Caring for the caregivers-a nursing management perspective

Opsomming The aim of the study was to explore the practice of caring for the caregivers in selected hospitals in KwaZulu-Natal. A qualitative research approach was used to ensure that the complexities of caring were reflected in the study. The qualitative analysis of the interviews with nurse manag­ ers and nurses indicated that they saw caring as an impor­ tant part of their management task. The participants in the study saw caring for nurses mainly as dealing with the interpersonal aspects of nurses. Caring for nurses was fur­ ther described in terms of solving the personal problems of nurses, promoting the development and growth needs of nurses with the focus, mainly, on the educational needs of the organisation itself, the welfare needs of nurses with specific reference to their family needs and responsibili­ ties, and a major emphasis on HIV/AIDS issues arising amongst nurses themselves. Die doel van die studie was om sorg aan sorgverleners (caring fo r the caregivers) in uitgesoekte hospitale in K w aZulu-N atal te ondersoek .’n K w alitatiew e navorsingsbenadering het verseker dat die kompleksiteit van sorg in die studie gereflekteer word. Die kwalitatiewe analise van die onderhoude met verpleegbestuurders en verpleegkundiges het aangedui dat sorg as ’n belangrike deel van die bestuurstaak van verpleegbestuurders gesien is. Die deelnem ers aan die studie het sorg aan verpleegkundiges hoofsaaklik as die hantering van interpersoonlike aspekte van verpleegkundiges gesien. Sorg aan verpleegkundiges is verder beskryf in terme van probleem oplossing van persoonlike sake van verpleegkundiges, die ontwikkeling en groeibehoeftes van verpleegkundiges met klem op hoofsaaklik die behoeftes betreffende opleiding binne die organisasie self, die welsynsbehoeftes van verpleegkundiges met spesifieke verwysing na die behoeftes en verantwoordelikhede betreffende hul familie en ’n sterk beklemtoning van MIV/ VIGS onder verpleegkundiges.


Introduction
This study aimed to explore caring for the caregivers.The phenomenological approach was utilized for the qualitative research to explore the meaning and expectations of caring among nurse managers and nurses and the lived experiences of nurses of being cared for within the context of nursing management (Riemen 1986:85-108).The aim of this study was to explore caring for the caregivers by asking the participants to describe the meaning o f caring fo r nurses in their own hospitals.The qualitative approach was chosen to help the researcher to understand the caring behaviour, and experi ences of nurse managers and nurses and the meaning of car ing in the context within which they functioned and lived every day.The goal of the qualitative research methodology was to try to understand caring from the point of view of the partici pants in their context in the hospitals as nurse managers and nurses.The researcher believed that the understanding of caring and the full complexity of human sense making could be lost, if the textual data were quantified.
Nurse managers have a unique responsibility to ensure the well being of nurses and patients and also to ensure that or ganisational objectives are met (Christensen 1988:46-55).This principle of beneficence guides the nurse managers actions and refers also to the obligation resting on the nurse to do good to others and not to harm them.The principle of benefi cence is often in contrast with bureaucratic systems where individuals experience depersonalisation (Christensen 1988: 46-55).In South Africa at the present time, for instance, nurses have to make do with so little and spend much of their time begging for supplies instead of caring for their patients.A poster on the walls of the Chris Hani Baragwanath hospital underlines this situation.It reads: A Our skeleton s ta ff has been reduced to a bag o f bones ^Gilbey 2000: 114/ The question is now, who cares for the patients and who cares for these bags o f bones'] During the past year many examples of the hard life of nurses were cited in the media, and the lowering of standards in the health services was evident from the conditions in the hospi tals.Mngomezulu (2000) (cited in Gilbey 2000:114-122) has said that the culture of caring and compassion amongst nurses has been eroded.Bad publicity has contributed to making the nurses job harder.Nurses are the backbone of the health serv ices and yet they are treated as slave labour.In the Eastern Cape, Thomas (cited in Gilbey 2000:114-122) blames declining nursing standards amongst other factors, on poor manage ment that has failed to provide effective supervision and en couragement.Nzimande (1995) asked the question Who cares'1 , in an article some years ago in the South African Nursing Times (1995:18-19).She indicated that the health services had been investi gating violations of caring rights of patients on the grounds that rights of caregivers were being violated.She suggested that we need to really examine A who cares and what the ethics of caring really were (Nzimande 1995:18-19).The research was therefore undertaken to explore caring for the caregivers.

