Response
Debate on articles in Contemporary Nurse
Susan Tregoning
School of Nursing and Midwifery, University of South Australia, SA
PP: 150 - 152
Article Text
In Volume 3(2), Julie Bligh wrote a very important Soapbox article on the need for clinicians, not just diabetes educators, to educate people with diabetes. I agree wholeheartedly with Julie and her encouraging words to all clinicians to be more active in this aspect of their role. However, I can also empathise with clinicians and I can hear some saying, 'When? We don't even have enough time to do the work we have now, without adding something else to the list!' So, I would like to add some thoughts of my own to Julie's comments and then make some suggestions on how nurses can incorporate education into their daily practice without increasing their workload.
The role of the specialist nurse, whether it be in diabetes education, stomal therapy or cardiac rehabilitation etc, was created to provide individualized education and management services for people with specific long term conditions. This specialized and systematic approach to the education and management of people with chronic illnesses was deemed necessary to overcome the 'ad hoc' service they had been receiving from the various health personnel encountered in the course of treatment. I don't believe it was ever envisaged that the specialist nurses would provide a complete education service to the relevant individuals.
Their role is to provide individuals with a solid foundation from which they can identify their own issues, needs and questions, leaving the ongoing day-to-day responsibility of responding to these with the nurses at ward, unit and community level. Of course responses may well include a referral to the specialist nurse or a relevant health professional. However, we cannot always know all the answers. We need to find out information ourselves. Perhaps the issue here is not really whose role it is to educate, but rather nurses allowing themselves to say I don't know!' One particular point made by Julie that I would like to further highlight is the issue of 'social stigma'.
Perhaps we tend to overlook this aspect of diabetes care to some extent and devalue the impact of the condition of an individual's lifestyle. Can any of you honestly admit that you would be okay if when you woke up in the morning you had to check your blood glucose level, decide what you can eat (not what you wanted to eat), plan all your activities for the day around food, medications and exercise only to go to bed at night to do it all again the next day? How many of you have ever stayed on a diet or new exercise program as planned? We all know it's very hard but I believe that sometimes we lose sight of the fact that living with diabetes in not easy, and these individuals deserve our respect and support.
You can help by being more understanding and correcting people you hear talking negatively about how individuals manage their diabetes. This sort of negative attitude serves no purpose and overlooks the person for the sake of the condition. We know that the root of discriminatory behaviour is based on fear and ignorance and, as health professionals, we have a responsibility to provide accurate useful information to the general public. Surely, the issues inherent in diabetes education are synonymous with those in primary health.
Pauline Hill, Lecturer, University of South Australia
Jennifer Greenwood's article on action research and action researchers in Volume 3(2) is timely. I hope further papers will come from Greenwood and others so that nurses can become informed about this research methodology. Action research has the potential to assist nurses to know and understand more about themselves and their work at a time when many nurses lack the terminology to articulate their specific contribution to health care. In its best form, action research helps practitioners find better ways to practise by engaging, extending and transforming their self-understanding and involving them in the process of theorising on their own practice. In other words, it is 'insider' research, done by nurses themselves. So who is the 'action researcher' who works as co-partner in the research process? My preference would be for a nurse-researcher.
The researcher must first grasp the meanings embedded in the world of the co-researchers-then go on to work within a partnership to create what Argyris, Putnam and Smith call a change oriented 'community of inquiry' within a 'community of practice'. The hyphenated role of nurse-researcher should encourage the mutual understanding and sensitivity to the reality of practice which are prerequisites for this process. The requirements for a good action researcher include: a commitment to the unitary nature of theory and practice revealed as self-reflective, informed practice; a respect for people; an ability to listen; an ability to work with others as equal partners, be they clients or colleagues; a high tolerance of uncertainty; an ability to let go; and a willingness to transform the present into a new future. As co-researcher, the action researcher is a full partner in the project and also formalizes the new understanding into a theory. In addition to supporting the new practice, this theory is made available to others.
