerned is patient teaching. Up until now, the curriculum focuses on teaching nurses rather than patients. However, there is a growing need for providing nurses with the knowledge, and that implies an 239 understanding of the way in which patients learn and interact with the facilitator since teaching is an interpersonal activity, not just instruction. This will help the facilitator make decisions on the content, time and place of the training sessions. Patient education begins with an understanding of the self (facilitator) and ends in an understanding the other (student patient), and as such, it is an integral part of therapeutic nursing. Nevertheless, therapeutic nursing can be as effective as the nurses themselves, the structures of the organisation they work for and the support they get from colleagues allow.

A further implication of the current study might be the necessity for further research on the nurses as individuals and their working behaviour since these two identities cannot be considered separately, and they both closely relate to the notion of holistic nursing. In an ever-changing world, we would also expect constant changes in nursing science, in health care practices and nurse-patient relationships. These constant changes call for more research on how nurses develop and grow as persons and professionals and the role non- directive teaching can play in their development and growth.

An area of research that also needs addressing has to do with the reasons some nurses do not or are not willing to adopt a new therapeutic approach towards to post-operative pain assessment and management and to what extent self-reflection can highlight the real reasons or even evoke a change in behaviour.

Further research is necessary on how complex clinical environments affect the nature of post-operative pain assessment and management decisions nurses’ make as well as the role and impact of encounter groups training on pain decision outcomes within these complex clinical environments.

Last but not least, a comparative study on the way post-operative pain is assessed and managed by nurses who have had a personal, painful post-operative experience compared to nurses who have not is imperative.

Future research should employ several data collection methods to produce more solid findings concerning post-operative pain experience and management and apply these methods to other clinical areas besides the surgical filed. Nursing education should design curricula that take into account not only the nurses but the patients as well. They should provide information on treatment options, guidelines for setting plans and goals for post-

240 operative pain management as well as an understanding of ethical considerations relating to acute pain.

241

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282 Appendix 1 Examples of development themes of data

Examples of the development of themes from the data Emergent themes Original Transcript Exploratory comments Observation The participant was “Participant 5 introduced working directly with the herself to the patient and patient, taking made it clear to him and responsibility for his/her the family that she would nursing care. be the person who would The recording includes be taking care of him for clinical observations and the next hours. The symptoms in relation to participant initiated a the patient’s activities, Building beneficial discussion with the patient feelings and behaviour. relationships: by asking how he was The participant invites the feeling, how intense the family to take an active  Post-operative patients pain was and how the pain role in the patient’s care become partners in had affected his daily provided that the patient their own care. routine. She also received and the family member are input from the family while willing to do so.  Developing proximity emphasizing to them the The atmosphere was with post-operative importance of their help at unforced, friendly and patients. this point of the treatment warm and emphasis was process. The participant given upon the individual was calm, focused on the care of the patient. patient and seemed to The participant helped the understand the patient’s patient face and explore condition and feelings”. his own concerns. “The participants talk with The participant adjusted the patients regularly the treatment program to throughout their post- the patient’s goals and operative care period. facilitated the process to Finally, they reset the targets make his decisions. they set with the patient depending on his needs and wishes every time”. Observation The participantexposed “I do understand you Mr herself to the patient whilst “B” I have also been being in the process of cooperated on the belly and I creating a close relationship can understand how much it with him. Reflection and evaluation hurts… I remember how She felt empathy towards difficult it was to stand up... I the patient and seemed to of post-operative couldn’t sleep or eat… It was understand the pain that he experience a lesson for me to see my was experiencing. weaknesses and through a The participant proved to be a different perspective dynamic human being whose appreciate things that in the attitudes, beliefs, theories and past I used to take for practices were continually in the granted”. process of evolving.

