The knowledgeable practice of critical care nurses: A poststructural inquiry

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International Journal of Nursing Studies 45 (2008) 588–598 www.elsevier.com/locate/ijnurstu

The knowledgeable practice of critical care nurses: A poststructural inquiry Beverley Copnell Department of Neonatology, The Royal Children’s Hospital and Murdoch Childrens Research Institute, Flemington Rd, Parkville, Melbourne, Vic. 3052, Australia Received 31 May 2006; received in revised form 23 October 2006; accepted 27 October 2006

Abstract Background: Contemporary nursing literature emphasises the desirability of clinical nurses being ‘‘knowledgeable’’. However, the need for nurses constantly to acquire more knowledge is reiterated. Lack of knowledge is seen to underlie an array of professional problems. Little is known of how nurses themselves understand what it means to practise knowledgeably. Objective: To explore critical care nurses’ understandings of knowledgeable practice and its relationship to being a ‘‘good nurse’’. Methodology: A poststructuralist framework informed the study. The study participants were 12 critical care nurses. Data were generated through three individual focused interviews with each participant. Data analysis involved deconstruction of the interview texts to reveal participants’ discourses of knowledgeable practice and the implications of these discourses for their subjectivity and for their work. Findings: A discourse of knowledgeable practice was revealed as central to participants’ sense of identity as ‘‘good nurses’’. Participants believed their knowledge resided in their heads (‘‘knowing why’’) and in their hands (‘‘knowing how’’). Fluency of action, which was achieved and maintained by frequent repetition of activities, contributed to their sense of being knowledgeable. Participants described being excluded from knowledge in some instances. In general, however, ‘‘actual’’ knowledge was of less importance than was being positioned, by themselves and others, as knowledgeable. This positioning was frequently undermined by other staff, both medical and nursing. Analysis revealed that the discourse of knowledgeable practice was underpinned by a dichotomy of ignorant/knowledgeable, in which ‘‘ignorant’’ was the dominant category; hence, nurses were assumed to be ignorant until they could ‘‘prove’’ otherwise. Conclusions: The findings contest the notion, espoused in nursing literature, that acquisition of knowledge can ‘‘empower’’ nurses, thus providing the solution to problems they may experience. Rather, strategies are required that challenge and disrupt relations of power that construct nurses as ‘‘ignorant’’. r 2006 Elsevier Ltd. All rights reserved. Keywords: Critical care nursing; Nursing knowledge; Poststructuralism; Power relations; Subjectivity

What is already known about the topic?

 Lack of knowledge is seen as the cause of a number

 The

need for clinicians to be ‘‘knowledgeable’’ is emphasised in nursing literature.

 E-mail address: [email protected]. 0020-7489/$ - see front matter r 2006 Elsevier Ltd. All rights reserved. doi:10.1016/j.ijnurstu.2006.10.010

of problems encountered by nurses, including lack of input into clinical decision-making and unequal relationships with medical staff. There is little information on how nurses themselves understand what it means to practice knowledgeably.

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What this paper adds

 Knowledgeable practice was central to nurses’ sense of identity as ‘‘good nurses’’.

 Actual knowledge was of less importance than their



positioning, by themselves and others, as knowledgeable. Nurses found it difficult to maintain this positioning, which was frequently undermined by the practices of doctors and other nurses. The study contests the notion that acquisition of knowledge can ‘‘empower’’ nurses and increase their ‘‘autonomy’’.

1. Introduction In westernised healthcare settings it is taken for granted that clinical nurses will be ‘‘knowledgeable’’, and that this knowledge will inform their practice. This notion emerged as part of the ‘‘professionalisation movement’’, in which nurses strove to shed their ‘‘handmaiden’’ image and to improve their status visa-vis other healthcare workers (Newman et al., 1991). Concurrent with this movement was the emergence of nursing specialities, which required nurses to acquire specific knowledge and skills (Stein et al., 1990); each speciality is understood as having a distinct body of knowledge that underpins clinical practice (Chaboyer et al., 2000). Indeed, as specialist nurses work in a variety of contexts such as academia and management, in addition to clinical areas, it can be argued that specialists are defined by what they know rather than the area in which they work. With respect to critical care nursing—the speciality with which this paper is concerned—knowledgeable practice appears to be a central focus of nurses’ identity and work. From a historical perspective, the need for ‘‘new’’ knowledge is described as driving the establishment of the speciality (Lynaugh and Fairman, 1992). Possession of this knowledge, which Lynaugh and Fairman (1992) suggest had hitherto been ‘‘forbidden’’ to nurses, is seen as structuring nurse–physician relationships (Stein et al., 1990). Knowledgeable practice is understood to be a major component of critical care nurses’ work (Happell, 1999; Schultz and Daly, 1989). Chaboyer and Creamer (1999) call this component ‘‘intellectual work’’, or the development and use of sound clinical reasoning skills. Others have described various ways in which nurses use knowledge in their practice (Benner et al., 1996; McDonnell, 1997). The need for knowledge is further articulated in explorations of what constitutes effective education and learning for critical care nurses to practise appropriately (Hardcastle, 2004; Little, 1999). Indeed, knowledge acquisition is a major theme in critical care nursing literature. Despite these nurses being viewed as ‘‘knowledgeable’’, their existing knowl-