Thus, it is a win-win outcome for both partners as, together, they increase their understanding of their shared world of nursing. I am privileged to see the light in the eyes of a graduate student currently undertaking an action research project within her own work setting. The project arose from a management decision to review the relevance of the current service to its rural constituents when funding for health care is contestable. Nurses had to reflect on their work as a matter of survival. The nurse group, co-researchers with the student, are theorizing as they go-exploring possibilities and sharing their ideas with the rest of the team. Now they are being encouraged to share their ideas with other nurses.
This project includes all four of the elements which Oja and Smulyan believe are conducive to effective action research:
- Frequent and open communicating between participants;
- Democratic project leadership;
- Spiraling cycles of planning, acting, observing and reflecting; and
- Positive relationships with the context in which the project occurs.
Action research has few rules and is difficult to do well. Critics abound. But even those of us whose academic recreation is critiquing others who do not share our own view, are aware that there is neither perfection in nor consensus on any research methodology.
Rigour should be present in every research method, and advocates of action research such as Argyris, Putnam and Smith prescribe this while also stating that '...action science tempers the mainstream value of precision with values pertaining to usability and to the kind of world created by using knowledge...in action research we seek explanations that are optimally incomplete.' Such openness should serve to encourage nurses to explore action research as a method for guiding their reflections on and transformation of practice, and to accept the challenge of generating and sharing the theoretical outcomes of the experience.
Judith Christensen, Senior Lecturer
Department of Nursing and Midwifery, Massey University, New Zealand
In response to the paper by Mari Botti and Jennifer Hunt in Volume 3(2), this study was well conceived and implemented and addressed an important issue in nursing, that of non-thinking routinized care. We have identified three issues about the research that warrant discussion: the conceptual framework, the sampling methodology, and the data collection strategy. The first paragraph states clearly that the concern was about 'the relationship of routine versus individualized patient assessment'.
The stated aims of the study limited this focus to an evaluation of the routine. That is, as the design was particularly sensitive to routinization, did the researchers find only what they were seeking? A conceptual framework which embraces a broad view of nursing in order to examine practice and decision-making might have avoided this bias and better detected individualized, case-specific judgements. For examples, common definitions describe nursing as the diagnosis and treatment of human responses. Questions to participants, such as 'What human responses were you assessing?' might have elicited replies such as 'altered protection' or, using nursing diagnosis language, 'potential for injury.' This question juxtaposed to the ones that asked, 'What did you do?' and 'Why did you do it?' might then have made the study better able to detect nursing actions and decisions related to individualized care practices.
Without such a framework, the stated rationale that actions are procedural or routine might have become the default reply. The concerns regarding sampling may relate to omissions rather than commissions. The term 'convenience sample' leaves us with more questions than answers as to procedures followed and potential for bias. Nurses were selected 'if they had been responsible for a particular patient's care for one to five hours in the immediate postoperative period.' We worry: what does this really mean? What was 'particular' about the patients identified? Were nurses then selected based only on this stated criterion? Was a particular time frame used for selection of nursing staff? Was this important? Did this lead to selection of specific nursing staff members? Who was not selected? Is care different at different times of day? What is practised at 2.00 am? Or, was there some other parameter in selection upon which we cannot speculate? Further description of 'convenience sampling' might have allayed these concerns.
Self-report is limited as a data collection strategy especially when questions asked relate to socially (or professionally) desirable behaviours. Questioning nurses about their behaviours in relation to taking postoperative observations fits this criterion. The authors state that 'nurses surveyed in this study carry out post anaesthetic vital sign measurements in the belief that the frequency of observations is outlined and predetermined by hospital policy.' Are the nurses then making statements about what they do because they believe it is the expected behaviour? Would direct observations have assisted in validating self-report? Likewise, would an anonymous pencil and paper self-report strategy be less susceptible than interview to social and professional pressure? A strength of this study is that it poses the right questions. The alternatives suggested do not detract from the integrity of the study in its own right. We hope they are useful and stimulate further discussion about nursing, nurse decision making and our practice.
Professor Rita Axford, Director
Ms Deidre Mackechnie, Peri-operative Educator
Centre for Graduate Studies in Clinical Nursing, Monash University
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