doi: 10.1111/nup.12052
Original article
Tracing detached and attached care practices in nursing education Ann Katrine B. Soffer MA PhD Fellow, Department of Education, Aarhus University, Copenhagen NV, Denmark
Abstract
The implementation of skills labs in Danish nursing education can, in itself, be viewed as a complexity. The students are expected to eventually carry out their work in a situated hospital practice, but they learn their professional skills in a different space altogether, detached and removed from the hospitals and practising on plastic dummies. Despite the apparent artificiality of the skills lab, this article will show that it is possible to analyse some of the fundamental aspects of care in nursing by ethnographically following this phenomenon of simulation-based training. These particular aspects of care are not explicated in the curriculum or textbooks; however, they surfaced once this crooked approach to studying care in a simulated practice was applied. The article start from the assertion that detached engagements are not recognized within the field of nursing education as an equal component to attachments. Yet empirical cases from the skills lab and hospitals illustrate how students sometimes felt emotionally attached to plastic dummies and how experienced nurses sometimes practised a degree of detachment in relation to human patients. Detached engagements will therefore be presented as part of care practices of nurses – rendering the ability to detach in engagement with patients a professional skill that students also need to learn. In the analysis to follow, attached and detached engagements are located on an equal plane by integrating both into the same conceptual framework, rather than imposing a priori notions about their dialectic relation. The analysis shows that it is the particular intertwinement of attachment and detachment that gives care its fundamental meaning. In conclusion, the need for a conceptual shift from a strong emphasis on attached engagement to a more balanced analytical approach to care work, as involving both attached and detached engagement within Danish nursing education, is advocated. Keywords: care, education programme, identity, knowledge, qualitative research, technology.
Correspondence: Dr Ann Katrine B. Soffer, MA, Department of Education, Aarhus University, Tuborgvej 164, Office J112, 2400 Copenhagen NV, Denmark. Tel.: + 45 3147 9233; fax: + 45 8715 0201; e-mail: [email protected]
© 2014 John Wiley & Sons Ltd Nursing Philosophy (2014), 15, pp. 201–210
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Care in a Nordic context In many of the nursing theories taught in the Danish nursing programmes, care is described as an initially inner process, which leads the nurse to orient herself out towards a normative engagement with the patient. Thus, the ability to attach, connect, and engage with the patient is considered the cornerstone of good, right, and desirable professional virtues within a Danish nursing context. The professional skills of Danish nurses are often understood within the framework of a specific ‘Nordic model’, within which care is perceived as an experienced-based and oftentimes tacit professional practice, and the idea of attachment is here a key notion (Benner, 1982; Andersen et al., 1999; Scheel, 2004)1. This specific Nordic notion of care is most clearly articulated through the influential work of Kari Martinsen, a Norwegian nurse scientist and philosopher, whose work figures extensively in the Danish nursing curriculum and textbooks (Martinsen, 1989, 1991; Dahl, 2000; Christensen, 2003). Martinsen’s central placement in the curriculum testifies to the conceptualization of care as an interpersonal practice of attachment as well as a bondedness between the nurse and the patient (Martinsen, 1991). Building on the work of theologian and philosopher K. E. Løgstrup, Martinsen defines care as a trinity of relationality, practicality, and morality. Her compassionate theoretical framework is one that expresses the foundational principles of care as an inner process, and care work as an always already openness and attachment towards the patient (Martinsen, 1989). She articulates how the human condition is one of social interdependence: ‘Care is to be concrete and present in a relationship by our senses and our bodies. It is always to be in a movement away from ourselves and towards the other’ (Martinsen, 1989, p. 11). However, the Nordic model is challenged by the current implementation of
simulation-based training in nursing education, which increasingly requires students to learn the ability to attach through simulated situations, when clinical bedside teaching is turned into staged scenarios with high-tech plastic dummies in a laboratory environment structured to resemble a hospital. While some simulated scenarios are focused on hands-on training of isolated skills, others are structured to play out longer clinical situations in real time. Reliance on these types of technologies as pedagogical tools for clinical training has increased in recent years partly due to changes to the way in which Danish health care services are structured and delivered. Shorter hospitalizations, increased use of outpatient treatment methods, and a growing focus on patient safety have fuelled the use of simulation-based training. Within nursing education, this type of training is also viewed as a means to overcome faculty and preceptor shortages as well as the growing lack of clinical placement sites. Thus, simulation-based training is effectively reshaping traditional approaches to teaching and learning professional practices related to health care2 as well as challenging the normative foundation of the Nordic model and leaving a conceptual void. Framing care work within nursing as a question of constant attachment and openness towards the patient puts certain limitations on the ways we think about care. Understanding care as a purely compassionate and altruistic attachment in the nurse–patient engagement glosses over the ambiguous intricacies of care and how professional practices that have to do with care are comprised of a variety of different forms of productive professional engagements. An ethnographic inquiry into the training of Danish nursing students, with a specific focus on simulation-based training in skills labs, wherein students receive clinical training on technological plastic dummies, offers a different conceptualization of care. In the analysis 2
1
Danish nursing education traditionally involved shorter theo-
In recent years, the implementation of so-called evidence-based
retical lecture sections and lengthy apprenticeship, where stu-
clinical guidelines has increased, contrasting and challenging
dents would learn the techniques and skills from experienced
some of the core tacit and experience-based values within the
nurses while working closely with patients. Today, the Danish
nursing education. The clinical guidelines are explicitly commu-
national nursing programme is a 3.5-year bachelor degree, con-
nicated and research based through the use of randomized clini-
sisting of 14 modules, with a distribution of 60% theoretical
cal trials rather than experience based.
lectures and 40% clinical placements.
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that follows, care proves to be linked to multiple, different (and sometimes conflicting) types of professional engagement practices, thereby unsettling the common sense assumptions that the care work of nurses is a purely generous, compassionate, and nurturing professional engagement characterized by relational attachments (Candea, 2010). A different framework is needed to capture and describe what nurses do: one that considers care practices in a more normatively flexible way and describes care as it slips into different modes of engagement (cf. Mol, 2002). The empirical case of the skills lab demonstrates how opposing ideas about attachment and detachment do not help us to understand why students sometimes feel emotionally attached to plastic dummies or why experienced nurses in the hospital practise a degree of detachment in relation to human patients. For the purpose of this analysis, the distance and separation entailed in care work is captured with the notion of detachment, which will be considered as equally significant as the already established notion of attachment put forth by Martinsen and other nursing scholars (Menzies, 1960; Martinsen, 1991; Scheel, 2004; Benner et al., 2009). Once professional attachment ideals are held up against the practices of the skills lab, not only existing understandings of care are challenged but also dominant ideas about simulationbased training in nursing education, and a new light is shed on the potential of the skills lab.
