The participants described five themes of caring behaviour among nurses, physicians and other healthcare providers including clinical psychologists and embryologists that formulate the essence of the experience. The five themes or components of caring behaviour are: (1) being available, (2) providing communication, (3) exhibiting compassion, (4) demonstrating competency and (5) promoting empowerment. It is important to note that the themes are dynamic, in that the women varied as to the hierarchy or value of one caring behaviour component over another at any given point in time or throughout their entire experience. For example, some women stated they valued the caring behaviour of ‘exhibiting compassion’ above all the other components consistently throughout their entire experience. Other women valued this component at varying periods or at precise moments during their experience. Furthermore, some women placed a higher value on one or more of the remaining four components. Noteworthy also is that the components, whilst reported as separate entities, are not mutually exclusive. Each of the components is described in detail below using a rich narrative of the women's words to illustrate the phenomena.
Being available was described by the participants as providing ongoing access to and, when appropriate, being humanly present with the nurses and other healthcare providers at the clinic. All of the women reported that the awareness and belief that the nurses and, if necessary, other health providers were available to them at any given moment, especially in the event of unforeseen concerns or circumstances, was indicative of caring behaviour.
From the initial human interaction with nurses and other heath care providers, the women identified caring behaviours associated with being available. In particular, verbal and non-verbal communication between the woman and the provider at their initial meeting set a foundation for and established trust and honesty between patient and provider.
Periods where nurses or other providers were physically present with the woman were also viewed as caring. As one women stated: ‘She [the nurse] spent an extraordinary amount of time with me I felt for sitting down and walking through what do I need to expect ... To me that showed that I was really dealing with a care facility that was top-notch.’ In addition to being with the woman at a particular time, the awareness that nurses were there over a continuum of time: ‘They've been along the journey’ was also viewed as supporting care.
The perception that providers were available for unanticipated concerns and could be contacted at any hour on any day with a quick response time promoted a sense of care. In describing the importance of this behaviour, one woman quickly offered the following exemplar where her physician stated to her:
You can call me any time and you [can] call and talk to the receptionist and ask her for my direct line. If you get my voice mail, I will call you back within twenty-four hours. If you need to talk to me, you have somebody find me!
Whether or not the women took advantage of contacting the nurses or healthcare providers outside of the typical clinic hours was not significant; however, clearly knowing that they could contact them and the healthcare providers would respond – at anytime, if necessary, enhanced care.
The importance of the nurses being available to the women was also manifest when the women expressed a desire to spend longer amounts of time in personal consultation with nurses when their worries and deepest fears about donor oocyte treatment were surmounting. Several women gave specific examples for when nurses should allow extra contact time. These examples include the reporting of doleful events such as a negative beta human chorionic gonadotropin (β-hCG) level or when serial β-hCG levels are decreasing postembryo transfer. Noteworthy as well, is the perception by the women that the nurses were managing care for multiple individuals amidst time restraints and high workload requirements as the following quotation elucidates:
[When] you're given bad news; you're getting it over the phone while you're at work and you're trying to sort through reactions ... Sometimes you wish you had a little longer to talk to them [the nurses]. They are so hard pressed with time that you feel like you're on and off pretty quickly. So you're kind of left sitting there.
The ability of nurses and healthcare providers to effectively communicate, predominately to educate and inform the women about complex biological and reproductive processes, medications, treatment plans, cycle requirements and procedures was perceived as beneficial and supportive and viewed as a component of caring behaviour. The women described specific examples of behaviour which they perceived as caring. Of particular help to the women were educational classes they participated in and use of supplementary brochures, forms or pamphlets that explicitly provided information about medications, treatment plans, cycle regimes and scheduling of reproductive interventions, such as the date of the donor-conceived embryo transfer, as the following example illustrates:
I liked the fact that you kind of knew where the next stages were. You went in for your shots, they explained everything, how you take your medicine was in a pamphlet so if you forgot or had a question you could go back through that information. So I thought the educational process of where your next step was, was great.
