Swedish nursing instructors' views of nursing

Swedish nursing instructors’ views of nursing

Sirpa Janhonen

The views of Swedish nursing instructors of the concept of nursing are examined. The approach is an inductive one based on grounded theory, which is derived from phenomenology and sociological field research methods. The data were collected by selective sampling and by interviewing 14 teachers in two nursing schools (one small and one large) in Sweden. The analysis shows that the core of nursing can be described as helping the patients either to manage their daily living or to die with dignity, and it consists of three stages which continually interact. Three types of nursing emerged inside this process of help. The relationships between (1) the nurse and different kinds of the art of nursing, (2) the nurse and various kinds of assumptions concerning the patient, and (3) the nurse and different kinds of co-operation with other health care personnel groups define the different types of process of help. The theory of nursing practice generated here is one that can be employed to test nurse orientation in many contexts.

INTRODUCTION

The content and structure of nursing education are undergoing great changes in all the Nordic

countries, the aim being to educate and train

nursing specialists to be able to accept the challenge of meeting the expectations that society has of the nursing profession. Under Swedish law (Svensk forfattningssamling 1985), a nurse has to be competent in planning the care

of the patient, in directing nursing care, and in taking full responsibility for practical measures.

Moreover, the nurse has to be able to accept full responsibility for educating and guiding both nursing staff and students. The criteria underly-

Sirpa Janhonen RN MA LictNursing), Senior Lecturer, University of Oulu, Department of Nursing, Kajaaninkatu 52D, 90220 Oulu, Finland (Requests for offprints to SJ) Manuscript accepted 3 April 1992

ing such expectations are that the nurse should

be able to work independently, respond to the

nursing needs of the patient, find and use information, think critically and state and

defend arguments supporting her decisions.

Nurse instructors have a great influence on

the training of new nurses, being responsible for

planning it within the framework of a loose national curriculum (Universitetsoch

hogskoleambetet 198 1). They should therefore

be aware that there are many ways of understanding nursing and nursing practice. Under-

standing their own values, knowledge and actions helps them to clarify, structure and enrich their nursing perspective. Such an understanding is manifested in a congruence between nursing theory and practice. Comprehension of different nursing perspectives gives the teacher an opportunity for exchanging information and co-operating with others in developing teaching methods. Such interaction between teachers is a

330 NURSE EDUCATION TODAY

necessary condition for creating a common nursing care (e.g. American Nurses Association

framework and conceptual structure as the basis 1991; Andrews & Roy 1986; Justus & Mont-

for teaching (Bevis 1989; Chinn 8c Jacobs 1983). gomery 1986; Yura & Walsh 1983).

There are no research findings concerning the views of Swedish nursing instructors on nursing.

Many reports from different countries (Eronen & Makitorma 1987; Gott 1984; Hentinen 1989;

Miller 1985) claim teachers try to teach what they

believe nursing should be (Janhonen 1989), and they tend to describe their views by conventional

phrases (Leino-Kilpi 1989). In the studies men-

tioned, it is also suggested that there is a gap between nursing theory as taught by instructors

and actual nursing practice. The purpose of this

article is to describe and interpret the manner in

which Swedish nursing instructors comprehend

nursing. A practical theory of nursing is defined, as generated by an inductive research method

known as grounded theory. All the teachers who took part in this study were registered nurses

and had also received further training as nursing

instructors.

Standards and guidelines for nursing care represent an effort to provide some direction for

the overall practice of nursing, including the

provision of care and professional role activities.

The purpose of standards is to describe a level of nursing care and professional performance

common to all nurses, individually and col- lectively (American Nurses Association 199 1). In

addition, the nursing literature maintains that

the nurse should provide care on the basis of her values, knowledge and skills in nursing

(Andrews & Roy 1986; Hentinen 1989; Jan-

honen 1989; Orem 1985).