Situating the rise of simulation as professional training Some nurse educators at the nursing school where my fieldwork took place considered the move towards teaching nurses in a simulated environment problematic. As a consequence of this new teaching practice, some nurse educators felt compelled to express their ideas about what truly constitutes care. Care often took on an idealized form resembling the Nordic model in these articulations, which did not always correspond with the ways in which I observed care being practised. It is precisely this tension between the ideals and practices of care that informs this analytical inquiry. Making use of different types
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of simulation-based training has a long history in European and North American nursing programmes, and although it has remained a rather marginal approach for many years, the development of these methods, especially in the 20th century, is well documented. The development of highly sophisticated simulation technologies that allows students to practise their skills without risking patient safety has increased dramatically in recent years. While not a new phenomenon in itself, simulation-based training has not yet been used as an empirical starting point for an analysis of care. In fact, in studies of simulation-based training, little attention has been paid to its limitations and possibilities within care work, especially considering its recent growth within nursing. Current research in the field of science and technology studies as well as social science at large has mainly focused on the use of simulation in medical and surgical training and education. The work of Prentice (2012) explores the implementation of new technologies incorporated in the design of simulators in order to develop the surgical skills of medical students. Johnson (2004) has studied the integration of gynaecological simulators into medical education and shows how medical practices and practitioners are constructed within simulationbased training. In Taylor’s (2011) work, the recent rise in the use of standardized patient performances in medical schools in the USA, which incorporates staged clinical encounters with actors who specialize in role playing the part of the patient, is examined. Taylor explores the simulation of suffering as real but not too real, which allows for medical students to imagine themselves in the moral and emotional role of a medical provider. Most previous studies on clinical education and training have focused on the socialization of medical students, showing that becoming a medical provider involves more than the acquisition of technical skills and physiological knowledge, and arguing that education and training also involve a process of socialization wherein norms, values, and behaviour that are acceptable within the profession are instilled. Here, the analytical focus is shifted onto professional practices in the care work of nurses, which I will refer to in the following as engagements.
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The ethnography of hospitals, schools, and laboratories The analysis is based on an ethnographic methodological approach grounded in participant observations and interviews. My fieldwork at a Danish nursing school was carried out over the course of two semesters in 2011. As a novice among novices, I set out to follow a group of first-year undergraduate nursing students in their day-to-day school activities and various clinical placements (Hasse, 2003). I prepared for the courses and took part in the theoretical lectures on anatomy, physiology, microbiology, ergonomics, and nursing care. Although the schools and hospital administration, students, teachers, nurses, and patients were aware of my position as a researcher, over time, I quickly became part of the class. I joined a study group with three other young female nursing students, reading and discussing the syllabus and preparing for exams. I followed two first-year students in their clinical placements, one at a Urology Department in a large urban specialized teaching hospital and the other at a Department for Internal Medicine at a smaller teaching hospital North of Copenhagen. During the clinical placements, I started my day of fieldwork at 7 a.m. when I changed into the nursing uniform and participated in a full day of work alongside the nursing student. Finally, I also conducted participant observations in three different skills labs, one located in the nursing school and two affiliated with different hospitals in the urban Copenhagen area.The simulation training in these skills labs ranged in character from role play – where students or teachers would play the role of the patient, hands-on training – practicing the use of different professional tools such as an electric thermometer and blood pressure monitor, to full-scale simulation making use of electronically enhanced plastic dummies to play out planned clinical scenarios in real time. As an ethnographer, I actively participated in simple simulations when invited by instructors and students, but took on a more observing role once the complexity of the scenarios increased. This ethnographic approach makes it possible to foreground some of the tensions and contradictions of learning and practising care, by approaching care not as a normative and given ideal
found in student textbook and classroom lectures, also called ‘ethics of care’ (Tronto, 1993; Edwards, 2009; Kohlen, 2011), but as a concept that is practised in a situated context. The particular conditions that this approach brings with it is a focus on the details, particularities, and demands of care work, which tend to be missed in curriculum overviews or textbook accounts of nursing, in order to ascertain and elucidate other aspects of a complex care practice. Doing fieldwork within health care and its affiliated spaces, I often found myself in unfamiliar and challenging situations. This fieldwork was a rather intimate one in many ways, just like care work itself. I saw many patients undress and listened to young students sharing their fears about engaging in this particular kind of professional practice. This intimacy is also reflected in the ethnographic data presented in this article. The analytical discussion that follows revolves around the less than glamorous task of giving a bed bath (cf. Pols, 2013). I do so not only because giving a bed bath is a core professional skill within nursing but also because practising and performing this skill unfolded differently once the patient’s body was replaced with plastic. Analysing a bed bath and other clinical nursing skills is part of an attempt to taking care work seriously, as Dutch anthropologist and philosopher Annemarie Mol encourages (Mol et al., 2010). Care work is not merely a practical matter confined to the personal sphere, it is also ‘an intellectually interesting topic’ (Mol et al., 2010, p. 7; cf. Pols, 2013). In the following, I will make use of two different empirical cases, one from the skills lab and one from the hospital. I do so in order to analyse whether care is different in the two different situations (Mol, 2002; Law, 2004).
Care in skills labs: tinkering with engagements The plastic dummies used for simulation training are designed and manufactured to express different aspects of the patient experience, represented in terms of specific and manipulable physiological values, such as detectable bowel sounds, a measurable pulse, respiration, blood pressure, and urination. During a simulation scenario, the plastic dummies
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and their physiological expressions were wrapped in uniquely designed clinical situations. Sometimes, these scenarios were pre-produced by the manufacturers of the simulation technologies and installed into the software of the plastic dummies. Other times, they were built by the faculty members themselves, by making use of good or exemplary clinical cases or episodes stemming from their own professional experiences. Yet other times, these scenarios were made up altogether in order to fit a specific learning objective. During the fieldwork, I witnessed a shared commitment among both faculty and students to uphold authenticity as a shared ideal when it came to scripting and carrying out the scenarios. Authenticity became a key aspect in legitimizing this teaching strategy as a justifiable replacement for real clinical experiences gained within a hospital setting. As I was discussing the daily operations of the skills lab with one of the instructors, she said: The more authentic elements we can put together in a scenario, the easier it is for the students to immerse themselves, and really take on their roles. So I always prioritize bringing together as many authentic components as possible. The hospital donates things that have expired or that they don’t use anymore – that really adds to the feeling of actually being there.
The faculty involved in scripting and developing the simulation scenarios referred to authenticity as a key concept, when they told stories of students crying when the plastic dummies did not make it through a critical scenario. Simulation scenarios such as these were notoriously recognized among the faculty as the most successful execution of a scenario and as an example of the ultimate student immersion. ‘If a student is moved to tears, then you know that they feel like they are really there with the patient’, one of the instructors told me. Meanwhile, detached engagements between students and plastic dummies, mostly student mucking about and making joking and silly comments were considered prime examples of why a skills lab did not work well for training nursing students. Scripting scenarios was not a straightforward process; rather, scripting and building scenarios depended on practical adaptions of authenticity
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and complexity until a suitable arrangement was achieved. Mol uses the notion of associations to describe how different actors relate and adapt to one another (Mol, 2010, p. 259). However, she explains ‘the term “association” cannot begin to cover all forms of relatedness. Further words are needed: collaboration, clash, addition, tension, exclusion, inclusion, and so on. Terms variously adapted to various cases. Terms that help us to attune to different events and situations’ (Mol, 2010, p. 259). The notion ‘tinkering’ is now more often used than the original concept of ‘association’ in order to capture the step-by-step activities performed by the various actors (Mol, 2010). Over the course of my fieldwork, I observed adjusting and tinkering with the different elements of the scenarios, such as taking out irrelevant or contradictory data from a case, or simplifying a patient history, in order to better meet the students’ skill sets and knowledge base. This tinkering was done in an attempt to create a built-in learning trajectory carefully adapted to the nursing students’ level of clinical competence and knowledge, rather than overwhelming them with too much clinical complexity. Paradoxically then, the labour of tinkering and manipulating the construction of the scenario, fitting it to the student learning trajectories, seemed to be a criteria for the success of an authentic scenarios. The act of tinkering is built on the belief that once the complexity of the scenarios is adjusted just right, the students can connect with the scenario and attach to the plastic dummy, achieving an authentic sense of actually being there. Attached engagements, then, worked as a benchmark for achieving authenticity. Although the students’ connection to the scenario and attachment to the plastic dummy were difficult to achieve, the connection between authenticity and attachment was explicitly linked to the accomplishment of a successful simulation and ultimately a valid representation of good care. The constant effort to maintain the plastic dummy as an acceptable representation of a patient generated this explicit focus on attachments in the skills lab, which was consistent with the textbook accounts of care work as an attached engagement. However, as follows, the lack of focus on detachment in nursing education will be problematized because, as I will show, detached engagements are present in care work and they matter.
