Nursing as a Therapeutic Activity

An Ethnography

Steven J Ersser

• Publisher: Taylor & Francis
• Year: 2019
• eBook ISBN: 9780429815812
• Edition: 1
• Topic: Social Sciences
• Subtopic: Social Work
• Index: Social Sciences

First published in 1997, this volume responds to the rapidly developing fields of nursing and health care fields and explores the meaning of nursing and the nurse-patient relationship through looking at the effects of a nurse's personality, approach and understanding as being therapeutic for the patient's experience. Steven J. Ersser explores areas including the concept of nursing as therapy, the presence of nurses and the effect of nursing on patient outcome. His book is part of a new series of monographs offering up-to-date reports of recently completed research projects in the fields of nursing and health care. The aim of the series is to report studies that have relevance to contemporary nursing and health care practice. It will include reports of research into aspects of clinical nursing care, management and education. This book, along with the series, will be of interest to all nurses and health care workers, researchers, managers and educators in the field.

1 Introduction to study

An important area of nursing scholarship is that directed towards enhancing our understanding of the effect of nursing on patient welfare. The significance of this issue needs to be understood in the context of the scale of the nursing service:

Nurses are responsible for the majority of professional care given in Britain. More than half of all NHS staff are nurses, with nearly a quarter of all health service expenditure directed at nursing (Beardshaw and Robinson, 1990, p. 5).

In this book an argument is advanced for the study of the therapeutic effect of nursing using an interpretive research approach. The views of patients and nurses on nursing as a beneficial and distinct form of social action deserve examination. Specifically, this study aims to examine whether nurses and patients hold views on the effects of nurses’ actions on patients and, if identified, to describe and compare their nature. The data will be used to develop a theoretical account of the nature and consequences of nursing action for patients. The focus of the study will be at the micro-level of nurse-patient interaction, rather than at the macro or wider community level. The scope of the study is confined to hospital-based nursing.

Structure of the book

This chapter introduces the focus of the study and signposts the structure of the book, charting the study from background influences through to an appraisal of the relevance and significance of the study to nursing. Specific attention is given to outlining the key experiences which developed my interest in the study area. Finally, the value of studying nurse and patient viewpoints is argued, culminating in a statement of the research questions.

Following the study introduction attention is given to the use of the terms therapeutic and therapy referred to within a nursing context in the literature in chapter 2, due to the need to create greater conceptual clarity in this area. This includes a mapping of the references made to the actions of nurses which are claimed to be therapeutic in effect, or having the quality of therapy for the patient. This analysis is used to provide a working framework for the empirical study of nursing as a therapeutic activity, based on views of how nurses have a beneficial or adverse consequences for patients.

Chapter 3 provides the methodological rationale for the study. The focus on nurses’ and patients’ viewpoints is delineated and the concept of nursing as a therapeutic activity is operationalised as a basis for empirical study. The substantive focus of the study is to develop an understanding of the relationship between the processes of nursing and related outcomes. A case is argued for the value of using a qualitative, interpretive approach to this important area, which has been neglected to date. The interpretive research paradigm is introduced briefly and following from this an outline is given of the sociological orientation of this nursing study, using the theoretical perspective of social action. The primary research approach, ethnography, is introduced. An argument for the adoption of an eclectic and reflexive approach to the study of hospital care, including due recognition of the fact that I, the researcher, am a part of the social world under study and as such need to monitor my own orientation to the research focus and my involvement in the field. In keeping with this approach, the first person is used at appropriate points throughout the book when addressing my own immediate engagement with issues. The support for the use of the first person in pursuit of reflexivity in academic writing is given by Webb (1992).

Chapter 3 sets the scene for the account of the method in chapters 4 and 4a. A reflexive account is given to the study, from an outline of design features to the pragmatic considerations of conducting a ethnographic fieldwork in the clinical setting. Details and a rationale are given for the selection of the ethnographic approach and specifically the sample of nurses and patients, the settings and the research methods. The latter are informed by the principles and procedures of grounded theory method, with the aim of generating concepts and propositions to inform understanding on whether and possibly how the informants construe nurses actions and their consequences for the patient. Details are given of how I negotiated access to the field, my field role and the ethics and rigour of the study.

Chapter 5 introduces the findings in the context of the study aims. The major conceptual elements of the data are mentioned and guidance is given on their location within a taxonomic analysis and how the data are presented.

The most salient core category, the ‘Presentation of the nurse’, is presented in chapters 5 and 6. The various characteristics or properties of this concept are illustrated using data excerpts, with some accompanying explanation. The ‘Presentation of the nurse’ has two major properties; the ‘Nurse as a person’ and the ‘Presence of the nurse’. In the latter part of each chapter these concepts are drawn on to re-examine the nursing, sociology and psychology literature. In particular, the data on ⁴ The nurse as a person’ is subject to a sociological analysis, discussed in the context of the interactionist literature. Data from nurse and patients are also compared.

