Skilled nursing practice — a qualitative study of the elements of nursing

International Journal of Nursing Studies 38 (2001) 405–417

Skilled nursing practice } a qualitative study of the elements of nursing Steve Bullera,*,1, Tony Butterworthb a

Clinical Nurse Specialist, Psychotherapy Department, Southern Derbyshire Mental Health Trust, Temple House, Mill Hill Lane, Derby DE23 6PF, UK b School of Nursing, Midwifery, and Health Visiting, University of Manchester, Oxford Road, Manchester, UK Received 4 January 2000; received in revised form 20 July 2000; accepted 27 July 2000

Abstract An understanding of skilled nursing practice has implications for the identity of nursing in service delivery, and for the learning environment of the developing nurse. Here I report a qualitative study, largely reliant on ethnography, which became a journey of exploration through accounts and descriptions given by nurses in a number of different practice settings. This journey is founded in an understanding of what I have called a phenomenological and psychosocial tradition, recognising the importance of a postmodern influence, which is in tension with a scientific and behavioural tradition. The emergence of four domains of skilled nursing practice in a contextualised narrative would seem to offer justification of assumptions concerning the value of embedded knowledge and intuitive clinical judgement in nursing practice, and lay a foundation for a qualitative study of the developing nurse. # 2001 Elsevier Science Ltd. All rights reserved. Keywords: Skilled nursing practice; Qualitative research; Ethnography; Embedded knowledge; Intuitive clinical judgement; Philosophical traditions

1. A challenge to scientific and behavioural approaches in nursing In the 1980s I began a journey of discovery which was to take me from an enmeshment with what I have come to call a scientific and behavioural philosophical tradition in western philosophy, to an attempt to understand nursing through an interpretation of a phenomenological and psychosocial philosophical tradition (Buller, 1998). Philosophical traditions of this kind have been influential on the development of inherent *Corresponding author. Tel.: +44-1332-364512; fax: +441332-293316. E-mail address: [email protected] (S. Buller). 1 The pronoun ‘I’ is used to acknowledge the reflexively personal interaction of the researcher in the field in a way that ‘we’ might reflect the collaboration of the authors.

value and belief systems of nursing, and the methods used by nurses in their research practices. A scientific and behavioural tradition was shaped by ontological and epistemological concerns of the enlightenment project, with a search for objectivity, realism and causal explanation. From this scientific and behavioural tradition, harbouring modernist concerns with rationality, emerged quantitative methods in nursing research. Research approaches arising in such a tradition, and consequent methods, have been in the ascendancy in the post-war period, and have led to an overwhelming array of classifications of nursing skills. The majority of these classifications have suggested that behavioural indicators of clinical competence can be identified and used to define and measure clinical nursing practice (Cruickshank et al., 1994). It is possible to point to a period in the early 1980s when scientific and behavioural ideas about nursing

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practice and competence were first challenged in a significant way. In 1982 Patricia Benner wrote The quest for competency statements and competency-based exams in nursing has led to what seems to be a premature faith in the current state of the art and capability of competency-based performance examinations in nursing. Carried along by a technological, measurement-orientated age, we have been convinced that many of our problems in nursing education and practice will be solved when we master the current measurement technology available } when we can simply and unequivocally describe the competencies involved in the practice of nursing and measure them. Some have gone so far as to say that any area of practice that cannot be so defined, described, and measured does not legitimately belong in the arena of professional practice. Unfortunately, this faith in the feasibility of competency examinations does not come to grips with the difficulties and issues inherent in the methodology (Benner, 1892, p. 303). Benner’s work was founded in Heidegerrian phenomenology, making use of the ideas of Polanyi (1958) and Kuhn (1970). She demonstrated how qualitative methodology could be effectively applied to clinical nursing practice in meaningful ways. Although her work has attracted criticism (English, 1993; Cash, 1995; Eason and Wilcockson, 1996; Paley, 1996) there has been a growing inclination towards qualitative methods by researchers, and a developing understanding of nursing practice through phenomenological and psychosocial perspectives (Taylor, 1994). These phenomenological and psychosocial perspectives are now firmly under the influence of a postmodern context with all that implies in terms of linguistic and feminist constructions of human endeavour. Consequently, constructivist and constructionist ontology and epistemology can be seen in how caring, subjective, and human aspects of nursing practice are explored and valued (Benner and Wrubel, 1989; Morrison and Burnard, 1991; Benner, 1994; Watson, 1999).