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edge base is seen as inadequate. Many studies have evaluated nurses’ knowledge in a particular area, and invariably found it wanting (Erkes et al., 2001; Munro and Grap, 2001; Pieper and Mattern, 1997). Lack of knowledge is frequently cited as restricting nurses’ practice (Glynn and Ahern, 2000), preventing their participation in clinical decision-making and limiting their ability to control their practice (Bailey, 1986; Bucknall and Thomas, 1997; Dunn, 1993), and as a major cause of problematic relationships with medical staff and poor interdisciplinary collaboration (Davidhizar, 1993; Kennerly, 1990). The literature is fuelled by the imperative that critical care nurses ‘‘need to know’’, and moreover, that they constantly ‘‘need to know more’’. However, the literature never explores the context in which this drive is formulated. While undertaking a study of change in critical care nursing practice, I was struck by nurses’ frequent referrals to their status—or lack thereof—as ‘‘knowledgeable practitioners’’ and their need to be recognised as ‘‘good nurses’’. These preliminary data gave rise to additional questions: How do nurses understand knowledgeable practice? How do these understandings relate to their self-identity as ‘‘good critical care nurses’’? This paper addresses these questions.

2. Methodology The theoretical framework underpinning this study was poststructural theory, drawn from the work of Foucault (1970, 1980, 1982) and Derrida (1976). Central to this theory is an understanding of power as being exercised, not possessed, and as inextricably linked with knowledge. Relations of power-knowledge are seen as implicit in constituting perceived reality. Specific ways of knowing, or discourses, structure everyday activities, or discursive practices, and subject positions, such as ‘‘good critical care nurse’’. ‘‘Subject position’’ differs from ‘‘role’’, in that it is not seen as external to the ‘‘real’’ self, but as constituting a person’s sense of identity (Davies and Harre´, 1990). The ability to maintain a particular subject position depends in part on the acceptance and support of others (Davies, 1994). Power-knowledge relations are also seen to operate through language, particularly in the use of specific literary techniques. One such technique, referred to in this paper, is that of ‘‘dichotomy’’ (Derrida, 1976). Dichotomies consist of a pair of opposing words or terms, which are identified either as discrete categories or as the extremes of a continuum. The categories do not have equal status; the superior or dominant category is seen as the normal way of being, is largely invisible and, hence, is rarely examined, while the subservient category is, in contrast, highly visible and is frequently spoken about and investigated.

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The study was approved by the University’s Ethics in Human Research Committee; formal approval by participants’ workplaces was not required. Participants were fully informed of all study procedures and gave written consent for their involvement. Access to raw data was limited to individual participants, transcribers, my academic supervisors and me. All data were, and are, stored in a locked cabinet and on a password-protected computer. To maintain anonymity I use pseudonyms in place of participants’ given names and refer to their workplaces as Units A and B. The study participants were 12 critical care nurses, recruited from two tertiary intensive care units (ICUs) in Melbourne, Australia, using networking and snowballing techniques (Minichiello et al., 1995). In both units, I sought access to potential participants mainly through informal processes. Three participants volunteered after I had told them about the study during a staff meeting. The remainder I invited to participate on an individual basis on the recommendation of colleagues or other participants; four were known to me prior to the study. My aim was to include male and female nurses who were engaged chiefly in clinical practice rather than administrative duties, and with a wide range of age and experience. I placed no other restrictions on participation. Eight participants were female and four male. All were either studying for, or had obtained, a specialist qualification in critical care nursing. Their experience in the speciality ranged from 18 months to 12 years, and tenure in the ICU where they were employed ranged from 2 weeks to 11 years. Their pseudonyms, some of which appear in this paper, were Debbie, Jane, David, Joanne, Anna and Linda (from Unit A) and Sue, Liz, Alice, Peter, James and Joseph (from Unit B). As a critical care nurse, I positioned myself as a research participant. At the time of the research I was working as a clinician in a paediatric ICU whilst undertaking doctoral studies; I had never been employed in either of the study ICUs. The data were generated through three in-depth, focused interviews with each individual participant, using a recursive style of questioning (Minichiello et al., 1995). The interviews, all conducted by me, took place over a timespan of 18 months. I negotiated the date, timing and venue of the interviews with each participant. The main focus of the interviews was on changes that the participants had experienced in their work; some of these findings have been published elsewhere (Copnell, 2006). The data on which this paper is based were rarely initiated by specific questions but were enmeshed in participants’ descriptions of their work and of changes to it. I elicited details and clarifications by more focused questions. The interviews were recorded on audiotape, and the tapes transcribed verbatim either by me or a professional transcriber. In

the latter case, I checked all transcripts for accuracy against the original tapes. The participants each received copies of their own transcripts, to verify their accuracy and make any amendments or deletions they wished. No-one made any changes. My approach to analysis of the interview texts was informed by the poststructural technique of deconstruction (Cheek, 2000; Davies, 1994; Opie, 1992). In analysing the data presented here, I sought to identify participants’ understanding of their self-identity as critical care nurses (their subjectivity), the discourses and discursive practices that constituted this subject position, and the implications of these understandings. A poststructural methodology acknowledges the contribution of the researcher in constructing the analysis, which is seen as one of several possible readings. Hence, I engaged in self-reflexivity and a deconstructive analysis of my contribution; these practices were central to my approach to validity (Lather, 1991, 1993). That analysis, along with a detailed description of the research process, has been reported elsewhere (Copnell, 2005).