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In the skills lab, I observed a continued effort to maintain the plastic dummy as a legitimate representation of the patient, because instead of patients lying in the hospital beds, plastic dummies had taken their place. Plastic, in this particular situation, was considered malleable, yet easy to hold still for the purpose of practice, allowing for the students to develop their emerging skills without the vagaries of the tricky fleshy bodies of real patients.
task, and in a joking manner reminded her to ‘be careful not to wash it to the point that it wears away’. Peter smiled and Amanda burst out laughing again. After collecting herself once more, she asked Peter what to do if a male patient had an erection during a bed bath. While asking Peter her question,Amanda never lifted her gaze, but kept her eyes looking down at her hands now washing the inner thigh of the plastic dummy. Peter replied: ‘Well, I guess there are many ways to deal with that situation, but I would suggest covering the patient back up, and telling him that you will be back a little later’. Amanda seemed relieved by the answer she got, and
Caring for plastic Before the use of simulation-based training, the students learned the skill of giving a bed bath through the principle of ‘see one, do one’ during their clinical placements, where they would start out by observing an experienced nurse perform the task, and with time carry out the tasks on their own. With the shift towards using simulation-based training, I will show how the student in the skills lab learns valuable insights about care work, not despite of, but exactly due to the detached engagement between the student and the plastic dummy while learning the skill of giving a bed bath. On one specific occasion, I observed something that could easily be written off as an example of a detached engagement, during an afternoon simulation session on lower body hygiene in the skills lab: Students were divided into groups of three or four and gathered around three different dummies, two with female genitalia and one with male. The students were instructed how to give a bed bath with single gentle strokes from the front to the back, and how to make use of this opportunity to inspect for signs of skin irritation and pressure ulcers on the surface of the patient’s skin. The students were in high spirits, and giggles and outbursts of laughter filled the air on several occasions. A male student instructor, Peter, who was in his last year in the nursing program, was responsible for the training on the dummy with male genitalia. The three nursing students in Peter’s group were blushing red, nervous and occasionally had to leave the bedside to shake off the
proceeded to pull the gown down into place and tuck the duvet in underneath the sides of the plastic dummy, before giving him a light pat on the abdomen (excerpt from field notes).
Amanda provides a compelling empirical demonstration of how her capacity to learn to care can be reconceived on foundations different from those of Martinsen (1989, 1991), where it is the attachment of the nurse to the patient, which is the centre of care.The engagements in the skills lab were characterized by jokes, laughter, and embarrassment, practices that would not be encouraged in actual nurse–patient encounters in a real hospital. But in this particular situation, the detachment found in the skills lab becomes an opportunity to learn rather than an obstruction of authenticity or an example of ‘bad’ care. Amanda’s inquiry was not surprising to me. It was not just an offhand remark or a joke but rather struck at the core of some of the larger concerns, which I heard voiced while spending time with the nursing students, about how to navigate the balance between intimacy and professionalism. Amanda had not found answers to her question by reading the syllabus for class, or attending the lectures on nursing care or physiology. Besides the practicalities of the bed bath, textbooks and lectures addressed issues such as ensuring adequate patient privacy and avoiding routinizing the bathing rituals too much, but erections were not discussed. It weighed on her not knowing exactly how to go about handling intimate situations like these.
embarrassment or giggles before returning to finish their
That is actually one of the things I’m most worried about
task. While one girl, Amanda, was taking her time to wash
going in to my next clinical placement. I know I will defi-
the genitals of the male plastic dummy with rather rough and
nitely have to do bed baths – maybe even alone. I’m not
repetitive stokes, Peter prompted her to move on to the next
really sure I can handle that.
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Amanda did not mention death or dying, severe illness, or making mistakes as her biggest concerns when I approached her after the simulation training that day. Thoughts of handling private and intimate moments such as the one described above in a professional manner was what made her anxious about finding herself in the real clinical setting. In other words, Amanda had not yet learned the value of detached engagements or the skill of carrying it out in practice. The male plastic dummy took on a character, which was just real enough to imagine the clinical situation, and ‘plasticy’ enough for the students to giggle, laugh, and effectively detach themselves from as a representation of anything but lifeless cold plastic. This specific assemblage of plastic and novice students, unfamiliar with the task of giving a bed bath, permitted important questions about intimacy and professionalism to be raised.Although the mode of engagement between the students and the dummies that day was detached in character, as Amanda washed a piece of plastic, she nonetheless achieved a deeper understanding of care as it is practised. What this brief glimpse into the skills lab at a Danish nursing school shows us is that the productive and professional potential that detached engagements possesses is neither described in the textbooks, as a nuanced way of thinking about care, nor it is carried out in the skills lab as a nuanced way of practicing care. This lack of focus on detached engagements makes for a restrictive understanding of care as a ‘persistent tinkering in a world full of complex ambivalence and shifting tensions’ (Mol et al., 2010, p. 14). In order to support this argument in favour of a more balanced approach to attachment and detachment in Danish nursing education, I would like to take the reader into the hospital to demonstrate how detached engagements are crucial skills in nursing and show how they are really practised.
Caring for patients I guess you could call me a ‘people person’, Helen said, and she continued: Because working with other people just really motivates me. I feel like that is where my personal strength lies.
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Upon meeting students at the nursing school, my opening question was their reasons for choosing nursing as their career path. The above statement came from one of my key informants, Helen, a 21-year old woman in her first year of the programme. In many ways, Helen’s response echoed countless versions of the same answer. In short, many students revealed to me that their main motivation for enrolling in the nursing programme was a desire to work closely with people.Training in the skills lab and interacting with plastic dummies seemed therefore contradictory to the motivation that drove many of the students into nursing in the first place. In the early stage of my fieldwork, I took this particular description of the nurse–patient relationship much for granted, but as my time in the field progressed, this characterization seemed too easy and closed down too quickly the very notions about care that should be kept open to analytical inquiry (Latour et al., 2012). My ethnographic approach provided an opportunity to examine how nurses work with patients. While the majority of patients in the hospitals only saw a doctor once a day during morning rounds, the nurses and students provided both physical and emotional assistance throughout the patients’ stay at the hospital. The nurses were responsible for ensuring a daily routine, which I became increasingly familiar with as my fieldwork progressed. They made sure that patients were woken up in the morning, served breakfast, administered medications, given a bath, prepared for rounds while also attending to specific medical needs, making necessary follow-ups or changes, consulting specialists, providing health education, and staying in touch with relatives. The nurses I encountered during my fieldwork often possessed a vast amount of knowledge about their patients, and the nursing students that I followed during their clinical placements were eager to get to work and care for the patients. As the student, Helen, explained to me, there was nothing more uncomfortable than feeling redundant or useless when surrounded by ill patients. But as a novice, with only a semester’s worth of training under her belt, she often felt like she fell short when it came to fulfilling the scope of practice as a professional nurse. As she put it:
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I still have a lot to learn before I can practice as a nurse. And so, a lot of times I just feel like I am in the way of the preceptors and the other nurses, because I can still only do simple basic things for the patient.
