Stories of Resilience in Nursing

Tales from the Frontline of Nursing

Michael Traynor

• Editorial: Routledge
• Año: 2019
• ISBN:
  9781351050258
• Edición: 1
• Categoría: Medizin
• Categoría: Pflegefähigkeiten

Ideas about resilience and identity continue to be promoted, discussed and debated in nursing. This book uses narratives to explore these complex and important concepts, unsettling our certainties and opening up new perspectives on what they might mean and involve.

This engaging book recounts direct and vivid stories told by or about nurses. These vignettes discuss nursing's ideals without idealising them and show nursing work and the lives of nurses in all their complexity. They include contributions from mental health nurses, a former nurse, student nurses, a migrant nurse and a whistle-blowing nurse, among others. The book ends with chapter-by-chapter contextual material to promote reflection, discussion and further reading.

Written with nursing students preparing to transition to the workplace and professional status in mind, this thought-provoking book is also suitable for nurses and nurse academics interested in resilience and issues around professional identity.

PART I

1

Let me tell you about this book

It has often been said that we learn through stories. We discover, or invent, who we are—heroine, observer or victim perhaps. In stories we surround ourselves with our group—it could be our fellow student nurses—and distance ourselves from the ‘other’—managers, doctors, qualified nurses or patients perhaps. Stories are everywhere. This book will use stories to explore the transition from student or trainee to nurse, as well as aspects of being a nurse.

Since the mid 1990s, qualified nurses, health visitors, district nurses, mental health nurses, managers and midwives, as well as students and support workers, have told me their stories in focus groups and in one-to-one interviews. My early-career research was to do with probably the first major reorganisation of the National Health Service (NHS), involving the introduction of so-called market forces. A language and an ethos from the world of business started to be used by politicians about caring for patients. Some managers I interviewed were excited about this new world: one ambitious nurse executive enthusiastically showing me his new electronic organiser, a clunky precursor to today’s smartphones. However, nearly all the nurses I interviewed were appalled. They told me that they did the real work and that managers were only interested in the finances of the organisation. In phrases that have reverberated ever since, they told me how little they thought managers cared about them and what they did. They told me stories of rushing through work with frightened elderly patients crying in their homes. Some years later, when ‘evidence-based medicine’ was being taken up across healthcare, nurses talked to me about how they were making clinical decisions. Their accounts were made up of vividly remembered first-person stories, sometimes of how a single nurse, the teller of the story, ‘somehow’ sensed that a patient was more seriously ill than their colleagues or doctors had realised—and was proved right. Shortly after this, nursing in the UK and elsewhere came in for bad press following revelations of poor and apparently cruel care dished out by nurses in Stafford in the UK, as well as in other parts of the country. The profession as a whole was poised on the edge of a serious fall from grace. At that time, student nurses studying in both mental health and adult branches of nursing told me how shocked they were by the poor patient care that they saw and how they believed that a caring nature was something that an individual nurse either had or did not have. Many told stories of conflict with and among qualified nurses. I began to notice that some students appeared to understand that systemic problems, such as poor staffing levels, unstable organisational structures and badly supported ward managers, had a big influence on how nurses behaved and how patients were cared for. Others appeared to blame poor nursing on bad nurses. It seemed to me that the first group of students had taken a slight distance from the distress of what they had witnessed in a way that the second group had not. They did this, I think, by acknowledging that there was a story behind the behaviour and events that they encountered.

But what unites these distinct research projects undertaken over 25 years is the way that groups of nurses naturally turn not to text books or theoretical concepts but to storytelling when they want to explore ideas about their work and their own identity. And it is stories that are foregrounded in this collection.

Ten chapters of this book are stories based on data I have collected from my research studies, other interviews, informal conversations as well as meetings arranged specifically for this book with student nurses, healthcare trainees, qualified nurses and a few individuals who have left the profession. The research studies had their own particular questions to answer but here I have let the words spoken take centre stage. The stories have been assembled along with some supporting material into these ten separate narratives. Pseudonyms have been used throughout and I have gone to great lengths to anonymise the tellers, sometimes changing the context of their original stories. So if you have spoken with me, you may find echoes of your words in these pages but not where you might expect them. Taken together, the chapters of this book set out their own story. The beginning tells stories of people thinking about becoming nurses or who are in training, the middle shows us the transition across the border between student and qualified nurse, the end presents stories of people who have been in the profession for many years or who have decided to move or leave. The intention behind this book is that the experience of reading these stories and then discussing them in the classroom or with colleagues will change the way you might understand what it is to be a nurse.