3. Findings Analysis indicated that the discursive constitution of being a critical care nurse was underpinned by a dichotomy of ‘‘good nurse’’/‘‘bad nurse’’. Participants described striving to position themselves, and be positioned by other staff, as a ‘‘good critical care nurse’’. They spoke of an imperative to be so positioned and, hence, to take up the constitutive discourses, one of which was ‘‘knowledgeable practice’’. The need for critical care nurses to be ‘‘knowledgeable’’ was a theme that recurred throughout the data. The discourse of knowledgeable practice was underpinned by the ‘‘pecking order’’, an unofficial hierarchy in which nurses were ranked according to their perceived knowledge. The pecking order was, in turn, constructed by dichotomies of ignorant/knowledgeable, inexperienced/experienced, and uneducated/educated. Participants referred frequently to the different attributes and practices that they believed could be observed in nurses at either end of the ignorant/knowledgeable continuum. Being ‘‘knowledgeable’’ was equated with being ‘‘safe’’, the need for safe practice being an overarching requirement of the ‘‘good nurse’’. Nurses who were not seen as knowledgeable were deemed incapable of practising safely without additional precautionary measures such as rules, policies and guidelines. Knowledgeable practice was seen to be constituted by a number of discursive practices. Chief among these practices were ‘‘being rational’’—knowing the reasons for nursing actions, and ‘‘being competent’’—knowing how to perform activities. To engage in these practices, participants indicated that they needed to access

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knowledge, but were sometimes prevented from doing so by a practice of ‘‘being excluded’’. The practice of ‘‘being recognised’’ by other staff as knowledgeable was also implicated, as nurses’ location in the pecking order was largely determined by the views of others. Participants also indicated that they were made vulnerable by the practice of ‘‘being undermined’’. I explore each of these discursive practices in the following sections. Where applicable, I include quotations from the interviews to illustrate points and support the analysis; in all cases the participant who speaks is identified by their pseudonym, as listed above. I use my own name (Bev) when quoting myself. 3.1. Being rational: knowing why Participants described the ‘‘good’’ critical care nurse as one who understands the rationale behind her/his actions. They referred frequently to the need to ‘‘think’’ about their work. Thinking and understanding were contrasted with ‘‘doing as you’re told’’—blindly obeying orders. One participant, Sue, suggested that the imperative to ‘‘think’’ was a fairly recent addition to the repertoire of desirable practices, contrasting current practices with those predominating in an earlier era: I mean you basically followed the medical officer’s directions, you didn’t think for yourself about what was appropriate or, you know, even be really, I don’t know, aware of a lot of the research and things that have been going on, I mean certainly nurses weren’t as well-read as they are now. ‘‘Thinking’’, the participants suggested, was associated with ‘‘being given’’ autonomy in their work. It also informed the need to take responsibility for their actions; as Jane said: ‘‘There’s a lot of responsibility that goes with the job, so you tend to think more about it.’’ Taking responsibility included interpreting information about patients and acting on it, rather than merely collecting and recording such information. ‘‘Thinking’’ was described at times as informing care that was patient-centred—that met the individual needs of specific patients rather than working ‘‘by rote’’. Knowing ‘‘why’’ required that nurses be able to justify their actions. Such justification was crucial in informing nurses’ relationships with other staff, particularly doctors. This theme recurred constantly, especially in relation to doctors ‘‘trusting’’ nurses. James explained: My personal relations with ICU consultants are on the whole extremely good, because I can back up my arguments, they know that if I bring up something there’s generally a good reason for doing so and that y I know what I’m talking about. I can be trusted. y They’ll generally listen, as long as you can validate, provide evidence for your actions.

