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Student Nurses' Perceptions of Mercy

A Qualitative Study

Thiel, Linda M.; Razmus, Ivy; Nauta, Becky; Keep, Suzanne; Thomas, Roberta; Moran, Katherine

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doi: 10.1097/CNJ.0000000000000782
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Abstract

INTRODUCTION

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Faith-based mission statements are foundational underpinnings for many hospitals and schools of nursing. As a summary of an organization's aims, the mission statement offers values and behaviors to which employees and associates can ascribe. The term mercy has been used throughout nursing history and is applicable to all nursing practice settings as well as to nursing education. Mercy is often a foundational value for faith-based hospitals and schools of nursing.

In 2016, faculty members undertook an assessment of the spiritual integration of mercy at the McAuley School of Nursing at the University of Detroit Mercy, a faith-based institution. To evaluate how fully the concept of mercy was understood and embraced by the students, faculty researchers conducted a qualitative study to explore the meaning of mercy to nursing students.

BACKGROUND

The University of Detroit Mercy, McAuley School of Nursing (MSON) is grounded in the mission and vision of Catherine McAuley (1778-1841), foundress of the Sisters of Mercy religious order (Sisters of Mercy, 2020). Several other nursing programs in the United States also are based on McAuley's mission and vision of mercy.

As a child, McAuley witnessed acts of loving mercy while accompanying her father in caring for the poor of Dublin, Ireland. (See Sidebar: A Profile of Catherine McAuley.) Later, in correspondence with her Mercy sisters and friends, she often wrote, “Be merciful, just as your Father is merciful” (Luke 6:36, NASB). Her letters would offer, “May God in his mercy bless and protect us all” (Mercy World, n.d.). McAuley's faith and desire to resemble Jesus in light of Scripture was motivational in her life (Regan, & Keiss, 1988; Sullivan, 2012) and endures today. At least 17 schools of nursing are rooted in the spirituality of mercy (Conference for Mercy Higher Education, n.d.).

Although nursing history and several nursing programs have included the concept of mercy in practice and education, it is not known how today's nursing students understand the term and what it means to their future nursing practice. To explore this topic, an assessment of the meaning of the term mercy was undertaken by asking students to respond to the open-ended question: “What does mercy mean to me?”

LITERATURE REVIEW

The literature review conducted by three authors did not result in scientific research pertinent to nursing and mercy. However, mercy-related literature was available within a Judeo–Christian and philosophical perspective.

Mercy is a term clothed in emotion and used in poetry, novels, songs, and liturgical worship. Mercy is part of the names of healthcare ships, soup kitchens, and mission experiences as well as websites and institutions (e.g., Mercy Health Hospital, Mercy College, Mercy Breast Center). Mercy has been used to describe a quality displayed by nurses who tend to the injured, sick, and dying (Wyatt, 2019). Nurses have been portrayed as angels of mercy (Betts, 2016) and religious institutions use mercy in describing a way of life or apostolate, such as the Sisters of Mercy (Sisters of Mercy, 2020).

Mercy can suggest an interpersonal relationship familiar in nursing. Webster's New World College Dictionary (2020) defines mercy as “...kindness in excess of what may be expected, compassion; kindness or compassionate treatment, relief of suffering.” These descriptions highlight the relational nature of mercy.

For a nuanced understanding, it is important to examine several related concepts. Many definitions of mercy include the companion concept forgiveness. Brush and colleagues' concept analysis (2001) defined forgiveness as “a time-dependent process of recognizing harm to or by others and the willingness to change hurtful actions or behaviors, repair or restore relationships, and let go of past wounds” (p. 32). Letting go of past injuries is possible, but challenging. The phrase, “Forgive, but don't forget” may allow for letting go but might not allow for ceasing to remember. There is a greater forgiveness which is incapable of remembrance: the way of mercy (Jubilee of Mercy, n.d.). To forgive and not remember is a transformational process to which all people are called. Although mercy and forgiveness involve not focusing on past actions, mercy suggests a dynamic process of doing (Scofield, 1992).

