5. Metodología
5.4 Unidad de análisis
Stories, accounts, myths and legends are often passed down the generations in professions and occupations and there is evidence of this in nursing and other healthcare professions (Barney, 2005; Clarke, 2008). They often contribute to the identity and image of a group or profession. This was evident in the
participants' narratives, and comparisons amongst perspectives revealed feelings of warnings that should be heeded if they were to avoid risks to their professional
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lives. This was evident across all the narratives, however, the participants with armed forces background and experience were the least concerned together with the midwives. The nurses frequently expressed anxiety with a powerful sense of alarm and fear.
'Something I’ve Heard' is a phrase that encapsulates the stories, accounts and
potential warning messages that participants spoke about. The sub-themes of media influences and stories reported by the media including social media provided a powerful narrative dominated by a sense of anxiety and helplessness about helping at scenarios where first aid may be needed during off-duty time. The sub-theme of 'some nurses' continued this narrative of anxiety with a focus on those who were perceived as unprepared, lacking competence or unwilling to offer help for a variety of reasons that centred around issues of poor cohesion and vulnerability. 'Something I’ve Heard' was most commonly viewed as a warning that served to remind healthcare professionals about the importance of 'being covered' and of the need for practising safely71. 'Something I’ve Heard'
also appeared to highlight a sense of urban or contemporary myth and legend as many of the accounts and inferences were unable to be substantiated by
participants or indeed, when followed up by the researcher, there was little or no evidence of their existence or having taken place. John (RN): “There’s a lot of
rumour, there’s a lot of conjecture – unfounded beliefs that if you do something wrong, you’ll be criticised or castigated. There is confusion, a lot of ill-informed views about it”.
Linda (RN) only noted stories read in the popular press. Viv (RN) also talked about risks to her personal safety and stories about healthcare in general relating them to concerns about the off-duty situation and disparaging accounts involving nurses that she had heard about anecdotally associating these with expectations that she considered to be, at times, unreasonable: "there's a lot of stories like
neglect, infections, lack of competence - we are judged by some very, very high
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standards which I don't know if they are always possible to attain, – that has come across in the media”.
It appeared that the notion of 'Something I’ve Heard' impacted as warnings about safety, being scrutinised and potential for adverse litigation and that there was a heightened awareness of this in the off-duty situation.
Charlotte (RN military): “You do hear of people being taken to the NMC for doing
the wrong thing. All the reports coming out of the media of nurses not doing the
right thing”72. Like Charlotte, Claire also voiced anxiety about errors of
competence and judgement and poor outcomes.
Claire (RN) “I think about stories from my past where I’ve been told about
people who’ve helped, and they’ve done the wrong thing. When I was much younger someone came off a motorbike, the person helping took the helmet off and caused damage to the neck and the person was left
paralysed from the neck down, so that kind of put me off – always stayed with me, that memory. It was so horrific - There’s a joke that a man has a heart attack at a conference and it’s full of consultants and doctors and he’s collapsed on the floor and a lady comes rushing up and she says, 'Let me through, I’m a social worker' and the consultants sort of stand back, maybe that’s a bit extreme”.
Urban myths and legends often lend themselves to the dark humour that is associated with healthcare (Brunvard, 2016). Claire's powerful anxiety was evident, however, even decades after the event that she described. The nature of 'Something I've Heard' varied from alarming to amusing and there was a sense of the myth and legend being a part of the wider story of nursing and midwifery history (Borsay and Hunter, 2012). Jennifer (RN military) and Zayna (RMN) recognised that 'stories heard' existed, but that these were not something of major significance to them. These counter cases with a narrative that paid little
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heed to urban myth and legend but instead focused on their individual social construction of their professional lives and presented a different perspective that was grounded in their own realities, although Zayna had previously drawn
attention to the power of the media and how 'certain nurses' would be unlikely to volunteer help when off-duty. For Zayna this did not translate as being
influenced by the myths and legends that she had heard.
Chloe (RN): “In my training I heard someone say about a nurse helping
someone and suing them – I just can’t remember what they did – the person wasn’t happy and sued the nurse. I can’t remember the story”.
