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THE LIVED EXPERIENCE:

NURSES’ EXPERIENCE IN CARING FOR

PATIENTS WITH TRAUMATIC SPINAL CORD

INJURY

SHAREENABIBIMOHDARIFPAULMCLIESHDRPHILIPPARASMUSSEN

Outline

ì IntroductionandSignificance

ì Aims

ì Methodology

ì FindingsandInterpretations

ì Discussion

ì Recommendations

ì Conclusion

Introduction and Significance

ì Thespinalcordisacomplexsystemthatkeepsthebodyalivebyconnectingthebodyandbrain.

ì Itfocusesonsensoryandmotorfunctions.

Sheerin,F2004,'Spinalcordinjury:anatomyandphysiologyofthespinalcord',EmergencyNurse,vol.12,no.8,pp.30-36.

Introduction and Significance

ì Spinalcordinjuryusuallyasudden,traumatic,unexpectedandirreversibleevent.

ì Patientsexperiencemajorchangesduetotraumaticinjuries– “shatteredreality”tooverwhelmingshock.Itrepresentlifelongchallengeasaresultsoflossofsomebodyfunctions.

ì Involvementofnursesisessential–fromadmissiontorehabilitation.

Dewar,A2000,'Nurses'experiencesingivingbadnewstopatientswithspinalcordinjuries',JNeurosci Nurs,vol.32,no.6,Dec,pp.324-330.Grundy,D&Swain,A2002,ABCofSpinalCareInjury,4thedn,BMJBooks,London.Hickey,J2002,TheClinicalPracticeofNeurologicalandNeurosurgicalNursing,5th edn,Lippincott,Philadelphia.

Significance

Initialsupportandcareareveryimportantanditisthenursesrole(noviceorexperienced)tofocusonpatients’care– fromadmissiontothetransitionfromacutephasetorehabilitationphase.

Chase,SK1995,‘Thesocialcontextofcriticalcareclinicaljudgment’,HeartLung,vol.24,no.2,pp.154–162.Itano,JK1989,‘Acomparisonoftheclinicaljudgmentprocessinexperiencedregisterednursesandstudentnurses’,JournalofNursingEducation,vol.28,no.3,pp.120–126.Radwin,LE1998,‘Empiricallygeneratedattributesofexperienceinnursing’,JournalofAdvancedNursing,vol.27,no.3,pp.590–595.

Theabilityofdecisionmakingamongnovicenursestendtobelinearoftenduetolimited

knowledgeandexperienceintheirjob.

Significance

Theexplorationandunderstandingofthephenomenainvestigatedinthisstudywillcontributetothebodyofknowledgeforallnurses.

…helpnovicenursesinpreparingthemselvestofuturechallengesanddecisionmakingwhilecaringforthesepatients.

ì Nursingcareforpatientswithspinalcordinjuriesaredifferentbaseontheinjuriesanddisabilities.Therefore,itisimportantfornursestounderstandhumanexperiencesandmeaningtoasituationinordertoprovideawelltailorednursingcare.

Inlargerscale– nursesunderstanding,patients’satisfactionand

complaints.Grundy,D&Swain,A2002,ABCofSpinalCareInjury,4thedn,BMJBooks,London.Itano,JK1989,‘Acomparisonoftheclinicaljudgmentprocessinexperiencedregisterednursesandstudentnurses’,JournalofNursingEducation,vol.28,no.3,pp.120–126.

ìAIM

Togainaclearunderstandingonnurses’experience

incaringforpatientswithtraumaticspinalcordinjuries

thathaveneurologicaldeficit.

ìSPECIFIC OBJECTIVES

1.Toexplorethelivedexperienceofnursescaringforpatientswithtraumaticspinalcordinjurywhoalsohaveneurologicaldeficits.

2.Todevelopanunderstandingofthesenurses’experiencesindealingwithpatientswithtraumaticspinalcordinjurywhoalsohaveneurologicaldeficits.

