Intensive and Critical Care Nursing (2014) 30, 45—53

Available online at www.sciencedirect.com

jo ur nal homepage: www.elsev ier .com/ iccn

ORIGINAL ARTICLE

A critical ethnographic look at paediatricintensive care nurses and the determinantsof nurses’ job satisfaction

Paula R. Mahon ∗

Department of Occupational Science, Faculty of Medicine, UBC, Developmental Neurosciences and ChildHealth, BC Children’s Hospital, F606, 4480 Oak Street, Vancouver, BC V6H 3V4, Canada

Accepted 11 August 2013

KEYWORDSQualitative research;PICU;Retention;Critical ethnography

Summary The aim of this study is to examine key features within the cultural context in aCanadian Paediatric Intensive Care Unit (PICU) environment as experienced by nurses and toidentify what these influences are and how they shape nurses’ intentions to remain at criticallyill children’s bedsides for the duration of their careers.

This is a qualitative study which follows a critical ethnographic approach. Over 20 hours ofobservation and face-to-face semi-structured interviews were conducted. Approximately onethird of the nursing population at the research site PICU were interviewed (N = 31).

Participants describe a complex process of becoming an expert PICU nurse that involvedseveral stages. By the time participants became experts in this PICU they believed they hadsignificantly narrowed the power imbalance that exists between nursing and medicine. Thisstudy illuminates the role both formal and informal education plays in breaking the powerbarrier for nurses in the PICU. This level of expertise and mutual respect between professionsaids in retaining nurses in the PICU. The lack of autonomy and/or respect shown to nurses byadministrators appears to be one of the major stressors in nurses’ working lives and can leadto attrition from the PICU.

Family Centred Care (FCC) is practiced in paediatrics and certainly accentuated in the PICUas there is usually only one patient assigned per nurse, who thus afforded the time to provide

comprehensive care to both the child and the family. This is considered one of the satisfiers fornurses in the PICU and tends to encourage retention of nurses in the PICU. However, FCC wasfound to be an inadequate term to truly encompass the type of holistic care provided by nursesin the PICU.

ts re

© 2013 Elsevier Ltd. All righ

∗ Tel.: +1 604 707 3825.E-mail address: pmahon@cw.bc.ca

0964-3397/$ — see front matter © 2013 Elsevier Ltd. All rights reserved.http://dx.doi.org/10.1016/j.iccn.2013.08.002

served.

46 P.R. Mahon

Implications for Clinical Practice

• Nurses attain a certain level of expertise (expert status) and knowledge that allows them to equalise their relationshipwith physicians.

• The impact of patient death on the PICU nurse, while distressing, does not appear to cause severe distress, in fact itmay be one of the more satisfying components of the job. Due to the fact that the nurse has time to spend with thefamily and the dying child, he/she is encouraged to make the experience as tolerable as possible for both patientand family. This is an aspect of Family Centred Care.

• This study has shown that the term and philosophy surrounding Family Centred Care is too limiting really to encompassthe practice/philosophy of health care workers in the PICU. Also, in all of the explanations and definitions of FamilyCentred Care there is no mention of the health care worker and the effect Family Centred Care may have on thecarer.

• Often, many of the actions or demands of administration, such as ‘floating’ nurses to other units if the PICU isquiet and doubling of patients if there is not enough staff, undermined the sense of team and belonging that are

I

PfcAdottPrtt

B

IbRcw

umpnfttwew

(nipad

um

tsdpai

PPosteab

P

Ccd(gatias(Vwceck

jta

fundamental to retention of the PICU nurse.

ntroduction

aediatric Intensive Care Units (PICU) are highly stressful,ast-paced environments, to which it is increasingly diffi-ult to recruit qualified nursing staff (Bratt et al., 2000).lthough difficulties in recruitment and retention are wellocumented, there is minimal research as to how the culturer environment of a PICU contributes to nurses’ intentionso remain in or leave bed-side nursing in PICU’s. The aim ofhis study is to examine the cultural context in a Canadianaediatric Intensive Care Unit and its environment, as expe-ienced by nurses; and to identify those key cultural featureshat shape nurses’ intentions to remain at PICU bed-sides forhe duration of their careers.

ackground

t is predicted that in the next twenty years the world wille faced with a severe nursing shortage. The World Healtheport in 2003 noted: ‘‘The most critical issue facing healthare systems is the shortage of people who make themork’’ (WHO, 2003, p. 110).

To understand why nurses stay or leave PICU we mustnderstand what it is that influences their work environ-ent. Duquette et al. (1994) found that burnout is a complexhenomenon with multiple dimensions that contribute toursing attrition. The authors identified that demographicactors such as age, nursing grade and experience appearo be linked to burnout in nursing. Burnout is a combina-ion of several factors which are significantly influenced byorkplace environment. In 1994 a literature review of thexisting data regarding factors related to burnout in nursesas conducted (Duquette et al., 1994).

Intent to stay in a job is associated with job satisfactionMealer et al., 2009). Borda and Norman (1997) reviewed theursing literature to identify the factors with the greatestnfluence on turnover and absence of qualified nurses. Theroposed causes of the high turnover include poor remuner-tion, lack of autonomy, lack of respect in the workplace,

eath, over-work and burnout (Epps, 2012).

