1. Reflexivity, the ethnographic vignette and the (rehabilitation of the?) research interview. Chris McLean Lecturer / PhD Student, Faculty of Health Sciences University of Southampton

2. 2 Research context The Research question  Person centred care demands that nurses see, think about, or treat the patients as a person.  This is known to be problematic in critical care  Study aim was to articulate the different roles / identities attributed to patients in the d(D)iscourse of critical care nurses. Research design and data collection  Naively conceived!  Participant observation and interview  No audio / video recording of naturally occurring interaction Key Influences  Foucault  Goffman

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4. 4 To perform suction Nurse F moves around the bedside and is now standing facing Mr. Young. The procedure itself is done quickly and wordlessly, and as Mr. Young retches and coughs at the end of the procedure Nurse F looks carefully at the contents of the suction catheter. As his breathing settles once more Nurse F begins speaking to him again but there is a clear change in her voice. I note that she is speaking quieter now and that there are changes in her intonation. It is my feeling that this procedure has been distressing for Mr. Young and I interpret these changes in Nurse F’s intonation as conveying sympathy for this. Field notes

5. 5 To perform suction Nurse F moves around the bedside and is now standing facing Mr. Young. The procedure itself is done quickly and wordlessly, and as Mr. Young retches and coughs at the end of the procedure Nurse F looks carefully at the contents of the suction catheter. As his breathing settles once more Nurse F begins speaking to him again but there is a clear change in her voice. I note that she is speaking quieter now and that there are changes in her intonation. It is my feeling that this procedure has been distressing for Mr. Young and I interpret these changes in Nurse F’s intonation as conveying sympathy for this. Field notes as construction yard Nurse F performs endotracheal suction… and talks to Mr. Young…

6. 6 To perform suction Nurse F moves around the bedside and is now standing facing Mr. Young. The procedure itself is done quickly and wordlessly, and as Mr. Young retches and coughs at the end of the procedure Nurse F looks carefully at the contents of the suction catheter. As his breathing settles once more Nurse F begins speaking to him again but there is a clear change in her voice. I note that she is speaking quieter now and that there are changes in her intonation. It is my feeling that this procedure has been distressing for Mr. Young and I interpret these changes in Nurse F’s intonation as conveying sympathy for this. Field notes as construction yard

7. 7 To perform suction Nurse F moves around the bedside and is now standing facing Mr. Young. The procedure itself is done quickly and wordlessly, and as Mr. Young retches and coughs at the end of the procedure Nurse F looks carefully at the contents of the suction catheter. As his breathing settles once more Nurse F begins speaking to him again but there is a clear change in her voice. I note that she is speaking quieter now and that there are changes in her intonation. It is my feeling that this procedure has been distressing for Mr. Young and I interpret these changes in Nurse F’s intonation as conveying sympathy for this. Field notes as mirror

8. 8 To perform suction Nurse F moves around the bedside and is now standing facing Mr. Young. The procedure itself is done quickly and wordlessly, and as Mr. Young retches and coughs at the end of the procedure Nurse F looks carefully at the contents of the suction catheter. As his breathing settles once more Nurse F begins speaking to him again but there is a clear change in her voice. I note that she is speaking quieter now and that there are changes in her intonation. It is my feeling that this procedure has been distressing for Mr. Young and I interpret these changes in Nurse F’s intonation as conveying sympathy for this. Field notes as mirror

9. 9 Re-appraising the ethnographic vignette  Requires a stance of “radical reflexivity” (Davies, 1999)  Awareness of constructed nature of text by a researcher / author  Recognition of the multiple ‘principle’ voices being represented  Enables recognition of the speculations and theorising of the ‘researcher’  Accounts are partial and reflect the researchers (identifiable) perspective(s)

10. 10 The ‘micro’ perspective When discussing Mrs. Williams’ progress at the end of handover, Nurse F comments that Mrs. Williams has a sodium level of 128, and that it was 130 earlier on in the day. Nurse F looks to me and comments in a joking tone “Not sure we can go home now”. Nurse 2 gives the handover quickly and smoothly. After summarising Mr. Richards’ reason for admission and his past medical history, she is talking through his current condition when her voice drops as she tells Nurse G that Mr. Richards has recently had an echocardiogram. She reports that this found him to have a septal defect and an ejection fraction of 15%. As Nurse 2 mentions the ejection fraction she holds Nurse G’s gaze for a few seconds and pauses as though to emphasise the significance of the information she is giving.

11. 11 The ‘micro’ perspective When discussing Mrs. Williams’ progress at the end of handover, Nurse F comments that Mrs. Williams has a sodium level of 128, and that it was 130 earlier on in the day. Nurse F looks to me and comments in a joking tone “Not sure we can go home now”. Nurse 2 gives the handover quickly and smoothly. After summarising Mr. Richards’ reason for admission and his past medical history, she is talking through his current condition when her voice drops as she tells Nurse G that Mr. Richards has recently had an echocardiogram. She reports that this found him to have a septal defect and an ejection fraction of 15%. As Nurse 2 mentions the ejection fraction she holds Nurse G’s gaze for a few seconds and pauses as though to emphasise the significance of the information she is giving.