2. Research in a phenomenological and psychosocial tradition It has been suggested that we live in a time of methodological revolution (Denzin and Lincoln, 1994). An important aspect of this revolution can be seen through developments in qualitative methodology where enquiry is grounded in contextualised accounts of phenomenon under investigation. It can be argued that philosophical traditions have been much more influential on research methodology, as applied in nursing than

many have considered. Research approaches are inevitably grounded in values, beliefs and attitudes that become organised within these traditions. In methods founded in a phenomenological and psychosocial philosophical tradition, there is a search for meaning in the complexity of personal, subjective experience rather than premature attempts at simplification into generalising models. In a postmodern context the researcher is reflexively engaged in an interpretive venture with multiple voices and experiences. There is a doubt that any discourse has a priviledged place, and an understanding that no emerging theory or interpretation has particular claim to authoritative position (Richardson, 1991). Out of these ways of considering enquiry a number of research strategies, and approaches, have found favour within what might be called a naturalistic framework (Lofland, 1967). Strategies such as grounded theory, phenomenology, case study, participant observation, biography, ethnomethodology, and ethnography have been implemented through a number of different approaches such as interviewing, strategic observation, reflexive participation, interpretation, and representation. In contradistinction to a scientific and behavioural tradition a phenomenological and psychosocial tradition has placed value on subjectivity and the interpretation of meaning. Hammersley and Atkinson (1983) suggest that ‘naturalism presents ethnography as the pre-eminent if not exclusive social research method (p. 9)’. There has been, and still is, considerable debate about the nature and form of ethnography within qualitative methods. Ethnography has been used in a number of different ways to investigate how human beings make sense of, and apply meaning to, the world in which they live (Gumperz, 1981; Lutz, 1981; Walker, 1981; Glaser and Strauss, 1967; Denzin, 1989; Aamodt, 1991). As a strategy within qualitative research it has been used by researchers in post-positivist contexts, and in thoroughly postmodern, constructivist contexts (Atkinson and Hammersley, 1994). Spradley (1979) defines ethnography as ‘the work of describing culture’, and it is in this context I have used it in the study reported here. Through an ethnographic approach I have seen myself as learning from people rather than studying people, and primarily concerned with the meaning of actions and events to the people I was seeking to understand. People make use of complex meaning systems to organise their behaviour, to understand themselves and others, and to make sense of the world in which they live. These systems of meaning constitute the culture of the environment in which people exist. Culture refers to the acquired knowledge that people use to interpret, experience and generate interpersonal behaviour. In a nursing culture this acquired knowledge can be referred to as embedded

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knowledge. Embedded knowledge is knowledge that accrues over time in the practice of an applied discipline (Benner, 1984). Using an ethnographic approach I have developed a narrative of embedded knowledge from the accounts of nurses within their own culture. In qualitative research narrative has become a significant aspect of enquiry. Through an evolving narrative a researcher can develop a way of ‘knowing about’ a field of enquiry and represent, or present (Eisner, 1991), that understanding to an audience (Polkinghorne, 1988, 1996). In a postmodern context a narrative, a storied form of discourse, expresses, in language, relationships in meaning and knowing in human experience (Ricoeur, 1992). Human experience, with its local knowledge and perceptions of difference, can be conveyed through narrative so as to take account of the emic nature of that experience for both researcher and researched (Richardson, 1990, 1991).

3. Engaging a dialogue with a clinical culture In my journey through this study, I adopted a qualitative methodology, largely informed by ethnography, as a way of describing, providing a narrative about, the nature of a clinical culture. An interpretive dialogue has been used to uncover embedded knowledge within this culture, and to understand the complex meanings applied by clinicians within the culture (Fig. 1). This process has led to the next part of this study which is to consider the effects of training on the acquisition of embedded knowledge, and hence on skilled nursing practice. As a method of enquiry, particularly in a postmodern context, ethnography has at its heart a

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reflexive, intersubjective posture. In keeping with this reflexive stance I engaged my study in an attitude of reflexive curiosity, initially exploring my own ‘lived experience’ as a nurse and researcher, and later retaining a reflexive position in relation to clinical nurses who were to become informants in the study. From the start this was no search for an exotic, foreign field as might be expected in traditional ethnographic research in anthropology. This was an engagement with a field which held cultural familiarity for myself as researcher at many levels. In this setting I was offering no pretence of ‘objective’ detachment but involving myself in a cultural context with which I was already familiar. From this perspective I set about finding informants and a way of enquiring with them into understandings of clinical practice within this culture. Purposeful and nomination methods of finding informants were chosen (Morse, 1994). Some of those who were to become informants were nurses with whom I was already acquainted. Others were recommended to me by those already approached to become informants. People were contacted by letter, or telephone, to arrange an initial meeting, and to convey preliminary information. All informants came from an NHS clinical culture in the Midlands and North of England, and from a number of NHS Trusts and GP Practice settings within this culture. For the main part of the study informants were ‘expert’, and ‘qualified’, nurses across a range of specialties. Expert nurses were chosen partly to allow comparison with Benner’s approach, and partly because I wanted to define their role in a later part to the study in observing the practice of developing student nurses. Models for choice of expert informants used in previous studies are similar (Benner, 1984; Brykczynski, 1989; Butterworth and Bishop, 1995; Kaiser and Rudolph, 1996). Attention was applied to a critique of these models (English, 1993, Cash, 1995; Paley, 1996) and it was decided that an expert informant would be a qualified nurse who had a minimum of five years clinical experience, was currently involved in clinical practice, and had undertaken recognised post-basic, or postgraduate training. Acknowledging that a culture in nursing is not defined wholly by expert nurses, other qualified nurses, not fulfilling the criteria for expertness, were coopted as informants.