Research objectives
The specific objectives for the study were to: Explore the meaning of caring for the caregivers from the point of view of nurse managers and nurses.Determine the expectations of professional nurses regarding caring as related to the management in nursing.Identify common themes and practices regarding caring prac tices in the management of nurses.

Theoretical framework
The framework that was used for this study was the Caring Theory of Watson (1985:9-10).Watson (1985:9-10) identified ten (10) carative factors which encourage health and develop ment of individuals, families and communities.The ten carative factors are the formation o f a humanistic-altruistic system o f values, the installation o f faith and hope, the cultivation o f sensitivity to ones self and to others, the development o f a helping-trust relationship between the care-receiver and the caregiver to ensure a relationship o f quality, the promotion and acceptance o f the expression o f positive and negative feelings, the systematic use o f the scientific problem-solving method fo r decision-making, the promotion o f interpersonal teaching and learning, the provision o f a supportive, protec tive, and (or) corrective mental, physical, socio-cultural and spiritual environment, assistance with the gratification o f hum an needs, the a llo w a n ce f o r e x iste n tia lphenomenological forces.Watson (1985: 10) emphasized that no one of the factors could be implemented on its own, and stressed the importance of a philosophical foundation for car ing in nursing.The provision of a human value system in nursing management would give nurses an environment con ducive to quality nursing care.Nurses should nurture hope in their patients and the nurturing of hope in the management environment could contribute to the willingness of nurses to instil hope in their patients and thus contribute to the recov ery process.Watson (1985:41) stated that the recognition and development of feelings helped in the self-actualization and growth of a person.She singled out the main responsibility of the management as being to help nurses towards growth and self-actualization and to enable them to encourage growth in others.

Target population and sampling
The target population included general provincial and private hospitals in KwaZulu-Natal.The hospitals were identified from the Hospital Yearbook for South Africa (1997).Purposive sam pling was applied where the hospitals were selected accord ing to the judgement of the researcher about the most repre sentative hospitals and also to include hospitals with differ ent financial and service systems to ensure the inclusion of a broad spectrum of the health care that is offered to general patients in KwaZulu-Natal (Polit and Hungler 1993:179-180).Three hospitals were included in the study and the sample consisted of a general provincial hospital, a private hospital and a mission hospital in KwaZulu-Natal.Rational purposive sampling with the following guidelines applied: 1.A medium size non-government hospital in the city with a reputation for caring in nursing care was included.(Hospital 1); 2. A medium size private mission hospital with a reputation for caring was included.(Hospital 2); 3. A medium sized general provincial hospital in a more rural area of the region that was known for quality patient care and with a reputation for caring was included.(Hospital 3).
The purpose and importance of the study was explained to the chief nursing service managers, of each hospital to assess their interest and willingness to participate in the study.

