Response
Debate on articles in Contemporary Nurse
Susan Tregoning
School of Nursing and Midwifery, University of South Australia, SA
PP: 045 - 047
Article Text
Sandra Schubert's article You're more your own boss: Nurses' experiences of agency work Vol 4(4) fills a gap in contemporary Australian nursing literature in describing the nature of agency work as experienced by four registered nurses. The findings mirror the issues which emerge from overseas studies of nurses' experiences with this type of employment. The flexibility to structure a working life which accommodates other demands such as family commitments makes agency nursing an attractive employment option for many nurses, despite its many drawbacks such as de-skilling and professional isolation.
One of the most interesting points for future exploration that emerges from this study is the concept of 'gate-keeping'. For example, in the employment relationship between a hospital and its nursing employees, it is expected that the hospital's administration assumes the responsibility for matching the skills needed with skill availability amongst its workforce. By contrast, in the case of agency work, at least as inferred from Schubert's study, the onus of responsibility for ensuring that an appropriate match occurs lies with the agency nurse. The women were able to self-regulate, that is, able to refuse assignments they viewed as unsuitable to their skill level (1996: 170).
Dependence upon agency work for income, however, must at some point impact upon this self-regulation. Agency nursing is casual employment and its availability is subject to the peeks and troughs of market demand. When work is plentiful, it is presumably easier to refuse an unsuitable assignment than when it is scarce. Faced with limited prospects of income other than taking the unsuitable assignment on offer, this self-imposed gate-keeping must become somewhat more problematic for the nurse involved. The potential inner conflict between financial need and exercising professional responsibility, and its ensuing effects upon the agency nurse is itself an area warranting attention by researchers.
This conflict may be particularly acute for the newly graduated registered nurse who takes on agency work perhaps whilst waiting for a place in a graduate nurse program. It is easy to envisage the attraction agency work could have for the new graduate. They have often experienced three years of financial hardship while studying, only to experience limited graduate nurse places upon completion of their course. The prospect of more financial hardship and a possible reduction in the skills so recently developed, could act as an impetus for seeking at least temporary employment as an agency nurse. The professional and social isolation experienced by the nurses in Schubert's study would, if generally experienced by agency nurses, compound the many problems a new graduate would experience in this form of nursing work. Schubert argues the need for further research in the area of agency nursing. If nursing follows the trend with an increase in the amount of casual employment, which is evident in many other occupations, then there is an urgent need to understand more about this type of nursing work.
Jenni Leigh BA (Hans), BSoc (Admin)
Lecturer, School of Nursing, The Flinders University of South Australia
Armitage and Kavanaghs' reported research, Continuity of care: discharge planning and community nurses Vol 4(4) is the type of nursing research, which if evaluated appropriately and acted upon by those with the power to implement policy changes, offers potential gains for the recipients of health care. Their research, evidently part of a wider study, identifies primarily that the employment of hospital-based nurse discharge planners decreases the possibility of vulnerable persons experiencing problems when discharged from hospital into the community.
Within the extensive (at present floundering) literature regarding issues of research rigour and the associated dual crises of representation and legitimation, it is commonly considered necessary to evaluate the appropriateness of the procedures within a research process for congruency with the stipulated method. Although notions of reliability and validity (or terms used as approximations for such) are increasingly being rejected regarding the value judgement of qualitative inquiry projects, the 'rigour spotlight' still tends to partly focus on method-procedure congruency.
Grounded theory method has become popular for nursing research. There are several major modes of grounded theory method and various modifications of these modes are reported within the literature. The method can be used within several paradigms of inquiry, not just within the post-positivist paradigm as is usual for the classic mode (Annells 1996). However, to justifiably claim that a method being applied is grounded theory method, certain minimal elements are necessary, as listed by Strauss and Corbin (1994: 283) to be:
- The grounding of theory upon data through data-theory interplay
- The making of constant comparisons
- The asking of theoretically orientated questions
- Theoretical coding
- The development of theory.
As such, grounded theory method research moves beyond the level of exploration and description to theory construction.
