Managing ambiguity and danger in an intensive therapy unit: ritual practices and sequestration

Challenges and reflections from an international, humanitarian, short-term surgical mission on collecting ethnographic data in a remote environment

BACKGROUND

The experiences of nurses participating in ethnographic fieldwork have been well documented, but often feature short-term, intermittent periods in the field of less than a day.

AIM

To provide an overview of methodological issues related to collecting data while undertaking a focused ethnography of nurses volunteering with a humanitarian organisation providing surgical care in a remote setting.

DISCUSSION

Particular challenges during the fieldwork included limited space and privacy influencing data collection and secure storage; sporadic and unreliable communications limiting contact with other members of the research team; the challenges of withdrawing from the intensity of the setting; and navigating blurred boundaries between the roles of clinician and researcher.

CONCLUSION

Social research in practice, despite the best of intentions and significant planning, may not always travel the expected path of rational enquiry.

IMPLICATIONS FOR PRACTICE

Awareness of the challenges involved before embarking on longer term entry into remote environments may help prepare future nurse ethnographers.

A revised model of uncertainty in complex healthcare settings: A scoping review

BACKGROUND

Uncertainty is a ubiquitous and dynamic presence throughout healthcare systems and encounters, affecting the quality and safety of care. Although previous research has attempted to categorize varieties of uncertainty, it is not clear if these classifications are applicable across various healthcare settings.

OBJECTIVE

The purpose of this review was to examine the applicability of the issues of uncertainty delineated in an established taxonomy across diverse healthcare domains, professions, and countries and to consider the complexity of these issues.

METHODS

Drawing on empirical research from three databases, we conducted a scoping review of the literature to identify types of uncertainty experienced by healthcare professionals. A framework synthesis design was employed to review and synthesize the literature across multiple healthcare settings.

RESULTS

The search identified 2285 articles, of which 94 met the inclusion criteria. Findings from included studies suggested professional uncertainty in healthcare is complex and pervasive. On the basis of our inability to categorize some studies in the issues of uncertainty outlined in the existing taxonomy, we proposed a revised model of uncertainty for healthcare professionals.

CONCLUSIONS

The revised model of uncertainty, the model of uncertainty in complex healthcare settings (MUCH-S), is applicable to various healthcare ecosystems and proposes a reflexive archetype that recognizes different issues of uncertainty while establishing that these are often interrelated in healthcare systems. This review offers healthcare professionals greater levels of understanding of this complex phenomenon and may support more informed and reflective decision-making, assisting them to better navigate uncertainties experienced in healthcare workplaces.

Taboo in the Workplace: A Qualitative Study of Taiwanese Nurses' "Not-Eating Pineapple" in Clinical Practice

There has been an increased emphasis on nurses' mental health and well-being in the workplace. Psychologists have established a correlative link between individual's beliefs on luck and mental health. The pineapple taboo has been observed among Taiwanese hospital nurses as a prevalent superstitious belief for bringing luck or warding off increased clinical workloads, but how and why the ritual persists in the hospital workplace remains unknown. This article aims to explore the latent meaning of observance of the taboo and how it is related to nurses' clinical practice and possibly affects their mental health at work. A qualitative research was designed in line with the hermeneutic phenomenological method. Through purposive sampling, 18 nurse participants were recruited for in-depth semistructured interviews. Resulting from the ensuing analysis, 3 modalities were identified as constituting the spectrum of observance of the taboo: (a) "strictly not eating pineapple"; (b) "not eating pineapple at work"; and (c) "eating pineapple without admitting to doing so." Each reflects the position of nurses revealed in relation to the pineapple taboo in clinical settings. Based on the subjective narratives of nurses, it may be understood as an active moral attempt at "being right" rather than a passive avoidance of bad luck in the taboo observation. The findings facilitate an appropriate understanding of the embedded meaning of nurses' workplace-related belief and its seminal function of empowerment for nurses in holistic nursing practice.

The contribution of ethnography to understanding nursing work: a comparative review of three nursing ethnographies

Introduction: This methods paper examines ways in which ethnography and in particular the ethnographic method of participant observation, informs understanding of the reality of nursing work.Methods: The relevance of ethnography for nursing practice is illustrated through three ethnographic studies of nursing work, all of which involved participant observation for periods of over twelve months. These studies were conducted in three different hospital settings inWales,United Kingdom; an intensive therapy unit, a gynaecological unit and a medical admissions unit. Definitions of ethnography are considered along with an account of three key ethnographic methods; participant observation, interviews and documentary analysis.Results: Two key themes which were apparent in all three of these ethnographies will be presented to demonstrate the contribution of ethnography in understanding nursing practice. These themes are; the embodied nature of nursing work and duality and tension in nursing work.Discussion and conclusion: It will be argued that ethnography as a research approach enables nursing practice to be understood as it is actually experienced in the uncertain, disruptive and often resource limited context of contemporary healthcare.