Children are approximately twenty percent of our pop-lation. Children in developed countries do not sufferortality and morbidity of diseases to the same extent as

tnc(

hat of the ageing adult population. However, while thismaller population cohort places less of an overall serviceemand on the health care system, the physiological andsychosocial challenges associated with caring for children,nd particularly those who are critically ill, are often signif-cant for health care providers.

In Canada critically ill children are usually cared for in aICU. As in other highly specialised care units in hospitals,ICUs often develop a ‘‘culture’’. A culture (or subculture)f PICU is implied but rarely explored in the literature. Aubculture encompasses a set of subconscious beliefs, atti-udes and assumptions that are shared by staff (Ohlingert al., 2003). The subculture of the PICU and its impact on

nurse’s intention to stay at or leave the bedside has noteen explicitly examined.

ower and knowledge

ulture within large organisations is neither universal noronsistent. Within each organisational culture are varyingegrees of integration due to the existence of subculturesHagberg and Heifetz, 2000; LaBarre, 2001). Subcultures areroups of people that work as departments, units or teams,nd may have unique values, norms, beliefs and assump-ions (Kaufman, 1999). The way relationships are structuredn health care organisations is informed by culture (Hagbergnd Heifetz, 2000), with consequences affecting the overallatisfaction and quality of work life of health care workersCanadian Council on Health Services Accreditation, 2004;arcoe et al., 2003). In order to discuss human relationshipsithin a cultural context, power and knowledge need to beonsidered. Power is central to the theory of truth in criticalpistemology, which is based in common forms of communi-ation (Carspecken, 1996). The relation between power andnowledge is of great importance.

The PICU nurse has another component that influencesob satisfaction, i.e. families (Bratt et al., 2000). The rela-ionships that nurses develop with families in this intensend often tragic period of a child’s life are fundamental to

he nurse’s concept of being satisfied with his/her work. Theurse does not care for the child in isolation; rather, he/sheares for the family as a unit with the child at the centreEpps, 2012). Foglia et al. (2010) conducted a study in PICU

sitmsshtocFa

ttoirq

S

Tirta

P

PstmuiitarEE

I

Tytttho

Cq

From the inside out

to understand why nurses were leaving PICU. They discov-ered that there are multi-factorial environmental factorsaffecting nurses’ decisions to remain in or leave PICU.

The term Family Centred Care is derived from CarlRoger’s work in the 1940s with families of ‘‘problem’’children (Rogers, 1939). Much of the literature on family-centred service has come from the family support and earlyintervention fields (Dunst et al., 1991). The role of the familyin the child’s life, and the importance of the insights of par-ents into their child’s abilities and needs have become morerecognized by professional caregivers (Moretz and Abraham,2012). King et al. (1996) describe three important aspectsof care giving: information exchange, respectful and sup-portive care, and partnership or enabling. These aspectsare fundamental to family-centred service according to Kinget al. (2004):

• That parents know their children best and want the bestfor their children.

• That families are unique and different.• That optimal child functioning occurs within a supportive

family and community context.

A significant gap in the literature exists regarding PICUnursing turnover (Foglia et al., 2010). Foglia et al. (2010)suggest that a study should be conducted to determine whynurses remain in their PICU. This research addresses thatgap. This study provides an in-depth interpretation of thenature of the experience of the PICU nurse’s work environ-ment through a critical ethnographic analysis.

Methods

To decide on a methodology it is necessary to take intoaccount the underlying culture of the environment in ques-tion. Nursing retention in PICU should not be viewed as anunmediated response to objective job characteristics, butas a culturally mediated response which depends upon hownurses invest their experiences with meaning and purposethrough interaction with others. Objective quantificationmay work for research disease processes but it is ques-tionable that such methods are appropriate when used inresearch on psycho-social stress related to work and workplace environments (Wainwright and Calnan, 2002). There-fore, critical ethnography (CE) was the methodology ofchoice for investigating influences on nurses. CE is based onboth Critical Social Theory (CST) and Ethnography: CST pro-vides the theoretical foundation for CE, while ethnographyprovides its methodological origins. CST questions historicalpower structures, and advocates for equity for marginalizedgroups (Giroux, 2004). Giarelli (1992) writes: ‘Critical theoryis, at its centre, an effort to join empirical investigation, thetask of interpretation, and a critique of this reality’ (p. 3).Browne (2000), one of the leading theorists on CST, describesfour central tenets of CST to be considered in health careresearch. First, CST is based on an understanding that novalue-neutral or foundational knowledge can be known out-

side the human dimension. That is, human beings, havingdeveloped foundational knowledge, have already placedvalues on it. Second, all social order involves some form ofdomination and power. Browne suggests that in all social

SA(r

47

tructures constructed by humans there is built-in powermbalance. Understanding these power dynamics is essentialo appreciating the complexities of health care environ-ents. Third, knowledge is mediated by power relation-

hips. That is, the process through which knowledge is con-tructed is influenced by the unequal power relations withinuman societies (Browne, 2000). Finally, language is the cen-re for the creation of knowledge. Language is the basis ofur communication and thus the driving force behind thereation and dissemination of knowledge (Browne, 2000).or these reasons, CST is a useful lens through which to lookt issues of power and equity in PICU settings (Basu, 2008).

