Introduction

This paper presents a pilot study of a tool that uses Pedagogical Symbols Plotted on a Map (PSPM), modelled on the technique employed in orienteering, applied to nurses from health care and healthcare education receiving supervision. Within health care and healthcare education, there is a need for nurses to explore and knowing how to use various symbols and to understand themselves as nurses, through reflection, in various associations, and situations. Nursing means relating to encounters with patients and their families in connection with health and health resources, needs and the problems and risks involved in both acute and long-term illnesses [1], with the intention of creating health processes in a caring relationship.

In these encounters, nursing includes working from a holistic view of human beings [2,3]. Focusing on encounters in nursing through reflection can provide knowledge of how emotions, thoughts and actions interact and affect each other in a specific context or situation. This requires participants in preceptorship to be given the opportunity to reflect on and freely associate about different nursing situations in a safe environment with the participants in the group and the preceptor [4,5]. Reflection is a central part of nursing practice involving thinking, openly, through a situation in an accurate and consistent manner that leads to a conclusion [6]. In addition, reflection was often intended to train the ability to integrate theoretical knowledge with practical skills. It also includes raising awareness of how one, as a professional, interacts with people, and practicing the ability to manage emotions that arise in encounters with other human beings [7]. Nurses need to reflect on the integration of the knowledge, which they acquired from clinical practice and encounters with the patients, families and team members. They also need to integrate knowledge through acting differently, in practice, in a specific professional situation [4].

Maps have long portrayed the story of how human beings perceive the world and their place in it [8]. A map is an aid in finding places or viewing itineraries. The first person who attempted to measure the earth was the Greek Eratosthenes, around 200 years BC. He developed the system of latitude and longitude to identify specific locations on the earth. Every map is based on assumptions that the reader needs to know in order to make it understandable. Maps can be drawn and used to find or view alternative pathways [8]. The word orienteering was used for the first time in 1886, meaning to cross unknown territory with the help of a map and compass [9], an activity then limited to the army. As a sport, it combines a physical and mental element. The basic objective is, with the help of map and compass, to proceed from course start to finish visiting a number of control points on the way, choosing the best possible route, taking into account the terrain, navigating and making quick decisions [9]. The basic steps in orienteering are to understand where you are situated on the map and where you are going; to select and plan your route; implement your plan; ensure that you are on the right path and can find the control points.

Three theories concerning reflection can serve as a basis for using the orienteering model. The first, taken from [10], is based on what a participant has seen, thought, felt and done. The second reflection model presented by [11] uses concrete thoughts and feelings and helps towards an understanding of them through exploring what had happened and formulating an alternative action plan. The third model is KASAM [12] in which the aim is to gain a feeling of being in a context where problematic situations can become more comprehensible, manageable and meaningful through reflection. Supervision in nursing clinical work and in education can be supportive, encouraging trust and reflection in order to develop skills, competence [13] and ethical awareness in caring situations [14]. This pedagogical process was grounded in nursing theories. Groups receiving supervision involved 5-8 participants, who met for 1.5 hours every other week for twelve months, with a nurse acting as the professional supervisor [15].

In the pilot study, carried out with three groups, an approach was designed to evaluate the effect of using pedagogical symbols on a map. The present study explores the participants’ decisions to find or view their own way in various nursing situations. The question to be answered in this study is whether the PSPM tool is effective with regard to reflection, which guided nurses´ professional understanding. The aim was to explore how participant nurses can be guided in their professional understanding of nursing by using an orienteering map with pedagogical symbols as a part of supervision.

Material and Method

The pilot study has a qualitative, inductive design using interviews, with a full sample selection responding to the aim [16].

Setting

The study was conducted in the south of Sweden from May to October 2016. The intervention took place in a classroom and two conference rooms, with the participants and a supervisor present.

Participants

The pilot study included three groups, where all 44 participants were registered nurses. The first group consisted of 18 supervisors in four groups (H1-H4); the second group comprised 19 registered nurses involved in student supervisions in four groups (U1-U4); and the third group was made up of seven registered nurses eight months after they qualified as nurses (B1-B7).