Considered reasonable and certainly not discouraged by such as Strauss and Corbin (1994), there is the tendency for some qualitative researchers to select bits and pieces of the grounded theory method for use within steps of other methods. Seemingly doing just this, Kavanagh and Armitage state that they applied 'a modified grounded theory approach' for interview questioning and consequent data analysis. In choosing to do this, they have apparently used constant comparative data analysis, but the other four of Strauss and Corbins (1994) listed essentials are not readily discernible in the reporting of the research.
Armitage and Kavanagh have therefore quite rightly not claimed that the method overall applied is that of grounded theory but that the method is descriptive and exploratory. Thus, the reader needs to evaluate the procedures used and the associated decision trail, for congruency with a qualitative method that claims to be descriptive and explanatory, and also as reflecting the philosophical perspectives of a postpositivist paradigm of inquiry, which in my assessment, is the paradigm embedded in the reported research.
I do wonder whether reports of research which have assimilated one or more of the procedures derived from the grounded theory method, should however, state simply what that procedure is, such as 'a constant comparative approach to data analysis', rather than classifying the procedural step as consistent with a modified grounded theory approach. This would minimalise the risk of the reader inappropriately evaluating the research as a grounded theory study. Descriptive and exploratory research, as reported by Armitage and Kavanagh, is worthy of informed and appropriate evaluation.
Merilyn Annells, PhD Candidate
The Flinders University of South Australia
In response to Megan-Jane Johnstone's article The scandalous neglect of mental health care ethics Vol 4(4) I wish to applaud her for raising this subject. No mental health professional could dispute Megan-Jane Johnstone's comments on the historical view of the mentally ill person as irrational and therefore devalued. The processes of stigmatisation and labelling were expertly discussed. Contemporary mental health professionals are very aware of these issues and are vigilant in their efforts to reduce the occurrence of stigmatisation and labelling within their own practice and the wider community. This awareness, however, has resulted in a new ethical dilemma which to my knowledge is rarely discussed.
In an attempt to reduce labelling and stigmatisation, mental health professionals are now more reluctant to 'give' a patient/client a diagnosis of a specific mental illness. A psychiatrist may be very confident that his or her client is suffering from schizophrenia, prescribes the appropriate treatment and documents the diagnosis in the client's file but he or she is often reluctant to verbalise the diagnosis to the client. I acknowledge mental illness is difficult to diagnose as signs and symptoms can overlap two or more disorders, and psychiatrists may withhold making a differential diagnosis until there is a second presentation of the illness.
The ethical dilemma arises for those who are to case manage a client who has not been informed of the provisional diagnosis, the case manager might agree with the rationale that by withholding the diagnosis, for example, schizophrenia (at least for as long as possible) it is reducing the emotional trauma of stigmatisation and labelling. The reality, however, is that this results in confusion and often anger of the client and the family who cannot understand why the mental health professionals 'do not know what is wrong with them'.
There is a hierarchy of mental illnesses that are more socially acceptable than others. Depression, anxiety disorders and bipolar affective mood disorder do not cause the same dilemma about whether the client should or should not be informed of their diagnosis. In my experience as a registered psychiatric nurse, the one disorder that causes the greatest difficulty for the mental health professional in regard to being honest and open about the diagnosis with the client is the borderline personality disorder. Mental health professionals will often lower their voices for fear of being overheard when stating that a client has a borderline personality disorder. Within the profession this disorder appears to be more stigmatised than schizophrenia.
As Megan-Jane Johnstone highlighted, the field of mental health has long been neglected by those interested in bioethics. Despite the honourable intention of reducing the effect of being labelled by withholding a diagnosis from a client it does present an ethical dilemma. This is an area urgently requiring research and investigation.
Judy Taylor RN RPN BN (Ed) Grad Dip Health Coun
Community Mental Health Nurse, La Trobe Regional Hospital, Gippsland Psychiatric Service
References
Annells M (1996) Grounded theory method: philosophical perspectives, paradigm of inquiry, and postmodernism. Qualitative Health Research 6(2).
Strauss A and Corbin J (1994) Grounded theory methodology: An overview. In Denzin NK and Lincoln YS (eds) Handbook of Qualitative Research. Sage Publications, Thousand Oaks.
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