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The requirement to justify their actions was seen by participants to lead to questioning of existing practices. As Joseph said: ‘‘It just makes you think about your practice. And there are some reasons why you do things, but for other things y the reason has been lost in the past and there’s no good reason why you do it.’’ This questioning was seen as an attribute of being educated or experienced; as David said, it was necessary to ‘‘[look] at the reasons why we’re doing things, because we now have this higher level of knowledge.’’ ‘‘Being rational’’ was described as an intellectual practice—as the process of knowing ‘‘why’’. Participants indicated that to be considered ‘‘good nurses’’ they must also be able to put their knowledge into practice; that is, they must know ‘‘how’’ to perform nursing work. They termed this ability ‘‘being competent’’. I explore this aspect of knowledgeable practice in the following section. 3.2. Being competent: knowing how The importance of translating knowledge into performance is attested to in nursing literature, with nursing often described as a ‘‘practice discipline’’ (Hayes, 1995). It is embedded in the notion of ‘‘competencies’’, in which knowledge is seen to be demonstrable by nurses, and observable and assessable by others (Redfern et al., 2002). Hence, nurses’ knowledge is understood to reside in their hands, as well as their brains; indeed, Walker (1993) notes that the most common phrase used to describe clinical nursing is ‘‘hands on’’. This understanding was apparent in participants’ narratives: they spoke of their knowledge level as being judged by their physical performance. Participants talked frequently of the need for a fluency of action. One aspect of this need was the routinisation of familiar practices, or the ability to perform some activities without conscious thought. In adopting this understanding of routinisation, participants were working with a discourse of expertise. Changes in work practices could disturb this routine and, hence, threaten participants’ sense of being competent. This threat was expressed chiefly by participants who were newly employed in either unit; feeling ‘‘incompetent’’ was a common theme among these nurses. Alice said she felt ‘‘like a total loser y [a] total lack of confidence in my abilities to, to do things that I really know how to do.’’ For nurses who had worked in a unit for a long period of time, threats to feeling competent could arise from small changes, such as the relocation of equipment. I suggest that resistance to such changes—often seen as ‘‘irrational’’—may stem from a desire to maintain a sense of oneself as competent. Peter agreed with this suggestion: Peter: y you like to feel that there are some things you can rely on, you know? Not, not having to be

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checking something out because you can take for granted that that’s the way it will be. In some situations you like to rely on that, and so there’s a certain coping strategy in resisting change in a few little things. y Bev: Do you think particularly when it’s something that is so familiar to you that you don’t have to think about it? Peter: Yes, absolutely. Bev: I’ve noticed y I’ve been working y one day a week, and it seems every time I go to work some little thing has changed, but we’ve also had major restructuring and so I can’t find anything, and I have found that so stressful because I have to think about every little thing I do. Peter: Exactly, yeah, for sure. Fluency of action and, hence, feeling competent, were maintained by the regular repetition of activities. Participants suggested that if nurses were unable to perform an action fluently, they were assumed, by themselves and others, to have ‘‘lost’’ the knowledge associated with it. As Liz said: ‘‘If you don’t see something in the Unit very often, then you can’t be expected to have that understanding of it all the time.’’ Part-time staff were said to have difficulty maintaining this competence because they had less opportunity to perform activities. Consequently, it was difficult for them to be seen to demonstrate their knowledge and be judged as competent: Sue described wanting junior staff to be able to ‘‘feel that they can access you as a resource, rather than wiping you off as this, you know, fly-bynight part-timer.’’ Demonstrating their knowledge through practice was, as I have indicated, extremely important to the participants. For them to be judged as competent and, hence, as a good critical care nurse, required that they perform activities based on a high level of knowledge, and that they be seen by others to perform them. Critical care nurses are often criticised for preferring to care for extremely sick patients receiving complex technological support (Sandelowski, 1997; Schultz, 1980). My analysis suggests this preference is underpinned by a desire to see themselves, and be seen by others, as knowledgeable, irrespective of any liking for or interest in technology. Participants did not view knowledge, either of ‘‘why’’ or ‘‘how’’ to practise, as a static entity. Rather, knowledge was seen to change frequently; participants described a constant need to acquire new knowledge, and indicated that the ‘‘good critical care nurse’’ was a perpetual learner. Ensuring their knowledge was ‘‘up-todate’’ could, however, be problematic: participants described themselves as sometimes being excluded from knowledge. I explore the practice of ‘‘being excluded’’ in the following section.

3.3. Being excluded: ‘‘we can’t find out what we need to know’’ Difficulties in acquiring knowledge were discussed mainly in relation to scientific or technical knowledge. Activities based on this type of knowledge were likely to be judged as important by doctors and nurses. Such knowledge included information that participants believed they required to care for a specific patient, and information relating to technology. Several participants described new technology being introduced to the unit with little or no explanation given to the nurses, who were expected to use it. Others spoke of encountering unfamiliar technology when changing their place of employment, and being unable to access information about it. In all these situations, the information was already held by doctors, who were seen to engage in practices that denied nurses access to it. Nurses’ reactions to such practices varied. Several participants suggested that, if they acted collectively and with the support of senior unit nursing staff, nurses could adopt practices that would enable them to resist being excluded. This resistance was exercised mainly when new technology was introduced with, nurses believed, insufficient education. In this situation, nurses refused to use the new equipment. As David explained: [The new equipment] was set up on a patient y and y the person that was previous to you handed over what they knew about the technology. The simple fact was though, is that wasn’t much or wasn’t enough, and we felt, many people felt that that was, like ‘‘Well how do I know if this is going wrong or if it’s going right’’ y So there was certainly people just saying ‘‘Well I don’t have a problem with the technology y but the education et cetera isn’t adequate. I’m going to shut it down and do it manually’’ y So, it was discussed with the medical staff when they were available again, during the week, that if this technology’s going to continue y then it’s necessary to keep our education up, and that’s pretty much what happened. In this instance, a discourse of safety reinforced the nurses’ resistance to the doctors’ practices: they saw their lack of knowledge as preventing them from practising safely. In other situations, participants engaged in practices that enabled them to ‘‘cope’’ with their lack of knowledge. Joanne described such a practice resulting from her unfamiliarity with pulmonary artery catheters (used to monitor patients’ haemodynamic status). Joanne expected that, as a ‘‘good critical care nurse’’, she would understand the clinical significance of the readings and calculations obtained from the catheter and act upon them accordingly. However, she felt she had been unable

