Stuart Nairn

A critical realist approach to knowledge: implications for evidence-based practice in and beyond nursing

This paper will identify some of the key conceptual tools of a critical realist approach to knowledge. I will then apply these principles to some of the competing epistemologies that are prevalent within nursing. There are broadly two approaches which are sometimes distinct from each other and sometimes inter-related. On one side, there is the view that all healthcare interventions should be judged on the principles of randomised controlled trials and the other is a preoccupation with language in which healthcare interventions are subjected to a discursive interrogation. These debates are configured through the idea of a hierarchy of knowledge that is accorded uncritical acceptance by some and virulent distaste by others. I will argue that the notion of hierarchy is problematic and is largely argued for in unproductive epistemological terms. What is required is a shift towards a theory that emphasises the contextual nature of the ways that knowledge is produced and disseminated. In other words, there is no single hierarchy of knowledge, but there are multiple hierarchies of knowledge.

An exploration of the perceptions of emergency department nursing staff towards the role of a domestic abuse nurse specialist: a qualitative study.

There is a clear body of evidence which indicates that a substantial number of people who have experienced domestic violence and abuse attend the emergency department (ED). However, many individuals do not receive effective identification or support. The present study sought to explore the perceptions of ED staff about the perceived value and utilisation of a new domestic abuse nurse specialist role that has been created in one ED in the UK. A qualitative design was used and involved sixteen in-depth interviews with a range of practitioners. The findings highlight that staff highly valued the role of the nurse specialist as one which offered support both professionally and personally. However, the study has also drawn attention to the conundrum that surrounds identification and management of abuse and of enquiry more generally. The ED is ideally suited to identify at risk individuals but is not institutionally organised in a way that prioritises the social concerns of their patients and this nursing role is one way that this issue can be addressed. In light of recent UK and global policy directives further research is needed to explore the development and implementation of identification, management and support in the future.

Reflexivity and habitus: opportunities and constraints on transformative learning

This paper will explore the relationship between Mezirows concept of reflexivity and Bourdieus theory of habitus in order to develop a more robust framework within which critical reflection can take place. Nurse educators have sought to close the theory practice gap through the use of critical reflection. However, we are not convinced that this has produced the depth and quality of reflection required. Furthermore, the contexts in which critical reflection takes place is often sidelined or erased so that the whole impetus in the literature is to educate nurses in reflection rather than empower nurses to understand the complex circumstances and barriers that obstruct critical reflection. This paper argues that the reason for this position is that nurse education does not always acknowledge the role that personal and cultural values systems have on reflective practices. The literature search was undertaken using CINHAL and MEDLINE. Keywords included: values systems, habitus, and critical reflection. Inclusion criteria were determined by the theoretical approach and included seminal texts, from as far back as 1956, to identify key themes. Although critical reflection is a potentially powerful way of enhancing care it has often failed to do so. It is suggested that this is because nurse educators have frequently used models of reflection without considering the impact that students personal values systems has on their perceptions of care and subsequently care delivery. The purpose of this paper is to promote deeper levels of reflection and is part of a programme of research aimed at developing a more robust approach to reflection in educational practice.

Diversity and ethnicity in nurse education: The perspective of nurse lecturers

This paper is a report on a qualitative study which considered the issue of how lecturers feel about teaching and managing the topic of culture and racism within their role as nurse educators. The issue of cultural diversity and the related issue of racism within nursing and society more generally means that the problem cannot be ignored since one of the central tenets of nursing is that care should be delivered in non-discriminatory ways. We interviewed a group of lecturers within a UK university to explore their views on the topic. We produced six themes: Culture; the existence of racism within nursing; challenging racism; political correctness; strategies adopted to address issues in the classroom and the presence of cultural diversity within the curriculum. We identified that the lecturers in our study were keen to address the issue but were also very concerned about their own abilities and confidence in this area.