Chapter 7 introduces the other two core categories, the ‘Specific actions of the nurse’ and⁴ Relating to patients’. An argument is made for giving relatively brief mention of these concepts and focusing instead on the nurse’s presentation, given its saliency and relative neglect in the literature. Again, the major properties of the concepts are highlighted with data illustrations and comparisons made across the informant data and with the literature.

Chapter 8 examines the effects or outcomes for the patient which are attributed to the nurse’s actions encompassed by the core concepts. Again, the main thematic areas are highlighted in accordance with the major categories of effect generated. Particular attention is given to the emphasis in the data on the ways nurses are seen to help the patient cope with their situation, especially through the nurses’ personal, expressive actions. Data illustrations are given or cross-referenced and comparisons are made across the nurse and patient data and with the literature.

At the end of chapter 8 a summary is provided of the comparisons between the nurse and patient data and thereby addresses the study aim to provide a comparative account of how the therapeutic effect of nursing is construed by nurses and patients.

Chapter 9 draws the book together through presenting the core story or emerging conceptual framework of the study. The focus is on presenting the various ways in which the informants construe the interrelationships between these core concepts and in turn their possible relationship to patient outcome. An analysis is given of each pair of core concepts and their saliency, with illustrations, where available. A summary of the key premises and propositions of the core story is provided. Since the study has been directed towards the aim of developing the elements of grounded theory an attempt is made to expose these elements to a rigorous theoretical appraisal, with due consideration to their relevance to nursing.

Chapter 10 returns to the issue of the need to develop a deeper understanding of the therapeutic effect of nursing and by looking back at what is known and looking forward in the light of the data. The significance and utility of the findings are examined from various perspectives; this includes the contribution to conceptual development and a reappraisal of key nursing issues, such as the therapeutic use of self and how nurses help patients to cope and nursing effectiveness. Emphasis is given to the study’s contribution to understanding the patient’s experiences of nursing and how patients evaluate nursing care, with due attention to how these findings compare with existing conceptual models derived from studies of patient satisfaction with medical care. This issue is extended into a review of the professional implications of the data, including an analysis of the contribution of ethnographic data to the study of nursing effectiveness. Critical reflections on the study are discussed in detail. The implications of the study for nursing and health service research and education are made.

Factors influencing the researcher’s substantive interests

This book has been structured to chart the evolution of my interest in and understanding of the study area. This provides a reflexive basis for pursuing an open-ended research approach which is concerned with learning from patients and nurses about their experiences of receiving and providing nursing care, respectively. This is consistent with Whyte’s (1981) statement:

… I am convinced that the actual evolution of research ideas does not take place in accord with the formal statements we read on research methods. The ideas grow up as part of our immersion in the data and out of the whole process of living (p. 280).

A concise description of the background influences which interested and informed me during the development of the study, their significance, interplay and how they culminated in the research questions now follows.

Working on a nursing unit and the study of nursing beds

In the autumn of 1985, prior to embarking upon the study, I began work as a staff nurse on a nursing unit called the Oxford Nursing Development Unit (ONDU), based at the Radcliffe Infirmary. This experimental unit was established in 1985 for the purpose of providing 16 nursing beds for people who had a significant need for nursing and rehabilitation 24 hours a day, but who only required a low level of medical care (Ersser, 1988). Nursing beds were a new service within the National Health Service. The experience of working on this unit and the study of its underlying theoretical stance at this time had a significant influence on the formulation of my research questions.

The ONDU project had its origins at the Burford Nursing Development Unit in Oxfordshire. Alan Pearson was the head of both the Oxford and Burford units and the initiator of the projects. Pearson’s early thinking on the development of nursing units was described in his book The Clinical Nursing Unit (Pearson, 1983). The concept of such units was said to be based on Tiffany’s (1977, unpublished study) premise that there is a need for units where nursing is the ‘chief therapy’ and the nurse the ‘chief therapist’.

Pearson was influenced by the work of Lydia Hall (1963,1969; Hall et al., 1975), who was the Director of a nursing unit in the United States called the Loeb Centre for Nursing and Rehabilitation at the Montefiore Hospital in New York. Loeb was a nurse-led unit which aimed to offer⁴… nursing as the chief therapy that the patient experiences’ (Hall, 1969, p. 81). Hall’s philosophy and programme of nursing was based on her views of the healing potential of nursing itself through a ‘process of nurturing’, which were examined through an experimental study (Hall et al., 1975, p. 2). It is interesting to compare the motivations of Hall and Pearson as described in their work in 1975 and 1983, respectively, in the development of nursing units. Both were driven by what they believed to be a gulf between contemporary thinking about the development of clinical nursing, as expressed in nursing curricula and the nursing literature, and prevailing nursing practice.