Helen did what she could during her clinical placement, which meant providing basic care needs. She would fluff pillows and fetch water, constantly attending to the patients she was assigned. I followed Helen as she took care of Edith, an elderly female patient, who had been admitted a couple of days earlier and had shown no noticeable signs of improvement during her stay. She was lonely with no visitors coming to see her. Edith continued making demands on the staff, asking for help and assistance with things that she was capable of doing herself, like having a sip of water or combing her hair. More experienced nurses declined her requests, telling her that she should first give it a try on her own. Helen, on the other hand, could not brush off her requests as easily. She would instead tend to her needs again and again – brushing her hair, changing channels on the TV, dialing the numbers on her phone, and I would help – fetching water, getting more sugar for her yoghurt. In passing the Nurses’ station, another nurse sent me an overbearing smile, as I was returning from the kitchen with added sugar on Edith’s strawberry flavored yoghurt. She was an experienced mid-career nurse who had spent most of her working life in healthcare. She pointed out that it was a deliberate decision on her part to refuse the patient’s requests. ‘If I make her think that I will come running all the time, I would not have time for any of the other patients, or all the other tasks that I have to perform in a day’. She said as she continued to type away on the computer. ‘[. . .] But more importantly’ she continued: ‘I also do it to prompt her to solve some of her manageable problems herself. If I help her with everything I make her passive, and she will lose her ability to take care of herself much faster that way’. She paused and looked up at me: ‘Helen hasn’t learned this yet. As you can see she is doing everything the patient asks her. But eventually she will understand that sometimes doing nothing is also caring for the patient’ (excerpt from field notes).
The experienced nurse described how being a nurse entails more than working with people, but more importantly she pointed out that detachment and distance in the nurse–patient engagement is not neces-
sarily an indicator of ‘bad’ care. At first glance, it seemed harsh to me that the nurses turned down a lonely elderly woman’s request to brush her hair or have a sip of water. Helen, on the other hand, took Edith’s requests seriously and tried to meet her demands. In doing so, Edith provided Helen with a sense of purpose, something to do, and thereby helped to overcome her feeling of being redundant. But in fact, the experienced nurse’s distant and detached engagement with Edith was an act of care in itself – keeping her from becoming passive and immobile, and prompting her to engage with her environment and seek manageable solutions to her needs and problems. Thus, the process of attuning the practice of care to Edith’s fragility does not necessarily only implicate attachments and closeness but also detachment and distance. Detachment, in this sense, was not necessarily in contradiction to attachment. In this instance, the more experienced nurse was able to draw on her empirically grounded and hard-earned professional experiences of engaging with many patients over time in order to tinker with the care engagement (Mol et al., 2010). Being an experienced nurse also meant being able to care through detached engagements, in order to avoid placing those who receive care in a position of passivity and dependence. In the eyes of the more experienced nurse, Helen’s behaviour was that of a newcomer, who had not fully grasped the complexity of tinkering with care yet. Once professional engagements are explored in practice, it becomes difficult to make clear analytical distinctions between attachment and detachment, allowing us instead to question the very dichotomy between the two and rethink their theoretical relationship. In a similar vein to Mol’s notion of tinkering, we find Pols’ attempt to replace the separated and opposed ideas of warm and cold care with a more practical and contextual idea of care through ‘an aesthetics of fitting’ (Pols, 2012). I too have shown different modes of attachment and detachment at play in care practice, each with its own set of priorities. Instead of relying on pre-established ideas of ‘good’ care as attachment and ‘bad’ care as detachment, Pols’ notion of fitting reminds us that ‘In practice, the two do not exist separately’ (Pols, 2012, p. 42). In both the skills lab and the hospital setting, tinkering with
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different modes of engagement in care work took place continuously, a practice that was not always harmonious or free of contradictions, like when the experienced nurse in the hospital practised a mode of detachment in relation to Edith, while the novice, Helen, displayed a different mode of engagement to the very same patient. This example both underlines the variation within care engagements, as well as it points to the cultural learning process in which collectively shared meaning, knowledge, values, and motivation cannot be immediately perceived by a newcomer but must be learnt over time (Hasse, 2011). In the analysis above, care is described as the work of arranging and tinkering with engagements in skills labs and hospitals, rather than merely being a matter of attachments and closeness. Instead of viewing attachment as the only relevant professional engagement in care work, this approach carefully analyses specific situations in order to allow for professional tensions and contradiction to surface. What we are left with is a more open-ended understanding of care as the ability to continually tinker with engagements and relations. Variations in engagement It is tempting to say that simulation-based training follows a reductionist models that aims to compress care skills into a single practice, which can be repeated over and over again with no risk of great variation, until mastery on the part of the student is accomplished. However, by ethnographically scaling down, unpacking, and situating the meanings of care in local practices – simulated as well as real – it becomes possible to remain open to the differences and ambiguities of care, as it is carried out across spaces and bodies, and instead ask what kinds of engagements care practices craft and encourage. The two analytical notions of attachment and detachment presented in this article allow for a framing of care work as neither natural nor entirely good, but instead as a flexible participant in various professional engagements. Therefore, I argue that care is not simply a question of either attachment or detachment but rather that nursing practice entails modes of engagement that depend upon capacities of normative hybridity, that defy such ‘either/or’ categorization
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altogether. The tensions and contradictions of care should be something to stay with when training and educating nursing students, rather than something to reduce or strip away, both when professional skills and practices are simulated and when they are real.
References Andersen A., Pedersen K. & Svejgaard K. (1999) På Sporet af Praksis: Antologi, 1. udgave, 1. oplag. Roskilde Universitet, København. Benner P. (1982) From novice to expert. The American Journal of Nursing, 82(3), 402–407. Benner P., Tanner C. & Chesla C.A. (2009) Expertise in Nursing Practice: Caring Clinical Judgment and Ethics. Springer Publishing Co, New York. Candea M. (2010) I fell in love with Carlos the meercat: engagement and detachment in human-animal relations. American Ethnologist, 37(2), 241–258. Christensen K. (2003) De stille stemmer. In: Omsorgens Pris: Kjønn, Makt og Marked i Velferdsstaten (ed. W.L. Isaksen). Gyldendal akademisk, Oslo. Dahl H.M. (2000) Fra kitler til Eget Tøj – Diskurser om Professionalisme, Omsorg og Køn. Forlaget Politica, Århus. Edwards S.D. (2009) Three versions of the ethics of care. Nursing Philosophy, 10(4), 231–240. Hasse C. (2003) Mødet – Den antropologiske læreproces. In: Ind i Verden: En Grundbog i Antropologisk Metode (ed. K. Hastrup). Hans Retzels Forlag, Copenhagen. Hasse C. (2011) Kulturanalyse i Organisationer: Begreber, metoder og forbløffende læreprocesser, 1. udgave. Samfundslitteratur, Frederiksberg. Johnson E. (2004) Situating Simulators: The Integration of Simulations in Medical Practice. Archive, Lund. Kohlen H. (2011) Care transformations: attentivenes, professional ethics and thoughts towards differentiation. Nursing Ethics, 18(2), 258–261. Latour B., Jensen P., Venturini T., Grauwin S. & Boullier D. (2012) ‘The whole is always smaller than its parts’ – a digital test of Gabriel Tardes’ monads. The British Journal of Sociology, 63(4), 591–615. Law J. (2004) After Method. Routledge, Oxon. Martinsen K. (1989) Omsorg, Sykepleie og Medisin. Historisk-Filosofiske Essays. Tano Forlag, Oslo. Martinsen K. (1991) Omsorg og makt, ord og kropp i sykepleien. Sykepleien Fagtidsskriftet, 2, 2–11. Menzies I.E.P. (1960) A case-study in the functioning of social systems as a defence against anxiety: a report on a study of the nursing services of a general hospital. Human Relations, 13(2), 95–121. Mol A. (2002) The Body Multiple: Ontology in Medical Practice. Duke University Press, Durham.