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to acquire sufficient knowledge to enable her to do so. Instead, she merely reported deviations to the doctor, a practice she believed the majority of nurses in Unit A also employed. Joanne explained: Initially I [found the lack of understanding frustrating]. Now it’s like, you know. Now I do the old trick like everyone else does, now I’ve been there a while. I say, ‘‘Excuse me Dr. So-and-so, can I have the aims for the shift please?’’ y And they write down, the aims: CVP [central venous pressure] 8–10, cardiac output blah to blah y And you just aim for the middle of it. y But I really don’t think half the staff on the unit would know the full meaning behind it all. But they’ve got to the point where, they ask for their aims, they go on that. Hence, feeling that they were excluded from acquiring knowledge resulted in nurses engaging in practices that were in conflict with their understanding of being rational and, hence, of being a ‘‘good nurse’’. Other participants described being excluded from information about particular patients and, consequently, from participating in decision-making. Doctors were seen as actively discouraging nurses from seeking this information, as Jane described: If you ask questions often they’re written off as rubbish. ‘‘I’m not sure about that. Can you just clarify that?’’ They go ‘‘Yeah, yeah, yeah, yeah’’, you know, just write an order down, or, you know. Even if you ask for aims to be written down on the chart, that’s a bit of a chore and I’m, and ‘‘You’re a bother to me’’ y And you’ll be ignored. Doctors will physically stand in front of you in a discussion, so that you can’t even be part of that y You have to put yourself in a position where you’re perceived as a contributor to a discussion, or to the management of a patient. But most of the time you’re fighting for a place, just to be equal in management of a patient. Be acknowledged. Participants spoke repeatedly of knowing as much as, or more than, doctors, particularly junior doctors; however, practices such as those Jane described challenged this perception. As Jane said: Medical staff always seem to have a better answer than us, or a, or a more knowledgeable answer about the science things, that we always think that oh, we don’t quite ever know enough, that we’re always pushed into submission, I think we’re often made to know ‘‘You are less knowledgeable than me. Because I’m a doctor.’’ In summary, participants saw doctors as engaging in practices that enabled them to control nurses’ access to knowledge, particularly knowledge deemed to be

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‘‘scientific’’. At times nurses were able to resist these practices and gain access to the information. In other situations, nurses continued to be excluded. Consequently, participants believed that doctors were able to maintain the perception of a knowledge differential between themselves and nurses. As expressed in nursing literature, the nurses were left feeling the need constantly to ‘‘know more’’. While participants frequently spoke of possessing ‘‘actual’’ knowledge, their sense of themselves as knowledgeable was, I have suggested, largely informed by the views of others. Hence, being recognised as knowledgeable was crucial to their ability to position themselves as ‘‘good critical care nurses’’. I explore the discursive practice of ‘‘being recognised’’ in the following section.

3.4. Being recognised: ‘‘acknowledged as knowing what you know’’ Participants referred repeatedly to the importance of having their knowledge recognised by other nurses, doctors and allied health staff. Such recognition, or its lack, structured their relationships with other staff and, to a large extent, shaped their work practices. As Debbie said: ‘‘I think [in Unit A] we’re particularly fortunate in that the nursing staff are quite—they’re acknowledged as knowing what they know, and we certainly do have quite a lot of autonomy.’’ Recognition of their knowledge enabled nurses to undertake a number of activities, such as caring for the sickest patients, performing certain technical tasks and educating other nurses. The performance of such activities was frequently controlled by other staff; patients were allocated to specific nurses by the nurse in charge, while some activities were delegated by medical staff. Participants frequently spoke of being ‘‘allowed’’ to perform activities, and indicated that this permission was related to their location in the pecking order. For example, Linda suggested that she would not be allocated to care for patients undergoing particular treatments until she had worked in the unit for some time; that is, until she had ‘‘moved up’’ the pecking order. David described the importance of being allowed to perform certain technical tasks as a result of completing a critical care program: It makes someone feel, that has put in the extra hours of study, the extra money, the extra time and expense, it makes them feel well, you know, there is a—I’m being rewarded. y [Some nurses in other hospitals are] not allowed to do some very basic functions, that they’re taught in their training to do. y I see that as very demoralising y you don’t feel that your knowledge was worth getting.