Research methodology
The principles of phenomenological research were applied to explore the meaning and expectations of nurse managers and nurses and their lived experiences of being cared for as nurses within the context of the management (Riemen 1986: 85).The participants were informed that their experiences should fo cus on their current positions.Each participant was assigned a code number according to the hospital as an assurance of confidentiality, for example (1.1).The participants were asked to identify a suitable venue, date and time for the interviews.Nurse managers, middle managers and professional nurses were interviewed (20-80 min) and the data were audio taped, with consent from the participants.Twelve nurse managers (ten nurse managers; three were nursing service managers in charge of the hospitals, and seven at middle management level and two professional nurses at first level management who were available and willing to participate in the study, were included from the hospitals.Nursing service managers were approached and the participants were asked to volunteer to take part in the study.It seemed to be a problem to interview the nurses in the wards because of the shortage of staff in the hospitals at that time.The data collection was terminated as soon as the data was saturated.A data collection protocol was used with caring concepts as a guide for the interviews.Questions such as: What does caring fo r the caregivers means in the management context o f nurses?Would you describe your health service as a caring service?Do you experience your work setting as a humane (caring) work environment?What do you expect from caring in the management process in nursing?How do you try to create a humane (caring) work setting in your service/unitl were included.
The data was collected in a contextually informed way by capturing not just the words but also the differences in pitch, gestures, body language, silences and simultaneous speech.The raw data, as recorded, was transcribed for each partici pant.Before working on the data, the researcher needed to identify her own preconceptions on the phenomenon of car ing.The researchers own preconceptions needed to be set aside (the process of bracketing).That enabled the researcher to be more open and to validate her own beliefs and concerns while recognising that biases cannot be controlled fully.
The data was analysed qualitatively with the help of the com puter software program for qualitative data analysis called NUD*IST 4. NUD*IST was used in this qualitative research to explore the meaning of lived experiences of nurse managers and nurses.The interviews and the observations during the interviews were made in natural settings.The steps to be fol lowed were: Step 1 Familiarising and immersion The data came in the form of audio taped interviews with par ticipants together with field notes of the researcher.The audiotapes were transcribed and typed into a word process ing computer programme.The data was read over and over and after careful thought free nodes were created with a de scription where applicable.By the time of data analysis a pre liminary understanding of the meaning of caring from the per spective of the nurse managers and nurses was formed.The issue of HIV/AIDS emerged from the first interviews and it was clear that nurse managers spent much of their time deal ing with it.The data was studied to identify material related to the phenomenon of caring.The data was then searched for deeper regularities and irregularities and for differences and similarities.Units with the same meaning or idea were identi fied.
Step 2 Coding Coding meant breaking the data down in analytically relevant ways (meaningful pieces) (Terre Blanche and Durrheim, 1999:101).The data was coded into free nodes from the inter views.No new free nodes emerged after interview eight, which indicated that the sample was adequate but the research at that stage included only two of the hospitals, and therefore the interviews proceeded to include the third hospital as well.
Step 3 Inducing themes The bottom-up approach as described by Terre Blanche and Durrheim (1999: 102) was used to organize the data that natu rally underlay the material.The content was not being merely summarized but the caring processes and concepts were be ing kept in mind when organising the data into themes.
After the data was coded sixty-three free nodes emerged from the data.Merging the codes was a tedious process via the computer.The nodes were studied to identify relationships between the nodes.The free nodes were merged by hand and grouped into codes.The major codes from the data were hu manity, problems, needs, HIV/AIDS, illness, funeral support, education, social problems, communication, counselling.Humanity, and the nodes that were related with similar pat terns to humanity, was categorised and transformed into a meaningful theme together with general aspects of the human environment into The general aspects of human environment theme.The next theme including communication and interper sonal aspects was grouped into The interpersonal theme.
Problem solving and the nodes concerning problems were categorised into The problem-solving theme.Education and all the nodes on development of nurses were categorised into The development and growth theme.Needs, illness, social prob lems and the nodes on all the different aspects of the needs of nurses were categorised into The needs theme.HIV/AIDS, counselling, dying of AIDS and funerals were categorised into HIV and AIDS theme.
Step 4 Interpretation and checking This step included the written version of the phenomenon of caring for the caregivers.The interpretation of the phenom enon under study was studied carefully to identify weak points and contradictions in the interpretations.The objectiveness of the researcher was of the utmost importance during this step (Terre Blanche and Durrheim, 1999: 104).

Trustworthiness
The trustworthiness of the study was demonstrated by the fact that the study was done over a period of three years and that the data was collected from the nurse managers and nurses in their own environment.The documented and transcribed evidence from the interviews was taken back to the partici pants who confirmed that the transcription was a true reflec tion of what was said during the interviews.The categories and themes were taken back to the participants for verifica tion.Evidence of the documented patterns and categories was kept for reference and the data collection and analysis were done over a long period of time, (three years).The same pat terns and categories of caring were present after interview ten (Poggenpoel 2000:349-350).This study shared the main concepts of the theoretical frame work of the Caring Theory of Watson (1995) which was used to guide this study.The HIV/AIDS category, which emerged as a new category in caring for nurses in this study, could be an indication of the seriousness of the infection rate and the effect of the disease on the health services currently in KWAZULU-NATAL.