4. Meeting informants

Fig. 1. The research process.

A rolling programme of contacts was set in motion which began with five expert nurses in the early months and ended two years later with 22 nurses who had become expert informants. In total I gathered the names of in excess of 40 possible expert informants, and made initial contact with 34 of these. Four declined, for a

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variety of reasons, not to participate. With three possible informants there were significant practical constraints in meeting which prevented further contact. A further five informants were never interviewed because of a growing awareness, as time passed, that further dialogue was producing no new terms } that I had achieved a level of saturation in the narrative. Ten of the final 22 nurses were Clinical Nurse Specialists. Seven of my expert informants were Ward Sisters and Charge Nurses in the in-patient settings. Two were Practice Nurses, two District Nurses, and one a Community Psychiatric Nurse. Informants worked in a variety of surgical, medical, psychiatric, and community settings. Thus, it was possible to engage 22 expert nurses who might be said to represent a cultural context within which the study was to take place, and typify a range of clinical areas. Given that a nursing culture is not composed only of expert nurses, some two years after commencing a dialogue with informants, I started a search to identify qualified nurses of a range of grades and experience who might also contribute to an emerging narrative. Again a rolling programme of contacts was set in motion. During the next three months seven qualified nurses had been recruited, and over the next year a further seven joined in the dialogue. Care was taken to ensure that these nurses would not fulfil criteria to become expert nurses. Of these 14 additional qualified nurses three were from Community Psychiatric Nursing, District Nursing, and Practice nursing, respectively. Four were Ward Sisters or Charge Nurses, and seven were Staff Nurses. All working in in-patient or outpatient settings. These qualified nurse informants worked in a variety of surgical, medical, psychiatric, and community settings. Although all contacts were made personally an information sheet was given to informants before a dialogue concerning the subject of the research commenced. Thus, I was able to engage fourteen additional informants, qualified nurses, who were able to enrich the narrative of the nursing culture, and further inform the dialogue with informants.

5. Exploring accounts and descriptions A strategy was developed to engage informants in a sequence of interviews, semi-structured conversations, through which I could make best use of their implicit and explicit understandings of skilled clinical practice (Fig. 2). Using this sequence of conversations it was possible for me to take informants from the first interview, through follow-up interviews, and, where possible, on to video observation interviews. Early in the study I had spent time with nurses, some of them who were to become informants, asking them what questions they would want to ask other nurses in order to elicit an

Fig. 2. Interview sequence for semi-structured conversations with informants.

understanding of their clinical practice. These questions along with understandings from a literature review, and a dialogue with the methodology, were used to compile a basis for a broad exploration through semi-structured interviews with expert and qualified nurses. Interviews were characterised by ‘grand tour’ questions, and there was a search for a broad account of informants’ perspectives of the nursing culture in which they worked. This protocol became known as the Clinical Practice Descriptive Interview. It evolved over a period of time, and the ways in which interviews were conducted was refined as enquiry progressed. Through an analysis of interview notes, and transcripts of audio tapes from interviews, I collected a large number of descriptive terms used by informants in their accounts of skilled practice. In follow-up interviews informants were asked to compare and contrast terms, group terms by using card sorts, in a format I called the Follow-up Clinical Practice Clinical Interview. From these follow-up interviews I was able to determine ways in which informants held shared understandings of meaning about terms being used. Later a further interview format was used to facilitate informants discussing a recent clinical situation in which they had been involved, called a Clinical Event Descriptive Interview. Some informants were familiar with video tape recording their clinical practice } others were eager to do so. During the course of the research I developed a Video Review Descriptive Interview format which engaged a dialogue with informants whilst watching their practice played back through a video system. The Video Review Descriptive Interview format utilised a process similar to clinical supervision, making use of a reflective space in which to discuss and describe aspects of practice. Within the project as a whole ethical issues, and hence matters of confidentiality, were carefully considered, and written protocols developed at an early

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stage. When tape recording clinical practice, informants worked within a protocol for recording clinical material which included a code of conduct, information for patients, and consent forms. Patients were given written and verbal information about the nature and purpose of video tape recording, and subsequently were asked for their verbal and written consent.