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For David, being ‘‘allowed’’ to perform these tasks was important because it represented an affirmation of knowledge and, hence, contributed to his sense of being a ‘‘good nurse’’. Engaging in the formal or informal education of other nurses was also seen as affirming a clinician’s knowledgeable status. Informal education—passing on knowledge within the clinical area during the course of everyday work—was seen to require recognition because it was incomplete if other staff did not take up the knowledge. If other nurses did not perceive the informant as knowledgeable then, as Sue said, they ‘‘aren’t interested in hearing anything from you.’’ Providing formal education was an activity that was outside the control of clinicians, usually being delegated to them by senior nurses. Joanne expressed considerable distress when the Nurse Unit Manager curtailed her educational activities, at least in part because it suggested her knowledge was inadequate. Being recognised as knowledgeable gave nurses space to speak about their work and enabled them to have some input into medical treatment and decision-making. Participants spoke frequently of themselves as advising or telling doctors what fluids or drugs to order. However, such overt input was not invariably accepted by medical staff; participants described several instances in which both medical and nursing staff engaged in the ‘‘doctor–nurse game’’ (Stein, 1967). Attitudes of medical staff in game-playing varied considerably. Some accounts featured good-natured game-playing in which nurses were ‘‘allowed’’ to speak to a greater or lesser degree, according to the level of their perceived knowledge. In contrast, Joanne described game-playing by doctors that appeared less good-humoured. Joanne positioned herself as an expert paediatric nurse, but found when she began working in Unit A that the paediatric intensivists, Colin and Alan (pseudonyms), used game-playing to forbid her to speak, and to negate her knowledgeable status. Joanne explained: Because there weren’t any [nursing] staff that knew what they were doing [in the unit], the consultants have really had a very easy life. They told the staff ‘‘Right, you do this, this, this and this’’ and because the staff haven’t known any better they’ve done this, this and this. They’re finding it very hard now that I’m there. I get on—Colin’s all right now. I get on all right with Colin. But, um, Alan’s still a little bit reluctant, er, ‘‘Do you think we’ll probably do this, this and this?’’ ‘‘No, no, no.’’ And you go off and do something else, and you come back and you find that the Panadol that you asked for’s been written up, and something else’s been written up. Same with the ventilators, you set the ventilator, the patient arrives, and Colin actually did this the other day, he walks over to the ventilator, and he starts fiddling. And

putting them [the settings] back to where I’d set them, but had to make it look like he was doing something there. And I can’t—they’re not open to suggestions at the present time. In her next interview, several months later, Joanne reported that the consultants, having ‘‘got to know’’ her, no longer played these games and listened to her suggestions. Her ‘‘space to speak’’ had increased as she moved up the pecking order. As I have indicated a number of times, nurses who were new to either unit were located at the bottom of the pecking order until they could demonstrate their knowledge. Indeed, there were many suggestions that nurses’ knowledge could never be assumed, regardless of their qualifications and experience. Alice, for instance, who had several years’ experience in other ICUs, said that she was treated ‘‘like an idiot’’ on starting work in Unit B, and described being shown how to make a bed by a junior nurse. Peter said that on changing hospitals ‘‘you’ve got to always re-establish yourself.’’ This attitude was also attributed to medical staff: participants suggested that doctors trusted and respected them, not because of their qualifications, but because ‘‘they get to know us’’. Sue defended this attitude, suggesting that it was ‘‘safer’’ to treat everyone as knowing nothing until they had ‘‘proved’’ themselves: I guess in some ways that’s come about because, there’s certainly been a number of people that you come across that may have certificates or qualifications up to gazoo, who aren’t good practitioners. Who, who are almost dangerous in the way that— I’ve come across some extremely dangerous people who have years and years of ICU experience, have a certificate and should know, should know better y you tend to treat most people with a deal of scepticism. In summary, being recognised was an important component of the discourse of knowledgeable practice. Recognition related to a nurse’s position in the pecking order. While participants gave many examples of the lack of recognition of their claims to be knowledgeable and, hence, their status as ‘‘good nurse’’ questioned, their responses to these situations varied. I explore these responses in the following section, in which I discuss the discursive practice of being undermined. 3.5. Being undermined: ‘‘do I know what I’m doing?’’ As I described in the previous section, participants indicated that other staff—medical and nursing—often positioned them as ignorant. While several participants said that being so positioned rarely affected their own perception of their knowledge, others indicated that, at times, they adopted this position, for example, Alice’s

