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CURRENT CONTROVERSIES IN CRITICAL CARE |
Nursing, like medicine, involves a rich, socially embedded clinical know-how that encompasses perceptual skills, transitional understandings across time, and understanding of the particular in relation to the general. Clinical knowledge is a form of engaged reasoning that follows modus operandi thinking, in relation to patients’ and clinical populations’ particular manifestations of disease, dysfunction, response to treatment and recovery trajectories. Clinical knowledge is necessarily configurational, historical (the immediate and long-term histories of particular patients and clinical populations), contextual, perceptual, and based upon knowledge gained in transitions. . . . [Through articulation research], clinical understanding becomes increasingly articulate and translatable at least by clinical examples, narratives and puzzles encountered in practice.Benner1
Subsuming things under categories is not the same thing as productive thinking, even though it is an important and necessary strategy for management, coordination, and communication.[paraphrase]
Logstrup2
I have been engaged in making the hidden work of nursing visible through articulation research. From the beginning, through my mentor Bert Dreyfus, I understood the articulation of knowledge embedded in nursing practice as a counter to oversimplified reductions typically used in the formal classification schemes used to communicate, coordinate, and legitimize nursing practice and knowledge to healthcare institutions, the public, accountants, physicians, and other nurses. In many ways, a formal classification of the work involved in nursing mirrors nursing’s relationship to medicine. Medicine, in the wake of Descartes’ followers, has separated the social from the medical, though there is an attempt in this era of an aging population, increased chronic illnesses, and dependence on technology, to reintegrate the social and the medical. Through the recent movement of evidence-based medicine, both medicine and nursing have increasingly understood science and technology as their primary legitimizing forces. The objective is chosen over the subjective, and even the clinical judgments of doctors and nurses are considered to be contaminated with too many subjective aspects to be considered sound.
Despite the efforts of social medicine and psycho-socio-cultural aspects of nursing to broaden this scientific lens in the current quest for evidence-based medicine, the social aspect is once again rendered invisible. Often, social medicine, or the impact of socio-cultural influences on the human experience of disease, has been considered to be more evidence of the need for a more objective, definitive science, so that the social aspect could be standardized or ruled out altogether. Clinical judgment may rank a poor second to a pure correlation between the evidence and the case at hand, even though it is impossible to use any evidence without astute perception and good clinical judgment about the case at hand.
Each organized, socially embedded practice has notions of good, which are internal to the practice.3 As Dreyfus4 has pointed out, this updates Aristotle’s earlier observations about the Socrates-Euthaphro dialogue about the nature of the knowledge of statesmen compared to physicians. Physicians supposedly had a formal theory of knowledge, which is easily classified because unlike a chef, the physician knows not only what tastes good, but what is good for you and why,4 which is a great advantage if you are building a systematic classification system. As Bowker and Star5 note, this vision of the formal classification of medicine and nursing has been overly optimistic.
The problem of current formal classification systems may be even more acute for nursing because nursing practice is often classified as other or as a different form of medical diagnostic process, even when the point is to assess the social resources of each patient and his or her positive capacities for recovery. The nursing goals of nurturing a patient and helping him or her to put his or her social, sentient body in the best position to repair, have always been intertwined with administering medical therapies and monitoring the condition of patients.6 Nightingale,7 the founder of modern nursing, did not believe in the germ theory of disease. She argued for a more complex, epidemiological view in which disease is caused by a combination of external agents, external social and physical circumstances, and the body’s own reparative, resistive forces. She was openly ridiculed for her views, which today seem to be a more accurate picture of the dynamics of becoming ill, no matter what the disease. The new candidate for a single factor theory of disease is genomics, but geneticists agree that a gene for a specific disease is too narrow and that internal and external environments have more influence than simply one’s genetic heritage.
There are currently 3 distinct classification systems in use in nursing: the Nursing Process Model, which is a linear statement of the problem-solving process; the Nursing Interventions Model that is linked to nursing diagnostics; and the Nursing Outcomes Model, demanded by managed care organizations, as a response to evidence-based nursing and medicine, and the need to be able to retrieve nursing information.