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Mol A. (2010) Actor-network theory: sensitive terms and enduring tensions. Kdlner Zeitschrift fiir Soziologie und Sozialpsychologie, 50(1), 253–269. Mol A., Moser I. & Pols J. (2010) Care: putting practice into theory. In: Care in Practice: On Tinkering in Clinics, Homes and Farms (eds A. Mol, I. Moser & J. Pols), pp. 7–27. Transcrips Verlag, Bielefeld. Pols J. (2012) Care at a Distance on the Closeness of Technology. Amsterdam University Press, Amsterdam. Pols J. (2013) Washing the patient: dignity and aestetic values in nursing care. Nursing Philosophy, 12(3), 186–200.
Prentice R. (2012) Bodies in Formation: Remaking Anatomy and Surgery Education. Duke University Press, Durham. Scheel M.E. (2004) Vinde, Tavs Viden & Sandhed – set i en Sygeplejefaglig Kontekst. Philosophia, Århus. Taylor J.S. (2011) The moral aesthetics of simulated suffering in standardized patient performances. Culture, Medicine and Psychiatry, 35(2), 134–162. Tronto J. (1993) Moral Boundaries: A Polotical Argument for an Ethic of Care. Routhledge, New York, NY.
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Original article
Tracing detached and attached care practices in nursing education Ann Katrine B. Soffer MA PhD Fellow, Department of Education, Aarhus University, Copenhagen NV, Denmark
Abstract
The implementation of skills labs in Danish nursing education can, in itself, be viewed as a complexity. The students are expected to eventually carry out their work in a situated hospital practice, but they learn their professional skills in a different space altogether, detached and removed from the hospitals and practising on plastic dummies. Despite the apparent artificiality of the skills lab, this article will show that it is possible to analyse some of the fundamental aspects of care in nursing by ethnographically following this phenomenon of simulation-based training. These particular aspects of care are not explicated in the curriculum or textbooks; however, they surfaced once this crooked approach to studying care in a simulated practice was applied. The article start from the assertion that detached engagements are not recognized within the field of nursing education as an equal component to attachments. Yet empirical cases from the skills lab and hospitals illustrate how students sometimes felt emotionally attached to plastic dummies and how experienced nurses sometimes practised a degree of detachment in relation to human patients. Detached engagements will therefore be presented as part of care practices of nurses – rendering the ability to detach in engagement with patients a professional skill that students also need to learn. In the analysis to follow, attached and detached engagements are located on an equal plane by integrating both into the same conceptual framework, rather than imposing a priori notions about their dialectic relation. The analysis shows that it is the particular intertwinement of attachment and detachment that gives care its fundamental meaning. In conclusion, the need for a conceptual shift from a strong emphasis on attached engagement to a more balanced analytical approach to care work, as involving both attached and detached engagement within Danish nursing education, is advocated. Keywords: care, education programme, identity, knowledge, qualitative research, technology.
Correspondence: Dr Ann Katrine B. Soffer, MA, Department of Education, Aarhus University, Tuborgvej 164, Office J112, 2400 Copenhagen NV, Denmark. Tel.: + 45 3147 9233; fax: + 45 8715 0201; e-mail: [email protected]
© 2014 John Wiley & Sons Ltd Nursing Philosophy (2014), 15, pp. 201–210
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Care in a Nordic context In many of the nursing theories taught in the Danish nursing programmes, care is described as an initially inner process, which leads the nurse to orient herself out towards a normative engagement with the patient. Thus, the ability to attach, connect, and engage with the patient is considered the cornerstone of good, right, and desirable professional virtues within a Danish nursing context. The professional skills of Danish nurses are often understood within the framework of a specific ‘Nordic model’, within which care is perceived as an experienced-based and oftentimes tacit professional practice, and the idea of attachment is here a key notion (Benner, 1982; Andersen et al., 1999; Scheel, 2004)1. This specific Nordic notion of care is most clearly articulated through the influential work of Kari Martinsen, a Norwegian nurse scientist and philosopher, whose work figures extensively in the Danish nursing curriculum and textbooks (Martinsen, 1989, 1991; Dahl, 2000; Christensen, 2003). Martinsen’s central placement in the curriculum testifies to the conceptualization of care as an interpersonal practice of attachment as well as a bondedness between the nurse and the patient (Martinsen, 1991). Building on the work of theologian and philosopher K. E. Løgstrup, Martinsen defines care as a trinity of relationality, practicality, and morality. Her compassionate theoretical framework is one that expresses the foundational principles of care as an inner process, and care work as an always already openness and attachment towards the patient (Martinsen, 1989). She articulates how the human condition is one of social interdependence: ‘Care is to be concrete and present in a relationship by our senses and our bodies. It is always to be in a movement away from ourselves and towards the other’ (Martinsen, 1989, p. 11). However, the Nordic model is challenged by the current implementation of
simulation-based training in nursing education, which increasingly requires students to learn the ability to attach through simulated situations, when clinical bedside teaching is turned into staged scenarios with high-tech plastic dummies in a laboratory environment structured to resemble a hospital. While some simulated scenarios are focused on hands-on training of isolated skills, others are structured to play out longer clinical situations in real time. Reliance on these types of technologies as pedagogical tools for clinical training has increased in recent years partly due to changes to the way in which Danish health care services are structured and delivered. Shorter hospitalizations, increased use of outpatient treatment methods, and a growing focus on patient safety have fuelled the use of simulation-based training. Within nursing education, this type of training is also viewed as a means to overcome faculty and preceptor shortages as well as the growing lack of clinical placement sites. Thus, simulation-based training is effectively reshaping traditional approaches to teaching and learning professional practices related to health care2 as well as challenging the normative foundation of the Nordic model and leaving a conceptual void. Framing care work within nursing as a question of constant attachment and openness towards the patient puts certain limitations on the ways we think about care. Understanding care as a purely compassionate and altruistic attachment in the nurse–patient engagement glosses over the ambiguous intricacies of care and how professional practices that have to do with care are comprised of a variety of different forms of productive professional engagements. An ethnographic inquiry into the training of Danish nursing students, with a specific focus on simulation-based training in skills labs, wherein students receive clinical training on technological plastic dummies, offers a different conceptualization of care. In the analysis 2
1
Danish nursing education traditionally involved shorter theo-
In recent years, the implementation of so-called evidence-based
retical lecture sections and lengthy apprenticeship, where stu-
clinical guidelines has increased, contrasting and challenging
dents would learn the techniques and skills from experienced
some of the core tacit and experience-based values within the
nurses while working closely with patients. Today, the Danish
nursing education. The clinical guidelines are explicitly commu-
national nursing programme is a 3.5-year bachelor degree, con-
nicated and research based through the use of randomized clini-
sisting of 14 modules, with a distribution of 60% theoretical
cal trials rather than experience based.
lectures and 40% clinical placements.