283 Examples of the development of themes from the data Emergent themes Original Transcript Exploratory comments Observation “Participant 3 sat right next Using instrumental touch to the patient. She introduced as a deliberate physical herself to the patient and her contact which was part of tone of voice was calm and the procedure. cheerful”; “Participant 10 initiated a discussion with Transference of feelings the patient. She used the through touch between the patient’s first name several The exploration of touch participant and the post- times in their conversation. in post-operative pain. She touched the patient, operative patient was usually on his hands and his observed even in non- head, while talking to him. verbal communication. She kept eye contact with the patients during their conversation. The participant was calm, focused on the patients and seemed to understand their condition ”;

Interview Post-operative painful “There were cases when experience shields the doctors were completely participants’ personality. indifferent about patients' pain management; The participants although you reminded maintained their them, they wouldn’t make perceptions of the man- it part of the schedule.” centered care for post- (participant 11) operative patients and through this they overcame Developing interpersonal “I have found that asking the problems of communication skills for appreciative questions and communicating with an effective staff and encouraging dialogue doctors. patient relationship. about hopes, values and emotions are valuable The participants developed ways to drive incremental effective communication or additive innovation by skills. building on the best of They wished to have more what already exists, and involvement in the this way can be patients’ care and they transformational.” created and maintained a (participant 1) close relationship the doctors and the other nurses.

284 Appendix 2 Consent Form

School of Nursing, Midwifery and Social Work The University of Manchester University Place Oxford Road Manchester M13 9PL +44(0)161 3067639

PARTICIPANT IDENTIFICATION NUMBER:

CONSENT FORM

TITLE OF PROJECT: How nurses’ personal experiences of post-operative pain affect their professional attitudes and behaviors towards their patient’s postoperative pain management.

NAME OF RESEARCHER: Gardeli Panagiota.

Please initial box

1. I confirm that I have read and understood the information sheet dated ...... ……………………for the above study and have had the opportunity to ask questions.

2. I understand that my participation is voluntary and that I am free to withdraw at any time, without giving any reason. 3. I understand that my interview will be taped and subsequently transcribed. 4. I agree to the use of my direct quotes in the written research and any reports or publications, if they are used in such a way that I will not be identified. 5. I agree to take part in the above study. 6. I agree to the use of my anonymised data for future work.

______Name of participant Date Signature

______Name of person taking consent Date Signature (if different from researcher)

______Researcher Date Signature

Thank you for agreeing to take part in this project.

You will have a copy of this form to keep. A copy will also be kept by the researcher. Appendix 2 Translation of Ethical approval from Greek scientific council

th 6 Hygiene Prefecture of Peloponnese, Patra 30.10.12

285 Appendix 3 Ethical approval from Greek scientific council

Islands of Ionian seas and Western Greece R.N.: 463 General University Hospital of Patras

SCIENTIFIC COUNCIL

Post Code : 26 500 Rio To: Administrative Council Information :Antonia Giannika Tel : 2610-994721, 997, 873 Fax :2610- 997, 873

The Administrative Council in the meeting of 29.10.12 and taking into account the decision of the Research Committee and Ethics, with number 320/13.6.12, approves the data collection in Surgical Departments of the General University Hospital of Patras for the purpose of the PhD study of Gardeli Panagiota. The title of the study is: “How nurses’ personal experiences of post-operative pain affect their professional attitudes and behaviors towards their patient’s postoperative pain management”.

The manager of administration Prof. Gimitrios Goumenos

Memebers Alex. Kourakli Kon. Giannakenas Vel. Lakiotis Eirini Lamprou Agar. Kaspiri

286 Appendix 4 Ethical approval from Greek scientific council

287 Appendix 5 Observation Schedule

Observation Schedule

The main focus of the observations is the nurse’s actions in relation to postoperative pain.

Preoperative information about pain

 Preoperative visit at admission.   Content of information   Preparation of patients immediately before operation   Responses to patient’s questions   How is pain and the importance of pain alleviation described?  Pain assessment and manaegement   Nursing or caring situations   When mobilizing postoperative patients   Giving medication   Responding to patients’ call for pain relief after a report of possible pain problems.   The expected pain for the situation (diagnosis, operation method, etc; experience is central)   Administration of medication after routine orders   Administration of medication after the patient’s request   Administration of medication after own assessment  (individual prescribed medication, as needed, standard prescription, maximum dose given)   What medication is given and how often?   Incidence of non-invasive methods: distraction, relaxation, visualization, cutaneous stimulation   Evaluation of pain management   Reassessment of patient after giving medication.   When and in which situations treatment is evaluated   What is done when pain is not alleviated?   Circumstances that increase or decrease pain alleviation   Spoken or written reports, routines for medication, support/no support from the doctor or other nurses for nurse’s clinical decisions; daily routines on the ward, co-operation with the physician, norms in relation to pain alleviation on the ward

288 Incidence of non-invasive methods - Non-Verbal Communication

 Nurse’s position.   How nurse posture her/him self in relationship with the patient?   Eye contact.   Therapeutic touch   Questions related to Observation   During my observation I noticed that you react like “this” in “that” patient’s words. Could you please tell me how did you feel about “that” patient’s request? Could you please describe me with your own words what that was like for you?   I found my observation of your practice very interesting in “that” part, why did you take “that” decision?   From my observation of your practice it was remarkable your reaction in “that” point. Why did you react like “this” in “that” situation? How did you feel?