Results
The results were discussed under the headings of the catego ries that emerged from the data.Direct quotes from the inter views are typed in italics and are indented in the text.The reference to a specific quote indicates the hospital and the transcript line number, for example (1,102).The text bracketed in italics was added by the researcher for better understand ing, for example (love is visible) In some cases to clarify meaning, a word or words may have been altered and this is indicated by square brackets around the alteration, [relieved].

Theme 1: Caring f o r nurses in term s o f general at tributes in the human environm ent
Respondents described caring for nurses in practical terms.One respondent described caring practically by the following example: (Caring is like) a sewing machine.See, you must look after it, service it and then it will perform well.That is what I do to the staff, doctors and all.You got to care (I, 61-63).
Caring in nursing management differs from caring in the pa tient care environment and it seemed to be a problem for some nurse managers to apply the caring concepts in nursing man agement and for nurses to perceive it as caring.This difficulty was illustrated by the following: I think hmm, the first thing that comes to my mind is that it is ever so much more difficult than in the nursing context.We have been taught to be nurturers and to be carers and to be people who are hands on in the sense that if someone is uncomfortable I relieve their pain.I f some body is untidy, I will clean them up.I f someone is bleeding I will stop the bleeding and my interpretation o f care is with my hands.Now suddenly in a managerial position, hmm, I am trying to care without that direct contact, physical con tact.I really think that we do not prepare our nurse manag ers [for] how difficult that is (2,316-337).
In comparison with the work of Watson (1985: 10-16) the de scriptions as given by the participants in the main theme, gen eral attributes of caring in the human environment such as kindness, concern and love, were caring concepts grounded in humanistic values which bring meaning to one s life through other people according to factor three of Watson (1985:17).The instilling of faith and hope (factor two of Watson, 1985:13) was not evident in the interviews.Watson (1985:13) described the instilling of faith and hope as the inspiration of the mind and soul so that the illness of a patient could then be treated.Faith and hope could be instilled as a caring attribute in the nursing management environment as an inspiration of nurses towards growth and development.Understanding and accept ance of the nurse as an individual, (factor three of Watson, 1985) were clearly described by the participants.

Theme 2 : C arin g f o r n u rses in term s o f in terp er so n a l rela tio n sh ip s.
Caring in terms of interpersonal relationships with other peo ple was described by the participants in various ways and by using different expressions.This main theme included affilia tion needs of individuals in relation to other people in inter personal relationships.The management of nurses is an inter active process and therefore emphasis was placed on rela tionships and interaction.The interest in, and openness to nurses and the availability of nurse managers to assist nurses in the nursing situation that were described by the partici pants were indications of how important nurse managers rate these aspects in their management functions in the health services.
Communication and listening were clearly defined from the nurse managers point of view and nurse managers indicated aspects related to communication and pointed out the aspects they (nurse managers) thought nurses expected from them: I feel part o f the team and I want them to know that I am there fo r them, should they encounter prob lems.We have meetings, every month, with my staff where we look at patient management, human relationships, and the medical staff also joins us in meetings.So we generally dis cuss problems and solutions and we look at solutions and we plan together.We schedule our meetings once a week so that we meet with everybody (1,(671)(672)(673).
In comparison with Watson (1985: 23-40) the categories for behaviour and relationships between human beings were in line with the nursing management situation in health services.The five categories of behaviour are according to Watson (1985:25) living with another, co-operation with others, estab lishing a healthy emotional and physical environment, estab lishing a bond and nurturing and accepting others.Aspects of the categories that were included were communication and listening to the other, and interest in the other person and knowledge of him/her.The openness to each other to estab lish a bond and availability to assist the other were empha sised and referred to by the participants in this study.

