Using ethnomethodology to explore how nurses, in an acute setting, make sense of care

Abstract

Aim:

To explore how nurses understand and make sense of multiple definitions of nursing practice.

Methodology:

The study used ethnomethodology to explore how nurses in an acute hospital ward shape, construct and sensemake nursing practice in their everyday worlds. Multiple data sources were used to triangulate different constructions of reality and generate a broader understanding, including non-participant shadowing of nurses during eight shifts, semi-structured interviews with six registered nurses and a review of the nursing section of the hospital’s Electronic Patient Record system. Data were collected in two surgical wards in an acute hospital (2019–2020). Data were iteratively coded and refined through all stages of the study.

Findings:

Nurses make sense of conflicting expectations by creating multiple realities which they apply in different situations to structure how they deliver care. This finding suggests that nurses move seamlessly and unknowingly through these created realities, supported by using specific but discrete languages that they can effortlessly adopt. A consequence is that no single model or theory contains all the realities.

Conclusion:

This study goes some way to explain the described difference between work-as-imagined and work-as-done. Failure to acknowledge the multiple realities constructed in practice during pre-registration education may explain the theory–practice gap that many new graduates experience and why anticipated outcomes described in research projects might not be realised in everyday practice.

Implications:

Nursing practice is not governed by a single theory or model, and nurses make pragmatic transitions between different expectations. Recognition of this is critical to effective planning and leadership of the nursing resource. Using electronic records as a single measure of nursing work has the potential to create a bias towards one reality and thereby render other aspects of nursing value invisible. Failure to embrace the totality of nursing practice may impede the delivery of anticipated patient outcomes and system efficiencies.

Introduction

Many studies have demonstrated an association between the number of registered nurses, the educational level of registered nurses and a range of outcomes (including mortality), but few, if any, have described the causal mechanism (Dall’Ora et al., 2019; Rafferty et al., 2007). The existing data sets reflect a narrow set of tasks that reflect a limited definition of nursing and fail to capture the breadth and depth of different aspects of nursing care.

Over the next decade, there will be many changes and challenges in healthcare in Ireland, including an increase in the provision of integrated care, through Slaintécare (Department of Health, 2019), an ageing population and a higher prevalence of people living with complex and long-term illnesses. In addition, in relation to the nursing and midwifery workforces, further challenges will continue in the recruitment and retention of healthcare staff. There will be a move from hospital-based to community-focused healthcare. These challenges will impact on the work of a nurse and where and how it is delivered.

Fundamental to adapting to this change will be a thorough understanding and appreciation of nursing care, especially from the perspective of those providing care. The use of ethnomethodology in this research addresses the critical gap in the appreciation of the complexity of nursing care, acknowledging that care is a social construct.

Defining nursing care

Defining nursing is a dynamic endeavour. Historically, nursing care was administered in the home as part of a woman’s unpaid domestic duties, and care was seen as a by-product of a woman’s duty (Rutty, 2010). When the provision of care was integrated with religion and providing care became established in the church, women lost control of the care they provided, and nursing started to be defined by others.

In an attempt to regain control and to ensure best practice, theories of Nursing began to be proposed from the mid-20th century onwards. These span from abstract grand theories to practical models of care delivery and have provided a platform for further research to identify what constitutes nursing care and how nurses are educated (Ball, 1984; Ball et al., 2016).

However, McCrae (2012) challenged the need for more nursing theories, noting their lack of appreciation for the complexity of providing care (McCrae, 2012). Henderson (2006) asserted that nursing requires a compassionate blend of art and science focused on patient needs, but Papastavrou et al.’s (2011) systematic review of nurses’ and patients’ perceptions of care noted the lack of congruent perceptions of what caring or caring behaviours are. This may, in part, be due to the fact that grand theories are idealised models that do not account for external pressures and challenges, making it hard to enact them. In the messy ‘real-world’ nurses must sensemake the situation and use a pragmatic model informed by theory, not driven by it. However, few studies have explored the nurses’ understanding and definition of care for themselves. In order to address this deficit, this study explores how nurses sensemake care as a concept in practice.

Ethnomethodology

Ethnomethodology, developed by Harold Garfinkel, is defined as gaining understanding by focusing on people’s methods for recognising, demonstrating and accounting for material matters in their everyday lives (Garfinkel, 1967; Hilbert, 1991). This differs from ethnography in that the focus of the research is on the ‘how’ people interact with their world rather than the ‘what’ way people interact (Dowling, 2007).