Another companion concept of mercy is compassion, defined as “the feeling or emotion when a person is moved by the suffering or distress of another, and by the desire to relieve it; pity and concern for the sufferings or misfortunes of others” (Oxford, 2020). Compassion enables an individual to put him or herself into social relation with another (Kasper, 2014). Compassion, as a nursing value, involves the affective dimension of empathizing with the suffering of others and the effective (cognitive) dimension of trying to relieve pain (Curtis, 2015). Mercy shares compassion's qualities of attentiveness and action.

Mercy in the Judeo–Christian tradition

The Christian Latin etymology of the word mercy, misericordia, has a broad meaning, combining the words miseriae meaning misery and cordis meaning heart, and takes on a heartful solidarity with those in need (Rummelsburg, 2015). Kasper (2014) stated, “The Christian form of mercy is ultimately a Christian existence on behalf of others” (p. 150). Saint Thomas Aquinas, a medieval theologian and Dominican priest, stated, “Mercy is the greatest of the virtues” (Bergoglio, 2013, p. 19).

In the Old Testament, mercy is primarily presented as one of God's attributes. God is portrayed to Israel as being rich in mercy: “For I desire mercy, not sacrifice” (Hosea 6:6, NIV). Mercy is grounded in covenantal love transformed into charitable action, especially for the poor (Sinnott, 2018). Isaiah 49:15 notes God's mercy as motivation for showing compassion to others and likened to human relationships as does Jeremiah 31:20.

Jesus embodied God's mercy in human terms. We hear cries for mercy and for restoration to wholeness from two blind men (Matthew 9:27) and ten lepers (Luke 17:11-14). Mark 7:24-30 records that Jesus healed the Syrophoenician woman's daughter, extending mercy beyond the Jews to all people. In the Sermon on the Mount, Jesus called his followers to mercy: “Blessed are the merciful, for they shall be shown mercy” (Matthew 5:7, NIV). Sister Faustina Kowalska described mercy as the highest of divine attributes and emphasized mercy as divine perfection “pure and simple” (Kasper, 2014, p. 7).

Although mercy is often considered synonymous with nursing, it can be difficult for nurses to demonstrate when under stress. Lamott (2017) noted that when we are busy, we can let irritation and being judgmental take over. Lamott added that when we are occupied and concerned about our own lives, we often may not extend mercy to ourselves, let alone others. Through reflection, we become conscious of the transformational spiritual journey and need to ponder the question: What does mercy mean to me? To address the mercy research gap, this study explored the meaning of mercy.

Purpose

The purpose of this qualitative study was to explore the meaning of mercy among nursing students enrolled in a faith-based institution. The research question was, “What is the meaning of ‘mercy’ for prelicensure BSN students?”

METHODS

Study design

Researchers used a qualitative descriptive design to interpret meaning from the content of text data responses. Summative content analysis was undertaken to establish categories and identify patterns/themes. The study collected data cross-sectionally (one point in time). Purposive sampling was aimed at achieving diversity through the recruitment of students across all undergraduate academic levels. Ethical considerations for research were upheld. The authors submitted the study to the Institutional Review Board (IRB) at the university where they were affiliated; the IRB granted exempt status. Faculty collected participant responses during classroom periods. Submission of responses to the question, “What does mercy mean to me?” was taken as participant consent.

Study participants, setting, and data collection

Participants were prelicensure BSN students enrolled in a private, faith-based university in the midwestern United States. A purposive sampling targeted the entire student body (n = 194). One hundred seventy-two (88.6%) students participated in the study during the fall 2016 semester.

Student participants were invited during class time to write a response to the question, “What does mercy mean to me?” Each participant was given a 3” × 3” Post-it note card on which to write a response within a 5- to 10-minute time frame.

Once the classroom instructor explained the activity, student questions about the activity were addressed, including the choice to participate or not and the assurance of confidentiality and anonymity. No identifying information was solicited. The professor collected the note cards, placed them in a sealed envelope, and forwarded them to one of the two coders. There were no incentives to participate.

Data analysis

This study used a qualitative approach in analyzing data (Statistics Solutions, 2017a–e). Researchers used a summative content analysis approach to identify and quantify categories of words describing mercy, followed by generation of themes. The summative method uses an inductive categorical development approach (Mayring, 2004) as the frequency of certain words is quantified. This approach “is not an attempt to infer meaning but, rather, to explore usage” (Hsieh & Shannon, 2005, p. 1283).

