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Exploring historical and contemporary fragments of nurses’ invisible practice Macfarlane, Kim 1993

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EXPLORING HISTORICAL AND CONTEMPORARY FRAGMENTS OF NURSES'INNISIBLE PRACTICEbyKim MacfarlaneB.S.N. University of British Columbia, 1987A THESIS SUBMITTED IN PARTIAL FULFILLMENT OFTHE REQUIREMENTS FOR THE DEGREE OFMASTER OF ARTS (EDUCATION)inTHE FACULTY OF GRADUATE STUDIES(Department of Educational Psychology and Special Education)We accept this thesis as conformingto the required standardTHE UNIVERSITY OF BRITISH COLUMBIAOctober 1993© Kim Macfarlane 1993Department oThe University of British ColumbiaVancouver, CanadaDate C_. c3Z In presenting this thesis in partial fulfilment of the requirements for an advanceddegree at the University of British Columbia, I agree that the Library shall make itfreely available for reference and study. I further agree that permission for extensivecopying of this thesis for scholarly purposes may be granted by the head of mydepartment or by his or her representatives. It is understood that copying orpublication of this thesis for financial gain shall not be allowed without my writtenpermission.(Signature)DE-6 (2/88)AbstractThe social context in the hospital setting is fraught with competing andcontradictory versions about who nurses are and what they do. Using asociocultural framework, this thesis provides an analysis of historical andcontemporary texts related to hospital-based nursing, and argues that manythemes operative in these "official versions" of practice have rendered the breathand complexity of nurses' everyday practices "in/visible." Given that "officialversions" of nursing practice are reified in nurses' job descriptions, this researchdevelops a necessarily partial response to the following question: What arenurses' ideas about their in/visible practice within a hospital setting? Nurses'in/visible practice is, here, defined as the disparity between their "actual" practices,and the job description's "textual representations" of their practice (Smith, 1987 &1990). This investigation took place in an acute care hospital in British Columbia.Seven nurses comprised the primary research group. The research methods usedto investigate nurses' in/visible practice included: career autobiographies, directobservation, journals, unstructured one-on-one interviews and concurrent groupdiscussions. Data obtained from these methods underwent qualitative analysis,and both the researcher and the researched (nurses) jointly constructed thematicinterpretations of nurses' in/visible practice. This particular analysis of nurses'in/visible practice suggests that there are "profound" disparities between nurses'actual practices, and those represented in their job description. Nurses appear tohave resisted such textual representations and, in turn, have (re)invented complextheories of "thinking-in-practice," interwoven with an informal "learning with/inpractice curriculum."Table of ContentsAbstract^ i iTable of Contents^ iiiList of Tables vAcknowledgement viChapter 1: Developing a Concept of Nurses' InNisible PracticeWith/in A Sociocultural Framework.^ 1Introduction^ 1Overview and Refinement^ 2A Sociocultural Approach to Nurses' InNisible Practice^ 6Historical Context: A Past for the Future^ 11Early French Nursing Traditions 11Early British Nursing Traditions 15Returning to Canada^ 18Florence Nightingale 20Canadian Adoptions and Adaptations^ 27Putting Nurses Back Into Their Proper Place -- The Hospital^29Unionization and Uprisings^ 31Professionalization^ 34Contemporary Context: The Past as Present^ 37Feminism and Nurses' Image^ 37The Hospital Setting^ 39Nurses and Nursing Administration^ 40Nurses and Physicians 41Nurses and Medical Technology 42Nurses' Job Descriptions^ 43Chapter 2: Methodology^ 47Philosophical and Theoretical Assertions^ 48Sample^ 52Participants^ 52Informed Consent 53Issues of Anonymity^ 53Methods^ 54Career Autobiographies and Group Discussion^ 55Direct Observation^ 57Journals^ 59111ivConcurrent Group Discussions^ 60Closing Group Discussion 62Issues of Validity^ 63Chapter 3: Sites of Nurses' InNisible Practices^ 65Setting and Duration of Study^ 65Framing an Analysis of Nurses' InNisible Practice^ 65Nursing Education^ 69Nurses' Job Descriptions 70A Look At the Nurses and Their Practice^ 77Creating a Community of Practice Without an Official Identity^81Philosophies and Practices of Caring 82Problematizing Caring^ 88Building Theories For/From Practice^ 91Theories of Lived and Shared Practice 93Story-Telling With/in the Community of Nursing Practice^102Theories With/in Actual Practices^ 106Simultaneous Thinking-in-Practice Related to One Patient^107Simultaneous Thinking-in-Practice Across a Group of Patients^112Learning With/in Practice^ 122Chapter 4: Discussion^ 127Educational Implications 127Emphasizing Transformative Resistance With/in Nurses' Practicesand the Research Group^ 131Bibliography^ 139List of TablesTable 1: Performance Appraisal Criteria For Nursing Students atthe Nightingale School.^ 23Table 2: The Hospital's Job Description for Nurses.^ 72Table 3: A Representation of Kara's Thinking-in-Practice.^109Table 4: A Representation of Liz's Thinking-in-Practice. 113VviAcknowledgementIt is with a particular respect and admiration that I acknowledge the profoundcontributions of my advisors Mary Bryson and Jackie Baker-Sennett. I thank themsincerely for sharing the voices of their minds. I, also, wish to forefront thekindness, words of encouragement and sheer brilliance of the nurses whoparticipated in this study. Without all of these people, this thesis would have beenjust a series of sterile pages.InNisible Practice1Chapter 1: Developing a Concept of Nurses' InNisible Practice With/in aSociocultural FrameworkIntroductionAs a nurse, I have always been amazed by the complexity and scope of nursingpractice. Yet, I have become increasingly concerned and, frankly, dismayed abouthow nursing and nurses are portrayed in their workplace, and in the media. Manynurses have said to me, that they never get credit for what they "really" do. In fact,many suggest that it is only the nurses, themselves, who know the real extent oftheir practice. Many patients acknowledge nurses' care and compassion, but havelittle understanding of the complexities of their practices (CNA, 1990). Also, somephysicians cast nurses in the role of secretary or the follower of doctor's orders,and do not acknowledge the crucial patient care decisions that are made in theirpresence or absence (Jenny, 1990). Despite the facts that one out of every 118Canadians is a nurse, and that nurses represent the largest number (52%) ofhealth care professions, their practice remains in/visible (RNABC, 1990b). Thefollowing anecdote from my own experience helps to clarify the concept of in/visiblepractice:As a critical care nurse, I have become experienced in dealing withcardiac arrest situations. During one such event, I saw that thephysician who was supposed to be "in charge" of this situation, wasunsure of what to do, so I chose to take charge. Thus, in responseto the particular and potentially heart rhythms that the patientexperienced, I ordered specific drugs and treatments. When thepatient was stable, the physician left the patient's bedside, and wentto the nursing station to get the patient's chart. I saw him writingdown the patient's medical number from the chart, and asked himwhy he was concerned about getting this number. He said that heneeded this number so that he could bill the government for thispatient's cardiac arrest management. I was shocked.In/Visible Practice2My experience, recounted in this example, is not usual. Both the voices of mycolleagues and empirical research such as that conducted by Griffith, Thomas andGriffith (1991) suggest that: "Far and wide, nurses are performing -- mostly withoutMD supervision [or acknowledge] -- exactly the same services for which physiciansare being reimbursed" (p. 22). What I wish to expose, in recounting the aboveexample, is that through specific governmental billing practices, physicians arepositioned as the legitimate "experts" in relation to other practitioners like nurses.Administrative practices such as these, particularly in hospital settings, serve tomaintain doctors' superior position vis a vis the caregiver hierarchy and, at thesame time, make in/visible the important contributions of nurses.To clarify this idea about in/visibility, it should be emphasized at the outset thatthis word should not be taken literally. Visibility and invisibility (hence, in/visibility)are construed, here, as necessarily co-constituted aspects of practice; aspects thatare always operating simultaneously and, apparently, in a contradictory relation toone another (Apple, 1986; Britzman, 1991; Lather, 1991; Van Maanen, 1988). Inthe above example from my clinical practice, if I look at my cardiac arrestmanagement practices as they are construed by specific aspects of governmentbilling, my practices seem to be "invisible." However, I know that I have performedthis practice and, thus, it is "visible" if only to me. In the following discussion, I willprovide an overview of the directions and theoretical propositions that will guidethis work. At the same time, I will refine and define the core concept of nurses'in/visible practice, and delineate the research question operative in thisinvestigation.Overview and RefinementsThe intent of this chapter is to develop a framework which provides a basis for acontextualized understanding of nurses and their in/visible practice. RecognizingInNisible Practice3that this chapter is rather lengthy, the next few paragraphs are devoted to anoverview of the main points brought forth in this work, and to the rudiments of adefinition of nurses' in/visible practice. Nurses are construed, here, as purposefulbeings situated in particular historical, cultural, political and institutional contexts;contexts which are intimately linked to both the constitution of, and theirunderstanding of everyday practices (Bruner, 1986; Lave & Wenger, 1991; Luria,1979: Vygotsky, 1978; Wertsch, 1985 & 1991). After elaborating further on thissociocultural view of practice, I provide a review of Canadian hospital-basednursing practice. An analysis of a small sample of historical texts presents some ofthe "official versions" of nursing practice, and provides the basis for the argumentthat these versions serve as the foundation for nurses' contemporary in/visiblepractice. Like women's history, nurses' history is usually written by people whohold positions of authority and power (Chua & Clegg, 1990; Foucault, 1980;Hubbard, 1988; Reverby, 1987). The primary focus, here, is on the specificaspects of historical documents that pertain to conceptions of nursing practice. Inparticular, the analysis emphasizes how these authors portray nurses, and howthese characterizations serve to obscure or make in/visible the nature and scope ofnursing practice (Freire & Faundez, 1989; Smith 1987 & 1990; Van Maanen, 1988).The historical descriptions of nurses and their practices tend to be structured inrelation to the following themes: 1) self-sacrifice and altruism (e.g., the patientalways comes first); 2) loyalty, subservience and unquestioning obedience (e.g., tothe doctors and hospital); 3) de-intellectualization (e.g., nurses are "doers" and not"thinkers"); and 4) amorality and promiscuity (e.g., in comparison to men, nurses,as women, have an inferior character) (Aaronson, 1989; Gibbon & Mathewson,1947; Growe, 1991; Hubbard, 1988; Melosh, 1982; Reverby, 1987). The coreconcept that nurses can neither be trusted to complete the job, nor reallyunderstand the rationale for it, provides a justification for hospitals' and doctors'In/Visible Practice4strict monitoring and control over nurses (Cockburn 1985; Freidson, 1970;Warburton & Caroll, 1988). Themes that relate to self-sacrifice, legitimate the ideathat, no matter how lamentable their working conditions may be, nurses areobligated to do the job and not to complain (George & Larson, 1988). Thede-intellectualization theme is especially powerful because it suggests that nursesreally do not know what they are doing, so there is really no point representingnurses as practitioners or as authors of complex practices (Campbell & Bunting,1991; Hubbard, 1988; Reverby, 1987). Hence, nurses must have their history andpractice written for them. Although these themes are presented in more detail inthe body of this chapter, I mention them here to illustrate how history establishesprescriptive social norms for nursing practice. What is lost in these historical textsis a contextualized understanding of what nurses' felt, thought and did. However,at times, these texts also reveal how nurses have resisted hegemonic renderings oftheir practice (Gramsci, 1988).Moving from the historical to contemporary context, I use aspects of currentresearch to describe how the historical themes continue to operate, and point tosome alternative ways to construct and emphasize the complexities and richness ofeveryday nursing practice. In these discussions, two varying versions of nursingpractice are developed: 1) the "official" and decontextualized ones, which havebeen written by people who are, by the nature of their positions, both physicallyand mentally removed from everyday practice; and 2) the "unofficial" andcontextualized ones, which are based upon limited research and my ownunderstandings of nursing practice (Bateson & Bateson, 1987; Hutchinson, 1990;Lather, 1991; Wertsch, 1985 & 1991). Although the unofficial versions are quiteincomplete (due to the lack of research in this field), they are different from theofficial ones. This difference suggests that, within their own peer group, nurseshave learned and developed other versions of nursing practice, which resist andInNisible Practice5defy some of the prescriptive historical myths and norms imposed on them (Apple,1989; Ball, 1990; Goffman, 1961; Hutchinson, 1990; Lave & Wenger, 1991). Theresearch problem, however, becomes a question of how to refine ideas aboutnurses' in/visible practice in a way that provides a greater understanding of thenurses' versions and then, specifically, captures the disparity between the nurses'and official versions?Since I am interested in a contextualized understanding of nurses' in/visiblepractice, the site of this research will be in a hospital, and the focus is a descriptionof nurses' versions of their actual practices. With this first refinement in mind, thequestion becomes one of what document in this setting represents the hospital'sofficial version of nursing practice? In the hospital, nurses are evaluated on thebasis of standards for practice identified in their job description (Ball, 1990; Smith,1987 & 1990). Besides containing general statements about what nurses "should"do in their everyday practice, this document also serves three institutionalfunctions: 1) to categorize the nursing labour group; 2) to define and, thus, scopetheir practice; and 3) to coordinate and, thus, separate their practice from otherdisciplines, like medicine (Apple, 1989). Thus, its basic functions are analogous tothe historical texts written about nurses -- to define and confine nursing practicewithin a seemingly "natural" social order (power relations) within the hospitalsetting (Apple, 1989; Ball, 1990; Giroux, 1988; Smith 1987 & 1990). In addition,most job descriptions contain some of the historical themes of nursing practice (asoutlined above), which obscure the actualities of everyday nursing practice.Given its functions and its reification of historical themes, the hospital's jobdescription represents the institution's theory of nursing practice, and is the officialdocument that makes certain aspects of nursing practice institutionally sanctionedand visible and, by means of exclusion, makes other aspects of nursing practicein/visible (Apple, 1989; Ball, 1990; Giroux, 1988; Smith 1987 & 1990). By situatingIn/Visible Practice6nurses in their everyday work world, this research seeks to uncover a preliminaryand necessarily partial response to the following question: What are nurses' ideasabout their in/visible practice within a hospital setting? Nurses' in/visible practiceis, here, defined as the disparity between their "actual" practices, and the jobdescription's "textual representations" of their practice (Smith, 1987 & 1990). Thisdefinition, however, extends beyond identifying the practices that remainunacknowledged in nurses' job descriptions, and includes descriptions ofcontextual or social circumstances that are involved in shaping nurses' agency andresistance at local levels of practice (Britzman, 1991; Hall & Stevens, 1991; Rogge,1986). The following section provides a theoretical underpinning for constructingnurses' in/visible practice as a socially defined and distributed phenomenon.A Sociocultural Approach to Nurses' InNisible PracticeDuring the last two decades, various models of so called "human thinking" havebeen proposed within the parameters of an "information processing" theory ofcognition (e.g., Anderson, 1990). Such models typically model posit a number ofmechanistic mental structures, as well as a number of general and domain specificoperations/strategies for thinking (Anderson, 1990). In effect, such models aim toexplain the internal workings of the "mind." But, framing definitions of thinkingaround the notion of individually owned or objectified mental processes only serveto limit our understanding of human thought. Such analyses, say little about howsocial contexts shape minds (Bruner, 1986; Lave & Wenger, 1991; Wertsch, 1985& 1991; Vygotsky, 1978). Given this profound constraint, I will focus on "how"social contexts shape what we typically refer to as "the mind." The importance ofsocial contexts in the formation of thinking will unfold, here, with the help ofVygotsky's (1978) and Wertsch's (1985 & 1991) theoretical perspectives. Arguingthat thinking has social and not individual foundations, sociocultural theorists workInNisible Practice7from a(n) inclusive and contextual approach to human thought; an approach whichsimultaneously considers the person's thinking and his/her social experiences(Wertsch, 1985 & 1991; Vygotsky, 1978). From this perspective, thinking is placedin relational and contextual terms which opens the door to a more complex andmultifaceted interpretation of human thought (Bateson, 1979; Belenky, Clinchy &Tarule, 1986; Lindesmith, Strauss & Denzin, 1988; Rohrkemper, 1989).Central to this sociocultural approach to thinking is an account of the role oflanguage. Both Vygotsky (1978) and Wertsch (1985 & 1991) view human thinking"as a world processed through language," (Bruner, 1986, p. 70); and argue thatlanguage is not most productively viewed as "neutral" or "innate" but, rather, as aproduct of our specific historical and cultural locations. From this perspective,language and the ways that we use it reflects our culture's storehouse of historicalknowledge (Luria, 1979). As a point of clarification, here, this discussion is notmeant to suggest that to be a member of a particular society is to know all, or tosuggest that people are the passive recipients of historiocultural knowledge. Nor isthis an attempt to suggest that all people think in the same fashion. What it ismeant to suggest is that people are instrumental. In other words, they have themental capacity to mediate experience, but the origins of these capacities, the waysin which we learn to think, are reaffirmed, limited and empowered by ourexperiences within the social context -- our social interaction through language(Bruner, 1986; Luria, 1979; Wertsch, 1985). Thus, the "mind" cannot be conceivedas something that works in isolation "inside the skull," but rather as something thatextends to and develops within a social context. The "mind," construed thus, issocially constructed and distributed (Lindesmith, Strauss & Denzin, 1988). Toexpand upon the notion of the socially constructed mind, I will discuss twointerrelated concepts developed by Vygotsky as follows: 1) the zone of proximaldevelopment; and 2) the general genetic law of cultural development. To VygotskyInNisible Practice8(1978), the social context, be it the home, school or workplace becomes anongoing zone of proximal development (ZPD) (Lave & Wenger, 1991; Rohrkemper,1989). Specifically, the ZPD represents the gap between what an person can doindependently, and what the person can do with the help of others (Vygotsky,1978). It is a place where mental apprenticeship occurs; a site of learning wherewith the help of others, a person learns his/her culture's language -- the specificways and means of knowing that are defined as historically, culturally andinstitutionally acceptable. A key assumption underlying the ZPD is that theprecursors to any person's mental functioning are situated within his/her socialcontext. The idea that the foundations for thinking are contextual is furtherexplained and refined by Vygotsky's general genetic law of cultural developmentwhich he describes in the following terms (quoted in Wertsch, 1991, p. 26):Any function in the child's [or adult's] cultural development appearstwice, or on two planes. First it appears on the social plane and thenon the psychological plane. First it appears between people as aninterpsychological [intermental] category, and then within the child's[or adult's] intrapsychogical [intramental] category. This is equallytrue with regard to voluntary attention, logical memory, the formationof concepts, and the development of volition. . . [I]t goes withoutsaying that internalization transforms the process itself and changesits structures and functions. Social relations or relations amongpeople genetically underlie all higher functions and theirrelationships.Vygotsky's law of cultural development makes a number of assertions. First, itunderscores the central role of language as the mediator of both "intermental" and"intramental" thought. Second, it goes beyond the notion that intramentalfunctioning involve mere duplications of intermental ones. He underscores theimportance of conceptualizing internalization as a process through whichintermental activities are reconstructed within intramental ones. This suggests thatparticular intermental functioning leads to related intramental ones. In this way, theInNisible Practice9nature of intramental functioning remains quasi-social; it is derived from thelanguage or "voices" of others (Wertsch, 1991). To make this point clearer, I willuse this paper as an example and pose Wertsch's (1991) question: "Who is doingthe talking?" (p. 63). Of course, the obvious answer to this question is that I am theauthor of this text and, therefore, that I am doing the talking. But is this really so?The structure of this paper is modeled upon the university's requirements for suchpapers, and the constraints delineated within Publication Manual of the American Psvcholociical Association (1983) guidelines. These standards for writingrepresent a particular discourse that is based upon specific and situated normativeassumptions. In addition to deriving the structure of this paper from such locations,I am also intertextually using the knowledge of the authors cited in the text of thispaper. Thus, the research question I am asking as well as the structure andcontent of this paper has its roots in a particular social context. Returning to thequestion: "Who is doing the talking?" I shall answer it here, provisionally by sayingthat I am doing the talking, but my voice has been shaped by, and superimposedover, the voices of many (Wertsch, 1991).Third, although Vygotsky's law of cultural development seems somewhatpolitically neutral, the social contexts are not necessarily liberating; oftentimes, theybecome restrictive through prescriptive norms that define acceptable forms ofthinking and action. I shall use my paper writing example to expand upon thispoint. Besides adding credence to the idea that the mind is socially constructed,this example also speaks to a broader issue and to the heart of this work. Itunderscores the idea that particular modes of thinking, like the way to structure aresearch paper, must meet some culturally acceptable norms in order to be seen asvaluable (Aronowitz & Giroux, 1991; Hubbard, 1988; Lather, 1991; Wertsch, 1991).These norms become unquestionably predominant and in this process, hegemonic;they assume that there is only one right way, even though there are possible andInNisible Practice10feasible alternatives (Goodman, 1989; Gramsci, 1988; Wertsch, 1991). And theconsequence for violating these norms, like using an alternative way for presentinga research paper, would surely result in some form of social sanction (e.g., therejection of the work). But, of course, given the right set of social circumstances,people do begin to question norms like these, and do learn to explicitly or implicitlyresist and violate them (Lewis, 1990; Wertsch, 1991). Thus, the idea explored inthis thesis of nurses' in/visible practice arises from a lived commitment totransformative resistance (Lather, 1991; Weiler, 1988).In keeping with the sociocultural traditions of Vygotsky and Wertsch, the intentof this literature review is to establish the historical, cultural and institutionalprecedents of nurses' contemporary in/visible practice. In so doing, this analysisfocuses on the language or "discourse" that purports to describe nursing practice.By focusing on language, I will attempt to expose the particular social norms orconceptual filters that place selective attention on particular aspects of nursingpractice, while ignoring and silencing others (Wertsch, 1985 & 1991). In addition,where the historical texts allow, I analyze aspects of nurses' practices that focus ontheir agency and resistance to specific oppressive social circumstances.Before I begin, however, it is important that I make explicit particularassumptions about history and language that I am using to guide thishistoriocultural review. History is here viewed as "stories a culture tells itself aboutitself' (Lather, 1991, p. 2). The notion of history as "stories" is an inviting one, as itassumes that each rendering of history is incomplete. No story can tell all and, inthis sense, history is always fragmentary in nature (Foucault, 1980). It alsoassumes that any account of history is constrained by the author's position in theculture, his/her conceptions about the audience to whom (s)he is writing, and bythe language and literary devices that (s)he uses (Van Maanen, 1988). Thefollowing history of Canadian hospital-based nursing has been written by people inInNisible Practice11dominant positions (e.g., priests, physicians, sociologists, as well as nursingtheorists and researchers) "for" nurses. With this in mind, my guiding questions forinterpreting and trying to uncover the thinking and experiences of nurses acrosstime are: "What is missing from these historical texts?" and "Why is the unsaidimportant?" (Aronowitz & Giroux, 1991). I do not intend to provide an extensivehistorical review; however, I will focus on historical fragments that seem to benoteworthy, precedent setting or cyclical.Historical Context: A Past for the FutureThrough Jacques Cartier's numerous voyages across the Atlantic, in the 1500's,France laid down its colonist rights to Newfoundland and vast areas along the St.Lawrence River (Kerr, 1988a). However, it was not until the next century thatSamuel de Champlain selected Quebec as the first Canadian site for colonization,and that nursing began within a specifically Canadian context (Kerr, 1988a).Within these beginnings, I discuss the French and British origins of Canadiannursing, and select a few textual fragments to discuss how this discourseconstructs and constrains nursing practice.Early French Nursing Traditions The French monarchy, in consultation with the Jesuit priests, decided that theestablishment and organization of health care services, in the new land, shouldprecede widespread colonization (Kerr, 1988a). To achieve this goal, the firstdoctors (some with their wives), and Jesuit priests arrived in the late 1610's, andeventually established a "sick bay" with immigrant male attendants at a garrison inPort Royal (Gibbon & Mathewson, 1947). At this point, these people provided"health care" to Native Indian populations. This latter statement does not suggestthat Native Indians did not have their own forms of health care; indeed, theypracticed extensive healing rituals, and used herbal remedies for various ailmentsInNisible Practice12(Gibbon & Mathewson, 1947). But, as the priests explored the country side on theirmission to spread Christianity to these people, they idealized and legitimized theirreligious practices by relating them to the "care and cure of the sick." As Parkman(1897, p. 179) wrote:The Jesuits singly or in pairs traveled in the depth of winter fromvillage to village, ministering to the sick and seeking to commend theirreligious teachings by their efforts to relieve bodily distress.As the Jesuits continued their ministry and "care of the sick," they wereincreasingly concerned about the "propriety" of men, like themselves, caring forsick women. As Father LeJeune (1634) wrote in the Jesuit Relations (Jesuitjournals that were sent back to France):As to men, we will take care of them according to our means; but, inregard to women, it is not becoming for us to receive them into ourhouses (quoted in Kenton, 1925, p. 49).When the news of this concern reached France, a call for nurses to immigrate tothe new world ensued. At this time, "young women of good character, who camefrom reputable families" were recruited by the Catholic Church and were trained asboth nuns and nurses (Kerr, 1988a, p. 11). In 1634, three nuns/nurses landed inQuebec. Kenton provided this account of the circumstances upon their arrival andin the ensuing months (1925, p. 157):Scarcely had they disembarked before they found themselvesoverwhelmed with patients. The hall of the hospital being too small, itwas necessary to erect small cabins, fashioned like those of thesavages, in their garden. . . The sick came from all directions in suchnumbers, their stench was so insupportable, the heat so great, thefresh food so scarce and so poor, in a country so new and strange,that I do not know how these good sisters, who almost had no leisurein which to take a little sleep, endured these hardships.Beyond the explicit descriptions of the environmental conditions within this text,there are some glimmers of the social values pertaining to nurses of this time.InNisible Practice13Nurses were supposed to sacrifice their own needs for the sake of their patients.This notion of self-sacrifice appears to be a universal theme, which transcendshistorical as well as sociocultural nursing contexts (Aaronson, 1989; Gibbon &Mathewson, 1947; Growe, 1991; Melosh, 1982; Reverby, 1987). Although theabove author writes in an empathetic tone, he is silent about: 1) the courage thatthese women must of had to travel to a(n) "new and unknown world;" 2) how thesenurses cared for their patients; and 3) what they thought and felt about theircircumstances. The latter point tends to be consistent in most historical writingsabout nursing (Jones, 1988). There are descriptive images of nurses, but noinsights into the particulars of their practice or discussions of what their nursingexperiences meant to them.In the subsequent years leading up to the Seven Year War (1756-1763)between the English and French, immigration and health care services markedlyincreased. Two hospitals were established under the Catholic Order at Quebec in1639 and at Montreal in 1644, and were both called Hotel Dieu (Dock, 1920). Thewidespread immigration of initially men followed by an influx of young women whowere to become these men's wives, brought numerous epidemics of small pox,yellow fever, plague, and so on. Typically, these diseases were introduced to theNew World by the passengers from Old World ships. The worst case on recordwas of a small pox outbreak, occurring in 1703, which killed 25 percent of the nunsat the Hotel Dieu of Quebec. As the archivists of the Hotel Dieu recounted (quotedin Gibbon & Mathewson, 1947, p. 35):Our sisters fell ill in such numbers from the very first that there werenot enough of those who were to look after the infected cases in ourrooms and wards. We accepted the offer of service from many goodwidows.Beyond the horrific circumstances described in this text, it is also important tonote that additional lay nurses were selected on the basis of their "single" orInNisible Practice14"widow" status. Nursing, for the nuns and lay women alike, was supposed to be a"calling" far beyond husband and most wifely obligations; and, at this point, nursingwas construed to be a "self-sacrifice" extending beyond life itself (Dock, 1920).The former theme strongly reemerges in Florence Nightingale's writings, andfollows nursing up until the 1960's (Dolan, 1979).During the Seven year war, the nuns in Quebec were close to the front lines ofthe war. In fact, the final battle was literally fought around their hospital.Importantly, the nuns administered care to injured soldiers of both English andFrench armies (Gibbon & Mathewson, 1947). Although they must have fearedretribution from the French government, the nuns' sense of "caring" seemed to takeprecedence over competing political agendas. Historical texts of this time tend torepresent these nuns as "angels of mercy." However, this characterizationobscures the fact that these women were actually exerting a form of autonomousregulation over their nursing practice, and actually resisting their government, inthat they were caring for "enemy" soldiers (Kalisch & Kalisch, 1978; Morawski,1988).The history of the early French traditions of nursing care in Canada is quiteprestigious. French nursing, under the Roman Catholic Church, brought toCanada: 1) a philosophy of humanitarianism; 2) a legacy of high status which hadthe autonomy to question; 3) a fortitude to undermine political authority; and 4) atraining program, which had "invented" sanitary practices to prevent the spread ofdisease (Gibbon & Mathewson, 1947). The latter point was especially important inrelation to the many epidemics. There was, for an example, an outbreak of plagueintroduced to the New World by a disease infested ship in 1740. The Hotel Dieuadmitted 241 plague stricken patients of which only 28 died (Gibbon & Mathewson,1947). This low death rate (12%) was solely attributed to the nuns' sanitarypractices. The death rate of those in the community was astronomically higher. InIn/Visible Practice15addition, the physicians mostly practiced in the community and, as a consequence,the nuns