REVIEW OF THE LITERATURE

Nursing has been defined as care aimed at either

maintaining or creating a high quality of life for the patient, the focus being on the patient’s

health (Benner & Wrubel 1989; Bevis 1989;

Leininger 1988). Many theories to describe and

explain nursing have been developed, using deductive logic within the framework of other

sciences. These theories describe nursing as:

The values of nursing, as a basis for know-

ledge and skills in nursing practice, tend to

revolve around the views of members of the nursing profession. The professional nursing perspective views nursing as one of many health care professions, each of which has its own

specialised knowledge and skills from which the patient as consumer derives benefit. The patient

has the right and opportunity to take part in

planning, improving and evaluating his care in equal co-operation with the staff Uanhonen

1989; Lauri 1986; Miller 1985). Thus co-

operation between professional groups and between them and the patient is a condition for

high quality health care (Engstrom 1988; Frid-

lund et al 199 1). On the other hand, according to technical nursing perspective (Janhonen 1989; Lauri 1986; Orem 1985) the focus should be on

therapeutical interventions responding to the patient’s illness or injury. Responsibility for

patient care is divided in a heirarchical way and health care staff collaborate in promoting mainly

medical care. Medical knowledge and technical skills are considered to be highly important for nurses as well as for physicians. The Swedish legislation stresses professional responsibility in patient care, with every professional group responsible for their work relative to their standards of education and training, but it also points out the rights of the patient with regard to decisions concerning his care (Svensk forfattningssamling 1985).

1.

2.

3.

4.

5. 6.

7.

The actions of a nurse (Abdellah 1970). Response to the needs of the patient (Hen-

derson 1961; Yura 8c Walsh 1983).

Concentration on the abilities of the patient in daily living (Roper et al 1985). Helping the patient to adapt to his situation (Roy 1984). Releasing patient’s stress (Neuman 1982). Concentration on self-care on the part of the patient (Orem 1985). Interaction between the nurse and the patient (King 1971).

Many nursing theorists also claim that the nursing process creates the basis for high quality On the basis of an analysis of nursing, the

following open questions were asked during the

interviews:

1.

2.

3 L .

4.

The

1.

2.

What is the content of nursing assumed to be by the teacher while teaching nursing? What kind of nurse is the teacher aiming to

produce? What view of the nurse-patient relation-

ship does the teacher present? What is the function of the nurse in the

health care system?

study questions were:

What is the basic process of nursing and the

conditions for it according to nurse

teachers? What types of nursing are there inside the

basic process of nursing and what are the conditions for them according to nurse

teachers?

APPROACH AND METHOD

Approach

The scarcity of literature on what nursing is and

how nurses understand it in the Nordic coun-

tries led to the selection of an inductive method, grounded theory, which is a sociological field

research method based on phenomenology and

social interaction (Glaser 1978; Glaser & Strauss

1967, Schatzman & Strauss 1973). It is a method which allows information to be obtained about what people know about their own world and

how they understand it. Its advantage is that it can form a basis for employing various frame- works or views against which the real thoughts

and actions of nurses may be evaluated (Johnson

1990).

Data gathering

The data were collected by using selective sampling (Schatzman & Strauss 1973), based on results (Janhonen 1991) from two volunteer nursing schools (one small and one large) and from 14 volunteer teachers of nursing. The teachers represented all the specialised branches

NURSE E:DL!c:A-I‘ION TODAY 33 f

of nursing and were teaching at various levels of

nursing education. One teacher with long

experience and one with short experience were

interviewed at each level. The teachers also represented different age groups and had been educated and trained as nursing instructors at

different times.

The teachers had the opportunity to be quite frank about their views, and the interviewer

strove to elicit concrete examples of their views on nursing practice by asking open questions.

The interviews took l-l.5 hours, depending on

the teacher’s willingness to discuss the subject. All the interviews were recorded on tape with the

teacher’s consent and transcribed afterwards

(30-40 pages for each interview). The data for

analysis consisted of the typed interviews, which

were checked against the original tapes before

analysis.

Data analysis

The method of analysis was continuous com-

parative analysis, the purpose of which is not to

describe the phenomena, but to understand and interpret them (Chenitz 8c Swanson 1986; Glaser

1978; Turner 1981). According to this method,

the construction of typologies should be based

on ‘earned’distinctions which are inherent in the

data, and not on ‘received’ distinctions. The

theory and typologies emerge upon comparing

codes with their conditions, covariances, contexts and consequences, and by dividing up the

content of the concepts. The researcher is

required to maintain connections between the original data and the emerging theory (Chenitz and Swanson 1986; Glaser 1978; Schatzman &

Strauss 1973). The method of analysis has been

described in detail by Janhonen and Vehvi- lainen ( 1992).

