Janice M. Morse

                                1

THE FRINGES OF KNOWLEDGE

                If I go out into nature, into the unknown, to the fringes of knowledge, everything seems mixed up and contradictory, illogical and incoherent. This is what research does; it smoothes out contradiction and makes things simple, logical and coherent.

—Szent-Gyorgi (1972, p. 966)

“Research” and “scholarship” form two keystones of the faculty role. “Teaching” and “service” are the other two interrelated components,¹ but the main worry of a faculty member in 2016 is meeting criteria of “research-and-scholarship” in order to be tenured, promoted, and keep one’s job teaching, researching, and scholarship-ing.

The reason for this anxiety is complex. First, doing research requires that one “come up” with a project that is reasonably unique, that will make an applied contribution, is fundable and publishable, and is, at the same time, interesting enough to hold one’s attention for 1 to 2 years. These are all components over which a person has little, if any, control—especially the funding criterion. However, there is a disjuncture: Whereas we teach research endlessly in the classroom, particularly at the doctoral level, in classes to develop research skills (i.e., mostly research design and statistics), classes for “scholarship” are missing—unless one makes a rather difficult argument that such content is integrated throughout the program.

I asked students what the difference was between research and scholarship. How were they interrelated? They agreed that they were connected and astutely pointed out the research could be technical, structured; scholarship more creative.

“Can you do one without the other?” I asked.

“No,” they said. “Scholarship is crucial for the development of the idea; for recognizing the implications and application of the research.”

My next question was: “Why is ‘research’ apparently more valued by universities and the public, than is ‘scholarship’?”

Students:

By this time I was feeling uncomfortable; were we so transparent that new graduate students could see our problems? Since when did academic research become a business? Scholarship appeared to be an essential skill—necessary for research; yet it did not have equal monetary reward and was not formally taught.

“How do you learn to become a scholar, if it is not taught?”

No answer.

This book is an attempt to fill this gap. In this book we discuss the theoretical foundations of nursing—how we find, develop, and use concepts and theory; how concepts and theory form the basis of research and how they are used and applied clinically. Most importantly, I hope the book will teach “how to think” and “how we think” as health care researchers and as professionals. I hope it will be the beginnings of appreciating scholarship, and revaluing it in nursing—for without it our research is a rote exercise, and we will be stymied as a profession, dogpaddling at the Olympics.

But scholarship is becoming valued, although rather awkwardly. The Magnet^® designation to improve nursing³ has required that philosophies of nursing and frameworks for practice be applied at the institutional level. But frameworks are selected by hospitals (or rather by nurses working in those institutions) and now used to organize our practice—those that were primarily developed in the 1970s and 1980s, and philosophies developed since the 1990s. Examples of frameworks for nursing care from the 1970s were Orem’s Self-Care Model (first published in 1971, followed by at least five editions since that time [Denyes, Orem, & Bekel, 2001; Orem, 1980, 1985, 1991, 1995]), Roy’s Adaptation Model (1970, 1988, 2009a, 2009b, 2011a, 2011b; Roy & Andrews, 1999; Roy, Wetsell, & Federickson, 2009), Leininger’s Sunrise Model (Leininger, 1978, 1995), Leininger’s Culture Care Theory, (1981, 1988, 1995, 2002), and, more recently, Kolcaba’s Theory of Comfort (Kolcaba, 2003; Kolcaba, Tilton, & Drouin, 2006). Examples of philosophies of care⁴ are Parse’s Human Becoming Theory (Parse, 1981, 1992, 1996, 1998, 1999, 2001) that posits quality of life from each person’s own perspective as the goal of nursing practice, and Watson’s Transpersonal Caring Relationships, which are used to guide our practice (Watson, 1985, 1988, 1999, 2000, 2002, 2006, 2007, 2008, 2009).

Although these conceptual modes or frameworks and philosophies have been used in research (e.g., Roy, 2014) and practice (e.g., Parker, 2010), they do not directly prescribe nursing interventions, but rather provide a way to conceptually organize or to guide caregiving. On the other hand, more specific concepts, models, and mid-range theories derived from qualitative research, wasting away in libraries and in journals, are still separated from patient care by the infamous research–practice “gap.”⁵ These models and mid-range theories are usually developed from detailed observations essential for directing patient-centered care: from interviews, stories of care from patients, nurses, or relatives, but they are considered too specific to guide comprehensive policies necessary for institutional use. This research, for instance, is directed to particular patient groups (patients with diabetes, or who have had a stroke, or are learning to breastfeed) or problems (experiencing immobility, a loss, or living in an abusive relationship). At the same time, quantitative theories, mainly directed toward improving technical, procedural aspects of care, are being tested, revised, and sometimes applied in practice. This research may compare and evaluate procedures, and make recommendations, thus contributing to evidence-based care.