3. Toexpandtheknowledgeofthisarea,toassistnovicenurses(andpotentiallyexperiencednurses)ofthefuturewhencaringforpatients

withtraumaticspinalcordinjurieswhoalsohaveneurologicaldeficits.

ìMETHODOLOGY

StudySetting:SpinalUnit,SouthAustralia

Population: 27 RN and 12 EN working at the spinal unit.Nurses with a wide range of experience and backgrounds in the

fieldwere recruited in order to provide the in-depth information.

Sample:Purposivesamplingtechnique.:Sixnursesvolunteeredtoparticipateinthestudy.

Researcher-BelongtotheTradition

Situation-Researcherawareofthehermeneutic

situation,awareofprejudices

Text- thetexthastheanswer

Truequestion-questiondoes

notarisewithoutreason

TheDialogue-dialetic

movement,hermeneutic

cycle

TheFusionofHorizons-comingto

understanding

Austgard,K2012,‘DoingittheGadamerian way— usingphilosophicalhermeneuticsasamethodologicalapproachinnursingscience’,ScandinavianJournalofCaringSciences,vol.26,no.4,pp.829–834.

METHODOLOGY:QualitativehermeneuticphenomenologyresearchdesignbaseonGadamer’sphilosophy

Assumptions (Researcher Pre conceived ideas)

ì Nursesthatworkinthespinalunitbelongtoauniquegroupofnurses.

ì Thenursesremembertheirexperiencespreciselywhencaringfortraumaticspinalcordinjurypatientsthathaveneurologicaldeficit.

ì Caringforpatientswithtraumaticspinalcordinjurywhoalsohaveneurologicaldeficitsisliketakingcareofpatientsinintensivecare,wheretheyneedindividualemotionalandphysicalcare.

Assumptions (Researcher Pre conceived ideas)

ì Itishardtogivehopetothesepatientswhenthereisastrongpossibilitythattheywillbecompletelyparalysed.

ì Itisdifficulttocommunicatewiththesepatientsandtheirfamilies.

ì Whenthepatientsaresilent,itmaymeanthattheyareafraidorthattheyhavegivenup.

ì Thesepatientsareverydependentontheirnurses.

Turningtoaphenomenonwhichseriouslyinterestsusandcommitsustotheworld

Investigatingexperienceasweliveitratherthan

asweconceptualizeit

Reflectingonessentialthemes,

whichcharacterizethephenomenon

Describingthephenomenonthroughtheartofwritingandrewriting

Maintainingastrongand

orientedrelationtothe

phenomenon

Balancingtheresearchcontextbyconsideringpartsandwhole

Researcher-BelongtotheTradition

Situation-Researcheraware

ofthehermeneutic

situation,awareofprejudices

Text- thetexthastheanswer

Truequestion-questiondoesnotarisewithout

reason

TheDialogue-dialetic

movement,hermeneuticcycle

TheFusionofHorizons- comingtounderstanding

VanManen’sMethodologicalstructure

VanManen(1997)

Gadamer’sHermeneuticphenomenologyAustgard(2012)

Method: Van Manen’s (1997) – the six methodological structure to

operationalised the hermeneutic phenomenological human

science research.

VanManen,M1997,ResearchingLivedExperience:HumanScienceforanActionSensitivePedagogy,

StateUniversityofNewYorkPress,Albany,NewYork.

Notesaremadeaftereachinterview

Immerseinthedata–readtranscriptandmake

notes

Readtranscriptagainanddoopencoding

SurveyListofcategoriesandgroupedtogether(collapsingintobroadercategories).Remove

dross

Newlistofcategoriesandworkedthroughagain

Twocolleagueinvitedtogeneratecategorysystem

Transcriptarerereadalongsidewithfinallistof

categories

Eachlistisworkedthroughwiththeopencoding,categoriesandfinalessentialthemes

Sortitout- toseetheaudittrail

Selectedrespondentwasaskedtocheckthecategorysystem

Filedupallsectionforreferencewhenwriting

upfindings

Writingupprocessbegin.Datacanbeusefor

commentarythatlinktoexamples

Decide:1st- writeupfindingsandinterpretit;2nd – writethefindingsalongsidereferencesto

theliterature

ThematicAnalysis- Burnard (1991)14stepsapproachsystematicstepstocodifyandcategorise theinterviewedtranscript.