Ethical questions

Both nursing schools and the instructors were volunteers, the researcher undertook not to publish their names, and the typist was unaware of the names of the instructors. Names of teachers used here are pseudonyms.


RESULTS

The analysis shows nursing to be a matter of helping patients either to manage their daily living or to die with dignity. This process of help consists of three stages: (1) meeting each other; (2) planning the aims for the patient; and (3) caring for the patient. The aim of this process is the health of the patient (see Fig.). Inside the process of help there emerged three types of

Society ------ - - __

-Health care

system -----------

care of the

patient

_

-.

nursing, which can be defined with the help of relationships between (1) various types of the art of nursing; (2) the nurse and the various assumptions concerning patients; and (3) the different types of collaboration between health care personnel groups.

The conditions necessary for each type of nursing will first be described. The definitions of the types of nursing will follow, and the stages of help will be defined and illustrated b; the teachers’ reports.

OTHERHEALTH ‘< - - \

CARE PRO- \

FESSIONALS

Nursing

I‘

Ability to carry

out

profes ionals

1

$71 The process of help - - -.

nursing

L-_l Ii

r\ ‘Y

Indirect methods:

Problems

with health _____7) An I individual in

a social

contexts

Figure The structure of nursing as a process of help and as part of patient care.

Conditions

It was found in the analysis that art of nursing

(i.e. the nurse’s competence, personality features and role) determine the various types of nursing. The patient emerged as individual in his social context. All teachers claimed that the patient has

the right to equal co-operation concerning his care. However, the actual meaning of co-

operation varied from one teacher to another.

The teachers also had different kinds of expecta-

tions of the patient during care. In the analysis

only one type of collaboration between the

doctors and the nurse emerged, i.e. carrying out the doctor’s orders. However, two kinds of collaboration between the nurse and auxiliary

personnel were found: co-operational collabor-

ation, and delegating collaboration. According to the teachers, nursing can be separated neither from the organisation (e.g. hospital) nor from

society. The nurses act in this organisation

alongside doctors, psychologists, and auxiliary personnel. The collaboration between the nurse and other health care personnel is termed indi-

rect nursing methods here. The conditions for

the types of nursing are described and illustrated by reports from the teachers’ interviews in the

Table.

Types of help

According to the analysis confirmed help places the focus of help on both the medical diagnosis

and the therapeutical interventions. The health

care personnel define, plan and implement patient care on the basis of their knowledge and

experiences. This kind of help consists of giving patients the care they need. The conditions for

confirmed help are:

The nurse has an open attitude and is positive. She assists medical staff in the patient’s treatment. She uses a delegating type of leadership with auxiliary personnel. The nurse expects the patient to be an obedient recipient.

NURSE E:DL'(:Al‘ION l‘OD.4k 333

The analysis revealed that understanding help concentrates on treating the patient with com-

passion. The nurse strives to take care into consideration the patient’s integrity and personality features, directs the helping process and hopes that the patient will follow her orders. Help consists of giving care according to the patient’s individual nursing needs. The conditions for understanding help are:

1.

2. 3.

4.

The

The nurse is willing to see the other per-

son’s problems. She uses a delegating type of leadership.

She assists the medical staff in the patient’s

treatment. The patient is a responsible recipient.

analysis shows that stimulating help concentrates on inspiring and encouraging the patient to use all his resources. Stimulation

includes co-operation with the patient and his

relatives to find solutions to problems arising

during the helping process. The patient takes full responsibility for his care during this time

and is encouraged to take part in planning,

carrying out and evaluating this together with the nurse. Through this co-operation, the nurse, the patient and his relatives strive to achieve the

nursing objectives. The content of this kind of

help is stimulating and identifying the resources of the patient.

Stages of help

The analysis revealed that nursing is seen as

helping the patient with the focus on meeting his

individual nursing needs, and the various types of nursing being dependent on certain necessary

conditions. The medical diagnosis has some influence regarding the needs of the patient, as described by the following teacher’s comment:

The medical diagnosis is the reason why the patient is there, that is why it is so important (Mari).

Three stages emerged in the helping process: (1) meeting each other; (2) planning the aims for

patient care; and (3) caring for the patient, and the process of help ends when the aims have been achieved.