Intervention

A pilot study of three groups of registered nurses receiving supervision was implemented and evaluated the efficacy of a map using pedagogical symbols in a nursing situation (Figure 1). Instruction was given new skills of plotting a map using the symbols, which represent emotions of the case that they encountered. The intervention began with a participant choosing a nursing situation (ethical reflection of doing the best) or three to four nurses working in a group choosing a common nursing situation (to defend the patient desires against doctor decision). The participants were then given a map with symbols and instructions as to what the training entailed. The symbols were taken from orienteering maps and represented a mountain, a lake, a ruin, a shooting range, an orchard, a bullet-proof vest, a dense forest, a narrow road, an out-of-bounds area, a ruin and an open ground. The participants chose where on the map they wanted to start and finish, based on the symbols that they selected. For each symbol chosen an explanation was written about how the path to "The finish" on the map was decided on. To discover what each participant or group concluded, they were asked why they decided or chose as they did and how they moved towards the target. To conclude, all participants also described how they experienced the intervention, what they learned from it, and if they would be able to use the PSPM model in different situations in their work. The symbols and emotions can together with a reflection theory, be more visible and conscious for each participant nurse.

Data Collection

Data collection was conducted by means of qualitative interviews in the form of evaluations of the PSPM model intervention [16]. All participants interviewed after the intervention were asked three questions: how they experienced the intervention; what they learned from it; and how they could use the PSPM model in various situations in their work. The interviews in the groups lasted from 20-40 minutes (average 35 minutes) which were transcribed directly from the forms from the participants’ protocols and the supervisors’ notes.

Analysis

The study used qualitative content analysis to draw a systematic conclusion from of the text and to extract its meaning. This technique ensures that the analysis is reliable, can be replicated and is true to the text [17]. In the first step, two of the authors (MJN, HW) individually read the text in order to gain an impression of it as a whole. In the second step, the text was analyzed in order to identify meaning units that reflected the aim of the study. The meaning units were then coded and sorted into subcategories and categories. In the final step, all the authors discussed the findings until consensus was reached.

Ethical Considerations

The study adhered to the ethical considerations laid down in the Helsinki Declaration [18] and followed the recommendations made by the regional Ethics Committee. Information regarding the study was given to the nurses orally. The study was conducted on a voluntary basis; the nurses knew they could withdraw their participation at any time without providing a reason. All information was treated confidentially, no unauthorized person had access to the material and no individual can be identified. The physical data were kept in a locked filing cabinet.

Result

The analysis of the interviews resulted in four categories with fourteen subcategories of the symbols that the participants had chosen (Table 1). By selecting symbols in a map and looking back over a day's work or a situation, the nurses and supervisors attempted to gain a clearer understanding of what had happened or was lacking. The study findings are presented in the text with quotations from the participants and symbols.

To Manage the Situation

The participants described how they too have stopped for some seconds in special nursing situations, to think and get the strength to carry on their daily work. Using their chosen symbols, they could prepare themselves both to recognize their own reactions and to handle difficult situations.

To Get a Break

The symbols gave the nurses the power to take a brief time-out and take on new views.

“In the Orchard you can stop and rest a little, eat the fruit and catch your breath” (B1).

"In the Dense forest the group reflects and has room to dawdle" (U1).

“On the Mountain, one can get a different perspective, make some jumps, but it is a hard climb, having company as collateral, shooting at me” (U3).

To Gain Insight

Gaining insight meant that participants reviewed themselves, and the symbols helped them to capture a direction for moving ahead in their profession, in complex nursing situations.

“The Dense forest helped me to find a solution and it was time to leave its protection” (H1).           

“Choosing the Ruins allowed one to see that there were remnants of the building one could build on" (H3).

“The Narrow road guides you to keep focused and fend off distractions” (H4).

To Take Responsibility

The nurses said their own responsibilities were clear and using the symbols was crucial to making their decisions.

“When rapid action is required, one sees oneself at a Shooting range” (H1).

“In the Out-of-bounds area, you could weigh the issues to get a context for the situation” (U4).

“In the Orchard, it became clear that all patients needed to be dealt with” (B6).