had autonomy over the administration of their practices hospitals settings(Gibbon & Mathewson, 1947). The key elements of hospital-based nursing withinthis period are that the nursing profession was overwhelming represented asfemale, and with strong affiliations to the church. Nursing, thus construed, typifiesthe female traits of "caring and compassion," and the church's requirements of"self-sacrifice, altruism and chastity" (Church, 1990). However, unlike the Britishtradition, which follows, nursing has some elements of autonomy, respect andpolitical authority.Early British Nursing Traditions In contrast to the French, the British who subsequently settled in the Maritimes,Ontario, and the West, brought a significantly different approach to nursing. Duringthe reign of Henry VIII (1491-1547), the Catholic Church was renounced and thenursing orders of nuns, who trained and worked in the large London hospitals, wereasked to leave (Jamieson & Sewall, 1940). Their replacements were typically poorand illiterate women who were put to work without any training. In the absence ofthe nuns' guidance and expertise, hospital care deteriorated. As a consequence,these women were construed as "incompetent," and the hospitals in which theyworked were now called "death houses" (Gibbon & Mathewson, 1947). At thesame time as hospital nurses were to a large extent discredited, the women healers(lay nurses) in the community received ongoing praise and support from thepeasant groups who received their care (Gibbon & Mathewson, 1947). Lay nurseswere illiterate, and their nursing education was informally handed down fromgeneration to generation through story-telling practices. These nurses"discovered" a number of "tried and true" herbal remedies, some of which are stillInNisible Practice16being used today (e.g., digitalis for heart problems, belladonna for abdominalspasms, ergot for pain) (Ehrenreich & English, 1973).Given their compassionate and, oftentimes, successful care of the sick, thesenurses had developed a strong power base within the peasant populations; apower base that dramatically clashed with the upper class' designs to establishmale physicians as the only valid health care providers (Bunting & Campbell,1990). To erode the power base of women healers and other politically powerfulwomen, the church and state typically labeled them as "witches." Church sermonswere scripted around the "witch persona," with the intention of frightening thegeneral public into believing that these women were evil. The church describedthem as follows [Kramer & Springer, 1928 (1484), p. 25]:All witchcraft comes from carnal lust, which in women is insatiable.. .Wherefore for the sake of fulfilling their lusts they consort with devils... it is sufficiently clear that it is no matter for wonder that there aremore women than men found infected with the heresy of witchcraft.. .And blessed be the highest who has so far preserved the male sexfrom so great a crime.. .What this text makes clear is that the devilish "amoral" character of women is"contagious," and that men through their relations with women can become infectedwith this "amoral disease" just as Adam was represented as having been afflictedby Eve in the Garden of Eden (Ehrenreich & English, 1973).For their supposed crimes of witchcraft elderly women, young women andfemale children were usually burned live at the stake. Common charges againstthese women included: first, sexual crimes against men --- basically, they wereaccused of possessing an agentive form of female sexuality; second, crimesrelated to being organized --- which usually amounted to organizing socialgatherings; and third, crimes related to the possession of magical powers forhealing---oftentimes, woman healers were specifically charged with having medicalInNisible Practice17or obstetrical skills (Ehrenreich & English, 1973). Sadly, the witch/nurse of thesetimes was usually poor and illiterate; thus, her history was only recorded throughthe eyes of the educated elite, in fact, her persecutors.The witch hysteria in England started in the mid 1600's and lasted throughoutthe 1700's. The empowerment of women by the peasants represented a political,religious and gender threat to the upper class and the church (Daly, 1978;MacPherson, 1985). They orchestrated the fearful witch persona, that ultimately,legitimized the slaughter of "millions" of women, whose only crimes were politicalactivism and caring for the sick poor. Although the medical profession reapedsome of the benefits of the witchcraft campaign, namely the suppression of thefemale nursing profession, it was not of their own design (Dolan, 1978; Ehrenreich& English, 1973; Jones, 1988). The witch hunts were ". . . well-ordered, legalisticprocedures that were financed and executed by the church and state institutions"(Bunting & Campbell, 1990, p. 17), with the general goal of maintaining socialcontrol -- that is to say, maintaining the various subservient roles of women (Daly,1978). And, the social construction of the nurse in the hospital setting served as ameans to maintain this social order.In the 1800's, poor and illiterate women were still working in deplorable hospitalconditions. In the hospital wards, overcrowding (some open wards held as manyas 100 patients) created the need to put beds so close together that it wasimpossible to clean between them and, as a consequence, garbage and excretacollected. The mattresses were either straw or feathers and were not alwayschanged between patients. These dirty beds promoted the growth of manypathologic organisms as well as ticks, bedbugs and roaches (Jamieson & Seawall,1940). In addition, popular medical treatments of this period included blood lettingand purging (Ehrenreich & English, 1973). Thus, poorly kept beds, floors and wallswere further contaminated with blood and feces. The women who worked in theseInNisible Practice18conditions received very little pay, yet were expected to work 12 to 48 hours in arow (Jamieson & Sewall, 1940). Moreover, their reputations were maligned as"drunken, heartless, amoral and incompetent" women (Jones, 1988). Dicken's[1968, (1844)] character of "Sairey Gamp" in his novel The life and times of Martin Chuzzlewit, seems to be exemplary of common views about nurses of this era.Like the witch persona, this character was more concerned with her personal andsexual pleasures than with the welfare of her patients (note: this character/image ofthe nurse resurfaces in the 1970's) (Kalisch & Kalisch, 1978; Jones, 1988). This,however, was only one perception of reality. According to another source (LondonTimes, 1857), these women were represented as the victims of their class andgender (quoted in Gibbon & Mathewson, 1947, p. 110) as follows:They [nurses] were sworn at by the surgeons, bullied by the dressers,grumbled at and bossed by the patients, insulted if old and ill-favoured, talked flippantly to if middle-aged and good-humoured.In this text, nurses are "not" portrayed as having deficient character traits (e.g., likethe Sairey Gamp image), but rather as a group of women who have had particularoppressions imposed on them (Melosh, 1982). Nurses are not creators, but ratherrecipients of these forms of oppressions.Returning to CanadaWhile the French Roman Catholic nuns played a major role in the establishmentof early Canadian hospitals, the British Anglican, Presbyterian, and MethodistChurches were more involved with the establishment of hospitals in the Maritimes,Prairies and British Columbia (B.C.). Although Canadian nursing was spared from"witch hunts," the British legacy of poor hospital conditions and the Sairey Gampimage became integrals part of Canadian nursing history.By the 1800's, Canada's major cities were settled by Loyalists who had left theUnited States after the Civil War, and by immigrants from mostly the British IslesIn/Visible Practice19and France (Kerr, 1988c). This constant immigration, coupled with the industrialrevolution which encouraged people to leave their country homes and move intothe cities, created overcrowding. As a consequence, it was difficult for cities todevelop and maintain adequate public sanitation. Thus, many epidemics brokeout, because of contaminated water supplies (Kerr, 1988c). These persistentepidemics resulted in overcrowded hospitals (Gibbon & Mathewson, 1947).The dismal state of the British hospitals was paralleled in Canada. Lay womenwho were, for the most part, poor and illiterate worked long hours in overcrowdedand filthy wards (Kerr, 1988c). And like their British counterparts, they weredescribed in terms of the "Sairey Gamp" image, as evident by the following textwritten by a physician (Gibbon & Mathewson, 1947, p. 146):In my day, age and frowsiness seemed the chief attributes of thenurse, who was ill-educated and was often made more unattractive bythe vinous odour of her breath. Cleanliness was not a feature, eitherof the nurse, the ward or the patient. . . Armies of rats frequentlydisported themselves about the wards, and picked up stray straps leftby the patients, and sometimes attacked the patients themselves.. .Many of them [meaning nurses] were so well described by Dickens.. .Although this physician makes explicit the terrible hospital conditions of the mid1880's, he has no sympathy in his voice for the nurses or, for that matter, thepatients. It is as if the nurses were "responsible" for these conditions, when in fact,they had nothing to do with creating them. Given that they worked up to 19 hours aday, it seems implausible to suggest that these women had the time or theinclination to enact the "Sairey Gamp" image (George & Larsen, 1988; Gibbon &Mathewson, 1947).In these historical fragments, I have addressed the origins of Canadian nursingpractice. In these discussions, the French nurses have resisted the politicalagenda of their government, and discovered the sanitary practices, which are stillbeing implemented today. In addition, the British lay nurses have pioneered someInNisible Practice20of the drug therapies still in use today. However, this heritage of creativity is mutedby or overlaid with the discursive themes of amorality, self-sacrifice and altruism.As hospital conditions deteriorated, these themes become instrumental in silencingnurses' forms of resistance, and in silencing the practices that they may haveinvented (George & Larsen, 1988). The next section presents a discussion ofFlorence Nightingale's impact upon nursing practice. As this discussion unfolds, Iinterconnect the impact of the "witch hunts" and "Sairey Gamp" image on FlorenceNightingale's designs for nursing education, administration and practice.Florence Nightingale No history of nursing, be it British, American or Canadian, can be put intoperspective without an understanding of Florence Nightingale's influences.Nightingale's prescriptions for nursing education, administration and practicecontinue to have profound impacts on contemporary nursing practice. Thus, tounderstand today's renderings of nursing practice, it is important to trace thehistory that influenced Nightingale's reforms to British health care.Florence Nightingale was born into an upper class English family and, throughthe help of her father, received an extensive classical education (Welch, 1990).Although her written work spanned across numerous fields including translations ofPlato, bio-statistics, children's stories and, of course, accounts of nursing(Whittaker & Olesen, 1964), there are two early themes that merit special attentionwith respect to her influence upon nursing: women's rights and faith in God. In herearly writings in the Cassandra, Nightingale (1930) voiced her frustrations withsociety's disregard for, and suppression of, the gifts and talents of women, asfollows: "why have women's passion, intellect and moral activity. . . been ignored .. there is no place in society where these talents can be exercised" (p.395-396).The other important theme found in her early work was that of her relationship toInNisible Practice21God (Corbett, 1990). In 1837, she reported in her diary a "vision from God" thatconvinced her to devote her life to "God's" service (Cook, 1913).Nightingale introduced herself to nursing education by, first, attending theInstitution for Nursing Deaconess in Germany. Finding this education less thanadequate, she then went on to the Paris hospitals and studied with nuns (the sameorders that had originally settled in Quebec). Here, she learned about the sanitarypractices that she eventually operationalized in the Crimean War (Gibbon &Mathewson, 1947).In 1854, persistent reports of the conditions at the Scutari hospital (in theCrimean) flowed back to England. Through the influence of her friend, SidneyHerbert the Secretary of the War, Nightingale was commissioned to establish betterhospital conditions (Chua & Clegg, 1990). She and 38 other nurses went to theCrimean and, after their establishment of sanitary practices, the mortality ratedropped from 47 percent to less than three percent (Gibbon & Mathewson, 1947).The news of this momentous success rapidly returned to England, and Nightingalebecame a celebrity.In the Victorian era, the main literary themes were romanticism andhumanitarianism, and Nightingale's Crimean mission appealed to these popularthemes (Whittaker & Olesen, 1964). As a result, she received many literarytributes including Longfellow's poem (1857) "Santa Filomena," which representedher as nothing less than a "saint" (quoted in Jones, 1988, pp. 237-238). In thispoem, Nightingale was depicted as a heroine -- an "angel of mercy" of the sick andwounded men who sacrificed life and limb for their country. However, the othermetaphor operating in this text was the extension of the Victorian mother role(Reverby, 1987; Welch, 1990). Instead of caring for her own sick children, thisnurse was caring for the sick and injured sons of England.In/Visible Practice22Upon her return to England, Nightingale was less concerned about her literaryaccolades and more concerned about the "incompetence" of the Crimean nurses.In writing to a friend, she described these women as needing "constantsupervision" and "discipline;" they were "unable to learn from experience," and"incapable of autonomous thought" (Cook, 1913). These writings, which inessence built a deficit model for nurses, were an extreme departure from her ardentconcerns for the rights of women found in the Cassandra. Given the conditions shewitnessed in the Crimean War and her beliefs about the incompetence of nursingpersonnel, Nightingale, now, thought that the health care of British people andservice to God should take precedence over the women's rights (Nightingale, 1954;Palmer, 1977). Put another way, she thought women's rights must be sacrificed forthe greater Christian good -- better hospital care for all British citizens. Thistransformation in her thinking had a powerful impact on how she set uphospital-based nursing education and administration.In 1860, Nightingale opened a two year nursing education program at the SaintThomas Nursing School. Here, she instituted a "militaristic discipline" and a "moralcode" that reflected her experiences in the Crimean as well as her religious beliefs(Pelley, 1964; Stevenson, 1990). Her nursing students, whom she called"probationers," underwent a rigorous training program, and devoted 12 hoursduring the day or night to schooling (Nightingale, 1954). Students' ward work wasunder the direct supervision of experienced nurses. This form of training was akinto the apprenticeship models that were popularized by trade occupations of thistime (Chua & Clegg, 1990). Students spent most of their time on the drill andpractice of numerous psychomotor skills (e.g., dressings, applying leeches, makingbeds, etc.), as evident by the performance appraisal form found in Table 1 (seesection entitled Clinical Performance p. 23).InNisible Practice23Table 1: Performance Appraisal Criteria For Nursing Students at theNightingale School.Moral Character:1. Sobriety2. Honesty -- especially as to taking petty bribes from patients.3. TruthfulnessClinical Performance:1. Punctuality--especially as to the administration of food, medicine and wine2. Quietness3. Personal neatness and cleanliness4. Dressing of blisters, burns, sores, wounds, fomentations and poultices5. Applying leeches, internally and externally6. Enemas for men and women7. Management of trusses and uterine appliances8. Rubbing body and extremities9. Moving, changing, cleaning, feeding, and preventing bed sores of helplesspatients.10. Making bandages and lining splints11. Making beds12. Waiting for operations13. Sick cooking--making gruel, arrowroot, egg flip, puddings and drinks14. Cleanliness of utensils for cooking and secretions15. Keeping the ward fresh16. Observations of the sick -- secretions, expectorations, pulse, skin, appetite,intelligence, delirium, stupor, breathing. sleep, states of wounds, eruptions, effectsof diet, stimulates and medicines, and signs of approaching death• On each clinical criterion, a student received an (E) for excellent or an (I) forimperfect.From: (Nightingale, 1954, pp. 254-255).In/Visible Practice24Item 16 in Table 1 (observations of the sick), was not meant to suggest thatstudents or, for that matter, nurses were "never" to consider making a medicaldiagnosis. This function was the sole right of the physician. As Nightingale wrote(1954, p. 165):A nurse should never diagnose. . . A nurse who realizes her part ofthe work may be of invaluable service to the doctor and the patient.. .We nurses are and never will be anything but servants of the doctorsand good faith servants of the doctors we should be, happy in ourdependence which helps accomplish great deeds.As the above quote indicates, Nightingale saw the role of nurses as "passive."Nurses were the vehicles "through which" physicians learned about patients'symptoms and, then, drew the appropriate conclusions. This idea polarized thephysician-nurse relationships in two ways. First, it divided nurses' work into acts of"mindless doing," and physicians' work into acts of "thinking" (Reverby, 1987;Stevenson, 1990: Welch, 1990). Basically, nurses were to have "good faith" and,thus, never think about or dare to question the conclusions of physicians. Second,nurses' roles were not autonomous but, rather, "subservient" to that of physicians.Thus, Nightingale reified Victorian era definitions of gender roles, seeing femalenurses as subordinate to male doctors. In addition, the polarization betweennurses and physicians was symbolized by the clothes they wore (Goffman, 1956 &1961). The above reference to the image of nurses as "servants" was reinforcedby their clothing. Students of the training school wore white frilly starched apronsthat tied into a bow in the back, and a rounded white linen hat (Cook, 1913). Thisstyle of uniform and hat closely resembled those worn by servants who worked forthe upper class (Dolan, 1978; Jones, 1988). Furthermore, like the military, thenurses' uniforms indicated rank. Students' uniforms were of a different colour andstyle than those of graduate nurses. In contrast to nurses, physicians simply woretheir everyday clothing to the hospital.InNisible Practice25The "witch hunts" and "Sairey Gamp" regime, which were particularlydevastating to nursing, played major roles in Nightingale's methods for reformsLearning from this history, she used two general strategies to uplift nursing: 1)make it nonthreatening, especially to medicine and the church; and 2) make it intoa moral domain (Melosh 1982; Stevenson, 1990). As discussed in the last fewparagraphs, Nightingale defined nursing in subservient terms in relation tomedicine. This strategy served to off set any concerns that doctors might haveabout maintaining their dominance in health care and, also, served to legitimize theprofession by reference to a "higher authority." The latter point was consistent withthe "ideologies of work" of this period (Chua & Clegg, 1990).Using the second strategy, that of making nursing moral, Nightingale refused toadmit any women into her training program who appeared to resemble the "SaireyGamp" image. She frankly wrote: "I must bar these fat, drunken old dames."(quoted in Gibbon & Mathewson, 1947, p. 110). Although she placed no admissionrestrictions in relation to class, religion, or race, Nightingale only admitted womenwho were "single and of high moral character" (Nightingale, 1859 &1954) . Sheenforced this moral standard throughout the program, as evident in theperformance appraisal form (see Table 1: Moral Character section, p. 24). Anybreach in sobriety, honesty or truthfulness was grounds for automatic dismissal(Nightingale, 1954). In addition, Nightingale required "all" students to live in asupervised residence on the hospital grounds. This ensured the sexual propriety ofa convent (in heterosexual terms), and served as a recruitment strategy to establishrespectability, so that women from "good homes" (e.g., upper class) would beattracted to the school (Chua & Clegg, 1990). The living-in system also excludedmarried women and widows from the school (Nightingale, 1954). Thus, like for thenuns, nursing was a calling that went before husband, and family obligations.InNisible Practice26Through the efforts of Nightingale to reverse the Sairey Gamp image, nursingbecame a socially acceptable form of work for women of all classes. However, itwas the upper class women who were promoted within the nursing departments ofhospitals (Warburton & Caroll, 1988). As a point of clarification here, these nursingmanagement positions like matron or supervisor, were under the authority of malehospital administrators and under the supervision of physicians (Warburton &Caroll, 1988). It was basically the same set-up as the male/priest and female/nunhierarchies found within the church (Reverby, 1987). After graduation, these upperclass women rapidly became heads of wards or even heads of nursing departments(Chua & Clegg, 1990). Although the female hierarchies expanded within nursingdepartments, the division of labour was based upon class distinctions: the upperclass nurses were administrators; and the lower class nurses were "ward workers"who provided direct patient care (Reverby, 1987; Warburton & Caroll, 1988). Liketheir relationships with physicians, ward nurses were supposed to be "subservient"to their elite bosses. "Unquestioning loyalty" and "silent obedience" were the"militaristic" prerequisite traits of the "good" ward nurse (Chua & Clegg, 1990;Reverby, 1987; Stevenson, 1990). In public, hospital administrators spoke ofnurses' work in terms of performing "distinctly women's work," comparing it to ". ..mothering adults who were, when sick, all babies;" and authors spoke of theprofession in terms of the ". . . quick eye, the soft hand, the light step, and theready ear of woman" (Chua & Clegg, 1990, p. 140).Nightingale defined the nurse as female and nursing as an art, rather than ascience (Baly, 1986 & 1989). It was the practical application of female traitsdedicated to the service of humankind (Mellar, 1989; Nightingale 1859 & 1954). Inessence, she professionalized the domestic roles of the Victorian woman (Hughes,1990). The popular conception of a "female nurse" became a kind of metaphor for"mother;" the "male physician" became a metaphor for "father;" the "patient"InNisible Practice27became a metaphor for "child;" and the "hospital" became a metaphor for "house"(Ashley, 1976; Schattshneider, 1990). Although Nightingale dramatically reformedthe hospital system for British citizens, it was paradoxically at the expense ofnurses' and women's rights. In her later writings, she admitted to this last point, asfollows: "I am brutally indefinite to the wrongs of my sex" (quoted in Cook, 1913, p.92). Unlike other women reformists of the time, she spoke in the language of "duty"and not in terms of "rights" (Reverby, 1987; Welch, 1990). In fact, her model fornursing was built upon the concept of militaristic duty, and duty was interpreted,here, in terms of an adherence to orders passed through the hierarchy of femaleadministrators and male physicians. Nightingale left the nursing professiondominated by physicians, and hospital bureaucracies (Welch, 1990). Thediscussion that follows addresses Nightingale's specific impact on Canadiannursing.Canadian Adoptions and AdaptationsNews of improved hospital conditions, nursing education and patient carereached Canada directly from England, and indirectly through the United States.Using a Nightingale "blueprint," the first school of nursing was established in 1874at St. Catherine's (Gibbons & Mathewson, 1947). Two nurses who had graduatedfrom the Nightingale program assisted with the school's educational developmentand implementation. Subsequently, schools opened at Toronto General Hospital(1881), and Montreal General Hospital (1884) (Gibbon and Mathewson, 1947).In Canada, the first nursing schools were attached to hospitals and werefinancially dependent upon them, unlike Nightingale's school, which had financialindependence and educational autonomy (Gibbon & Mathewson, 1947;Nightingale, 1954). Hospital administrators soon recognized the advantages ofhaving a nursing school, as it provided them with a cheap labour force of young,InNisible Practice28disciplined women, in exchange for room, board and education (Reverby, 1987;Wotherspoon, 1988). Nurses-in-training worked on the wards for up to 19 hours aday (Nightingale, 1954; Dolan, 1978). Like Nightingale's program, Canadiannursing schools emphasized discipline, obedience and self-sacrifice (Lock, 1970;Nightingale, 1954). Thus, students' long hours were legitimized as "necessaryevils" to meet patients' needs (Reverby, 1987). As one nurse said about hertraining at Montreal General in 1890:Thinking of those days so long ago, I think I hear Miss Livingston say--- Nurse the patient ---- the patient always comes first! (Mathewson &Gibbons, 1947, p. 149).As nursing schools came into being, hospital mortality rates and operating costsdramatically declined (Dock, 1920). Education in sanitary practices, and the use ofstudents to more adequately staff hospitals accounted for these changes. Inrelation to the former change, nurses were specifically credited with makinghospitals safe places for patients. As a result, the profession had become popular.For the women of this time, nursing offered a socially acceptable career, and thedemand for nurses' training increased (Gibbon & Mathewson, 1947). By 1909,Canada had 70 hospital-based schools of nursing (Gibbon & Mathewson, 1947).Of these 70 schools, 10 offered a two year program; three offered a two and a halfyear program; and 57 offered a three year program. By 1930, the number ofschools had rocketed to 220 (Wotherspoon, 1988). However, the national andprovincial nursing associations had no legal authority to regulate or standardizecurricula, or to set minimum lengths of programs for these schools (Dock, 1920).Thus, the quality of education and program lengths varied from school to school.Interestingly, most of the graduates from these schools rarely found employmentin their training hospitals. Hospital administrators continued to exploit nursingstudents to the point that most hospitals were totally staffed by them. Thus,InNisible Practice29graduate nurses turned to the community for work (Growe, 1991). Here, theyprovided care to patients in their homes, and their practice was, for the most part,independent and autonomous (Gibbon & Mathewson, 1947). Although theirnursing practice certainly involved caring for the sick, their major focus was onhealth promotion (e.g., nutritional consulting and establishing hygienic and othersanitary practices to prevent disease) (Mellor, 1989). But, as would appearinevitable, this changed. Like their historical counterparts in medieval times,community-based nurses posed a threat to doctors' professional practice andcontrol. Nurses' practices were based upon health promotion, which was in directopposition to doctors' practices of the diagnosis and treatment of diseases(Gordon, 1992).Puttinq Nurses Back Into Their Proper Place -- The Hospital The increasing popularity of nursing practice in the hospital and communitysettings was perceived by doctors as a threat to their control of health care. Inrelation to hospital-based nursing, one physician wrote in 1906 (quoted inAaronson, 1989, p. 275):Every attempt of initiative on the part of the nurses. . . should bereproved by the physician and by the hospital administration.As is made evident by this quote, doctors had a strong influence in the hospitalsetting and, thus, their strategy became one of moving the community nurses backinto the hospital where they could be "controlled" (Kalisch & Kalisch, 1978; Melosh,1982; Wotherspoon, 1988). However, to understand how doctors were able to dothis, it is important to address specific parts of their professional history.By the turn of the nineteenth century, doctors had a fairly strong foothold onhealth care knowledge and delivery. Pasteur's articulation of Germ theory in 1863;the discovery of anesthetics like nitrous oxide in 1844; and Lister's subsequentInNisible Practice30surgical reforms in 1889, established medicine as a science, and created thedisease/cure model (Dock, 1920). In addition, physicians had establishedthemselves as the only group who could admit patients to hospitals. In legal terms,they had set up a relationship with nurses called "nested differentiation" (Aaronson,1989). This concept meant that physicians (the first party) arranged for nurses (thesecond party) to provide care to patients (the third party) (Aaronson, 1989). Giventhis legal arrangement, nursing was further legitimized as an appendage of medicalpractice. But, most importantly, this arrangement provided physicians with absolutecontrol over patients' access to nurses, and nurses' access to patients.With respect to doctors' goal of confining nursing to the hospital setting, twofortuitous historical events worked in their favour. First, the Weir (1932) and Eaton(1938) reports articulated the inadequacies of hospital-based nursing educationprograms, and nurses' poor working conditions. In particular, Weir (1932)documented explicit admissions by hospital administrators that their nursingschools' major purpose was to supply hospitals with a "cheap" or even a "slave"labour force. Weir further concluded that these schools had extended students'ward hours to such a degree that they had insufficient time for study or recreation.Reaffirming this latter point, Eaton (1938) documented that students spentanywhere from 12 to 19 hours a day on the wards. He recommended that students'and graduate nurses' work be reduced to eight hours per day. Both of theseauthors argued that nursing education should be removed from the hospitals, andplaced under the auspices of provincial education systems (Wotherspoon, 1988).To prevent this outcome, hospital administrators appeased critics by reducingstudent and graduate nurses' daily work hours (Wotherspoon, 1988). However,this reduction in hours created a need to employ more nurses (Growe, 1991).The Depression and Second World War created economic hardships forCanadian people (Gibbon & Mathewson, 1947). During this time, a series of socialInNisible Practice31reforms, including health care insurance plans, were introduced to pacifygeneralized public unrest (Baumgart, 1988; Warburton & Caron, 1988). Theseplans included medical care and hospitalization but, interestingly, did not coverpayment for community nurses' care. As a result, these nurses facedunemployment, and returned to hospitals for their economic survival (Growe, 1991).As an outcome of the Weir (1932) and Eaton (1938) reports, and as aconsequence of hard economic times, a majority of nurses ended up working inhospitals. Here, administrators and physicians constructed and constrainednursing practice (Waitzkin, 1989; Freidson, 1970). The institutionalization ofnurses in hospitals was, for the most part, complete.For nursing, the movement of the community nurses back into the hospitalsetting marked the end of the profession's last arm of independence (Growe,1991). Community nurses no longer had an autonomous relationship with theirpatients (Baly, 1989). In fact as hospital employees, nurses had three competingand, oftentimes, conflicting loyalties: 1) they were supposed to follow doctor'sorders even though they were not employed by them; 2) they were supposed tofollow administrators' policies and procedures because these people were, indeed,their employers; and 3) they were supposed to provide the best possible nursingcare, as they were entrusted to do by their patients (Corcoran, 1988; Hutchinson,1990; MacPhail, 1988; Schutzenhofer, 1987; Slote, 1990). These conflictingloyalties provide one important basis for nurses subsequent unionization andlabour unrest.Unionization and UprisingsThe infusion of community nurses into hospitals led to widespread criticism ofhospital conditions and functions, which resulted in the development of collectivebargaining units for nurses. Community-based nurses, who had enjoyed a fairlyInNisible Practice32autonomous practice, were troubled by restrictions placed upon them by hospitaladministrators, physicians and debilitating working conditions (Growe, 1991).These nurses acted as the catalysts, who encouraged other nurses speak outabout their conditions and demand changes. By the mid 1940's, nurses went totheir provincial and national associations to establish collective bargaining units toimprove hospital working conditions and salaries (Kerr, 1988b). In 1944, theCanadian Nurses Association approved collective bargaining with two stipulations:first, it was to be formed by the provincial associations; and second, strike actionwas prohibited (Jensen, 1988). The latter point was overturned in 1972 (Kerr,1988b). In 1945, the Registered Nurses Association of British Columbia (RNABC)became the first provincial bargaining unit in Canada. They achieved this positionrather quickly, because they were afraid that nurses would join the trade unions,which were organizing other hospital employees during this time (Growe, 1991).All other provincial associations slowly followed suit, with the exception of Quebec(Jensen, 1988). By contrast, Quebec nurses went to their association withcollective bargaining in mind, but the association refused to support such efforts.In 1946, these nurses turned to the Quebec Federation of Labour (a trade union),and formed one of the most politicized and militant bargaining unions in the country(Growe, 1991).Although it took 10 years for the RNABC to establish collective bargaining fortheir nurses, initial results were impressive. The slogan at the time was "Collectivebargaining for nurses by nurses" (Jensen, 1988, p. 463). With this process inplace, the