Burnard,P1991,‘Amethodofanalysinginterviewtranscriptsinqualitativeresearch’,NurseEducationToday,vol.11,no.6,pp.461-466.

Goal

Setting

NursingPractice

Empathy

ChallengesProfessionalboundary

Teamwork

NursesSharing

SupportingOthers

FINDINGS

Essentialthemes:

ì Thepassageofcare

FINDINGS

Essentialthemes:

ì PatientsNeeds

Essentialthemes“Patients’needs”

PhysicalNeeds

PsychologicalNeeds

FINDINGS

Essentialthemes:

ì Hope&Grief

Essentialthemes:HopeandGrief

Thefivestagesofgrief

Hope(realhope&

unrealhope)

FINDINGS

Essentialthemes:

ì Nursesinterpretationofpatientsandfamilies

Essentialthemes:Nursesinterpretationofpatientsand

families

Families Patients

ìDISCUSSION OF MAJOR FINDINGS

Discussion: The passage of care

ì Thenurseswereclearabouttheirgoal– thepatientssettleintotheward- medicallystable- rehab.

...wheneverthey’rebeingtransferredtotheward.It’sjustamatteroftryingtoexplaintothemtheroutinenursingcare,theexpectationsoftheward,alsothejourneyfromheretowhereverthey’regoing.(ChrisP6,L215–218)

Thepositiveeffectofgoalsettingisthatitmotivatesstafftoachievetheirgoals,ashasbeenhighlightedinmanystudies.

(Elliott&Dweck 1988;Erez&Kanfer 1983;Locke&Latham2002)


However,theprocessofachievingtheirgoalscouldbedifficultattimes,especiallywhenthepatients’andthenurses’goalswerenotthesame.

Therefore,itwasessentialfornursestodevelopgoalsthatweremutuallyagreedwiththeirpatients.Thisfacilitatedafeelingofself-worthandautonomyforthepatientsandatthesametimeenabledthenursestoachievetheirmission,whichwastostabilise thepatientfortherehabilitationprocess.

(Playford,Siegert,Levack &Freeman,2009)


ì Thepassageofdeliveringcareinthespinalunitwasverydynamicandtheparticipantsdescribeditas‘gooddays’and‘baddays’.

Agooddayiswhenthingdon’tgowrongandit’snottoobusyandeverythinggetsdonewithoutrushingtoomuch.Andtherearenoproblems.(Nate:P4,L151–152)

...andifyouhadabaddayandthenyoucametoworkandgotabused.(Colette:P2,L341–343)


Generally,healthcareprofessionalshaveanexpectationthatpatientsthatenteranacutehospitalsettingwillcooperatewiththeirtreatment,recoverandreturntotheirnormalroleinsociety.

(Larsen2013)

However,indynamicclinicalsettingstheseexpectationsarenotalwaysrealisedsmoothly.Attimesduetotheinefficientsupportsystemsuchasdelayedornotgettingthemedicationsneededforpatientsnotonlyaffectedthenurses’roleindeliveringcarebutalsoresultedindelayedormissedcarefortheirpatients.Hence,ithadanegativeimpactonboththerecoveryandthelong-termoutcomesofthepatients.

(Winters&Neville2012)


ì Caringforpatientswithspinalcordinjuriesthathaveassociatedneurologicaldeficitwasperceivedasbeingthesameascaringforanyotherpatients.

...Itisthesameascaringforanypatients.Really.Everyonehastheirowndifferentneeds...(Nate:P4,L14–16)

Itwasanevidentthatthenursesperceivedtheirpatientsinaverymatureway.Insteadofseeingthesepatientsasuniqueandspecialcases,asreportedinothersimilartraumastudies,thenursesinthisstudymanagedtoseetheirpatientsasindividualhumanbeingsandprovidedcarebasedontheirindividualrequirements.