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sense of ‘‘feeling like a loser’’. Often, however, this acceptance was less explicit. The following passage is an example. Alice described being seen as unable to speak ‘‘rationally’’ as a newcomer to the unit: The consultant said to me this morning, ‘‘I think I’m going to talk to the [patient’s] family about withdrawing treatment’’ and I said ‘‘I totally support that,’’ I said ‘‘I’ve felt the whole way along, this man isn’t going to get out of hospital.’’ He said ‘‘Well, I totally respect your intuition, but we’re talking about the numbers here.’’ You know, it was like—[laughs] I wasn’t talking about intuition, I was talking about what I know. I guess it was intuition, but I knew. I can look at the numbers as well, I can see just as well as he can. Alice was unable to attribute her knowledge of the patient’s condition solely to intellectual reasoning, in spite of her attempts to do so, adding ‘‘I guess it was intuition.’’ Neither she nor the consultant had any doubts that the doctors’ opinion was based on ‘‘reason’’. To an extent, Alice accepted the doctor’s assessment of her opinion as ‘‘irrational’’ and, hence, herself as lacking scientific—acceptable—knowledge. Not only low-ranking participants positioned themselves as ignorant. Joanne and Jane, the most senior of the participants in Unit A and both employed as Clinical Nurse Specialists, displayed a reluctance to describe themselves as ‘‘knowledgeable’’ or ‘‘competent’’, correcting themselves when they began to do so by adding that they were ‘‘supposed to be’’ knowledgeable. Joanne explained that, when her knowledge was challenged by other staff ‘‘it makes you start to feel like ‘Well, did I say the right thing? Is that right?’’’ Jane said ‘‘I have a certain knowledge level. But I think there’s always room to improve, there’s always—somewhere to aim, to make yourself better, there’s always greater knowledge to gain, there’s always something new to learn.’’ As perpetual learners, participants constituted the state of being ‘‘knowledgeable’’ as one they had yet to achieve. The most informative example of being undermined was given by Sue. She had worked as a Clinical Nurse Specialist in Unit B for 7 years, and had recently taken a clinical position in an ICU in another hospital, continuing to work one night shift a week in Unit B. Hence, as she had not reduced her total working hours, her fluency of practice was unaffected. However, she believed that other staff in Unit B questioned her competence because she was a part-time worker and because many of the nurses and doctors did not know her. She indicated their attitudes made her vulnerable to being undermined. Sue: I guess it’s almost like going to a new unit because you—from those sort of staff you’re almost treated like, yeah, you don’t know what you’re doing.

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Bev: Does that affect the way you—your perception of yourself as a nurse I guess? Sue: Yes! [laughs] I mean I’m not a Rock of Gibraltar, I guess that no-one likes to be treated like an idiot or somebody that doesn’t know what they’re doing. y And you sort of do begin to doubt your own abilities. y I have done some soul searching since I’ve been part-time y And if you get through the whole 10-hour shift and you liaise with the medical staff and do all those sorts of things that you would do normally without any problems, is that that’s — basically it gives you reassurance at the end of that. y Sometimes I’ll bounce things off other people, and say ‘‘Look’’—you know, someone I’ve known for years, ‘‘Look, I am doing the right thing aren’t I’’, you know, or ‘‘I haven’t missed anything have I,’’ that sort of reassurance I guess, gaining, that you sort of just need that positive reinforcement that you are doing the right thing. But yeah, I mean it does shake you a bit, especially when—you know, like even at handover, in the tea-room and you’re sort of left till last [to be allocated a patient], and you think ‘‘Oh, OK.’’ Yes, so, it’s a bit tricky. Bev: When you get that positive feedback, do you instantly—yeah, switch back into that ‘‘Yes, I am a competent nurse, yes I do know what I’m doing’’? Sue: No y No, I guess that it depends on what the— you know, it depends on what’s happened too, often if you get that sort of reaction at the start of the [shift], I mean that feeling might last with me the whole night. It depends too, I mean if you have a fairly quiet patient, that—I mean see this is the other thing too, if you’re sitting in the tea-room and you’re the last one to get allocated. And you get the extubated patient with no infusions, and you sort of think, well they’ve got no confidence in you. And you think ‘‘Gee, maybe I’m losing it. Maybe I’m not all that good.’’ I mean that might last the whole night because you’ve got nothing to challenge you. Do you know what I mean, you’ve got nothing to make you think ‘‘Well hang on a minute, yeah, of course you know what you’re doing’’. I mean if you’re looking after what’s almost like a ward patient, you think ‘‘Well gee whiz I’m really slipping, I’ve lost all those more highly tuned skills and thinking’’. You know? And yeah, it might last not only the shift, it might last until you get a day where, you know, things happen, everything comes together and, you know, it’s fine. Yeah. It can last a while I guess. Sue’s story contains several points that I have made throughout this paper about the constitutive elements of being a ‘‘good critical care nurse’’. First, knowledge had to be demonstrated by performing activities requiring a high level of skill, both to ensure the nurse retained the skill and to display competent behaviour to other staff.

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Second, nurses’ knowledge had to be recognised by other staff; this recognition—or its lack—was apparent to Sue in the way other clinicians treated her and in the complexity of patient care that she was ‘‘allowed’’ to undertake. Third, if such recognition was not forthcoming, Sue not only assumed that other nurses thought her knowledge and skill inadequate, she began to believe in her own inadequacy. I suggest that within the ignorant/knowledgeable dichotomy, ‘‘ignorant’’ is the dominant category—it is viewed as the ‘‘normal’’ state for nurses. Being ‘‘knowledgeable’’ is ‘‘other’’: it is seen as unusual, is highly visible and is, therefore, an object of inquiry—as witnessed by its repeated presence in nursing literature. Furthermore, it is a category in which nurses constantly struggle to locate themselves, and be located by others. It was notable, however, that only female participants displayed difficulty in positioning themselves as knowledgeable. Although the men acknowledged the importance of having their knowledge recognised, and described instances when it was not, they did not seem to take up others’ positioning of them to the same extent as did the women. Walkerdine and Lucey (1989) argue that in dominant contemporary discourses of gender, masculinity is seen as being ‘‘naturally’’ associated with being knowledgeable, but that this position can be maintained only by constantly asserting and ‘‘proving’’ women’s lack of knowledge. Indeed, Alice suggested that gender was implicated in the positioning of nurses as knowledgeable or ignorant, saying: ‘‘I think doctors quite often accept [male nurses] more. Patients accept them more. ‘You must know a lot more, you’re a man’!’’