nurses made 10 major gains, as follows: 1) salaries doubled; 2) jobsecurity increased; 3) grievance procedures were established; 4) vacation timeincreased; 5) communication between hospital administrators and nursesincreased; 6) discrimination about hiring married women stopped; 7) nurses withexperience and postgraduate degrees received differential salaries; 8) yearly payInNisible Practice33increments were started; 9) nurses received a stronger voice in identifying changesnecessary to improve their working conditions; 10) shifts were reduced to eighthours (Hood, 1956). Note that the latter improvement had already beenrecommended by Weir (1932) 23 years earlier. Although the RNABC memberswere satisfied with this success, other provincial associations did not do as well(Growe, 1991).At the same time as RNABC nurses received their collective agreement, othernurses from different provinces expressed disillusionment with their professionalassociations (Melosh, 1982). These associations were typically comprised of anursing "elite;" comprised mostly of nurses who worked as hospital administrators.Not all nurses were happy with their collective bargaining arrangements (Growe,1991). Nurse administrators had the power to hire and fire ordinary nurses, and itseemed that asking administrators to improve working conditions represented aconflict of interests (Growe, 1991). Needless-to-say, some associations didnothing to improve working conditions of hospital nurses until nurses stronglypressured them to do so in the 1960's (Growe, 1991). During this time, nurseswere petitioning the courts about this apparent conflict of interests, and in 1973 theSupreme Court ruled that the associations could no longer act as bargainingagents for them. It was, indeed, a conflict of interests (Jensen, 1988). In thefollowing years, nurses established provincial unions that were separate from theirprofessional associations (Kerr, 1988b). The primary difference in the mandates ofthese organizations is that: 1) the professional association is concerned withprotecting the public (from incompetent nurses); and 2) the union is concerned withprotecting nurses from poor working conditions (HLRA & BCNU, 1989; Jensen,1988; RNABC, 1990a). As the nurses were asserting themselves in theirworkplaces, their professional associations were beginning to assert themselvesInNisible Practice34within the political landscapes of Canadian health care. Associations were trying toestablish nursing as a "legitimate profession."Professionalization The history of nurses' attempts at professionalization can be viewed as anattempt to duplicate that of physicians. Since medicine was particularly successfulat professionalization, nurses have tried to emulate the doctors' strategies, with theassumption that full professionalism will be the outcome (Wotherspoon, 1988). Asa consequence, nurses have closely adhered to the criteria within the Flexnerreport (1910), which was widely credited with finalizing doctors' professionaldominance in health care. Flexner's recipe for professional control and autonomyincluded the following six criteria (1915, pp. 578-581):1. It is basically intellectual, carrying with it high responsibility.2. It is learned in nature, because it is based on a unique body ofknowledge.3. It is practical rather than theoretical.4. Its techniques can be taught through educational discipline.5. It is self-regulating and well organized internally.6. It is motivated by altruism.Of particular importance to professionalization is a relation of autonomy (self-regulation) vis a vis professional education/practice, and the articulation of a highlyspecialized knowledge base (Abbott, 1988; Baer, 1987; Freidson, 1970). Thefollowing discussion will confine itself to these two points. With regard toautonomous regulation of education, the Canadian Nurses Association (CNA),since its inception, has been trying to achieve this goal (Growe, 1991). Like theCanadian Medical Association (CMA), the CNA had set educational standards, butunlike the CMA, they were unable to enforce them because they had no legalcontrol over hospital-based nursing schools (Growe, 1991). In the late 1950's, theCNA commissioned a review of nursing schools, which found that only 16 percentInNisible Practice35of schools met their standards, and concluded that provincial associations shouldhave the legal authority to standardize and regulate nursing schools (Mussallem,1960). The educationally unsound practices of these schools were reaffirmed bythe Royal Commission on Health services  (Mussallem, 1964). As a result of thesereports, nursing education was established in post-secondary settings under thecontrol of provincial governments, and hospital-based programs were eventuallyphased out. Finally, after years of fighting against the vested interests of hospitalboards and physicians, the CNA was able to enforce the very samerecommendation that had originally been articulated in the Weir report (1932).Recently, the CNA and provincial associations have established that abachelors degree ought be a minimum standard for nursing practice by the year2000 (CNA, 1984 & 1990). It should be clarified, here, that Canada has haduniversity-based programs since 1919, but for numerous reasons (e.g., underfunding, competition with hospital-based programs that offered stipends, society'sbeliefs about the need for women to receive higher education and so on) theseprograms have been under-utilized (Baumgart, 1988; Growe, 1991). Even today,only 12.8 percent of nurses have a bachelors degree, while the rest have diplomasfrom community colleges or hospital-based schools (Statistics Canada, 1986). Thestrategy for all nurses to have university degrees in order to practice nursing isprobably a further attempt to legitimize nursing as a profession (Beletz, 1990; CNA,1984).In relation to the second criterion, that of possessing a unique knowledge base,nursing has tried to divorce itself from the medical disease/cure model, and hasdeveloped two types of nursing models, as follows: "declarative" and "procedural"(Anderson, 1990; Lister, 1990; Fawcett, 1990). Declarative models are supposedto represent nurses' "world views of patients" (e.g., the patient's physiological andpsychological needs and desires), and there are a number these models to chooseInNisible Practice36from [see Orem's (1985); Roy's (1984); Henderson's (in Adams, 1980)]. Clinicalproblem solving models like the nursing process, are supposed to representnurses' procedural or "how to" knowledge (Anderson, 1990; Moorehouse, Geissler& Doenges, 1987; Radwin, 1990). The nursing process is typically represented ashaving four "stages" in which nurses: 1) assess patients for problems; 2) develop aplan to correct these problems; 3) implement the plan; and 4) evaluate theeffectiveness of the plan (e.g., did the patient's problems get better, as a result ofthe nursing care plan?) (RNABC, 1992; Woolley, 1990). Both types of modelsrepresent "grand theories" for nurses' knowledge about patients (declarative), andnurses' clinical problem solving (procedural) (Lather, 1991). As "grand theories" forpractice, these models have been developed in the academic community, and arebased upon the presupposition that these models can be applied to all forms ofnursing practice (Lister, 1990). In other words, irregardless of context, thesemodels posit that nurses will describe and interpret their patients and practices inbasically the same ways. However, Tanner's (1992) and Benner's (1992)preliminary research findings suggest that within nurses' personal narratives orphenomenological accounts of their practice, there is no evidence of support forthese models. Researchers have found that nurses, in a manner not unliketeachers, speak about their practice in detailed, contextualized and differing ways,which are in direct opposition to the generic and decontextualized assumptionsinherent to the current grand theories for nursing practice (Britzman, 1991; Tanner,1992).Although it is difficult to argue against nurses' general goal to achieve autonomyand a specialized knowledge base, the reasons underlying the professionalizationcriteria to achieve this goal seem to have been left unexplored. Socialized toconform to rules, most nursing leaders have never questioned the facts behind themyth of medical professionalization or even why, given the present criteria, it wouldInNisible Practice37constitute a desirable outcome for nursing (Cockburn, 1985; Meyer, 1982;Newman, 1990; Pavalko, 1971; Purcell, 1990; Stevenson, 1990; Roberts, 1983).Instead, they continue to keep a running total on how close nursing is coming tomeeting the professionalization criteria, and to this point, nursing has not achievedthis goal (Lambert & Lambert, 1989). Nursing is just following the rules set downby their "medical leaders" and, in so doing, nursing has only built a deficit model forthe profession. It seems clear that nursing ought, ideally, to generate its ownversion of, and standards for, professionalization (Abbott, 1988; Becher, 1989;Thompson, 1987).In this partial and tentative analysis of some historical texts, I have identified anumber of themes that obscure or render in/visible the scope and complexities ofnursing practice: self-sacrifice and altruism (nurses are angels of mercy);subservience and silent obedience (to people in positions of authority);de-intellectualization (nurses are doers, not thinkers); amorality and chastity(except for the nuns, nurses have questionable characters) (Aaronson, 1989; Chua& Clegg, 1990; Church, 1990; Gibbon & Mathewson, 1947; Growe, 1991; Hubbard,1988; Melosh, 1982; Reverby, 1987). In the next discussion, I move into thecontemporary world of nursing practice. In these discussions, I centre on some ofthe contemporary social forces affecting nursing, and describe some of the currentsocial circumstances operating in hospital contexts. In addition, questions areraised about how nurses' job descriptions construct and constrain their practiceand, thus, promote their in/visible practice.Contemporary Context: The Past as PresentFeminism and Nurses' ImageBefore moving into the hospital setting, I discuss aspects of two contemporaryissues which affect nursing: feminism and nurses' image. Although male doctors'InNisible Practice38domination of the female nursing profession (98 percent of nurses are women) canperhaps most profitably be represented as a feminist issue, historically feministsand nurses have had, at best, tenuous relationships (Gordon, 1991; Growe, 1991).These relationships have been strained, in part, because both feminists and nurseshave seen each other in stereotypical terms (Growe, 1991). Feminists haveconstrued nursing as the profession that most typifies the domestic hand-maidenimage of women. At times, they have been impatient with the in-place relationshipbetween a dominant physician and a subservient nurse. In this instance, feministshave viewed nursing as the "ultimate female ghetto," from which women should beencouraged to leave (Vance, Talbot, McBride & Mason, 1985). Occasionally,feminists have, also, ignored the specific contributions that nurses have made tothe movement (Bunting & Campbell, 1990). As an example, Judy Chicago's artproject "The Dinner Party" gave tribute to many woman who have made importantcontributions to society, included in this work was Florence Nightingale andMargaret Sanger. Although Nightingale was identified as a medical reformer,policy-maker and statistician, and Sanger was identified as a social reformer,neither of these women were identified as nurses (Vance, Talbott, McBride &Mason, 1985). Nurses have, also, tended to see feminists in stereotypical terms.Nurses have proven cautious vis a vis the feminist movement, because of themisconception that joining the movement meant abandonment of the essence ofnursing -- that is to say, abandonment of caring (Chinn & Wheeler, 1985; Gordon,1991). In recent years, feminists and nurses have overcome some of theirmisconceptions of each other, and are beginning to work together as allies. Thefirst joint nursing and feminist conference was held at Queen's University in the fallof 1991 (Miller, 1992).Interestingly, concurrent with the rise of feminism, there has been a demise innursing's image. The historic "Sairey Gamp" image was reprised under theInNisible Practice39contemporary image of "Sex Object" (Kalisch & Kalisch, 1978). This image wasespecially damaging to nurses, as it promoted myths like nurses lack morality;nurses see nursing as a means to find a man (doctor); and nurses have no sincereinterests in their careers. Such television shows as "Trapper John," "M.A.S.H." and"Nightingales" are examples of this image. However, on a defiant note, in 1989,nursing associations in Canada and the United States successfully organized apolitical lobby that removed "Nightingales" from the air.The Hospital SettingIn the 1980's, health care came under financial constrains and, in keeping withthis trend, the metaphor of hospital as "house" changed to the hospital as "factory"or, more specifically, a cost effective corporation (Curran & Miller, 1990; Foucault,1980; Kaufman, 1990; Melosh, 1982; Shaw, 1989). During this time, languagerelated to titles of positions within the hierarchy changed. The hospitalAdministrator's title changed to the "President and Chief Executive Officer;" theDirector of Medicine's title changed to "Vice President for Medicine;" the Director ofNursing's title changed to "Vice President for Nursing;" and the Head Nurse's titlechanged to "Unit Manager" (Curran & Miller, 1990). Nurses were still callednurses, but within this metaphor they, now, were the "workers" in the business ofsupplying a "cost effective product" -- patient care (Campbell, 1988; Melosh, 1982;Silver, 1981).Although titles have changed, there is not an appreciable difference in hospitalpositions and their interrelationships (Melosh, 1982; Murray & Smith, 1988;Zaleznik, 1989). Even though both nurses and doctors have supposedly equal vicepresident level positions, doctors actually have more power in the organization.These new terms just serve to disguise the same power relations (male/femalehierarchies) established by the Catholic Church (male priest/female nunInNisible Practice40hierarchies) (Chau & Clegg, 1990; Zaleznik, 1989). Also, the relationships withinthe female nursing hierarchy are consistent with the Nightingale period (Chau &Clegg, 1990). On the whole, vice president and nursing unit managers unilaterallyset policies and procedures that ward nurses must follow (Kane, 1990; Schmieding,1990). With respect to hospital wards, doctors' and nurses' unequal roles remainunchanged. Physicians are supposed to have ultimate authority and responsibilityover decisions about patient diagnosis and treatment, while nurses are supposedto continue in a caregiver role which generally includes patient comfort, monitoringpatient status, providing patient education, and helping the patient and family copewith their health care problems (Baumgart, 1988; Campbell, 1988; Schutzenhofer,1987; Waitzkin, 1983 & 1989). In the following sections, I will critique some currentresearch that addresses: nurse and nurse administrator relationships; and nurseand doctor relationships.Nurses and Nursing AdministrationThe quality of the interpersonal relationships between nursing administration andnurses is an important factor in determining job satisfaction (Curran & Miller, 1990;Kennedy, Camden & Timmerman, 1990, Nyberg, 1990). Because of the high jobturnover rates amongst nurses, many studies have looked at this relationship inmore detail. Job turnover is defined as the number of resignations of nursesdivided by the total number of nursing staff within a hospital (CNA, 1990). Thesestudies have found that nurses are dissatisfied with nursing administration,specifically in relation to: 1) excessive workloads; 2) inflexible shift schedules; 3)excessive paper work which takes them away from their patients; 4) poorcommunication between nursing administration and nurses; 5) lack of support withrespect to interdisciplinary conflicts between nursing and medicine; 6) lack ofopportunities for advancement; 7) lack of reward; and 8) lack of accurate tools toInNisible Practice41measure work performance (Alberta Hospital Association, 1980; Barry, Soothill &Francis, 1989; Carson, McGuire & Lamb, 1987; Hiscott & Connop, 1990; Kennedy,Camden & Timmerman, 1990; Kramer & Hafner, 1989; Murray & Frisina, 1988;Murray & Smith, 1988; Robinson & Lewis, 1990; Schmieding, 1990). Most of thesestudies nicely itemize and categorize the end products of nurses thinking (e.g.,their problem representations), but few address the thinking processes or contextsbehind these conclusions. As a consequence, these studies obscure theunderlying substance and issues behind nurses' thinking, and tend to build deficitmodels of either nurses or nurse administrators (Campbell & Bunting, 1991; Parker& McFarlane, 1991; Roberts, 1983; Thompson, 1987). In addition, because thesestudies focus on nurses' complaints, they are silent about the ways in which nursesresist and defy some of these organizational constrains (Lather, 1991; Rogge,1986).Nurses and PhysiciansThe historical relationship between nurses and physicians has been construedas physician dominance and nurse subservience. However, in the contemporarycontext, nurses are socialized upon mixed messages about their relationships withphysicians (Allen, Jackson & Youngner 1980). On one hand, in their post-secondary education programs, they are taught to believe that their relationshipswith physicians are collaborative, meaning that both physicians and nurses haveunique knowledge bases, which are of equal value for patient care (Katzman, 1989;Trueman, 1991). On the other hand, when nurses enter the hospital setting, theyare oftentimes confronted by physicians who have been socialized to believe thatthey are the "natural" leaders of the hospital and health care system (Webster,1988). As a result of these role disparities, interprofessional conflicts develop.Recent studies show that some nurses are verbally abused (being yelled at orIn/Visible Practice42insulted), physically abused (pushed, slapped or struck), or simply ignored byphysicians (Diaz & Macmillan, 1991; Katzman & Roberts, 1988; Kennedy & Garvin,1988; Kerr, 1986). In addition, when nurses report these conflicts to the hospitaladministration, most of them are resolved in favour of the physician (Murray &Smith, 1988). However, these studies have the same constraints as the onesmentioned in the nurse and nursing administration section. By focusing onproducts of nurse/doctor conflicts and by constructing nurses as "passive"recipients of "doctor abuse", these studies tend to build deficit models of nurses,and do little to reveal the ways in which nurses resist their historically prescribedsubservient roles (Lather, 1991; Parker & McFarlane, 1991; Roberts, 1983;Thompson, 1987).Nurses and Medical TechnologyOver the past few decades, hospitals have acquired more and more technologywith the intend of innovating and improving patient care (Romano, 1990).However, there is increasing evidence to suggest that in some situationstechnology does not benefit nurses or patients (Coile, 1990; Lindsay, 1991;Misener, 1990; Morgan, 1983). Nurses, especially in the critical care units, havebeen encouraged to become "high tech, low touch" caregivers (Growe, 1991;Knaus, Draper, Wagner & Zimmerman, 1986). In other words, nurses must nowdivide their time between caring for the technology and caring for the patient, andsometimes the technology takes up more time than the patient. For many nurses,time spent with machines only translates into more dissatisfaction with their jobs, asit takes away from the thing they value the most -- their relationships with patients(Moccia, 1988; Robinson & Romano, 1990). Furthermore, nurses witness manysituations in which technology can prolong terminally ill patients' lives, but in theprocess inflict much suffering (Morgan, 1983). It is physicians who order thisInNisible Practice43equipment, but it is nurses who must watch their patients suffer. When they knowthere is no hope, and patients have expressed their wishes to terminate the uses ofthe equipment, some nurses challenge physicians' decisions to keep patients alive.Eventually, the equipment will be shut off but, in the interim, nurses are tornbetween watching patients suffer, and maintaining the equipment that is creatingthe suffering (Corcoran, 1988; Hedin, 1989).In this cursory examination of the contemporary hospital context, I haveidentified some of the ways, in which current research has socially constructednurses' relationships with nurse administrators and physicians. These renderingsseem to silence any of the nurses' attempts to resist this social ordering. Inaddition, I have addressed a few examples of how medical technology constructsand constrains nursing practice. The following discussion will describe how nurseshave had their practice defined for them by hospital-based job descriptions. Thesedescriptions will be briefly analyzed in terms of how they represent andmisrepresent nursing practice (Apple, 1989).Nurses' Job Descriptions In B.C., hospitals' job descriptions for nurses are developed from a number ofexternal documents: the CNA Code of Ethics for Nursing (1991); the RNABCStandards for Practice in B.C. (1992); the Canadian Council on Health FacilitiesAccreditation standards for Acute Care: Large Community and Teaching Hospitals(1992); the Master Collective Agreement (HLRA & BCNU, 1989) and relevantlegislation (e.g., B.C. Nurses Registered Act, the Medical Practitioners' Act, theCriminal Code of Canada, the Canadian Charter of Rights and Freedoms etc.). Inwriting the nurses' job description, a hospital administrator (usually a Director orVice President of Nursing) incorporates these external documents in a way thatmeets the hospital's organizational needs. Although there will be some variation inInNisible Practice44nurses' job descriptions from hospital to hospital, their primary intent remains thesame -- to define and confine nursing practice within the natural social order(power relations) of the organization (Apple, 1989; Ball, 1990; Smith 1987 & 1990).In the following discussions, I outline some of the key components of these jobdescriptions, and argue that these renderings of nursing practice remain true to thehistorical myths surrounding nursing, and that they do little to articulate theconstitutive work of nurses.One of the fundamental assumptions embedded in nurses' job descriptions isa(n) decontextualized and individualized account of both professional practice andeducation (RNABC, 1992). Job descriptions tend to focus on individual attributesand actions without examining the social circumstances that create and definethem (Apple, 1988). As a result, nurses' practices are measured againstdecontextualized standards in their job description, and can be judged in simplisticand dualistic terms: the "good nurse" obeys or conforms to these standards;whereas, the "bad nurse" disobeys or does not conform to these standards.Unfortunately, these types of interpretations tend to build deficit models of nurseswho do not "conform" or live up to the established standards, and through thelanguage of deficits, some nurses are blamed for contrary ways of thinking andacting, that are not necessarily good or bad, but need to be situated and explainedwithin the complexities of their work context (Belenky, Clinchy, Goldberg & Tarule,1986; Wertsch, 1985 & 1991). In addition, conceptualizing nursing practice inindividualistic terms, precludes discussions about how nurses collaborate with, andlearn from each other (Lave & Wenger, 1991).Each hospital typically has only one job description for nurses, and thisdocument is supposed to represent all nurses' practices. As a consequence, thejob description establishes basic standards for practice and, therefore, makes nodistinctions between what constitutes novice or experienced nursing practiceInNisible Practice45(Apple, 1988; Smith 1987 & 1990; RNABC, 1992). Because of this standardization,it is easy to see how many nurses may never be acknowledged for their clinicalexpertise (Benner, 1984 & 1992). In addition, these standards are usually writtenin behaviorist terms. Thus, each standard (statement) about nurses' practicesstarts with an action verb (e.g., plans, organizes, observes, etc.). The use of thisbehaviorist language in job descriptions reifies the historical myth of representingnursing practice as acts of "mindless doing" instead of acts of "thinking-in-practice"(Wertsch, 1991).In articulating what nursing practice is, the content of most job descriptionscentres around the two types of nursing models that I have discussed earlier. Thefirst type of model provides a particular " world view" of patients and, thus, issupposed to represent nurses' declarative knowledge. The second type of modelprovides a particular "world view" of nurses' clinical problem solving and, thus, issupposed to represent nurses' procedural knowledge. As grand theories fornursing practice, these models universalize and, thus, decontextualize nurses'thinking-in-practice (Lather, 1991). Thus, like the historical descriptions of nurses,these models over-simplify and, in effect, de-intellectualize nurses' thinking (Apple,1989). Furthermore, these models obscure questions about how the diversespecialty areas in which nurses work shape their practice (e.g., Hemodialysis, BoneMarrow Transplantation, Intensive Care, Pediatrics and so on). Surely, a nursewho works with bone marrow transplant patients is going to have different forms ofpractice in comparison to a nurse who works with hemodialysis patients.In addition to constructing nursing practice, job descriptions like the historicaltexts, represent nurses' practices as subservient to those of doctors. Unfortunately,this institutionally sanctioned unequal power relationship denies nurses the right ofcollaborative practice with doctors, and silences discussions that focus on theIn/Visible Practice46conflicts that arise between nurses and doctors when their plans for patient carediffer (Trueman, 1991).In this chapter, I have argued for an inclusive way of looking at nurses' thinkingand practices; one that unites and situates nurses' minds/practices within theirsocial contexts: historical, cultural and institutional settings. By providing a smallsample of texts from these social contexts, I have presented aspects of officialversions of nursing practice, and have argued that these versions obscure or makein/visible the richness and complexity of everyday nursing practice. Since mostauthors of nursing history and theory do not actually practice nursing, they tend toprovide only decontextualized versions of nurses' practices. As a consequence,there is little understanding about how nurses "actually" practice nursing. Within aspecific hospital setting, I am interested in developing a beginning and necessarilypartial understanding of nurses' in/visible practice by identifying some disparitiesbetween nurses' "actual practices," and their job description's "textualrepresentations" of nursing practice (Apple, 1986; Ball, 1990; Smith, 1987 & 1990).In the following chapter, I will discuss the research methodology that will providethe basis for articulating fragments of nurses' in/visible practice.InNisible Practice47Chapter 2: MethodologyIn the last chapter, I developed a partial and fragmentary analysis of thehistorical, cultural and institutional contexts for Canadian hospital-based nursing(Aronowitz & Giroux, 1991; Foucault, 1980; Lather, 1991). In this, I have examinedaspects of certain texts, and argued that these texts have consistentlymisrepresented nurses' work across time, within our culture and institutions. In thischapter, I will develop a framework for research which emphasizes andproblematizes nurses' practices within their everyday work life (Smith, 1987 &1990). By situating nurses in their everyday world, this research seeks to uncovera beginning understanding of the following question: What are nurses' ideas abouttheir in/visible practice within a hospital setting? Nurses' in/visible practice is, here,defined as the disparity between their "actual" practices, and the job description's"textual representations" of their practice (Apple, 1986; Ball, 1990; Smith, 1987 &1990). As argued in the last chapter, the nurses' job description is a(n) official andcontemporary text that limits and misrepresents the breath and scope of nursingpractice. Although job descriptions are supposed to represent the art and scienceof contemporary nursing practice, they seem to remain true to the historioculturalmyths of nursing [e.g., the de-intellectualization of nurses' thinking into acts ofmindless doing; nurses' subservience to the greater authority (doctor) and so on](Reverby, 1987; Warburton & Carroll, 1988). To uncover a preliminaryunderstanding of nurses' in/visible practice, I will take a feminist and institutionalethnographic approach; thus, this investigation is interested in the subjectiverealities and lived experiences of female nurses in a specific hospital setting(Anderson & Jack, 1991; Belensky, Clinchy, Goldberg & Tarule, 1986; Lather,1991; Personal Narratives Group, 1989a & 1989b; Smith 1987 & 1990; Van Manen,1990). Prior to detailing the particulars of this research process, I shall begin byInNisible Practice48describing the central philosophical and theoretical assertions that underlie thisparticular methodology.Philosophical and Theoretical AssertionsIn the last chapter, one of the basic and critical arguments presented is thatpeople (e.g., priests, doctors, nurse theorists etc.) who purport to understand andwrite about nursing practice have no intimate knowledge of it. They provide the"official" textual versions of nursing practice; yet, ironically, the positions that theyhold are both physically and mentally removed from the everyday actualities ofnursing practice (Britzman, 1991; Lather, 1991). Thus, in order to bring to the foreany understandings about nurses' in/visible practice, I must turn to the people whoexperience practice -- the nurses, themselves (Personal Narratives Group, 1989b).Given this proposition, I am working from the assumptions that nurses are "expertpractitioners" in their everyday work world, and that they have intimateunderstandings of how it is put together, and how their everyday practices areaccomplished (Freire & Faundez, 1989; Smith, 1987 &1990; Strauss & Corbin,1990; Van Maanen, 1988; Van Manen, 1990). Thus, this research project will focuson nurses' interpretations of their actual practices, and develop preliminarycontextualized accounts of nurses' perspectives on their in/visible practice(Anderson & Jack, 1991; Lewis, 1990; Lindesmith, Strauss, Denzin, 1988).Situating nurses within their social context (the historical, cultural andinstitutional) is a predominant theme throughout this work and needs to be revisitedas the conceptual foundation for the research process. The key point that I amreinforcing here is that learning about what it means to be a nurse is, in itself, asocially constructed and contextually defined activity (Bruner, 1986; Lave &Wenger, 1991; Luria, 1979: Vygotsky, 1978; Wertsch, 1985 & 1991). For thenurses in this study, the hospital is their social context. This context is fraught withInNisible Practice49competing and contradictory messages about who nurses are and what they do(Gordon, 1992; Hutchinson, 1990; Melosh, 1982; Moccia, 1988; Nelson, 1988). Atthe heart of the institutional process of definition is the nurses' job description. Jobdescriptions not only set prescriptive norms for what nurses should do, but alsoestablish nurses' position at the bottom of the hospital hierarchy (Smith, 1987 &1990). This document, however, is not a stagnant piece of paper that is placed ona shelf somewhere; it is inherently social, and its language comes alive every timenurses engage in conversations with hospital personal (particularly those inpositions of authority) (Apple, 1988; Ball, 1990; Smith, 1987 & 1990). Within theseconversations, nurses learn about what is expected of them, and how they shouldexpect to be treated by others (Goffman, 1956 & 1961). Importantly, within thiscomplex web of social expectations, there is another group of voices, those of thenurses' peer group.In the hospital setting, nurses are socially interconnected by their position at thebottom of the hospital hierarchy, and by their practice. They are members of agroup or community that practices nursing (Lave & Wenger, 1991). Within their"community of practice," nursing practice is socially constructed and, as such, doesnot reside in the "mind" of an individual nurse (on the intramental plane); rather, itis interwoven into the intermental plane, socially distributed amongst nurses (Lave& Wenger, 1991; Vygotsky, 1978; Wertsch, 1985 & 1990). The social nature ofthis community is similar to Vygotsky's (1978) concept of the zone of proximaldevelopment; it is the social place where nurses, with the help of other nurses,learn about their heritage, practice and position within the hospital (Bruner, 1986;Lave & Wenger, 1991; Luria, 1979; Wertsch, 1985 & 1991). In the hospital setting,nurses' ideas about their practice are mediated by the people who live inside, aswell as outside of their community (Lave & Wenger, 1991). In particular, nurses'ideas about their practice are mediated by their peers who actually practiceInNisible Practice50nursing, and by nurse administrators who author the prescriptions for nursingpractice in the job description. Within the community of nursing practice, it is thedisparity between the "actual," and "prescribed" practices that is the interest of thiswork. At one level, this research is interested in articulating the "actual" practicesthat are enacted by nurses, but have been silenced by their job description. Atanother level, the whole concept of in/visible practice assumes that nurses havedeveloped actual practices that differ from the ones in their job description which, inturn, speaks to their degrees of agency and resistance within their everydaypractice -- within their community of practice (Britzman, 1991; Freire & Faundez,1989; Lather, 1991; Van Maanen, 1988).The intent of the research project is to seek a beginning understanding ofnurses' in/visible practice as socially defined within a community of nursing practicein a specific hospital setting (Lave & Wenger, 1991). In this project, nurses as"experts" of their own work world are asked to share, enact and analyze their"actual" practices to provide a(n) collective, or intermental understanding of theirin/visible practice (Lather, 1991; Wertsch, 1985 & 1990; Vygotsky, 