LIVING NURSING VALUES: A COLLECTIVE CASE STUDY Mary Helen Rook A thesis submitted to the Victoria University of Wellington in fulfilments of the requirements for the degree of Doctor of Philosophy in Nursing Victoria University of Wellington 2017 ABSTRACT Distinctive humanistic values are foundational in professional nursing practice, commonly shared by members of the profession and the mainstay of how nurses act. The foundational values of the nursing discipline are balanced with clinical knowledge and technical skill. Nursing values presuppose nurses’ responsibility to nurture and protect, to heal, to cultivate healthy behaviours and attitudes, and to be present (physically and intellectually) during times of vulnerability, illness or injury. The rationale for this study came from the recognition that nursing has changed, so too have the characteristics of patients and the way healthcare is operationalised. Nurses are challenged on a daily basis to negotiate between meeting the complex needs of patients whilst addressing healthcare priorities and attending to their own personal and professional requirements. There is a growing philosophical debate about whether the healthcare climate is dehumanising health care professionals’ encounters with patients, including those of nurses, and creating a culture where enacted values are inconsistent with professionalism. The purpose of the research was to explore the values of professional nurses practicing in medical ward environments and how these values are lived in day-to-day practice. Case Study methodology was used to capture the contextual conditions of nursing values in nurses’ daily practice. Data collection was carried out in three medical wards in New Zealand; data were triangulated using observations, focus groups, interviews, burnout survey and theoretical application. The major theoretical and philosophical influences on the research, which were used to explore the data, were those of Isabel Menzies’ defences against anxiety and Edith Stein’s phenomenological theory of motivation and value. Key findings indicate that healthcare environments obstruct the enactment of humanistic nursing values stimulating value dissonance for nurses between how they want to practice and how they actually practice. Conflict arises from nurses experiencing systems that foster managerialism and cultures of anxiety. In order to cope with value dissonance, nurses i enact unconscious defence mechanisms; resulting in constrained nursing practice, exhaustion, cynicism and burnout. This thesis challenges the nursing profession to acknowledge and address the visibility of nursing values in contemporary practice, as well as acknowledge the dissonance that exists between the values of nursing and the values that drive healthcare delivery. Humanistic nursing values remain important to practicing nurses. This study identifies in detail the every-day difficulties nurses face in seeking to enact their values and the managerial challenges that confront them. This information offers a trustworthy analysis of the challenges the nursing profession faces in addressing this problem. It also offers a basis for developing approaches that could strengthen nurses’ ability to enact the humanistic values they are professionally committed to provide. It is critical that any attempt to embed nursing values into clinical nursing practice is founded on a strategy that recognises and mitigates against dysfunctional organisations and organisational constraints. Drawing on findings from this thesis, it is recommended that the articulation and development of nursing values in acute clinical environments is responsive to organisational factors. Through this, the nursing community can develop, articulate and operationalise nursing values. Keywords: Professional nursing values, nursing, values, Isabel Menzies, defence mechanisms, managerialism, value dissonance, Edith Stein, medical wards, case study. . ii DEDICATION To Mum and Dad for giving me roots and wings. iii ACKNOWLEDGEMENTS I have never known a doctoral thesis to be plain sailing, I therefore set out on my journey with clear navigational charts and a survival kit, fully expecting to be tipped into the water at a moment’s notice. That is exactly what happened many times. The choices that are made whilst bobbing in the ocean are the ones that make some swim for shore and others climb back on board. What helps make the latter decision are those who have also pinned their colours to the mast. Dr Kay de Vries from the moment we discussed my ideas over coffee, I knew you would stay with me through whatever was thrown at us and you have done that and so much more. Your supervisory and teaching skills are second to none; you have a natural ability to make complex theoretical and philosophical arguments simple and relevant to professional nursing practice. Above all it was your hard work, honesty and practical approach that acted as a beacon in the troubled waters. Your intelligence and wit have been steadfast. Without you Kay none of this would be possible and I will be forever grateful to you. Thank you for your guidance and friendship. I was truly blessed to have you. Dr Therese Meehan your knowledge and attention to detail has had me down rabbit holes I never knew existed. In my view you reflect the values of the nursing profession, excellence, kindness and respect for human dignity. Our intellectual conversations have crossed the globe and challenged and energised me throughout this journey. Thank you for your kind letters and little packages and for staying with me throughout it all. Blessed as I was with two wonderful supervisors my colleagues and fellow students at the Graduate School of Nursing Midwifery and Health were profoundly supportive, offering friendship, advice and the occasional hug. Thank you all. The Faculty of Humanities and Social Sciences provided financial grants, as did the Cowley Nurses Trust, I am very grateful for this support. Special thanks go to Professor Mo Coombs, Dr Kathy Nelson, and Associate Professor Tracy Long-Sutehall for lovingly supporting me, and for the times iv when I was stuck in rough seas making sure a life jacket was ready and a lighthouse was lighting the way. Research is nothing without its participants. I want to thank all those, nurses and patients who granted me access, agreed to talk to me and or observe them. This study is complete thanks to your contribution and generosity of spirit. I own an intellectual debt to Isabel Menzies, Edith Stein, Alistair McIntyre, and Philip Zambrado for opening my mind to the vast world of psychoanalytic thinking, phenomenology, philosophy and social psychology. I had the privilege to spend some time with Dr John Paley and Dr Mette Lebech both who stretched my thinking and then stretched it some more. Andrew, Conor and Aidan you were with me from start to finish. Thank you for making dinners, feeding dogs, bringing me cups of tea, loving me and most of all believing that I could and would do it. I could not have done it without my beautiful funny boys. Aidan and Conor I love how you think about what I have been doing, captured beautifully in your art, and yes, it is finished! Andrew you are a true partner, I love you. I could not have put this better myself so I cautiously leave the last words to Sawicki (2000, p. XXIII) “Blessed as I have been with such abundant earthly assistance and heavenly surveillance, I beg the indulgence of critics from both planes for whatever shortcomings remain”. v © 2016 Conor Rook – Age 8 © 2016 Aidan Rook – Age 7 vi TABLE OF CONTENTS ABSTRACT ........................................................................................................................ I DEDICATION................................................................................................................. III ACKNOWLEDGEMENTS ........................................................................................... IV TABLE OF CONTENTS ............................................................................................. VII LIST OF TABLES ....................................................................................................... XIII LIST OF FIGURES ..................................................................................................... XIII CHAPTER ONE: INTRODUCTION ............................................................................. 1 1.1 Introduction ............................................................................................................... 1 1.1.1 The image of nursing ......................................................................................... 1 1.1.2 Rationale and justification for the research ....................................................... 