12. 12 The ‘micro’ perspective When discussing Mrs. Williams’ progress at the end of handover, Nurse F comments that Mrs. Williams has a sodium level of 128, and that it was 130 earlier on in the day. Nurse F looks to me and comments in a joking tone “Not sure we can go home now”. Nurse 2 gives the handover quickly and smoothly. After summarising Mr. Richards’ reason for admission and his past medical history, she is talking through his current condition when her voice drops as she tells Nurse G that Mr. Richards has recently had an echocardiogram. She reports that this found him to have a septal defect and an ejection fraction of 15%. As Nurse 2 mentions the ejection fraction she holds Nurse G’s gaze for a few seconds and pauses as though to emphasise the significance of the information she is giving.

13. 13 Interview as co-text with field notes CReading that actually (.) it’s um (.) its actually quite bad isn’t it. In relation to nursing in intensive care but it’s(.) its something that you see a lot actually (.).hhhh reading that is very familiar Interview: Nurse C

14. 14 Nurse E places Mrs. Marshall’s walking frame in front of her then steps back and tells Mrs. Marshall to stand, but gives no further encouragement or support as she does so. Once Mrs. Marshall is standing she is stooped over the frame, and Nurse E steps forward to say that she should stand straighter and briefly places her hand very lightly on Mrs. Marshalls’ shoulder. I have the impression that Nurse E considered Mrs. Marshall to be ‘stuck’ at this point. Once Mrs. Marshall is standing up and has her balance fully, Nurse E steps away again and watches as Mrs. Marshall turns and sits herself in the chair.

15. 15 IntWas there a particular strategy a way of nursing that you were adopting while that was happening? EBy putting her in the chair? IntYeah. Not by putting her in the chair but but well (.) by that and by the way it was achieved, by the way it happened EErrr:: (.) Just trying to regain her independence I think. Because I know that I know that at home she does normally.hh you know here (.) What she would normally do at home would just be transferring IntMm EShe doesn’t really go on long hikes or anything (.) So (1) I was just trying to get her that kind of a sense of normality really and to get her to move (.) herself rather than us moving her Nurse E: Interview 1

16. 16 IntWas there a particular strategy a way of nursing that you were adopting while that was happening? EBy putting her in the chair? IntYeah. Not by putting her in the chair but but well (.) by that and by the way it was achieved, by the way it happened EErrr:: (.) Just trying to regain her independence I think. Because I know that I know that at home she does normally.hh you know here (.) What she would normally do at home would just be transferring IntMm EShe doesn’t really go on long hikes or anything (.) So (1) I was just trying to get her that kind of a sense of normality really and to get her to move (.) herself rather than us moving her Nurse E: Interview 1

17. 17 IntWas there a particular strategy a way of nursing that you were adopting while that was happening? EBy putting her in the chair? IntYeah. Not by putting her in the chair but but well (.) by that and by the way it was achieved, by the way it happened EErrr:: (.) Just trying to regain her independence I think. Because I know that I know that at home she does normally.hh you know here (.) What she would normally do at home would just be transferring IntMm EShe doesn’t really go on long hikes or anything (.) So (1) I was just trying to get her that kind of a sense of normality really and to get her to move (.) herself rather than us moving her Nurse E: Interview 1

18. 18 IntWas there a particular strategy a way of nursing that you were adopting while that was happening? EBy putting her in the chair? IntYeah. Not by putting her in the chair but but well (.) by that and by the way it was achieved, by the way it happened EErrr:: (.) Just trying to regain her independence I think. Because I know that I know that at home she does normally.hh you know here (.) What she would normally do at home would just be transferring IntMm EShe doesn’t really go on long hikes or anything (.) So (1) I was just trying to get her that kind of a sense of normality really and to get her to move (.) herself rather than us moving her Nurse E: Interview 1

19. 19 Conclusions An approach to these data which is both reflexive and linguistic provides a means of: – Evaluating an ethnographers’ / practitioners claims to speak from an ‘insider’ perspective – A recognition of these data as constructed, but as bearing a relationship to a social reality – Examining the ways in which participants accept, recognise or resist particular descriptions and interpretations of events – Balancing ‘macro’ and ‘micro’ persepctives through characterising both institutional Discourse(s) and their influence upon situated interaction – Enabling the identification of the “shifting of discourse across contexts” (Blommaert, 2005) “pushing ethnography towards the analysis of clearly delimitable processes, increasing the amount of reported data that is open to falsification” ?? Rampton et al, 2004