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Sunday, June 13, 2010
Nursing
Joan Liaschenko (1994), a nursing researcher interested in the nature of nursing and nursing work, and who acknowledges a Foucauldian philosophical influence (Foucault, 1975), has argued that nurses now routinely extend the physician's "gaze" within and across various health care settings. Such an extension impacts the nursing profession's ability to implement its own more holistic gaze as well as its ability to facilitate patient agency. She has argued that nursing work, whether carried out in the home or in institutional settings, is conducted within "gendered space" that reflects “literal and metaphorical space in the social and political life of societies" (Liaschenko, 1997, p. 51). In a qualitative study in which she asked experienced, educated nurses to speak about an incident from their practice that highlights ethical concerns, she found that the delivery of patient care and the execution of nursing practice were subject to the social and political space occupied by both patients and nurses. Multiple "spatial vulnerabilities" were found which then significantly impacted both patients and nurses. These vulnerabilities included poverty, the exploitation of patients to meet institutional needs, the homogenization of patient identity, and the fragmentation of patient and family care. After asking, "... what is the place of nurses" and "Do they even have a place?" (p.52) she argues that, although nurses are seen as both nurturers and executors of physician orders, the socially reinforced portrayal of nursing work "fails to reveal a whole domain of absolutely essential work" (p.52) (what she calls complex connecting or relational work) that "literally keeps the patient cared for and the institution going" (p52). Dissertation Introduction
The reason nursing work is not seen, she argues, is because, "as a society we have been schooled to see the work of medicine rather than the work of others as most significant in patient care." (p.52) - this invisibility of nursing work occurs because it is work conducted by women, viewed as women's work, and therefore devalued. Nursing work, Liaschenko argues, becomes at risk of turning into instrumental work that serves more powerful and visible interests (physicians, administrators, insurers). She concludes by making a case for a linkage between nursing and human and/or cultural geography because of the scope (local, global, structural) that this sub discipline can bring to a consideration of care environments.
In a related article, Peter and Liaschenko (2004) note that the construct of proximity, that is, nearness to patients, is problematic because of the issues related to moral ambiguity and moral distress that it can elicit—proximity "(can) propel nurses to act, it can also propel nurses to ignore or abandon" (p218). It may be that proximity itself is not the problem but rather the deficiencies and inequities within the health care system that is revealed by the various types of proximities that nurses are able to develop with patients and families. Peter and Liaschenko argue that nursing needs to bring others (administrators, physicians, policy makers, and the public) into proximity with patients so that the moral ambiguities can be better understood and appreciated. They also argue that nurses need more frequent breaks and quiet areas away from patient care, and that nurses in academia need to teach new nurses how to "articulate their practice, including the social space they occupy" (p.223). Finally they argue that a more robust exploration of nursing ethics, especially as it relates to the moral ambiguity that can develop with proximity to patients, could assist in deescalating the moral distress that may be a large component of the stress nurses experience in their work.
Malone (2003) has also considered issues encompassing physical space, health policy, nursing care and nursing ethics - arguing that the ethical integrity of contemporary professional nursing practice in hospitals is increasingly at risk because the three types of proximity that hospital nurses have traditionally had with patients (physical, narrative, and moral), and that are fundamental to ethical nursing practice, are being threatened by contemporary health care management practices and policy. In particular, "hospital nursing is spatially vulnerable (and that) a taken-for granted proximity to patients...” is acutely threatened by the localized special and power dynamics of macro-originated economic and ideological pressures." (p. 2318). Malone grounds her argument within two theoretical perspectives: 1) The phenomenological perspective on space and place that argues that place "grounds our subjective, embodied experience and can only be understood through experience" (p. 2318) as articulated by Casey (1993) and Malpas (1999); and 2) Critical and historical perspectives that address the power relations embedded in place and space (Foucault, 1975; Foucault, 1977; Lefebvre, 1991; Massey, 1994).Dissertation Introduction
Malone portrays professional nursing practice as a relational one in which the nurse develops three types of proximity with patients—physical, narrative, and moral. Physical proximity is a proximity that develops when a nurse gains particularistic knowledge about a patient's body. Narrative proximity is a proximity that develops when a nurse gains particularistic knowledge about a patient's background, i.e. his or her "story". Moral proximity is a proximity that develops when a nurse has developed both a physical and narrative proximity with a patient, and because of these proximities (knowledge), is able to infer what a patient may desire or wish, but may be unable to articulate. She argues that these proximities are nested within each other—physical proximity enables narrative proximity, which then enables moral proximity—and that these three types of proximities are limited bycontemporary forces in health care, which include: 1) chronic nursing shortages, the use of flexible staffing structures, and the use of lesser-trained and lesser-empowered health care workers; 2) shorter lengths of stay, structured forms of nurses' notes (charting by exception), and multiple care settings; and 3) abstract classification systems and standardized plans of care that reduce patient care down to a series of tasks to bemanaged and/or outcomes to be achieved. Malone calls this evolution "distal" rather than "proximal" nursing and believes that it may lead to a "we're just running the trains" mentality within the profession (p. 2324).