3 1.1.3 Research interest ................................................................................................ 4 1.1.4 Research question and objectives ...................................................................... 6 1.2 Defining values ......................................................................................................... 6 1.2.1 Axiology ............................................................................................................ 7 1.2.2 Motivational values ............................................................................................ 8 1.2.3 The place of virtue and morality ........................................................................ 9 1.3 Importance of healthcare values ............................................................................. 11 1.3.1 New Zealand healthcare values ....................................................................... 13 1.3.2 The impact of ‘productivity’ on healthcare values .......................................... 15 1.4 Nursing values ........................................................................................................ 17 1.4.1 Quality of nursing care and Codes of Conduct ................................................ 19 1.4.2 Nursing values and Code of Conduct in New Zealand .................................... 22 1.5 Thesis overview ...................................................................................................... 24 CHAPTER TWO: LITERATURE REVIEW .............................................................. 26 2.1 Introduction ............................................................................................................. 26 vii 2.2 Emerging areas of knowledge about nursing values ............................................... 27 2.2.1 Professional socialisation of nurses ................................................................. 27 2.2.2 Measuring professional nursing values ............................................................ 31 2.2.3 Measuring professional nursing values in New Zealand ................................. 33 2.2.4 Teaching nursing values .................................................................................. 35 2.2.5 Teaching nursing values in New Zealand ........................................................ 38 2.3 Effect of healthcare climate on nurses and nursing ................................................ 39 2.3.1 Managerialism in healthcare ............................................................................ 40 2.3.2 Quality of life for nurses .................................................................................. 43 2.3.3 Compassion fatigue and burnout ..................................................................... 44 2.4 Approaches to the organisation of nursing practice ................................................ 49 2.4.1 Functional or task nursing ................................................................................ 49 2.4.2 Primary nursing ................................................................................................ 50 2.4.3 Team nursing ................................................................................................... 51 2.5 Theoretical Influences ............................................................................................. 53 2.5.1 Isabel Menzies ................................................................................................. 53 2.5.1.1 Splitting up the nurse-patient relationship ................................................ 56 2.5.1.2 Depersonalisation; categorisation and denial of the significance of the individual depersonalisation ................................................................................. 56 2.5.1.3 Detachment and denial of feelings ............................................................ 56 2.5.1.4 Elimination of decisions by ritual task-performance ................................ 57 2.5.1.5 Reducing the weight of responsibility in decision-making....................... 57 2.5.1.6 Collusive social redistribution .................................................................. 58 2.5.1.7 Purposeful obscurity in formal distribution of responsibility ................... 58 2.5.1.8 The reduction of the impact of responsibility by delegation to superiors . 58 2.5.1.9 Idealisation and underestimation of personal development possibilities .. 59 2.5.1.10 Avoidance of change............................................................................... 59 2.5.2 The adoption of Menzies thinking in nursing .................................................. 59 2.5.3 Edith Stein ........................................................................................................ 62 2.6 Summary ................................................................................................................. 65 CHAPTER THREE: METHODOLOGY .................................................................... 67 viii 3.1 Introduction ............................................................................................................. 67 3.2 Constructivist epistemology and Case Study .......................................................... 68 3.2.1 Early history of Case Study methodology ....................................................... 71 3.2.2 Criticisms of Case Study methodology............................................................ 72 3.2.3 Types of Case Study ........................................................................................ 73 3.2.4 Case boundaries ............................................................................................... 75 3.3 Triangulation ........................................................................................................... 75 3.4 Research propositions ............................................................................................. 77 3.5 Chapter Summary ................................................................................................... 77 CHAPTER FOUR: METHODS .................................................................................... 79 4.1 Introduction ............................................................................................................. 79 4.2 Study setting............................................................................................................ 79 4.2.1 Access and gatekeeping ................................................................................... 80 4.3 Participant recruitment ............................................................................................ 82 4.3.1 Nurse recruitment............................................................................................. 82 4.3.2 Patient recruitment ........................................................................................... 83 4.3.3 Family/whānau recruitment ............................................................................. 84 4.4 Data collection ........................................................................................................ 85 4.4.1 Preparation for data collection ......................................................................... 85 4.4.2 Data collection strategies ................................................................................. 86 4.4.3 Interviewing (nurses, patients and family/whānau) ......................................... 87 4.4.4 Focus groups .................................................................................................... 90 4.4.5 Observations .................................................................................................... 92 4.4.6 Documents as data ........................................................................................... 94 4.4.7 Burnout Scale ................................................................................................... 95 4.5 Data analysis ........................................................................................................... 95 4.5.1 Focus group and individual interview data analysis ........................................ 97 4.5.2. Burnout Scale data analysis ............................................................................ 98 4.5.3 Document analysis ........................................................................................... 98 4.5.4 Cross-case analysis .......................................................................................... 99 4.5.5 The significance of triangulation ................................................................... 100 ix