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that follows, care proves to be linked to multiple, different (and sometimes conflicting) types of professional engagement practices, thereby unsettling the common sense assumptions that the care work of nurses is a purely generous, compassionate, and nurturing professional engagement characterized by relational attachments (Candea, 2010). A different framework is needed to capture and describe what nurses do: one that considers care practices in a more normatively flexible way and describes care as it slips into different modes of engagement (cf. Mol, 2002). The empirical case of the skills lab demonstrates how opposing ideas about attachment and detachment do not help us to understand why students sometimes feel emotionally attached to plastic dummies or why experienced nurses in the hospital practise a degree of detachment in relation to human patients. For the purpose of this analysis, the distance and separation entailed in care work is captured with the notion of detachment, which will be considered as equally significant as the already established notion of attachment put forth by Martinsen and other nursing scholars (Menzies, 1960; Martinsen, 1991; Scheel, 2004; Benner et al., 2009). Once professional attachment ideals are held up against the practices of the skills lab, not only existing understandings of care are challenged but also dominant ideas about simulationbased training in nursing education, and a new light is shed on the potential of the skills lab.
Situating the rise of simulation as professional training Some nurse educators at the nursing school where my fieldwork took place considered the move towards teaching nurses in a simulated environment problematic. As a consequence of this new teaching practice, some nurse educators felt compelled to express their ideas about what truly constitutes care. Care often took on an idealized form resembling the Nordic model in these articulations, which did not always correspond with the ways in which I observed care being practised. It is precisely this tension between the ideals and practices of care that informs this analytical inquiry. Making use of different types
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of simulation-based training has a long history in European and North American nursing programmes, and although it has remained a rather marginal approach for many years, the development of these methods, especially in the 20th century, is well documented. The development of highly sophisticated simulation technologies that allows students to practise their skills without risking patient safety has increased dramatically in recent years. While not a new phenomenon in itself, simulation-based training has not yet been used as an empirical starting point for an analysis of care. In fact, in studies of simulation-based training, little attention has been paid to its limitations and possibilities within care work, especially considering its recent growth within nursing. Current research in the field of science and technology studies as well as social science at large has mainly focused on the use of simulation in medical and surgical training and education. The work of Prentice (2012) explores the implementation of new technologies incorporated in the design of simulators in order to develop the surgical skills of medical students. Johnson (2004) has studied the integration of gynaecological simulators into medical education and shows how medical practices and practitioners are constructed within simulationbased training. In Taylor’s (2011) work, the recent rise in the use of standardized patient performances in medical schools in the USA, which incorporates staged clinical encounters with actors who specialize in role playing the part of the patient, is examined. Taylor explores the simulation of suffering as real but not too real, which allows for medical students to imagine themselves in the moral and emotional role of a medical provider. Most previous studies on clinical education and training have focused on the socialization of medical students, showing that becoming a medical provider involves more than the acquisition of technical skills and physiological knowledge, and arguing that education and training also involve a process of socialization wherein norms, values, and behaviour that are acceptable within the profession are instilled. Here, the analytical focus is shifted onto professional practices in the care work of nurses, which I will refer to in the following as engagements.
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The ethnography of hospitals, schools, and laboratories The analysis is based on an ethnographic methodological approach grounded in participant observations and interviews. My fieldwork at a Danish nursing school was carried out over the course of two semesters in 2011. As a novice among novices, I set out to follow a group of first-year undergraduate nursing students in their day-to-day school activities and various clinical placements (Hasse, 2003). I prepared for the courses and took part in the theoretical lectures on anatomy, physiology, microbiology, ergonomics, and nursing care. Although the schools and hospital administration, students, teachers, nurses, and patients were aware of my position as a researcher, over time, I quickly became part of the class. I joined a study group with three other young female nursing students, reading and discussing the syllabus and preparing for exams. I followed two first-year students in their clinical placements, one at a Urology Department in a large urban specialized teaching hospital and the other at a Department for Internal Medicine at a smaller teaching hospital North of Copenhagen. During the clinical placements, I started my day of fieldwork at 7 a.m. when I changed into the nursing uniform and participated in a full day of work alongside the nursing student. Finally, I also conducted participant observations in three different skills labs, one located in the nursing school and two affiliated with different hospitals in the urban Copenhagen area.The simulation training in these skills labs ranged in character from role play – where students or teachers would play the role of the patient, hands-on training – practicing the use of different professional tools such as an electric thermometer and blood pressure monitor, to full-scale simulation making use of electronically enhanced plastic dummies to play out planned clinical scenarios in real time. As an ethnographer, I actively participated in simple simulations when invited by instructors and students, but took on a more observing role once the complexity of the scenarios increased. This ethnographic approach makes it possible to foreground some of the tensions and contradictions of learning and practising care, by approaching care not as a normative and given ideal
found in student textbook and classroom lectures, also called ‘ethics of care’ (Tronto, 1993; Edwards, 2009; Kohlen, 2011), but as a concept that is practised in a situated context. The particular conditions that this approach brings with it is a focus on the details, particularities, and demands of care work, which tend to be missed in curriculum overviews or textbook accounts of nursing, in order to ascertain and elucidate other aspects of a complex care practice. Doing fieldwork within health care and its affiliated spaces, I often found myself in unfamiliar and challenging situations. This fieldwork was a rather intimate one in many ways, just like care work itself. I saw many patients undress and listened to young students sharing their fears about engaging in this particular kind of professional practice. This intimacy is also reflected in the ethnographic data presented in this article. The analytical discussion that follows revolves around the less than glamorous task of giving a bed bath (cf. Pols, 2013). I do so not only because giving a bed bath is a core professional skill within nursing but also because practising and performing this skill unfolded differently once the patient’s body was replaced with plastic. Analysing a bed bath and other clinical nursing skills is part of an attempt to taking care work seriously, as Dutch anthropologist and philosopher Annemarie Mol encourages (Mol et al., 2010). Care work is not merely a practical matter confined to the personal sphere, it is also ‘an intellectually interesting topic’ (Mol et al., 2010, p. 7; cf. Pols, 2013). In the following, I will make use of two different empirical cases, one from the skills lab and one from the hospital. I do so in order to analyse whether care is different in the two different situations (Mol, 2002; Law, 2004).
Care in skills labs: tinkering with engagements The plastic dummies used for simulation training are designed and manufactured to express different aspects of the patient experience, represented in terms of specific and manipulable physiological values, such as detectable bowel sounds, a measurable pulse, respiration, blood pressure, and urination. During a simulation scenario, the plastic dummies
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and their physiological expressions were wrapped in uniquely designed clinical situations. Sometimes, these scenarios were pre-produced by the manufacturers of the simulation technologies and installed into the software of the plastic dummies. Other times, they were built by the faculty members themselves, by making use of good or exemplary clinical cases or episodes stemming from their own professional experiences. Yet other times, these scenarios were made up altogether in order to fit a specific learning objective. During the fieldwork, I witnessed a shared commitment among both faculty and students to uphold authenticity as a shared ideal when it came to scripting and carrying out the scenarios. Authenticity became a key aspect in legitimizing this teaching strategy as a justifiable replacement for real clinical experiences gained within a hospital setting. As I was discussing the daily operations of the skills lab with one of the instructors, she said: The more authentic elements we can put together in a scenario, the easier it is for the students to immerse themselves, and really take on their roles. So I always prioritize bringing together as many authentic components as possible. The hospital donates things that have expired or that they don’t use anymore – that really adds to the feeling of actually being there.
