Nurse Education Today (1990)10,151-155
Langman Group UK Ltd 1990 02606917/90/0010-0151/$10.00
Desmond Ryan and Hazel E McHaffie
Desmond Ryan MA D Phil Dip Sot Admin
Hazel E McHaffie SRN SCM PhD both at Department
of Nursing Studies, University of Edinburgh,
12 Buccleuch Place, Edinburgh EH8 9JT
(Requests for offprints to HM)
Manuscript accepted 11 July 1989
This is a two-pronged critique of a study of the socialisation of neophyte nurses in a neonatal intensive care unit in the USA. The authors, respectively an educationalist and a nurse researcher experienced in neonatal intensive care, agreed in finding that the study fell short of what it promised, but differed as to their reasons. They decided to publish their critiques as a complementary pair, in the hope that those supervising research students would benefit from seeing a disappointing study simultaneously in two perspectives, educational and clinical.
AN EDUCATIONAL PERSPECTIVE
Failure is so much more instructive than success, yet the reasons for failure are rarely examined in much depth. This book (Myers 1982) had the ingredients for success – a good idea, interesting first-hand data – but blew it in conceptualisation and presentation. The result is very instructive, and every nurse should study it carefully as they approach the writing up of the results of their own research enquiries, in whatever field they may be. Lecturers who have to teach those illogical courses known as ‘Methods of research’ will benefit from having a real-life model for hands-on student criticism, a flawed gem with which to challenge the students to work out how they would do it differently. Conceptualisation and research objectives What is a ‘failure in conceptualisation’? The fundamental weakness of the book is the absence
of a leading point of view. The author has so effaced herself as an organising mind that her book never gells. The quality of the different bits varies, but they remain very much bits; they do not hang together as the achieved vision of a person who asked a question and has now got her answer. There is no continuing thread through the data, be it in the form of a puzzle in search of solution, a problem to be unpacked, the disciplined following of a logical sequence of questions, or an organising framework from an illuminating theory. Data hangs about in great chunks, waiting vainly for a synthetic welder to turn up.
Analytic welders there are aplenty. The short chapter reviewing the literature throws up far more analytical approaches than can possibly be used in an empirical study. Unless intended to contribute to a methodological debate, this is academic name-dropping, ritual provender for thesis examiners to grind their paradigm-hungry jaws on. In a book for those outside the ritual process of academic initiation, surely it is sufficient for the key authors in the tradition in which the author places herself to be carefully reviewed and the redundant names thanked and sent on their way with some critical comment on why their approach does not fit the intentions behind the study? To do otherwise is inevitably to disorient the reader at a crucial stage, that of the construction of the expectation set for the work as a whole. What should we expect? The author’s aim is to fill a gap by providing a case study of the occupational socialisation of neophyte nurses, observed in a natural setting. On the one hand, excellent – we really need lots of such studies, for comparative insights. On the other hand, misgivings – filling a gap is rather low-level as a primary intellectual objective. Is it from right back here that the basic flaw derives? If she intended merely to present facts, is it surprising that there is no higher meaning to the book? Again, filling a gap implies that all the other studies which have collectively left this gap are uniform in nature and thus part of an accumulating edifice of accepted factual knowledge about socialisation. This is in principle impossible, as socialisation is not an unproblematic entity consensually reducible to single paradigm research programmes. To refer only to the most well known, the Merton/ Becker studies on the socialisation of doctors differ in how they conceive of and study the phenomenon, not what is examined (Merton 1957, Becker 1961).
Whichever way, the lesson for nursing research is an important one: since every good reader approaches a new book with one or more questions in his or her mind, a good book has to be an answer to a question convincingly put by the researcher, not large tracts of data from which the reader is to ask their own. There is possibly a secondary lesson, for nurse education: are nurses being taught to be good readers? It is a capability that is a precondition to being good researchers, in many ways even to being intelligent.
Research problems require appropriate research methods
Let us go deeper into this question of presenting the ‘facts’ about socialisation. Did this commonsense intention obscure from the author the basic sociological principle that how things come to be ‘facts’ is often part of the same socially conditioned process as ensuring that newcomers pick them up as such? And that therefore she herself had to be reflexively self-aware of the process of coming to accept the ‘facts of the neophytes’ world’, perhaps sharing with us her mistakes and misunderstandings as she learned her own way into it? Since socialisation is about learning the meanings of a culture, the decision to focus on socialisation necessarily conditions the approaches open to a researcher. The key ones must be meaning-seeking.
So whereas this study should be constantly unpacking the logic for the participants of the actions described by the observer as the ‘old timers’ go about getting the newcomers to inhabit the same meaning-world as they do, in fact we get very little of this. Instead some would be scientific tic (or subsidiary supervisor) draws the author towards the respectability of measurement. As the ‘where’ (a neonatal intensive care unit) does not change, the author can only measure the ‘who’, the ‘what’ and the ‘when’. So instead of insights into the way in which different aspects of the work of the unit are understood by the participants, we get well presented piecharts and tables with meaningless figures about who interacted with whom on what tasks, how often and for how long – meaningless because they don’t really get at the question of ‘why?’