1978). Thisdoes not mean, however, that there will be one agreed upon or unified perspectiveon their in/visible practice (Aronowitz & Giroux, 1991; Lather, 1991). Given thecomplex context in which nurses work, I would expect the opposite -- multipleversions of their in/visible practice. However, within all of these versions, nursesare speaking from the "truths" of their social experiences (Personal NarrativesGroup, 1989b). To expand upon this last point, I must emphasize that the researchquestion I am asking strives toward a contextualized explanation of nurses'in/visible practice, and not an evaluation of nurses' thinking in relation to dualisticterms like "true" and "false," or "right" and "wrong" (Lather, 1991; Van Manen,1990). Contrary and differing ways of conceptualizing nurses' in/visible practicecannot be reduced to discrete notions of right or wrong, but need to be situated andIn/Visible Practice51described within the multifaceted nature of nurses' social experiences (Leonard,1989).Thus far, I have spoken about some of the central philosophical and theoreticalassertions of this research project. However, I have yet to discuss my roles andrelationships, as researcher, within this social learning process. The traditionalhierarchical relationship between a researcher and a given study's participants isinadequate; in fact it would detrimental to this study. Given nurses' long history ofauthority figures who speak for them, it would be absurd to place this asymmetricalrelationship within this work (Hall & Stevens, 1991). Indeed, it would establish thesame social conditions that, as I have argued, promote nurses' in/visible practice.Instead, the research process described here was developed and implementedwithin a horizontal and, thus, a democratized relationship across the traditionallyhierarchized roles of researcher and (nurse) participants (Lather, 1991). Withinthis social arrangement, all involved became co-researchers and collaborators inthis investigation. Besides participating in the data collection phase, the nurseshad equal input into the data analysis phase (Hall & Stevens, 1991; Lather, 1991;Mishler, 1986). This meant that all participants assisted in the development andcritique all drafts of the results of this study, and that all edits, deletions andrevisions were mutually agreed upon by the group. Within this nonhierarchicalsocial structure, all co-researchers learned about their in/visible practice with thehelp of each other and, as a group, they mutually negotiated and jointly constructedthe meaning, breath and scope of their in/visible practice (Freire & Faundez, 1989;Lather, 1991; Mishler, 1986; Personal Narratives Group, 1989a, Van Manen,1990). This approach to the research process emphasizes that thinking/learningas well as authorship is multivoiced (Wertsch, 1991).For the co-researchers in this study, one of the important things that their historyhas taught them is that speaking out against the hospital system usually hasIn/Visible Practice52professional and personal costs (Growe, 1991; Reverby, 1987; Stevenson, 1990;Welch, 1990). Thus, in conducting this study, I was acutely aware of the doublebinds nurses felt between their desires for their voices to be heard, and thepotential threats they saw for raising their voices (Bateson, 1979; Bateson &Bateson, 1987; Lewis, 1990). Although their anonymity was secured and theresearch process itself established some level of comfort in speaking out, I thoughtthat it was crucial that the prevailing value within these discussions was that theyonly shared what they felt comfortable sharing (Patai, 1991). With this in mind, thetopics for all group sessions (the details will be discussed in the next section) weremade known in advance, and required some preparatory work. This work gavethem a chance to reflect upon what they would like to say: indeed, to reflect uponwhat they felt comfortable saying (Lewis, 1990). The following sections willaddress the research sample and methods.SampleTo facilitate the accessibility of nurses to this study, I advertised and presentedan information session about this research project in the specific hospital where ittook place. In this section, I discuss various relevant characteristics of theparticipants. I, also, include issues related to informed consent and anonymity.Participants Given that the nurses' job description constructs nurses and their practices ingeneric and homogeneous ways, I used a purposive sampling technique which isbased upon a fundamental notion of diversity. In particular, the research sample ishere composed of seven registered nurses who: 1) have diverse personal andprofessional backgrounds; 2) work in the same hospital; 3) practice in one of threenursing specialty areas; and 4) have volunteered for the study (Goetz & LeCompte,1984) All participants are women. In Chapter Three, I have reported the followingIn/Visible Practice53demographic information about the participants: average age, educational andethnic backgrounds, average years of experience, years of experience in theircurrent nursing specialties, and the group's cumulative years of experience.Informed ConsentFollowing the approval of the research protocol by The University of British Columbia Behavioral Sciences Screening Committee For Research and OtherStudies Involving Human Subjects, I secured an "informed consent" from allparticipants before the research began. To enable the nurses to make an informedjudgment about entering (or not entering) this study, I advertised and presented aninformation session which discussed the following points (McMillan & Schumacher,1989):1. participation is voluntary, and anyone can withdraw at anytime from thestudy (without penalty).2. the purpose and nature of the study.3. the roles and relationships between the researcher and participants.4. the anticipated time and work commitments of participants.5. the strategies used to maintain participants' anonymity (discussed below).Since this research took place in a hospital setting, I also obtained an "informedconsent" from patients, unit managers, doctors and secondary nurse participants.The above criteria were applied to these participants' informed consents. In thenext section, I address the strategies used to safeguard participants' anonymity.Issues of AnonymityIn this research, I was responsible for maintaining the anonymity of both theparticipants, and hospital involved in this project (Goetz & LeCompte, 1984;McMillan & Schumacher, 1989; Strauss & Corbin, 1990). Information about thepeople participating in this study was held in the strictest confidence. This meantthat no one outside the research project had access to the names of theIn/Visible Practice54participants, or any individual data about them. In addition, the researcherassigned a number to all primary nurse participants, and instructed them to use it(and not their names) on any written work. Only the researcher knew the assignednumbers given to the participants (McMillan & Schumacher, 1989; Strauss &Corbin, 1990). In relation to reporting the results of this study, some examples ofverbatim conversations were used. However, when reporting these conversationsalias names were used for all participants (Goetz & LeCompte, 1984; Van Manen,1990).This research project, also, has an obligation to the hospital to maintain itsanonymity. This issue particularly relates to the use of quotes from the nurses' jobdescription as the basis for comparing prescribed and actual practices. Althoughthe gist of each hospital's job description may have similar roots, each one has itsown institutional emphasis and wording. The idea that quoting from a specific jobdescription may pose a threat to hospital's anonymity is unfounded, because thesedocuments are not public (Canadian Council on Health Facilities' Accreditation,1992). However, as an extra means of protection for the hospital involved in thisresearch, I will refer to it in obscure terms -- as an acute care hospital in B.C.Thus, given that job descriptions are not public documents, and the researcher'sadditional measure of referring to the hospital in vague terms, it is unlikely that thehospital's identity can be determined.MethodsThis section describes and provides rationale for the research methods used toinvestigate nurses' in/visible practice: career autobiographies, direct observation,journals, one-on-one interviews and group discussions. Besides providing themeans for qualitative analyzes, these methods are consistent with the overallphilosophical and research goals of this work: 1) to provide a historicalInNisible Practice55understanding of the participants; 2) to locate the analysis of in/visible practicewithin the nurses' everyday work world; 3) to name the practices which arerendered in/visible by the nurses' job description; and 4) to explore the socialcircumstances that facilitate nurses' degrees of agency and resistance in theircommunity of practice.Career Autobiographies and Group Discussion The starting point of this research began by asking the nurses to write anautobiography about the histories of their nursing career. By starting this projectwith an unobtrusive method, I tried to establish an initial and ongoing precedent,meaning that the interest of this work was in attending to nurses' personalexperiences, and not to the researcher's conceptions of them (Anderson & Jack,1991). The following questions were given to the nurses in this study:1. Tell a story about the events, and people that encouraged you to enternursing school. At this time, what did this decision mean to you?2. Tell a story about one vivid experience from your nursing education. Talkabout the people involved. What is it about this experience that makes itstand out?3. Tell a story about your clinical practice in this hospital, one that you keepthinking about over the years. Talk about the people involved. What is itabout this experience that makes it so memorable?These questions were purposefully stated in general terms, so that the nursescould reflect upon their own careers, and choose for themselves the stories thatthey viewed as central to understanding their past (Benstock, 1991; Brady, 1990;Corbett, 1990).Beyond establishing the unobtrusive intent of this work, these autobiographicalquestions are linked to this work's theoretical foundations, and seek to uncoverfragments of the nurses' own implicit theories of practice (Bryson, 1990; Chanfrault-Duchet, 1991). The theoretical linkage is twofold. First, the idea of starting off withthe nurses' own histories is linked to the theoretical proposition that a prerequisiteInNisible Practice56to understanding the present begins with an understanding of the past. Second,these questions are tailored to identifying some of the social circumstances andprescriptions that impact upon nurses' ideas about their actual practice, therebyunderscoring the social nature of the nurses' knowledge (Bateson, 1979; Wertsch,1985 & 1991; Van Manen, 1990; Vygotsky, 1978).The specific content of these autobiographies was extremely important inidentifying some of the social values, beliefs and defining features of the nurses'implicit theories of practice (Benstock, 1991). Making these ideas more explicitwith group discussions, nurses began, in general terms, to compare their owntheories of practice with those of the hospital's, as implicitly and explicitly statedwithin their job description. Thus, the ultimate purpose for these autobiographieswas to build a beginning and partial conceptual framework for nurses' in/visiblepractice that articulated some of the theoretical disparities between the nurses andthe hospital. Other research methods (discussed later on) established: 1) howthese theories potentially changed and expanded over time; and 2) how thedisparities between the nurses' and the hospital's perspectives formed the basis of,and determined the actualities of, their day to day in/visible practice (Goetz &LeCompte, 1984).The first group discussion centred on articulating nurses' implicit theories ofpractice, and comparing them with their job descriptions. This group session, aswell as the ones that followed, was based upon the notion of nurses' community ofpractice, wherein nurses create and recreate their practice (Lave & Wenger, 1991).Here, the nurses were asked to share their autobiographies, and collectivelyidentify some of the overriding theoretical tenets implicit to their stories. After doingthis, the group turned to their job descriptions, and engaged in the same analyticprocesses. Now, knowing some of the major theoretical positions of bothInNisible Practice57themselves and the hospital, the nurses identified, and discussed some of the maindisparities between them.At the end of this session, the nurses gave me their written autobiographies.When there were subsequent clarifications that I needed to make in relation to thiswritten work, I contacted the nurse(s) and conducted one-on-one interview(s). Boththe group session, and interview(s) were audio taped and transcribed (Goetz &LeCompte, 1984; McMillan & Schumacher, 1989). To facilitate ongoing reflectionbetween this and subsequent group sessions, each nurse received a photocopy ofher own autobiography, and a transcript of this group session (when it becameavailable). No names appeared on these transcripts.Direct Observation After the completion of the first group session, I entered the nurses' clinicalsettings and observed their "practice-in-action." In comparison to some of the othermethods used (e.g., autobiographies and journals), the direct observation of nursesin their clinical setting captured an array of situations and circumstances which, inturn, added variety, specificity and immediacy to the nurses' contextualizedunderstandings of their in/visible practice. And, because this method was localizedwithin the nurses' "natural" (clinical) setting, it provided opportunities for identifyingsome of the spontaneous, and more subtle forms of in/visible practice, which didnot appear in their journal work, or within group discussions (Goetz & LeCompte,1984; McMillan & Schumacher, 1989; Smith, 1987 & 1990).Direct observation allowed me to witness, first hand, nurses' lived practices, andinvolved accompanying each nurse to her clinical nursing unit, and following alongwith her as she engaged in her daily routines, activities and conversations withhospital personnel and patients (Van Manen, 1990). This method was extremelyhelpful as it provided me with an opportunity to ask the nurses questions aboutInNisible Practice58their practices as they were engaging in them, and about their interpretations ofconversations with specific people in the hospital (Bateson, 1979; Goffman, 1961).Based upon my observations and ongoing discussions with each nurse, I wrotedaily field notes which included (Goetz & LeCompte, 1984; McMillan &Schumacher, 1989):1. a description of the setting(s)2. a description of the nurse's actual practices along with herinterpretations of them.3. verbatim accounts of conversations that she had with hospitalpersonnel and patients, along with her interpretations of them.4. verbatim accounts of conversations that the nurse and I engagedin.At the end of each day, I shared my field notes with the nurse so that she had anopportunity to corroborate and potentially extent their content (Mishler, 1986). Theintent of this meeting was to be short (after all it is the end of the day) and, initially,focused on the actualities of the nurse's practice. However, as my residency witheach nurse continued, these discussions developed a more expanded focus whichincluded discussing some preliminary ideas about her in/visible practices. Thesemeetings were audio taped and transcribed.All nurses received a photocopy of each day's field notes, and a transcript ofeach "end of the day" meeting. As a means for preparing for the concurrent groupsessions, it was important that the nurses continued to have access to thisinformation so that they had an opportunity to review it, continue to reflect upon it,and try to develop some ideas about their in/visible practice that could be sharedduring the concurrent group sessions (Allen, Bowers, & Diekelmann, 1989).I spent at least two or three days directly observing each nurse in her clinicalsetting. This time limit, however, was flexible and was extended as necessary.The decision to extend this time was based upon the nurses' belief that theinformation gathered, thus far, did not adequately reveal the subtleties,InNisible Practice59complexities and scope of her practice. In other words, I continued to directlyobserve the nurse's clinical practice until she determined that the informationobtained reflected prototypical experiences and key aspects of her practice (Hall &Stevens, 1991).Journals The main purpose of the journals was to provide additional information aboutthe nurses' personalized understandings of their everyday conversations andpractices. When they were not being directly observed by me in the clinical setting,they were asked to keep a journal of their interactions with physicians, unitmanagers, patients and other nurses on a daily basis for two days. Within thesejournals, they wrote down these conversations, described their ideas about the rolerelationships inherent to them, and discussed their feelings about them (Goffman,1956 & 1961). At the end of each journal, they were asked to describe a particularpractice that they did well, but did not receive recognition for. As they werecompleted, these journals were collected (by me), photocopied and returned totheir respective authors. When there were subsequent clarifications that I neededto make in relation to this written work, I contacted the nurse(s) and conductedone-on-one interview(s).These journals were returned to the nurses so that they could reflect upon theirwritten work and, over time, develop some ideas about: 1) how the expectations oftheir job description came alive through everyday conversations; and 2) what typesor aspects of their practice seemed to be unacknowledged (Allen, Bowers, &Diekelmann, 1989; Cissna & Sieberg, 1981; Kennedy & Garvin, 1988; Heineken,1982). These ideas could, then, be shared during the concurrent group sessions.InNisible Practice60Concurrent Group Discussions The main functions of the concurrent group sessions were twofold: to constructmultivoiced understandings of nurses' in/visible practice, and to democratize theresearch analysis process (Lather, 1991). Initially, the discussions focused onuncovering the specifics of their in/visible practice, and were guided by, but notlimited to, the following preliminary questions:1. How are y/our implicit theories of practice operationalized ineveryday practice? Under what social circumstances are thesetheories and actions (in)consistent?2. How do the whats, whys and wherefores of y/our actual practicecompare/contrast with the job description?3. How are y/our conversations with other hospital personnel andpatients linked (or not linked) to the roles and relationshipsoutlined in the job description?These questions break down the overall research question into its componentparts by: 1) linking the nurses' implicit theories of practice to their actual practices;2) comparing/contrasting their theories and practices with those inherent to theirjob description; and 3) underscoring the social nature and circumstances within allof these perspectives.The nurses were given these questions prior to attending the first concurrentsession, and were asked to keep them in mind as they reviewed and reflected uponthe information within their autobiographies, field notes, journals, interviews,ongoing group discussions and other experiences that were not captured within theaforementioned methods. These questions were purposefully stated in generalterms so that the nurses could reflect upon their own experiences, and choose forthemselves the instances that they viewed as central to describing andunderstanding their in/visible practice.During the ongoing group discussions, each nurse had an opportunity to shareher thinking and practice with the other group members, and the group membersIn/Visible Practice61had opportunities to ask questions about, or generally comment on, each other'sstories. Within this dialogue, the discussions were be guided by the abovequestions and focused on uncovering a collective understanding of the nature andscope of nurses' in/visible practice. Initially, these sessions were more directed tothe specifics of the nurses' in/visible practice (data collection); however, as moreand more examples of their in/visible practice were presented, the group began todevelop preliminary and ongoing themes (data analysis). Working as a group touncover the patterns and themes of the nurses' in/visible practice located thisanalysis in the minds of the "experts," the nurses themselves, and thus maintainedthe horizontal power relations between the researcher and nurses. Thiscollaborative analysis also facilitated a(n) increased flexibility, mutuality, diversityand authenticity in the overall results of this work (Hall & Stevens, 1991).Using the information collected through the various methods, the group(including the researcher) looked for emerging patterns and possiblecategories/themes that refined and described their in/visible practice. Findingsimilar and recurrent themes about nurses' in/visible practice certainly added to therigor of this work but, it was further strengthened by finding exceptions within thesethemes (Yin, 1989). Themes are developed at certain levels of generalization,which in turn can limit or ignore some of the contextual complexity and plurality ofnurses' in/visible practice. Thus, attempts to establish consensus in themes did notcircumvent variety within or divergence from them. Given the differences in thenurses' experiences, differing views of their in/visible practice do and must coexist(Lather, 1991). These differences, however, needed to be explained within thesocial circumstances that created them (Wertsch, 1985 & 1991). Thus, as thesethemes were developed we, as a group, continued to ask: "What aspects of y/ourin/visible practice are misrepresented or not represented in this theme?" (Strauss &Corbin, 1990; Strauss, 1997). This question not only sought to find alternativeInNisible Practice62explanations of nurses' in/visible practice, but it also sought to expose and validatethe diversity of ideas within the group.These concurrent group discussions were held on a biweekly basis during thedata collection phase and triweekly during the analysis phase. However, given thatnurses work a variety shifts and all of the days of the week, it was quite difficult toget the group together. Hence, these time frames were flexible. Moreover, allgroup sessions were audio taped, and transcribed. To facilitate ongoing reflectionbetween these concurrent group sessions, the nurses received a transcript of eachsession (when it became available). No names appeared on the transcripts givento the nurses.Based upon these ongoing group sessions, I developed working drafts, whichwere presented to and critiqued by the group. These sessions concluded when thegroup agreed that there were no new ways or means of representing their in/visiblepractice, and when they approved the final draft of the results (Hall & Stevens,1991).Closing Group Discussion This last group discussion brought closure to this research project by reflectingupon the group's collective accomplishments, and by determining the impact of theresearch project on the nurses' lives (Lather, 1991). I, also, established the timewhen I will present all members with a copy of the final research project. Thissession was audio taped and transcribed.Throughout this section, I have discussed a research methodology plan thatsought to uncover preliminary, contextualized and subjective understandings ofnurses' in/visible practice, and that embraced a democratized research process inwhich nurses learn from each other, and analyze their own practices. I think thatthis blueprint for research must been seen as flexible. Although I will write aboutInNisible Practice63the circumstances that maintained and changed this overall plan, I think it is alsoimportant to talk about the analytical processes or decision-making trails that wereused throughout the course of this investigation (Van Manen, 1990). Thisdiscussion leads quite naturally to the next one, which addresses issues of validity.Issues of ValidityValidity, as traditionally construed, is typically discussed in relation to thequestion: "do researchers actually observe what they think they observe?"(McMillan & Schumacher, 1989, p. 191). In relation to this study, validity issuespertain to the degree to which the researcher can "authentically" represent nurses'phenomenological realities of their in/visible practice (Leonard, 1989; Van Manen,1990). In attending to validity issues, I built in a number of safeguards into the datacollection process which include:• reciprocal relationships between the researcher and nurses directed towardjointly constructing meaning.• directly observing nurses in their "natural" clinical setting, which reflects theimmediacy and realities of their lived experience.• individual and group discussions that were mechanically recorded and, thus,preserved as quasi-authentic discourse.With respect to analyzing and reporting the results, the following strategies wereused to attend to the validity of this work:• establishing relationships amongst nurses' implicit theories of practice, theiractual practices, their job descriptions and the social conditions within theircommunity of practice, which enables agency and resistance.• detailing how the group used the triangulation or constant comparison processto sort data, and identify themes around nurses' in/visible practice.InNisible Practice64• describing the contextual circumstances around affirming and diverging fromthese themes.• providing a variety of verbatim conversations and descriptions of practices thatsupport, extend or refute the various themes.• identifying the similarities or differences between the multiple data sources(e.g., spontaneous compared to elicited; individual compared to group).• explaining the group's analytical processes or decision making trails throughoutthe course of this investigation.• discussing how the researcher influenced the content as well as, the decisionsmade within this study.• corroborating the nurses' perspectives through ongoing discussions, and bygiving them all drafts to critique.What I hoped to achieve with these safeguards/strategies was a credibledescription and explanation of nurses' in/visible practice that could be understoodby the nurses in this study as well as, anyone who reads this work (Campbell &Bunting, 1991; Goetz & LeCompte, 1984; Hall & Stevens, 1991; McMillan &Schumacher, 1989; Yin, 1989).InNisible Practice65Chapter 3: Sites of Nurses' InNisible PracticeSetting and Duration of StudyThe research project took place in an acute care hospital in B.C. on thefollowing nursing units: Emergency Room (ER), Intensive Care (ICU) andOperating Room (OR). However, all group sessions were held away from thehospital site, and in the nurses' homes. On an alternating basis, each nurseopened her home to the group. This project spanned over a two and a half monthtime period. During this investigation into nurses' in/visible practice: 136 hours (or17 days) were devoted to direct observations of the nurses in their clinical setting;eight and a half hours were devoted to one-on-one interviews; and 12 hours (orseven group sessions) were used to analyze the nature and scope of nurses'in/visible practice. In addition, the nurses spent on average four hours writingcareer autobiographies, and six hours writing in journals.Framing an Analysis of Nurses' InNisible PracticeThere are several converging ideas that are interwoven into the structure andanalysis of this research project. In the following discussion, I will articulate theconceptual framework that structures the ways in which this study's findings will bepresented. I will revisit the notion of nurses' in/visible practice, discuss some of thetheoretical perspectives within this ethnographic work, and close with an overviewof how the data analyses are presented.One of the primary points that was made in Chapter One was that the twinnotions of visibility and invisibility should not be taken literally; hence the use ofin/visibility. In the prior chapters, I have used the question -- "What is left unsaid?"-- as an analytical tool for exposing what might be lost or rendered in/visible by theofficial paradigms for nursing practice described within historical texts, and thenurses' job descriptions (Aronowitz & Giroux, 1991). In the following discussion, IInNisible Practice66describe a framework that focuses on articulating and analyzing nurses'phenomenological realities of practice -- their implicit theories of practice and theiractual practices. From the nurses' perspectives, I can begin to describe what isvisible within their paradigms of practice, and at the same time, contrast these withthe ones articulated within their job description. At one level, this analysis will pointto the types of practices that are rendered in/visible by the nurses job description.But, at another and more provocative level, this analysis will point to nurses'resistance (Apple, 1986; Lather, 1991). Within the hospital setting and its inherentpower relations, nurses have developed degrees of control and resistance withintheir everyday practices (Britzman, 1991; Growe, 1991; Lather, 1991). Thus, myprimary consideration for structuring the analysis of this work is to representnurses' practices in a way that not only makes their practice visible, but alsodemonstrates their commitment to transformative resistance within their everydaywork world (Lather, 1991; Smith, 1987 & 1990).As a general research framework, I re-introduce here the notion of institutionalethnography -- looking at nurses' ideas about their in/visible practice from theirvantage point within a specific hospital setting (Smith, 1987 & 1990). Within thishospital, the nurses' vantage point is from the bottom of the organizationalhierarchy. As a consequence, there is an unequal power relationship between thenurse administrators who live at the top of the hierarchy and write the nurses' jobdescription; and the nurses who actually practice nursing, but live at the bottom ofthe hierarchy. But even when people are at the bottom of a power structure, theydo have degrees of control and degrees of resistance at a local level of practice(Freire & Faundez, 1989; Giroux, 1988; Lather, 1991; Smith, 1987 & 1990). AsVan Maanen (1988) argues the task of ethnographic work is to ". . . display theintricate ways individuals and groups understand, accommodate and resist apresumably shared order" (p. 14). He assumes that knowledge and powerInNisible Practice67relations may be prescribed by people in positions of power, but that these edictsfrom above have degrees of flexibility and negotiation at local levels of practice(Britzman, 1991). Considering that this research takes place within the local levelsof nursing practice, it is important that I make explicit the assumptions that I amusing to frame the social structure or fabric of nurses' work lives.At this local level, nurses are bound together by their position at the bottom ofthe hospital hierarchy, and by their practice. They are members of a social groupor community that practices nursing (Lave & Wenger, 1991). Thus, in comparisonto nurse administrators who work within a community that practices managementand prescribes nursing practice, nurses' community of practice is based upon"actual" practices (Lave & Wenger, 1991). Nurses' knowledge within thiscommunity of practice is relational; it is based upon nurses' actual practices aslived and shared experiences (Lave & Wenger, 1991). Within this community, thenurses have varying perspectives, interests, and degrees of participation. Nursestalk and learn about: their individual and community identities; the historicallegacies of their practice; and the ways their practices can be shaped andtransformed (Lave & Wenger, 1991). Through these interactive means, thecommunity produces and reproduces itself (Lave & Wenger, 1991). I do not wantto leave the impression that nurses create this community by formal conventions --they do not schedule and hold discussion groups on the nature and plight of theirpractice. Their discussions occur informally as they practice with each other, or asthey talk with each other over meal and coffee breaks. In this community of nursingpractice, nurses' understandings of practice do not occur in isolation or withoutoutside influence. In the hospital setting, their community of practice isinterconnected to: other communities within nursing like nursing administration;other professional communities like medicine; and the broader community orsociety (Lave & Wenger, 1991). These communities, also, have prescriptions forInNisible Practice68nursing practice that must be examined by individual nurses, and the community ofnursing practice (Van Maanen, 1988). It is the disparities between the"prescribed," and "actual" practices within the community of nursing practice, that isthe interest of this work. How (and why), at their local level of practice, havenurses learned to resist some of these prescriptions for their practice and creatednew ways of knowing?In the last few paragraphs, I have presented some of the theoreticalperspectives that are interwoven into, and provide direction for, this researchproject. Now, I would like to turn to the general considerations for structuring andpresenting this data analysis. As the nurses talked about their practice in ourongoing group discussions, a recurrent pattern or theme began to emerge. Thenurses made ongoing contrasts between their current practices, and those that theyhad learned in their post-secondary education. In addition, they also madeongoing contrasts between their actual practices, and the ones outlined in their jobdescriptions. Given their own intuitive path for analyzing their in/visible practice, Iwill present the findings of this work as the disparities with/in: 1) the practices thatthe nurses learned about in their post-secondary education programs; 2) thepractices outlined in this hospital's job description for nurses; and 3) the nurses'actual practices. This triangulation method will trace nurses' learning across time,and will serve as the springboard for rendering nurses' actual practices visiblewithin this hospital setting (Strauss, 1987; Strauss & Corbin, 1990). As thefoundation for this triangulation method, I will summarize and extend some keypoints brought forth in the first chapter about nursing