Ethnomethodology was chosen to provide an understanding of how groups collectively construct social orders and is, therefore, a clear fit with sensemaking. This approach is both new and novel, whereas ethnomethodology has been used extensively across the fields of sociology and psychology, this research has flexed ethnomethodology in a new way.

This model of social research notes the significant distance between abstract principles and their execution in practice, and this sits well with the experience of the theory–practice gap in nursing. Bridging the gap between abstract and empirical involves constructing analytic frames and images, the combination of which creates a representation of social life. Analytic frames are the deductive reasoning of abstract ideas; images are the inductive explorations of evidence (ten Have, 2010).

This study explores how a group of nurses manage the care process and the contextual influences of creating a shared understanding of care. Care is constantly being produced, negotiated and maintained through the everyday activities and routines of the nursing staff. In this study, sensemaking offers a unique perspective on the nurses’ understanding of the care they provide.

Sensemaking

Weick (1997) maintained that sensemaking fundamentally differs from the normal process of understanding a person’s cognitive process; he put it more simply as ‘the making of sense’ (Weick, 1997). The core process that an individual or group of individuals utilises when sensemaking, includes:

• ○ Reality is an accomplishment.

• ○ Individuals attempt to create order.

• ○ Sensemaking is a retrospective process.

• ○ Individuals attempt to make situations rationally accountable.

• ○ Symbolic processes are central in sensemaking.

• ○ Individuals create and sustain images of a broader reality.

• ○ Images rationalise what individuals are doing.

Combining sensemaking with ethnomethodology

Sensemaking as a research method often involves moving from the simple to the complex and back again. The move to the complex occurs as new information is collected and actions are taken. Then, as patterns are identified and new information is labelled and categorised, the complex becomes simple once again, albeit with a higher level of understanding.

Sensemaking is not about finding the ‘correct’ answer but about revealing an emerging picture that becomes more comprehensive through data collection, reviewing and immersion.

Combining ethnomethodology (exploring how groups create a shared endeavour) with sensemaking (how groups assign meaning to that endeavour) provided an opportunity to understand how nurses manage dissonant messages. The analysis of the data involved mentally mapping out how nurses plan, administer and communicate their care and how nurses use these processes to construct the meaning of care. During the data collection, the way nurses changed the meaning was captured during the shadowing and discussed in the interviews. A significant change was seen with the introduction of the electronic patient record (EPR) and its effect on the ward routines, handover and the language used.

Research setting and participants

The research was undertaken in an acute hospital but confined to two acute surgical wards. Ward A is a vascular and colorectal surgery ward with 26 inpatient beds, and Ward B has 35 patient beds. The clinical specialities cared for include patients with ear, nose and throat and gynaecological and colorectal conditions. The staff in Ward B also noted that some of the patients who required gynaecological care might have frequent or regular admissions and have built up a relationship over time. The typical daily staffing complement was higher in Ward B than in Ward A, as there were more beds. Typically, on both wards, there were five registered nurses, one or two healthcare assistants, one Clinical Nurse Manager 1 and one Clinical Nurse Manager 2 on duty.

1. The decision to limit the fieldwork to two surgical wards was made for three reasons: the researcher’s own clinical background was in surgical care. This choice of setting provided the researcher with a degree of familiarity with the routines and jargon used and, hence, more open to questioning the assumptions proposed. Using a clinical setting that was not familiar to the researcher would risk some of the nuances being missed over the time of the shadowing or interviews. Being on a surgical ward also meant that questions asked during the shadowing were more pointed and deliberate and not just for clarification or context. From an ethnomethodological point of view, having knowledge of a context is helpful in identifying and understanding normal routines (Coulon, 1995).

2. Having a similar clinical background also allowed the staff to have confidence in the researcher, as the researcher’s background was explained to the participants. This was explained to the participants so that during the shadowing data collection, they did not feel they had to explain their basic actions and reactions as they felt it was understood.

3. The surgical care environment is noted for its transactional nature, where patients are admitted for a specific disease or treatment option, usually receive surgery, recover and are discharged (Jangland and Muntlin Athlin, 2017). Some literature suggests this precludes surgical wards from delivering task-based care more than other care environments (Blackman et al., 2015; Pua and Ong, 2014).

Ethical approval

The university and hospital ethics committee granted ethical approval. The researcher was not present at the point of patient care, but there was the potential for interactions while the researcher was on the main corridor or at the nurses’ station.

Data collection

Utilising ethnomethodology’s reflexive approach to data collection allowed the researcher to triangulate the data collection using different techniques.