The women also described specific areas where they felt more communication between nurses and patients would enhance oocyte recipient care. In particular, the women requested more education and information about the affects of alternative therapies and navigating disclosure decisions. Having trusted providers discuss these issues and address the current scientific findings or lack thereof was perceived as adding to the overall quality of care. One recipient woman expressed frustration about the lack of education on alternative therapies by nurses and healthcare providers when she said, ‘I would have done it [alternative therapy] in a heartbeat, you know, but I went through two and a half to three years without doing anything.’ Several women suggested that nurses need to provide more information and education on detailed aspects of the experience of oocyte recipients, for example, disclosure decisions. As one recipient woman stated:
Well, part of me wants to have some information about other people that have done this before. So I would like to read personal accounts, anonymous or what- not of women that have done this, that have raised children. That would be interesting to me. [Particularly] what they have found works as far as telling them and all that stuff.
The key to providing communication is the ability of nurses and other healthcare providers to convey explicit information about complex data regarding the individual woman's response to the donor oocyte treatment process in a clear and cogent manner. Several women described instances where they either did not receive explicit information from healthcare providers or they misunderstood or misinterpreted information they received. For example, one woman who felt her individual plan of care was not reviewed from previous treatment cycles stated, ‘Oh, no, I didn't think that they [healthcare providers] were looking at the past IVF cycles at all, because why repeat what you just did when it was a failure?’
Providing communication also included conveying appropriate social dimensions of care such as when it is acceptable for the woman to have a support person present with her at the clinic. As one woman reflected upon an ultrasound procedure ‘I didn't know, you don't really know, is he [husband] supposed to be here? Is he not? Nobody really tells you.’ Information and direction on the appropriateness of the woman's supportive individual to be present during procedures and testing was perceived as important and essential in providing salubrious care.
Nurses and healthcare providers exhibited compassion through words and behaviours that express respect and empathy and by demonstrating an understanding of the woman's unique infertility experience and her personal values. Recipient women expressed awareness that they were in a ‘fragile’ state during the donor oocyte treatment process and perceived caring when nurses’ behaviours were considerate of their vulnerability and conveyed an understanding of the scope and seriousness of their situation. For example, the women praised nurses who gave parental ownership of the developing donor oocyte offspring to the recipient women. Recognition that the resulting child would be ‘your child’ and not exclusively ‘my husband's child’ or ‘the egg donor child’ enhanced caring.
Consistent with exhibiting compassion were specific verbal statements made by nurses that expressed encouragement or understanding of the women's unique experience. Statements that were made within a perceived ‘judgement’ context were viewed as detrimental to caring or considered non-caring behaviour. provides illustrations of caring and non-caring statements compiled directly from the women's voices.
Exhibiting compassion: caring and non-caring verbal statements
In regard to women's personal values, some donor oocyte recipient women valued maternal genetic lineage and wanted to know that they had exhausted all treatment using their own oocytes before they would consider using donor oocytes. As one woman stated:
My last IVF round of my own, she told me they [oocytes] are not as mature as they need to be – ‘This doesn't look good but we will give a try so that we know that we tried everything.’ So she used the same things that I had raised as my hopes like knowing we tried everything.
For other women, the potential to become pregnant expediently or to establish a ‘healthier’ pregnancy using donor oocytes was valued higher than maternal genetic lineage. These women felt compassion and perceived caring when healthcare providers moved quickly into the donor oocyte treatment process.
Often the women stated they needed time on their own to process their experience and find meaning and make sense of it. The nurses’ ability to understand this need and allow the woman ‘space’ when she needed it was ‘respectful’ and enhanced caring. Conversely, some women reported a desire for ‘venting’ their deepest concerns about the donor oocyte process to an empathetic and respectful nurse.
Competency was demonstrated by nurses and healthcare providers when the woman achieved and maintained a healthy pregnancy and through behaviours where a high level of technical, ethical and organizational knowledge and skill were observed by the women. For some of the recipient women, the caring component of competency was of eminent importance. As one woman stated, ‘I don't necessarily need a lot of handling and a lot of sympathy or empathy from my healthcare professionals, I just want them to be really competent and really good at what they do – and that makes me feel good.’