education, and then I will takea critical look at the specifics within this hospital's job description for nurses.InNisible Practice69Nursing EducationThe primary purpose of this discussion about nursing education is to providebackground information on, and a critique of, the nursing curriculum, and theteaching practices used to impart this knowledge. As articulated in Chapter One,nurse educators have built curriculum models around two types of theories: onetype represents nurses' declarative knowledge about patients and the otherrepresents nurses' clinical decision making or procedural knowledge (Bevis &Watson, 1989). Within this educational framework, students' learning is construedas passive and linear as their "minds" are receptacles for inserting and extractingprescribed knowledge, which is measured by acts of mindless doing. Whenlearning is attributed to behavioral acts and the absence of learning is attributed tonot displaying the proper observable behavior, education and learning becomenarrowly focused on decontextualized knowledge (Belensky, Clinchy, Goldberg &Tarule, 1986). There is no emphasis placed upon how students might constructtheir own knowledge; there is no emphasis placed upon what students might learnfrom their conversations and experiences with patients and other students (Freire &Faundez, 1989; Vygotsky, 1978). As a consequence, contextualized meaning,multiple meanings and contrary ways of knowing become washed away intoobjective and, thus, decontextualized traits or behaviors (Britzman, 1991; Lather,1991). Thus, students' understandings that fall outside of these generic behaviorsbecome silenced or unrecognized; these understandings become illegitimate(Bevis & Watson, 1989).In general terms, I have discussed some of the authoritative and oppressivecircumstances within nursing education, but this abstract analysis has littlemeaning until it is made concrete within nurses' specific experiences. So, I wouldlike to break from the convention of putting all of the research findings into onediscrete section and mention one of Leah's experiences in nursing education.InNisible Practice70Leah's remarkable story is about resilience and resistance under inauspiciouseducational circumstances; her story is about creating new ways of knowing:When I was in training, there was this "meanie" instructor. Shescreamed at the students in front of patients, visitors, nurses anddoctors. She would make the students do things that made them lookstupid . . . She failed five students out of seven within six weeks. Ihated going for my interviews with her each week, because shealways gave me negative feedback. At one point she told me that Iwould never make it to be a nurse. I felt very down and upset, anddid reconsider if nursing was for me. I withdrew, but I returned thenext semester after some good talks and thoughts. I believed theproblem was not in me, but in her. She failed to do her job, to teach,guide and give support.There is an interesting contradiction between the philosophical frameworks andbehaviorist modes of teaching within most nursing education programs. As Bevisand Watson (1989, p. 5) argue:Nursing education is out of step with its philosophy . . . For, as itcurrently exists, schools write out a philosophy that is human sciencehuman experience valuing, holistic, qualitative and caring orientiated,yet plan a curriculum that is based upon behavioral objectives andoppressive. This inconsistency is a handicap to nursing.This inconsistency not only fragments philosophy from practice, but it alsofragments and distances (student) nurses' experiences from the curriculum(Britzman, 1991). Considering that nursing is an inherently social, relational andesthetic practice, the profession's insistence on grand theories for practice, andauthoritative and behaviorist modes of education, leaves much of what studentslearn and practice unexpressed or in/visible (Benner, 1984; Bevis & Watson, 1989;Freire & Faundez, 1989).Nurses' Job DescriptionsIn this hospital, the nurses' job description has a remarkable resemblance to theways in which nursing education constructs nursing practice. This document usesInNisible Practice71grand theories to articulate nursing practice, and reduces nursing practice togeneric behavioral traits (e.g., all statements about nursing practice begin withaction verbs). However, the purposes of this job description are not educational.The nurses' job description is a two page document that serves three primaryfunctions: 1) to define and thus scope nursing practice; 2) to identify the nurses'position within the nursing and hospital hierarchy; and 3) to make clear distinctionsbetween nursing and medical practice. Table 2 (on the next page) presents thetext of the nurses' job description. In the following discussions, I will use some keyquotes from this job description, which focus specifically on nurses' practice, andargue that these renderings of practice do little to articulate the constitutive work ofnurses.Within the nurses' job description, their practice is defined by the followingstatement: "(nurses) implement Henderson's model for nursing through the use ofthe nursing process." Like nursing education, this hospital defines nursing practicewithin the constrains of two universal or "grand theories" (Lather, 1991)."Henderson's model" represents nurses' declarative knowledge about patients, andthe "nursing process" represents nurses' procedural knowledge or clinical decisionmaking (Adams, 1980; Moorehouse, Geissler & Doenges, 1987). I have talkedabout the constraints of these theories in Chapter One, and I will revisit a fewpoints. Within these theories, there is no room for variations within nurses'practices or across nursing specialties. In this hospital setting, nurses work inspecific specialty areas like intensive care, emergency room, surgical andoperating room nursing. Given that these theories are context-free, they presentnurses' practices as if there are no differences across these specialties. But, thecontextual realities within these specialties are quite different. As an example, theknowledge of a surgical nurse who cares for pre-operative and post-operativepatients, is going to be quite different from that of an intensive care nurse whoInNisible Practice72Table 2: The Hospital's Job Description for Nurses.Job Summary:Using Henderson's model, the nurse assesses, plans, implements and evaluatesnursing care for assigned patients; plans, organizes and completes assignments tomeet priorities for patients' care; assists with staff and patient teaching, andsupports research. All activities are carried out in accordance with: the philosophyof the hospital; the hospital, division and unit beliefs, objectives, policies,procedures and standards.Responsibilities:Practice: • Implement Henderson's model for nursing through the use of the nursingprocess.• Collect data about assigned patients by observation, interview, physicalexamination and review of records.• Analyze data by determining the interrelationship between variables, anddetermines patients' actual or potential problems.• Plan nursing care by setting priorities, writing desired outcomes and selectingnursing interventions which have the highest probability of success.• Implement the medical plan of care.• Document the care given and the patient's response, and report significantchanges to the physician or unit manager.Management: • Participate in the development of unit and division statements of beliefs,objectives, policies, procedures and standards by being a member of a nursingcommittee.• Organize equipment, supplies and medication to provide care.• Delegate specific tasks to auxiliary personnel.• Ensure a safe environment for patients and other staff.Education: • Maintain clinical competence by regularly attending continuing educationprograms.• Interpret to new staff the hospital, division and unit beliefs, policies, procedures,standards and ward routines.• Include patient teaching as a part of the plan of care.Research: • Change practices or procedures to reflect current research findings.• Participate in approved research projects.InNisible Practice73cares for critically ill patients. In the intensive care setting, the critical nature of apatient's illness and the technology [e.g., electrocardiogram (heart rhythm)monitoring or mechanical ventilators (machines used to help patients breath)] usedto treat these illnesses are absent from the surgical nurse's world. But, when grandtheories are used to articulate nursing practice, these differences across nursingspecialties are obscured or rendered in/visible. In addition, given the generic andbehaviorist nature of the nursing process (assess, plan, implement and evaluate),this model does not distinguish nurses' procedural knowledge from otherdisciplines. The nursing process could be applied to any discipline like secretaries,plumbers, physicians, and so on. At some general level, all of these disciplinesassess, plan, implement and evaluate what they do (Ball, 1991; Smith, 1990).The nurses' job description stresses the idea that theory (and implicitlyresearch) must be developed outside of nursing practice and then applied tonursing practice. This idea is further reinforced by two statements within the jobdescription as follows: "(nurses) maintain clinical competence by regularlyattending continuing education programs;" and "(nurses) change practices orprocedures to reflect current research findings." Like nursing education, this jobdescription defines and confines nurses' learning to received knowledge fromofficial sources within the academic community. Thus, situated learning withinnurses' everyday practices, and the ways in which nurses are instrumental inhelping each other learn is rendered in/visible. Moreover, considering that theentire job description uses generic statements that are supposed to apply to allnurses, there are no distinctions between what constitutes beginning orexperienced nursing practice (RNABC, 1992). Thus, nurses may never beacknowledged for their learning endeavors aimed towards clinical expertise(Benner, 1984).InNisible Practice74Thus far, I have looked at some of the central statements within the nurses' jobdescription. These statements represent the administratively prescribed andconstrained practice for nurses (Ball, 1991; Smith, 1990). The power of thesestatements cannot be over emphasized. Not only do they identify the normativeprescriptions that define the expectations of the "good nurse" (Goffman, 1961) but,more importantly, they explicitly define what is to be observed, reported andevaluated as nursing practice (Smith 1987 & 1990). In other words, thesestatements form the hospital's institutional theory of nursing practice, and are thepivotal ingredients that make certain aspects of nursing practice institutionallysanctioned and visible; and at the same time, exclude other aspects of nursingpractice. This job description, also serves another primary function. It establishesthe power relations between nurses and doctors.The discrete nature of the following statement within this job description servesto disguise nurses' knowledge of, and authority within medical practice (Smith,1987 & 1990): "(nurses) implement the medical plan of care." In practice, nursesdo critique medical interventions. As an example, although the doctor's role is toprescribe medications for patients, nurses are legally responsible for themedications that they administer (Johnson & Hannah, 1987). This means that if adoctor orders a medication for a patient which a nurse deems as inappropriate(e.g., say, she thinks the dose of the drug is too high), she is legally mandated torefuse to give it. Yet, in determining that this drug dose is unsafe for the patient,this nurse has really taken on the medical role of prescribing medications.However, within this job description the above statement serves to subordinatenurses in their relationships with doctors, and makes in/visible the overlap betweennursing and medical practice (Smith, 1990). It obscures the notion that, beyondproviding nursing care, nurses are also responsible for critiquing aspects ofIn/Visible Practice75medical care and, therefore, nurses are not subordinates at all (Warburton &Carroll, 1988).Furthermore, the above quote from the job description implicitly speaks to thestatus and value the hospital places on medical and nursing care. Doctors areseen as the 'master planners' of patient care; whereas, nurses are seen as thepeople who simply carry out this plan. Nurses, also, develop a plan for patientcare, and implement a number of practices that are independent of the medicalregimen. However, the importance placed on the medical plan and the de-emphasis placed upon the nursing plan maintains and legitimates an asymmetricalpower structure between nurses and doctors -- nurses are supposed to work inconcert with doctors making sure that their care is consistent with the overallmedical plan (Gordon, 1992). But, the reverse is not necessarily true. Having theultimate institutional authority as the master planners of care, doctors are notrequired to be aware of or consistent with the nurses' plans for patient care. Like inthe Nightingale (1954) days, doctors have no obligations to nurses, but nurses areobligated to do, and not question what physicians say (Melosh, 1982; Warburton &Carroll, 1988; Wotherspoon, 1988). Unfortunately, this institutionally sanctionedunequal power relationship silences nurses' medical practices, and inhibitsdiscussions that focus on the conflicts that arise between nurses and doctors whentheir plans for patient care differ (Trueman, 1991).Although this job description is supposed to represent the art and science ofcontemporary nursing practice, it remains true to the historiocultural myths of de-intellectualization, and subservience to the greater authorities (like nurseadministrators and doctors) (Gordon, 1992; Growe, 1991; Hughes, 1990; Melosh,1982; Reverby, 1987). By characterizing nurses as doers and not thinkers, itjustifies the power relationships between nurse administrators and nurses. Nurseadministrators must monitor nurses' practices, and ensure that the official theoriesInNisible Practice76of practice are adopted (Apple, 1989; Ball, 1990; Giroux, 1988). And by notacknowledging the idea that nurses have an integral role in the medicalmanagement of patients, doctors can still take credit for patient care and maintaintheir position as the natural leaders in the health care system (Abbott, 1988;Freidson, 1970; Griffith, Thomas, & Griffith, 1991; Warburton & Caroll, 1988;Wotherspoon, 1988). In these respects, this job description legitimates andmaintains the power base of others (Smith 1987 & 1990). This job description maybe developed "for" nurses, but this does not necessarily mean that this documentrepresents the everyday life and work of nurses.I have spoken about how the nurses' job description defines and confinesnurses' practices, and how this job description legitimates nurses' positions at thebottom of the hospital hierarchy. I would like to leave this preliminary discussionwith an account of Jan's feelings and ideas about living at the bottom of thehospital hierarchy. Her story is about herself, OR nurses (that she works with),seagulls and hospital administrators:We are looking out for a mother and baby seagull. We call our babyHarold Hospitalla. They nested on a perch under our OR deck. Wehaven't mentioned a word of this to anyone outside of the OR nurses.Last year, a mother seagull built a nest at the other end of the deck,and laid two eggs. Some people from the administration officescomplained to maintenance because the gull kept shitting on theirwindows. Next thing we knew the nest was gone. The maintenancemen had come up, and thrown the nest to the ground, eggs and all.They killed the babies, the poor mom. We were shocked when wefound out. We told them, too. This is a hospital. We are supposedto help life and look what our administrators did for clean windows.They won't find out about baby Harold this year!In Jan's story, this baby seagull (who is now learning to fly) seems to represent ametaphor for the care and attention she might bestow on a colleague, and for howthe OR nurses see their positions at the bottom of the hospital hierarchy. WithinInNisible Practice77this community at the bottom of the hospital hierarchy, there seems to be a lot ofcare and support for nurses and, of course, seagulls.Before I begin to move away from the official accounts of nursing practice andinto the lived experiences of nurses, I would like to emphasize one of the centralthemes within nursing education and the nurses' job description. The theme thatnurses are a homogeneous group. The use of grand theories for practice and thebehaviorist renderings of nursing practice leaves the impression that nursesconstitute a homogeneous group. There is no variability within each nurses'practice or across nursing specialties. I would like to begin deconstructing thisnotion of homogeneity by introducing the nurses who participated in this study.A Look At the Nurses and Their PracticeGiven the emphasis on homogeneity within nursing education and the nurses'job description, my primary criterion for this purposive sample is based upon anotion of diversity (Goetz & LeCompte, 1984; Lather, 1991). The nurses whoparticipated in this study come from diverse personal and professionalbackgrounds, and practice within one of three different clinical nursing specialties.In this discussion, I will present some demographic information about these nursesand, then, present some excerpts from their autobiographies, journals and groupdiscussions, wherein, each nurse talks about her personal and professionalidentities (Personal Narratives Group, 1989a & 1989b).Including the researcher, eight nurses are the primary participants in this study.The average age of this group is 38 + 7 years old, and the ethnicity of the group isdiverse. Although most are of European descent (e.g., Italian, Welsh, British,Dutch, Scottish and Irish), one nurse is of Chinese heritage, and another is amixture of Irish and Native Indian heritage. In addition, four nurses have beenraised in other countries: Brazil, New Zealand, South Africa and Hong Kong.InNisible Practice78The nurses' educational backgrounds were varied. Although most receiveddiplomas in nursing from college-based programs, one received her diploma from ahospital-based program, and three received Bachelor of Science degrees inNursing from university settings. Five nurses attained post-basic certificates: onein Hospital and Health Care Administration; one in Post-anesthetic Nursing; one inNeurological Nursing; one in Critical Care Nursing; and one in Operating RoomNursing.All nurse participants are full time employees, and have worked in this hospitalfor an average of 5 + 3 years. Each nurse practices in one of the following clinicalspecialty areas: Emergency Room (ER), Intensive Care Unit (ICU), and OperatingRoom (OR) nursing. They have an average of 5 + 4 years work experience in theirchosen specialty area, with an average overall work experience of 12 + 6 years.The group's collective work experience is "103" years. In addition to this primarynurse group, 39 patients, 20 doctors, three unit managers and 21 secondarynurses participated in this study.In the above paragraphs, I have presented demographic information about theprimary nurse participants. This information gives an extremely limited glimpse ofthese women. To speak about them as a collection of numbers, averages, andethnic and educational backgrounds oversimplifies the complex identities thatthese women embody. They have identities which are interwoven across theirprofessional and personal lives (Belenky, Clinchy, Goldberg & Tarule, 1986;Personal Narratives Group, 1989a & 1989b). In their autobiographies, journals andgroup discussions, they have talked about some of their identities. To introducethese women and their identities, I have compiled some excerpts from thesesources. I have, also, included excerpts about myself to stress the point that theresearcher is an in/visible member of this group:InNisible Practice79Sue:^Susan is 47 years old, and has been practicing nursing for 17years. "I entered nursing after the breakup of my marriage. Iwanted to be independent. I needed to support my family. I wasa single parent, raising two kids, two dogs and six cats who werehaving kittens . . . I didn't have much time to study. The kidswould be going in the front door and out the back door. It's just ablur to me. After nursing school, I worked in intravenous therapyand emergency nursing. For five years, I have worked in theintensive care unit. I just get right to the point. I know I am bossy.I know I have a big mouth . . . but I love our little unit and I wantthings to go right. Two years ago my son was in a major caraccident. It was just devastating. It took a year, but now he'sbetter, so I am trying to concentrate on my daughter, now -- tohelp her get started."Leah:^After high school, Leah immigrated to Canada from China. She is33 years old, and works in the emergency room. "I graduatedfrom 12, then I got married and had two kids, and later on I wentinto nursing school. After graduation, I worked on a surgical unitfor eight years. It got so boring, it became so straight forward .. .So, I left (nursing) and went into sales. After a year, I found that Ijust didn't have the personality for it. I'm too shy. So, I came backto nursing. I work day and night shifts to spend more time with mykids."Kara:^Kara is 40 years old, married and has always worked in criticalcare settings. "I was in the first graduating class from CapeTown University's degree program for nursing. One experiencethat has impacted on me is how the older doctors reacted to thestarting of the degree program. The older doctors said, 'we'd endup to be half baked doctors;' others said, 'we'd just be goodfor sitting at the desk, getting further and further away from ourpatients.' This made me wild, and I think has influenced me, to alarge degree, to stay with beside nursing -- to prove themwrong. I have two kids. My daughter developed a serious andchronic illness when she was very young. We take turns beingsad and depressed about her condition. It's steadily worsening.When I'm down he helps me; when he's down, I try to comfort him.I don't know what will happen if we are ever down together."InNisible Practice80Jan:^Jan is 43 years old, and single. She graduated from ahospital-based nursing program in New Zealand, 17 years ago."At 18, I was in charge of a ward, and yet I lived in a nurses'residence. We were weighed every six months to make sure wewere not pregnant. Now there's chastity for you. About five yearsago, I went back to the place I trained, and worked there. I foundI was much too outspoken. I felt very uncomfortable, so I left. Nomatter where I've worked, I have always considered myself as anOR nurse. Now, I live in a Co-op, and my best friend who is anex-nurse, lives just a few doors down from me. We have our ownspace, but we have helped each other through some difficulttimes. We look after each others cats, too."Liz:^Liz is 31 years old and single. She has worked for many years insurgical and medical nursing. Last year, she decided to enterintensive care nursing. "Don't misunderstand me, I love what Ido. But, I don't always like what I see around me. I had a dreamlast night about going to one of those nursing departmentmeetings -- the ones that we are supposed to share our ideas in.All of the nurse managers were sitting around a table talking toeach other, and I was kneeling on the floor silently foldingnapkins. It was a bizarre, but revealing dream about where I seemy place in the scheme of things. I keep thinking about it. I havemany friends who are nurses. We talk about what goes on, andwe support each other. . . Sometimes, I get rid of my frustrationsthrough painting . . . around midnight, I'll turn up the classicalmusic and paint all night. I ponder. Just because I'm fairly quiet,doesn't mean much passes by me."Tye:^Tye grew up in Brazil and moved to Canada in 1978. She is 30years old, and single. Most of her work experience is in criticalcare, and most recently in the emergency room. "The past fewyears that I have been in nursing have been difficult ones for me;mainly because of my personal life. I know work is work andhome is home, but it's hard to separate them. I know I havelearned a lot, and there still is a lot more to learn. It's okay to giveyourself credit. Often, I have not realized I have made adifference until much later. One day I went out with my sister forlunch and this gentleman comes up to me. As it turns out, Ilooked after him as a patient. He remembered everything aboutIn/Visible Practice81me. How I spent a lot of time explaining things to him, and howmuch he appreciated all of this. He has never forgotten me.""I'm so thrilled about becoming a mom soon. If Joe wants tobe involved that's fine, if he doesn't that's fine, too."Ann:^Ann is 40 years old, and married with two young children. Beforecoming to the intensive care unit, Ann had worked on a medicalunit. "When I decided to go into nursing, I had been in the workforce for 13 years. I had held various clerical positions andhad worked the majority of the time in libraries. Although most ofmy jobs were out of the ordinary and challenging, the businessworld with its cut throat and smile persona was sickening. Iwanted to get completely away from it. Since nursing school, myhusband has gone back to school, too. We both have newcareers." Most of the time, I enjoy nursing, but the cut throatbusiness world has followed me into to the hospital. My kids helpme stay sane."Kim:^"I am 37 years old and have practiced nursing since 1978. Withthe exception of my first year of work experience, I have worked incritical care. Over the past eight years, I have straddled betweenbedside nursing and nursing education, in a purposeful attempt tonot loose my roots. The past year has been very difficult for me,as five of my family members have died. I have some dear friendsand a wonderful partner who has helped me. I also have twodelightful pet rabbits named Natalie Bunny and Denise Hopper."Creating a Community of Practice Without an Official IdentityI have structured this analysis around the disparities with/in: 1) the officialrenderings of practice in nursing education; 2) the official renderings of practice inthe nurses' job description; and 3) nurses' actual practice. As I mentioned at thebeginning of the chapter, this focus on disparities between the official renderings ofnursing practice and nurses' actually practice takes on two interrelated meanings.First, it suggests that these nurses are resisting the official prescriptions for theirpractice, and second, it suggests that they are creating alternative or new forms ofInNisible Practice82practice (Lather, 1991; Van Maanen, 1988). These differing ways of knowing are"created" and "recreated" within these nurses community of practice (Lave &Wenger, 1991). When reading about the nurses and their practices, notice howthe they refer to themselves. Occasionally, they speak in the first person singular,"I," but most oftentimes, they speak in the first person plural, "we." Their emphasison "we" is a subtle, yet, significant testimony to their membership within a specificcommunity of practice (Lave & Wenger, 1991). But, this community of practice willnot have an official identity, until its members' practices are visible. In the followingsections, I will discuss nurses' philosophies/practices of caring and nurses' theoriesof/in actual practice.In this analysis of nurses' in/visible practices, I would like to underscore thenotions that this work is by nature fragmentary, partial and multivoiced (Foucault,1980; Wertsch, 1991). It is a collection of stories about nurses and their practices(Britzman, 1991; Lather, 1991). I have become the narrator with/in these nurses'stories. As story tellers, we (meaning myself and the nurses) are constrained bywhat we think can and should be told, and we are constrained by the particulartime-frame in which this study was conducted.Philosophies and Practices of CaringThroughout my discussions of nursing's history, one of the primary adjectivesthat is used to describe nurses' practices is "caring" (Gibbon & Mathewson, 1947;Growe, 1991). Nurses are not really nurses unless they care. And, even nursingpractice was (and is) synonymous with nursing "care" (Morse, Solberg, Neander,Bottorff & Johnson, 1991). One of the first things that the nurses noticed abouttheir job description is that it did not mention caring. Interestingly, if you turn backto Nightingale's performance appraisal for nursing students (see p. 23), you willsee that caring is not mentioned there either (Nightingale, 1954). One of theInNisible Practice83problems with Nightingale's criteria for judging nursing practice, and the nurses'contemporary job description is the behavioral renderings of nursing practice.Moreover, in most of contemporary nursing literature, nursing practice isresearched within scientific and behaviorist models (Bevis & Watson, 1989).Within the constraints of these quantitative and decontextualized paradigms, thequality of caring becomes difficult to represent (Belenky, Clinchy, Goldberg &Tarule, 1986; Hall & Stevens, 1991; Van Manen, 1990). So, oftentimes, like in thishospital's job description, caring is ignored (Bevis & Watson, 1989). Even in theface of this omission from this job description, caring is still in the forefront of thenurses' everyday practices. From this point on, I will focus on what the nurseshave learned about caring in their post-secondary education; and how they practicecaring, today. At the end of this section, caring will be re-situated in its historicalcontext, and then re-evaluated and problematized within the nurses' everydaypractices. In these discussions, I will develop a beginning and partialunderstanding of caring within the constraints of the following questions: how doescaring become personalized within nurses' lived experiences?; in what ways mightcaring take on different forms across the nursing specialties?; and when and howdoes caring become problematic in nurses' everyday practices? (Smith, 1987 &1990; Van Manen, 1990).One of the frank omissions within nurses' job description is that it mentionsnothing about caring. Yet, this quality seems to be at the heart of each nurse'spractice. During our second group discussion, Liz, Leah, Kara and Sue commenton this omission from their job description:Liz :^It's amazing that this job description doesn't mention caring. Thisdocument was drawn up by women administrators, but it takes allof the female qualities out. And, it's those qualities that makesnursing so special. This thing (job description) de-feminizes us.Leah:^Yeah, it makes our jobs look dull and bleak.InNisible Practice84Kara:^Totally uninteresting.Sue:^That's right. It makes us look like we are uncaring robots.Liz: Have you ever noticed that if you emphasize the tasks and leaveout people's feeling and emotions, you'd be done in no time?As their conversations indicate, caring seems to be a quality that these womensee as the driving force within their practice. Focusing on situations from theirnursing education and current practice, I will look at some of nurses' practices ofcaring. In these first examples, Sue and Ann share recollections from their nursingeducation:Sue:^Jill kept coming into hospital because of a huge ulcer on herbuttock. She was a paraplegic. Each time she came in, she wasusually there for three or four months. All the staff memberswould make her feel welcome. The staff would bring herpresents . . . The most important thing was the kindness,attentiveness and individuality we gave this woman. She wasn'tjust a room number or a name; she was a person. . . The finalblow came when she was to have surgery to debride the hugeulcer. According to the surgeon, the ulcer was so big that ahuman hand and half an arm could be put in. . . Apparentlymaggots had set in. Jill died on the operating table at age 35. Iremember this shook me up for months. It still brings tears to myeyes.Ann:^At the end of my training, I was working with a buddy -- one ofthe regular nurses. We were warned by the previous shift thatthis man was probably brain dead and was pretty awful to lookat. We approached the bedside in the dimly light room and sawa very bloated man with blood oozing from his eyes, ears, andany puncture site or bruise. He had an inflated catheter in hisnasal passage to stop the bleeding (in his esophagus) and wason a ventilator (a mechanical breathing machine). Beside himwas a very distraught old woman with two canes. She was tryingto comfort him, and he just lay there, occasionally experiencingsmall seizures. While Rachel assessed the patient, I took thewoman out of the room and tried to comfort her. She really didn'twant to know about his condition. She just reminisced about howhe used to be. Mostly, we discussed her feelings and fears. Iremember that I felt very ineffectual and wasn't really helping hermuch, but later she sent me a personal thank you note for justlistening.InNisible Practice85In Sue's story, she seems to place specific emphasis on certain aspects ofcaring: seeing a patient as a person, and not as a collection of deficits like adiagnosis or an ulcer. She, also, appears to point to one of the paradoxes withincaring. She speaks about how heart wrenching it is for her to care about thiswoman and, then, have to mourn and still mourn her death. In Ann's story, sheunderscores the idea that caring is a holistic concept that moves beyond theboundaries of a patient to the patient's family (Morse, Solberg, Neander, Bottorff &Johnson, 1990). It is interesting that, at first, she thinks that "just listening" did notseem valuable, but then she learns that it is. Although Sue's and Ann's stories talkabout how they have learned about caring from their patients and other nurses,Kara points out, that she has also learned about caring from their instructors:They (instructors) would ask us about how this patient feels?; orwhat is the patient really telling you? We were being taught aboutempathy and respect for people -- seeing things from our patients'perspectives.But, as Leah indicates, caring is also idealized in nursing education:I remember having to write a paper on one patient. I wrote 50 pagesand the instructor said I needed to write more. It's so idealistic .. .You can't know every little detail about every patient . . . You wouldnever have the time to care for anybody.Leah's emphasis on the way caring is idealized in nursing education is a commonelement across all of the nurses' educational experiences. However, as Leah