Book Reviews
Negotiated Realities: Making sense of interaction between patients diagnosed as neurotic and nurses
Stephen Tilley
ISBN: 1-8562893-9-7 1995 431 pages Aldershot, Avebury
Trudy Rudge
School of Nursing and Midwifery, Flinders University of South Australia, Adelaide, SA
In this monograph based on his doctoral research, Tilley sought to answer questions about his practice as a mental health nurse and therapist. Such an undertaking was based in the belief that psychiatric nursing practice, and research about such practice, assumed that nursing practice in psychiatric settings was atheoretical in its approach. Tilley locates his research endeavour in this on-going conversation about the characteristics of psychiatric nursing practice.
In analyzing these practices, Tilley used a rather eclectic collection of interpretive methodologies and methods to ascertain the nature of the work done during nurse-patient interactions. The analysis is largely accomplished through an analysis of accounts from nurses and patients, of conversations which they have had together. Through comparison of nurse and patient accounts of such conversations, in two different in-patient units, Tilley suggests several key issues are salient to understanding how the reality of nurse-patient interaction is negotiated. This work, he suggests, is predicted on questions by nurses about patients such as why is she here and what can we do for her. The patients' work in such interactions is based on questions such as why am I here and what do I have to do. Using these simple questions as a basis for the analysis of the interactional work that nurses and patients do, Tilley argues that such work is guided by knowledge as both common sense and working ideologies; by the deployment of power and definitions of powers and responsibilities; and by the negotiation of moral orders which are both internal to the unit and external, that is; common to the wider community.
The strengths of such analysis lie in Tilley's explanations of its particular form of data collection and its methodological basis in the local practices of nurses and patients. Such ethno-methodological approaches to the definitional and practical accounts of nurses and patients afford some interesting insights into the justificatory work and different rationalities they use to 'account' for their interactions. However, the conclusions realised from the date are laboured sometimes and lacking in focus. Many of the difficulties with analysis were more than adequately covered by Tilley's critique of his research in the concluding chapter. As Tilley suggests, the results could be enriched considerably by application of Foucaultian analysis for theoretical insights as the ways in which knowledge/power and language usage intersect in discourses to produce and reproduce local and global moral orders. Such an emphasis may well have produced a more effective analysis of psychiatric nursing knowledge as well as the mechanisms behind the use of the concept of responsibility within the nurses' and patients' interactions. Nevertheless, Tilley's monograph is a beginning look at the work done by nurses and patients in the mental health setting which exposes many assumptions unrecognised in earlier research into nurse-patient relationships, and for this alone it is useful to nurses working in such settings.
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