Nursing and the new biology: towards a realist, anti‐reductionist approach to nursing knowledge

As a system of knowledge, nursing has utilized a range of subjects and reconstituted them to reflect the thinking and practice of health care. Often drawn to a holistic model, nursing finds it difficult to resist the reductionist tendencies in biological and medical thinking. In this paper I will propose a relational approach to knowledge that is able to address this issue. The paper argues that biology is not characterized by one stable theory but is often a contentious topic and employs philosophically diverse models in its scientific research. Biology need not be seen as a reductionist science, but reductionism is nonetheless an important current within biological thinking. These reductionist currents can undermine nursing knowledge in four main ways. Firstly, that the conclusions drawn from reductionism go far beyond their data based on an approach that prioritizes biological explanations and eliminates others. Secondly, that the methods employed by biologists are sometimes weak, and the limitations are insufficiently acknowledged. Thirdly, that the assumptions that drive the research agenda are problematic, and finally that uncritical application of these ideas can be potentially disastrous for nursing practice. These issues are explored through an examination of the problems reductionism poses for the issue of gender, mental health, and altruism. I then propose an approach based on critical realism that adopts an anti-reductionist philosophy that utilizes the conceptual tools of emergence and a relational ontology.

Families' Stressors and Needs at Time of Cardio-Pulmonary Resuscitation: A Jordanian Perspective

Background: During cardio-pulmonary resuscitation, family members, in some hospitals, are usually pushed to stay out of the resuscitation room. However, growing literature implies that family presence during resuscitation could be beneficial. Previous literature shows controversial belief whether or not a family member should be present during resuscitation of their relative. Some worldwide association such as the American Heart Association supports family-witnessed resuscitation and urge hospitals to develop policies to ease this process. The opinions on family-witnessed resuscitation vary widely among various cultures, and some hospitals are not applying such polices yet. This study explores family members’ needs during resuscitation in adult critical care settings. Methods: This is a part of larger study. The study was conducted in six hospitals in two major Jordanian cities. A purposive sample of seven family members, who had experience of having a resuscitated relative, was recruited over a period of six months. Semi-structured interview was utilised as the main data collection method in the study. Findings: The study findings revealed three main categories: families’ need for reassurance; families’ need for proximity; and families’ need for support. The need for information about patient’s condition was the most important need. Updating family members about patient’s condition would reduce their tension and improve their acceptance for the end result of resuscitation. All interviewed family members wanted the option to stay beside their loved one at end stage of their life. Distinctively, most of family members want this option for some religious and cultural reasons such as praying and supplicating to support their loved one. Conclusions: This study emphasizes the importance of considering the cultural and religious dimensions in any family-witnessed resuscitation programs. The study recommends that family members of resuscitated patients should be treated properly by professional communication and involving them in the treatment process. The implications concentrate on producing specific guidelines for allowing family-witnessed resuscitation in the Jordanian context. Finally, attaining these needs will in turn decrease stress of those witnessing resuscitation of their relative.

Pierre Bourdieu: Expanding the scope of nursing research and practice

Bourdieu is an important thinker within the sociological tradition and has a philosophically sophisticated approach to theoretical knowledge and research practice. In this paper, we examine the implication of his work for nursing and the health sciences more broadly. We argue that his work is best described as a reflexive realist who provides a space for a nonpositivist approach to knowledge that does not fall into the trap of idealism or relativism. We emphasize that Bourdieu was not an abstract theorist, but only utilized theories to understand and explain the social world in all its empirical complexity. Theory is emphasized over method without denying the importance of method. We then provide a brief overview of some of his key concepts: habitus, field and capital. His work is a scientifically astute practice that has an emancipatory purpose, with particular resonance to the problems of nursing as a social practice. Some have criticized Bourdieu for undermining agency and we briefly address this issue, but argue that his conceptual framework helps us to understand what endures in social practice and why change is often problematic. In short, this paper argues that Bourdieus work is a fruitful resource for critiquing existing nursing approaches that are preoccupied with agency over structure.

The development of the specialism of emergency medicine: media and cultural influences.

In this article we analyse, via a critical review of the literature, the development of a relatively new medical specialism in the United Kingdom, that of emergency medicine. Despite the high media profile of emergency care, it is a low-status specialism within UK medicine. The creation of a specialist College in 2008 means that, symbolically, recognition as a full specialism has now been achieved. In this article, we will show, using a sociology of professions approach, how emergency medicine defined itself as a specialism, and sought to carve out a distinctive jurisdiction. While, in the context of the UK National Health Service, the state was clearly an important factor in the development of this profession, we wish to develop the analysis further than is usual in the sociology of professions. We will analyse the wider cultural context for the development of this specialism, which has benefited from its high profile in the media, through both fictional and documentary sources.