says:I can only say this because of what I've learned at work.Before looking at some of the inherent contradictions within the concept of caring, Iwill draw from my field notes and interviews with Jan and Tye to discuss a fewexamples of their caring-in-practice.In this first example of caring, the conversation is between two OR nurses, Janand Gwen, and their patient Penny. Penny is about to undergo a breast biopsy.InNisible Practice86This conversation opens as Gwen brings Penny into the OR theatre for hersurgery:Gwen:^Penny says I look like the nurse from the movie "Misery!"Penny:^Its your voice.Jan:^Gwen, your loosing your reputation as a kind and loving nurse(laughing)!Gwen:^To bad I don't have her Academy Award (laughing)!Jan:^Yeah, you could start a new career!Penny:^Yeah (smiling and peering around at Jan and Gwen).Dr. Ons: I'm just going to give you some medication to help you sleep(injects some medication through Penny's intravenous).Jan:^Just close your eyes and have nice dreams -- just let yourself go(Jan holds Penny's hand until she is asleep).After Penny was anesthetized and her surgery had started, we talked about thisconversation:Kim:^That conversation with Penny was just incredible. In thebeginning, she was so scared . . .Gwen:^I think that the most important thing we can do for our patients ishelp them have a restful sleep (under anesthetic).Jan:^We try to help them calm down, divert their attention away fromthe anxiety of the surgery. And, if I think they've got a sense ofhumour, I'll go with it.Gwen:^Yeah, sometimes you can ask them about their jobs, theirfamilies -- anything to help them relax.In this next example of caring, Tye escorts her patient Rose into a chair in theER. Rose has come to the ER, because her breasts are sore and swollen. Thisconversation opens as Tye kneels down beside Rose, and starts to talk to her:Tye:^When did your breasts get sore?Rose:^About two weeks ago.Tye:^Have you had a mammogram?Rose:^No.Tye:^Are both breasts swollen or sore?Rose:^Just this one (pointing to her left breast).Tye:^Okay, I'll just take a look, and then I'll ask the doctor to examineyour breasts.InNisible Practice87A little later, when Tye had a few minutes to talk, I asked her a few questionsabout her initial conversation with Rose:Kim:^I noticed that once Rose was sitting in the chair, you kneeleddown beside her and then started to ask her questions.Tye:^Yeah, I can't imagine anything worse than the power of havingsomeone towering over you. So, I was just trying to equal theplaying field. Most of our patients are on stretchers, so you can'tdo that, but it's nice when you can.Kim:^You can do breast exams. I was wondering why you left Rose'sbreast examine for Dr. Holt?Tye:^I was just trying to save her some pain. No matter if I do one ornot, Dr. Holt will do one. So, I just thought that she shouldn'thave to go through this pain twice.In these examples, there are partial pictures of some of the ways in which Jan,Gwen and Tye practice caring. Jan's use of humour is fascinating. Based uponPenny's remark about "Misery," Jan has improvised and created a set of socialcircumstances to put Penny at ease. But, Jan is also quick to qualify her use ofhumour. She only uses it when she thinks a patient has a sense of humour. Gwenmentions another caring practice. In some circumstances, she practices caring byhelping the patient define him/herself beyond the identity of patient (e.g., askingpeople about their families and jobs). In comparison to Jan and Gwen, Tye's caringpractices are still different. Tye's kneeling beside Rose appears to symbolicallyreduce the hierarchical relationship between nurse and patient. In addition, sheseems to anticipate Dr. Holt's exam Rose's breasts, and the pain associated withthis exam. So, she chooses not to do a breast exam herself (e.g., to prevent Rosefrom experiencing this painful exam twice). In these examples, it could be arguedthat Jan's, Gwen's and Tye's caring practices arise from an implicit respect andconcern for their patients. Moreover, each nurses' caring practices is different, andthey talk about their practices as flexible. They seem to have developed caringInNisible Practice88practices that fit their own personalities, and the specifics of each patient'scircumstances.Although I have just highlighted a few fragments from some of the nurses' caringpractices, all of the nurses agree that caring is their common philosophical position,and that it comes to life in their practices. But, caring is neither a simple nor benignphilosophical position; it is riddled with paradoxes in the day to day realities ofthese nurses' practices.Problematizinq CaringHistorically, caring is construed and enacted as "women's work" (George &Larson, 1988; Melosh, 1982). It is perhaps not surprising to find that nurses' workand caring go hand in hand. Throughout history, nurses' work is seen in suchterms as: "distinctly women's work" and caring is "simply" the mothering of sickadults (Chua & Clegg, 1990, p. 140). Within this natural order metaphor, caring isnot a choice; rather, it is nature's prescribed function of nurses (and women)(Hubbard, 1988). This metaphor leaves very little space for nurses who would liketo confess that caring has personal costs, or that caring can make them unhappy(Hughes, 1990; Reverby, 1987). In other words, it silences discussions about thepersonal sacrifice or altruistic component within this definition of caring (Growe,1991). And, the absence of caring within this job description does the same thing.Without the concept of caring in this document, the nurses have no official mediumor voice to either articulate their caring practices (like the ones described above),or discuss the personal costs associated with caring. In the following discussions,I have selected three excerpts from our ongoing group discussion, whichproblematize the notion of caring in nurses' everyday practices (Smith 1987 &1990).InNisible Practice89In this first example, Kara, Liz, and Ann talk in general terms about the idealizednotion of caring within their post-secondary education, and how this has made itdifficult for them to establish limits for their caring practices:Kara:^Not all nurses care. Some just shut off and focus on the tasks.Liz: I think that's true, but you've got to remember that caring wasdrilled into most us in training. Care, care, care! And, some ofus never learned how to shut it off.Ann:^That's for sure!Liz:^And sometimes its hard for us to shut it off. So, sometimesnurses just shut off completely.Jan:^It's hard. In the OR, the sterile fields (linens) we use around theoperative site usually go above and beyond the patient's face.Thank God, we don't have to look at the patient's face as thesurgery is going on. That would just be too much, we'd just turninto blithering idiots. We wouldn't be able to do anything.Kara, Liz, Ann and Jan seem to be empathizing with each other about theirattempts to draw boundaries around their capacities to care. Although Kara andLiz make a special point of mentioning that some nurses "shut off' their caring,there seems to be no blame attached to these nurses. To Kara and Liz, it wouldappear that "shutting off' is more of a protective mechanism than a deficit. Inaddition, Jan's abilities to establish some physical boundaries for caring is anunique circumstance within her OR specialty.In this second example, Ann, Liz, and Tye talk about the problematicconstruction of caring when Ann is confronted by male patients who exposethemselves:Ann:^In the past three weeks, I have had three men exposethemselves in ER. The last time, I told this young guy to turnover on his stomach, and I'd be back to give him an IM(intramuscular injection) in his butt for his nausea. When I cameback he was laying on his back with the bed covers downexposing himself. I just told him to get over on his stomach, and Ijust rammed that needle into his butt. He screeched and jumped!Liz:^Good for you!InNisible Practice90Ann:^Well you know, I feel guilty about doing it. But, I'd just hadenough!Tye:^Don't feel guilty! He's got no respect for you. He deserved it.Please (stated with emphasis), come see me in action. I wouldn'thave put up with that for a second. I would have told him off, butquick.Kim:^Did you report it to nursing admin.?Ann:^No, because nothing ever happens when you do. I've reportedstuff like this before, and you never hear from them.I think that this conversation amongst these nurses gives some interesting insightsinto how the community of nursing practice works toward debunking and resisting ahistorically and culturally prescribed vision of caring (Van Maanen, 1988). Even inthe face of sexual harassment, Ann's account gives a personalized look at thedilemma she faces in setting boundaries for caring. This seems to be furtherperpetuated by an apparent unresponsiveness of the hospital to act in such cases.Although Ann's actions are supported by Liz and Tye, her guilt is not. To help Annovercome this guilt, Tye offers help. Tye invites Ann to watch her in action or rolemodel, how she has learned to make dividing lines within caring. I think that Tye'sconversation with Ann is extremely insightful. Although she does not use the wordaltruism, Tye seems to be trying to help Ann remove the altruistic component withinher conception of caring. I should also point out that Tye's help seems to be basedupon her "caring" for Ann.In this last example, Leah talks about the paradox between nursing "care" andmedical "cure." Kara describes one of her experiences in relation to this paradox:Leah:^We try to help people have peaceful deaths, but sometimes thedoctors just won't stop things. They try to cure people, and theysee death as a failure.Kara:^I remember this poor old man. He was on a ventilator, with everyother tube in creation. I couldn't take it anymore . . . I yelled atDr. Jons, for God sake turn this equipment off, the man is dead!He refused. So I when to the family, to let them know what wasreally happening. All they wanted was to be told about theirDad's prognosis -- that's their right.Leah:^What did Dr. Jons do?InNisible Practice91Kara:^Well, the family pushed him to let their Dad go, and he did. But,he knew I talked to them. He snubbed me for a month. But, thatdidn't bother me.As I mentioned at the beginning of this chapter, according to the nurses' jobdescription, medical interventions are supposed to supersede the nurses' plan ofcare. However, Kara seems to resist this interpretation based upon her implicitperspectives of caring. Although Kara does articulate her views about "the right todie" to Dr. Jons, he appears not to consider her perspective. But, Kara re-strategizes and talks to the family. Within her conversations with this family, Karaseems to have found a legitimate voice for her practices of caring. Leah's generalcomment about medicine's emphasis on "cure" and nursing's emphasis on "care,"seems to reaffirm Kara's actions. In addition, the equipment that Kara asks to beremoved is specific to the ICU setting.I have purposefully not tried to confine this discussion by offering textbookdefinitions of caring. Instead, I have tried to represent aspects of caring withinsome of the nurses' lived experiences. Given that the nurses' job description doesnot mention caring, I have emphasized caring in this opening section, not toartificially separate it from the nurses' theories of practice, but to underscore itsimportance as a philosophical belief that drives and constrains the ways nursespractice. In the next discussion, I will look more closely at prescribed theories for,and nurses' implicit theories from, practice.Building Theories For/From PracticeAll of the nurses agreed that the following statement in their job description doesnot account for the realities and complexities of their practice: "(nurses) implementHenderson's model for nursing through the use of the nursing process." To tracethe roots of this disparity between these "prescribed" models for nursing practiceand nurses' theories from actual practice, I will focus on some aspects of: 1) whatInNisible Practice92these nurses have learned about nursing theories in their post-secondaryeducation; and 2) how they (re)create their own implicit theories from practice.During one of our group discussions, I asked the nurses to reminisce about theirnursing education programs, focusing on how they had been taught aboutprescribed nursing models, and what they thought about these theories forpractice. The following conversation is an excerpt from this session:Kim:^You made a really interesting point in your autobiography whenyou talked about nursing school and having to learn all theseneeds in these categories. But independently of each other, andthen you were supposed to put it all together.Tye:^Oh yeah, I remember. In semester one, we started to learn aboutthe seven needs of a person. We studied every need separately. . . You thought of the seven needs that the person had, but youdidn't think of them all as one . . . This was all to come togetherin semester two. By semester two, . . . It was very difficult to putall these needs together.Liz:^I remember (in nursing school) working with cardiac patients, andnot knowing what the hell I was supposed to put together. Now Isay to myself oh that's what I was supposed to know, to learn, toput together.Leah:^These models are too cumbersome if you follow them verbatim.You really can't do a good job, as you should be doing it, as theinstructors' expected you to do . . . and follow these models.Sue: When I was at school trying to learn that stuff. I just said I can'tdo it, and my teachers would say oh yes you can. I never reallydid, though.Ann:^Yeah, its not natural.Kim:^So, you were taught to use these models, but you really didn'tuse them?Jan:^I don't think we did. I think that probably all of us here decidedthat we will go our own ways. We would do our own (models).Within these discussions, there seems to be two general points: one is abouteducational practices, and the other is about educational content, nursing models.Tye's comments about how she was taught a nursing model seems to emphasizethe notion that nursing curriculum is compartmentalized into discrete topics (Bevis& Watson, 1989; Britzman, 1991). In her education program, it appears that eachInNisible Practice93need within the model is taught separately. The difficulties she speaks about --trying to make connections between each need and trying to see this model in aholistic way -- appears to be more of a problem with the educational practices forteaching this model, than a reflection of her abilities to learn. Liz, Leah and Sueseem to have had similar educational experiences. Leah, also, suggests that themodel she was learning about in the classroom setting did not seem to "fit" in withher clinical experiences. Leah's words "too cumbersome," Sue's word "stuff," andAnn's words " its not natural," appear to address the irrelevance of theseprescribed models to their practice. They seem to be talking about a profound voidbetween the prescribed or received models for practice, and their own implicittheories from practice (Britzman, 1991; Lave and Wenger, 1991). Jan's statementabout resisting the prescribed models for practice and creating her own model ofpractice, implicitly suggests that the origins and development of such a modelwould be relational or based upon her own experiences. But, how might suchtheories take shape and be reshaped in practice?Theories of Lived and Shared PracticeAs I started to piece this section together, I found it increasingly unproductive, tofragment nurses' knowledge into reified types such as "declarative and procedural"(Anderson, 1990). As this discussion unfolds, it will become evident that thesenurses remember certain experiences for specific reasons, and in highlycontextualized ways. In their utterances, various knowledges are intricatelyinterwoven together. Initially, I will talk about the forms and functions of thesenurses' experiences, and about how these nurses (re)create theories from theexperience of practice (Britzman, 1991). Although this discussion is based uponthe nurses' journals, and my field notes from direct observation, most of the nurses'conversations will come from our group discussions, where we tried to collectivelyInNisible Practice94analyze these theories from practice. In this regard, this discussion represents aretrospective analysis of nurses' theories.As these theories are being discussed, I will also try to chip away at the notionof homogeneity. This assumption is basic to the nurses' job description and theprescribed theories for nursing practice (e.g., Henderson's model and the nursingprocess). To begin to deconstruct this assumption, I will focus on how the nurses'theories are composed of experiential differences, and contextual differencesacross nursing specialties (Bruner, 1986; Luria, 1979; Wertsch, 1985 & 1991;Vygotsky, 1978). Lastly, I do realize that I have not discussed the nursing process,yet, but I will interweave into the next section which addresses nurses' theories inthe action of practice.In our group discussions, I suggested that the nurses talk about some of theirexperiences as a way to look at the nature or structure of what they remembered,and determine why these memories are important to their practice. Both Jan andLeah talk about one of their memorable experiences, and their reflections on theimportance of their experiences:Jan:^I was called in for an Open Reduction and Internal Fixation of afractured ulna (forearm bone). The fracture was complicatedbecause their was two different types of fractures. One cleanbreak straight across the bone, and the other was an obliquespiral. During the surgery, the orthopedic surgeon attempted tostabilize the clean break with a multi-holed plate. This was astruggle because it was difficult to hold the shaft of the ulnasteady enough to apply the plate and drill the holes for thescrews. After at least an hour of struggle . . . I was unable tostop myself from saying, 'what would happen if the pieces ofbone at the oblique fracture site were screwed together first?' .. .It was not too long after this discussion that the surgeon didexactly what I had suggested - stabilized the oblique fracture andthen plated the clean fracture.InNisible Practice95Jan's Reflections:It's like putting your experience together, and coming out withsomething different . . . Besides, even though Dr. Jurgens didn'tacknowledge it, I'd showed him a different way of doing it, and I tookgreat pleasure in that.Leah:^He was sitting on the edge of the bed and he had the table infront of him and he was pulling this table into him; that's howanxious he was and I had to start yelling at him to look at me andto breath with me because otherwise he was gone . . . so I'mgiving him some ventolin (a drug used to improve breathing), andhe is just panicking. I listen to his chest, air was going in, I meansort of. At that point, I didn't have a oxygen saturation on him,because it was too far to go and there was just too muchhappening at the same time. The next thing I knew, my eyeskind of wandered down toward his feet . . . he was all mottledfrom his legs right up to his stomach. I knew he was in bigtrouble.Leah's Reflections:I guess it's a good reminder about what to look for. . . Mr. Klein'sbreathing was the obvious problem, but that mottling was more aboutCHF (congestive heart failure). The breathing wasn't really a lungproblem. It was a cardiac problem.Jan's and Leah's reflections seem to speak about two different ways that pastexperience is used to create new ways of knowing. Jan's experience seems torepresent a turning point in her practice -- a point where she synthesizes her pastexperiences and creates a new way of dealing with this type of complex fracture(Bruner, 1986; Lather, 1991). Whereas, Leah's experience seems to behallmarked by the notion of preventing premature closure -- going beyond theobvious symptomology related to shortness of breath and looking for alternativeexplanations. Tye, also, provides an interesting perspective on the experiencesthat she deems noteworthy to her practice:InNisible Practice96Tye:^I try to remember the unusual things. Like, usually there's certainthings about the patient's history and presentation that lets youknow what's going on, but you have to watch out because youcan get fooled. . . About two years ago, this older guy came in (tothe ER) with bad chest pain. He was diaphoretic (sweating), andjust clutching his chest. I thought for sure he was having a MI(heart attack). As it turned out, he had esophagitis. Then, lastyear, this woman comes in with a sore chest. She was calm andonly 36. So, I thought she had pleurisy or something. Herenzymes (blood tests) came back high. . . she'd infarcted (had aheart attack). So, you have to be careful about what you decide.Tye appears to be talking about two strategies for learning from her experiences:on the one hand, she tries to find similarities across her experiences to createtypical presentations of patients; on other hand, she tries to look for differences --patient presentations that do not fit the usual ones (Britzman, 1991). Her ideaabout going beyond the typical and looking for the atypical is similar to Leah's ideaabout preventing premature closure. In these partial examples of nurses'experiences, I have tried to identify a few strategic ways that some nurses use theirpast experiences to guide their current practice. However, the construction ofmeaning from experience can be different for different nurses.On different shifts in the ICU, Liz and Sue looked after the same patient, Mr.Larson. Mr. Larson came to the ICU immediately following a complicated andextensive abdominal surgery. Although Liz and Ann came to the same conclusionabout his condition, the data that they used to form this conclusion are different:Liz:^When I came on shift there was no (urine) output from the tube(in the ureter) and the foley catheter (in the bladder). So Iirrigated the tubes. Still no output was coming back. Only thesame amount that I used for irrigation, and nothing more. Then Iemptied the hemovac (a drainage tube inserted into theabdominal cavity), and there was a lot of drainage there .. .about 200mIs. The drainage (from the hemovac) looked like theurine that should have been coming from the tube and catheter.So, I phoned Dr. Allan and told him . . . First of all he said that heInNisible Practice97didn't think that the drainage coming from the hemovac wasurine. . . Try Lasix (a drug used to increase urine output). But,after the Lasix most of the output was coming from the hemovac ... So, definitely the urine was draining from there . . . When hezoomed in and looked at it, he realized that the urine wasdraining from the hemovac.Sue:^I thought the same thing. Was this just blood in the hemovac?Because I think right from the start there must have been someurine in there. It (meaning the drainage) wasn't clotting.Although Liz and Sue come to the same conclusion about where Mr. Larson's urineis draining from, they have emphasized different findings in the constructions of thisconclusion. Liz's conclusion appears to rest on three interrelated observations: nourine output from the ureteral tube or from the catheter in the bladder; the urine-likecolour of the drainage from the hemovac; and the increased output from thehemovac following Lasix. Interestingly, Sue's conclusion seems to rest on oneobservation: the drainage from the hemovac did not clot like it normally should. Itcould be argued that the differences within Liz's and Sue's analyses of this clinicalsituation rests upon the contextual differences within their past experiences -- howtheir differing experiences have shaped and influenced the current ways in whichthey construct knowledge (Vygotsky, 1978; Wertsch, 1985 & 1991).Based upon the partial collection of nurses' practices presented, I would like tocoordinate and interrelate some of the key points. I do realize that I will be makingsome generalizations about nurses' implicit theories of practice, but thesegeneralizations are not meant to be restrictive like the ones found within thenurses' job descriptions (e.g., Henderson's model). These generalizations aremeant to be fluid. They will depart from the homogeneous assumptions underlyingthe grand theories for nursing practice, and will stress some of the ways in whichvariations across nurses' implicit theories of practice can be interpreted on thebasis of contextual differences (Vygotsky, 1978).InNisible Practice98Throughout my earlier discussions on the practices of caring, and in thisdiscussion on creating theories from practice, there seem to be recurrent elements.When nurses talk about their practice, they tell very detailed stories about patientsand events in context (Britzman, 1991). As Kara said:If I try to slow my thinking down, I would describe it as watchingpictures unfold in my mind.Hence, she narrates her stories from the pictures in her mind. Most of the nurses'stories presented, thus far, are like ". . . packages of situated [and interrelated]knowledge. . . " and appear to represent turning points or transformations withintheir thinking and practices (Jordon, 1989; quoted in Lave & Wenger, 1991, p.108). The nurses talk about constantly integrating and interconnecting their stories-- constantly interweaving past and present experiences to renew and recreatetheir approaches to patient care (Benner, 1984; Tanner, 1992).Within this (above) description, if I remove the word "story", and replace it with"case study," it would be possible to make analogies between the nurses' clinicalstory building, and ethnographers' case study methods (Goetz & LeCompte, 1984;Van Manen, 1990; Yin, 1989). Like ethnographers, these nurses focus oncontextualized experiences; they analyze large bodies of qualitative data; and theyare interested in developing themes (similarities) and in finding differences withinthese themes. However, unlike ethnographers, these nurses are engaged inresearching their own lived experiences (Van Manen, 1990). In addition, unlikeethnographers who usually remove themselves from the research site for dataanalyses, these nurses do most of their analyses as they practice.I have tried to build this particular analogy between nurses' stories and theresearch method of case study analysis for two reasons. First, the idea of nursesas "researchers of their own practice," deconstructs the following statement withinthe nurses' job description: "(nurses) change practices or procedures to reflectIn/Visible Practice99current research findings." As researchers of their own practices, nurses are theactive (re)constructors of their own implicit theories of practice (Lather, 1991; Lave& Wenger, 1991; Wertsch, 1985 & 1991). Second, the notion of nurses asresearchers, also, deconstructs the hegemony of universal or grand theories fornursing practice, which is reified by nursing education and this hospital's jobdescription (Gramsci, 1988). As active researchers and constructors of knowledge,nurses can be re-situated with/in the contextual diversities of their practice. Basedupon these contextual differences, each nurse has unique experiences, which inturn, influences the ways in which she (re)constructs her theories of practice(Belensky, Clinchy, Goldberg & Tarule, 1986; Van Manen, 1990). And to extendthis point further, each nursing specialty has contextual differences which, in turn,creates particular practices in particular specialties. I will expand upon this lastidea.In the last group of examples from nurses' experiences -- Jan's from the OR,Leah and Tye's from the ER, and Liz's and Sue's from the ICU -- the types ofpractices that they describe seem quite different. In these examples, Jan'spractices seem to focus on the events around a particular surgery; Leah's andTye's practices appear to focus on analyzing their patient's chief complaints (e.g.,shortness of breath and chest pain); and Liz's and Sue's practices seem to focuson recognizing a rare post-operative complication. Within their accounts ofpractice, there seems to be no evidence of a generic theory for practice likeHenderson's model. They do not speak about generic needs or divide theirpatients up into needs as this model would suggest. Rather, their experiences andpractices appear to be shaped within their specific work contexts or specialty areas,and within specific patient circumstances (Britzman, 1991). In our groupdiscussions, Kara and Jan extend this idea:InNisible Practice100Kara:^I think that whatever your specialty is, you have your own theoryor model for that . . . What I really found interesting was when Istarted a new job and changed specialties . . . I initially startedexplaining everything in relation to my previous experience whichwas dealing with cardiac patients. And now I was working withpatients with renal failure. In the beginning, I would explaintheir care to myself in relation to my cardiac experience, becausethis was where my background was.Jan:^Like, I can only explain things from an OR nurse's point of view,because that is what I know.What Kara's and Jan's ideas seem to suggest is that there are specificcontextual differences within each nursing specialty which, in turn, create differentperspectives and practices. These specialties are like specific communities ofpractice within the broader or more general community of nursing practice (Lave &Wenger, 1991). Although I have only presented examples from nurses' practicesthat suggest some contextual differences across their communities of practice,each nursing specialty is not completely different from each other. There are someinstances where nurses' practices from different communities can intersect (Lather,1991). But at these points of intersection, what might be similar and different?In our third group discussion, Ann talked about a patient, Mr. Sanchez, whomshe admitted into the ER. Mr. Sanchez came to the ER, because he wasexperiencing extreme shortness of breath. In this following excerpt, I asked thegroup to talk about how they would care for Mr. Sanchez, so that we might be ableto uncover some of the similarities and differences across the ER, ICU and ORcommunities of practice:Ann:^In the ER, we'd focus on his history --when did the SOB(shortness of breath) first start . . . is there orthopnea (unable tobreath when lying flat)? . . . what meds is he taking?Liz:^We don't have to worry about those things (in the ICU), becauseby the time he gets to us all of that information is in the chart.We'd check his respiratory rate and listen to his lung and heartsounds right away, and do an 02 sat. (a machine that measuresthe oxygen saturation level in arterial blood).InNisible Practice101Tye:^(In the ER) We'd do that, too. We'd probably give some ventolinor Lasix. . . then watch the urine output and recheck his lungsounds and 02 sat.Kara:^Yeah, we'd watch for that (in ICU).Jan:^We admit patients to the OR just before their surgery . . . So, welook out for things like SOB, but we really just have to recognizeit . . . watching for a fast respiratory rate and looking at the colour. . . Then, we'd just tell the anesthetist and he'll deal with it.It would appear from these conversations that all of the nurses have priorexperiences in caring for people who are experiencing shortness of breath, andthat they have developed some strategies for examining and caring for this patientsituation. However, Ann's emphasis on focusing on a person's history appears tospeak to a unique situation in the ER setting. When patients come into the ERfrom home, they do not bring a chart containing all of their previous medical history,doctor's summaries and diagnostic test results with them. So, the ER nurses mustbuild a clinical history and picture of the patient. These circumstances are uniquein comparison to the ones encountered by ICU or OR nurses. By the time a patientis admitted to one of these specialty areas, the patient has a comprehensive historyin his/her chart. Thus, thanks to the ER nurses (and ER doctors), the ICU and ORnurses have a comprehensive background on the patient.Within this (above) conversation, the ICU nurses (Liz and Kara) and ER nurses(Ann and Tye) share some similar practices (e.g., listening to lung and heartsounds, analyzing oxygen saturation levels, etc.). But, Jan's examination practices,within the OR setting, are less extensive. I am not using the word "less" here tosuggest that Jan's examination is not as important as the others. Rather, I amtrying to indicate that across their specific communities of practice, these nurseshave similar and varying degrees of participation in the care of this patient. Lastly,it is interesting to note that what is considered "medical practice" in the OR setting(e.g., the anesthetist would look after the management of the patient's shortness ofbreath) is considered "nursing practice" in the ICU and ER settings.InNisible Practice102In this section, I have tried to piece together some of the components of nurses'implicit theories, and argue that these theories bear no resemblance to theprescribed model for nursing practice within the nurses' job description. I haveemphasized that the nurses remember certain experiences for specific reasons,and in very detailed and contextualized ways. Each nurse seems to use an evergrowing repertoire of experiences like an ethnographer would use case studies --to analyze the similarities and differences within and across specific events, and toguide and create new ways of knowing. I have also talked about these casestudies as stories. The stories each nurse tells herself about her practices, and thestories she tells other nurses about her practice. I will further explore the role ofstory-telling within the community of nursing practice.Story-Telling Within the Community of Nursing PracticeWithin the excerpts from our group discussions that I have presented and myown observations as I watched nurses in practice, I noticed that nurses areconstantly telling stories about their practice. This heritage of story-telling can betraced throughout nursing history. In Chapter One, I talked about how the "lay"nurses handed down their "tried and true remedies" of practice through story-tellingpractices (Ehrenreich & English, 1973). However, many of the nurses from the pastwere illiterate, so this was the only way that the legacy of nurses' practices couldbe passed on and, thus, (re)produced (Lave & Wenger, 1991). In current times,the circumstances are different; clearly, nurses can read and write. However, theoral tradition of story-telling still lives on. Why? I will work through two examplesof nurses' story-telling practices and, then, look at one possible reason for thislasting tradition.One day, while I was directly observing