Theme 3: Caring to nurses in terms o f problem solv ing.
Problem solving and identification of problems seemed to form a major part of the job of a nurse manager.An interesting fact that came to the fore was that problems seemed to be more social problems of staff than patient care problems, as would be expected.The participants indicated that problems were shared and means to solve the problems were in place such as discussing the problem.Referrals were done if necessary, for example: You counsel her, and look at options like, fo r instance, if she persistently comes late on duty and when she tell you about this problem, then you talk with her and perhaps suggest, how about taking her (mother that she is looking after) to a home, inviting a relative to assist her, and look after [her] mother and give [her] a break so that [she can] actually concentrate on [her] work.So you plan to gether with her but she takes the leading part (1,(725)(726)(727)(728)(729)(730).
Problem solving was an important part of caring in the sense that nurses, particularly the nursing students, needed knowl edge and understanding for the application of the problem solving and decision-making process in nursing (Watson 1985:51-66).The components, such as assessment, analysis and diagnosis, planning, implementation and evaluation of the problem-solving process, did not emerge clearly from the discussions with the participants.The counselling of nurses was indicated by the participants as an important aspect of problem solving.

Theme 4:
Caring for nurses in terms of development and growth.
Growth and development of staff was identified as a major theme in caring and for the purpose of this research it was categorised as a major theme.Growth and development, par ticipative management and feedback formed a major part of the theme on growth and development.Caring was under stood as helping the other to grow, and therefore mentoring and leading by example formed important aspects of the growth process, which was described in detail and many examples were given as to how the development of nurses was being dealt with, for example: (2,(389)(390)(391)(392).

Personally my greatest jo y is watching people grow and take off. I really love it when you have worked yourself out o f a job and somebody else takes o ff with it, and they even stop talking about you having been associated with it and now talk about that person running it
Leading by example was very prominent in one hospital only.The synonym for leading by example, such as role modelling was also mentioned by the other hospitals.At the one hospi tal, however, one participant described leadership and devel opment.It seemed that the participant who commented on this aspect believed strongly in leading by example and role modelling.It was expressed as something one should do al though no examples were given of how actually to lead by example: They got to see you doing it and once they see you are doing that most o f the time they will copy it besides you teaching it (1,(49)(50).
Well, I think we should set an example as leaders.We should be exemplary because you cannot expect the subordinate to be caring if you do not have that attitude (1,(408)(409)(410).
In the comparison with the theory of Watson (1985: 69-79) development and growth of nurses is described as the teach ing-learning process in nursing as it engaged both the nurse and the other person.It includes the issues of information as well as consideration of the nature of learning and what inter personal processes facilitate learning.Nursing educators al ways maintain that health teaching is one of the main func tions of a nurse.According to Watson (1985, p. 79) The sci ence o f caring concerns itself theoretically and practically with all the aspects o f interpersonal teaching-learning A supportive and corrective environment provides for a person s mental, spiritual and socio-cultural harmony and well being.Nyberg (1993: 13) makes it clear that caring requires us to recognize the potential o f people we care for, by empowering them and not by having power over them.Caring makes the nurse manager different from other managers in that caring defines the behaviour and attitude of the nurse manager in a more relational and growth-orientated way.It also asks for openness, listening to and valuing of the other while the goals of the organisation stay important.The duties do not change in caring management but the manner in which one goes about executing it does.The use of power changes to empowerment and growth and development and this is a constant challenge for nurse managers.

