Within and between: an ethnographic study of the work of nurses in adult acute care wards Sarah Elizabeth Lake, RN, MN (Distinction) Susan Wakil School of Nursing and Midwifery The University of Sydney A thesis submitted in fulfilment of the requirements for the degree of Doctor of Philosophy May 2020 Page i Candidate statement I certify that, to the best of my knowledge and belief, this thesis does not include without acknowledgment any material previously submitted for a degree or diploma in any university, or any material previously published or written by another person except where due reference is made in the text. Signed: Date: Page ii Abstract Within and between: an ethnographic study of the work of nurses in adult acute care wards That nurses working in acute care hospitals each look after a caseload of patients every shift is taken-for-granted in this setting. But how do nurses accomplish nursing within and between patients’ needs-for-care in acute care hospital wards? This thesis explores nursing in practice as nurses work with multiple patients concurrently within this complex and dynamic environment. To study these nursing practices as they occurred in this environment I undertook an ethnographic study informed by Bourdieu's theory of practice, using the dialectical relationship between habitus, capital and field, where doxa is about the power of the rulings and protocols of this social space as field, to explain nurses’ practices in the everyday world. In a series of participant observation and transcribed interview sequences with six nurse participants, as they practised in adult acute care wards, I wrote fieldnotes and gathered textual data of clinical records and other documentation relating to each sequence. Attending to the validity of the study, I engaged in Bourdieu's notion of participant objectivation toward ensuring that this ethnography is from data and theory rather than from my preconceptions of what had been my way of life for 30 years. Incorporating this notion into the study has enabled me to use my knowledge and experience as a nurse both to gather data and in the writing up to then make the most of it. When viewing practice as a matter of concern, rather than a matter of fact, as they work in acute care nurses’ practices of work happen in a lived space, a place where everything is happening at once. This lived space is the within and between space where nurses get things done, undeterred by the complexities of this work environment. The term nurses’ practices of work is used in this thesis to fuse the idea of the professional practice of nursing, i.e. the practical work of practising nursing, with the idea of work as social relation, gathering nurses’ relations of work as professionals, clinicians and employees. Regulated because they align with the rulings of the doxa yet improvised because they are contingent and differ in each instance, nurses’ practices of work are characterised by reconnaissance, alertness, responsiveness, initiative and tenacity. In this temporalisation of Page iii nursing habitus toward anticipated futures, I have shown that nurses, working with multiple patients, colleagues and the concerns of healthcare delivery, accomplish the work of nursing in acute care in their practices of work. Further, when recognised as regulated improvisations in practices of work organised by the context of the work, this understanding of what nurses do is transferrable to any practice (of nursing) in any context. I have also shown that in misrecognising doxa as charisma, nurses and others underrate what nurses accomplish through their practices of work, and thus also misrecognise where the knowledge, skill and power lies in acute care which is in the work nurses do with and for patients, their practices of work within and between, their nursing. Page iv Acknowledgements I would especially like to acknowledge the support and commitment of my supervisors, Professor Trudy Rudge and Associate Professor Sandra West, who have challenged me to extend my thinking when I fell short, encouraged me to greater endeavours even when I thought I was already trying hard, believed in me when I wasn’t always sure I would get here, and enabled me to say what I wanted to say. This thesis, the realisation of my long-held aspiration to have what nurses do appreciated in this way, would not be what it is without their combined effort. I would also like to acknowledge the companionship and support of my colleagues at Sydney Nursing School as we worked on our individual research problems, attending schools, workshops and conferences while we shared workspaces, experiences and learning. And I would particularly like to thank my family who have been unswervingly supportive of my work and me, no matter