Using a private password-protected computer, responses were entered verbatim into an Excel file. Only one member of the research team had access to the password-protected electronic database. A second member of the team compared the original responses with entries for accuracy. A few entry errors were identified and corrected. The same two researchers/coders analyzed student responses and coded the responses independently.

Summative analysis: Identification, quantification, categorization

The summative analysis process undertaken in generating categories was based on 100% agreement by the study's two coders.

Step 1: Single-word text. Data analysis used an Excel computer-assisted search for frequency of a single term (descriptor) with similar forms, such as forgive (n = 5), forgiveness (n = 7), and forgiving (n = 3). The term with the highest count (forgiveness, n = 7) was coded or labeled as that category (i.e., forgiveness). Category selection was based on 100% agreement by the two coders. To ensure that meaning of each category was consistent throughout analysis, a category definition log was generated.

Step 2: Multiword text. The same approach used in Step 1 was used for coding responses which included phrases. The definition list generated in Step 1 was used to maintain analysis consistency between coded categories. New definitions were added to the log.

Step 3: Response (i.e., text) removed. Responses that implied a disconnect with the purpose of the study, such as “leadership” and “being merciful to students during exams” were not included. The decision to remove a term or text was based on 100% agreement by the two coders. Steps 1, 2, and 3 concluded generation of categories (Table 1).

Table 1. - What Does Mercy Mean to Me?
Category Freshman 2020a Sophomore 2019a Junior 2018a Senior 2017a Total
n (%) n (%) n (%) n (%) n (%)
Compassion 13 (23.2) 14 (25.0) 19 (33.9) 10 (17.9) 56
Forgiveness 14 (43.8) 1 (3.1) 11 (34.3) 6 (18.8) 32
Caring 4 (15.4) 9 (34.6) 11 (42.3) 2 (7.7) 26
Kindness 5 (26.3) 4 (21.1) 6 (31.5) 4 (21.1) 19
Love 8 (50.0) 1 (6.2) 4 (25.0) 3 (18.8) 16
Giving 8 (57.1) 2 (14.3) 3 (21.5) 1 (7.1) 14
Hopeful 4 (40.0) --- 1 (10.0) 5 (50.0) 10
Selflessness --- 2 (20.0) 7 (70.0) 1 (10.0) 10
Opportunity/Another Chance 4 (40.0) --- 3 (30.0) 3 (30.3) 10
Other, less than 10 per category 8 (19.5) 4 (9.7) 17 (41.5) 12 (29.3) 41
68 37 82 47 234
Note. Category by cohort, frequency, and percentage (N = 234)
aYear of graduation

Summative analysis: Thematic analysis

Thematic analysis was used to determine patterns. Single- and multiple-word responses became the basis for thematic analysis and determination of patterns. One coder collated verbatim text. Research team members discussed major concepts and themes. Each member worked independently, prior to group work, to consider concepts and themes. Group decision to retain, collapse, or remove an overall theme was unanimous. One team member wrote narrative themes based on 100% agreement by the research team. To hold in abeyance preconceived beliefs or opinions (bracketing) regarding mercy, research members made conscious efforts to hold responses with openness. Self-reflection (reflexivity) was an important practice to suspend preconceived beliefs/opinions during thematic analysis.

RESULTS

Demographics

One hundred seventy-two or 88.6% (N = 172) of the total BSN student body of 194 participated. Participation rates between and among cohorts exceeded 78%: freshmen 88.3% (53/60), sophomores 95.1% (39/41), juniors 93.6% (44/47), seniors 78.2% (36/46).

Enrollment data of the student body were used as demographics because specific data on participants were not collected. The total student population during fall semester 2016 was 194 students between 17 and 29 years old. Most students were female (90.7%, n = 176) with 23% (n = 44) of the student body representing first-generation student status. Ninety-one percent (n = 176) of students indicated class/ethnicity as White; Hispanic/Latino 3% (n = 5); Black or African American 2% (n = 3); Asian 1% (n = 1); American Indian/Alaska Native 1% (n = 1). Four percent (n = 7) answered “unknown” category. Respondents (40%, n = 77) indicated their religion as Catholic, whereas 11% (n = 22) indicated Christian. Thirty-three percent (n = 64) of students indicated “unknown” religion. All students claimed residency in the United States. These demographics should be interpreted with caution because they do not necessarily represent those who participated, but the potential pool of participants.