nurses' practices in the OR setting, Mayasked me to look at Rose's inventive tubing set up for the Phaco machine. ThisIn/Visible Practice103machine is used during cataract surgery for applying ultrasound in the eye'scapsule to "break up" the cataract; for applying suction to remove the cataractpieces; and then irrigating or cleansing the eye's capsule. As this conversationopens May is about to escort me down to the OR theatre, where a cataract surgeryis in progress:May:^(Kim) Have you seen Rose's excellent set up for the Phacomachine.Kim:^No, but I'll come down and take a look.May:^(Rose) I brought Kim in to see what you've done with the tubingon the Phaco.Rose:^Come over, here (smiling) . . . Well, when we got this newmachine, it came with instructions for setting an IV bag andtubing for irrigation . . . one day while I was assisting with anabdominal peritoneal resection, I noticed that the patient wasgetting two units of packed cells (blood) through "Y" tubing (thistubing is called "Y" because it has two ports at the top, where twoIV bags can be attached. So, the tubing is shaped like a "Y").Then, it hit me. I could use the same thing for the Phaco.Kim:^What do you mean?Rose:^Well, when one bag is finished, I can just turn on the secondbag. It's much saver for the patient, because you don't have toworry about running out of irrigating solution, and running aroundto get a new bag. So, when the fluid starts to get low I justquickly turn on the second bag.Kim:^Your brilliant!In this remarkable conversation, I am witnessing Rose's creativity-in-practice.Rose appears to have taken a practice from one situation and transformed it into anew practice in another situation. She has shown the other OR nurses how to setup this tubing, and through these story-telling practices, the other OR nurses areable to reproduce her creation, and in this way her legacy lives on (Lave &Wenger, 1991; Wertsch, 1991). However, her creation is not written down in thehospital's official procedure manuals or in any of the textbooks and journals that welooked through (and we did look through numerous reference texts and journals).InNisible Practice104The next example is along the same vein only it is situated across the ER and ICUsettings.In the ER and ICU setting, it is very important to be able to distinguish anginafrom myocardial infarction (heart attack) pain. Oftentimes, it is difficult to knowwhich is which, because the chest pain associated with these conditions can bevery similar. However, angina does not cause heart damage, but myocardialinfarction does. With the administration of thrombolytic agents (drugs that dissolveclots in the heart's arteries), frequently, the extent of the infarct (heart damage) canbe reduced as long as these drugs are administered within six hours of the onset ofthe chest pain. For the ER and ICU nurses, this means that the faster they candifferentiate between angina and myocardial infarction (MI), the faster the patientwith a MI can receive these drugs. The following excerpt from our group discussionopens as Tye starts to talk about how she examines people who are experiencingchest pain:Tye:^Well, usually there's that typical pain: mid sternal with radiationto the arm or jaw. And then there's a cardiac history, that's goodto know.Kim:^Say none of the test results were back. How can you tell anginafrom MI?Ann:^Oxygen usually eases up the angina, but not MI pain.Leah:^Yeah.Ann:^Just something tells you. It's all these things together, theyusually have a (cardiac) history, usually this pain just started onits own while they were at rest, not doing anything; that's usuallya good indication of MI.Kara:^They're usually diaphoretic (sweating). They look kind of ashyyellow.Sue:^But, there's something about their color that kind of pale ashenlook.Leah:^Yeah, that kind of gray chalky look.Ann:^Yeah, oh my god, you know, that chalky look.Tye:^I think that colour is a very important thing.Kara:^And then, there's that fear, that anxiety.Tye:^They'll just kind of lay on the bed, still.InNisible Practice105Ann:^They're quietly hyperventilating. They're not saying anything toomuch.Leah:^That's part of the anxiety.Ann:^Yeah, that's right they usually express their anxiety that way.In this collective effort, the nurses appear to be trying to piece together parts oftheir experiences that represent similarities and differences in the clinicalpresentation of people who are experiencing angina and MI. Although theymention a number of observations that are similar to both of these conditions, theirideas about differentiating these conditions based upon the "person's colour," and"expression of anxiety" are fascinating. We have combed through many texts andjournals trying to find the emphasis that these nurses place upon skin colour andthe expression of anxiety. We have not found it. It is something that the nurseshave learned within their practices, and shared through story-telling, but it seems tobe something that the official authors of nursing texts have ignored.In both of these glimpses of clinical practice, I have tried to show how nurses'practices move beyond the "minds" of individuals, and become situated along theintermental plane within and across specific communities of nursing practice(Bruner, 1986; Lave & Wenger, 1991; Luria, 1979; Vygotsky, 1978; Wertsch, 1985&1991). Through story-telling, the nurses share and enact each other's practices.Interestingly, in both of the (above) examples, there seems to be a disparitybetween how the "official" authors of texts represent nursing practice, and hownurses actually practice. Some of the specifics and intricacies of practice may notbe well represented in nursing textbooks, and may not be written down anywhere.So, like their historical counterparts, these nurses appear to use story-telling as ameans for sharing and learning about actual and situated practices within theircommunity of practice. For the community of nursing practice, story-tellingbecomes a significant social mechanism for praxis -- sharing, uniting, enacting andInNisible Practice106(re)creating nurses' theories in practice (Britzman, 1991; Lather, 1991; Lave &Wenger, 1991).By its very nature, this discussion about nurses' implicit theories of practice andthe importance of story-telling within the community of nursing practice isfragmentary and tentative (Aronowitz & Giroux, 1991; Lather, 1991). I have usedspecific, but partial examples that indicate some of the different ways nurses'practices can be represented. In this discussion, I see my main task as trying torepresent aspects of nurses' implicit theories of practice in similar, different andcontextualized ways (Britzman, 1991; Lather, 1991). Within this discussion, thereis a profound disparity between how these nurses represent their practices, andhow their job description represents their practices. This disparity speaks to thecreativity within each nurse's practice, and to nurses' collective resistance of theprescribed ways for constructing nursing practice within their educationalprograms, and within this hospital's job description. The next discussion will look athow nurses' theories of practice come alive in actual practice.Theories With/in Actual PracticesI do not have data that specifically relates to how nurses were taught aboutclinical decision-making models in their post-secondary education. But during oursecond group discussion, the nurses did critique such models. In the followingconversations, the nurses discuss the applicability of the "nursing process model"to their actual practice:Kim:^What about the nursing process?Liz:^I don't use it either. I think most of the times I've got about 5 or 6things going on in my head about a patient. I think that thenursing process doesn't really allow for that.Kara:^It's vertical. We work on the horizontal. Everything.Sue:^Yeah, integrating everything at the same time.Kim:^Like, there's a number of things happening and you're looking athow they affect each other.InNisible Practice107Kara:^Yeah, but it comes automatically without even thinking about it.Sue:^Just even an eye ball. You can just look at a patient. Like I justcan look at a patient. I can go up to the patient and know. . . Oh,shit this patient is going down the tubes. And it happens.Leah:^It's like multi-sensory. It's a kind of multi-sensory type thing, youknow. . . you walk in to take a look at somebody, and you take areal good look at the way their body is; what's their physicaldemeanor; what they look like in general; kind of how they smell.And a whole bunch of different sensory things going on, and Ithink that's how you kind of get those impressions.Jan:^Yea, like you're splitting your consciousness in differentdirections; we do that.Tye:^Sometimes you don't even have to see the patient. You just lookat the chart and know this patient's in big trouble!Jan:^I guess we can throw it (the nursing process) out the window,too. Nobody uses it here.Like Jan's last statement implies, it can be concluded that the nursing process doesnot adequately represent the ways in which these nurses' make clinical decisions.In contrast to the nursing process which emphasizes the linearity of nurses'thinking, all of these nurses mention the simultaneous nature of their thinking. Liz'sstatement, "I've got about 5 or 6 things going on;" Kara's idea, "We work on thehorizontal (as opposed to vertical or linear); " Leah's comment, "It's a kind of multi-sensory type thing;" and Jan's notion, "splitting your consciousness in differentdirections;" all tend to merge on the simultaneous nature of their thinking. But, howmight this form of thinking take shape in actual clinical situations?Simultaneous Thinking-in-Practice Related to One PatientGiven that we had arrived at the idea of simultaneous thinking as a way ofrepresenting clinical decision making early on in the course of this research project(e.g., during our second group discussion), I tried to keep this idea in mind as Idirectly observed each nurse in her clinical specialty. So, whenever it was possible-- when I was not disrupting the nurse's care of her patients -- I would ask her tohelp me piece together her thinking with the observations that I had made in myfield notes. The following representation of thinking-in-practice is a result of theseInNisible Practice108collaborative efforts. In this glance at Kara's thinking-in-practice, I haveconstructed a table with three categories: conversations between Kara and herpatient, John; her actions; and her reflections on what she was thinking at the time.And for the sake of brevity, I have only included the initial part of her examination ofJohn. John is middle aged, and came to the ER experiencing severe chest pain.After Kara helps John onto a stretcher, she begins her examination (refer to Table3, on the next page).I think it is important to mention that Kara is an experienced ER nurse. Thisexperience seems quite obvious in the way she has used specific interviewquestions, performed definitive examinations, anticipated future difficulties andredesigned her care around the specifics of John's circumstances. It could beargued that she has designed her care of John based upon past experiences -- herown case studies about similar patients in similar circumstances.When I interviewed Kara immediately following her care of John, we tried to piecetogether my notes, with her interpretations of her thinking-in-practice. During thistime, she said:. . . so much of this comes automatically to me . . . I can tell you aboutsome of the things that were going in my head . . . but, some of it, I'mnot really conscious of . . . it just comes naturally.Kara has made a very interesting point not only about herself but also about me.First, my field notes are constrained by my own conceptual lens, which allow me tosee some things and not others (Mishler, 1986). Second, based upon Kara'sexperience, it would seem that she has developed highly automatized strategies forexamining people with chest pain (Anderson, 1990). So in relation to this example,there may be other ideas and events happening, and what we have captured, here,is only what she and I are conscious of. However, what is captured is important,and needs further explanation.In/Visible Practice109Table 3: A Representation of Kara's Thinking-in-Practice.Conversations: Actions: Kara's Reflections:Kara: Where is thepain?John: It's in my chest(points to the middle ofhis chest).Kara: Wendy, will youmake out the reqs. forcardiac enzymes and a12 lead.Wendy: In just a sec.Kara: Does your painmove anywhere?John: Down my (left)arm. It feels numb.-puts John on oxygen.-helps the patient offwith his shirt andattaches him to thebedsideelectrocardiogram(ECG) monitor,and looks at the ECGmonitor to see thepatient's heart rhythm.-takes a printout of theECG rhythm.-puts her stethoscopeon her chest and listensto his heart and lungsounds.-looks at the arm.-if this is heart pain, theoxygen will help; if it'snot, the oxygen won'thurt him.-it looks like prettyintense pain. He'sgrimacing.-he looks a little ashen,and he's so thin.-he looks like a hippiewith those clothes andthat long beard.-looks like normal sinusrhythm with ST segmentelevation (the latter isan indication of reducedblood flow to the heart; itcan indicate angina orMI).-no heart murmurs, sothe valves are okay,and his lungs are clearso no heart failure, yet.-better find out if itsangina or MI.-typical pattern ofradiation.-he's moving his armokay. I'll check hismotor strength later.In/Visible Practice110Table 3: A Representation of Kara's Thinking-in-Practice (continued).Conversations: Actions: Kara's Reflections:Kara: (Kim) Would youget me an 18 gauge andtubing?Kim: Sure.Kara: I'm just going toput in an intravenous inyour arm. Then I'll giveyou something for thepain. Are you allergic toanything?John: Yes, pork insulin.Kara: Oh, so you'rediabetic.John: Yes.-takes John's bloodpressure (B/P)and looksat his arm veins.-Kim returns with the IVcatheter and tubing.-Kara starts priming theIV tubing.-better find out if itsangina or MI.-B/P is okay.-I'd better get an IV intohim, because I'm goingto give him some nitro(drug) for the pain and Ican't have his B/P dropafter the nitro within anIV line to compensate bygiving fluids.-he's got veins likegarden hoses, I'll put ina big one, an 18 gauge.-that size will be best, ifhe has a cardiac arrest.-he's really sick so Ican't leave him alone.- I always make sureabout allergies, before Igive any drugs.-he's quite alert so hisblood sugar is probablyokay.-diabetes is a bigcardiac risk factor.In/Visible Practice111In this representation of simultaneous thinking-in-practice, Kara appears tohave: 1) developed two fairly specific, but tentative diagnoses (angina or heartattack); 2) ruled out three possible diagnoses (low blood sugar, heart valve diseaseand heart failure -- however, she still thinks the later may occur); and 3) filed awaythe arm numbness for future diagnosis. This latter point speaks to her priorities.She seems to think that the time it would take to investigate this numbness shouldnot take precedence over dealing with John's chest pain. At the same time, shehas: 1) started an interview with John; 2) put him on an ECG monitor; 3) taken hisblood pressure; 4) assessed his heart and lung status; and 5) set up IV tubing.Also, she appears to be anticipating and preparing for future problems such as: alow blood pressure, which is related to the administration of nitroglycerin; a lowblood sugar level which is related to the patient's diabetes; and a cardiac arrestwhich is related to the John's cardiac status. With regard to the last point, shedoes not leave John's bedside, and delegates the laboratory requisitions to Wendy,and the obtaining of IV equipment to me. This is not a usual practice. Based uponthe critical nature of John's condition, she has apparently redesigned her practice.If John does have a cardiac arrest, she seems to want to be at his bedside so thatshe can spring into immediate action. In addition, she appears to have made somejudgments about John's identities beyond that of patient. She seems to think hemay be a "hippie." If her practice has not made you dizziness, yet, you shouldknow that all of what appears in this table took place within a 20 to 30 second timeframe. Also, I should point out that all of what Kara has done, thus far, is withoutthe direction or supervision of the ER doctor.Although nurses' simultaneous thinking-in-practice is evident across the threeclinical specialties, the specifics within this thinking process is different in the ORsetting. Jan explains how the OR context shapes her thinking:In/Visible Practice112We do the same sort of thing, but its different. When your working asthe scrub nurse, you're like the surgeon's assistant . . . you're alwayssplitting your consciousness . . . making sure about the integrity of thesterile fields . . . looking into the operative site to see what's going on ... where's the surgeon's hands? . . . where should you put yourhands? . . . what does the surgeon need next? . . . what otherinstruments are needed . . . should some sponges be added?In her care of one patient, Jan's simultaneous thinking appears to be actualizedsomewhat differently than Kara's. Beyond focusing on the immediacy of theinstruments, sterile fields and other equipment, it would seem that monitoring andanticipating the surgeon's practices becomes an extension of her multifocusedpatient care.Simultaneous Thinking-in-Practice Across a Group of Patients Up to this point, I have looked at thinking-in-practice from the standpoint of anurse's care of one patient. However, in the ICU and ER, nurses care for a numberof patients at the same time. As a result, the nurses are usually in constant motion,repriorizing and redesigning their practices in concert with the multiple necessitiesof all their patients' care. For these nurses, this type of work context not only callsfor thinking-in-practice for a specific patient, it also requires thinking-in-practice fora group of patients. Tye aptly sums up this form of thinking-in-practice by saying:It's like having your brain everywhere!In the next ICU clinical example, Liz and I have pieced together someobservations from my field notes with her reflections on her practice. In thisrepresentation of Liz's practice, a two column table is constructed: the first columndepicts some of the conversations and actions that Liz engages in; and the secondone identifies some of her reflections on these events. This situation opens as Lizand Rita start "day" shift, and decide which patients they will care for (refer to Table4, on the next page).InNisible Practice113Table 4: A Representation of Liz's Thinking-in-Practice.Time: Conversations & Actions: Liz's Reflections074407310730We listen to each patient'sreport . . . We have to know alittle about all of the patients,and a lot about our ownpatients.You can't remembereverything, so I write downsome important points abouteach patient.At the same as you listen toreport you have to make surethat everyone's okay. Soyou're always looking at themonitor.These ECGs are likebaselines. They need to becompared with the patient'sprevious ones and to anychanges that might occur lateron today.My plan was to see Mrs. Mayofirst because she's new .. .she's had a head injury so itsreally important that I get asense of her mental status, andmotor function early . . . so I'llrecognize even the slightestchange later on . . . I alreadyknow Mr. Jacob from yesterday. . . he's pretty stable so I justLiz: "Do you want to have the samepatients as yesterday?"Rita: "Sure that's fine."Liz: "I can take Mrs. Mayo (a newpatient), too."Rita: "Good, okay."Liz and Rita sit down at the nursingstation and listen the audio taped"end of shift report" that the nightnurses, Paula and Sarah, haveprepared.While sitting at the nursing station(or desk) and listening to report,Liz:a) -jots down a few notes.b) -on several occasions, Lizgazes at the screens on thecentral ECG monitoring systemat the desk.c) -takes printouts of herpatient's ECG rhythms, then,measures the waveforms andanalyzes them.-goes up to Mr. Jacob's doorwayand says: "I'll be in to see you inabout 10 minutes or so."InNisible Practice114Table 4: A Representation of Liz's Thinking-in-Practice (continued).Time: Conversations & Actions: Liz's Reflectionsstopped in to make sure. Helooks fine -- his ECG is normal,his colour's good, and he'sbreathing fine.-walks into Mrs. Mayo's room, chatswith her, and starts to examine her.0747 -the phone rings, and Liz runs to I knew Rita wouldn't have timeanswer it. to answer it, because she's inwith Mrs. Logan and she'sreally sick.That was Mrs. Logan'sdaughter on the phone, so Itold her about how her motherwas doing.-at the same time, she is talking onthe phone one of the ECG alarms That's nothing -- just (patient)goes off, and she de-activates it asshe is looking at the rhythm on thescreen.movement on the monitor.0749 -returns to Mrs. Mayo's room and She is oriented, and her handfinishes her examination. grasps, and leg movements areall equal and strong. So, she'sdoing pretty good right now.Her right pupil is a little largerthan the left, but that's nothingnew . . . she came in with that ... but it needs to be watchedclosely.0753 -starts walking towards Mr. Jacob'sroom, then Dr. Reist appears in thehallway.-Liz says to Dr. Reist: "We need to That was something that Sarahdraw some lytes (abbreviation for mentioned during report .. .the blood test electrolytes) from Mr. We are always organizing whatJacob. the doctors need to order andreorder.-Mrs. Fresen's call bell sounds, andLiz walks into her room.InNisible Practice115Before I begin to comment on certain aspects of Liz's practices, I think it isimportant to mention the central functions of "end of shift report" within the ICU(and ER) communities of practice. In essence, these "reports" are another exampleof nurses' story-telling practices, that I described earlier. These reports are thestories that one shift of nurses tells the next shift of nurses about their patients. Inthese stories, the nurses usually include a detailed discussion about: 1) theirongoing examinations of each patient (e.g., Is the patient's condition the same orhas it changed? What are the specific examination practices that the oncomingnurses should focus on?); 2) each patient's special considerations (e.g., Who arethe people that make up the patient's social support system and have they been into visit the patient? What approaches seem to be helpful in caring for the patient?);and 3) any treatments or drugs that the doctor has ordered (e.g., Why the doctorprescribed a new drug and how the patient is responding to this drug). In theserespects, report facilitates the continuity and (re)production of nursing practicesacross shifts (Lave & Wenger, 1991).In this glimpse of Liz's practice, the notion of simultaneous thinking acrosspatients becomes evident while she is listening to report. During this time, sheappears to be performing at least three different thinking tasks at the same time:1) determining and writing down some key points about all patients; 2) scanningand making judgments about all patients' ECG rhythms on the central monitor; and3) formally analyzing her own patients ECG rhythms on the printouts. Also, it couldbe argued that, while listening to report, Liz is developing some tentative plansabout the care of her own patients. By the end of report, Liz has apparentlydecided to focus on performing an extensive examination of Mrs. Mayo, prior todoing the same for Mr. Jacob. Thus, on the basis of report, Liz appears to havemade some initial judgments about the acuity of her patients, and opts to examinethe more acute patient, Mrs. Mayo, first. Interestingly, while en route to Mrs.In/Visible Practice116Mayo's room, she evidently verifies this plan by stopping at Mr. Jacob's doorwayand performing a cursory examination of him (e.g., He looks fine -- his ECG isnormal, his colour's good, and he's breathing fine). In addition to making someinitial plans for her patients' care, she appears to have made some preliminaryjudgments about the acuity and workload requirements of Rita's patients.Given her conclusion that Rita ". . . wouldn't have time . . . because she's in withMrs. Logan and she's really sick," Liz seems to anticipate and compensate forRita's workload by answering Mrs. Fresen's call bell, and the telephone call. Inthese ways, Liz is simultaneously and peripherally participating in the care of Rita'spatients (Lave & Wenger, 1991). Interestingly, Liz and Rita did not talk about howthey would deal with call bells and telephone calls. Liz's collaborative practicesacross Rita's patients appears to demonstrate how these nurses have learned torely on each other, "without having to ask." Moreover, Liz's plans for her patientcare possess an inherent flexibility. She appears to be constantly redesigning hercare around the specifics of her own and Rita's patients; and around the contextualconstraints of a(n) telephone call, patient call bell, ECG monitor alarm and doctor'svisit. In this partial rendering of Liz's practice, we (Liz and myself) have triedidentify some of the ways in which her thinking-in-practice extends beyond theimmediacy and boundaries of caring for one patient, and moves into the collectivecare of all ICU patients. Although aspects of thinking-in-practice for a group ofpatients is evident across the ICU and ER nurses' everyday practices, thecontextual differences in the OR creates interesting variations within this form ofthinking.In our group discussions, the nurses used the field notes (that I had written) asa basis for sharing their clinical practices with the group, and for analyzing thesimultaneous nature of their thinking-in-practice. Within these conversations, JanInNisible Practice117analyzed the ways in which her simultaneous thinking in the OR setting differs fromthat of the ICU and ER nurses:In the OR there is two nurses in each OR. We work as partners. Weflip our roles around . . . but for each (surgical) case, one of us is thescrub nurse, and the other is the circulating nurse. The scrub nurseworks with the patient and alongside the surgeon . . . the circulatingnurse looks at everything that's going on . . . the total picture .. .keeping an eye on how the patient is doing, how the anesthetist isdoing, how the surgeon is doing, how the scrub nurse is doing .. .Your constantly looking around to get a sense of what's going on, andwho needs or might need what.In Jan's account, she seemingly emphasizes how the contextual realities of the ORsetting influence the ways in which she simultaneously thinks-in-practice. Incomparison to the ICU and ER setting, where each nurse appears to interweavesimultaneously thinking for a specific patient with simultaneous thinking acrosspatients, the OR scrub and circulating nurses appear to share these forms ofthinking across the intermental plane (Vygotsky, 1978). The scrub nurse's roleseems to be primarily focused on simultaneous thinking in relation to one patient;whereas, the circulating nurse's role seems to be primarily focused onsimultaneously thinking across the activities in the OR theatre. As Jan hasmentioned, the OR nurses are like "partners" who share these two forms ofsimultaneous thinking-in-practice. Another variation, in the OR setting, lies withinJan's simultaneously thinking across the activities in the environment. In contrastto ER and ICU nurses' thinking across patients, Jan's analysis suggests that thecirculating nurse's simultaneous thinking is not related to a group of patients, but toa group of professionals. She seems to relate the circulating nurses' thinking to thesimultaneous observations of, and judgments, about the anesthetist's, surgeon'sand scrub nurse's practices.Be it in the OR, ICU or ER setting, the concept of nurses' simultaneous thinkingbeyond the immediacy of one patient can take on subtle, yet, significant forms. InInNisible Practice118the next clinical examples, I will draw from my field notes and interviews with Janand Leah to identify some subtle observations inherent to their simultaneousthinking. In this first example, Jan is working as the circulating nurse, and has justfinished helping the anesthetist, Dr. Forg, intubate Joanne, who is about to undergosurgery. At the same time, the scrub nurse, Marty, has finished setting up hersterile fields and laying out her instruments:Dr. Forg: We're ready to start. Where's Dr. Toberth (the surgeon).(Looking at Jan) Would you call for him (over the intercom).Jan:^I'll wait a second, because I think he's on his way in.A short time after this conversation between Dr. Forg and Jan, Dr. Toberth walkedinto the OR theatre. I, then, asked Jan how she knew that Dr. Toberth was on hisway in:Well, I heard the water running in the sink outside the room, and Ithought that it was probably Dr. Toberth doing his surgical scrub .. .You know, its interesting you asked me about this because I'm alwayssplitting my concentration . . . You tend to observe things withoutnoticing. And you might have to think back on the sequence of events,but you can say, yes, I did hear that . . . that's how I knew, it was thewater running.In the next example, Leah is finishing her initial examination of Julia who hascome into the ER seeking treatment for severe nausea and vomiting. As thisconversation opens, Leah is about to leave Julia's bedside and go to Bob's,bedside:Leah:^I'm going to let Dr. Orson (the ER doctor) know how you're doingand I'll come back with an injection of gravol for you.Julia:^Okay. (walks away from Julia's bedside and walks to Bob'sbedside).Leah:^(Bob) Your ventolin treatment (a liquid drug nebulized throughcompressed air) is finished . . . I'll just put you back on theoxygen and listen to your chest.InNisible Practice119In relation to the geographics of this situation, Julia and Bob were situated atopposite ends of the ER. After we left Bob's bedside, I asked Leah how she knewthat his ventolin treatment was finished:You know, when the air goes through the ventolin it makes that kind ofa gurgling noise . . . and after all the ventolin is gone the gurglingnoise is gone, and you get that kind of high pitched flow noise from thecompressed air.In these clinical fragments, Jan and Leah have evidently earmarked certainsounds in their environments as important and deserving of their attention.Although these sounds may serve the same "attention gaining" function as theones identified in Liz's example of simultaneous thinking (e.g., patient call bells,ECG monitor alarms and telephones ringing), there are inherent differences in theorigins of these two types of sounds. The ones described in Liz's example havebeen designed by others to gain the attention of the nurses; whereas, the onesdescribed in Jan's and Leah's clinical practice apparently arise from, and aredeemed important by their experiences in practice. Beyond the reasons mentionedby Jan and Leah for earmarking some sounds, Sue explains how a certain soundhelps her recognize a potential emergency situation:Sometimes its just in how the patient coughs. There's the usualcoughs, and then there are those kind of strange coughs that are likea cough, cry and gasp all in one. You investigate that one, becauseit's a noise that patients can make as they are having a cardiac arrest.It could be argued that the nurses' earmarking of certain sounds is one of thestrategies that they use to facilitate their simultaneous thinking beyond theimmediacy of one patient. These sounds appear to help them divert their attentionaway from their immediate practices, and help them make judgments about what isgoing on around them. However, to understand why nurses have developed sucha strategy, it is important to underscore the complex mental demands placed uponInNisible Practice120their memory and attention, as they simultaneously think and act in practice. Tomake this point clearer, I will interconnect a few points that I have made earlier.In the earlier discussions of Kara's examination of John's chest pain, and in Liz'sexaminations of her own patients and care of Rita's patients, I think that it isimportant to notice that these nurses have not "charted" or written down anythingabout these patients. This is not an omission on my part, but rather a reflection ofthe nurses' actual practices. Thus, all of the information that the nurses havecollected about their patients, and all of the judgments that they have made abouttheir patients are committed to memory. During one of our group discussions, Sue,Ann, Liz, Tye and Kara extend this point:Sue:^Charting is something we do when we get time.Ann:^Yeah, you have to deal with what's going on first . . . sometimesthere's so much going on, that you don't get around to chartingtill much later . . . sometimes not until the end of the shift.Liz:^But, it (meaning charting) is always very detailed.Tye:^Well, sometimes we ad lib a bit.Kara:^Yeah, we can't remember everything . . . Our jobs are aboutcaring for the patients . . . we chart to cover ourselves legally.In this discussion, these nurses seem to be talking about how the contextualcircumstances of their practice creates a lag time between: when they perform theirpatient examinations; and when they write down their findings in the chart. This lagtime means that the nurses must remember the details of their patient examinationsfor extended periods of time -- until they find time to chart. The mental effortsnecessary for remembering, coupled with mental efforts necessary forsimultaneously thinking-in-practice, creates another layer of complexity withinnurses' thinking (Anderson, 1990). While thinking about and carrying out theactions of patient care, the nurses are, also, trying to remember the details of eachpatient's initial and ongoing examinations. Given the mental energies devoted toremembering the details of each patient's examination, and to simultaneousIn/Visible Practice121thinking-in-practice, it is plausible to suggest that the nurses might developcompensatory strategies like earmarking certain sounds to help them attend tospecific and important events in their environments (Anderson, 1990). In addition,the notion that nurses learn to remember detailed accounts of their patients (inpractice) can be interconnected to my earlier discussion on story-telling practices.What I am suggesting, here, is that the nurses have learned to remember detailedaccounts of their patients as a commonplace practice, and that this may be one ofthe explanations for their abilities to reproduce stories of practice with suchprecision and detail.In these discussions, I see my main purpose as presenting aspects of nurses'simultaneous thinking-in-practice in similar, different and contextualized ways.Within these fragmented examples of nurses' thinking-in-practice, there