CE as an interpretative research methodology evaluateshe cultural aspects of a society, a group, or an organisa-ion ‘within their setting’ to understand and expose meaningf the relationships of their world, without meaning beingmposed on them externally (Brewer, 2000). To conduct thisesearch project, Carspecken’s (1996) five stages for criticalualitative research are followed.

etting

he 22-bed paediatric intensive care unit studied is locatedn Western Canada. It is the principle employer of theesearcher. Management team data in this unit showed thathere had been approximately a 20% nurse attrition rate pernnum for the previous two years prior to this study.

articipants

articipants were nursing staff working in the PICU. Nursingtaff in the PICU are approximately 80% of the workforce;hey are a significant component to consider in the culturalilieu of a PICU. Approximately one third of the nursing pop-

lation of this PICU were interviewed (N = 31). They rangedn age from late twenties to sixty years of age, had a min-mum of two years’ experience in PICU and a maximum ofhirty-five years. The population included 3% males, which isn accurate reflection of the male population in PICU. Theesearch protocol was approved by the hospital Researchthics Committee and by the School for Health Researchthics Approval Panel at the affiliated University.

nclusion/exclusion criteria

he researcher avoided restricting participants according toears of work experience so as not to lose valuable informa-ion by not interviewing those who were just starting out onheir PICU careers. More than 30 participants volunteeredo be interviewed. Five of these participants were staff whoad worked in PICU on a full time basis and now work in PICUn a casual basis.

arspecken’s (1996) five stages for criticalualitative research

tage one — compiling the primary record staple of CE research data collection is observationMadison, 2005). To compile the primary record theesearcher commenced documenting everyday working of

4

Pc

SRiaptmrAibeip

STsitCmttPtbTtshmwc

caIatiicthbctwcai

aroTi

ppiosi

SItrdgdwvRraq

STdsootfaetmae

F

TsdwoewaCi

T

Citlna

8

ICU (Mulhall, 2003). More than 20 hours of observation wasonducted by the researcher in the PICU.

tage two — preliminary reconstructive analysiseconstructive analysis involves making explicit thosemplicit structural features and their implications on thectors, identifying values and power balances that are aart of the culture but are not articulated by the actorshemselves. The researcher reconstructed a written docu-ent into a ‘Story of PICU environment’ as observed by the

esearcher. Stage two moves the researcher to the analysis.nalysis of the primary record is conducted by deconstruct-

ng the primary record and eventually, reconstructing ity suggesting possible subjective, objective and normativevaluative claims. This allowed the researcher to considernteractions and observations and then diagnose biases orower imbalances

tage three — dialogical data generationhe insider’s view is described as the emic perspective. Thistudy consists of a single site for data collection. This sites the primary employer of the researcher. In some researchraditions this may be seen as a limitation. However, theE researcher is an insider investigating her own environ-ent or one with which she becomes familiar. Extended

ime in one setting is needed to gain an understanding ofhese features (Madison, 2005). Although certain features ofICUs are similar, in some aspects of environment and cul-ure they will be incomparably different. Therefore, onlyroad principles could be applied across sites and cultures.hese broad principles can be identified at a single site oncehe insider researcher can identify individual cultural per-pectives. By documenting her self-critique and discussinger ongoing reflexivity concerns with her thesis committeeembers, content experts and colleagues, this researcheras able to create a ‘check and balance’ approach to dataollection and analysis.

All PICU nurses were informed of the study through dis-ussion at the PICU management meeting, announcementst PICU nursing education days, distribution of a ‘Participantnformation Sheet’ and an ‘Invitation to Participate sheet’t the PICU front desk and coffee room, and via email. Inhese documents staff were invited to participate in a studyntended to explore how features of the PICU environmentnfluence nurses’ intentions to stay in or leave children’sritical care bed-side nursing. It was stated that their con-ributions to this study will increase the understanding ofow nurses in PICU’s are influenced in their career choicesy their work environment. All staff were encouraged toontact the researcher if they had further questions. Oncehe researcher was contacted by a potential participant,ritten consent was obtained and confidentiality was dis-ussed. A date and time was set for each interview. Consentnd confidentiality were reviewed at the beginning of eachnterview.

During the semi-structured interviews, participants weret ease and spoke freely and in depth about their expe-

iences. The specific details about reactions, behavioursr events occurring during the interview were recorded.his interpretive information aided in the analysis of the

nterview content. Validation of the findings was sought by

l

ih

P.R. Mahon

resenting ideas from previous interviews to new partici-ants. This aided in democratisation of the process. Thenterviews were audio-recorded. Field notes were kept inrder to enhance the recorded information with impres-ions and observations that the researcher made about thenterview process and content.

tage four — describing system relationsn stage four the relationships between the environmen-al influences at the site of interest were examined. Theesearcher was assisted by use of N-Vivo for the studyatabase. Primarily, themes were extracted from the data,iving evidence to support these themes from the primaryata. A full description of the documented relationshipsas developed and added to the database. Reflexivity isiewed as an essential component of rigour (Morse andichards, 2002). Fetterman (1998) suggests that qualitativeesearchers spend time reflecting upon their own biases andssumptions in order to prevent them from influencing theuality of the study.

tage five — system relations as explained by findingshe main goal of CE research is to create narrative thatescribes a specific culture (Morse et al., 2002). The firsttep in the analysis is aimed at developing an understandingf the cultural setting through data collection. The sec-nd analytic step is to develop thick descriptions throughhe process of coding. A synthesis of Carspecken’s (1996)ramework was utilised in this phase. Data obtained fromll sources were compared in order to generate and testxplanations concerning the relationship between unit cul-ure and nurses’ intentions. By being reflective, the author’sy insider’s perspective benefits both the interview and the

nalysis process, as the researcher can draw upon personalxperiences and theoretical knowledge to generate insights.