The other strand that unites these stories is that they all have something to say about resilience in its different forms. Resilience is the subject of many texts and articles and it was the topic of my last book. I was and am sceptical about the way that the idea of resilience has been used in nursing. Too often it is seen as an alternative to change, an alternative to challenging dysfunctional and exploitative working situations—situations that may well compromise patient safety. Nurse writers who promote resilience among nurses often fail to distinguish between the trauma intrinsic to the work itself—dealing with sickness and death—and the organisational and political forces that sometimes feel like they are designed to make effective nursing as difficult as possible. Sometimes the narrators in this book talk overtly about resilience in the various ways they understand it, and sometimes it is never explicitly referred to. In Chapter 3 I will say a little more about resilience for those readers who are not familiar with discussion around it or who have not read the previous book.

Nurses under pressure

Taken together with health visitors and midwives, nurses are the largest professional group employed within the UK’s NHS today, making up 55% of the workforce (NHS Digital 2016). It is a similar story in most countries’ health systems. With the UK government relentlessly implementing cost control across the welfare sector and 70% of hospital spending being on staff, nursing work is clearly in the frontline for pressure. The nurse-to-population ratio in the UK is 8.2 per 1000 population (2014 figures), below the OECD¹ average of 8.9 per 1000 and representing a fall from its 2011 level (Charlesworth and Lafond 2017). This ratio is lower in the UK than Canada, Australia, the USA, New Zealand and the Scandinavian countries. The National Audit Office (2016) claims that the supply of clinical staff for the NHS in England is insufficient for the demand. It estimates a workforce shortfall of around 50,000 NHS staff, including 27,980 nurses. The House of Commons Committee of Public Accounts (2016) claims that this is a result of fewer nurses being trained, with the Department of Health cutting training places by 3,400 in 2012/13 from the 2008/09 level. The number of nurses in training has reflected the rises and falls in funding to the NHS as a whole and varies a great deal from year to year (Charlesworth and Lafond 2017).

So it is easy to see that many nurses work in situations that are likely to thwart their best efforts at delivering safe and high-quality care. Professional aspirations and ideals can only be maintained in such an environment with extraordinary effort and perhaps a degree of unremitting commitment that no employer has the right to expect from their workers, or indeed that is healthy and sustainable. Training, of course, also takes place in this context. That it works as well as it usually does is a tribute to the dedication, imagination and flexibility of students and mentors alike. That it is often, too often perhaps, unsatisfactory is entirely predictable. The need for nurses and those in training to understand the causes of their dissatisfaction is urgent, along with the need for action to influence and change.

How to use this book

This book can be used as a teaching aid for nurse education. It makes an ideal companion to final year modules that deal with professional identity or the transition to qualification. It can be used in the classroom to start discussion about nursing work and nursing identity. Each chapter/narrative deals with different issues and can form the basis of one session, or two can be compared. The stories show nursing work and the lives of the individuals and groups who tell the stories or feature in them in their complexity, so any ‘lessons’ drawn are unlikely to be simple ones but they will, I hope, be both profound and useful. Each chapter is supplemented by material that provides suggestions and questions for tutors and students to open up each narrative.

But I think the stories have the ability to stand on their own and to have an effect on the reader without the intervention of either myself or others. Because of this, I have separated the teaching material I mentioned above largely into a chapter at the back of the book. There you will find sections that correspond to each narrative. There are also pointers to further background material. I separated the book in this way so that those who simply want to enjoy or be challenged by the stories and their emotional and other overtones can do so without the distraction of overtly didactic interruptions.

Finally, I have sourced some images for many of the chapters, some provided by the tellers of the stories and some from elsewhere.

I end this introduction with a quotation from Arthur Frank, whose ideas I will return to in the next chapter. It is taken from his book about storytelling and analysis, Letting Stories Breathe. I place it here because I think it makes a good description of the stories in this book.

… [good] stories do not present themselves as simple models for action. They do not direct action directly but conduct it by indirection. Characters in good stories do not exemplify what anyone anywhere must do: they are doing what they have to do, where and when they find themselves.

Frank 2010, p. 160; my emphasis

On a personal level

On a personal level, this book is an attempt to deal with some unfinished business: the mystery and trauma of my own history and involvement with nursing and, at one remove, another history and involvement with National Socialism, in that part of my family grew up in Nazi Germany, subsequently emigrated and failed to engage with the horrors and reality of how the Nazi project implicated the whole nation. I keep returning to what has been referred to as Trümmerliterature and Trümmerfilm, creative work focussing on the immediate post-war ruin and trauma in Germany. One (of many and highly recommended) works looking back on this period is Europa (1991), an early film by Danish director Lars Von Trier.