289

Appendix 6 Interview Schedule

Interview Schedule

Personal Experience

 Could you, to begin with, describe your postoperative experience to me in your own words  please?   Could you describe the pain that you experienced with your own words please?   What does the pain feel like?   How long have you felt the pain?   Does pain change in any way?   How did the pain begin?   How did the pain come on?   Does anything affect your pain, make it better or worse?   Do you know what causes your pain?   Why your pain persists?   Why hasn’t your pain been cured?   Has your pain changed things for you at all?   Is anything different now?  Do you do anything or feel differently since you had the pain? How? Could you give  examples?   How would you describe yourself as a person?   How do you feel about yourself?  Has having pain changed the way you think or feel about yourself or on your nursing of  other people’s pain?   Are you any different now as a person after having pain? Do you see yourself differently?   In what ways are you a different person now? Can you give an example of this effect?   Why do you think that change has happened (if it has)?   What has caused the change?  What has brought that change about?   Pain assessment   How do you know when someone is in pain? Could you give some examples?   How do you feel about pain assessment tools?  What you consider to be a pain management action? Education

 Have you attended pain management education programs, seminars, lectures or  conferences?  Greek Health Care System  How do you feel about the Greek health care system?

290 Prompts and Probes   You have mentioned “that”: what do you feel about that?   Would you elaborate on that?   Could you say some more about that?   That’s helpful. I’d appreciate if you could give me more detail.  I’m beginning to get the picture: but some more examples might help.   Finish Interview  What was the most valuable thing you have learnt about your own experience of postoperative pain?

291

School of Nursing, Midwif Appendix 7 Participant information sheet and Social Work University of Manchester University Place Oxford Road Manchester M13 9PL PARTICIPANT INFORMATION SHEET A study to explore nurses’ personal experience of pain and how this affects their attitude towards pain management of their patients.

PART 1.

Invitation

My name is Panagiota Gardeli and I am undertaking a PhD at nurses’ personal experience of pain and how this affects their attitude towards pain management of their patients. We would like to invite you to take part in our research study. Before you decide we would like you to understand why the research is being done and what it would involve for you. I am interested in registered nurses’ (RN) personal experiences of post-operative pain. More specifically we are trying to understand how a nurse’s pain experience contributes to their postoperative pain management practice. Many studies have been conducted on the topic of pain management either focused on patients or on single factors of pain management. We are focusing on registered nurses as we wonder whether nurse’s experiences of post-operative pain has an effect on their professional attitudes and behaviors towards patient’s with postoperative pain.

Please take time to read the following information carefully and discuss it with others if you wish. This information sheet is divided into 2 parts. Part 1 tells you the purpose of this study and what will happen to you if you take part. Part 2 gives you more detailed information about the conduct of the study. Please contact us if anything is not clear or if you would like more information. Our contact details are at the top of this page. Take time to decide whether or not you wish to take part. What is the purpose of the study?

The purpose of the study is to find out whether Greek registered nurses’ feel that personal experiences of post-operative pain effects their management of postoperative. Currently we know little about what the impact of having a post-operative painful experience has on nurses practice. We will be finding out this information within this study.

292 Why have I been invited?

You have been asked to take part because you are a register nurse who has undergone surgery so you have the experience that we need to answer our questions. We hope to recruit up to 18 nurses who have had a post-operative pain experience to participate in the project.

Do I have to take part?

It is up to you to decide to join the study. We will describe the study and go through this information sheet. If you agree to take part, we will then ask you to sign a consent form. You are free to withdraw at any time, without giving a reason. This would not affect your employment rights career in any way now or in the future.

What will happen to me if I take part?

This study is in two parts. Part one is observation and part two is an interview.