Table The conditions of the types of nursing (names of teachers are pseudonyms)

Condition Content of condition Examples of the meaning of the condition in the teachers’ reports

The art of nursing

1 Competence ‘The nurse has to have both a good knowledge base and she has to be skilful, it is a question of patient’s safety.’ (All teachers)

1.1 Fundamental knowledge basis -medicine ‘The nurse has to know how to treat patient’s illness.’

(Gamma) -pharmacology ‘She has to be able to count and give medicine right.’

(Jane) -behavioral science ‘The nurse has to interact and to solve problems in many

contexts.’ (Delta) -framework for nursing

-treatment skills

‘The structure of nursing helps the nurse to see the whole situation of the patient.’ (Kati) ‘The nurse has to be able to care for wounds, to give injections etc.’ (Alfa)

1.2 Personality features -an ability to interact ‘She has to have an ability to deal with individual human

relationships.’ (Alfa) -a willingness and ability ‘The nurse has to be willing to see the problems of the

to help other person.’ (Irene) -a suitable attitude of mind

1.3 The role of the nurse

‘The nurse has to be happy, positive, and open.‘ (Lena)

‘She has to know her role as a nurse. She is responsible for carrying out medical treatment, for caring for the patient, for leading the nursing group, for educating nursing staff, and for developing nursing in the ward.’ (All teachers)

The patient 1 Definition of the patient The patient is an individual in his social contexts

2 What is expected of the patient 2.1 A responsible co-operator

2.2 An obedient receiver

2.3 No right to abuse

‘The nurse must know the patient, and both the closest relatives and environment of the patient. Also, the culture of the patient is important.’ (All teachers)

‘The patients have the right to equal co-operation both in planning the aims for their care and during the care.’ (Alfa)

‘The patient has to follow the orders and information he gets, and use the resources he has during the care.’ (Ellen)

‘The patient should not demand more caring than he needs.’ (Celia)

Collaboration 1 Definition of collaboration in nursing The content of collaboration can

be defined as using the system

2 Types of collaboration (indirect nursing methods)

2.1 Carrying out the doctor’s ‘The doctor determines medical treatment and the illness orders in patient care is the reason why the patient is there.’ (All teachers)

2.2 Leading the nursing group -co-operative collaboration ‘Nursing staff function as a work group.’ (Lena) -delegating collaboration ‘Auxiliary personnel function according to the nurse’s

orders.’ (Irene)

NL’KSE EDL’C:ATION ‘IWDAY 335

The analysis shows that the first encounter

between nurse and patient, called here meeting each other, forms the beginning of and basis for

helping the patient. In confirmed help it consists of collecting data concerning the patient’s holis- tic care; in understanding help it consists of

meeting the patient with compassion; and in

stimulating help, the nurse and the patient get to

know one another. The following reports

illustrate teachers’ views:

Confirmed: ‘The nurse meets the patient and

she interviews him. Actually this includes

mostly giving information to the patient and collecting data about the patient and his situation’ (Irene).

Understanding: ‘We must meet the patient with compassion. A human being is a whole

person, and everything has to be taken into

consideration’ (Celia).

Stimulating: ‘The nurse and the patient and

his relatives have to get to know one another.

So, they must have access to all the resources which are available’ (Nina).

According to the analysis the second stage of the

process of help is planning the aims for patient care. While offering confirmed help, the nurse

plans the process of help on the basis of her knowledge and experience; with understanding

help, the nurse plans the individual helping

process for the patient with compassion; and in

offering stimulating help, the nurse helps the patient to plan his objectives. The following

comments illustrate:

Stimulating: ‘Through interacting with the

patient, by listening, discussing, and utilising the whole system, the patient will be stimulated toward better health’ (Alfa).

Confirmed: ‘The nurse will plan the care of the patient on the basis of her knowledge and

experience’ (Irene).

Understanding: ‘The patient is a whole person. It is important that the nurse respects his personal integrity highly while planning the aims for nursing him’ (Celia).

Stimulating: ‘The nurse will help the patient to plan the aims of nursing. The patient and his relatives will co-operate with the nurse in meeting these objectives’ (Alfa).