To Experience the Obstacles

The participants were unprepared for the various difficulties that became obstacles in their path. The selected symbols gave a clear picture of various obstacles.

To Lose Direction

The strength of the experiences revealed were made clear in the choice of symbols.

“Conflicts in the staff group, as a Shooting range” (B3).

“Nowhere to go, to be on a Narrow road” (U3).

"How can I get an overview through the Dense forest” (H3).

To Be Exposed

Regardless of the experiences, the symbols served as reminders that it is not always easy to be part of nursing patients or in a team.

“You are a target for close once and need a bulletproof vest” (H3).

 To be stepped on if I went into the Out-of-bounds area” (U1).

“Contact with different doctors, it felt like drowning in the Lake” (B2).

To Be the Guide

To be attentive and listen was a great help to participants in choosing the right path in the meeting with both patients and colleagues.

To Be in the Conversation

The choice of symbols in conversation became clear, as did the participants being in the here and now of experiences.

“Even though it was a Narrow road, the direction was forward” (U1).

“Navigate away from a misery, despite the Inaccessibility of the area” (H4).

“Discover the experiences, by wading in the Lake” (U3).

Not to Face Any Obstacles

Many of the participants understood the power of symbols and saw opportunities for getting around obstacles, even in difficult situations.

"Don't run but go around the Out-of-bounds area (B1).

“Finding freedom in the Open ground” (H2).

” Sow the seeds in the Orchard, to grow” (H3).

To Have the Gumption

To find solutions using the symbols was a way to remain working as a nurse and develop in the profession, getting to understand nursing.

To Have Courage

The symbols roused their courage to venture into problematic situations.

“I have found the appropriate path and crossed over the Mountain” (B1).

“I built something new from the Ruin” (H2).

“I dare to try and cross the Inaccessible area” (B3).

To Have Strength

The participants, by using the symbols, find the courage to challenge themselves.

” I will stay and go through the Open ground” (H4).

“Stay on the Narrow road to keep focused” (H4).

“Go up to the Mountain to see how to plan relevant talks” (U4).

Discussion

Methodological Considerations

The aim in this study was to explore how participant nurses can be guided during supervision towards a professional understanding of nursing, using a map with pedagogical symbols derived from the sport of orienteering. This pilot study had a qualitative inductive design with interviews. A full sample selection of participants was asked to respond to the aim. All (44) participants in the three groups were actively occupied in nursing, were nurses being educated as supervisors, or were already supervisors. Obtaining the results from a variety of areas within nursing supports their credibility.

The strength of the study lies in the participants having the competence to use the map to guide themselves in exploring their emotions and thoughts during supervision so as to develop their ability to deal with complex nursing situations [14]. Being experienced in their daily work as nurses and supervisors gave them the opportunity to recognize how the symbols grasped situations that occur in nursing. A further strength of the study was that the group of participants could reflect together and deepen their understanding of situations using the same method involving symbols as when interpreting the language of photographs [19]. The limitation of the study was that it was initially problematic, because the images captured something personal, as a private commitment was required. This is described in the caring and ethical perspective [20].

Reflection on the Result

The results in this study show how participant nurses are guided during supervision towards a professional understanding of nursing, using an orienteering map with pedagogical symbols. The result indicate that the participants explored and reflected on the context of their nursing using pedagogical symbols during supervision involving different self-perceived situations as also finds in [5]. This study also illustrates that the participants found and followed their own map, with symbols, which led to their daily nursing practice being better adapted to actual work circumstances. Pictures used as symbols in different settings can function as a tool for reducing worry, improving self-esteem, increasing social activity, and raising expectations of health [19,21]. Reflection on daily practice brings together epistemology in terms of the personal, emotional, and interpersonal aspects as well as theoretical views and ontological perspectives which influence our interpretations [22]. Benner [22] also argues that making one’s own overview, in this case in the form of a map. The participants thought that they now had the possibility of providing better nursing, because of their own orientation on the map. They described how, through using maps, people can perceive the world and their place in it [8].