Although the need for excellent, useful patient-centered theory remains an urgent requirement for the provision of care, nursing’s theoretical foundation continues to be weak. The art of nursing suffers. We have little to build upon, and little that separates our theory from social science theory in general. We still use concepts borrowed from sociology, anthropology, public health, or other disciplines. These are concepts that fit our caregiving mission poorly, discounting important aspects of the patient experience, such as intimacy and dependency, and theories that appear stagnant and static in our fast-paced, flexible, and rapidly changing discipline.

THE SCIENCE OF THE ART

Nursing is a fascinating profession. Everyone agrees it is essential at the societal and individual levels. Everyone agrees it is a rewarding and satisfying profession. Yet no one⁶ can be certain about how nursing works—what good nursing is—or even agree on a definition of nursing.

Now, this is a common problem in science: I study patient falls, and no one can produce a valid and comprehensive definition of a fall either, but we will not solve that problem in this book.⁷ Nevertheless, there is a huge difference between defining an event (a fall) and something as important, essential, and comprehensive as a nurse and nursing. And as many have noted, not being able to articulate what a nurse—or nursing—is and does, cripples our professional identify (Summers & Summers, 2010).

But, there is worse. We cannot agree about what a nurse does, and how we attempt to determine this is impeded by our profession’s value placed upon “real” science; we fund studies on particular nursing care problems (usually physiological or technical), but ignore our largest and most significant problems (such as how to endure illness, of noncompliance, and what it means to be ill).

We do not have a clear understanding of the nursing phenomenon associated with our nursing practice. In the 1980s, we conducted time-and-motion studies, trying to get at this question (e.g., see Giovannetti, 1978); now we have moved toward demonstrating nursing competency by measuring inputs and outputs, indicators of morbidity at the population level⁸ (Aiken et al., 2012) leaving the internal, daily caring, unexamined. Can we be satisfied with the nurse–patient relationship, integral to our profession, as being described as “intuitive” (Benner, 1984, 2004; Benner & Tanner, 1984; Benner, Tanner, & Chesla, 1996/2009)?

We know, of course, that nursing is distinct from medicine and that we have a different focus, different concerns, and different practices, yet we have difficulties even with understanding the everyday phenomena that we handle. Pain is an excellent example of a nursing phenomenon that we do not approach comprehensively from the nursing perspective. Even the evaluation of pain using a 1 to 10 rating is the butt of jokes.⁹

Drugs for the alleviation of pain are primarily the purview of pharmacy and medicine, although even this line is blurring.¹⁰ Administering pain medication is largely within the scope of nursing (but usually under the prescriptive privilege of medicine), but analgesics are not the only way to alleviate pain. Nonpharmaceutical methods of alleviating pain are important and within the purview of nursing, yet they are poorly integrated into our practice, seldom listed in our nursing notes, and poorly researched. And even if we knew such techniques, if we do not have time to do them, then they are lost to our profession.¹¹

Nursing becomes impotent.

Rest and sleep is another example of an everyday nursing care problem that is poorly addressed by nursing. Even Florence Nightingale made a case for the patient to “be in the best positions for nature to heal” (Nightingale, 1860/1969), yet we continue to wake patients, shine lights in their faces while they sleep, permit a noisy environment during the day (as well as night), and keep patients busy with examinations, tests, visitors, and other poorly coordinated events during their short hospitalization. In this noisiness we do not schedule or provide for daytime rest periods. No time to heal.

We do not practice what we know.

We spend little time observing patients, and little time learning what it is like to be a patient, to be in pain, facing loss, facing death. If we understood these things, the mechanisms of how they worked, and the impact on our patients as persons, our interventions would be on target, our intervention “kit sets” would increase many fold, and we could truly make our care evidence-based and our outcomes appropriate.

We could stop guessing.

