The consequences of using advanced physical assessment skills in medical and surgical nursing: A hermeneutic pragmatic study.

AIMS AND OBJECTIVES: The aim of this study was to explore the consequences of the nurse's use of advanced assessment skills on medical and surgical wards. BACKGROUND: Appropriate, accurate, and timely assessment by nurses is the cornerstone of maintaining patient safety in hospitals. The inclusion of "advanced" physical assessment skills such as auscultation, palpation, and percussion is thought to better prepare nurses for complex patient presentations within a wide range of clinical situations. DESIGN: This qualitative study used a hermeneutic pragmatic approach. METHOD: Unstructured interviews were conducted with five experienced medical and surgical nurses to obtain 13 detailed narratives of assessment practice. Narratives were analyzed using Van Manen's six-step approach to identify the consequences of the nurse's use of advanced assessment skills. RESULTS: The consequences of using advanced assessment skills include looking for more, challenging interpretations, and perseverance. The use of advanced assessment skills directs what the nurse looks for, what she sees, interpretation of the findings, and her response. It is the interpretation of what is seen, heard, or felt within the full context of the patient situation, which is the advanced skill. CONCLUSION: Advanced assessment skill is the means to an accurate interpretation of the clinical situation and contributes to appropriate diagnosis and medical management in complex patient situations. RELEVANCE TO CLINICAL PRACTICE: The nurse's use of advanced assessment skills enables her to contribute to diagnostic reasoning within the acute medical and surgical setting.

Hermeneutics and pragmatism offer a way of exploring the consequences of advanced assessment.

Linking specific nursing actions to outcomes in the healthcare setting is challenging. Patient outcomes are varied and influenced by a myriad of factors, and always involve a wider team than any one nurse. It is difficult to control for a single action or set of actions of a particular nurse. Furthermore, practice is seldom about any 'one' action, for one thing leads to another, all within a complex interplay of influencing factors. In this article, we outline a research method which combined Dewey's pragmatism with Gadamer's hermeneutics to explore the consequences of the nurse's use of advanced assessment skills in the acute care setting of medical and surgical wards. This pragmatic hermeneutic methodological approach allowed the complex interplay of influences to be revealed in the unfolding story. Reflection of the nurse brought insights that may otherwise have been passed over. The philosophical notions of Dewey drew attention to the play of 'means' and 'ends'. A hermeneutic approach that calls for 'thinking' extends understanding and raises insights that can inform education and practice.

Narratives in research: story as 'showing' the eminently ordinary experience of ageing.

AIM: To offer a perspective when research narratives about how ageing is lived in everyday life are the primary data. METHODS: A literature search explored the garnering of narratives about everyday life in advanced age in qualitative research. Narrative examples from the authors' research, and supervised student research, are drawn on to illustrate the experiences of ageing when going about an ordinary day. RESULTS: Stories show the lived experience of ageing is both ordinary and complex. Notions revealed are: age as constructed, as assumed by others, as being engaged every day, and as living the day my way. CONCLUSION: Understanding what it means to be older is in part shaped by which stories are told, who tells the stories and what sense is made of them. In gerontology research, 'story telling' can be a potent means of knowing what it means to be 'older' and of being worthy to self and others.

The dwelling space of postnatal care.

BACKGROUND: This paper considers the dwelling space of postnatal care, how being-there feels for the woman going through the experience of matrescence. The research takes a hermeneutic approach and draws on philosophical notions from Heidegger. QUESTION: 'What is the nature of the dwelling space of valued postnatal care?'. METHODS: Appropriate ethics approval was gained. Participants were midwives, nurses, women, and other relevant stakeholders. There were 4 focus groups involving 11 participants and 19 individual interviews. Data collection was conducted over a one week period by a team of three researchers. An interview schedule had been organised by the administrator at the Centre. Participants chose whether to come to the centre to be interviewed, or be interviewed in their own homes. Most interviews were an hour. All interviews were tape recorded and transcribed, with the participant's permission. Data was analysed through a hermeneutic process set in the context of related literature. FINDINGS: When women are invited into a dwelling space that strengthens them they feel 'mothered': being listened to, have their needs anticipated, and are cared for in a loving manner. In such a way they grow confidence. A child health nurse reported the difference such care made to on-going mothering at home. IMPLICATIONS FOR PRACTICE: All women deserve a dwelling space in their early days of matrescence. Small birthing centres perhaps achieve such care and ambience more easily than large institutional units. Nevertheless, wherever the place, practices need to be enabled that foster the spirit of dwelling.

International humanitarian nursing work: facing difference and embracing sameness.

This article explores the experience of humanitarian disaster and emergency nursing, asking the question, "How is difference (and sameness) in being a nurse revealed when working in a disaster/relief context?" The articles discusses interviews with seven nurses, plus the primary researcher, who tell their stories of humanitarian nursing. Stark differences are revealed: extent of injuries, limits of treatment, and overwhelmingness of need. Alongside this is the huge difference of personal danger. Sameness shows itself in the human-to-human call and response to need that holds nurses in such work. Difference and sameness are not fixed; one readily becomes the other.

Doing Heideggerian hermeneutic research: a discussion paper.

BACKGROUND: Much has been published related to the epistemology of Heideggerian hermeneutic research. We seek to reveal insights from our experience of enacting such research. OBJECTIVE: To articulate the lived experience of 'doing' Heideggerian hermeneutic research. DESIGN: The authors of this paper shared their experiences with the primary author towards articulating the process of 'doing' such research. PARTICIPANTS: The authors all have long experience with Heideggerian hermeneutic research and meet regularly at the Institute for Interpretive Phenomenology. They supervise student's research and are mindful of the process of coming to understand how to work in a phenomenological/hermeneutic manner. METHODS: First the section on philosophical underpinnings was written by the primary author and then shared with all authors. There was published data related to the experience of three of the participants already available. This provided a spring board to further conversations when the primary author visited America, able to engage in daily conversations with three of the co-authors. In the spirit of phenomenology this paper represents a process of reading, talking, writing, talking, reading, re-writing, re-talking and so forth. RESULTS: The process of doing hermeneutic phenomenology is represented as a journey of 'thinking' in which researchers are caught up in a cycle of reading-writing-dialogue- which spirals onwards. Through such disciplined and committed engagement insights 'come'. The researcher is always open to questions, and to following a felt-sense of what needs to happen next. However, it is not a process of 'do whatever you like' but rather a very attentive attunement to 'thinking' and listening to how the texts speak. CONCLUSION: This paper argues that alongside a disciplined understanding of the methodology, both researcher and reader need to share a commitment to 'thinking' which is willing to question, and open to trusting the resonance of understanding that 'comes' without expecting answers that are declared 'truth' for all time.

Thinking.

This paper argues that thinking is assumed within nursing education. There are strategies to promote thinking: reflective practice, critical analysis and problem solving. I suggest that by categorising thinking into such boxes there may be a danger of limiting the rich possibilities of simply 'thinking'. The writings of Heidegger (1889-1976) are cited, highlighting the need to 'call' thinking, and to meditate or ponder on the things that matter. The paper comes from research that asked the question 'What calls for thinking in postgraduate education?' Findings reveal examples of teachers and students recalling 'thinking experiences' but also suggest there is a danger that students do not have time to think in a busy classroom situation. It appears that thinking is more likely to happen outside of the classroom, with peers, in assignment writing, or when thoughts simply come. The challenge to nursing education is that not only may teachers be limiting students thinking opportunities, but they may be directing thinking in a way that maintains the status quo. If nursing is to equip itself as a dynamic profession and take initiative for shaping its own future, then close attention must be paid to enabling thinking.