Bowker and Star5 note that the Nursing Intervention Classification (NIC) System aspires to fit into the minimal nursing data set of nursing diagnosis, nursing interventions, and nursing outcomes. The classifiers systematically created a new beginning or clearing for the new information system. They tacked the system onto the medical diagnostic system, designing a flat classification of named unique nursing diagnoses and corresponding interventions and outcomes to go with these diagnoses. Following the rules of scientific classification systems, the goal was to create classes or categories that did not overlap. The NIC system also sought to make these categories unique in relation to medical diagnoses, while still choosing the medical system of diagnosis, intervention, and outcomes for the classification. This has been problematic on 2 fronts. Firstly, nurses’ work uses and is intertwined with medical diagnoses, so in terms of a diagnostic system (ie, the identification of injury or pathophysiology and directly seeking to intervene in the deficit or problem) a medical/physiological taxonomy is most appropriate. Secondly, nursing’s uniqueness lies in the vast other left out necessarily by any diagnostic approach of naming deficits and correcting them. Nursing work attends to the omitted other category of embodiment, suffering, lifeworld possibilities and constraints, and human responses to illness left out by Cartesian curative medicine.
NIC classifiers purposely ignore the nursing theory and knowledge claims that nursing treats human responses to illness that built upon the coping, physical, and spiritual resources of persons coping with illness (or the human experience of disease). They also intentionally forgot that medical interventions are designed to repair deficits created by disease or injury. Nursing is the other category in relation to medicine, because nursing deals with the social, sentient human body and not just the physiological body separated from the social lifeworld. How do you classify the other of human vulnerability, suffering, coping, spirituality, and lifeworld? Lifeworlds notoriously shrink as one becomes ill, institutionalized, or medicalized. It is precisely these aspects of humanity that the medical curative system seeks to overlook in order to attend to physiological mechanisms and pathophysiology. While medicine and nursing both seek to address urgent medical needs and the social and human aspects of illness, they cannot claim a large category of human life exclusively for nursing or medicine. Nurses and physicians draw on family members, friends, chaplains, psychologists, social workers, and others to alter the social environment as they try to learn and respond to patients’ and family members’ concerns.
The NIC system identifies discrete interventions that may or may not currently match up with nursing diagnoses. For example, NIC offers a range of interventions from the use of humor to checking the resuscitation cart. These classifications of nursing interventions can make nursing work more visible and traceable in the medical records. However, the categories belie the logic of caring practices, nursing knowledge, and skill that cannot be reduced to techniques or discrete interventions. Nurses are required to trade one form of invisibility for another. The invisible practices of nursing are relational and address the suffering and vulnerability of people coping with illness and medical interventions.
My colleagues and I have tried to counter the flattening of nursing practice by the diagnostic or medical model of classification, inductively generating domains of nursing practice exemplified through narrative or observational accounts of actual practice. The articulation of judgment and craft is difficult because practices occur in multiple and complex settings. For example in critical care nursing, interventions are instantaneous, highly context-dependent, and interpretable primarily in terms of the immediate clinical history of events, interventions, patient responses, and problems. We have identified 2 habits of thought and action and 9 domains of nursing practice that uncover aspects of clinical judgment, clinical knowledge development, and the everyday skillful comportment of critical care nurses (Table 1
).8 The habits of thought and action refer to styles of practice, thought, and action that constitute typical approaches, while the domains of practice can be thought of as strong situations in that they are organized by common clinical goals.
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We have certain parameters that we go by. We have standing orders on some things, but you just do other things.8
The following situation illustrates necessary medical action, which a protocol does not address, in the case of an elderly man who was septic from yeast in his urinary tract, overloaded from 10 liters of fluid, and hypotensive with a systolic blood pressure of 60.