The faculty involved in scripting and developing the simulation scenarios referred to authenticity as a key concept, when they told stories of students crying when the plastic dummies did not make it through a critical scenario. Simulation scenarios such as these were notoriously recognized among the faculty as the most successful execution of a scenario and as an example of the ultimate student immersion. ‘If a student is moved to tears, then you know that they feel like they are really there with the patient’, one of the instructors told me. Meanwhile, detached engagements between students and plastic dummies, mostly student mucking about and making joking and silly comments were considered prime examples of why a skills lab did not work well for training nursing students. Scripting scenarios was not a straightforward process; rather, scripting and building scenarios depended on practical adaptions of authenticity
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and complexity until a suitable arrangement was achieved. Mol uses the notion of associations to describe how different actors relate and adapt to one another (Mol, 2010, p. 259). However, she explains ‘the term “association” cannot begin to cover all forms of relatedness. Further words are needed: collaboration, clash, addition, tension, exclusion, inclusion, and so on. Terms variously adapted to various cases. Terms that help us to attune to different events and situations’ (Mol, 2010, p. 259). The notion ‘tinkering’ is now more often used than the original concept of ‘association’ in order to capture the step-by-step activities performed by the various actors (Mol, 2010). Over the course of my fieldwork, I observed adjusting and tinkering with the different elements of the scenarios, such as taking out irrelevant or contradictory data from a case, or simplifying a patient history, in order to better meet the students’ skill sets and knowledge base. This tinkering was done in an attempt to create a built-in learning trajectory carefully adapted to the nursing students’ level of clinical competence and knowledge, rather than overwhelming them with too much clinical complexity. Paradoxically then, the labour of tinkering and manipulating the construction of the scenario, fitting it to the student learning trajectories, seemed to be a criteria for the success of an authentic scenarios. The act of tinkering is built on the belief that once the complexity of the scenarios is adjusted just right, the students can connect with the scenario and attach to the plastic dummy, achieving an authentic sense of actually being there. Attached engagements, then, worked as a benchmark for achieving authenticity. Although the students’ connection to the scenario and attachment to the plastic dummy were difficult to achieve, the connection between authenticity and attachment was explicitly linked to the accomplishment of a successful simulation and ultimately a valid representation of good care. The constant effort to maintain the plastic dummy as an acceptable representation of a patient generated this explicit focus on attachments in the skills lab, which was consistent with the textbook accounts of care work as an attached engagement. However, as follows, the lack of focus on detachment in nursing education will be problematized because, as I will show, detached engagements are present in care work and they matter.
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In the skills lab, I observed a continued effort to maintain the plastic dummy as a legitimate representation of the patient, because instead of patients lying in the hospital beds, plastic dummies had taken their place. Plastic, in this particular situation, was considered malleable, yet easy to hold still for the purpose of practice, allowing for the students to develop their emerging skills without the vagaries of the tricky fleshy bodies of real patients.
task, and in a joking manner reminded her to ‘be careful not to wash it to the point that it wears away’. Peter smiled and Amanda burst out laughing again. After collecting herself once more, she asked Peter what to do if a male patient had an erection during a bed bath. While asking Peter her question,Amanda never lifted her gaze, but kept her eyes looking down at her hands now washing the inner thigh of the plastic dummy. Peter replied: ‘Well, I guess there are many ways to deal with that situation, but I would suggest covering the patient back up, and telling him that you will be back a little later’. Amanda seemed relieved by the answer she got, and
Caring for plastic Before the use of simulation-based training, the students learned the skill of giving a bed bath through the principle of ‘see one, do one’ during their clinical placements, where they would start out by observing an experienced nurse perform the task, and with time carry out the tasks on their own. With the shift towards using simulation-based training, I will show how the student in the skills lab learns valuable insights about care work, not despite of, but exactly due to the detached engagement between the student and the plastic dummy while learning the skill of giving a bed bath. On one specific occasion, I observed something that could easily be written off as an example of a detached engagement, during an afternoon simulation session on lower body hygiene in the skills lab: Students were divided into groups of three or four and gathered around three different dummies, two with female genitalia and one with male. The students were instructed how to give a bed bath with single gentle strokes from the front to the back, and how to make use of this opportunity to inspect for signs of skin irritation and pressure ulcers on the surface of the patient’s skin. The students were in high spirits, and giggles and outbursts of laughter filled the air on several occasions. A male student instructor, Peter, who was in his last year in the nursing program, was responsible for the training on the dummy with male genitalia. The three nursing students in Peter’s group were blushing red, nervous and occasionally had to leave the bedside to shake off the
proceeded to pull the gown down into place and tuck the duvet in underneath the sides of the plastic dummy, before giving him a light pat on the abdomen (excerpt from field notes).
Amanda provides a compelling empirical demonstration of how her capacity to learn to care can be reconceived on foundations different from those of Martinsen (1989, 1991), where it is the attachment of the nurse to the patient, which is the centre of care.The engagements in the skills lab were characterized by jokes, laughter, and embarrassment, practices that would not be encouraged in actual nurse–patient encounters in a real hospital. But in this particular situation, the detachment found in the skills lab becomes an opportunity to learn rather than an obstruction of authenticity or an example of ‘bad’ care. Amanda’s inquiry was not surprising to me. It was not just an offhand remark or a joke but rather struck at the core of some of the larger concerns, which I heard voiced while spending time with the nursing students, about how to navigate the balance between intimacy and professionalism. Amanda had not found answers to her question by reading the syllabus for class, or attending the lectures on nursing care or physiology. Besides the practicalities of the bed bath, textbooks and lectures addressed issues such as ensuring adequate patient privacy and avoiding routinizing the bathing rituals too much, but erections were not discussed. It weighed on her not knowing exactly how to go about handling intimate situations like these.
embarrassment or giggles before returning to finish their
That is actually one of the things I’m most worried about
task. While one girl, Amanda, was taking her time to wash
going in to my next clinical placement. I know I will defi-
the genitals of the male plastic dummy with rather rough and
nitely have to do bed baths – maybe even alone. I’m not
repetitive stokes, Peter prompted her to move on to the next
really sure I can handle that.
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Amanda did not mention death or dying, severe illness, or making mistakes as her biggest concerns when I approached her after the simulation training that day. Thoughts of handling private and intimate moments such as the one described above in a professional manner was what made her anxious about finding herself in the real clinical setting. In other words, Amanda had not yet learned the value of detached engagements or the skill of carrying it out in practice. The male plastic dummy took on a character, which was just real enough to imagine the clinical situation, and ‘plasticy’ enough for the students to giggle, laugh, and effectively detach themselves from as a representation of anything but lifeless cold plastic. This specific assemblage of plastic and novice students, unfamiliar with the task of giving a bed bath, permitted important questions about intimacy and professionalism to be raised.Although the mode of engagement between the students and the dummies that day was detached in character, as Amanda washed a piece of plastic, she nonetheless achieved a deeper understanding of care as it is practised. What this brief glimpse into the skills lab at a Danish nursing school shows us is that the productive and professional potential that detached engagements possesses is neither described in the textbooks, as a nuanced way of thinking about care, nor it is carried out in the skills lab as a nuanced way of practicing care. This lack of focus on detached engagements makes for a restrictive understanding of care as a ‘persistent tinkering in a world full of complex ambivalence and shifting tensions’ (Mol et al., 2010, p. 14). In order to support this argument in favour of a more balanced approach to attachment and detachment in Danish nursing education, I would like to take the reader into the hospital to demonstrate how detached engagements are crucial skills in nursing and show how they are really practised.
