Nursing the “whole person” in critical care?: Implications for professional values, healthcare ideals and disciplinary identities Chris McLean, PhD Lecturer, Health Sciences, University of Southampton

Background and research question There is an expectation that high quality health care will be person centred (DH 2008; DH 2009; DH 2010a; DH 2010b) A focus on the whole person is argued to be particularly characteristic of nursing (E.g.RCN 2004) Critical care nurses are known to experience moral distress whilst attempting to care for the ‘whole person’ (Cronqvist et al. 2006; Lawrence 2011; McAndrew et al. 2011) “How do critical care nurses think about patients?”

Methods Ethnographic study in one UK critical care unit Data collected over 8 months during 2006 to 2007 –7 participants (3 novice; 4 experienced) –Participant observation (92 hours) –13 tape recorded interviews Data analysis adopted the perspective of linguistic ethnography (Key influences: Foucault 1969; Goffman 1974 )

Findings (1): Seven different ways of thinking about patients

The patient as the site of routine work “So – the 5 o’clock obs, do the ward round and do some eye and mouth care” The patient as a set of needs “She needs reassuring… reassurance and consent I believe is what I did’” The patient as body “I think with those things you probably have depersonalised …you’ve taken the person away from that I think” The patient as an (un)stable set of systems ‘She comments as the patient’s systolic blood pressure drops to 55 that even if the patient is lucid “I don’t like 55”’

The patient as a medical ‘case’ ‘She tells me that Mrs. Hargreaves has been admitted with Pneumonia on top of her COPD and diabetes… “and that’s it”’ The patient as a social being ‘Nurse A is smiling broadly, “I know you” Mr. Langden looks up and greets Nurse A. He too is smiling.’ The patient as a valued individual “That’s a big thing isn’t it … that’s someone's’ whole life turned around”

Summary of findings (part 1) Nurses think about patients in different ways Knowledge that these different ways of thinking relate to one coherent being can only be tacit “We know more than we can say” (Polanyi 1966). Thinking about a patient as a ‘whole person’ –is literally unachievable –does not explain or guide practice

Findings Part 2: Talking about persons Participants often talked about their practice as being problematic. Analysis of these data revealed that their identity as nurses was dependent upon caring for persons.

9 “I don’t know if this is a really un-nursey thing to say ((laughter)) but I think the most important thing is making sure the patient’s safe“ “with the sickest ICU patients you are - unfortunately focusing more on their observations. I mean you are obviously caring for them as a person but in quite a different way” “If you always thought of them as a person it would be time to get out as well. I think those are the ones who leave ITU within a month” “Its nice for us to see her as a person as well as the patient in the bed…but at the same time its something for him to focus on as well” “Privacy and dignity is one of the nursing …things that nurses are supposed to …((laughs)) But the most important thing was to make sure that they maintained their airway and they were breathing.”

Nurses’ professional identity is associated with caring for a ‘whole person’ Nurses can hold professional values and identity which are at odds with their role in care delivery Quality in healthcare is not guided or explained by a simple assertion that practitioners should think about patients as persons. Summary of findings (part 2)

Conclusions / implicationsAnd so… Practitioners think about patients in many different ways Quality of interaction is what matters to patient experience rather than how practitioners talk and think Role - values conflict is associated with burnout (Maben et al. 2007) Policy makers, educators, and leaders need to take care in communicating the values and ideals of healthcare Competing professional ideologies can lead to interdisciplinary conflict Need to examine how differences between ‘nursing’ and ‘medicine’ (and other professions) are constructed and sustained Untheorised discourses were associated with most ‘natural’ interactions Is a shared humanity more important than a distinct professional identity?

References Cronqvist A, Lützèn K and Nystr ӧ m, M. (2006) Nurses' lived experiences of moral stress support in the intensive care context. Journal of Nursing Management 14(5): pp Department of Health (2008a) High Quality Care For All: NHS Next Stage Review Final Report. London: DH Department of Health (2009) The NHS Constitution. London: DH Department of Health (2010a) Essence of Care London: DH Department of Health (2010b) Liberating the NHS: Legislative Framework and Next Steps. London: DH Foucault M (1969) The Archeology of Knowledge. London: Routledge. Goffman E (1974) Frame Analysis: An essay on the organization of experience (1986 Edition). New York: Harper and Row. Lawrence L (2011) Work Engagement, Moral Distress, Education Level, and Critical Reflective Practice in Intensive Care Nurses. Nursing Forum 46(4): pp Maben J, Latter S and MacLeod-Clark J (2007) The sustainability of ideals, values and the nursing mandate: evidence from a longitudinal qualitative study. Nursing Inquiry 14(2): pp Polanyi M (1966) The Tacit Dimension. London: Routledge and Kegan Paul. Royal College of Nursing (2004) The Future Nurse: the RCN vision. London: RCN