Theme 5: Caring f o r nurses in terms o f needs.
The identification of needs was categorised according to Maslow (cited in Booyens 1998:458) in the lower, social and higher categories of needs.
Lower order needs that include the physiological and secu rity needs, such as comfort, spiritual needs, welfare of nurses, enough equipment and safety, were aspects that were identi fied by the participants.These identified needs could contrib ute to an environment that is conducive for nurses to render quality patient care in the hospitals.Basic to the environment created for the nurses is enough equipment at the disposal of nurses in the health services.This need was emphasised by participants as follows: I make sure that nurses, so called understaffed or stressed, have got everything they need in order to function.Now I put a lot o f energy into that.You know making sure that every single one o f my nurses has got everything that she needs.I have learned to turn that into my concept o f caring, if I can make sure o f that, and know that the nurses in my area have got absolutely everything to achieve patient care, I see that as part o f my caring role (2,(363)(364)(365)(366)(367)(368).
Social needs are, according to Maslow (cited in Booyens, 1998:458), the needs of employees to take part in social activi ties in the hospitals.After the satisfaction of physiological and safety needs, social needs (belonging needs) become pre dominant.Social needs, the affiliation needs of nurses, were seen to and examples of socialisation within the hospitals are: [There is] a netball club in the hospital.The nurses organise it in their own time in lunch times.And when they have to go to tournaments I make arrangements fo r them to go by asking others to relieve them.With music as well, we have a hospital choir that practises during their lunch time and a football club fo r the males that helps with teambuilding (3,(143)(144)(145)(146)(147).
The higher needs or self-actualisation needs were dealt with to a great extent under the growth and development theme and should be seen as part of this need as well.
In comparison with Watson (1985:81-100), nurse managers ad dressed the needs of nurses to a certain extent by putting the emphasis on personal problems of nurses due to illness and family problems.

Theme 6:
Caring for nurses in terms ofHTV and AIDS HIV/AIDS was identified as a major theme in caring for the caregivers.For the purpose of this research it was categorised as a major theme because of the emphasis placed on it by nurse managers.HIV/AIDS and the problems associated with it seemed to take up a lot of the time of nurse managers.It also seemed important to look at the competencies needed by nurse managers to deal with the complex problems and the demands that this killer disease put on nursing resources.HIV/AIDS and support to the families of nurses with the disease seemed to be a major issue because of the influence of it on health services and the nurses themselves.Nurse managers saw car ing for nurses to a great extent as dealing with the disease and support to the families of nurses.Nurse managers saw their caring task as supporting the staff members in dealing with the disease and organising the funerals of staff members who died of AIDS.Support to nurses was described from the con text of illness or HIV/AIDS and not in the context of true car ing to help the nurses to grow and develop in their profes sional lives.The following were examples described by the nurse managers: We nursed her here and when she died I communicated with her mother, because she was a bread winner, and I asked her mother if there was a sister who was actually big enough to get employment at the hospital, then I discussed it with the management, and we all agreed that we should offer this fam ily assistance, because it was a very, very poor family.So what I did I asked the mother to bring the sister here, I inten'iewed the sister and I employed her as a general assistant.She was qualified and did a secretary course after standard ten.But she accepted the post as an assistant.I did not have a post fo r a secretary with the hope when there is a post in admin, then she can apply fo r it, she was employed here.Unfortunately she also contracted HIV/ AIDS and she died, she died two months ago (3,(47)(48)(49)(50)(51)(52)(53)(54)(55)(56)(57)(58).
Caring for nurses was mainly referred to in terms of AIDS counselling and support as follows: Hmm, h m m l can go into lots o f caring.We do AIDS counselling.I m yself am an AIDS counsellor.I do know some o f the staff are HIV positive and in the allocation list, (I do the allocation), I try to place them in suitable de partments.For a lot o f them, I have torn up the HIV results and keep it confidential.I think also in the office here, confi dentiality plays a very important role (3,(207)(208)(209)(210)(211)(212).
Nursing is down because the nurses them selves are sick, they are sick with HIV and in all these wards the patients (twelve a day die), gone dead, they are dying, that is so demoralising and they even said you know they are going to die and even themselves (the nurses) they die by HIV/AIDS (1,(33)(34)(35)(36).
With the few resources they always have a complaint, we are overworked, because they (the nurses) are sick.They d o n ' t come on duty, they stay o ff sick, put in leave again and again because their immune system has gone down.Flu, so many [of the nurses J have flu they stay away with flu fo r two months.No doctor' s certificate is presented, that is a problem (1,(43)(44)(45)(46)(47)(48).
C are for dying staff was very prominent at the hospitals and it was expressed as follows: They want the matron to visit them at the hospital and they want the management to be there at the nurse's funeral and to take a lead in organising the nurse' s funeral, especially the African nurses.The other races are not a problem, but the African nurses want the management to get involved in organising the funerals fo r a nurse who dies, and the management to be there at the funerals (3,(105)(106)(107)(108)(109)(110).
Employees, who have HIV/AIDS, were managed well by nurse managers in the health services.Employees living with HIV/ AIDS will be productive for a long period if they receive the medical, social and psychological support they need.It is im portant to develop guidelines and policies for managers to assess and manage the situation (Davies, Schneider, Rapholo andEveratt 1997:10-15).HIV/AIDS is never far from the headlines and the scenario that was created at the Nursing 2000 Conference in Midrand during the first week in September 2000 indicated that twenty percent of the South African nursing population could theo retically be HIV positive.That means that of the 174 000 nurses available for duty in South Africa, 34 000 nurses could be HIV positive and one student nurse would die of AIDS every month, (Geyer 2000:1).The Gauteng Department of Health in dicated that there is no proof of these statistics and it is not clear how these figures were leaked and questions are being raised about their accuracy.
The fact that nurse managers spend a lot of their time on HIV/ AIDS related aspects, could be an indication of the serious ness of the infection rate and the effect of the disease on the health services.Nurse managers indicated that they spend a great deal of their time on counselling nurses with HIV/AIDS, care of the ill nurses, and organising funerals of nurses who have died of AIDS and related diseases.