The beliefs and values of Hall became an integral and formalised part of the orientation programme for nurses working on the Oxford unit and served as a basis for developing nursing practice. The importance of a working philosophy of nursing as a practical prerequisite for developing practice was argued by Prophit (1986, unpublished seminar) in a seminar at ONDU, and more recently by Johns (1989). The beliefs of Hall became a part of the working ‘philosophy’ or perhaps, more precisely, an ideology, for many of those working on the ONDU.

The belief that nursing could directly contribute to patient welfare as a form of therapy, became a working assumption propagated by Pearson from the outset of the ONDU project and became a part of the unit’s culture. From what Pearson et al. (1987, p. 2) themselves held as an ideology of therapeutic nursing, a particular style of nursing emerged.

Pearson set out to study the therapeutic impact of nursing through the study of nursing beds. The evaluative study aimed to explore whether there were differences in patient outcome and cost as a result of patients being admitted to the nursing unit, through a series of research studies (Pearson, 1985, unpublished thesis; Pearson et al., unpublished report, 1987, 1988, 1992). These were based on Hall et al.’s (1975, unpublished report) earlier work. It was assumed that there was a qualitative difference in the nursing care provided for patients admitted to nursing beds compared with that received in a conventional medical bed facility. However, Pearson et al. (1992) do not give a clear explication of the experimental variable, other than the admission of patients to the nursing unit. Characteristics of the ideology of ‘new nursing’ (a phrase coined by Salvage, 1988, unpublished dissertation) are described in the literature review, including the reorganisation of work patterns, the development of a ‘close relationship’ with patients and basing practice on a conceptual model of nursing (Pearson et al., 1992, p. 16). However, it is not clear from the literature what the specific differences in nursing practices used within the nursing unit, which clearly differentiated it from the control wards. The researchers were able to conclude that nursing-led care may have had a positive effect on recovery, quality, satisfaction and mortality (Pearson et al., 1992, p. 99) The elusive nature of the therapeutic features of nursing action continued to stimulate my motivation to conduct this study.

Evidence of the researcher’s substantive interests in the pre-study period

Two points of recorded reference highlight my early beliefs about nursing, as they related to the substantive area at the time of working on the unit: a book chapter written between 1986-1987, on the theme ‘Nursing Beds and Nursing Therapy’ (Ersser, 1988) and my reflective clinical diaries.

Writing took place during the period in which the research questions and the design were still in an early stage of development. The chapter began to explore the idea of nursing as a potential form of therapy for patients and its relationship to the development of nursing beds. It also served as an argument supporting the need to verify the value of nursing beds for specific patients and helped to focus my interest in the chosen research area. However, a distinction needs to be drawn between my initial concern with the therapeutic value of nursing beds and the subsequent research interest of broader relevance with patients’ and nurses’ views on the therapeutic effect of nursing, in conventional hospital settings where medical beds are the norm. Evidence of a commonly held belief in nursing as a type of therapy by other nurses working on ONDU is seen in the writings of Muetzal (1988) and Tutton (1986).

Two reflective clinical diaries were completed between 1986–1987. I wanted to record something of my understanding of nursing as a health care practice of therapeutic potential, through drawing directly on my own clinical practice. I hoped that this would inform the development of research questions on what I recognised early on as a complex research area. The diaries also serve as an indicator of my concerns, prejudices or assumptions during the pre-fieldwork period. These are published in my doctoral thesis.

At one stage I explored the possibility of studying one type of nursing action which reflected nursing action of a potentially therapeutic nature in my view at the time. The study of the n...

Table of contents

• Cover
• Dedication
• Title Page
• Copyright Page
• Table of Contents
• Figures and tables
• Acknowledgements
• Foreword
• 1 Introduction to study
• 2 The concept of nursing as therapy
• 3 Selecting a methodology: rationale for the method
• 4 Method: ethnography in clinical situations and rigour of the study
• 4a Settings for the study
• 5 Introduction to core concepts and their interrelations
• 6 Presentation of the nurse: II – presence of the nurse
• 7 Core categories: relating to the patient and specific actions of the nurse
• 8 The effect of nursing on patient outcome: an interpretive perspective
• 9 The core story: the core concepts and their interrelationships
• 10 Conclusions and implications: developing an understanding of the therapeutic significance of nursing
• Bibliography
• Appendices