6. Developing curiosity Those people who assisted me in the early stages of this study were nurses I mixed with on a daily basis, and it was with these nurses that I began my search for questions. At that stage I had already started a research diary, and I recorded an encounter with a District Nurse at a GP practice meeting with a reflection on how nurses are curious about nurses Research Diary: New District Nurse at Dr. Q’s today. She lent across and said ‘‘am I going to be one of your guinea pigs?’’ We joked } she was persistent and inquisitive. This isn’t the right place and I’m not prepared. Explained what I’m thinking of doing } she has lots of questions } wants to know what I will be asking. Asked her what she would want to find out from nurses she might interview. Thought that was a hard question. ‘‘I’d want to know about feelings’’. ‘‘I’d want to know how they would handle difficult situations’’ } ‘‘I’d want to know about handling situations that were routine } ordinary’’. This interaction represents a common phenomenon I discovered amongst nurses, especially more experienced nurses, who showed what I have called ‘curiosity about curiosity’. There is often an eagerness to be involved in the process of discovery } an ability and willingness to reflect on practise in ways that somehow ‘look in on themselves’. The conversation also raises an interesting observation. In our dialogue the term ‘handling situations’ arose which, although I was unaware of it at the time, was going to have significance in an emerging narrative. A curiosity discovered in those early conversations became a mirror for my own need to develop a questioning stance with regard to those I was encountering. It became important to me that I could adopt a position that was self-conscious in relation to the culture of nursing with which I was engaging, and self-critical in regard to my own preconceptions and embedded attitudes. Hence I was concerned to develop a way of being curious that would not just develop a series of questions, as important as that was going to be, but also a motivation and attitude that would allow me to use

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these questions in a way that would fully engage informants. Discovering important questions, grand tour questions, mini tour questions, was important in itself, however the means to convey these as part of a discovery of meaning in an intersubjective experience was going to be essential. I set out to ascertain what it was that nurses, those I met in my everyday life and in the course of commencing this study, would want to ask other nurses. What it was that they would be curious to discover from other nurses, or to question about their own practise as a nurse, given the opportunity. In reality this was not a hard task. The nurses I met were, in the main, more than ready to discuss these issues. At an early stage in the study my meetings with nurses were largely guided by my search for expert informants. In this context I approached senior nurses in hospitals and community settings who might employ nurses who would fit criteria for expertness in their areas of responsibility. One such senior nurse was a clinical manager in a large city centre hospital. I had been introduced to her by the Director of Nursing Services. A note in my research diary reads Research Diary: Diane } Office on Green Ward but about to move. On the phone when I arrived } must have rung a dozen times during the fifteen or twenty minutes I was there. Thought about our phone call } Carol a Ward Sister on male surgical will fit the bill . . .. . .. . .. . . ‘‘Of course you can contact the staff on the ward’’ } As long as I don’t get in the way or interrupt the work! Can she see the results? } a bit intrusive. Joking. She’d want to know how nurses think things have changed over the last couple of years. Whether they really think communicating is as important as they put in their protocols. Are they really informed about the judgements they make? It was questions like this that eventually informed the compilation of a guide for semi-structured interviews with informants which became known as the Clinical Practice Descriptive Interview. In one sense it was meetings like these that were to prove most useful in the early stages of the study. Not only were they such a helpful point of access to a range of potential informants, they were also offered striking insights into potential perspectives on the interviews I was to undertake.

7. Locating descriptive terms As questions emerged so did the names of potential informants, and it was with some trepidation that I

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embarked on the first interviews. The second informant I contacted, and the first I met worked as a Clinical Nurse Specialist in a hospital setting. For the past five years she had been Clinical Nurse Specialist in the same specialist department. I was given her name by another Clinical Nurse Specialist, from a different hospital, who was also to become an expert informant in this study. Arranging a meeting was not easy. She was busy, so was I } and it meant me travelling some distance to get to the hospital in which she worked. However, she was to become a regular and enthusiastic participant in dialogue. Here is a segment from our first conversation Researcher: Can we move on a bit. I was . . . Informant: Um. Researcher: I was wondering about your current practice. What it is that you are. . . feel are the important things about your current practice. Informant: That’s a hard one. . . it’s much easier, well easier, thinking about someone else’s practice. Researcher: Yes, perhaps. . . Informant: I think it’s, perhaps, all starts with how you are with patients } yes erm some nurses just do what they have to do, do it well, get on with the task in hand but that’s different if you like being with the patients. You can tell the difference. Researcher: Right. Informant: Em ah. Getting things done is very important though. . . it’s more than just getting things done, it’s a whole attitude. It’s a bit like confidence, when you know what you’re doing. I wasn’t always like that, still not at times (laugh), but conveying that confidence to the patients, it’s a big hurdle. Like being professional } confidence } when you’re putting up a drip, or taking out sutures em so there’s a contrast. I mean things like that are important but so is being approachable or having a good reputation. . . Researcher: Having a good reputation? Informant: Yes, knowing that people, patients, think well of you. Colleagues too. I want people to think ‘she’s a good nurse’ because I am, because I can show that I am, I mean. After each interview, as soon after as possible, I wrote a reflective note in my research diary, and carefully read the notes I made during the interview. Transcripts of tapes were generally made within a couple of weeks of the interview, and so within a matter of weeks it was possible to review a number of texts concerning that particular interview. As I read these I started to make a list of terms that seemed important. I was looking for words that nurses use to describe clinical practice. I was also attempting to distinguish this type of description from those used to give an account of the setting in which they worked, or perhaps the means of