(Alzghoul2014;Bostrom,Magnusson&Engstrom 2012)

Bytailoringindividualcare,nursesaremovingtowardsthefoundationofatherapeuticrelationship.


ì Newnursesjoiningthespinalunittooktimetolearn,understandthepatients’needsandadapttothenursingpracticesandtheroutineoftheunit.

ì Thisprocesstooktimeevenifthenurseshadpreviousexperienceincaringforpatientswithspinalinjuries.

SoIhadbeeninsomeplacesthatpeoplewereparaplegicandallthat...Ihadalittlebitofexposure,butitwouldhavebeenverylimited,...It’saveryparticularroutinethatyoudon’thaveinotherareas...ittakesmonths,yesdefinitely.(Kate:P5,L597–601,L614– 619)

However,theirpreviousexperiencebenefitedthenursesintheirabilitytoidentifyproblemsmorequicklyandunderstandthepatientsandtheenvironmenttheywouldbeworkingin.


ì Being exposed to the same environment for months or yearshad an impact on the nurses.

ì The nurses began to refer the patients based on theircondition; for example, as tetraplegics rather than by theirnames, and this indirectly dehumanised the patients.

A study by Haque and Waytz (2012) explains that this can be aspontaneous method to cope with stress while caring for patients.


ì Inthisstudy,thenursesexposedtothesameenvironmentformonthsoryearsalsonaturallydevelopedafeelingofdesensitisation.

…I’vebeenworkinginthisenvironmentforquiteawhilenow,Ihavebecomeabitdesensitised,andalthoughIhatethat,it’spartofworkingthatyoudoseeitallthetime,…(Pink:P1, L18-19)

ì Thismadecaringforpatientswithspinalcordinjuriesthathaveneurologicaldeficitsseemnormal.

Similarfindingswereidentifiedamongnursesworkingwithtraumapatientsincriticalcareandemergencysettings;thesenursesdevelopedaprotectivemechanismtoshieldthemselvesfromemotionalattachmenttotheirpatientsandthishappenednaturally.

Theybecame‘hardened’,andthenursesalsodescribedfeelingsofguiltwhentheyvoicedthisexperience.

(Alzghoul2014)


ì Positive side to desensitisation - It helped the nurses to develop a ‘thickskin’ and the ability to ‘switch off’.

…so I don’t go home and lose sleep worrying about them, or I’m able toswitch off when I leave work, because it’s a very routine ward.(Pink:P1, L18-26)

This provided a protective mechanism for the nurses that enabled them todeal with their patients’ grief and not let it affect them.


ì Desensitisation does not mean the nurses lack empathy for their patients.

In this study the nurses described their feelings of empathy and how hard it wasfor them to deal with it.

However, these feelings of empathy were balanced with the need to be ‘tough’with the patients in order to empower them to be as independent as possibleand to move on in their lives.

...sometimes you have to use tough love with patients... (Rick: P3, L1033–1034)


ì Feeling greater empathy for their younger patients than their olderpatients may influence the nurses’ sense of urgency regarding their careand the emotions associated with the patients’ lives.

... some staff members...seem to feel that it’s worse being a 20-year- old having anaccident... than it is if you’re 80 years old because you haven’t got long to go…(Rick: P3, L859–861, L865–866)

Similar findings were identified among nurses caring for cancer patients andcritical care patients.

(Alzghoul 2014; Parish 2006)


ì Moving along in the passage of care, nurses were bound to facemany challenges.

ì Despite all these challenges, the nurses highlighted that they gainedsupport through working as a team and that they supported eachother by sharing their knowledge and experiences.

...so you’re working with personalities, and everyone has a different way of doingthings, but you’re working together for the benefit of your patients. (Kate: P5,L353–355)

This finding was also reported by Alzghoul (2014), who emphasised theneed for peer support when dealing with the challenges.