So there is here another lesson: qualitative researchers have to keep their nerve, to the very end! An inappropriate deference to the canons of one tradition of scientific method when presenting findings can destroy the real scientific value of years of careful work in collecting data. In the intellectual as well as the moral life, a virtue misplaced can become a vice.
A similar neglect of the ‘why’ mars the author’s superbly detailed chapter describing a typical day on the unit, summarising which, instead of unpacking for us the internal meanings accompanying the process of bringing the neophytes to understand this or that aspect of their role, we get given a short list of functional practices, viewed totally externally: ‘Spatial organization of activities is achieved by the placement of sick or recovered neonates near or far from the central nurses station . Cultural identity is exemplified through dress such as coIoured uniforms, pins and gowns.’ A Martian parked in the corner who understood neither English nor babies could hardly give us less. (Strangely, she is much better about giving us the meaning of the behaviour of doctors and relatives than of nurses – could it be that the best kind of anthropologist is someone not raised in the culture in question, and therefore someone to whom it’s all exotic?)
For the non-nurse there is lots of value in this book, but it is mostly the raw data rather than the interpretation. One is given a series of suggestive but fragmentary insights into a work setting of a very particular kind inhabited by some very particular individuals. But the individuals are not fleshed out (i.e. given their personal meaning) as case studies any more than the constraining logic of the setting is worked out as a system. For her diligence and thoroughness in the data collection the author should be congratulated. But she was perhaps building a leaking vessel right from the start; on conceptual organisation and presentation her academic socialisers and her publisher have let her down. It is an object lesson, and therefore of genuine scientific value.
A CLINICAL PERSPECTIVE
This book promised much (Myers 1982). There is indeed very little data on the socialisation of neophyte nurses in a natural setting. Here was a good idea with a discrete focus to contribute to the greater understanding of nursing. Unhappily its potential was never realised: partly because there is no logical progression from problem to answer, no proper organisation; and partly because the researcher has not fully grasped what is contextually important. The end result has a hollow ring for nurses with experience of working in a neonatal unit.
The setting
Firstly, she has not understood what is really important in setting her scene. In an effort to provide a ‘cultural framework’ for understanding the data, a detailed description is supplied of the hospital and its organisation. The rationale for this is sound, but there is a strange incongruity between the aspects considered important enough to include in this section and the subsequent analysis of the data. Of far more value than funding, the cost of parking and Dairy Queen Sundaes would have been a setting of this particular unit into historical and medical context. With tremendous advances having been made over the past two decades in the management of sick and low birthweight infants, it is vital to understand not only the adoption of new forms of care (and their ethical dimensions) but more importantly the attitudes of both professionals and public that accompany them. Without some basic knowledge of this context the reader is unable to form an independent assessment of the value of the researcher’s interpretations of events and behaviours.
We are told that the nurses, having recently moved to new premises, are adjusting to a ‘new concept of providing intensive care’, but the emphasis is much more on adjustments in technical management than on attitudes. Also, later in the book, there is brief mention made of hospital policy on restraining infants and a detailed account of a specific occasion when nurses refused to give a ‘controversial drug’. But some sense of staff attitudes to such issues as the resuscitation of infants born on the edge of viability, the management of abnormal infants and the adequacy and sophistication of the available equipment would have greatly helped to set the subsequent discussion of critical events into some sort of meaningful context. As it is, one neophyte’s questioning of the moral dilemmas hangs in a vacuum.
The Neonatal Intensive Care Unit
Secondly, the author does not understand what is taking place within the unit. She rightly acknowledges the limitations of a study of this kind – it is not possible to generalise from her findings. There is no fundamental problem in that. But a reader versed in the ways of neonatal intensive care is left with an uncomfortable feeling that interpretations were due less to the unit’s idiosyncratic differences than to the observer’s failure to understand what was being done. Somehow some of the explanations just do not ring true.
Although she is a registered nurse, there are disturbing signs of a lack of knowledge and understanding of the basic management of sick and preterm infants. She appears to have a problem with a variety of things: bradycardia, parenteral nutrition, life-support equipment, monitors. In attempting to explain the meaning behind actions, failure to comprehend the significance of what is going on must surely call into question any effort of interpretation. Perhaps this explains the odd choice of categories and detailed explanations of rather trivial happenings such as the ordering of a procession carrying a new baby to his mother.