their own professional development } as interesting and informative as these things proved to be. I was looking for words and phrases that these nurses held in their vocabulary to convey a sense of what they, and other nurses, did with patients. Out of the first interview, of which a portion is reported above, I uncovered eleven terms (Fig. 3). As terms were identified in the texts I did a number of things. I began writing out lists of the terms on sheets of paper, sometimes using the whole sentence in which the term appeared in the text. Using a ‘cut and paste’ facility on a computer word processor meant it was possible to construct pages of terms, perhaps the same terms in a different order and layout on different pages. I also transcribed each term onto a small, plain card which was stored, in alphabetical order for easy retrieval, in a large card box (a plastic food container proved to be exactly the right size and shape to efficiently hold a large number of cards). This box was to be a constant companion for interviews with informants, and the cards proved to be a powerful tool in working with informants, and in analysis. As terms were copied to paper and cards they were referenced to their place in transcripts of interviews, so as to be readily located in their original contexts. In this way it was possible to ‘play’ with several terms together, either written on a sheet of paper or by laying out a number of cards on a large table. I am using the word play here in the sense given it by Winnicott (1971, 1986) as creative activity that takes place in the potential space between people as part of unfolding intersubjective experience. Actually the floor proved a good place to play with cards. From further interviews came more texts, transcripts of audio tapes and written notes, and more terms. Some terms began to be repeated, others appeared to be very similar to terms which had already been identified. After three interviews a list 91 terms had been identified.

Fig. 3. Descriptive terms from the first interview with the first informant.

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8. An evolving dialogue and emerging domains Over time I established a working relationship with informants, and as terms emerged from the accounts and descriptions of practice given by these informants, I started to consider ways in which to progress an analysis. First of all I began to search amongst emerging terms and descriptions for possible categories or domains. To do this I was looking for cover terms, and ways in which other terms might aggregate under these cover terms. Several terms were tried as possible cover terms, and potential domain descriptors. I was now thinking about potential follow-up questions which might help clarify, and expand upon, the ways in which informants used terms, and the meanings that these terms might hold in common. In following Spradley (1979, 1980) I started to consider possible mini tour, structural and contrasting questions, and began to try these out in interviews. The general aim of these questions was to gain more descriptive material concerning particular areas be explored, to help understand how cover terms, and included terms, are constructed in domains. Questions of this type also enabled an exploration of meanings that apply in cover, and included terms. As part of an initial analysis of the first interviews I considered a possible domain whose cover term was ‘being professional’. In this early, tentative domain I proposed a potential relationship between a number of the emerging terms and the proposed cover term. I then used this potential relationship to consider possible structural questions that would enable an exploration of relationships between terms and cover terms. I formulated some specific structural questions: * * *

Are there different ways of being professional? Is ‘being responsible’ a way of being professional? Are there other terms that are ways of being professional?

The use of these questions was part of a learning process which served to encourage me to consider a number of other general mini tour descriptive questions, structural questions, and contrast questions: * * *

In what ways is . . . used in clinical practice? Can you tell me a bit more about . . .? How is . . . different from . . .?

With these follow-up questions, in addition to the grand tour questions from my Clinical Practice Descriptive Interview format, I embarked on further interviews with new informants, and follow-up interviews. I met with a new informant, a charge nurse in a