Summative analysis: Identification, quantification, categorization

Participation by 172 students resulted in 237 text statements. Three participant responses were discarded due to lack of clarity and relevance to the study; therefore, 234 responses were used. The majority (58.8%, n = 143) of responses consisted of multiworded responses (i.e., “helping each other,” “seeing Christ in the person I encounter”) compared with single-word (n = 100, 41.2%) responses (“caring,” “compassion,” “God”). The three highest categories were (1) compassion (n = 56, 23.0%), (2) forgiveness (n = 32, 13.7%), and (3) caring (n = 26, 10.7%).

Summative analysis: Thematic analysis

Two main themes emerged from the question, “What does mercy mean to me?”

Movement toward radical inclusivity. Participants indicated mercy is an act of giving directly to others. The giving act depicts inclusivity and minimizes boundary keeping and the formation of barriers. Crossing boundaries inhibits the development of barriers. The movement of mercy softens the “I - Them” boundary and eventually reaches an “Us” perspective.

Responses included “wanting everyone to achieve,” “showing compassion to all people,” “accepting all people despite their background,” “putting others before myself,” “having forgiveness for yourself and each other,” and “getting a second chance.” Radical inclusivity evolves into a letting go of self or what could be described as movement toward a selfless ego (Carreita, 2014).

Being mercied. Respondents indicated mercy as a relational experience manifested through several attributes. Being mercied is an experiential encounter in which the roles of giver and seeker are interdependent and transitional; the seeker of mercy becomes a giver of mercy, as one exists only in relationship with the other. This interdependence was reflected in participants' terms such as, “all,” “together,” “to give,” and “to receive.” The theme was supported by the attributes of compassion, forgiveness, caring, love, kindness, and giving (Table 1). Examples of participants' statements of this pattern include “overflowing with compassion,” “forgiving others with love,” “caring unconditionally and holistically,” “doing every action with love,” and “treating all with kindness.” These attributes reflect being mercied with a relational awareness of interdependence.

DISCUSSION

As nursing history is associated with the Judeo–Christian perspective, the concept of mercy is deeply embedded in nursing practice. Mercy has been a fundamental nursing attribute; therefore, compassion, forgiveness, and caring were the most reported student terms describing mercy.

The compassion category received the highest count. Compassion is considered one of the most important characteristics for nurses (Aagard et al., 2018). Forgiveness was the second most frequent category identified. As forgiveness requires reviewing personal feelings and actions in relationship to self and others, it supports the importance of reflective assignments in nursing education. Caring was the third highest category. Caring is identified as an essential nursing characteristic by various nurse theorists (e.g., Watson, Swanson, Boykin, & Schoenhofer).

The two themes generated, movement toward radical inclusivity and being mercied, reflect a transformational interaction (relational, interdependence), which is intrinsic to nursing practice. It reflects a phenomenon that includes nurse/student, patient, environment, and health, which are active, unique, and difficult to quantify. These themes resonate with nurses as they carry out acts of mercy toward patients.

Although mercy is inherent in nursing practice, it is not necessarily integrated in curricula. The integration of mercy through teaching strategies, including reflective learning, can enable student nurses to see their role as a profession based on mercy and acts of mercy. The findings suggest a degree of integration within the student participants.

The study's themes and attributes are reflective of values recognized by the Religious Sisters of Mercy. These values are considered a gift of grace bestowed for the benefit of others, not for oneself (Dulles, 2003). The idea of giving clearly resonated with participants and their responses are congruent with the nursing program's mission to prepare competent baccalaureate nurses who serve in faith with a focus on social justice and compassionate nursing care.

LIMITATIONS

Participants' solicited reflections were limited to class time that may have impacted recall, and faculty presence may have influenced student responses. The sample was derived from participants in a single faith-based nursing program; therefore, findings may not translate to other settings. Freshmen nursing students had not received formal knowledge on the school of nursing's tradition. The instructions given to participants were not written; including written instructions may have eliminated clarity issues and supported instruction consistency between classes. Despite limitations, the study does provide contextual data regarding students' understanding and integration of mercy and provides data for teaching strategies.