Audit of standards of practice in suspected hip fracture

BACKGROUND Hip-fracture is a common orthopaedic injury presenting to the Emergency Department, particularly within the elderly population. Standards of practice dictating the care of these patients include the early administration of analgesia and an accurate clinical assessment. Once a hip-fracture has been confirmed with diagnostic-imaging, the patient should be transferred to an orthopaedic ward as soon as possible. These standards have been identified from a range of national policies and evidence-based literature. AIM To identify standards of best-practice for the care of patients with a suspected hip-fracture in the Emergency Department and to audit compliance with these standards. METHOD A retrospective-audit of 185 Emergency Department Information System records for adult patients admitted with a suspected hip-fracture was conducted using a purpose-designed data-extraction spread-sheet based on discrete standards of audit. FINDINGS It was found that the Emergency Department performed well on some audit standards, such as the medical assessment of patients. However, some problems of assessment were identified in relation to pressure-care, the timely transfer of patients to a suitable ward and the delivery of pain-relief. CONCLUSIONS AND RECOMMENDATIONS There were examples of good practice in this audit, but also areas that require improvement. We recommend that a care bundle be implemented to focus on improvements in pain-relief, pressure-care and fast-tracking.

The politics of beds

In an account of an Accident and Emergency (A&E) department, Sweeney (2000, p. 27)) argues that: ‘The curse in the NHS is to be ill, but not life-threateningly ill,’ or as the title of the article puts it: ‘You’re either dying or waiting.’ The winter of 1999/ 2000 generated the traditional, yearly debate on hospitals under stress, with patients waiting in corridors for admission to wards and where bed occupancy had reached saturation point. Government ministers tended to emphasise the flu outbreak as an exceptional occurrence: close to, if not an actual epidemic. Health workers were more likely to point to underlying problems. The Observer (9/01/00) newspaper reported that London had lost 40% of its acute beds since 1982, while the number of A&E departments had shrunk from 47 in 1981 to 31 now. The result, they argued, was that occupancy rates for beds had increased from 75% a decade ago to a level of 95%. With no slack in the system, even a small surge in demand results in crisis (McVeigh & Brown 2000, p. 5). Bed numbers have been decreasing from a peak of 480,000 in 1948 (DOH 2000a, p. 8) to the present level of 187,000 (see Table 1). While beds have decreased, activity across specialities has increased: care is more intense, but hospital stays have become shorter. In the mid 19th century, the average length of stay in hospital was 36 days, in 1938 18 days, in 1979 9.4 days, in 1989 6.4 days (Armstrong 1998), while statistics for 2000 suggests 6.2 days (see Table 2). There is, as Armstrong (1998) points out, a reduction in numbers of hospitals and beds alongside increased rates of hospitalisation, which, as Table 2 illustrates, has an international dimension so that increased admission rates and falling bed numbers go hand in hand. Decreases in length of stay is, according to the DOH (2002a) a sign of improved efficiency, but in the same document, emergency re-admissions are shown to have increased, suggesting that clients are being discharged prematurely from hospital. For example, re-admissions rates for fractured hips are up by 4.8%, while overall the increase is 1.7%. In most comparable countries to the UK, bed numbers per 1000 of the population has been decreasing in line with changing philosophies of how to deliver care (Hensher et al. 1999), but even accounting for this, the UK is worryingly low in comparison to countries such as France, Germany, and the Netherlands, although on a par with Spain and Poland and slightly better than the United States and Sweden (Table 3). The hospital may still be considered a modern cathedral (Illich 1976, p. 87), but its status is being reconstituted as economic pressures begin to question its efficiency, and discursively as biomedicine researches its efficacy. These problems are expressed most forcefully in bed crises. The hospital has evolved in ways that exacerbate these crises. Hospitals are increasingly focused on science and technology that concentrates on more specialised approaches. Collins (1997) argues that the centralisation of acute care into large hospitals will improve care as surgical expertise can be organised more efficiently and effectively. District General hospitals will close and new mega-hospitals would emerge to meet the specialisation of knowledge that contemporary medicine increasingly demands. Others are less clear that this will produce improvements in care, arguing that with the growth in technology, telemedicine and the virtual hospital, such centralisation will become anachronistic as clients are diagnosed and treated locally in smaller units, thus Accident and Emergency Nursing (2003) 11, 68–74 0965-2302/03/