indings

he data collected in this research reflects PICU nurses’ per-pectives and how their environment may influence theirecisions to stay in or leave PICU. During the analysis itas discovered that there were several over-arching themesr influences on PICU nurses in PICU. The most importantnvironmental/cultural influences identified in this researchere: Trust and Communication, Entering the Inner Scantumnd Recognition, Education and Power, Care of the Dyinghild. Nurses identified these influences as having the most

mpact on their ability to work and stay in PICU.

rust and communication

onsistent with the literature, when discussing trust, partic-pants described it as a necessary component of successfuleamwork; participants felt they needed to trust their col-eagues’ abilities to look after the patients. If this trust wasot there, participants described a deep level of stress andgitation at having to take on the added responsibility of a

ess experienced nurse’s patient.

Communication was a significant theme throughout thenterviews. An interesting observation by participants wasow their method of communication changed over time.

a

tnwtei

aY(taraiet

E

Taaue

b

wa

n(ra

From the inside out

Several participants noted that the way they expressedthemselves had changed from when they started in PICU asjunior staff members. They described this process as tak-ing several years. They mainly described this as a changefrom a subjective to a more objective form of speech. Therewas also a confidence and assertiveness that comes withthe acquisition of knowledge and skill. Some participantnurses believe they were schooled to communicate fromthe counsellor or listener perspective, while physicians arethought to communicate very objectively — using the med-ical model. The documentation and discussion of facts isthe predominant component in this medical model and theconcept of feelings or psychosocial aspects is of lesser impor-tance. However, this has improved over the last twenty years(Harden and Crosby, 2000). Participant 19 described indetail how she believes nurses are taught to communicate,and then have to change how they communicate in order tobe understood by physicians; they believe they learn howto communicate effectively in PICU. She also explored howmen and women communicate differently.

Researcher: How do you see it differently in the waywe express ourselves; do we use a different language?Participant 19: ‘‘. . . So that’s one of the things I thinkwe learn as ICU nurses, to be more objective, but I thinkwe could still be better at it.’’

Researcher: Do you think that’s a learned skill for usbecause we’re women or because we’re nurses?

Participant 19: ‘‘I think that we’re more subjective.We speak more subjectively because we’re women. Prob-ably because we’re nurses as well, with the way that wewere taught. . . we probably do tend to speak more withfeelings.’’

Entering the Inner Sanctum and recognition

During the analysis it became apparent that becoming a PICUnursing expert is a process. Peer review was seen as oneof the most important aspects of being accepted in PICU.It was seen as a positive monitor of skills and expertise,while the management group’s (Clinical Leaders, Managers,Educators etc.) opinions were seen to be negative and, toa degree, an abuse of power by the use of subjective andoften uninformed judgments.

The concept of arriving, being an expert, being seento be an expert and being considered part of the teamwas the most influential and repeated component of whatkeeps the PICU nurse in PICU. The environmental influencethat is most profound for this idea of team and belong-ing in the PICU is respect. This is based on mutual trust.The author has suggested that nurses attain a certain levelof expertise and knowledge that allows them to equalisetheir relationship with physicians but not necessarily withthose removed from the bedside. The implication of this isthat nurses need further recognition for their achievementsfrom hospital managers and administrators. Participant 3describes the very personal feeling of belonging in PICU

and how it makes her feel when she knows that otherhealth care workers consider her to be an expert. Shedescribes being part of a team and the comfort that belong-ing brings.

spto

49

‘‘. . . people know me by name and it’s nurses, dieticians,physios, occupational therapists, I’ve worked over theyears with. Um, it’s how we can. . . do really good work,and be very focused on. . . what we’re doing and at thesame time still manage to have some fun and some jovialtimes when they’re appropriate but we keep each otherup and we’re supportive of each other. . .. . .. . .’’

Participant 26 describes the concept of respect afforded nurse once he/she has gained expert status.

‘‘I think we’re such a specialised unit and the more thatyou’re there, the more respect given by the doctors andI think you definitely get more, so I think that also helpsas well where you work with specific people. . . you havebeen proven to be someone who is reliable and this andthat, and says what you have to say — they’re gonnarespect you.’’

Floating to other wards when the PICU is quiet appearso cause a degree of outrage and upset to the participanturses. For example Participant 6 describes a situationhere she was forced to float because it was her turn, even

hough she had been caring for the same patient who wasnd-of-life, for the last three days. The emotional responses profound. Participant 6:

‘‘I felt there was no continuity and I couldn’t quite getpast that. . . I knew I had to go upstairs. I think the biggestthing is I wasn’t heard. I felt I wasn’t heard.’’

PICU participant nurses strive to attain this expert levelnd are very resistant to giving it up or losing these skills.et, it is this very skill that may be creating the ‘shock’Mitchell et al., 2001) that causes them to leave. Par-icipants perceive that their expert status is abused bydministrators. That is, administrators view nurses as aesource, there to get a job done, rather than as profession-ls who need a degree of respect and job satisfaction, whichncludes continuity of patient care. This clash of views mayventually cause burnout in the PICU participant nurses dueo the feeling of lack of control over their work allocation.

ducation and power

he majority of nurses came to PICU for the challengend the advanced technological component. There wasn expectation of increased education and the gaining ofnique and complex skills. Several nurses described thisxpectation.

