Research and Nursing Practice
|Opening thought ||Research without practice is like building castles in the air.|
Practice without research is building castles on slippery grounds.
This introductory chapter will examine the sources of knowledge for practice and the meaning of, and rationale for, nursing research. The role of nurses in research and the relationship between research and practice will also be explored.
Sources of knowledge for nursing practice
Much has been written about the variety of sources of knowledge from which practitioners draw. Of these, the main ones are tradition, intuition, experience and research.
The bulk of our knowledge has been accumulated over centuries and passed down to us through literature, art, music, oral history and other such media. Traditional nursing knowledge is learnt mainly from books and journals, by word of mouth and by observing the practice of others.
Much traditional practice takes the form of rituals. For example, a traditional fasting rule for patients admitted for elective surgery is nil by mouth from midnight for a morning theatre procedure, or a light breakfast for an afternoon one (Rycroft-Malone et al., 2012). Yet there is robust evidence to show that ‘it is safe for healthy adult patients undergoing elective surgery to have clear water and clear fluids up to two hours before the induction of anaesthesia and food up to six hours prior to induction’ (Rycroft-Malone et al., 2012). While fasting times are generally prescribed by doctors, there are many rituals in nursing practice, such as routine blood pressure monitoring, set feeding times or putting all patients to bed at the same time, regardless of whether they want to go to sleep or not.
Jefford et al. (2009) explain that routinely performing a vaginal examination during birth to check for the nuchal cord is a ritual that started in the late seventeenth century when all aspects of birth were ‘medicalised through fear’. According to them, ‘when the midwife avoids routine invasive checking for the cord and instead makes individual clinical decisions for each particular woman and baby, this may be a marker of her willingness to practice as an autonomous decision maker and not just a follower of ritual’.
Traditions are important not only in passing down knowledge, but also in giving groups in society a sense of identity, belonging and pride. Through socialisation, we learn the culture of those who have gone before us. Similarly, traditional nursing knowledge and practice are learnt by novice nurses through the process of socialisation in educational institutions and clinical areas. Much of this traditional knowledge and many ritual practices are the outcomes of sound reasoning. Today’s new knowledge and practices will likewise eventually become traditional. The term ‘traditional’ is sometimes used in a negative sense, meaning backward, outdated or unprogressive. Knowledge in itself is harmless; it is the use people make of it that can be harmful or beneficial. It should neither be rejected too quickly nor clung to rigidly, if we are to benefit from the experiences of our predecessors and continue to make progress.
Debating ‘the pros and cons’ of routines, Barton (2011) explains that a routine can ‘be desirable, bringing comfort, certainty and quality to life, or constraining, monotonous and ineffective’. Semple (2011), on the other hand, sees ‘rituals as characterised by mechanistic repetitious actions that lack thought and detract from individualised care’. However, he concedes that some routines may have a role in healthcare. No one denies that routines can provide some structure to one’s practice, without which there could be confusion and misunderstanding. Guidelines and checklists can, to some extent, if used insensitively, lead to routine practice.
Intuition by its very nature is not easy to define. It is a form of knowing and behaving that is not apparently based on rational reasoning. The use of intuition in nursing is only now beginning to attract nurse researchers’ interest, so not much is known about ‘how’ nurses come to know there is something ‘wrong’ or whether they have a ‘sixth’ sense that tells them what to do. According to Kenny (1994), nurses use empathetic intuition in their daily practice:
This type of intuitive thinking often occurs within the context of a nursing situation, and feeling, rather than conscious thinking, seems to predominate. Nurses know that there is something wrong but cannot explain what it is.
Intuition involves the use of all human senses such as touch, smell, hearing, sight and even taste, as well as previous experience (in the form of tacit knowledge) to assess, and react to, a situation. It happens in ways which seem to be beyond comprehension. McCutcheon and Pincombe (2001) studied nurses’ understanding
of intuition and their perceptions of their use of intuition, and assessed the impact of intuition on nursing practice. They found that intuition is the result of a complex interaction between a number of factors including knowledge, experience, expertise, personality and environment.
Greenhalgh (2011), who believes that intuition has a place in medical practice, explains that:
Intuition is not unscientific. It is a highly creative process, fundamental to hypothesis generation in science. The experienced practitioner should generate and follow clinical hunches as well as (not instead of) applying the deductive principles of evidence-based medicine.
Experience and reflective practice
Nurses and midwives base their practice on their own experience and on the experience of others. Experience is a useful way of learning. There is a wealth of untapped knowledge embedded in the practice and ‘know-how’ of expert nurse clinicians (Benner, 1984). It is also reckoned that what we learn by experience is more enduring than what we are taught. However, our experience in itself is rather narrow. For example, in treating depression, a nurse may use one or two approaches. While the experience obtained is invaluable, she will be unfamiliar with other treatments and may either be reluctant to try them or may reject them out of hand.
We also learn a lot from the people we care for, as they have a wealth of experience with the conditions we are trying to grapple with. Livesley (2004), in her paper on ‘How a personal account contributes to nurse knowledge’, argues that story-telling is an important tool for nurses seeking to explore and discover the meanings of their own personal and professional experience and the experiences of those with whom they work.
There is also a degree of trial and error when learning by experience. While this may be inevitable in a few cases, there is, by and large, a risk of reinventing the wheel and a greater risk of unsafe practice. Experience is therefore an important source of nursing knowledge, but relying solely on it and overstating its importance can be detrimental to nursing practice.