Shadowing

Traditional ethnographic field methods can require significantly more time than interviews or document reviews to observe a relevant and appropriate interaction (ten Have, 2010). They tend to be primarily observation, with little input from the researcher to ‘test’ what is happening. Ethnomethodology seeks to understand how subjects are constructing their reality, and thus shadowing staff and asking them to articulate not only what but why they are doing things through shadowing is a different data collection method from ethnographic observation (Ferguson, 2016). From non-participatory observation to quasi-involved shadowing, the scope of interactions must be determined by both the context and the aim of the data collection exercise. The researcher tried to truly shadow the participant and followed the participant everywhere they went; mobility allowed the researcher to see interactions and social relationships. Thus, shadowing revealed what the participant does and how the participant interacts with other people and their environment.

The nurses in this study were not individually selected; the researcher based themselves in the common ward areas (i.e. nurses’ station or ward corridor) and observed nurses as they went about the usual routines and practices of delivering care. This approach met two outcomes: firstly, it maintained space between the researcher and patients outside the scope of this research; secondly, it facilitated the researcher to observe nurses from a distance. This approach facilitated the research exploring their grouped understanding and sensemaking of care (Quinlan, 2008).

Semi-structured interviews

Interviews were used to explore further the participants’ insight and understanding of the social construct of care. Participants for an interview were recruited from the wards included in the shadowing part of the data collection. The semi-structured approach enabled interview questions based on observations made during the shadowing exercise. The questions were deliberately ordered to ease the participants in the conversation. The interviews were scheduled as the shadowing data collection was concluding; this allowed for the observations gained during shadowing to inform the interview questions.

EPR review

As a data source, the EPR was vital to understand the ordinary and routine process nurses went through to construct their understanding of care. EPR has become a primary method for nurses to document their work and understand how nurses sensemake care within the prescribed criteria of the software program provided vital insight. Access to the EPR was provided through a ‘test’ module, which is routinely used for training staffing on the EPR. It has all the functionality of the ‘live’ EPR, but with no patient or staff data accessible, therefore a safe environment.

Throughout the shadowing and interview data collection processes, the researcher observed significant weight given to the influence of the EPR on many of the nurses’ processes, languages and outcomes. The shadowing data collection showed the amount of time each nurse spent interacting with the EPR, whilst the interviews gave more depth to the nurses’ interactions and experience, including the identification of the system and associated loss of nursing autonomy.

Findings

The fieldwork comprised eight shadowing shifts of 10 to 12 hours each, six interviews and the EPR review. Data were coded and reflectively compared. The resulting themes were checked against the different data sources. The most significant theme was that ‘many aspects of nurses’ input are informal and not recorded. This means that some aspects of their work were only known by the nurses themselves, other parts by themselves and some other members of the team, and only a fraction was known widely. This finding illuminates the shortcomings in datasets on nursing based on electronic records, with implications for both management and research, further perpetuating the invisibility of large amounts of nursing work.

The analysis identified that nurses managed this invisibility of large parts of their work by constructing different ‘realities’. The term realities is used to describe the concept of the social reality constructed by a group; to avoid confusion over other methodologies, the term realities is used here rather than the more commonly used term ‘constructs’.

Nurses’ input and outcomes were rarely recorded in a way that captured the time and complexity of the care provided. Frequently, the EPR would reduce the care provided to a series of tasks or checkboxes for verification, removing the complexity and agency of the nurses.

I mean what you’re recording on EPR is what you’ve done that day. Each day, when I’m on EPR, you do all your normal daily checks, but I will always write a nursing note because then it’s the story for the day, for each patient.

(Interview, Participant 2)

It became clear that the nurses subliminally described, supported and transitioned through many different realities while delivering their care, reflecting the multiple contexts of their work. They were unaware of the subtle language changes they instantly made, how they redefined clinical information to suit different audiences, or even how their role shifted at any moment, depending on the context. During interviews or shadowing, the nurses never displayed conscious awareness of switching their language or behaviour as they moved from one reality to another, and this appeared to be a subliminal learned behaviour.

Handovers

A common core sense of nursing care was consistently present in all formal and informal handovers. This was augmented by informal ‘catch-ups’ throughout the day when there was direct nurse-to-nurse exchange of information about patients (and therefore sensemaking); these were not documented. Given the unofficial and reactive nature of the ‘catch-ups’ and how they were often done under time pressure, they provide an interesting early insight into what nurses consider essential in their patient’s care.

