Locating Critical Care Nurses in Mouth Care: an Institutional Ethnography

Locating Critical Care Nurses in Mouth Care: An Institutional Ethnography by Craig M. Dale A thesis submitted in conformity with the requirements for the degree of Doctor of Philosophy Lawrence S. Bloomberg Faculty of Nursing University of Toronto © Copyright by Craig M. Dale 2013 Locating Critical Care Nurses in Mouth Care: An Institutional Ethnography Craig M. Dale Doctor of Philosophy Lawrence S. Bloomberg Faculty of Nursing University of Toronto 2013 Abstract Intubated and mechanically ventilated patients are vulnerable to respiratory tract infections. In response, the Ontario government has recently mandated surveillance and reporting of ventilator-associated pneumonia (VAP). Serious respiratory infections – and the related costs of additional care – can be reduced, in part, through oral hygiene. However, the literature asserts that oral care is neglected in busy, high-tech settings. Despite these concerns, little research has examined how mouth care happens in the critical care unit. The purpose of this institutional ethnography (IE) was to explore the social organization of mouth care in one critical care unit in Ontario, Canada. As a reflexive and critical method of inquiry, IE focuses on features of everyday life that often go unnoticed. In paying special attention to texts, the ethnographer traces how institutional forces that arrive from outside the practice setting coordinate experiences and activities. Inquiry began in the field with day/night participant observation to better understand the particularities of nursing care for orally intubated patients. Other data sources included reflexive fieldnotes, stakeholder interviews, and transcripts as well as work documents and artifacts. Over time, the analysis shifted from the critical care unit to the larger social context of Ontario’s Critical Care Transformation Strategy (OCCTS). Analysis traced the discursive and ii translocal social relations that permeate nursing work. Findings revealed a disjuncture between the ideals of VAP prevention and the actualities of mouth care. Tensions and contradictions emerged as nurses described their location within an expansive accountability network: nursing duties now extend beyond oral care to a controversial project of epidemiological surveillance. Patient comfort and safety now rest upon a hidden nursing agenda to overcome limited time, training and tools in oral care. Nurses worried that the effectiveness of preventative oral care was inhibited by technical problems of application that remain uninvestigated and unresolved. As a counterpoint to assertions that oral care is neglected, this study demonstrates how nursing knowledge and agency is obscured. Because international infection-prevention guidelines increasingly endorse oral care, novel research investigating the practice problems nurses encounter is warranted. iii Acknowledgments “A sore mouth can cause misery quite disproportionate to the size of the area affected.” (Allbright, 1984) “The world can only be grasped by action, not by contemplation. The hand is the cutting edge of the mind.” (Bronowski, 1973) During some of the most challenging points in writing this dissertation, I turned my thoughts to the unremitting work of critical care nursing. For example, if I was awake and writing at 4 AM, it was comforting to know that many critical care nurses were also awake and at work. With my collective experiences in mind, I can confirm that the intensive part of ‘intensive care’ is nursing. Without a doubt, nursing’s mission is arduous and extensive. However, the individual and collective contributions of nursing are rarely acknowledged. The demands of ill bodies are often concealed and unspeakable. In response, this dissertation seeks to bring the innovative work, words and expertise of critical care nurses forward. Without the guidance and generous participation of nurses, this dissertation would not have been possible. It has been an extraordinary privilege to work with the members my doctoral committee. My doctoral supervisor Dr. Jan Angus is unmatched in her integrity as a scholar, teacher and nurse. Her unwavering intellectual direction, careful timing and pragmatic comments have made iv this thesis possible. The many hours we spent speaking about nursing work have enabled an analysis that I did not foresee. I cannot thank her enough for this extensive contribution. Dr. Eric Mykhalovskiy is an exceptional academic and friend. His guidance in institutional ethnography and analytic writing extended my capacities to speak of the world I inhabit. Dr. Taz Sinuff has been a steadfast supporter and colleague. Her clarity, thoughtfulness and scholarship continue to inspire. To the members of my examination committee, I wish to extend my thanks for