seems to aprofound gap between how these nurses actually practice, and how their practice isconstructed by the nursing process. The nursing process represents nurses'clinical decision making in behavioral and linear ways; however, there appears tobe no evidence of this form of thinking within the nurses' everyday practices. Itcould be argued that the nursing process has undervalued the complexity,nonlinearity and contextualized nature of nurses' thinking-in-practice (Benner, 1984& 1992; Bevis & Watson, 1989; Britzman, 1991; Smith, 1987 & 1990; Tanner, 1986& 1992). Given that this model only focuses on clinical decision making for onepatient, the notion of simultaneous thinking across a group of patients interweavesanother layer of complexity into nurses' thinking-in-practice. It would appear thatnurses' thinking-in-practice is shaped by the contextual realities of theirexperiences, and by their resistance to prescribed models like the nursing process(Vygotsky, 1978; Lather, 1991). In the next and last section, I will interconnectaspects of prior discussions, with some of the strategic ways nurses learn to learnwith/in practice.In/Visible Practice122Learning With/in Practice Throughout this analysis of nurses' in/visible practice, I have been implicitly andexplicitly articulating how nurses learn in practice. Given that their theories of/inpractice appear to be different from the ones taught in their post-secondaryeducation programs, and the ones identified in their job description, it is plausiblethat their ideas about learning with/in practice might be different. As I mentionedearlier, nursing education is structured around behaviorist interpretations oflearning which tend to promote and legitimate: 1) the establishment of hierarchicalrelationships between educator and student; 2) the student's learning process aspassive and based upon their abilities to recant prescribed knowledge as outlinedin the curriculum; 3) the evaluation of student's learning on the basis ofdecontextualized behavioral acts; and 4) the separation of theory from practice(Aronowitz & Giroux, 1991; Bevis & Watson, 1989; Freire & Faundez, 1989).These prescriptions for education/learning are reified in the nurses' job descriptionby the following statements: "(nurses) maintain clinical competence by regularlyattending continuing education programs;" and "(nurses) change practices orprocedures to reflect current research findings." In this segment from our groupdiscussions, the nurses describe how their ideas about learning with/in practiceresist, and depart from the traditions established in their post-secondary educationprograms and their job description:Sue:^When I was is nursing school I just said where's the reality here?We'd be in the classroom most of the time . . . I just think it wasthe school of unreality, nonsense!Liz:^I know what you mean . . . I went back to do my BSN. . . It wasworse than my original training . . . You ended up having to livein a head space that says do I prostitute myself, prostitute myvalues and beliefs in order to get marks? That's what happenedto most of us who went back. And the profs weren't happy withus because we couldn't be cloned. We already had a sense ofreality.InNisible Practice123Leah:^Yeah it's like learning is based upon the number of degrees youhave or the number of courses that you've taken.Ann:^It's like, as long as you've paid money and shown up for acourse, then, that's okay, that's learning. But, it could have beenterrible.Tye:^The last course I went to was terrible. It was so stilted. It wasobvious that the women teaching had no clinical experience.She was trying to do it right, but not getting it right . . . shecouldn't do it the natural way, she had no hands on experience.Kim:^The academic community says that we must justify ourselves asa profession based upon the number of degrees and courses wehave, but this is so short sighted, because what they haven'tdone is give credit to the expert nurses who practice.Leah:^Right, you don't take 16 million courses and all these degrees tobecome an expert nurse. The best way is experience, hands onexperience.Ann:^Yeah, and we learn from each other.Liz: We do that all the time. Somebody says to me what do you thinkabout this patient. And I say well it looks like bla, bla, bla. Andthen somebody else comes along and says something a littledifferent. And you learn two different opinions and we both havethe same basic knowledge. But each one has a little differentedge.Ann:^Yeah, it's like asking another nurse to help me care for a type ofpatient that I have never cared for. That's continuing education.Kara:^Your right. The first ventilator patient that I looked after was alittle girl . . . You had the ventilator; you just had to learn. So,when I came on (shift), I said, how does this work . . . she(another nurse) showed me . . . when I ran into problems shewas my back up.Sue:^I remember when I started in ICU . . . I heard about this particularnurse -- how good she was . . . so I'd kind of go in and watch her.. . . to pick up her expertise . . . I'd watch her very carefully . . . I'dask about the decisions she'd made. What she was thinking andwhy she was thinking that?Jan:^Students come up to the OR. And I remember how terrified I feltwhen I had my first OR experience. I figure that if I make it seemfun, and make it enjoyable they'll learn. The students enjoycoming up, because we have got the time to explain things tothem, and their not stuck in the corner while we dash around in amad circle. . . We let them get scrubbed up with us, and let thembelly up to the bar.Tye:^You know, in every shift we work, we are always learning fromeach other . . . finding out what works, what's the best, what to donext time . . . that's learning.InNisible Practice124Kara:^And when things don't work out right, that's not necessarily bad.We still learned something new.The apparent sarcasm in Sue's comment, "the school of unreality;" and Leah'scomment, " You don't take 16 million courses . . . to become an expert nurse;" tendto merge on the notion that their post-secondary education failed to teach themabout the actualities of practice and, thus, failed to teach them about how topractice nursing. Interestingly, Tye's recent experience at a continuing educationcourse seems reiterate similar sentiments. Tye appears to have judged this courseas "stilted" and "terrible" based upon her perception that the instructor "had nohands on experience." In addition, Liz's emphasis on "we couldn't be cloned"seems to relate to some of the authoritative and inculcating teaching practices thatshe has encountered, and to her resistance of those practices.In this group discussion, the nurses continually refer to learning with/in theexperience of practice. In some respects, their ideas about learning-in-practiceappear to be similar to Lave's and Wenger's (1991) notion of "legitimate peripheralparticipation (p. 29)." They speak about contextualized learning; learning with thehelp of more experienced nurses; and learning about practice by first participatingon the periphery, and then moving toward the centre of patient care (Lave &Wenger, 1991). In relation to this last point, Sue's comments about closelywatching a nurse "to pick up her expertise," and Jan's comments about helpingstudent nurses learn by having them "get scrubbed up with us," seem to addressthe peripheral participation of neophyte nurses. However, in Kara's discussionabout caring for her first ventilated patient, she mentions a learning strategy called"back up." In this situation, Kara evidently participates at centre of this patient'scare until she runs "into problems," and needs the "back up" of a more experiencednurse. Ann seems to intimate this back up strategy when she talks about "askinganother nurse to help me care for a type of patient that I have never cared for."In/Visible Practice125This back up strategy appears to coincide with Kara's and Ann's participation at thecentre of patient care and, thus, it could be argued that, within the community ofnursing practice, this strategy is shared across experienced nurses. Kara and Annseem to fully participate in their patients' care until they encounter a novel or newsituation. Interestingly, there seems to be an implicit respect and trust underlyingthis strategy. The decision to consult a more experienced is apparently left up toKara and Ann. They seem to fully participate in their patients' care until they deemit necessary to consult a more experienced nurse. However, given the notion ofsimultaneous thinking across patients, it could also be argued that a moreexperienced nurse would have an awareness of, and would be making judgmentsabout, how Kara and Ann are coping with their patient care.Beyond the notions of contextualized learning and degrees of participation inpractice, it would appear that these nurses establish nonhierarchical learningrelationships (Belensky, Clinchy, Goldberg & Tarule, 1986; Lave & Wenger, 1991).Jan's ideas about making learning "fun" and enjoyable," Liz's comment, "we bothhave the same basic knowledge . . . But each one has a little different edge," andthe frequently repeated idea that "we learn from each other," seem to imply arespect, kindness, and support for each other, which is possible when learning isconstructed as a nonhierarchical and collaborative effort. Within these nurses'conversations, the concept of helping each other learn seems to be the "socialresponsibility" of "all" nurses within the community of nursing practice. The notionof nurses' nonhierarchical, contextualized and participatory learning relationshipsappears to dramatically depart from the educational practices employed in theirpost-secondary education, and reified in their job descriptions. As the activeconstructors of their own educational/learning experiences, the nurses appear to,once again, defy external prescriptions for their practice.InNisible Practice126As I look back on this preliminary and fragmented analysis of nurses' in/visiblepractice, I am fascinated by the breath, complexity and scope of these nurses'practices. And at the same time, I am astounded by how this hospital's jobdescription has undervalued the sheer brilliance of their practices. I think that Liz'scomment aptly sums up the nurses' sentiments and thus, the central propositionwith/in this analysis of nurses' in/visible practice:"We are more intelligent than the hospital says."InNisible Practice127Chapter 4: DiscussionThe assumption that nursing practice can be "prescribed" by others (than thosedirectly involved in patient care), and written about in "decontextualized" terms, isnot a contemporary development but, rather, a social norm that can be tracedthroughout history, and that is reified in this nurses' job description. However, whatseems to be unquestioned is: 1) how the writing of "others" has establishedparticular world views of nursing practice that are not necessarily authentic or innurses' best interests; and 2) how these views continue to subtly permeate andinfluence contemporary ideas about nurses' practices in ways that obscure thebreath and intricacies of their everyday practices. This multivoiced analysis ofnurses' in/visible practice is a particular testimony to a contrary conceptualizationof nursing practice; one that considers nurses to be the expert "authors" and"researchers" of their practices, and one that contextualizes nurses'thinking-in-practice. From this perspective, it would seem that nurses haverejected this hospital's simplistic and decontextualized versions of practice, asrepresented in their job description, and have (re)invented "complex" and"contextualized" versions of practice with/in their community of nursing practice.Thus, with/in the confines of this necessarily incomplete analysis, there appears tobe no support for the hegemony of: 1) externally prescribed authorships of nurses'practices; 2) de-intellectualized accounts of nurses' practice; or 3) universal orgrand theories for nurses' practices. Based upon these propositions, I will exploresome educational implications and, then, address some methodologicalconsiderations for this, and future research.Educational ImplicationsSince the Nightingale days, nursing education has revolved around aprescriptive orthodoxy. Nurse educators define the curriculum, specify behavioralInNisible Practice128objectives for the curriculum, and define/confine learning to the mastery of theseobjectives. However, it would appear that the nurses in this study have rejectedthis form of orthodoxy, and have invented a "learning with/in practice curriculum,"which is connoted here as contextually (re)defined, (re)negotiated and(re)interpreted by the collaborative efforts of nurses in their community of nursingpractice (Lave & Wenger, 1991). As represented earlier, nurses' theories of/inpractice are highly contextualized and elaborate. Operative in these theoryconstructions is nurses' learning with/in practice. I do realize that this study is apreliminary representation of nurses' learning with/in practice; however, theirnotions of learning seem to dramatically differ from those represented in nursingeducation. Thus, I will tentatively discuss how one could redesign aspects ofnursing education to accommodate some of the intricate forms of nurses' learningrepresented here.Within their community of practice, nurses have evidently developedcollaborative learning strategies that are simultaneously interactional, experiential,and nonhierarchical. The interactional or social emphasis on learning is, of course,an extreme departure from their experiences in post-secondary education, whichemphasized non-participatory forms of learning like classroom lectures (Bevis &Watson, 1989). From the nurses' perspectives, practice is apparently sociallyconstructed and distributed. As such, one aspect of learning with/in practice isenacted by actively conversing or consulting with other nurses, rather thanpassively listening to instruction. Thus, instead of defining/confining nursingeducation to received and passive forms of learning, it could be reconceptualizedas "interactional practices" among nurse educators, graduate nurses and studentswith the intent of learning the "sociocultural practices" of the community of nursingpractice (Lave & Wenger, 1991). As a social construct, nursing education would,also, have to be contextualized and localized with/in students' experiences.In/Visible Practice129The notion of "hands on experience" is a pivotal theme in this work, and it hasequally important implications for nursing education. It suggests that nurseeducators will have to abandon their "grand theories" of practice, and learn to helpstudents build theories of practice from their experiences in practice. Currently,many nurse educators do not actually practice nursing. However, in order to helpstudents (re)create theories from practice, nurse educators must intimatelyunderstand nursing from the vantage point of participating in "actual" practice.Thus, I propose that a nurse who positions her/himself as an "educator of nursingpractice" should, indeed, maintain an "active" clinical practice. Without aparticipating knowledge in practice, nurse educators are limited to decontextualizedknowledge and grand theories of practice, which in turn limits students' learningwith/in practice.A de-emphasis on classroom learning and a re-emphasized access to clinicalpractice is an imperative. Currently, students spend more time in classroomsrather than in clinical settings (Bevis & Watson, 1989). As a consequence, whenstudents come to a clinical unit they seem be like "visitors" rather than "beginningand participating members" of the community of nursing practice. In my ownobservations, this "visitor" concept is frequently reified by the educator/studentrelationships, and the lack of a student/practicing nurse relationships. Oftentimes,students' clinical learning is limited, directed and interpreted by nurse educators.Thus, practicing nurses on a given unit have little input into students' learningwith/in practice. However, in this study, nurses seem to have developed a widerange of practices that are (re)created with/in the specifics of everyday practice,and that are not officially recognized in nursing curriculum or textbooks. Hence, toprovide interpretive support for students' understandings of actual practice, theirlearning experiences need to be guided by practicing nurses and practicingeducators. From this perspective, students' learning becomes a collectiveIn/Visible Practice130responsibility, which is shared across the intermental plane, amongst students,practicing nurses and practicing educators (Vygotsky, 1978). As thus construed,students' learning is structured with/in nonhierarchical relationships, and issocialized and localized with/in experiences of practice. Such learning strategiesas case study building, story-telling and apprenticeship would seem to be criticalelements of a learning with/in practice curriculum. The strategies of case studybuilding and story-telling not only emphasize what students can learn frompracticing nurses and educators, but also emphasize what students can learn fromeach other.In addition, this notion of a learning with/in practice curriculum is not conceivedwithin, or predetermined by, stagnant and individualistic forms of objectifiedknowledge. As a situated and fluid curriculum, it arises from and is improvisedwithin, the variety and unpredictability of everyday nursing practice (Lave &Wenger, 1991). Thus, the traditional notions of: 1) measuring learning on the basisof the presence or absence of behavioral traits; and 2) quantifying learning in theform of grades, do not belong in this curriculum. Learning with/in practice, does notreside in the mind of an individual student and, thus, cannot be objectified orgraded; rather, it is a social effort, wherein experienced others help students(re)create and interconnect understandings at local levels of practice (Vygotsky,1978). This curriculum is about learning to become a member of the community ofnursing practice through degrees of guided and supported participation in thesociocultural practices of this community (Lave & Wenger, 1991).These proposed transformations to nursing education are, of course, tentativeand based upon aspects of nurses' learning, which are represented in this study.Certainly, more research needs to be devoted to identifying other forms ofthinking/learning-in-practice by selecting participants who have varying degrees ofexperience, and by extending this investigation into other hospital settings, andInNisible Practice131other clinical nursing specialties. However, what has been proposed, aseducational reforms, seems to be directly related to the emphasis this researchplaced upon nurses' commitment to transformative resistance at their local levels ofpractice.Emphasizing Transformative Resistance With/in Nurses' Practices and theResearch GroupIn emphasizing nurses' commitment to transformative resistance in theireveryday practices, this research has extended some of the traditionally construedboundaries with/in "critical" and "feminist" research (Campbell & Bunting, 1991;Stevens, 1989). Instead of articulating the oppressive circumstances inherent tonurses' position in the hospital, this research has emphasized nurses' degrees ofagency in their everyday practices. Like most of society's institutions, hospitals arestructured in a way that promotes power/labour divisions in a hierarchical system,and in this system nurses live at the bottom of the hierarchy. However, thisemphasis on nurses' degrees of agency with/in such a power structure is adeparture from some traditional forms of research. Oftentimes, in a traditionalcritical analysis of unequal power relationships in institutions, there is a strongemphasis placed upon the dualistic notions of "oppressors" (e.g., nurseadministrators and doctors), and "oppressed" (e.g., nurses). This form of analysisis problematic for several reasons. Frequently, the researcher forefronts andspeaks about the oppressive circumstances created by people in positions ofauthority and, then, describes the disparaging ways this oppression comes to life inthe world of the oppressed (Van Maanen, 1988). In such an analysis, theresearcher continues to speak through the voices of the oppressor. Emphasis isprimarily placed on the people in positions of authority, and the means by whichthey oppress the people who live at lower levels of the power structure. Thus, theInNisible Practice132oppressed people become secondary; they become the objects of this oppressionand are presented as the "passive" recipients of the controls placed upon them. Inother words, they are represented as sharing and "ventriloquating" the "prescribed"power structure or presumed natural order (Wertsch, 1991). Such an analysis iscounterproductive, because it creates a deficit model of the people who are beingresearched (e.g., they lack the ability to see and/or do anything about theiroppressive circumstances) (Lather, 1991). Moreover, this analysis creates asimplistic and circular argument. By showing the ways in which people areoppressed, the basic assumption that oppressed people are controlled by theiroppressors is reified. However, as this research suggests, nurses as an oppressedgroup, do have opportunities for agency in their everyday world -- that is to say,nurses can and do circumvent the hospital's natural order. Thus, instead offocusing on stories of despair and passivity as would be the case in a traditionalanalysis, I have emphasized stories of hope and creativity. I have presentedstories that demonstrate how nurses resist the hospital's power relations andprescriptions for practice as stated in their job description, and (re)invent new waysof knowing. Given the proposed changes in the health care system, the notion thatnurses are the leciitimate "authors" and "researchers" of their own practice is ofcentral importance.In B.C., the health care system is currently undergoing significant changes.The British Columbia Royal Commission on Health Care and Costs (Seaton,Evans, Ford, Fyke Sinclair & Webber, 1991) has mandated a radial change in thedirection of health care, moving it out of hospitals and into communities. Thisrepresents an important opportunity for nurses as it will return them to the placethat, historically, has brought them autonomy, satisfaction and respect (Growe,1991). Thus, it becomes crucially important to displace the myth that nurses "need"hospital administrators to create and monitor their practice, and replace it with theIn/Visible Practice133notion that the community of nursing practice possesses its own forms ofknowledge creation and regulation. Although further research is required tosupplement and extend the nature/scope of this community's knowledge creationand regulation, it would appear, in this preliminary research, that nursescollaboratively (re)produce their own practice with/in practice (Britzman, 1991).Thus, there seems to be no support for the assumption that nurses' practices mustbe created and monitored by people like nurse administrators, who are removedfrom, and thus external to, the actualities of everyday nursing practice.Furthermore, with additional research, it may be possible to argue that, givennurses' own knowledge creation and regulation, the community of nursing practiceis well prepared for its move into an autonomous form of community-basedpractice.In addition to focusing on nurses' commitment to transformative resistancewith/in nursing practice, I have pointed to some of the ways in which nurses debunkthe historical myth that there is a "clear" dividing line between nurses' and doctors'practices. Jan's practice related to inventing a new surgical procedure; Kara'stentative diagnoses of John's chest pain; and Liz's request of Dr. Reist to orderspecific laboratory tests for her patient, all appear to be examples of how nurses'in/visible practices intersect with doctors' practices. Jan's, Kara's and Liz'spractices seem to suggest that nurses "can and do," facilitate, critique and createmedical practices, and that nurses have "legitimate" knowledge of doctors'practices (Griffith, Thomas & Griffith, 1991). One possible explanation for thisphenomenon is that, in the hospital setting, nurses learn about medical practicesthrough their exposure to a variety of doctors, and a variety of ways in whichdoctors diagnose and treat particular patients. In the OR, for example, nurses mayassist many doctors who are all performing the same type of surgery (e.g.,appendectomy). However, in one way or another, each surgeon's technique willInNisible Practice134vary. From these different examples of surgical techniques, OR nurses learn aboutwhat has worked or not worked in specific cases. The same argument could beposed for the ER and ICU nurses. From the variety of doctors that they deal with,ER and ICU nurses learn about what information doctors use to make particulardiagnoses, and what treatments they use for them. From these experiences,nurses learn about what works and what does not. In other words, through theireveryday interactions with doctors, nurses can learn to create and critique medicalpractices. However, the notion that nurses can become adept at doctors' practicescould be construed as threatening to the medical profession (Cockburn, 1985).Based upon the claim that they possess a unique and specialized body ofknowledge and practices, doctors have justified their elitist position in the hospitaland health care system (Flexner, 1910 & 1915). According to this claim, onlydoctors are educated to perform medicine. But, when nurses are enacting doctors'practices, they are eroding doctors' primary claim to power. Nurses can learndoctors' practices "on the job" and, thus, are debunking the myth that "only" doctorshave the capabilities to practice medicine (Ferraro & Southerland, 1989). It isperhaps not surprising, then, that the nurses' job description renders nurses'medical practices in/visible, so that this natural order is maintained (Ashley, 1976).However, this research suggests that there are no clear divisions, but only "blurred"lines between nurses' and doctors' practices.Thus far, I have addressed some of the power relations established within thenurses' job description and argued that the following implicit and explicit assertionsseem to be questionable: 1) the presumption that nurse administrator positions arejustified upon the notion that nurses' practices must be monitored; and 2) thepresumption that doctors' elitist positions are justified upon the notion that they arethe only ones who possess medical knowledge. However, I do not think thatquestions about these power relations could have been raised without thisIn/Visible Practice135research's focus on nurses' commitment to transformative resistance with/inpractice.Transformative resistance is, of course, an integral concept in some feministresearch traditions (Lather, 1991). However, I think that it is first important tounderscore the lack of feminist research in the nursing profession and, then,identify where I have extended the boundaries of this tradition. For varioushistorical reasons mentioned earlier, feminists and nurses have had at best atenuous relationships. As a consequence, it has only been in recent years thatnursing research has incorporated aspects of feminist methodologies. This study isan attempt to add to this small collection of research, and, in particular, todemonstrate how some of the philosophical tenets with/in a feminist methodologycan be operationalized into participatory and nonhierarchical relationships betweenthe researcher and the researched. In so doing, this research has aimed towardsdemonstrating the importance of, and continued need for, collaborative andparticipatory forms of research in nursing practice. I do not think that the detailsand complexities inherent to this analysis of nurses' in/visible would have beenpossible without the joint construction of knowledge between myself and thenurses.Beyond the emphasis placed upon nurses' resistance to prescribed renderingsof practice (e.g., the nurses' job description), this study is also interested in thetransformative nature of the research project (itself), and thus, departs from thefeminist tradition of "the appropriation/give back paradigm." Oftentimes, thisresearch paradigm of appropriating data from the participants and, then, givingthem something back is applied to help participants in relation to some of theiroppressive circumstances. Although this notion of "giving something back" toparticipants seems benevolent, it de-emphasizes what participants have learnedInNisible Practice136while being a part of the research process, and makes in/visible what they arecapable of doing on their own. As Benmayor (1991) argues:Rather than being a final stage in an "appropriation/give back"paradigm, we have discovered that "return" is an ongoing andorganic part of the entire program. Participants do not depend onthe research(er) to get something back (p. 165).Benmayor's notion of focusing on the transformative nature of the research processis similar Lather's (1991) conception of "catalytic validity," as follows: ". . . thedegree to which the research process re-orients, focuses and energizesparticipants toward knowing the reality in order to transform it . . . " (p. 68). Thus,my interest here is in the transformative nature of the research process, itself.During our last group discussion, the nurses discussed their ideas about the natureand meaning of the research process:Sue:^I've really enjoyed these meetings. Even with all the differentpeople, it's been so nice.Kim:^Honestly, at first I thought it was going to be a nightmare trying toget us together for these meetings. I've been amazed about howwe all have been able to work around everybody's commitmentsand shifts. I can't thank you enough . . . But more than that, Ithink our commitment to meet goes beyond just research.Ann:^Yeah, there's a lot of support, here.Kara:^Yeah, my son calls them our group therapy sessions.Ann:^We seem to have a connectiveness and camaraderie and it'snice.Jan:^I even noticed when I come to ICU or when I come to ER, now,the nurses say hello, how are you, and ask me different things .. .. I'm person, now, rather than a nurse just dressed up in ORgreens.Tye:^I think that's neat . . . we should be doing more of that . . . startingpersonal relationships with nurses in other areas.Liz:^Yeah, we've learned about each other's specialty, each other'sperspectives . . . some quite good ideas about how you canhandle certain things that you probably haven't even thought ofbefore.Jan:^It's interesting, too, because in the group we've all kind of workedtogether. There hasn't been any cliques that have formed. Wehave all stayed together.InNisible Practice137Kara:^We should stay together, have pot luck dinners once a month,and just talk.Ann:^Yeah, and we don't just have to talk about nursing. We can talkabout raising our kids, talk about anything we want.Tye:^Yeah, I think so, too.Liz:^With all of us together, we can speak out with more power, too.Sometimes when you are vocal, the other nurses only support youso far.Ann:^Yes, until that scary stage, and then you better have yourparachute on.Liz:^So, we can be each other's parachute.Kim:^What do you think about adding some more nurses to the group?Tye:^Yeah, we should do that. Put together a group of real fighters.Kara:^Yeah, the higher ups are going to make some changes soon. Andwe've got to fight them. And the more nurses we pool togetherthe stronger we will be.Jan:^Especially from the OR and Critical Care, we are pretty outspokengroups, and the hospital can't function without us.In this discussion, the nurses seem to be: 1) developing a retrospective analysis ofthe importance of relationships formed within the group; and 2) developing aprospective agenda for the continuation of the group. In relation to the former, theoften repeated words "support" and "nice," Ann's statement about, "connectivenessand camaraderie," and Sue's and Liz's emphasis on entertaining and learning fromdifference perspectives, seem to speak about the nurses' respect and commitmentto each. In particular, Jan's statement about: "There hasn't been any cliques thathave formed" suggests that the social group structure is nonhierarchical. Thishorizontal structure, also, appears within, and seems to be pivotal to, thediscussions about nurses' learning with/in practice. Given these shared values inthe group, it appears that the nurses have become interconnected to one anotherin meaningful ways, and that they would like to continue meeting. Interestingly,Jan's experience of, " when I come to ICU or when I come to ER, now, the nursessay hello, how are you, and ask me different things," apparently identifies one ofthe ways in which being a member of this group has been helpful in personalizingher presence in other clinical specialty areas in this hospital.In/Visible Practice138As far as future endeavors, the nurses are evidently committed to continuingand extending the group's purposes. In relation to transformative resistance, Tye'scomment about putting "together a group of real fighters," and Kara's statementabout "The higher ups are going to make some changes soon . . . And we've got tofight them," seem to address future intentions of the group. However, Sue'ssuggestion that, "we don't just have to talk about nursing. We can talk aboutraising our kids, talk about anything we want," implies that being a nurse is onlyone of these women's identities, and that a future goal of the group needs to more"holistic"-- meaning that the group's commitment to, and support of, each othershould extend into each other's interwoven and multiple identities. It would appearthat this research project has been meaningful to the group, and the catalyticnature of this project seems to rest upon the nurses' commitment to continue.As I close these preliminary chapters on a representation of nurses' in/visiblepractice, I thought it appropriate to leave this work with the (above) voices of thenurses who apparently have been, and will continue to be, forging out personal andprofessional practices that are simultaneously in/visible, inventive and resistive.Like any research project, this one has a particular research question, which inturn creates a particular emphasis; an emphasis on nurses' in/visible practice.Given this emphasis, I think it is critically important to mention that the practices ofother hospital personnel like dietary aides, housekeeping staff, doctors and socialworkers have been rendered in/visible by this research project.In/Visible Practice139BibliographyAaronson, L. (1989). 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