Handover is recorded on a digital recorder by the night staff and played back by the CNM to the oncoming day staff. There are three bays and eight side rooms the ward is split into two teams, one team takes two bays and one side room, the other takes the third bay and the remaining side rooms

(Shadowing Day 1)

The physical space was also seen to influence how care is delivered across multiple realities. Ward handovers were delivered in the day room, in a space removed from the patients, and this influenced the content of the handover, which was one-directional and pre-recorded, and nurses had no opportunity for discussion. This was introduced to streamline the process and include only the data that one version of reality perceived to be necessary. The nurses acquiesced with this reality; however, the shadowing data demonstrated that after the formal handover, there was an informal ‘catch-up’ with the night staff before they went home to share nursing information relevant to an alternative reality of nursing, one that was not acknowledged through the formal procedures.

Impact of different handovers

The distinction between the formal handover (one reality) and the informal handover (another reality) reinforced a hierarchy about how care is valued, with clinical, unidirectional and non-patient-focused information as the primary focus of formal handover. This echoed Sujan et al. (2017) findings that practitioners can often have a ‘tension’ in what information must be handed over compared to what they would like to impart. This trade-off is dynamic and is determined by the practitioner’s skill, competency and experience (Sujan et al., 2017).

We have a new system now. Earlier, we had something called bedside verbal handover where you go bedside and handover, but now what we have, is we have a tape-recorded handover. So, on every shift, the handover is recorded, and the staff adhere to that. It’s, say, about 15 to 20 minutes. It depends. So, that would be the thing. If there are any queries after that, then they come to the staff and ask them. But it’s mostly an audio-recorded handover that we do.

(Interview, Participant 5)

Formal handovers focused on physical tasks, as opposed to mental, emotional and social care, together with medical diagnosis and treatment plan.

I remember that from college and like you’re always okay when you look at your patient from head to toe, making sure everything is okay. Looking at the dressings, drains and pain. Making a change and checking if what you did was effective. (Interview, Participant 1)

The formal handovers had less emphasis on the psychosocial assessment and self-care needs. Although informal catch-ups translated the handover into tasks of care, more consideration was given to the emotional or social care requirements. There was an opportunity for questions, discussion and engagement between the nurses, reflecting a different reality of the meaning of nursing care when nurses were given discretion about what to discuss.

The flexibility nurses demonstrate in effectively balancing both approaches, based on the patients’ needs, underpins the challenge required to juggle the multiple realities in order to maintain the meaning of care that they themselves valued.

Semantic differences between the different realities

Moving through the realities was usually the result of a slight change in the language used; either the vocabulary changes from clinical to a nursing language that was perceived to be less formal, or the dialogue used more colloquial terms. Indeed, each reality was maintained by its own distinctive vocabulary. Although the language might be considered impersonal when referring to a patient as a bed number, the data collected shows that nurses maintain the multiple realities by using shorthand, allowing them to move between realities quickly. Nurses could momentarily dehumanise the patient in order to rapidly communicate critical clinical information but use highly person-centred language just one second later when switching to a different reality. The most apparent indicator of realities switching was the jargon used. Each reality’s language utilises jargon to define the limits of the individual reality. The jargon is also a mechanism to alert other nurses as to which reality they are communicating.

I mean what you’re recording on EPR is what you’ve done that day. Each day, when I’m on EPR, you do all your normal daily checks, but I will always write a nursing note because then it’s the story for the day, for each patient.

(Interview, Participant 2)

The reality of the influence of the EPR on both wards was immediately apparent.Ward nurses spent significant amounts of time at the EPR station, and EPR was a significant influence on handovers. The nurses appeared at times to defer their decision-making to the EPR, with nurses using phrases such as ‘EPR said I must. . .’ to justify their decisions.

When you’re doing your admission, unless you do it through Care Compass, you might have done everything, but you didn’t do it there; it’s still coming up as seven red tasks that are not complete even though they are. We would know to do it, but let’s say someone else did the admission, and they didn’t know; you’re going back then and clicking in and out and saying not done, but it actually is done. That takes a little bit of time.

(Interview, Participant 4)

The EPR, through in-built, generic care plans, creates task lists for every patient, including generic tasks (medication and observations) and specialist care tasks. The nurses relinquished their professional autonomy and followed the EPR to determine, shape and prioritise care. The nurses were not mandated to complete the task lists but did have to acknowledge them every time they interacted with the EPR; therefore, its influence was very much one of the ‘nudging’ practices without a conscious decision to defer. The nurses also noted that the EPR was the source of information for the ward’s/organisation’s key performance indicators (KPIs). Nurses were conscious of completing the correct care plans as required, as it would negatively impact the ward’s metrics if not done correctly. They recognised that providing data for KPIs was another role the nurses had adopted, and they were aware of how important the KPIs were in the managerial reality. The nurses acknowledged that the KPIs did not always reflect the reality of the care they provided but also that the EPR was the primary data source. The example of the assessments (falls and shift assessments) was discussed during the shadowing when a clinical nurse manager was orientating a new staff member. The Nurse Manager drew the staff member’s attention to the importance of ensuring each box was ticked as complete; otherwise, the EPR would not record it as care being provided.