Caring for patients I guess you could call me a ‘people person’, Helen said, and she continued: Because working with other people just really motivates me. I feel like that is where my personal strength lies.
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Upon meeting students at the nursing school, my opening question was their reasons for choosing nursing as their career path. The above statement came from one of my key informants, Helen, a 21-year old woman in her first year of the programme. In many ways, Helen’s response echoed countless versions of the same answer. In short, many students revealed to me that their main motivation for enrolling in the nursing programme was a desire to work closely with people.Training in the skills lab and interacting with plastic dummies seemed therefore contradictory to the motivation that drove many of the students into nursing in the first place. In the early stage of my fieldwork, I took this particular description of the nurse–patient relationship much for granted, but as my time in the field progressed, this characterization seemed too easy and closed down too quickly the very notions about care that should be kept open to analytical inquiry (Latour et al., 2012). My ethnographic approach provided an opportunity to examine how nurses work with patients. While the majority of patients in the hospitals only saw a doctor once a day during morning rounds, the nurses and students provided both physical and emotional assistance throughout the patients’ stay at the hospital. The nurses were responsible for ensuring a daily routine, which I became increasingly familiar with as my fieldwork progressed. They made sure that patients were woken up in the morning, served breakfast, administered medications, given a bath, prepared for rounds while also attending to specific medical needs, making necessary follow-ups or changes, consulting specialists, providing health education, and staying in touch with relatives. The nurses I encountered during my fieldwork often possessed a vast amount of knowledge about their patients, and the nursing students that I followed during their clinical placements were eager to get to work and care for the patients. As the student, Helen, explained to me, there was nothing more uncomfortable than feeling redundant or useless when surrounded by ill patients. But as a novice, with only a semester’s worth of training under her belt, she often felt like she fell short when it came to fulfilling the scope of practice as a professional nurse. As she put it:
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I still have a lot to learn before I can practice as a nurse. And so, a lot of times I just feel like I am in the way of the preceptors and the other nurses, because I can still only do simple basic things for the patient.
Helen did what she could during her clinical placement, which meant providing basic care needs. She would fluff pillows and fetch water, constantly attending to the patients she was assigned. I followed Helen as she took care of Edith, an elderly female patient, who had been admitted a couple of days earlier and had shown no noticeable signs of improvement during her stay. She was lonely with no visitors coming to see her. Edith continued making demands on the staff, asking for help and assistance with things that she was capable of doing herself, like having a sip of water or combing her hair. More experienced nurses declined her requests, telling her that she should first give it a try on her own. Helen, on the other hand, could not brush off her requests as easily. She would instead tend to her needs again and again – brushing her hair, changing channels on the TV, dialing the numbers on her phone, and I would help – fetching water, getting more sugar for her yoghurt. In passing the Nurses’ station, another nurse sent me an overbearing smile, as I was returning from the kitchen with added sugar on Edith’s strawberry flavored yoghurt. She was an experienced mid-career nurse who had spent most of her working life in healthcare. She pointed out that it was a deliberate decision on her part to refuse the patient’s requests. ‘If I make her think that I will come running all the time, I would not have time for any of the other patients, or all the other tasks that I have to perform in a day’. She said as she continued to type away on the computer. ‘[. . .] But more importantly’ she continued: ‘I also do it to prompt her to solve some of her manageable problems herself. If I help her with everything I make her passive, and she will lose her ability to take care of herself much faster that way’. She paused and looked up at me: ‘Helen hasn’t learned this yet. As you can see she is doing everything the patient asks her. But eventually she will understand that sometimes doing nothing is also caring for the patient’ (excerpt from field notes).
The experienced nurse described how being a nurse entails more than working with people, but more importantly she pointed out that detachment and distance in the nurse–patient engagement is not neces-
sarily an indicator of ‘bad’ care. At first glance, it seemed harsh to me that the nurses turned down a lonely elderly woman’s request to brush her hair or have a sip of water. Helen, on the other hand, took Edith’s requests seriously and tried to meet her demands. In doing so, Edith provided Helen with a sense of purpose, something to do, and thereby helped to overcome her feeling of being redundant. But in fact, the experienced nurse’s distant and detached engagement with Edith was an act of care in itself – keeping her from becoming passive and immobile, and prompting her to engage with her environment and seek manageable solutions to her needs and problems. Thus, the process of attuning the practice of care to Edith’s fragility does not necessarily only implicate attachments and closeness but also detachment and distance. Detachment, in this sense, was not necessarily in contradiction to attachment. In this instance, the more experienced nurse was able to draw on her empirically grounded and hard-earned professional experiences of engaging with many patients over time in order to tinker with the care engagement (Mol et al., 2010). Being an experienced nurse also meant being able to care through detached engagements, in order to avoid placing those who receive care in a position of passivity and dependence. In the eyes of the more experienced nurse, Helen’s behaviour was that of a newcomer, who had not fully grasped the complexity of tinkering with care yet. Once professional engagements are explored in practice, it becomes difficult to make clear analytical distinctions between attachment and detachment, allowing us instead to question the very dichotomy between the two and rethink their theoretical relationship. In a similar vein to Mol’s notion of tinkering, we find Pols’ attempt to replace the separated and opposed ideas of warm and cold care with a more practical and contextual idea of care through ‘an aesthetics of fitting’ (Pols, 2012). I too have shown different modes of attachment and detachment at play in care practice, each with its own set of priorities. Instead of relying on pre-established ideas of ‘good’ care as attachment and ‘bad’ care as detachment, Pols’ notion of fitting reminds us that ‘In practice, the two do not exist separately’ (Pols, 2012, p. 42). In both the skills lab and the hospital setting, tinkering with
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Care Practices in Nursing Education
different modes of engagement in care work took place continuously, a practice that was not always harmonious or free of contradictions, like when the experienced nurse in the hospital practised a mode of detachment in relation to Edith, while the novice, Helen, displayed a different mode of engagement to the very same patient. This example both underlines the variation within care engagements, as well as it points to the cultural learning process in which collectively shared meaning, knowledge, values, and motivation cannot be immediately perceived by a newcomer but must be learnt over time (Hasse, 2011). In the analysis above, care is described as the work of arranging and tinkering with engagements in skills labs and hospitals, rather than merely being a matter of attachments and closeness. Instead of viewing attachment as the only relevant professional engagement in care work, this approach carefully analyses specific situations in order to allow for professional tensions and contradiction to surface. What we are left with is a more open-ended understanding of care as the ability to continually tinker with engagements and relations. Variations in engagement It is tempting to say that simulation-based training follows a reductionist models that aims to compress care skills into a single practice, which can be repeated over and over again with no risk of great variation, until mastery on the part of the student is accomplished. However, by ethnographically scaling down, unpacking, and situating the meanings of care in local practices – simulated as well as real – it becomes possible to remain open to the differences and ambiguities of care, as it is carried out across spaces and bodies, and instead ask what kinds of engagements care practices craft and encourage. The two analytical notions of attachment and detachment presented in this article allow for a framing of care work as neither natural nor entirely good, but instead as a flexible participant in various professional engagements. Therefore, I argue that care is not simply a question of either attachment or detachment but rather that nursing practice entails modes of engagement that depend upon capacities of normative hybridity, that defy such ‘either/or’ categorization
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altogether. The tensions and contradictions of care should be something to stay with when training and educating nursing students, rather than something to reduce or strip away, both when professional skills and practices are simulated and when they are real.
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