The results also show that, during the mapping of their own professional life, they found that colleagues took a different route from themselves, and that no one influenced the way they made their decision. They found a way of mustering the courage and strength to carry on, as found in [20]. The results from a study on the concept of moral courage in nursing shows that nurses found a private moral courage to orientate themselves correctly within professional care in order to create peace of mind by being a well-functioning nurse [23]. Maps can be drawn to both find and ponder over roads [8]. This new knowledge, gained from integration, is a tool to help practitioners act professionally [4] and to acquire the ability to manage the emotions that arise in practice [7].

The results show that being guided to choose a path on a map was helpful when confronted with unfamiliar nursing situations (where the patient is threatening the nurse, related screaming at the nurse or nurse feel inadequate to care). It was like orienteering; finding the way by using the tools of a map and compass, but in this case, the compass was replaced by symbols. The participants could also use orienteering’s basic steps [9] to manage the situation by being creative and flexible, asking themselves where am I and where am I going; selecting a plan and route; implementing the plan; making sure they are on the right path and navigating their nursing [9]. However, the results also show that participants became stressed because there were obstacles in the team, which could lead to their totally losing direction and having to fight to find a way or to get back to the chosen way. Just taking a break was one technique that allowed them to have a quick time-out in order to take on new views or ways of seeing things.

Using an orienteering map with pedagogical symbols during nursing supervision can involve employing different models for reflection, according to [10-12] that will allow the capture of the nurses’ stories of their experiences which in turn, will help them to understand the route to excellent nursing and help them to move forward.

The symbols on the maps represented different codes on a real orientation map that were transposed into pictures on a “Nursing” map (Figure 1). The symbols had different meanings for the participants; some were pleasant such as the Orchard others, like the Dense forest or the Mountain, were chosen as places that offered the chance to take a break, to reflect and gain a different perspective. The Shooting range, the Narrow road and the Dense forest were chosen to represent the feelings of risk and concern over some negative development. The Dense forest was also a place where one could find a direction that would lead to a solution; the Narrow road maintained focus and the Ruins were remains that could be built on. The results also make the pathway to their decisions visible; three symbols were used as they explored the idea of themselves being on a Shooting range, in the Out-of-bounds area where they could weigh up the issues they had and finally in the Orchard where they saw that all patients need care.

The results also show deviations from the road to a better understanding of nursing represented by the choice of the Shooting range symbol when there were conflicts among the staff, the Narrow road when there was nowhere to escape to, or the Dense forest which could provide area. The results even showed an experience of being unprotected, not being part of the team and needing to wear a “Bulletproof Vest”, in the Out-of-bounds area, being trodden on or drowned in the Lake because of having contact with so many doctors. In addition, the result show ways of being in a conversation, choosing the Narrow road to symbolize moving forward. Similarly, seeing opportunities in difficult situations is visualized as going around the Out-of-bounds area, crossing the Open ground to reach independence as a result of the inner growth in the Orchard. Symbols may be used in Augmentative and Alternative Communication (AAC) to express thoughts, needs, wishes and ideas [24].

The results illustrated that it is possible to find ways to pass over the Mountain, to build something new on Ruins, or even to try to take a new way around the Impassable area. The results also pointed out the participants’ own courage in challenging themselves and going across the Open ground, using the Narrow road to keep their focus or climbing the Mountain to plan talks, which are relevant. Other studies in which images are used as symbols, provide an avenue of living events where feelings, thoughts, and experiences can be shared [8,19,21].

Conclusion

The overall findings of this study for each nurse was that they have new tool to combine their emotions with symbols, which could be one way of own empowerment to prevent burn out. One way in which to raise the quality of nursing in daily practice is to develop and improve the nurses´ reflections on nursing situations. This may be aided by a map that can indicate a possible route to achieving an overview of circumstances and of various choices for improvement, a route to developing one’s own competence and to finding moral courage in the exercise of professional care.

Acknowledge

The authors would like to thank the participants in this study and Stefan Nilsson who has illustrated the map.

Declaration of Conflicting Interests

The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Funding

The authors received no financial support for the research, authorship, and/or publication of this article.

Figure 1: Map using pedagogical symbols in a nursing situation.

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