Nurse: . . .he moved into a ventricular bigeminy rhythm and he was also in renal failure. Knowing that his acidosis was out of whack, I didn’t want any premature ventricular contractions that weren’t going to respond to treatment, because if he went into code, being acidotic, [he] wouldn’t respond to anything. I empirically gave him some potassium because he’d been third spacing. He had a large gastrointestinal output and the potassium that I drew came back at 2.8 mEq, which was really low. After [several potassium replacement doses] over 3 hours, even though he was in renal failure, his potassium increased to 4.4 mEq and he had no more ectopy. He was weaned off the lidocaine without incident. I gave him a concentrated dose of potassium because he couldn’t tolerate a lot of extra fluid. At that point, his fluids had been reduced and he was being resuscitated with dopamine for his blood pressure rather than fluids, to avoid fluid sitting in his lungs or something. I infused a high concentration of potassium in 50 mL of fluid over an hour, 3 times. . . . I thought that was the safest. It worked out fine for him.8The crisis management practices of critical care nurses fall into a gray area of practice, ie, an area not yet legitimately or formally recognized as being within nursing’s domain, but present a clinical and moral necessity to act independently and expediently. Trying to cover all these eventualities by specific protocols is not practical or possible because the "emergency" is contextual. . . . If a physician had been available, the nurse would have consulted him and secured a prescription for the potassium to cover her actions. But in the face of ventricular dysrhythmias, coupled with very low potassium levels, immediate action before seeing laboratory results is necessary. No one would advocate potassium therapy without a physician’s order or without a laboratory assessment of the serum potassium; however, the risk is prudent in [this] situation.8
In this situation, the action is understandable. Other examples of nurses’ actions taken before a physician could be present would be measures to lower a dangerously high blood pressure or raise a dangerously low one. Examples are required to determine the wisdom of the action. While no classification system could incorporate narratives in the actual classification or codes, selected on a daily basis, there is no reason why a classification system could not refer back to a recognized coding protocol of domains of practice that include the skilled know-how, the in-order-to’s, and the for-the-sake-of’s (goals and significance of actions).
Snapshot, prespecified categories of medical diagnosis do not follow the logic of clinical reasoning in medicine required to arrive at diagnoses (ie, reasoning across time about the particular through changes in the patient and/or the clinician’s understanding). This reasoning through transitions about the particular by the clinician necessarily escapes static classification systems that tend to capture endpoints or billable procedures. All classification systems reduce skilled know-how, notions of good embedded in socially organized practices and organizations, down to what can be represented in categories.
Evaluating What Is Safe to Leave Invisible and Untraceable in the Classification System
No classification system can render all activities and work visible. Classification systems as formal systems run into the limits of formalism. They cannot make explicit all the knowledge within the classifications. Those constructing classification systems have to determine what it is safe to leave invisible and to identify the sources and kinds of visibility and invisibility. No wise psychiatrist or psychologist imagines that his or her work, or even the understanding of a patient is captured by the Diagnostic and Statistical Manual of Mental Disorders, 4th edition. The major functions of official classifications systems are 1) retrieving records; 2) documenting work; 3) providing legitimacy and recognition for work; 4) providing strategies for accounting, costing, and getting reimbursed for services rendered; 5) communicating and coordinating work across boundaries of specific workers; and 6) guiding knowledge development or reification of work. As Bowker and Star5 point out, classification systems can trivialize a practice. Classification systems will be trivializing when they consistently overlook a major domain of relevant work (eg, the nondiagnostic, nonelemental aspects of nursing work) and when they overlook the intent and content of the work (ie, the in-order-to ends and the for-the-sake-of become the goals of the work). The reification of documentation systems and formal categories of work captured in information systems will be a problem to the extent that organizations consistently overlook the shadow world of the unclassified. All that healthcare professionals do cannot be classified; therefore, we must find alternative ways of valuing the unclassified. The pervasive and consistent kinds of invisibility created by all classification systems are shown in Table 2.
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This article has been cited by other articles:
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  D. Oman, T. A. Richards, J. Hedberg, and C. E. Thoresen Passage Meditation Improves Caregiving Self-efficacy among Health Professionals: A Randomized Trial and Qualitative Assessment J Health Psychol, November 1, 2008; 13(8): 1119 - 1135. [Abstract] [PDF]
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