Discussion of caring for the caregivers
The general aspects of the human environment were described with an explanatory comparison of caring in nursing manage ment by a participant, in terms of the maintenance of a sewing machine.The example implied that if you look after the nurs ing staff and you keep them up to date and supply the nurses with well functioning equipment, they will perform well and give high quality nursing care.This view of the nurse manag ers was in agreement with the view of Kurtz andWang (1991) (cited in Barker, Renolds andWard 1995:386-397) that fornurses to be caring with their patients, they must experience and feel cared for by nurse managers.
Concern was expressed by a participant that nurses were taught to nurture and care for patients with their hands but when a nurse became a manager then the nurse must care and be caring in another dimension, without direct and physical con tact with the person.Nurse managers should be prepared to make the shift from direct care to a more indirect type of care when they become nurse managers.Nyberg (1993:11) holds the view that the duties of the nurse manager do not change, but how one goes about those duties differs.The manage ment functions need to be more flexible, and interactive deci sion-making should be the norm in the health services of to day.
Caring in terms of interpersonal relations and interaction was described as communication and listening and this was em phasised as very important in the management of nurses.Twoway communication seemed to be a problem in nursing in the sense that the message from the top did not always reach the bottom.Nurse managers expressed their concern with the fact that nurses were unable to perceive the message at some stages.Problem solving received less attention from nurse managers and it was referred to as the solving of social problems of nurses and not problems related to patient care as had been expected.
The focus of caring for nurses in terms of development and growth was well described by nurse managers by providing opportunities to nurses and allowing nurses to improve their skills and rectify mistakes.A lot of time and effort was spent on in-service education to meet the needs of the health serv ices, and not so much to meet the needs of the nurse herself in her own professional development.
Caring in terms of needs fulfilment focused mainly on the wel fare, illness and family needs of nurses outside the work place, (the lower level needs of Maslow).The fulfilment of the lower level needs of nurses was emphasised by the efforts of nurse managers to ensure that nurses have got everything they need in order to render patient care in the health services.
Nurse managers saw their caring role for nurses with HIV/ AIDS mainly as supportive, being involved in family prob lems and counselling and guiding nurses living with HIV/AIDS.Nurse managers were involved in planning and organising the funerals of nurses who died from HIV/AIDS.The nurse managers seemed to play a major role in counselling the nurses suffering from HIV/AIDS in the health services.Nurses needed counselling not only because they contracted the disease, but also to help them to cope with the changing demands of the high number of patients who no longer recover from their illnesses, but die as a result of AIDS.
If the scenario which was painted during the Nursing 2000 Conference in Midrand (Geyer 2000:1) is true where the indi cation was that 20% of the nursing population might be HIV/ AIDS positive, with an estimation of 34,000 nurses HIV/AIDS positive in South Africa, then the emphasis that was put on this issue by the nurse managers in this study, should be seriously considered in the training and development of nurse managers currently and for the future.