Participant 5: ‘‘. . .so I thought coming down here woulde a good opportunity to gain even more skills.’’

Participant 6: ‘‘. . .because I wanted the complexity. Ianted to increase my skills, increase my knowledge base,nd a lot of it was for the complexity of it.’’

This study supports previous research findings that PICUurses experience a journey through novice to expertBenner, 1984). The majority of nurses interviewed in thisesearch indicated that having educational milestones wouldllow them to gauge their progress, thus implying that a

tructured educational plan is of benefit to the PICU nurses’rogress in becoming an expert. For the purpose of reten-ion it would be best that the PICU have a structured systemf education, not only allowing nurses to understand their

5

ocnnti

eiPtpp

C

Cpsta1esfindwaowtpC

amdnabtctitrPobtpftt

wt

tt

ddebPsfapenn

D

WppnwiiTcpittntaeLaihwTfp

n‘u

0

wn progress but also assisting in the peer support and edu-ation of their more junior colleagues. In order for the PICUurse to gain expert status this rite of passage appears to beecessary. That is, a structured approach allows the nurseo have an outward appearance of progression and insightnto his/her own progress.

This study has confirmed that as PICU nurses becomexperts in their field due to experience and education theres a reduction in the power imbalance that exists betweenICU nurses and the medical professional, and that this leadso more equality in the team approach in the PICU. Thearticipants describe this as one of the most satisfying com-onents of their job.

are of the dying child

aring has been defined as ‘‘the mental, emotional andhysical effort involved in looking after, responding to, andupporting others’ Baines et al. (1991, p. 11)’’. Many nurseheorists have described caring as central to nursing’s rolend as being the defining characteristic of nursing (Swanson,993). Caring can have profound implications for perform-rs of caring roles (Hochschild, 1983). The concept of jobatisfaction has been studied extensively. This study has con-rmed many of the findings from previous research. Theurses reported the stresses and strains of caring for chil-ren in the PICU. The impact of death on the PICU nurse,hile distressing, does not appear to cause severe distress,nd in fact it may be one of the more satisfying componentsf the job. Due to the fact that the nurse has time to spendith the family and the dying child, he/she is encouraged

o make the experience as tolerable as possible for bothatient and family. This is also an aspect of Family Centredare.

PICU nurses go out of their way to facilitate as tolerable death as possible for the child and for the family or pri-ary caregiver of the child. In general, staff did not describeeath as a traumatic event for them although they recog-ise it as traumatic for the family. Once appropriate time isllowed they find that it is a very rewarding process. Theyelieve they have made one of the most difficult times a lit-le easier by their presence and their interactions with thehild and family. It is described by several nurses as one ofhe most satisfying aspects of their job. Participants’ desires to make the worst time in the lives of these children andheir families a little more tolerable or less traumatic, byesponding effectively to their requests at this tragic time.articipants describe these experiences as positive. Severalf them became tearful when remembering these deathsut their upset was neither lasting nor subjective; rather,he interviewer saw it as the sadness of an occasion. Thearticipants believe they made a bad situation better. Theollowing are some very poignant examples from several par-icipants. The majority of participants discussed death inhis positive perspective.

Describing her work in caring for two dying children whoere being kept alive in order to harvest their organs, Par-

icipant 26 said:

‘‘. . . I think there is something very unique about thisjob. . . you see people at their worst times and it’s reallyhard on you, it’s very emotionally draining, you feel like

phmb

P.R. Mahon

you’re just becoming part of that family. But it is alsovery special.’’

Participant 18 articulated her passion for families andhe great satisfaction that comes from caring for a family athe time of child death.

‘‘. . .what I love about it is working with families who arein the process of losing a child and walking with themthrough that experience; it’s a real privilege to be a partof that. And if there’s anything that I can do to make thatexperience a bit more gentle for them, then I’ve done agood job.’’

This is not to imply that the more dramatic unanticipatedeath in PICU does not affect the nurse. The unplannedeath can be very challenging for the nurse in PICU. How-ver, it is the time to support the family which appears toring the most comfort and satisfaction to the PICU nurse.ICU deaths are relatively infrequent (>2% of all admis-ions at the research site, in the USA the PICU deaths rangerom an average of 1.8—2.8% NACHRI, 2012) and thus wouldppear to have less impact on burnout for the PICU partici-ant nurse than for ICU nurses in the adult world (Duquettet al., 1994). The researcher concluded that death did notecessarily induce severe distress in the majority of PICUurses interviewed.

iscussion

all (2010) notes that more critical research about nurses’rofessional lives is needed. She adds that knowledge androfessionalisation are important concepts and ‘can provideew perspectives for deeper questioning about nurses’ork experiences.’ (2010, p. 145). As a methodology, crit-

cal ethnography brings a particular focus to qualitativenquiry, drawing attention to issues of equity and power.his research explores the usefulness and some of theomplexities of critical ethnography as methodology, witharticular attention paid to what the methodology bringsnto focus, and some of the complexities of this approacho inquiry. It became clear during analysis of the data thathe issues of power and respect are crucial to the PICUurses, to their level of satisfaction with their job, andheir intention to continue in that role. Critical ethnographicnalysis demonstrated that PICU nurses expect to developxpert status. Trust, Communication, Caring and Emotionalabour were found to be fundamental influential factors thatffect nurses in the PICU. Nurses believe that with increas-ng knowledge and practical expertise the nurse elevatesim/herself to an equal footing with the other health careorkers involved in PICU patient care, especially physicians.he findings elucidate the process by which nurses’ moverom novice to expert in PICU. This is a process that givesride and satisfaction to the individual nurse.