Caring and technology in an intensive care unit: an ethnographic study

BACKGROUND

Critical care practice is a mixture of caring and technological activities. There is debate about whether the balance between these two elements is correct and a concern that critical care units can dehumanize the patient. This research sought to examine aspects that might affect this balance between the caring and technology within the critical care setting.

AIM

What aspects affect registered health care professionals' ability to care for patients within the technological environment of a critical care unit?

METHODOLOGY

A qualitative approach using ethnography was utilized as this methodology focuses on the cultural elements within a situation. Data collection involved participant observation, document review and semi-structured interviews to triangulate methods as this aids rigour for this approach. A purposeful sample to examine registered health care professionals currently working within the study area was used. A total of 19 participants took part in the study; 8 nurses were observed and 16 health care professionals were interviewed, including nurses, a doctor and 2 physiotherapists. The study took place on a District General Hospital intensive care unit and ethical approval was gained.

FINDINGS

An overarching theme of the 'Crafting process' was developed with sub themes of 'vigilance', 'focus of attention, 'being present' and 'expectations' with the ultimate goal of achieving the best interests for the individual patient.

CONCLUSION

The areas reflected in this study coincide with the care, compassion, competency, commitment, communication and courage ideas detailed by the Department of Health (2012). Thus, further research to detail more specifically how these areas are measured within critical care may be useful.

RELEVANCE TO PRACTICE

Caring is a complex concept that is difficult to outline but this article can inform practitioners about the aspects that help and hinder caring in the technical setting to inform training.

A cyborg ontology in health care: traversing into the liminal space between technology and person-centred practice

Person-centred practice indubitably seems to be the antithesis of technology. The ostensible polarity of technology and person-centred practice is an easy road to travel down and in their various forms has been probably travelled for decades if not centuries. By forging ahead or enduring these dualisms, we continue to approach and recede, but never encounter the elusive and the liminal space between technology and person-centred practice. Inspired by Haraway's work, we argue that healthcare practitioners who critically consider their cyborg ontology may begin the process to initiate and complicate the liminal and sought after space between technology and person-centred practice. In this paper, we draw upon Haraway's idea that we are all materially and ontologically cyborgs. Cyborgs, the hybridity of machine and human, are part of our social reality and embedded in our everyday existence. By considering our cyborg ontology, we suggest that person-centred practice can be actualized in the contextualized, embodied and relational spaces of technology. It is not a question of espousing technology or person-centred practice. Such dualisms have been historically produced and reproduced over many decades and prevented us from recognizing our own cyborg ontology. Rather, it is salient that we take notice of our own cyborg ontology and how technological, habitual ways of being may prevent (and facilitate) us to recognize the embodied and contextualized experiences of patients. A disruption and engagement with the habitual can ensure we are not governed by technology in our logics and practices of care and can move us to a conscious and critical integration of person-centred practice in the technologized care environments. By acknowledging ourselves as cyborgs, we can recapture and preserve our humanness as caregivers, as well as thrive as we proceed in our technological way of being.

Patients' narrative accounts of open-heart surgery and recovery: authorial voice of technology

In this narrative inquiry, we examined patients' experiential accounts of technology in open-heart surgery and recovery. A convenience sample of sixteen individuals was recruited from a preoperative clinic at a regional centre for cardiac services in Canada. Each participated in two interviews following transfer from cardiovascular intensive care and 4-6 weeks post discharge from the hospital. Participants also documented their experiences in journals during the first 3-4 weeks following discharge. The focal point of the study's theoretical foundations was narrative emplotment, which directs attention to the active processes of plot construction and shaping forces of stories. In our narrative analysis, we used narrative mapping to document the temporal flow of events. We found that technology acted as the authorial voice, or controlling influence, over how participants' narratives were shaped and unfolded. Key were the ways in which technology as the authorial voice was linked with participants becoming background characters and surrendering agency. Problematic and important to health care professionals is ensuring that authorial voice shifts back to patients so that they become active in shaping their own course of recovery. This study underscores the benefits of using literary techniques such as narrative analysis in health science research. Examining the narrative structures and forces that shape patients' stories sheds light on how health care professionals and their technologically-driven practices of care strongly affect the stories' content and how they unfold. By focusing on how stories unfolded, we revealed ways in which cardiac surgery practices and patients' course of recovery could be enhanced.

Rituals, death and the moral practice of medical futility

Medical futility is often defined as providing inappropriate treatments that will not improve disease prognosis, alleviate physiological symptoms, or prolong survival. This understanding of medical futility is problematic because it rests on the final outcomes of procedures that are narrow and medically defined. In this article, Walker's ;expressivecollaborative' model of morality is used to examine how certain critical care interventions that are considered futile actually have broader social functions surrounding death and dying. By examining cardiopulmonary resuscitation and life-sustaining intensive care measures as moral practices, we show how so-called futile interventions offer ritualistic benefit to patients, families, and health care providers, helping to facilitate the process of dying. This work offers a new perspective on the ethical debate concerning medical futility and provides a means to explore how the social value of treatments may be as important in determining futility as medical scientific criteria.