ì Providing support to family members was challenging andtook time. It became difficult for nurses to delve deeper andbalance the needs of patients and families.

ì In order to deal with this, the nurses would refer them todoctors or social workers.

This concurred with the findings of the study by Bostrom,Magnusson and Engstrom (2012) who described supportingfamily members as a difficult task due to a lack of time.


ì Throughout the passage of care, the nurses realised that time is themost important thing that they can give to their patients.

ì An understanding of what patients valued most and delivering it issimilar to the improvement technique adapted by the NationalHealth Service (NHS) Institute in one of their quality improvementprogrammes, known as Lean.

(NHS Institute for Innovation and Improvement: Lean 2008)

Lean aims to understand what patients value and develop a product ordesign a service to deliver ‘the right things to the right place, at the righttime, in the right quantities’.


ì Throughout the passage of care, it was an undeniable fact thatestablishing the nurse–patient relationship was fundamental tocare.

In nursing, patients are often considered vulnerable due to thenature of their condition.

(Holder & Schenthal 2007)

ì Patients may disclose personal information.


ì In this study, such disclosures usually happened with long-staypatients and especially when the patients and nurses shared acommon background.

ì Any disclosure of personal information by a nurse to theirpatient has the potential for professional misconduct.

(Holder & Schenthal 2007)

It is therefore important for nurses to be knowledgeable enough tomaintain the appropriate professional boundaries.

Discussion: Patients’ Needs

ì The importance of respecting and fulfilling the patients’ needs - physical andpsychological needs.

Unique:

ì Despite mentioning physical needs, the majority of the nurses tended to discuss atgreater length the ways to accommodate the psychological needs of their patients.

This is a unique finding, because spinal cord injury is usually associated with physicaldisability and care has been predominantly focused on meeting the physical needs of thepatient, rather than viewing the physical and psychological aspects of care asinterdependent.

(Dewis 1989; Olson & Ustanko 1990)

Discussion: Patients’ Needs

Partridge (1994) described that on admission to hospital, the patient with spinalcord injury will be in a state of physical and emotional shock.

Although sustaining life may be the initial nursing priority, it is also necessaryfor nurses to provide care for the person’s psychological needs.

A lack of psychological care restricts a patient’s participation in rehabilitationand their community.

(Cardol, Gam, Beelen, de Groot, & de Haan, 2002)

ì Reflecting on this finding: It would be interesting to examine thisphenomenon from the perspective of spinal injury patients.

Discussion: Hope and Grief

…everylossinlifeprovokesgrief,andtheyseetheirpatientsgoingthroughthestagesofgrief…

ì Theirgriefincludedabroadrangeoffeelingsandreactionsthatarecommonafteraloss.

(Dunne2004)

They’llbegoingthroughthewholegriefsyndromeinitially...thediagnosisdoesn’thit,ittakesawhileforittosinkin.(Kate:P5,L193– 195)

ì VeryChallenging


ì AccordingtoLohne andSeverinsson (2004)nursesneedtolearntheskillstofosterhopeandempowerrecentlyinjuredpatientstolookbeyondtheirimmediatesituationanddirecttheirenergiesappropriately.

Hopeisgood,butfalsehopeisnot,…(Colette:P2,L568–573)

Differentopinion:

…hopeisbasedonhowweconceptualise it…hopetobeallowedatallphasesofillness,includingattheendoflife,whenhopeisforagooddeath.

(Miller2007)


Hopeisconsideredasacrucialalternativetoadaptationtoillness.

(Coward&Reed1996)

Therefore,hopeisneededbyallthroughoutthelifecycle,andespeciallythroughthehealth–illnesscontinuum,includingattheendoflife.

(Miller2007)

Discussion: Nurses’ interpretation of the patients and

families.

ì Thetraumaassociatedwithspinalcordinjurychangedpatients’personalities.