The methods of help were classified into two categories: direct and indirect. Direct methods operate through the immediate relationship

between the nurse and the patient. Here the nurse is not carrying out the orders of a doctor. The instructor’s expressions ‘helping’, ‘support-

ing’, ‘listening’, ‘hearing’, and ‘teaching or guid-

ing the patient’ have been placed in the category of direct method. together with ‘giving informa-

tion’, ‘using the nursing process’, ‘documenting nursing’, ‘caring for the patient’, ‘using problem solving’, ‘research methods (observation, daily

interviews, asking questions)‘, ‘nursing tech- nology’, and ‘teaching methods’. Indirect methods are those which are carried out in a hierarchical system through leadership of a nursing group and execution of a doctor’s orders.

The analysis revealed that caring for the patient is the next stage of the process of help. While

using confirmed help the nurse organises and leads the nursing group and carries out the medical treatment. In offering understanding

help, the nurse leads and organises the work of

auxiliary personnel and carries out the medical

treatment; while the nurse who uses the stimu-

lating type of help concentrates on interacting

and utilising the system. The following reports illustrate:

Confirmed: ‘By writing objectives for the patient’s individual needs, by organising and

leading the work of auxiliary personnel, and by carrying out the doctor’s orders, it will be

possible to produce alternative models of nursing, to develop methods and to give individ-

ual nursing’ (Beta).

Understanding: ‘By developing close contact

with the patient, by the use of sensible leadership systems, and by carrying out the medical

treatment according to the doctor’s orders, we

will provide a better quality of nursing than

earlier’ (Celia).


Leadership of a nursing g-roup consists of taking responsibility for patient care and making decisions in nursing practice, as well as supervis- ing and delegating the work (Table). It includes a great deal of interaction with both the auxiliary nursing staff and the whole organisation. The nurse, as a leader, is a key person involved in teaching, development and study in her ward. Leadership of a nursing group can be of two types.

1. Co-operation, in which the work is shared out at discussions during regular meetings. All staff are involved in co-operating with the patient and with each other. Moreover, the work is not task-centred, but patient- centred.

2. Delegation, which means that the nurse divides the tasks up according to a plan drawn up by her, in which each staff group carries out its own set of tasks.

The carrying out of a doctor’s orders consists of observing the patient’s symptoms, giving information concerning these symptoms to the doctor, and administering medicines (injections, infusions etc.). The nurse also carries out various tests. Helping the patient is based on the medical diagnosis of the patient, where it is the doctor who makes the diagnosis, defines the medical treatment, and directs the care provided.

Only a few teachers mentioned the question of how and when helping the patient comes to an end. One said that ‘the patient leaves the hospital when the doctor says he is ready to be dischar- ged’. Only two of the teachers mentioned the possibility that the patient might die, by using the term ‘terminal stage patient’. The first one did so while discussing the role of a priest or counsellor as a support for both the staff and the patient at times of difficulty in the ward, and the other one (Nina) related an excellent example of nursing carried out in co-operation with a dying patient, her relatives and friends, in which the desire of the patient was to die at home with dignity. However, all teachers mentioned health as the aim of patient care, and two clear concepts of health emerged: (1) an ability to use one’s maximal capacity; and (2) the balance of physical, mental, and social health and well being. In

some cases teachers had no clear definition of health, using example such as ‘The patient leaves the hospital when the doctor says he is ready to do so. He may be healthy or something like that’ (Beta). This kind of view is termed here an unclear concept of health.

The teachers mentioned that ‘ideal nursing’ as they described it does not portray ‘the real nursing practice of today’, and that nurses practice neither the direct helping methods nor the leadership of a nursing group to the extent that they should, but are willing simply to carry out a doctor’s orders, as the following report describes:

Then he (a patient) said to me, “why do you plan everything so badly? Why on earth is it necessary to have so many people taking care of fragmented tasks? Why can’t you plan all these tasks at the same time?” I had to agree that no one plans the treatment properly. Women in the ward work like housewives in the kitchen, adding a little salt, a little flour etc., following a recipe they have. The nurse devotes herself to serving the doctor when he needs her (Jane).

DISCUSSION

Discussion on reliability and validity

‘The purpose of grounded theory is to specify sets of action/interaction pertaining to a phenomenon and the resulting consequences. It is generalisable to those specific situations only’ (Strauss & Corbin 1990). The researcher was fully aware that a theory generated by means of grounded theory is also an individual interpreta- tion of the phenomenon of interest (Atwood & Hinds 1986). But a theory of this kind is intended to be tested in different surroundings (Chenitz & Swanson 1986; Glaser 1978; Schatz- man & Strauss 1973). The validity and reliability of this kind of study is based on valid and reliable data gathering, the adequacy of the research process, and valid and reliable empirical

NURSE EDU(:A’I-ION -I‘OI)AY 337

grounding of the research findings (Sandelowski

1986; Strauss & Corbin 1990).