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specialist mental health setting. During our dialogue the following exchange took place: Informant: It’s something about intuition } I suppose. Some people, nurses I mean, want it to be so rational } as if you can parcel things out, parcel it out in neat packages. But when it comes to handling difficult situations . . . . You learn to rely on your intuition. . . . Researcher: Can you tell me a bit more about using intuition like that? Perhaps you could. . . . Informant: Yes } well } if I’m facing something tricky I often surprise myself by how I can handle the situations. And it’s the same with colleagues } we had a situation yesterday in the clinic. A young man turned up without an appointment. Jackie (Staff Nurse) was on the desk } she’s got a lot of experience, bright, and been working here a couple of years so she knows the ropes, so to speak } Debbie our receptionist had gone up to [the name of a large psychiatric hospital] to deliver some papers. This young fellow starts kicking up a right stink } his injection is due } overdue I’d say. I came up from the day area and Jackie was handling it } very professional } I was proud of her. Researcher: Is handling a situation like that part of being professional? Informant: Yes, I think so, yes. It’s just that I spoke to her afterwards and she said, she just reacted on a gut reaction, intuition, to calm things down. That’s what I’d expect from her } she is very professional. What was it? Researcher: I. . . . Informant: Yes, handling situations is part of being professional } I think there’s more to it than that though. Professionalism is a big issue. Researcher: What are the other ways you might describe being professional. Informant: That’s a big one. Someone I would call professional would have to be credible, I guess, I can think of people who aren’t. The people who I would call professional put patients first, they’re relaxed in their role, they’re sure of themselves but not in a cocky way. . . . A number of things came out of the conversation with this informant. I uncovered further evidence that ‘being professional’ might be a cover term. David had suggested describing ‘being professional’ was a ‘big one’, suggesting that it might possibly cover other smaller terms. He then offered other terms and phrases that might be included under it } ‘being credible’, ‘putting patients first’, ‘relaxed in their role’, ‘sure of themselves’, and ‘not being cocky’. David also points to ‘handling situations’ as a part of ‘being professional’. Through a continuing analysis of emerging accounts

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with other informants, I began to accumulate more evidence about domains and cover terms. Working in follow-up interviews, with descriptive texts on paper and on cards, and returning terms and possible cover terms to informants for consideration, ‘being professional’ took on increasing significance as a potential cover term. Soon I found six possible terms which aggregated into a group under this cover term, suggesting that it probably defined a domain (Fig. 4). The ‘being professional’ domain sustained its prominence, and found its place in an emerging narrative.

9. Handling situations Several descriptive terms, which I recorded in my opening conversations with nurses at the beginning of this study, recurred in subsequent interviews with informants. As we have seen, the term ‘handling situations’ came to be located in a domain called ‘being professional’. Closely associated with ideas of confidence, but quite distinct in the minds of informants, was the way in which professional practice is manifest in how practitioners react in particularly demanding circumstances. An introduction to a possibility concerning aspects of practice that would lead to an understanding of the term ‘handling situations’, and its domain, came from an informal conversation with a Staff Nurse, who was to become a qualified nurse informant, recorded in a note in my research diary Research Diary: . . . and it’s those people who flap all the time, they drive you up the wall, not just the staff the patients too. This small aspect of dialogue led to further conversations regarding the ways in which nurses react to a multitude of different events, and potential events, that happen around them in the course of a working day. These conversations inspired a cognisance of professional skill which manages ‘unusual circumstances’, ‘rapidly changing situations’, and ‘critical events’. The term ‘handling situations’ came to describe this aspect of ‘being professional’. A Staff Nurse, a qualified nurse

Fig. 4. ‘Being professional’ } a proposed cover term and possible included terms.

informant, described returning to work after two days off and being in charge of the ward Informant: I hadn’t been on duty long after two days off } and in charge. All of a sudden there was a commotion just opposite the nursing station. I was at the other end of the ward. I could see Tony (Staff Nurse) at Mr. T’s bed } his wife was hysterical. I got there and Tony was mopping up blood } trying to see what was happening. You know how it can happen. It was only later I could look back and see what I had done } you go on to sort of automatic. Get nursing assistance, get medical assistance, allocate staff to the relative, coordinate activity, monitor the situation. (Pause) It’s not panic, it’s well considered } but not consciously } it’s sort of second nature. Afterwards Tony said ‘‘I was glad you were there } you’re good at handling situations like that } very professional’’. Quite a complement from him } but I think it’s just the extra experience. Descriptions such as ‘getting (. . ...) assistance’, ‘allocating staff ’, ‘coordinating activity’, and ‘monitoring the situation’, as important as they are, do not capture the full impact of ‘handling situations’. The description ‘not panicking’ places some greater understanding in the picture which is apparent in a similar account which came from another Staff Nurse, a qualified nurse informant: Informant: Jane (Ward Sister) and I had just gone down to make him (John, a male patient) comfortable } his wife and son had already arrived for visiting. We got to the foot of the bed and his wife was moving out of the way to let us through and he just ‘went off’. You know monitor whining and him slumping over. My mind went blank but Jane was brilliant } she spoke to Debbie (Staff Nurse) on the other side (at another bed) } Debbie went off to put out the ‘crash’. Almost at the same time she (Jane) was asking John’s relatives to move to the day room and pulling the curtains on her side. She (Jane) is so good at handling situations like that. Actually we had him round again by the time the crash team arrived. It really shook his relatives up though. ‘Handling situations’, as part of the ‘being professional’ domain, came to describe an aspect of practice concerning unusual circumstances, rapidly changing situations, and critical events. An ability not to panic under these circumstances, but to undertake necessary actions, such as allocating staff and coordinating activity, became an important part of what is conveyed by this term. Interestingly, informants considered that experience was a major factor in the development of this aspect of skilled nursing practice.