If we developed our concepts, we would have a consistent language that explained nursing phenomena. It would give us a language, so we would be able to understand and communicate about our practice, both to ourselves and to others. Research would be consistent, on target, and would take a giant leap forward.¹²

Which of our concepts are underdeveloped? Even our major ones: No one suggests that the nurse’s role is not important. We are an integral part of caring and the maintenance of health—at least half of the equation. Yet the term “caring” is ambiguous, and lacks precision. We do not fully grasp how the caring interaction works; if we did, we would be a step closer to understanding what we do, would do it more deliberately, and would even demonstrate evidence and efficacy.

We cannot develop a profession from the “fringes of knowledge.” But before becoming too discouraged, let us take stock of our assets. We are advantaged by having a discipline that is well established, so that we are not developing our knowledge base from scratch. Thus it seems reasonable that if we analyze the care nursing actually provides in the moment, then we will be able to describe, to articulate, to classify, and to identify concepts and to develop nursing-specific theories. We will be able to understand the mechanisms of nursing care and identify our outcomes. We will develop as a profession.

EXPLORING THE FRINGES: THE CLINICAL UTILITY OF CONCEPT INQUIRY

Why do we care? Qualitative inquiry has assumed the role of describing nursing care. But qualitative inquiry has produced compartmentalized studies; these are generally isolated units that do not build on one another. Even qualitative researchers, who cite one another in their literature reviews and discussions, insist on developing their studies entirely inductively, from scratch, and naming their categories, themes, concepts, and theories by creating their own emic labels. Emic labels refers to those names that are terms generally used by the participants and derived from data that are particular to each study. Some qualitative researchers using emic labels do not take the time, or care, to go the additional step and compare their findings with other qualitative researchers’ findings or the concepts already described in the literature. The result is that our literature is cluttered with similar concepts and processes with various names and results in something that I have labeled as “theoretical congestion” (Morse, 2000). This keeps our research close to data, and does not result in the development of a set of useful concepts, enable abstraction, generalization, the incremental building of theory—or even enabled confirmation of others’ findings by our colleagues. The fact that we must work inductively does not excuse us—researchers can avoid deductive threats to validity when using the work of others (or one’s own prior work), by building within scaffolds (i.e., creating dense detail within the frame of another’s work) or on skeletons (i.e., the using the work of others as a foundation; Morse & Mitcham, 2002). Neither do recent efforts at qualitative meta-syntheses facilitate the type of concept formation and theory building that is needed.¹³

We desperately need good concepts: concepts for and about nursing. These are concepts that can be understood in use: concepts that would clarify our practice. We desperately need pertinent, solid, and valid operational definitions building consistent quantitative concepts; we need excellent pertinent nursing theory that will guide our practice in the institution and at the bedside.

THE ESSENTIALNESS OF EXAMINING OUR PRACTICE

“You study that!” This comment of disbelief was from a quantitative researcher who had dropped into my office to see what qualitative research was all about. At that particular moment, I was analyzing a video of trauma care, with all its apparent confusion and noise from everyone speaking at once, crowded around the gurney. I dissected the scene for him, explaining the roles of each person and what I call the channels of communication—who is talking to whom. I explained the focus of my study, the nurse and the patient; how they used the loudest of all of the channels of communication—and that their voices could be easily be heard over the top of the noise. As the patient screamed, my guest shrugged, made a face, and quickly left.

Undoubtedly such scenes of providing urgent care appear chaotic to those unfamiliar with trauma care—but to trauma nurses, the confusion is not an issue when describing their roles or responsibilities. They understand some of their actions, what they actually do and why. I am not talking about taking blood pressures, or recording, or other established and formalized technical tasks, but rather, how nurses interact and help patients through the assessment and treatments, how they assist patients to maintain control, how they manage the environment—even controlling the panic and shouting of the physicians—and how they keep care paced and prevent multiple procedures being done at the same time to various parts of the patient’s body. Nurses new to the trauma care told me that they “watched experienced nurses ‘like a hawk’” for at least a year—not to learn technical procedures, but to learn how to “manage” patients. They were especially concerned about patients who could not be considered responsible for their own behaviors: patients in agony, inebriated, mentally ill, or patients who fought care and fought off caregivers.

But if we observe carefully, or interview nurses, asking them to tell us about their interventions, their emotions, and other components of care that cannot always be observed, we find that nurses have complex cognitive responses and do much that is not described in textbooks or taught in the classroom—or reported in the media.

Once I asked emergency room (ER) nurses if I could come and observe how they comforted patients, and they told me: “Sure you can come, but we do not have time to comfort patients.” I came, observed, and classified their actions into categories of comforting.

Some of these were:

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