When the women observed that nurses and other healthcare providers were working diligently and in a team approach to achieve pregnancy for the women, caring was enhanced. As one woman surmised, ‘They honestly have a desire to get you pregnant. They really do. That's their job, they work hard at it; everybody there works hard at it. They want it to happen.’
In addition to the observed behaviours that exhibited competency, the women also perceived competency when they were aware of nursing clinical expertise in the area of assisted reproduction. When asked specifically about caring behaviours, one participant summed up many of the women's perceptions when she said:
I would say that overall the fact that IVF is a separate process versus the rest of the infertility is really important so that you feel like you are being cared for by people who are experts in that. So for example, the nursing team was all specific to donor IVF, so I think that was really rewarding.
Organizational aspects of patient care within the infertility clinic, specifically the awareness that patient testing and hormonal cycles are being scheduled in an appropriate and efficient manner further demonstrates competency. As one participant said, ‘That kind of order is huge’. Another woman who underwent infertility treatment at two separate clinics said at one clinic she felt she had to be ‘vigilant’ about ‘knowing everything and keeping everything set and knowing what to do’. She went on to say:
When I got to [the recruiting infertility clinic], everything was just...I felt like they've got it under control. When [the nurses] layout the schedule for you, then that's your schedule. That means a lot to me, too. That just makes me feel like on top of everything else I don't have to worry about – I mean I have to remember to do this stuff, but you just felt like they have done this before and you're in good hands, so that [pauses] just the competence.
Lastly, several women indicated that participating in this investigation, initiated by nurses and supported by the recruiting clinic, demonstrated that the nurses and other providers at the clinic were interested in providing the highest level of competent care possible to donor oocyte recipient women.
Empowerment occurred when nurses and other providers encouraged the women to engage in aspects of decision making and when nursing professionals acted in ways to promote the women's sense of control and understanding over their infertility treatment and subsequent obstetrical care. The women experienced a greater sense of caring and well-being when they were involved in the decision-making process. For example, one woman said that when she was engaged in specific aspects of the donor oocyte process such as choosing the donor, she found nurses and physicians caring by ‘...kind of lay[ing] out the options for you and [stating] here's how some people deal with it and here's how different people deal with it’ as opposed to having providers say ‘Well, here's what you do, this is how you do it.’ By providing objective information and laying out rational choices, the women felt in control of their infertility experience and empowered ‘to make good decisions’.
The women described an astute awareness of the subtle intricacies of the donor oocyte recipient experience that are transmitted to recipient women at the infertility and obstetrical clinics by healthcare providers. In particular, several women reported difficulty in making personal decisions about how to navigate the short- and long-term implications of donor oocyte use because of conflicting behaviours by nurses and other providers. As one recipient woman conveyed, ‘the infertility clinic sells hope‘ and ‘the OB [obstetrical] clinic sells caution [italics added]’. Women perceived caring behaviour when nurses and providers offered ‘balance’, ‘realism’ and continuity of the donor oocyte experience by their professional healthcare members, especially when transitioning from infertility to obstetrical care.
Several specific caring behaviours that established a sense of control over the donor oocyte experience were delineated by the women. One participant revealed that she had kept a personal journal of her infertility treatment with assistance from nursing professionals. She viewed these actions as establishing and maintaining her sense of awareness, greater involvement and ultimately control over her infertility. The act of writing and recording personal experiences within the donor oocyte process, such as medications and responses, test results, fluctuations in mood and thoughts, current or future disclosure decisions along with information and encouragement provided by nurses, was empowering.
Another woman narrated how she developed a ‘hope box’, with encouragement and direction she received from nurses. The hope box was a small decorative container where information about the oocyte donor, such as the donor's health history and picture, and information supporting the establishment of pregnancy, such as β-hCG level reports, post-transfer ultrasound pictures and personal cards and notes received from close relatives and friends who supported her throughout the process, were kept as reminder of her donor oocyte recipient journey.
Model exemplar of caring behaviour
In the voice of a pregnant, donor oocyte recipient woman, provides a model exemplar case demonstrating the essence of caring behaviour.
Model exemplar of the essence of caring behaviour