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10. Four domains and cultural themes Out of a reflexive dialogue with informants I have been able to construct a narrative of skilled nursing practice within the defined culture. In dialogue with informants I uncovered four domains, and 24 descriptive terms, which they used to inform their understanding of practice (Fig. 5). The four domains } ‘being professional’, ‘relating and communicating’, ‘doing the job’, and ‘managing and facilitating’ } provides a means for expert nurses to talk about their own practice, and the practice of other nurses. An ethnographic approach suggests that an analysis of accounts and descriptions, as well as arriving at terms, cover terms and domains, will also uncover cultural themes or principles that show relationships between domains (Spradley, 1979). In my analysis a number of themes were interwoven in the narrative text. I hesitate to claim that these themes are of the substance of cultural themes because this was not the primary focus of my analysis for this study. However, they are themes which were important to informants as being overall locators for emerging domains and their included terms. One of the important

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themes in this study was ‘caring’ which was held by informants as a primary feature of skilled nursing practice. Another was ‘intuition’ which was found by informants to be the basis of so much of good practice. A third theme was ‘being ordinary’ which conveyed for informants the deceptive, apparent simplicity of skilled nursing practice which belies its actual complexity. A fourth was the nature of ‘role modelling’ which informants pointed to repeatedly as a crucial influence on their own development.

11. Representing and writing As descriptive terms, and domains, emerged in a reflexive dialogue with informants I was confronted with a consideration of how to make sense of a developing narrative, and in what way to convey this understanding to others. A so-called ‘crisis in legitimisation’ in qualitative research, particularly ethnography, has become thoroughly enmeshed with a ‘crisis of representation’ (Denzin and Lincoln, 1994). Foucault’s deconstructive exploration of discourse as a means of asserting power through the production of truth

Fig. 5. Skilled nursing practice in this study } its four domains and some overall themes.

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contributed considerable impetus to a postmodern turn in phenomenological and psychosocial dialogue (Foucault, 1980). Knowledge, according to Foucault in this context, is not power itself but is inherent in power relations through authority claimed for that knowledge. A poststructuralist development in understanding relationships between power, knowledge and enquiry is seen in the complementary discourses concerning feminism (Weedon, 1987; Olesen, 1994) and a critique of ethnographic practice (Clifford and Marcus, 1986; Rosaldo, 1989; Clough, 1992; Van Maanen, 1988). A critique of phallocentric, colonising research practices, found in positivist and postpositivist ethnography, questioned the way in which ‘Others’ have been studied, and represented, in ethnographic texts (Marcus and Fisher, 1986). A crisis of representation has resulted from a reaction to what has been seen as an oppressive, and unthinking treatment of ‘Others’ in the research process. A growing awareness of subjective involvement of researcher with researched, plurality in perspective and reflection on intersubjective experience, has led to new ways of considering how we present what we find, and indeed how we find what it is we present. Merleau-Ponty (1973) brings our attention to the inseparable nature of thinking and language, when understood from within in a phenomenological and psychosocial tradition, suggesting that it is only when we speak that we discover what it was that we wanted to say. Seen in this way enquiring, interpreting, describing, and writing are inseparable components of a qualitative research process (Richardson, 1994). Ways in which the ‘Other’ finds a place in the text becomes an important issue in the postmodern idiom. Representational practices have implications for whose voice is heard in the text, and who privileges the discourses which emanate in a polyphonic influence (Richardson, 1991; Denzin and Lincoln, 1994). Through a subjective involvement in the research setting authority can be claimed for an emergent text through an explicit reflexivity which acknowledges, as openly as possible, influences on the researcher, and the researched (Marcus, 1994). Triangulation and respondent validation are ways in which I have approached a narrative which, in a subjective reflexivity, privileges constructivist and emic principles (Hammersley, 1992; Silverman, 1993; Denzin, 1994; Denzin and Lincoln, 1994; Richardson, 1994; Guba and Lincoln, 1994). As I have unfolded an account of my journey, I have attempted to find a coherent and enduring voice for those nurses with whom I had dialogue. In writing here I am endeavouring to represent something which I have written about more fully, and perhaps no more completely, elsewhere (Buller, 1998) which are not things at all, and not just words, written or spoken. The things about which I have written are

also experiences, mine and other peoples, and what has been seen, observed. So I have been trying, in writing, to represent many things, which as I say are of course not things at all. They are people, and people relating to other people, and people watching people relating to other people. As such I have been writing, in part, about being. What it is to be a researcher. What it is to be a nurse. What it is to be an expert nurse. What it is to be a developing nurse. I have been attempting to represent a number of different discourses, and I have asked myself ‘what is the dominant discourse?’. I hope it is that of the qualified nurse within the settings I have participated. I think it has a part for those qualified nurses who became expert informants. But it is not just a narrative of the ‘Other’ because there is also here a discourse which is mine } a nurse, nursing, watching nursing, talking to nurses. Together perhaps we have come together around a shared discourse } an understanding which is socially constructed in our shared lived experience of this nursing culture.