Though, of course, a satisfying and important profession, for me—and some readers of this book—nursing will never be far away from trauma.

1The Organisation for Economic Co-operation and Development (OECD) is an intergovernmental economic organisation with 35 member countries, founded in 1961 to stimulate economic progress and world trade.

2

A tale told by a nurse…

In this chapter I set the scene for the stories that follow by talking about the study of narrative. I draw on the work of well-known teller of tales Arthur Frank among others. The chapter summarises a history of storytelling from aboriginal myths, through ancient Greek drama, religious stories, medieval mystery plays, Shakespeare (…full of sound and fury) and modern drama, to reality television and YouTube. It presents a summary of research and reflection on professional socialisation and its relationship to resilience.

Narrative, story and narrative research

‘This book will change the way you think and feel about your life’. The claim appears on the front cover of my edition of Zen and the Art of Motorcycle Maintenance, a novel by Robert Pirsig (1983), first published in 1974, shortly before I was born. That cover makes quite a claim. Though I am not sure that thinking and feeling are unentwined, the idea, I think, is that stories have a mysterious power to do something to us through the enjoyment of encountering them, even when the stories themselves might be unsettling or a little heavy-handed, as Pirsig’s book turned out to be.

Despite the decision to put the stories centre stage in this book, I want to frame them by talking about what stories are and how stories have been used in the nursing and healthcare professions. However, I want to tell you at the start that this book is not a textbook about narrative research. Think of this book as fiction, a collection of short stories. The only difference is that the stories here are true stories that happened and continue to happen.

What are stories?

To understand human life many look to the stories that individuals and groups circulate among themselves—the stories that are told and believed in. Aboriginal groups are well known for sharing stories about their origins and the origins of the land and creatures around them (see http://dreamtime.net.au/). Their stories, for example about the birth of the Emu, are often enigmatic and obey a logic that most contemporary Western readers or listeners do not share. They are considered to be a way of maintaining culture and identity in an oral society and of teaching skills and values to new generations.

More familiar to Europeans, though equally enigmatic, are ancient Greek myths and the scriptural stories of the Abrahamic religions.¹ These stories also feature accounts of origins—of the world, god(s) and humans. They include a supernatural realm of origin and influence on the affairs of women and men. Apart from communal entertainment, these stories, particularly those associated with what we now tend to separate out from the rest of life and think of as ‘religion’, appear to have served the purpose of maintaining strong group identity in the context of nomadic encounters with other tribes. These stories provide explicit teaching about acceptable and unacceptable behaviour in the form of laws originating from supernatural sources. The stories also form the basis of subsequent interpretations and reinterpretations as sanctioned teachers and scholars look for enduring principles that can guide the lives of those who believe in them.

The messages and morals of Greek drama tend today to be debated by literature scholars and psychoanalysts, rather than theologians and religious leaders. At the centres of these stories are kings and other powerful figures who, often with the noblest of motives, struggle against the inexorable powers of fate. They captivate us as audiences by evoking pity and horror, at Oedipus² stabbing out his own eyes after realising he has killed his father and had sex with his mother, to take just one example. Such dramatic figures have become known, unsurprisingly, as ‘tragic heroes’, often brought to terrible ruin by the playing out of some ‘flaw’ in their character, a flaw that can simultaneously be seen as an admirable quality, wanting to know the truth in Oedipus’ case.

One aspect of public storytelling across Europe in medieval times³ took the form of ‘mystery’ or, later, morality tales. Performed in the vernacular rather than Latin—the language of church services—and with plenty of spectacle, music and detailed stage directions, the plays generally presented religious allegory. As these plays were sanctioned by the church and performed from the back of a cart in the street, their purpose was clearly public religious education. Morality plays featured personifications of various moral attributes, such as Perseverance, Pity or Good-Deeds, and a protagonist who represented humanity as a whole—‘Everyman’ as he is called in one well-known play from the period—rather than what we think of today as an ‘individual’ character. We have to wait until Shakespeare (1564–1616) to find stories that combine the externalised personification of evil—the witches in Macbeth for example—with the ‘internal’ struggles of conscience of Macbeth himself or, famously, of Hamle...

Índice

• Cover
• Half Title
• Title Page
• Copyright Page
• Contents
• Figures
• PART I
• PART II
• PART III
• Bibliography
• Index