Thenursescategorised patientsintothreegroupsbasedontheirpersonalities:

…he’sjustneverdealtwiththeinjuryatall...Whereas,somepeoplearetheopposite,it’sright,I’vegotthis,Igetonwithmylife,I’lldealwiththis;andthenyou’vegotthepeopleinbetween.(Colette:P2,L100–103,L110–111)

ì Inordertodealwiththesepatients,thenurseshadtoadjusttheirwayofapproachingthem.


families.

ì It’s the same when dealing with family members as well, becausedifferent cultures handle the outcome of trauma differently.

ì The extent of the change and trauma to the family members’ livesis just as great as that of the injured person.

Providing social and educational support could enhance adaptation tospinal cord injury. This was considered important not only for thepatients, but also for their family members.

(DeSanto-Madeya, 2009)


families.

ì Thefindingsalsoshowedthatthefamilymemberstendedtostepintothepatient’slifeandforgetthatpriortotheirinjurythepatientwasanindependentindividual.

ì Instead,familymembersmaytreatthepatientlikeachild,andthiscanbeoverwhelmingforthepatient.

Thecaregiversforpatientswithtraumaticspinalcordinjuriesseldomreceivedthenecessarypreparationfortheirnewroles.

(Dickson,O’Brien,Ward,Allan&O’Carroll,2010)


families.

Therefore, it is essential for nurses to educate the family aboutthe patient’s condition, to treat patients as individuals and dealwith their trauma at the pace that is appropriate for eachpatient.

(Watts & Horne 1994)

In addition, nurses need to help families manage these difficulttimes, and this can be achieved by being present and creating anopen and trusting relationship with them.

(Freeman, Bourbonnais & Rashotte 2014)

Study Limitations

ì This is the first qualitative research study to explore nurses’experience of caring for patients with traumatic spinal cordinjuries that also have neurological deficits.

ì This study was based on a sample of only six participants. Whendetermining the sample size, the researcher judged the qualityof the data collected against the aim of the study. Theparticipants provided rich descriptions of their experiences.

ì The inability to generalise the findings; instead, the findings canbe transferable to one setting or to similar situations.

(Lincoln & Guba 1985)

ìRecommendations

Recommendations for practice

Nurses that go through the passage of care for patients withtraumatic spinal cord injuries that have associatedneurological deficits must be prepared for the journey.

ì It is recommended that novice nurses or nurses that arenew to a spinal unit to be educated on the nature of theroute that they are going to travel with their patients.

ì The experiences of senior nurses can be shared as part ofthe orientation programme for these new nurses.


Desensitisation occurs after a few months in the spinal unit.

Nurses described feelings of guilt due to their desensitisation,however, desensitisation enabled them to switch off from theconfronting feelings raised when dealing with these patients.

ì Having mixed feelings can be stressful for nurses. It isrecommended that an ongoing counselling session to be offered tonurses in order to help them ventilate their feelings and ease theguilt while caring for their patients.


Maintaining professional boundaries is important for thetherapeutic treatment of patients.

ì It is recommended that nurses to be educated regardingthese boundaries and have clear guidelines, which shouldbe kept in the ward for the nurses’ reference.

ì It is also important to educate nurses that maintainingappropriate professional boundaries is everyone’sresponsibility.


Adaptation to spinal cord injury may take time for patientsand their families.

ì The majority of the care focus is on the patients; thereforeit is essential to provide social and educational support fortheir family members as well.

ì This is recommended to be done at an early stage in orderto prepare them for future life outside the hospital.

Recommendations for education

Caring for patients with spinal cord injuries is challenging, andnot only encompasses managing patients’ physical needs, butalso includes caring for their psychological needs.

ì It is recommended to include a stronger component ondealing with the psychological needs of patients and theirfamilies, and particularly on the skills needed to fosterhope, in nurse education programmes.

Recommendations for further research.

ì The unique finding in this study was that the nurses weremore concerned about the accommodating thepsychological needs of their patients than they were abouttheir patients’ physical needs.