what, providing me with a dependable background within which to study. Most of all I would like to thank Esk, Glenda, Ptraci, Polly, Susan and Agnes, the participants in this study, who generously gave of themselves and their time, making their practices available to this researcher. As representatives of the many, many nurses who work in the everyday of adult acute care wards, they have made it possible for the intricacy and complexity of nursing work in this dynamic context to be better understood. This thesis is dedicated to these nurses as, in practice, they ‘just do it’, accomplishing nursing moment-by-moment in the within and between. Contents Page v Contents Candidate Statement……………………………………………………………………………………………………………..i Abstract…………………………………………………………………………………………………………………………………ii Acknowledgements………………………………………………………………………………………………………………iv Table of contents…………………………………………………………………………………………………………………..v List of Appendices………………………………………………………………………………………………………………viii Lists of tables and figures.……………………………………………………………………………………………………..x Preface………………………………..…………………………………………………………………………………………..…..xi List of acronyms………………………………………………………………………………………………………………….xiv Chapter One: Introduction…………………………………………………………………………………………………….1 Why this study…………………………………………………………………………………………………………..1 Within and between: nurses’ everyday work practices on the wards…………………………3 Introducing the New Zealand healthcare system……………………………………………………….5 DHBs and nursing…………………………………………………………………………………………..6 Clinical decision-making: is this what nurses do?..........................................................8 Further cornerstones of the research ………………………………………………………………………11 An ethnographic approach………………………………………………………………………………………13 The organisation of the thesis………………………………………………………………………………….14 Summary…………………………………………………………………………………………………………………15 Chapter Two: Bourdieu's theory of practice as theoretical framework………………………………..17 Foundations of the theory of practice……………………………………………………………………..17 Bourdieu's philosophy of knowledge……………………………………………………………18 An ontology of practice……………………………………………………………………………………………20 The temporalisation of habitus…………………………………………………………………….20 Ontological correspondence in an activity of practical construction …………….22 Regulated improvisations…………………………………………………………………………….23 Contents Page vi Nursing in practice……………………………………………………………………………………….24 The practical tool kits of the theory of practice……………………………………………………….25 Habitus…………………………………………………………………………………………………………25 Field and capital…………………………………………………………………………………………..28 Symbolic power……………………………………………………………………………………………31 Relevance and critique…………………………………………………………………………………………….33 Summary…………………………………………………………………………………………………………………35 Chapter Three: Ethnography: Resolving methodological matters………………………………………..37 Ethnography as methodology ………………………………………………………………………………….37 Participant observation and participant objectivation………………………………….39 Thinking about the study design…………………………………………………………………..42 Planning for fieldwork ………………………………………………………………………………….45 Applications for ethical approval………………………………………………………………….47 Introducing the research site and the participants……………………………………….47 Fieldwork…………………………………………………………………………………………………………………48 Going about the observations………………………………………………………………………50 Making fieldnotes………………………………………………………………………………………..51 Negotiating situational identities…………………………………………………………………52 Identifying patient details…………………………………………………………………………….53 Field Logs and conversational interviews……………………………………………………..54 Gathering relevant background information………………………………………………..55 Textwork as rewriting, interpretation and analysis………………………………………………….57 Minimally manipulated accounts…………………………………………………………………57 Layers of interpretation……………………………………………………………………………….58 Situated vocabularies…………………………………………………………………………………..60 Initial exploration of the hospital documents……………………………………………….60 Contents Page vii Writing up……………………………………………………………………………………………………………….62 Rigour as congruence and integrity……………………………………………………………..64 Summary…………………………………………………………………………………………………………………65 Chapter Four: Working the gaps………………………………………………………………………………………….67 'Handover' and the patient list printout…………………………………………………………………..68 Taking stock, making and accepting adjustments…………………………………………………….75 Taking note of the ward management situation…………………………………………..75 Adjustments to caseloads…………………………………………………………………………….79 Nurse-nurse handovers………………………………………………………………………………..82 ‘Embellishing’ the map: from abstract space to practical space……………………………….87 Omissions from the handover………………………………………………………………………93 Summary…………………………………………………………………………………………………………………96 Chapter Five: Nurses’ work with patient flows…………………………………………………………………….98 Nursing as preparing