Conclusions
The qualitative nature of this research study enabled the iden tification of a major theme in caring for the caregivers, namely caring for nurses in terms of HIV/AIDS.Participants put a great deal of importance on the various aspects related to HIV/AIDS of nurses during the study.It was clear that caring in nursing management was an important function to the par ticipants.On the whole the reflections on the meaning of car ing for the caregivers in the management of nurses were inter esting and surprising.Caring for the caregivers was seen as keeping the nurses in a good physical condition to enable them to do the job.The physical welfare of nurses was seen as very important by nurse managers.Two-way communication was seen as an important aspect of caring for the caregivers and nurse managers made it clear that communication with nurses was open at all times.Nurse managers were aware of the fact that communication in the hospitals was a problem at certain stages and that communication could be distorted and blocked at times.It was clear from this study that nurse managers were knowl edgeable on caring but in their management role their descrip tions of caring for the caregivers in the management reflected mainly concern about the physical well being of nurses and support to nurses in dealing with HIV/AIDS issues.The major emphasis that nurse managers placed on HIV/AIDS issues such as support, guidance and counselling of nurses on their HIV/AIDS illnesses, problems and the organising and attend ing of the funerals of the nurses should be seen in the light of the crisis currently in the health services regarding the han dling of the number of HIV/AIDS cases in KwaZulu-Natal.

Recommendations
Nurse managers must be made aware that caring for the caregivers includes not only illness and HIV/AIDS issues, but many other caring concepts and aspects as well.The car ing task of nurse managers is aimed at all the staff, including the wellness of nurses as a whole.Nurse managers and nurses should receive information on the caring theory of Watson (1985) and the practical application of it in the management of nurses.Clearly caregivers can no longer define quality by their standards (structural processes) only.The standards should be the foundation for services and for continuous im provement of caring in the human resources of nurses.Fur thermore the following recommendations were made in the study:

Recommendations for caring for the caregivers regarding research:
• A survey should be undertaken to assess the cur rent situation regarding HIV/AIDS amongst nurses, to enable appropriate planning.

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The effect of HIV/AIDS on the health delivery sys tem should be researched further to establish the needs of nurse managers regarding support, guid ance, counselling and care to dying nurses.

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The influence of HIV/AIDS positive nurses on the management of the hospitals should be estimated and additional support systems should be put into place.

Recommendations for caring for the caregivers regarding nursing services:
• The ability of nurses living with HIV/AIDS should be established and their capabilities to render nurs ing care should be investigated to enable nurse man agers to supply enough nurses to do the job.

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Sufficient additional support and guidance to nurse managers and nurses should be provided to cope with the demands of HIV/AIDS positive nurses.
Recom m endations for caring for the caregivers regarding nursing education: • The nurse managers should attend workshops and discussion groups on caring for nurses.In these work shops, caring in the management strategies should be planned strategically.

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Caring for the caregivers as part of the management should be emphasised in the curriculum of all the nursing courses for registration as a professional nurse.

Conclusion
Nurse managers need basic traditional management skills to gether with caring attributes in the management of nurses in health services of today.Furthermore nurse managers need specialized skills, in dealing with the impact of HIV/AIDS on nurses and health services.The organisation-wide caring phi losophy could be enhanced by enlisting the nursing staff in the whole process, discussion of and reviewing the concepts identified as problematic in this study and relating them to nursing practice and care for the caregivers.The next step should be the formulation of caring standards and behav ioural criteria and development and implementation of an edu cational and marketing plan.It came to the fore that manage ment skills were needed but these are not enough to survive in the current health services.Therefore the decision to train nurse managers and to upgrade the management knowledge and the implementation of the practice of caring concepts in nursing management with relevant care and support for HIV/ AIDS nurses, is of the utmost importance, to equip nurse man agers to survive in these demanding circumstances.