Human/Cultural Geography
Gavin Andrews, a geographer within the School of Nursing at the University of Toronto, has echoed and reinforced Liaschenko's call for a link between nursing and geography, calling for a "geography of nursing" linking the broad constructs of nursing, people, health, space, and place (Andrews, 2003 a). He argues that Nightingale used geographical references to space and place within Notes on nursing: What it is and what it is not, such as her articulation that, for proper healing, patients need, among other things, ventilation, warmth, light, and proximity to nurses (Andrews, 2003b), and that given the increasing diversity of places and spaces in which nursing occurs, an emerging area for a trans-disciplinary scholarship linking nursing with health geography could begin to examine the dynamic relationship between people, health, and place (Andrews, 2002).
Health geography emerged in the 1990's as a theoretical and social development of medical geography, an area of 20th century research that has traditionally addressed spatial and geographical issues related to disease distribution as well as the distribution, accessibility, and utilization of health care services facilitated by humanistic and Marxist oriented critiques of the prevailing views of geography as spatial science that emerged in the 1970's (Andrews, 2003). Andrews notes that work by Liaschenko has already begun to examine how patient care settings reflect larger economic, social, and cultural issues. Other scholars have noted that the discipline of cultural studies may be a vantage point to study the complex interrelationship between power, technology, culture, and space (Poland, Lehoux, Holmes & Andrews, 2005).
One study pertinent to a consideration of hospital nursing work environments that reflects the geography of nursing emphasis called for by Andrews is a study of English hospital nurses conducted by sociologists (Halford & Leonard, 2003). It explores how the material space within hospital settings influenced the construction and performance of nursing identities. Repeated observations were made of staff level nurses within a large 700-bed district hospital and smaller 60-bed community hospital. Observation sheets were used to record details related to the physical environment, the individuals present, activities, movements, and conversations that the researchers had with the nurses. The findings included that, in comparison to physicians, nurses had less access to various hospital spaces and that many of them were virtually confined to the wards in which they worked. Additionally, the public "ward space" of the units was the only space that many nurses had access to and that within these ward spaces, little or no space that was allocated to them as specific individuals. They also found that nurses were allocated significantly smaller amounts of private space than physicians. They concluded that the material space within the hospital work environments did have implications for the construction and performance of the nurses' workplace identities.
Work-Related Stress and the Physical Work Environment
Work-related stress (defined as work-related physical and mental strain) is accepted as a contributing factor in negative individual and organizational outcomes such as poor job performance, absenteeism, job dissatisfaction, turnover, and health problems (Brisco, 1997; Caplan, 1975; Heerwagen et al., 1995; Theorell & Karasek, 1996). Worker health and organizational productivity has also been linked (Murphy & Cooper, 2000). The role of the physical work environment on worker health and productivity and organizational health and productivity has also been theorized (Becker, 1981; Becker & Steele, 1995; Carnevale, 1992; Vischer, 1996). The health of work environments has been theorized as varying along a continuum; healthy work organizations promote and/or maintain worker health and organizational productivity. Healthy work environments are conceptualized as ones that successfully address the issue of work stress. Karasek has theorized that employee involvement and input into the work environment, reduces the risk of heart disease among workers (Karasek, 1990).
The management of occupational stress through changes in the physical work environment is the subject of a review (Heerwagen, et al., 1995), which arguea that although the issue of work stress is of critical importance, organizational leaders all too often assume that the root causes of these problems lie within individual workers, not the physical environment. Australian researchers reached a similar conclusion in a case study of work stress within a public hospital (Trubshaw & Dollard, 2001).
PE Fit theory has been proposed as a theoretical framework for addressing work related stress (Caplan & Van Harrison, 1993; French, 1982; Van Harrison, 1978). The roots of the theory have been attributed to Kurt Lewin's Human Needs Field theory (Lewin, 1951) and Henry Murray's Needs-Press theory of personality (Murray, 1938). Lewin theorized that human behavior was a function of the person within the environment. Murray envisioned people as having basic needs (for safety, socialization, privacy, accomplishment, etc.), while the environment exerted various types of "press" or demands on them. PE Fit theory argues that people within their environments exhibit varying levels of congruence or "fit". When a person's needs match his or her environmental press, it results in congruence or a "good fit", which facilitates the satisfaction of needs and attainment of goals. A "bad or poor fit" hinders the satisfaction of needs and attainment of goals leading to strain, dissatisfaction, and/or other negative outcomes.Dissertation Introduction
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