It would be of value to investigate this phenomenon from theperspective of the patients.

Recommendations for further research

Anotherfindingofthisstudyshowsthatdehumanisationofpatientsoccursspontaneously.

ì Dehumanisationmaydecreasethesenseofempathy,andthismayhavedestructiveconsequences,especiallywhendealingwithpatients.

(Haque&Waytz 2012)

Lackofresearchlookingintothisphenomenon,thereforeitwouldbebeneficialtocarryoutmorestudiesonthistopic.

Recommendations for further research

Whencomparedtotheliteratureonnurses’experiencescaringforpatientswithothertraumaticinjuries,thefindingsofthisstudyshowmanysimilarities.

ì Therefore,thefindingsofthisresearchcouldalsobeusedforfutureunderstandingofnurses’experienceincaringforpatientsexperiencingothertraumaticevents.

CONCLUSION

Caringforpatientswithtraumaticspinalcordinjuriesthathadneurologicaldeficitisaconfrontingandchallengingendeavour.

Itisessentialfornurseswhoareinterestedinthisspecialtytobepreparedforthedynamicenvironmentofcareandnursing

practice.

Thefundamentalsofnursingcareremainunchanged;however,thespecificexperience,skillsandknowledgerelatedtospinalcare

remaindistincttospinalnursing.

REFERENCES

Alzghoul,MM2014,‘Theexperienceofnursesworkingwithtraumapatientsincriticalcareandemergencysettings:qualitativestudyfromScottishnurses’perspective’,InternationalJournalofOrthopaedicandTraumaNursing,vol.18,pp.13–22.

Bostrom,M,Magnusson,K&Engstrom,A2012,‘Nursingpatientssufferingfromtrauma:criticalcarenursesnarratetheirexperiences’,InternationalJournalofOrthopaedicandTraumaNursing,vol.16,pp.21–29.

Cardol,M,deJong,BA,Gam,Beelen,A,deGroot,IJM&deHaan,RJ2002,‘Beyonddisability:perceivedparticipationinpeoplewithachronicdisablingcondition’,ClinicalRehabilitation,vol.16,no.1,pp.27–35.

Coward,DD&Reed,PG1996,‘Self-transcendence:aresourceforhealingattheendoflife’,IssuesinMentalHealthNursing,vol.17,no.3,pp.275–288.

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Doherty,M&Thompson,H2014,‘Enhancingperson-centred carethroughthedevelopmentofatherapeuticrelationship’,BritishJournalofCommunityNursing,vol.19,no.10,pp.502–507.

Dunne,K2004,‘Griefanditsmanifestations’,NursingStandard,vol.18,no.45,pp.45– 53.

REFERENCES

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Dickson,A,O’Brien,G,Ward,R,Allan,D&O’Carroll,R2010,‘Theimpactofassumingtheprimarycaregiverrolefollowingtraumaticspinalcordinjury:aninterpretativephenomenologicalanalysisofthespouse’sexperience’,Psychology&Health,vol.25,no.9,pp.1101–1120.

Elliott,ES&Dweck,CS1988,‘Goals:anapproachtomotivationandachievement’,JPersonalandSocialPsychology,vol.54,no.1,pp.5–12.

Erez,M&Kanfer,FH1983,‘Theroleofgoalacceptanceingoalsettingandtaskperformance’,AcademyofManagementReview,vol.8,no.3,pp.454–463.

Freeman,L,Bourbonnais,FF&Rashotte,J2014,‘Theexperienceofbeingatraumanurse:aphenomenologicalstudy’,IntensiveandCriticalCareNursing,vol.30,pp.6– 12.

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Haque,OS&Waytz,A2012,‘Dehumanisationinmedicine:causes,solutions,andfunctions’,AssociationforPsychologicalScience,vol.7,no.2,pp.176–186.

REFERENCES

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Parish,C2006,‘Nursingtraumatisedpatientscanleavestafffeelingalienated’,NursingStandard,vol.20,no.22,p.11.

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REFERENCES

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