The researcher did engage with the nurses to understand how they planned their care during the shift. Most translated the care that a patient required into single checkboxes of tasks to be completed throughout the day. This approach provided a structure to the nurses’ day, with patient care now seen as a task list, and it also made the ‘catch-ups’ during the day much easier and efficient, too, as only the outstanding checkboxes were handed over. Additionally, this approach to translating care mirrored how care was reflected in the EPR, with most assessments and records reduced to boxes to be ticked when complete.

The difference between what patients need and what the nurse needs to do

The tasks driving the work of nurses were not always focused on patient care needs. When asked to speak to their to-do list during a shift, most nurses included a number of jobs to be done that would not affect their patient directly; for example, they included falls assessments, ‘update EPR’ or ‘awaiting review’. Although it could be argued that these elements of care may affect a patient over time, there was a clear divide between what the patient needed and what the nurses needed to do. As shown in Figure 1, the care plan to Reduce the Risk of Falls highlights a series of task-based interventions required for the nurses to complete as part of the assessment. Notably, none of the interventions requires communication with the patient beyond providing an information booklet.

Figure 1.

Example of falls assessment from EPR review.

Discussion

Understanding how nurses make sense of care is essential to the theory of nursing practice. By combining ethnomethodology and sensemaking, it became evident that the nurses experienced multiple different requirements which reflected different theories and models of practice rather than a single unifying model. This part reflected structural factors beyond their control that did not capture care as nurses defined it. Nurses managed this by constructing different mental models or realities and were able to move seamlessly through several realities by immediately switching languages used and the type of information required or provided as appropriate. The choice of reality to engage in at any time was influenced by who they were interacting with (other nurses, other professions, the patients or the EPR). This reflects the multiple roles that nurses are required to fulfil simultaneously, the different expectations of nursing care held by different stakeholders and is marked by subtle changes in language used (see Figure 2).

Figure 2.

Main and sub-findings.

Conclusion

This research has contributed to the understanding of the nursing practice through the novel use of ethnomethodology to understand how nurses construct their understanding of care. This is an active process involving managing conflicting expectations. Nurses do this by creating multiple parallel realities and moving seamlessly between them. The introduction of EPR has promoted a single version of nursing reality, but researchers and policymakers must be cognisant that it does not capture all nursing work. The unseen work may include significant causal mechanisms in the associations between nursing and positive patient and organisational outcomes. The emotional labour of managing different realities must also be recognised and may contribute to burnout (particularly when some realities are not acknowledged) and staff dissatisfaction.

Nursing theories and models should acknowledge that nurses construct multiple realities through which they move seamlessly. This has implications for how nursing practice is researched, taught and managed.

Key points for policy, practice and/or research.

• Nurses create multiple realities to make sense of conflicting expectations, applying these different realities in various situations to structure how they deliver care.

• Nurses seamlessly transition between these constructed realities, supported by their ability to adopt specific but discrete languages effortlessly.

• No single model or theory of nursing practice captures all the realities nurses operate in, highlighting the complexity of nursing work.

• The theory–practice gap may be explained by the unacknowledged multiple realities in practice, which are not fully addressed during pre-registration education.

• Using electronic records as a single measure of nursing work may create bias, favouring one reality over others, potentially rendering certain aspects of nursing practice invisible and impeding patient outcomes and system efficiencies.

Biography

Ray Healy is the Nursing and Midwifery Board of Ireland (NMBI)’s Director of Registration. He is a Registered General Nurse, having worked in orthopaedic and neurosurgical settings across public and private services. Prior to his appointment to NMBI in 2021, he was a project officer in the Chief Nursing Officer’s Office in the Department of Health, project managing the Safe Nurse Staffing and Skill Mix brief. He was also appointed as the secretariat for the Expert Review Body of Nursing and Midwifery and brought the Body’s report to publication in 2022. He holds a MSc in Leadership from the Royal College of Surgeons in Ireland and recently completed his Doctorate in Nursing from London South Bank University, which focused on how nurses in an acute care setting, define the care they provide.