Selected sampling was used to try to obtain data that was as diversified as possible. During the data gathering the researcher scheduled the

interviews at the convenience of the teachers so

they would not be hurried. The teachers had the opportunity to give their opinion quite frankly.

They were also asked to give concrete examples concerning their ideas, to enable the researcher

to get a deeper understanding in their views

(Kagan & Tippins 1991; Schatzman & Strauss 1973). The data were compiled by audiotaping

the interviews and having them transcribed by a native speaker of Swedish in order to minimise mistakes (Hirsjarvi & Hurme 1979).

The data analysis was performed by a nursing

instructor with a command of Finnish, Swedish and English, and four of the instructors who

took part in the study, in order to guarantee

internal consistency, face and content validity in

the study (Atwood & Hinds 1986). The researcher tried to achieve construct validity by reliable

and valid data analysis, as illustrated in the reports from the interviews (Atwood & Hinds 1986; Glaser 1978; Miles & Huberman 1984;

Schatzman & Strauss 1973). The empirical grounding of the research findings has also been

described with reports from the interviews

(Strauss & Corbin 1990).

Discussion on findings

All the nursing instructors who took part in this

study were able to provide examples both from

their work in teaching nursing and nursing practice. Their notions of the understanding

and confirmed types of help are congruent with Leino-Kilpi’s ( 1990) findings that good nursing care is defined largely in terms of doing some-

thing to, or on behalf of, the patient, but she did

not refer to help by stimulation, or to co- operation on the part of the patients. Help by

stimulation has many associations with the kinds of nursing described by Burnard (1987a) and Morrison and Burnard (1989), and emphasises

the aspects of being present, hearing, listening and also acting as a catalyst in the nurse-patient relationship, which includes co-operation

during the helping process. These features are

discussed in the nursing literature (Andrews & Roy 1986; Orem 1985). Stimulating also involves

all aspects of caring, ‘human traits, affects, moral imperatives, interpersonal interaction and

therapeutic intervention when the outcomes of caring are both the patient’s subjective experi-

ence and the patient’s physical response’, as

defined by Morse et al (1990).

Help through understanding points to the traditional ideals of nursing, e.g. close, understanding contact with the patient, or being kind

and generous to the patient. On the other hand, this type of nursing stresses the authority of the

health care personnel, who base their actions on their specialised knowledge. These features

have very close associations with Eriksson’s ideas

of nursing (1979, 1983), and her later idea

(1987, 1989a) of Caritas. Irnderstanding also strives to take into consideration the aspects of

caring outlined by Morse et al (1990) but it ignores the ideal spirit of interpersonal interaction in nursing, i.e. co-operation between the

nurse and the patient. Confirmed help has links with traditional nursing practice, in which health

care experts plan and execute specialised care

for a passive recipient called the patient (Brickman et al 1982; Cronenwett 1982; Jan-

honen 1989). Confirmed help concentrates on

therapeutic interventions in nursing (Morse et al

1990; Timpka Xc Arborelius 1990). It was evident from the analysis that there

were three definitions of the concept of health as

the aim of nursing. ‘An ability to use one’s

maximal capacity’ is congruent with the ADL (activities of daily living) view of nursing (Koper et al 1985), while the view that health is a balance of physical, mental and social well-being is the

same as Eriksson’s (1989b). The third response, that health is an unclear concept, probably

indicates that the teacher did not consider health

to be the aim of nursing. The instructors pointed out how important it

was the the nurse should be competent in nursing practice, reflecting the content of the Swedish Law on Health Care (Svensk forgatt- ningssamling 1985), but their opinions con- tained features of hierarchy in nursing practice and are inconsistent with the usual definitions of


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Acknowledgements

I wish to express my appreciation and thanks to Professor Maija Hentinen for her input and helpful comments during my work. Her suggestions helped greatly to improve the results presented here. I am also very grateful to Vivian Paganuzzi for his valuable assistance with the language of this paper. This work was supported by grants from the Finnish Academy.

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Swedish nursing instructors' views of nursing

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