12. Nursing identities I believe that representational practices which seek new ways to legitimise subjective and intersubjective experience in the research process have particularly poignant applications in nursing enquiry. In a special sense the last two decades have seen a growing preoccupation with discrete process and content in nursing activity. Part of the focus for this preoccupation can be located in the context of growing concerns with an efficient use of resources and how health services are planned and commissioned (Department of Health, 1997). An associated factor has been a consideration of the place that training and education have in equipping people for practice, and an exploration of the body of knowledge that underpins practice and its development (Department of Health, 1999; UKCC, 1999b). It is possible to suggest that nursing is in a state of perpetual crisis. This crisis, it can be argued, is largely one of identity demonstrated in debates about skill, competence, levels of practice, and organisation of training. One perspective on such an identity crisis may be seen in current debates regarding a higher level of practice, advanced nursing, specialist practitioners, and expert nurses (UKCC, 1999a). Another perspective can be seen in the way nurse training has once again come into question (Buller and Butterworth, 2000; Chaffer, 1999). An association between levels of practice and education can be found in considerations of the place that training and education have in equipping people for practice, and an exploration of the body of knowledge that underpins practice and its development.

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Such an association can also be found in how continuing education and training may be needed to maintain the quality of on-going practice. A number of serious questions have been raised concerning the usefulness of current systems of continuing training and education, and how difficulties in this arena might be addressed (Benner, 1982; Burnard and Chapman, 1993; Shanley, 1988). There are those who tell us that in the last two decades these questions about identity, training and practice, have gone beyond what has been described as selfabsorption within an emerging profession struggling with its own identity (Jolly and Brykczynska, 1995). It has become current to ask what part nursing, or perhaps especially what part of nursing, is required or needed in these services (NHSME, 1993). It is possible to ask fundamental questions about what nurses do, how they know about what they do, how they come to do what they do, and how they come to know about what they do. Qualitative studies, such as this one, have a particular strength in representing nursing identities. Postmodern ethnographic exploration of ‘real-life’ nursing can illustrate the rich and valuable content of practice in professional, organisational and social contexts. The four domains emerging from this study help to show how nursing identities are found in particular skills and knowledge in these contexts. Those planning, and delivering, services can make use of qualitative methods, as suggested here, to inform a process of identifying skilled nursing practice in a local context, and to ensure the quality of this skilled practice.

13. Summary and conclusions I have described here what I have come to see as a journey through a nursing culture, with perspectives on the various places and people I have visited on the way. It has been a journey of discovery at many levels starting with philosophical underpinnings, progressing through an understanding of the impact of these foundations on methods of enquiry, and ultimately into dialogue with a nursing culture through expert, and other qualified nurses. I have uncovered a notable tension between a scientific and behavioural tradition and a phenomenological and psychosocial tradition, and have developed an understanding of this tension as it has shaped research, and nursing practice. The same tension has emerged in the consideration of skill classifications, and in the way nursing skill has been understood and explored. I have successfully employed a qualitative methodology to uncover four domains from the accounts and descriptions given by expert and qualified nurses within a clinical nursing culture. These four domains, ‘being professional’, ‘relating and communicating’, ‘doing the job’ and ‘managing and facil-

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itating’, emerge in a narrative which represents nurses in their cultural context. A phenomenological and psychosocial tradition, using paradigms concerning experience, embedded knowledge, intuition and clinical judgement has, as I have described it here, provided a postmodern context for a study in which contextuality has particular relevance. These paradigms have supported a renewed interest in the human, caring aspects of nursing which had become lost during the period when scientific and behavioural paradigms held sway. As part of the journey I have travelled through aspects of being and knowing } ontological and epistemological issues that are part of a nursing culture } and been confronted by values, attitudes and beliefs that permeate cultural contexts in which we work. These ontological and epistemological issues illuminate tensions in a dualism between subject and object, perspectives in idealism and realism, and a momentum found in constructivist and constructionist paradigms. It is possible to suggest that all classifications of core skills draw on common elements, perhaps on a common foundation of knowledge. However, the domains of skilled nursing practice described here are derived from within a particular clinical context. As such the four domains have relevance to a local culture of nursing practice. This would be consistent with constructivist and constructionist paradigms, with emic considerations, in ways that might view skilled nursing practice as a socially constructed phenomenon. An important shared understanding within this culture has provided a foundation for a qualitative study of the developing nurse and nurses in training, and this is a continuing project. As a text in a postmodern context within a phenomenological and psychosocial tradition, it is, de rigueur, an incomplete representation of the discourses engaged in the course of the study, and an element in a process. In particular, it raises further questions about contextualised enquiry into nursing identity, and the development of this identity.

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