PRACTICE IMPLICATIONS

Findings from this study suggest several implications for practice.

  • The definition and thematic analysis of mercy could be used in nursing curricula (especially faith-based programs) to direct faculty and assist students in understanding how mercy could be incorporated into practice.
  • The definition and thematic analysis of mercy is useful to nurses in daily practice.
  • The reflective (qualitative) approach and summative analysis could be used by practicing nurses to make the meaning of mercy concrete.
  • Faculty could use reflective methods and integration of reflective practices/assignments (e.g., journaling, reflective pauses) to assist students with mercy integration.
  • The establishment of baseline mercy assessments is useful to enhance the teaching-learning process (formative and summative).
  • The development of processes and measurements with other disciplines could be used for mercy integration throughout healthcare.

The importance of reflective practice is not to be underestimated as it fosters self-awareness and personal growth, two essential components of nursing education. This practice includes self and group journaling, reflective pauses, and discussion. Reflective practices can be explored to guide nurses and students toward the integration of mission-driven values and behaviors into a personal practice framework.

CONCLUSION

The study results are important to nursing and faith-based organizations because there is a paucity of literature exploring the link between the values presented within these organizations. Values such as mercy, caring, and compassion are what make students and nurses unique. Although the University of Detroit, Mercy McAuley School of Nursing tradition was used to describe congruences between program mission and generated themes, other faith-based programs may find these results encouraging. It is hoped that through experience and knowledge, students will grow in their relationships with clients and develop into professional nurses whose practice is characterized by acts of mercy.

Sidebar: A Profile of Catherine McAuley

As the founder of the Sisters of Mercy, a Roman Catholic community of religious women, Catherine McAuley's life theme revolved around mercy. She grew up in Ireland after her birth in Dublin in 1774. Both her parents died when she was young; the family she lived with after her parents' death eventually left her an inheritance. Desiring to help the poor people in Dublin, she invested her inheritance in a “House of Mercy.” Along with other lay Catholic women, McAuley provided housing, food, education, and medical help for poor women and children in the city.

McAuley chose to enter the religious life, becoming a nun in 1831 and seeking to make the House of Mercy into a convent. She requested that Rome officially approve, stating “the principal purpose of this congregation is to educate poor little girls, to lodge and maintain poor young ladies who are in danger, that they may be provided for in a proper manner, and to visit the sick poor” (McDermott, 2003). Rome granted McAuley's request and soon she and other nuns were extending their ministry of mercy throughout Dublin, becoming known as the “walking nuns” (Catherine McAuley Center, n.d.).

As more women joined, the House of Mercy ministry spread quickly outward through Ireland and England. McAuley was known to travel by any means necessary to be present for at least a month during the launch of each new community (Mercy International Association, 2020).

In 1843, 2 years after McAuley died, the first Sisters of Mercy community took root in the United States in Pittsburgh, Pennsylvania. Today, the Sisters of Mercy of the Americas is the largest single congregation of religious women in the United States, with 2,608 sisters (Stockman, 2019). They also sponsor or cosponsor six health systems in the United States, 19 hospitals and healthcare centers, a mobile clinic, a senior living center, and an assisted care facility. Healthcare ministries also flourish in Belize, Guam, Guyana, Peru, and the Philippines (Stockman, 2019). “We've had an extraordinary legacy in health care,” summarized Mercy Sister Patricia McDermott, President of the Religious Sisters of Mercy of Alma, Michigan (Stockman, 2019).

Catholics and the Sisters of Mercy religious women continue to hold McAuley in the highest regard. Mercy Sister Mary Sullivan, one of McAuley's biographers, said McAuley is an ongoing inspiration. “She was a very loving, practical, humorous and merciful person. She had a vision of mercifulness to all God's people, especially the so-called least of these, and that vision got passed on to other people. Even today, you'll find Sisters of Mercy saying, ‘I think this is something Catherine McAuley would want me to do’” (Stockman, 2019).

—Karen Schmidt, BA, RN, JCN contributing editor

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            Keywords:

            Catherine McAuley; compassion; faith-based schools of nursing; mercy; nursing; nursing students

            InterVarsity Christian Fellowship