By using critical ethnography the author has presented aew perspective on the experience of PICU nursing. As an‘insider’’, using interviews of PICU nurses and conductingnobtrusive observation the author was able to identify their

erspectives on their work environment. These perspectivesave shed light on their expectations of their work environ-ent. Working in PICU for these nurses is not just a jobut a career. They strive to achieve expert status and once

tTftftsbtdiDftfpctnr

imfTtTpsptseinhh

FmamtoCnafictCwufpCl

From the inside out

this is achieved they believe they are a member of a team,which brings respect and admiration from colleagues and thepublic alike. Anything that interferes with this perspective,such as floating, can cause significant upset and create the‘‘shock’’ as described in the theory of job embeddednessthat causes them leave this environment.

The author has indicated that overlooking or disruptingthis balance, by not showing the expert nurse due respect, isa profound cause of job dissatisfaction. This lack of respectfor nurses’ expertise appears to be wide-spread, and cul-minates in the practice of floating (in this instance), thuscreating a new power imbalance for the nurse; a stereotypi-cal display of the hierarchy embedded in nursing. This lack ofrespect for the professional PICU nurse counteracts much ofthe self-worth gained by knowledge. The power balance thusbecomes skewed by these organisational practices, leavingthe nurse in a position where the status and authority gainedby becoming an expert in PICU is diminished considerably byestablished professional identities and gender stereotypes.Floating should be seen as a cause for expert nursing attri-tion in the PICU, and it must be taken into considerationwhen hospital administrators are defining hospital staffingpolicies. This is not to suggest that PICU nursing expertiseshould not be utilised more appropriately throughout thehospital; the efficient running of the organisation has to betaken into consideration. This study supports utilizing PICUnurses as a resource for the ward staff, in an advisory, con-sultant or teaching role, rather than by merely substitutingward nurses with PICU nurses.

Death and family centred care

The concept of death and how participant PICU nurses per-ceive death appears to differ significantly from that ofnurses working in other areas. The majority of the public donot consider death good at any time, the literature supportsthe idea that there is no such thing as a ‘good death’ in hos-pital. Moskowitz and Nelson (1995) note that the attitudestowards modern illness, treatment and death are viewedas a paradox: while patients come to hospitals to stave offdeath they have a fear of the hospital death, assuming itwill be overly medicalised and lack dignity (Seymour, 2001).Hospitals are the place of death for the majority of people indeveloped countries (Griffin, 1991). Timmermans (1999), inhis work on hospital staff’s approach to resuscitation, notesthat certain social characteristics of the patient have moralconnotations that affect how the resuscitative effort willproceed. The most important of these characteristics wasage and the perceived outcomes or the particular illness(Timmermans, 1999). This suggests that death in the PICUmust evoke a different response from the nurse than that inthe adult environment.

Seymour (2001) suggests that it is the meaning of technol-ogy that determines the ‘good death’ in ICUs. She believesthat how technology is employed by the clinical staff affectsthe concept of death in ICU. She goes further to add thatopen communication and trust are keys to the perception

of the ‘good death’ for families. This concept supports theauthor’s findings in the PICU under study. It also supports theexpanded meaning of Family Centred Care. The majority ofparticipant nurses believe that the experiences of death that

aaw

51

hey have observed have been uniquely spiritual and ‘good’.he nurse explains this by his/her ability to encompass theamily in the process of the child’s death. The PICU nurse ishere as the support; the pillar to lean on. These nurses canacilitate any reasonable request to allow the family to feelhis is a good experience. They express their own naturalense of grief later, and openly, thus avoiding any possi-ly negative psychological effects the death could have onhem. The impact of patient death on the PICU nurse, whileistressing, does not appear to cause severe distress, in factt may be one of the more satisfying components of the job.ue to the fact that the nurse has time to spend with theamily and the dying child, he/she is encouraged to makehe experience as tolerable as possible for both patient andamily. This is also an aspect of Family Centred Care. Thehilosophy of care in the PICU is one which supports theare of the patient plus the immediate and sometimes evenhe extended family throughout their stay in the unit. Theurse is encouraged to take the time required to fulfil thisole.

This study confirmed that the PICU environment has sim-larities to the general adult ICU environment, with oneajor exception: the philosophy of caring is significantly dif-

erent. This is presently termed as ‘Family Centred Care’.he literature has encouraged the adoption of a Family Cen-red Care approach in paediatric hospitals in North America.his approach is supported by not just the health careroviders but also by administration. This shift in the philo-ophical approach to care in paediatrics supports staff inroviding this type of care. This type of care tends to takeime. This study has shown that the term and philosophyurrounding Family Centred Care is too limiting really toncompass the practice/philosophy of health care workersn the PICU. However, in all of the explanations and defi-itions of Family Centred Care there is no mention of theealth care worker and the effect Family Centred Care mayave on the carer.