A number of studies have shown that experiential knowledge and information gained by consulting colleagues are the main sources that nurses draw upon when making clinical decisions (Gerrish and Clayton, 2004; Pravikoff et al., 2005; Thompson et al., 2005). In a recent study in Ireland, Yadav and Fealy (2012) found that ‘psychiatric nurses in Ireland get most of their knowledge from their everyday experiences of nursing patients and from fellow practitioners, but few seem to get knowledge to guide their practice from sources such as published professional and research journals’.
We all engage in reflection in our daily lives. This type of informal, ad hoc reflection can be deliberate or may happen spontaneously. Reflective practice, on the other hand, is a formal reflection on our actions. Although there is no consensus of what reflective practice is, it is a term that can simply mean ‘adopting a thinking
approach to practice’ (Finlay, 2008). The degree of formality and the models, theories or frameworks that practitioners can use to guide their reflection vary between individuals and professions. Critical reflection is generally believed to be ‘a process by which practitioners can better understand themselves in order to build on existing strengths and take appropriate future action’ (Somerville and Keeling, 2004).
Reflective practice requires practitioners to think though the process of decision-making that leads to particular actions. The two types of reflective practice that are generally referred to are ‘reflection-on-action’ and ‘reflection-in-action’ (Schön, 1987). The former is a retrospective ‘analysis’ of an action that has already taken place, while the latter involves reflecting while the action is taking place. Now and then, we must stop and consider what we do, why and how we do it and to what effect, otherwise we will turn what we do into thoughtless routines. For progress to take place, we must ask if we are doing the right things and if there are alternative ways to make things better. According to Rolfe (2001), in order to become ‘knowledge generators’, practitioners can use reflective practice ‘to uncover the rich store of experiential knowledge that lies buried within their own practice’.
Reflective practice has its own limitations. It assumes that the practitioner is capable of reflecting in a meaningful way on his or her decisions leading to a particular action, despite the acknowledgement that the rationale for action can be intuitive and difficult to verbalise. It is also believed that we can examine our prejudices, which may underpin our practice. Yet people are generally reluctant to admit their prejudices, many of which they may not be conscious of. The process of group reflection can be a daunting and threatening experience with ethical and political implications. The use of diaries and journals for reflective purposes has been criticised by Mackintosh (1998) as giving rise to issues of confidentiality. Problems and poor practice, when identified, have to be addressed; otherwise this can lead to frustration, low morale and ethical dilemmas.
Reflection as a concept to learn about our actions and about ourselves has much to commend it. Despite its problems and limitations, it should not be rejected, nor should it be the only strategy for developing practice. It must be recognised that all methods of generating knowledge have limitations, and that closing our minds to other methods can be unproductive and often dangerous.
Reflective practice has the potential to raise questions that can thereafter be explored by other means, including research. In Paget’s (2001) study of practitioners’ views of how reflective practice has influenced their clinical practice, some of the respondents reported that reflective practice encouraged the use of research findings in their practice. Elliott (2004) describes how the use of the ‘critical incident technique’ (which involves reflection on a particular incident to find out what worked or did not) led to a literature review and the identification of a researchable topic in intensive care.
Research, in contrast to tradition, intuition and reflective practice, is a systematic way of knowing and lays bare its methods for all to see. Researchers collect and
analyse data systematically and rigorously, and this process is described to others by means of oral and/or written presentations. Research findings by themselves are not solutions to problems. They provide new insight into phenomena or add to, confirm or reject what is already known. Decisions still have to be taken about whether the findings should be used (or not used), and how.
One may argue that, by using common sense, nurses can take the right decisions. However, they still need relevant and valid information in order to do so. What may seem simple and straightforward is not necessarily so. For example, in some cultures babies suffering from diarrhoea are not given fluids because it is believed that this will aggravate the situation. To the parents, it makes sense that in order to stop the baby from passing ‘watery’ faeces, they must stop the administration of fluids. In doing this, the baby is put at risk of dying from dehydration.
One of the important factors in decision-making is the availability of relevant and up-to-date information. Traditional knowledge, although an important source of information, needs to be updated. What was relevant a decade ago may not be so now. Research has the potential to provide up-to-date information that may facilitate decision-making. The perception of research data as superior to other forms of knowledge is not purely a matter of personal preference, but is dependent on the quality of the research itself. Traditional knowledge may have suited a world in which ‘authority’ was not questioned, people did what they were told and things were right because someone ‘important’ said so. However, we now live in an age when most clients are no longer the passive recipients of services, and those who hold the purse strings require business plans for the allocation and use of funds. The need to justify one’s practice is greater now than it has ever been.
Using more than one source of knowledge
By separating the sources of knowledge for the sake of explanation, the impression may be given that practitioners use one source to the exclusion of others. In practice, nurses and other practitioners use a combination of these, consciously and unconsciously, depending on what their interventions consist of. Referring to the lack of consensus about what kind of knowledge is at work in the actions of social workers, Nygren and Blom (2001) ask:
What is the role of theoretical knowledge in the moment of action, when a child is separated from its parents, when a dialogue is opened with a drug abuser, or when the client is told how much money she or he will get? To what extent is it a question of personal talent, creativity or charisma that is crucial to what will happen? Is knowledge applied in a prescriptive or instrumental way, or does it take the shape of a ‘mass’ or a matrix of knowledge – a more or less conscious background against which social workers reflect their sensory impressions.
Benner et al. (2008) po...