Chloe went on to recount the story about a motorway incident involving a chemical spillage where a nurse attempted to help at a traffic collision: “She lost both of her legs as she didn’t even get to the car, to the guy, because
the fluid had just gone up. It was some kind of hazardous liquid or whatever - the liquid had dissolved her legs. Someone on our training said about that. It was a warning to be careful”. It is interesting that whilst no evidence of this happening
could be located, a feature film called 'Volcano' (1997) depicted a dramatic scene shows a fire-fighter responder dissolving in lava whilst attempting to go to the aid of another.
Helen (RN): “Yes, I mean there’s always the horror stories about the nurse
that ends up facing court because probably these are the legal issues – They’d gone to the court because the patient had died or whatever when they’ve been out on the street – there’s been the expectation that the person would be ok or whatever - It’s always hearsay – those stories don’t help – maybe that’s why I don’t say that I’m a nurse”.
Katy (RN): “People do sue, don’t they? – That’s what everyone says isn’t
it? I mean I don’t know. You must have heard it, people on the street, friends or whatever say, I wouldn’t get involved. I’ve got to protect my PIN, I hear that probably at least 3 or 4 times a day, just from the nurses and I get told that as well”.
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Maudsley (quoted in Merrifield, 2015), a former nurse and midwife, and currently a barrister warned staff that 'You may be liable in negligence so be very careful' when considering possible Good Samaritan acts when off-duty. This advice was at the annual RCN Congress conference whilst talking about the revised NMC code of conduct (NMC, 2015). This provoked a variety of vigorous responses on the NT on-line website that raised a number of perspectives relating to fear of litigation, moral agency and anecdotal accounts of 'off-duty' scenarios. At the same conference 'good news' stories were reported where 'Nurses save man's life' while at RCN Congress' (Stephenson, 2015; Ford, 2016).
Clearly accounts, stories and reports of events about nurses and midwives offering help when off-duty are powerful and persuasive especially when they emanate from respected sources. Stories, however, where the origins and truth are questionable are also very powerful leading to a sense of myth and legend that can become deep seated in the minds of nurses and midwives.
Immersion in and with the data showed the individual ways in which participants incorporated 'Something I've Heard' into their working lives both on and 'off-duty' reflecting the narrative about the multiple lens with which reality is viewed and perceived (Chang et al., 2007). The sub-themes of media influences and 'some
nurses' appear to feed the sense of urban myth and legend that was articulated
as 'Something I've Heard'. Reflection in action is apparent to some extent across this in vivo theme as participants navigated this often chaotic and unexpected terrain with the additional complexities of the stories and accounts that exist with or without trustworthy foundation.
The in vivo theme 'Something I've Heard' pertaining to the off-duty scenario when a nurse or midwife is away from their usual place of practice appears to heighten the awareness of risk of adverse litigation, the sense of negatively charged scrutiny and issues around professional identity and cohesion. 'Something I've
Heard' with its sub-themes of media influences and 'some nurses' uncovered a
powerful narrative that for the nurses in this study was a significant consideration in relation to not only the research area but their practice in general. Those
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nurses with armed forces experience exhibited a more confident and pragmatic approach. The critical narrative throughout this in vivo theme focuses on myth and contemporary legend as warnings that induced fear and anxiety in what appears to be a climate of poor professional cohesion. Despite this, participants largely believed that doing what they considered to be the morally right action would prevail.73
148 Table 9 - Key Findings Theme 1
The invivo theme 'Something I've Heard' involves ideas and accounts of stories as warnings that exist in nursing and midwifery.
Sub themes: media influences and 'some nurses' include issues and concerns surrounding public expectation, visibility, accuracy of reporting and professional behaviour. Most of these accounts are largely unsubstantiated or evidenced.
These accounts may be part of the urban myth and legend often seen in professions.
They often serve to act as warnings and increase fear and anxiety around professional activity.
