Within and between: an ethnographic study of the work of nurses in adult acute care wards

Abstract

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 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.