the generous and constructive review of this dissertation. I am eternally grateful to Dr. Marilou Gagnon, School of Nursing and Faculty of Health Science, University of Ottawa, Dr. Margaret Fitch of the Lawrence S. Bloomberg Faculty of Nursing, U of T, and Dr. Fiona Webster of the Faculty of Family & Community Medicine, U of T. The collective comments and insights you have posed continue to energize my commitment to nursing and health care inquiry. I take pleasure in acknowledging the visionary work of Dr. Dorothy Smith, the leadership of Dr. Janet Rankin and the individualized support I received from Dr. Liza McCoy. Their scholarship has brought me into the IE family. They have provided many resources to which I have turned on innumerable occasions. What follows registers their influence and foresight. Thanks to Alan Yoshioka for editorial assistance with the developing chapters. The generous financial support I have received from the Canadian Institutes of Health Research (CIHR) and the Lawrence S. Bloomberg Faculty of Nursing enabled my tenure as a full time doctoral student. Concurrent to my studies, I also had the advantage of several paid roles in the nursing faculty including research assistant, teaching assistant and clinical instructor. These collective opportunities enabled a space for extended research training and my ongoing academic v development. These favorable conditions are due to an extensive history and vision of nursing scholars. I wish to extend my thanks to Dr. Sioban Nelson for her foresight. Doctoral training would be inconceivable without the support of colleagues and friends. Early in my term as a graduate student, I had the good fortune to meet Dr. Francine Wynn at the Lawrence S. Bloomberg Faculty of Nursing. Her attention and encouragement have been pivotal. She continues to inspire and open doors. Similarly, I have met many doctoral student colleagues who have made this an unexpectedly joyous journey. I have often commiserated and (more often) celebrated with Marit Leegaard, Maki Iwasi, Oliver Mauthner, Marnie Kramer-Kile, Lisa Seto Nelson, Ruth Lowndes, Laura Fairley, Jennifer Lapum, Shan Mohammed, Jon Oskarsson, Tim Stewart, Laurie Clune, Sophie Pomerleau and Laura Bisaillon. Moreover, I continue to benefit from the abiding friendship, collaboration and inspirational leadership of many critical care colleagues including Dr. Louise Rose, Orla Smith, Dr. Robert Fowler, Dr. Damon Scales, Leasa Knechtel, Grace Walter, Linda Nusdorfer, Lars Kure, Angie Jeffs, Karen McCormick and Deb Carew. Throughout this process, I have been buoyed by the very special support of family and close friends. Words cannot express my gratitude to my parents, May and Mel Dale, as well as my sister Andrea Dale and her family. To the many friends who have created so many pleasurable diversions, I thank you. Special appreciation is extended to Dr. Mary Louise Adams, Helen Humphreys, Renee Walsh, Heather Wilson, Lesley Fraser and Lucinda Wallace. Finally, I would like to dedicate this dissertation to my partner, Bruce Martin, who has endured and encouraged like no other. The depth of your support is immeasurable. Thank you for such exceptional care throughout this journey. vi Mathew Cusick, Red & Blue (2010) vii Notes to the Reader I wish to offer the following points of assistance for readers. Language specific to the intensive care unit, nursing and health services appears throughout this dissertation. To limit problems of comprehension, a list of abbreviations and a glossary have been provided. Further, I have created a brief history of the mouth in critical care to highlight the importance of the oral space in the development and dilemmas of intensive care. I must emphasize that I will employ the terms critical care and intensive care interchangeably. This means that I use both terms to describe one medical specialty in addition to a repertoire of patient units where intubated and ventilated adult patients receive care. I do not differentiate between these two terms. Brief quotes from participants will appear within double quotation marks (Bill explained, “…”). I will use single quotations to emphasize an active concept in practice or the literature (e.g., ‘good’ nursing care). In denoting emphasis, I am directing the reader to the tension or pressure for clinicians to carry out the attendant concept. When quoting participants, I use a verbatim style of reporting in using exact words from our conversation. In sections where I reproduce interview transcripts, I identify myself as Craig and participants are assigned a pseudonym. For example: Craig: My question or comment for the participant Participant: Verbatim comments from the participant In addition to participant pseudonyms, the name of the study hospital has also

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