For part one you will be observed at work by the researcher for five shifts, day and/or night. The observation will be arranged on dates convenient to you. The purpose is to observe you as you undertake postoperative pain management. Notes will be taken by the researcher as she observes you. Observations do not judge your ability to manage post- operative patients’ pain. After the final observation you will be interviewed by the researcher at a time and location convenient to you. The focus of the interview will be on your personal painful experience and your attitudes and beliefs about the challenges you face when dealing with post-operative patients’ pain. The interview will be audio-recorded for the purpose of analysis. It is anticipated that this will take no more than an hour. Once the interview is completed your participation in the project will be over.

What are the possible disadvantages and risks of taking part?

There are no risks associated with participation. It is clear that if during the observation or interview you become distressed, the observation or interview will be discontinued immediately. The researcher is trained health care RN who will be able to assess the effects of the observation or interview on you and would stop if they thought that it was necessary.

What are the possible benefits of taking part?

293

There are no real direct benefits of taking part however the results of the research may help us to understand more about patient’s post-operative pain management. This will contribute towards developing standards of care and guidance on the design and delivery of post-operative pain management.

What if there is a problem?

Any complaint about the way you have been dealt with during the study or any possible harm you might suffer will be addressed. The detailed information on this is given in Part 2.

Will my taking part be kept confidential?

Yes. We will follow ethical and legal practice during the observation and interview process and all information about you will be handled in confidence. The details are included in Part 2.

If the information in Part 1 has interested you and you are considering participation, please read the additional information in Part 2 before making any decision.

PART 2.

What will happen if I don’t want to carry on with the study?

You can choose to withdraw at any time and this will not affect your rights of employment in any way. If you want to stop the observation or the interview before it is completed you can do so without having to give a reason. If you complete the observation or the interview and at a later date decide that you wish for us not to use the data then you can approach us at any time during the lifetime of the study and we will remove your information from our database and the questionnaires completed during the observation and the interview will be destroyed.

What if there is a problem?

If you have a concern about any aspect of this study, you should ask to speak to the researcher (Panagiota Gardeli 2610 643 502) who will do her best to answer your questions.

If she is unable to resolve your concern or you wish to make a complaint regarding the study, please contact the University Research Office on 0161 2757583 or 0161 2758093 or by email to [email protected]

Will my taking part in this study be kept confidential?

294 Yes all information about you will be kept confidential.

Once you consent to participate you will be given a participant number. This number will be used on all of the data sheets instead of your name. All data will be inputted onto a computer database using that number as a reference. Your name will be written on a master sheet against your participant number and this master sheet will always be kept separately from your data and the computer database. It will be stored securely in a locked filing cabinet away from all of the data.

Only the principal investigator Panagiota Gardeli and the research supervisors will have access to the master sheet.

Anonymous data may be used for future analysis.

All data will be kept for ten years and then disposed of securely using the University of Manchester disposal of confidential material procedure.

What will happen to the results of the research study?

All results will be anonymised and grouped together so there will be no way to identify particular individuals from the results. Reports of the results will be written and broad scientific statements made. These reports will be developed into research papers which will be published in scientific journals. A summary of the results will be available for the participants to see after the publication of the study and participants should not hesitate to contact the researcher in order to get a copy.

Who has reviewed the study?

All research in the NHS of Greece is looked at by an independent group of people, called a Research Ethics Committee, to protect your interests. This study has also been reviewed also by The University of Manchester Research Ethics Committee.

Further information and contact details

If you want further details of this research project please contact:

Gardeli Panagiota. PhD Student at University of Manchester.

Tel. 2610 643 502

E-mail address: [email protected]

Also you can contact with the supervisors of the research:

295 Dr Cliff Richardson. Lecturer. School of Nursing, Midwifery and Social Work, University of Manchester, Jean MacFarlane Building, Oxford Road, Manchester, M13 9PL.

Tel. 0161 306 7639 Email: [email protected] Or

Dr Penelope Stanford. Lecturer School of Nursing, Midwifery and Social Work, University of Manchester, Jean McFarlane Building, Oxford Rd,Manchester,M13 9PL

E-mail address: [email protected]

If you wish to make a formal complaint about any aspect of this project please contact: The University Research Office on 0161 2757583 or 0161 2758093 or by email to research- [email protected]

Thank you very much for taking reading this information sheet.

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