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5 In Vivo Theme 2 'Am I Covered?' 5.1 Introduction to the chapter
Chapter 5 begins with the exploration and critique of the sub-themes followed by a discussion and analysis of the key in vivo theme 'Am I Covered?', concluding with a summary of the key findings. This chapter explores the data that emerged to form the in vivo theme identified by participants as 'Am I Covered?' based on a narrative, thematic, and comparative analysis that was characterised as levels of anxiety about personal and professional protection. The narratives provide the basis for the development of the theme 'Am I Covered?' and ultimately contribute to the construction of the core theme 'The Right Thing to Do' and the substantive theory. Exploration of data makes links with the literature surrounding the
research area. Due to the lack of direct primary research, a variety of relevant extant data is considered in order to contextualise this key theme. Examples and quotes from the data lead, underpin and inform the discussion providing an audit trail that demonstrates the process of constant comparative analysis with the interpretation of the participants' voices being paramount (Charmaz, 2010). The multi-dimensional nature of grounded theory continued to develop and consisted of a number of sub-themes that connected to construct and explain the broader concept of protection and 'being covered' (Birks and Mills, 2015). The sub- themes arising from the narratives illuminate and explore the contextual issues as components of the emerging grounded theory (Figure 13). These are public expectation; unpredictable and unfamiliar environment; and safety. Public expectation is defined and characterised as the participants’ beliefs about what the wider population expect of nurses and midwives within the context of a changing society. Unpredictable and unfamiliar environment is defined more broadly by participants and relates to the unplanned and unexpected nature of events where medical first aid may be needed. Safety is defined in two key ways by participants. Personal safety relates to physical risks and professional safety was a concern in relation to safety in law and risk of adverse litigation. The sub- themes arose from the narratives as they progressively began to reveal beliefs,
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perceptions and experiences emerging from the broad context of the changing climate of healthcare that was heavily influenced by views about a rights aware and increasingly litigious society both in the UK and globally. The sub-themes of public expectation, unfamiliar and unpredictable environment, and safety
appeared as a who, where and how of participants' thinking in relation to the central issue of protection voiced as 'Am I Covered?'
The sub-themes of public expectation, unfamiliar and unpredictable environment, and safety, highlight anxiety about scrutiny and personal and professional
protection building a picture of concern regarding protection in law with a
powerful sense of vulnerability. The properties and dimensions were displayed with varying levels of anxiety including questioning, hesitancy, non-confident body language and seeking clarification and knowledge about the area. It was notable that participants with midwifery qualifications or armed forces
backgrounds were less anxious and whilst they did talk about 'being covered' they did so with confidence and knowledge about their position in law, both professionally and personally. Midwives may be clearer about position in law as this area is given a higher priority in midwifery curricula given that along with paediatrics it is one of the two specialities to have the highest levels of adverse litigation (NHS Litigation Authority, 2016). The nurses who had armed forces backgrounds displayed a clearer sense of their professional identity74 and some
understanding of their position in law. The theme 'Am I Covered?' also identified issues around the concept, understanding, and application of 'duty of care'. There was overlap and some inter-connection with the other themes of
'Something I've Heard' and 'Just Who I Am'. Participants persistently
underpinned many of their perspectives with their views of right or moral action articulated as 'The Right Thing to Do'.
Concern about the general risk of and potential for adverse litigation is something that has been aired in the literature from a number of healthcare professions in
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addition to nursing and midwifery (Annandale, 1996; Hickson and Entman, 2008; Ball et al., 2008; Williams, 2008). There are a variety of largely anecdotal
discussions in disciplines such as teaching, medicine and policing that indicate a need for more clarity. Improved access to justice and the perception of a more rights aware society may contribute to these concerns and debates (Sokol, 2006; Crouchman, 2009; Lau, 2012). Participants in the initial interviews identified issues concerning position in law and this persisted throughout all the interviews. Good Samaritan principles, however, continued to underpin and temper
participants' narratives. Turning first to the sub-theme of public expectation, the process of focused coding and constant comparison continued to draw out the analytic story and developing construction (Charmaz, 2014).