4. Discussion This paper analyses a discourse of ‘‘knowledgeable practice’’, seen as one of the constitutive forces in constructing the subject position ‘‘good critical care nurse’’. It supports the centrality of knowledgeable practice to critical care nurses’ sense of identity that informs much of extant nursing literature. Within this literature, knowledge is described as the driving force in the development of the speciality (Fairman, 1992), as a major component of critical care nurses’ work (Benner et al., 1996; Chaboyer and Creamer, 1999; Happell, 1999), and as instrumental in constituting relationships with other workers, particularly medical staff (Lynaugh and Fairman, 1992; Stein et al., 1990). This literature postulates actual knowledge as the critical element, and the need to acquire more knowledge is reiterated constantly. Participants’ narratives were similarly informed: they spoke of never quite knowing enough and related this perception to an ‘‘actual’’ lack. They believed this perception was shared by other workers: participants reported doctors engaging in practices to

exclude nurses from acquiring knowledge, particularly of a scientific or technical nature. Such practices have been described in other nursing contexts (Street, 1992). Other researchers have implicated the ‘‘quality’’, rather than the ‘‘quantity’’, of knowledge, suggesting that nurses hold and use specific types of knowledge that are deemed inferior to those of medical staff (Ceci and McIntyre, 2001; Coombs and Ersser, 2004; Manias and Street, 2001). This study found, however, that nurses’ ‘‘actual’’ knowledge, of whatever type, was of less importance in shaping their identity than was being positioned, by themselves and others, as knowledgeable. This positioning was difficult to maintain, and was frequently undermined. This undermining was performed, not only by medical staff, but also by other nurses. Indeed, the discourse of knowledgeable practice was underpinned by a dichotomy of ignorant/knowledgeable, in which ‘‘ignorant’’ was revealed as the dominant category. Thus, nurses were assumed to be ignorant until they could ‘‘prove’’ otherwise. These findings contest the notions that a lack of knowledge is the root cause of an array of problems experienced by nurses, and that knowledge acquisition will solve those problems (Bucknall and Thomas, 1997; Davidhizar, 1993; Glynn and Ahern, 2000). Male and female participants reacted differently to practices that undermined their positioning as knowledgeable practitioners. This finding, together with other indications in the data, not presented here, suggests that the position of ‘‘good critical care nurse’’ was understood to be gendered, with different practices being required of male and female nurses in order for them to be so positioned. Further investigation of this issue was beyond the scope of this study. Previous studies of men in nursing have focused mainly on their experiences as members of a minority group (Anthony, 2004; Whittock and Leonard, 2003), or examined their impact on ‘‘traditional’’ doctor–nurse relations (Porter, 1992). I suggest further research is needed to investigate the ways in which men and women might constitute themselves differently as nurses. The study participants understood their knowledge as residing in both their heads and their hands. While such a notion is implied in the concept of a practice discipline, its implications have mainly been considered in relation to identifying the knowledge nurses need to perform their work (Hardcastle, 2004; Pelletier et al., 2000). For nurses in this study, physical performance was crucial to their being positioned as knowledgeable, and hence, as ‘‘good nurses’’. They identified several instances in which their knowledgeable status was challenged either by being prevented from performing certain activities or by losing their accustomed fluency of action. These findings suggest that practice changes that have a similar effect in threatening nurses’ sense of self are likely to be

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strongly resisted. One such change, currently being implemented in some Australian ICUs, is the introduction of level 2 nurses, resulting in the adoption of alternative models of practice (Walker, 2002). This study was undertaken in two ICUs in one country, and its findings cannot be assumed to extend beyond this context. I encourage nurses in other units, in other countries, to reflect upon their own practice, and determine for themselves the applicability of these data.

5. Conclusion This study found that knowledgeable practice was a core component of nurses’ sense of being a ‘‘good nurse’’. Practising knowledgeably entailed both being rational, or knowing ‘‘why’’, and being competent, or knowing ‘‘how’’. However, nurses’ claims to practise knowledgeably were frequently challenged by practices of exclusion, recognition (or lack thereof) and undermining. Nurses’ authority to speak about their work was seen to depend, to a great extent, on their ability to position themselves as knowledgeable; the challenging and undermining of this positioning, by nursing and medical staff, effectively silenced many nurses. Nurses frequently seek ‘‘empowerment’’ and an increase in ‘‘autonomy’’ through acquisition of knowledge. This study contests this possibility. Rather, nurses are encouraged, both individually and collectively, to find ways to resist being positioned as ‘‘ignorant’’.

Acknowledgements I thank my academic supervisor, Dr. Nina Bruni, for her support and encouragement throughout my candidature, and the 12 anonymous nurses who participated in the study. This study was supported by an RMIT Postgraduate Award, and research grants from the Royal Children’s Hospital Nursing Research Management Group, the Nurses’ Memorial Centre, the Australian Institute of Nursing Research and the Florence Nightingale Committee of Victoria.

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