The participant nurses feel that they always practiceamily Centred Care but know how to balance it. Theyay also feel threatened a little in that the power bal-

nce between the nurse and the family has shifted to aore even standing. However, this concept warrants fur-

her research. It may be time to elaborate on the philosophyf Family Centred Care. The discourse on Family Centredare is taken to mean so many things. As it stands it doesot encompass the true underpinning of the type of care itttempts to describe. The author suggests more precision inraming the concept of Family Centred Care to include nurs-ng/physicians/allied health engagement in the care of thehild, especially in an area like the PICU. The types of rela-ionships forged in this highly acute area are unique. Familyentred Care does not describe the authentic engagementith families that nurses describe. This type of care may benique to the PICU, which affords the nurse the time to careor one patient at a time, thus allowing the nurse to encom-ass the patient’s family as part of the care plan. Familyentred Care is closely linked to the concept of emotional

abour.

This research has uncovered that Family Centred Care is

n important underlying philosophy on PICU, where nursesre encouraged to spend time talking and discussing careith families. This is indeed a shift from fifty years ago when

5

nslte

L

IrppcHett

S

Iafooici

sahraantP

tTstawcocw

C

Tmwtrkta

et

dfjttfpoeiTOsamt

uGartd

nbmmtt

A

IawM

R

B

B

B

B

B

2

urses busied themselves with non-nursing duties such astocking linen rooms and shelves. Family Centred Care phi-osophy does not encompass, nor does it place merit on,he value the health care worker receives from this vitalngagement with families.

imitations of the study

t is accepted that there are limitations to the study. Thisesearch studied only the perspectives of the nurses. Theerspectives of the patients, family members and the otherrofessionals involved in the care of children in the PICUould have given a broader understanding of the issues.owever, the perspective of others might have diluted thessence of the study, which was the nurses’ perspective onheir environment, and the reasons why they stay in or leavehe PICU.

uggestions for further research

f findings from this present study were to be replicated on larger scale, a greater degree of generalisation and trans-erability of findings might be possible. Additional researchn this topic is necessary in order to create a greater bodyf knowledge on the PICU environment, and the influencet may have on nursing recruitment and retention. Specifi-ally the impact of ‘floating’ on nursing retention should benvestigated.

Comparisons could be studied: Are the implications the;ame for general adult ICU’s? Do other specialty areas suchs oncology and NICU have similar findings? A study of otherealth care workers in the PICU, such as physicians andespiratory therapists would be appropriate, with particularttention paid to how they perceive how the environmentffects their practice. This could complement the PICUurses’ perspective. It may also be worth considering howhese professionals view the role of the expert nurse in theICU environment.

In the author’s opinion, the most important findinghat requires further research is the concept of FCC.his research has shown that the terms and philosophyurrounding FCC is too limiting to encompass fully the prac-ice/philosophy of health care workers in the PICU. There is

need to change the term to a more encompassing one thatill truly capture the essence of holistic care that healthare workers provide for children and families in hospital. Anbservational study of a multidisciplinary sample of healthare workers throughout at least two paediatric hospitalsould more fully evaluate this concept.

onclusion

his study explored the potential contribution of one specificethodology, critical ethnography to the inquiry into nurses’ork environments and nursing work. This study illuminated

he reason why power is relevant to nursing and nursing

esearch, highlighting the importance of understanding thenowledge/power relationship and how we use knowledgeo reduce the power imbalances among professions. Theuthor has suggested that nurses attain a certain level of

B

B

P.R. Mahon

xpertise (expert status) and knowledge that allows themo equalise their relationship with physicians.

The impact of patient death on the PICU nurse, whileistressing, does not appear to cause severe distress, and inact it may be one of the more satisfying components of theob. Due to the fact that the nurse has time to spend withhe family and the dying child, he/she is encouraged to makehe experience as tolerable as possible for both patient andamily. This is also an aspect of Family Centred Care. Thehilosophy of care in the PICU is one that supports the caref the patient plus the immediate and sometimes even thextended family, throughout their stay in the unit. The nurses encouraged to take the time required to fulfil this role.he institution supports this philosophy, at least in theory.ften, many of the actions or demands of administration,uch as ‘floating’ nurses to other units if the PICU is quiet,nd doubling of patients if there is not enough staff, under-ined the sense of team and belonging that are fundamental

o retention of the PICU nurse.A critical ethnographic focus aids the opening up of these

nseen power imbalances and our perceptions of reality.aining this type of knowledge will allow nurses to recognisend address any of these issues that may exist in their envi-onment. It would also serve hospital administrators well toake note of this notion if they are to retain nurses in theseifficult-to-staff areas.

This study has demonstrated that research based on PICUurses’ and nurses’ environment can make a useful contri-ution to research. The views and experiences of nurses asembers of the PICU team must be ascertained and docu-ented in order to enhance our understanding of how best

o recruit and retain these essential members of the careeam in an ICU of a paediatric hospital.

cknowledgements

would like to thank the nurses who participant in this studylong with CACCN and Xi Eta for grants received. Also, Iould like to thank Dr. David Wainwright and Dr. GladyscPherson for their ongoing support.

eferences

aines C, Evans P, Neysmith S, editors. Women’s caring: feministperspectives on social welfare. Toronto: McClelland & Stewart;1991.

asu S. How students design and enact physics lessons: five immi-grant Caribbean youth and the cultivation of student voice. JRes Sci Teach 2008;45:881—99.

enner P. From novice to expert: excellence and power in clinicalnursing practice. Menlo Park, CA: Addison-Wesley; 1984.

orda R, Norman I. Factors influencing turnover and absence ofnurses: a research review. Int J Nurs Stud 1997;34:385—94.

ratt M, Broome M, Kelber S, Lostocco L. Influence of stress andnursing leadership on job satisfaction of pediatric intensive careunit nurses. Am J Crit Care 2000;9:307—17.

rewer J. Ethnography. Buckingham, UK: Open University Press;2000.

rowne A. The potential contributions of critical social theory tonursing science. Can J Nurs Res 2000;32(September (2)):35—55.

