CHAPTER 1

INTRODUCTION: THE ISSUE AND THE CONTEXT

Late in 1994, a nurse in the USA typed a message into a computer keyboard. It was sent by e-mail (electronic mail) to a computer in Canada, whence it was automatically redistributed within minutes to over 1200 other nurses around the world. An extract from that message reads:

Nursing is the only field in which massive numbers of workers within it do not believe that the substance of the science and the profession should be defined, researched, elaborated, and taught by those who are educated to the highest level in that field. Why is this??? If we are ever to have parity with other disciplines this must become a reality. Speaking as someone who was an unlicensed health care worker, an LPN, an ADN, a BSN, MSN, and now a PhD-prepared nurse and a professor, I honestly believe that those who hold the PhD in Nursing Science shoild have the greatest say about what is nursing science, nursing art good nursing practice, bad nursing practice, NOT nursing practice, etc.

CMC is a new phenomenon for many nurses, particularly in the UK, although it has been in use within clinical and educational nursing settings in other countries, especially the USA, for many years. Currently, only a small proportion of the nurses who could have relatively easy access to the facilities actually use CMC (Anthony 1994a,b), even in 'developed' countries with a history of healthcare computing. In the UK most nurses do not currently have access to computer networks at places of work or education, thus a study investigating CMC use among a random sample of nurses would be unlikely to provide useful information.

Computer networks provide a variety of ways for nurses to communicate and exchange information, including searching for and retrieving data from distant sites (Grobe 1994). Much of this activity is little different from what is possible in a well-equipped library, with modern electronic data storage, although the facility with which information can now be located and obtained has important effects on nursing research, and potentially on practice.

While these aspects of computer networks have undoubted importance, the possibilities of nurses using such networks to "talk" to each other has even more profound implications. Much of nurses' everyday work, whether they are involved in clinical, educational, administrative, or research work, or the new field of nursing informatics, necessitates communicating, by spoken or written means, with colleagues or with patients/clients. While the global total of nurses currently using CMC is relatively small, it is growing rapidly. The question arises of who these nurses are, but more importantly what they say to each other and how, and what impact it has on their everyday experience as nurses. Rather than reiterate the rhetoric of how computer networks might be used, I decided to investigate the realities of nursing CMC. The use of an interpretive approach was largely self-selecting, given my interest in investigating real-life experiences and discourse. As this is a very new area of research, on which little has been so far produced, the case study approach is the obvious choice, and its applicability is discussed in depth in Chapter 5.

This study is not a comparison of nursing discourse conducted via CMC with that conducted by face-to-face (FTF) means, but investigates communication among a particular group of nurses, via a particular medium, within a particular spatio-temporal context. As with all interpretive case studies, the generalisability of findings is for the reader to decide, although I, as the researcher, will provide some thoughts on the issue. The main method of data analysis is discourse analysis (DA), performed on a small corpus of messages, using Fairclough's (1992) method, as it incorporates consideration of the context of the discourse. Additional data have been gathered, from list messages and a number of interviews, conducted via e-mail with individuals participating in the discourse.

There is no standard format for either undertaking a case study or writing the report (Merriam 1988, Robson 1993, Moody 1990, Yin 1989), however, this report essentially follows Merriam's (1988) guidelines. Starting with this introductory discussion of the issues resulting in the study, subsequent chapters describe its frame of reference (Chapter 2), provide a critical review of selected literature addressing pertinent issues (Chapter 4), and discuss the methods used (Chapter 5), including consideration of issues of rigour and generalisability. A brief introduction to the Internet and some of the facilities available is also included (Chapter 3). Chapter 6 combines description of the study's results with concurrent analytic discussion of those results, linking this where appropriate to features arising from the literature review. This approach is consistent with the overall integrative framework of the study, as discussed more fully in Chapter 5.
 

The utility of CMC and DA in nursing

The use of computer-based technologies, for information management and for communication, will increasingly be part of the normal work experience of many nurses. Nursing has been described as an information-intensive profession (Ball et al 1988), with nurses needing access to accurate, pertinent and timely information in order to provide the highest quality of care (Hays et al 1994). Advances in nursing and health care depend as much on the quality of communication as on the quality of information. Two UK developments that will have particular impact on nurses' use of information technology (IT) and of CMC are:

a] the National Health Service Management Executive's (NHSME) Information Strategy, especially aspects aimed at national networking, and

b] the integration of nurse education into higher education, with associated increased access to the Joint Academic Network of computers (JANET) and the wider Internet. One of the key milestones for the NHS IM&T strategy is for all major NHS organisations to communicate electronically by 1996 (Dept. of Health 1992, COI 1994).

American examples illustrate ways in which nurses might use computer networks to assist patients. Ripich et al (1992), for example, see CMC as one solution to the provision of community-based care. Some American nurses already use CMC to disseminate ideas, exchange information, enlist help etc., illustrating the interaction that is "essential to the continued growth of our knowledge base. It is also the very core of the uniting power within nursing - uniting clinician, educator, researcher and administrator" (Cull-Wilby & Pepin 1987:520).

Discourse analysis (DA) is relatively new to nursing research. Its adaptation from its roots in a variety of other disciplines is congruent with the view that research tools and theoretical and conceptual perspectives from a variety of disciplines should be considered, and their applicability to or adaptability by nursing evaluated (Moody 1990). In a recent study investigating nurses' experience of medication errors, and using Potter & Wetherell's (1987) method, Arndt (1994:520) presents "the voices of nurses who have lived through this experience...to understand the meaning such an experience had for them". Johnson (1993) analysed conversations between American nurse-practitioners and patients, attempting to understand differences between outcomes of nurse-patient and doctor-patient interactions, and whether this reflected differences in health care ideologies (Brykczynski 1993, Johnson 1993). Brown (1994) used DA to understand the individualisation of care by expert nurses, while Lawler (1991) used a form of DA to investigate the problem of the body in nursing. DA and the method chosen will be discussed in more detail in Chapter 5.

This study integrates aspects of the modules undertaken in the first year of this course. Nursing theory is addressed by considering the applicability of a postmodern and post-structuralist philosophical approach to nursing development, while use of the case study method illustrates its value as a tool within nursing research. Discourse analysis, of aspects of nursing discourse undertaken through a particular communication medium, is the primary analytic method used, while, finally, the list considered is undeniably international in nature, although at present, it is generally restricted to 'developed' countries.

Having briefly outlined the applicability of CMC and DA to nursing, the next chapter considers the study's frame of reference.

Chapter 2

Contents

Copyright: Peter J. Murray 1996, 1997, 2000

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