The nurses
Was the awesome degree of responsibility and autonomy apparently given to these neophytes a reality? Was there no proper structure to safeguard the infants from the choices and inexperience of these newcomers? Any seasoned ICU nurse knows all about the vagaries of ‘high tech’ machinery and the frustration of constantly ringing alarms, but were the neophytes in this study really left to decide by trial and error whether it was a faulty sensor or a collapsed baby? Did they take full responsibility for deciding if bright red drainage from a gastrostomy tube should be reported to the doctor? If so, then the comment of one neophyte who described herself and her colleagues as ‘all fakers faking around like we know something yet know nothing’ was indeed apt. If we could be sure about their responsibility, such evidence would be a valuable contribution to the literature on standards of care.
But the curious freedom they seemed to have to choose whether to go on an assignment or to take time off to sleep raises doubts about the comprehension of the observer in relation to casual comments, behaviours and coping strategies. So for example when a doctor laughs when he finds a problem for which there is no treatment, or refers to the abuse to his ego when he has difficulty siting an IV line, or a nurse laughs at attempts to disguise an abnormal head -was this really ghoulish humour or was it rather an attempt to cope with grim reality and stress and at the same time perform efficiently? A father making reference to his son’s potential as a boy scout because he has a true knot in his umbilical cord is thought to be indicating a social aspiration. An alternative explanation is surely that he is attempting to cope in a stressful and intensely personal situation with humour and communicate with the doctor at an understandable level. Providing other possible interpretations with some justification for the one preferred would have made this a more scholarly work. The neonatal unit is a splendid setting for a study of this kind. But it is also an environment full of stress and intense emotion. Without some real appreciation of what such pressures can do to the men and women who people it, it is not possible to unpack what is seen and heard in order empathically to understand any meanings behind words or actions.
Perhaps the author gets nearer to a true understanding of the impact of events in a neonatal unit when she considers coping with dying (although interestingly doctors are seen to have no feelings – for them dying is a purely ‘physiological, medical event’). Nurses, however, are permitted to set dying into a range of contexts and attach a variety of meanings to it. By drawing the analogy of a game of dodgeball, the writer attempts to understand nurses’ adaptive strategies to critical events.
The theory is plain. But when it is translated into the particular strategies for coping with dying babies, the framework outlined is disappointing. In addition, after detailed discussion the researcher concludes that the social significance of death and dying are not respected as much as the medical aspects and that the ‘nurses are not aware that social loss and the meaning of death are derived individually from the different perceptions parents may hold or wish’. Since death is a not uncommon event in intensive care of neonates it seems unlikely that the old timers could have failed to grasp this dimension even if they did entirely fail to ensure that the neophytes took it on board.
On a surprising number of occasions the nurses are depicted as refusing to do a task – to care for an irritable baby, to carry out a ‘death watch’, to attend a 13-year-old in labour, to put up an IV line. Was it the nurses’ apparent reluctance to do such things that prompted the researcher to decide that ‘while doctors have high interest in medically controlled processes toward the end product of recovery states for the sick neonate, nurses have higher interest in the processes of becoming socially accepted as nurses, becoming a member of the group . . .’ This rather radical statement would seem to need some evidence to substantiate it.
The researcher
It has long been recognised that useful insights are gained by obtaining feedback from respondents on their perceptions of the researcher and the author of this study was right to include this issue in her methodological appendix. She is to be applauded too for the honesty of her report. It was then disturbing to discover that, by her own admission, she was perceived by the nurses as a nuisance, a spy, intruder, irritant. The reader must inevitably address the question of whether it was possible that the data were not influenced by such an attitude and just how much of the recorded behaviour reflected this perception of her. It would seem unlikely that the observed would give thoughtful and deep insight into what experiences meant to them if they were entirely out of sympathy with the researcher and her motives. Had she actually been a ‘participant observer’ in this study this problem should not have arisen. She would have had to become as a neophyte picking up the meanings of what was being said and done in order herself to be accepted and to survive. Her better success with visitors and parents is heartening and perhaps explains why she occasionally drops quotes from parents in a seemingly irrelevant way into some of her accounts.
Further, were some at least of her own interpretations coloured by the response she got from the nurses? Is this the key to her problem? It must have been disconcerting to feel so suspect, so excluded. Would the researcher have been persuaded to try to the same extent empathically to understand how these nurses behaved, how they thought and felt if she felt so misunderstood herself? On one level she had good reason to see them as grudging and unsympathetic.
A hope is expressed in this book that the study may serve as inspiration to others to perform systematic investigation of the socialisation of nurses. If it serves instead to warn potential researchers of some of the pitfalls in such an exploration it will not have been written in vain.
References
Becker H S, Geer B, Hughes E C, Strauss A L 1961 Boys in white. Univer&y of Chicago Press, Chicago
Merton R K. Reader K. Kendall P L 1957 The studentphysician. Harvard University Press Cambridge, Mass
Myers L C 1982 The socialization of neophyte nurses. Ann Arbor, UMI Research Press, Michigan.
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