M

M

M

M

M

M

M

N

O

R

S

S

T

V

W

W

From the inside out

Canadian Council on Health Services Accreditation. Achievingimproved measurement — Accreditation program. Ottawa, ON;2004.

Carspecken P. Critical ethnography in educational research: a the-oretical and practical guide. New York, USA: Routledge, Oaks,Sage; 1996.

Duquette A, Kãcrowc S, Sandhu B, Beaudet L. Factors related tonursing burnout: a review of empirical knowledge. Issues MentHealth Nurs 1994;15:337—58.

Dunst C, Johanson C, Trivette C. Family-oriented early interven-tion policies and practices: family-centered or not? Except Child1991;58:115—26.

Epps K. Burnout in critical care nurses: a literature review. Dynamics2012;23(4):25—31.

Fetterman D. Ethnography, vol. 17. Thousand Oaks, CA: Sage Publi-cations; 1998.

Foglia D, Grassley J, Ziegler V. Factors that influence pediatricintensive care unit nurses to leave their jobs. Crit Care NursQ 2010;33(4):302—16.

Giarelli J. Critical theory and educational research: an introduction.Int J Qual Stud Educ 1992;5(1):3—5.

Giroux H. Critical pedagogy and the postmodern/modern divide:towards a pedagogy of democratization. Teacher Educ2004;31(1):31—47.

Griffin J. Dying with dignity. London: Office of Health Economics;1991.

Hagberg R, Heifetz J. Corporate culture/organizational culture:understanding and assessment; 2000 http://www.hcgnet.com/html/articles/understanding Culture.html

Harden R, Crosby J. AMEE medical education guide no. 20: the goodteacher is more than a lecturer — the twelve roles of the teacher.Med Teach 2000;22:334—47.

Hochschild A. The Managed Heart: Commercialization of HumanFeeling. Berkeley, CA: University of California Press; 1983.

Kaufman S. The clash of meanings: medical narrative and biograph-ical story at end’s life. Generations 1999;23(4):77—82.

King G, King S, Rosenbaum P. Interpersonal aspects of care-givingand client outcomes: a review of the literature. Ambul ChildHealth 1996;2:151—60.

King S, Teplicky R, King G, Rosenbaum P. Family-centered service

for children with cerebral palsy and their families: a review ofthe literature. Elsevier Inc; 2004.

LaBarre P. Marcus Buckingham thinks your boss has an attitude prob-lem. FastCompany 2001;August(49):88.

W

53

adison D. Critical ethnography: methods, ethics, and perfor-mance. Thousand Oaks: Sage Publications; 2005.

ealer M, Burnham E, Goode C, Rothbaum B, Moss M. The preva-lence and impact of post traumatic stress disorder and burnoutsyndrome in nurses. Depress Anxiety 2009;26(12):1118—26.

itchell T, Holtom B, Lee T. How to keep your best employees:developing an effective retention policy. Acad Manage Exec2001;4:96—108.

oskowitz E, Nelson J. The best laid plans. Hasting Center Rep(Suppl) 1995;November—December:53—5.

orse J, Richards L. Read me first for a user’s guide to qualitativemethods. Thousand Oaks, CA: Sage Publications; 2002.

oretz J, Abraham M. Implementing patient and family centeredcare: Part II. Strategies and resources for success. Pediatr Nurs2012;38(2):106—10.

ulhall A. In the field: notes on observation in qualitative research.J Adv Nurs 2003;41:306—13.

ational Association of Childrens Hospitals and Related Associa-tions; 2012, www.nachri.org/http://www.childrenshospitals.net//AM/Template.cfm?Section=Home3; http://www.mch.com/page/EN/254/Pediatric-Critical-Care-Medicine/Pediatric-Intensive-Care-Unit-(PICU).aspx

hlinger J, Brown M, Laudert S, Swanson S, Fofah O. Development ofpotentially better practices for the neonatal intensive care unitas a culture of collaboration, communication, accountability,respect and empowerment. Pediatrics 2003;111:471—81.

ogers C. The clinical treatment of the problem child. Boston, MA,USA: Houghton Mifflin; 1939.

eymour J. Critical moments: death and dying in intensive care.Buckingham, UK: Open University Press; 2001.

wanson K. Nursing as informed caring for the well-being of others.Image: J Nurs Scholar 1993;25(4):352—7.

immermans S. Sudden death and the myth of CPR. Philadelphia,PA: Temple University Press; 1999.

arcoe C, Rodney P, McCormick J. Health care relationships incontext: an analysis of three ethnographies. Qual Health Res2003;13(7):957—73.

ainwright D, Calnan M. Work stress: the making of a modern epi-demic. Buckingham, UK: Open University Press; 2002.

all S. Critical perspectives in the study of nursing work. J Health

Organ Manage 2010;24(2):145—66.

orld Health Organisation (WHO), Beaglehole R, Irwin A, PrenticeT. The world health report — shaping the future. WHO LibraryCataloguing-in-Publication Data; 2003.