Seminar 2 Summary

Culture and context matter: understanding the culture of the ward and community environment

>> Seminar 2… in 20 seconds… 

> Engaging with the social sciences can enable students to wrestle with wicked problems that have no straightforward solutions.

> Embracing complexity enables nurses to act as ‘interfaces’ by making complex medical ideas accessible to patients.

> Understanding culture and context is crucial to develop critical honest insight into practice.

> Developing cultural understanding is fundamental to challenging assumptions and enables more empathetic nursing care.

Seminar 2 opened with a welcome by Professor Kate Seers followed by a brief overview of the series and the opening seminar in Inverness by Dr Iain Atherton and Dr Richard Kyle.

‘Wicked Problems’ and ‘Suspended Solutions’

Professor Celia Lury then presented on ‘Problems and Solutions from an interdisciplinary perspective’. This paper provided the platform for the day’s discussion raising a number of key issues that were revisited and wrestled with by participants throughout the seminar.

First, Professor Lury raised the importance of recognising that many problems do not have straightforward and clear-cut answers, but rather require to be held in tension. Such so-called ‘wicked problems’ defy simplistic solutions. Instead they call for an understanding of evidence and an ability to discuss and reason, perhaps without reaching a conclusion. They both need and encourage the development of analytical skills. These are skills that are vital for health professionals to cultivate but doing so may prove challenging as they may unsettle the assumptions that underpin the medical model.

Second, Professor Lury introduced participants to the ideas of Bowker and Star (1999) that provided a way to think through the complexities of an individual’s experience of living with ill-health. This highlighted the way in which a person’s biography and biological disease have several different trajectories that sometimes converge and at other times diverge, with implications for both an individual’s experience of their life, self and relationships, as well as the supportive care that might be provided by healthcare professionals. The complexity was further untangled through discussion of the places, times and power relationships that further shaped a person’s entwined disease and biographical trajectories.

Third, Professor Lury considered ideas of ‘interface’, the idea that nurses represent a means by which patients and families can engage with complex ideas in a manner that makes these difficult concepts understandable. Analogies were drawn with computer programmes where users do not have to understand how to develop a program for themselves, but rather are able to engage with the computer as a result of an operating system that is designed to be accessible. For healthcare professionals, adopting an interface role is not straightforward and requires an ability to take complex medical ideas and concepts and conceptualise and communicate these to patients by translating technical terminology into accessible lay language.

Professor Jane Coad served as the day’s first discussant. She usefully reflected on how the ideas developed by Professor Lury might be applied to interdisciplinary education and pondered why, following her own review of the field, thinking around the importance of interdisciplinary education had seemed to fall out of fashion in nurse education since 2008. Professor Coad closed by posing a critical question: what is the goal of interdisciplinary education?

Ward Culture and Patient Care

Professor Kate Seers then spoke about the importance of culture in the ward environment and understanding its implications for patient care. She suggested that the socio-cultural context could be more influential than organisational policies. Pain control was used as an example to highlight the value of ethnographic work that opens up a critical understanding of what really happens on the ward. For example, many people have heard ‘pain is what the patient says it is’, however an ethnography revealed that “pain is what the patient says it is, but…”. In short, understanding the realities of pain control means that although listening to what the patient is saying is an important first step, there are often other issues that need to be taken into account. While pain management charts continue to be underutilised it is often nurses’ assumptions that continue to guide pain management decisions. Insights from ethnography provided a deeper understanding of how pain management worked and how important the culture and context are for effective care. This knowledge can provide students with opportunities to discuss their own experiences on the ward, or in community nursing settings.

Chameleons and Creativity

Professor Coad again acted as discussant. She highlighted the ways in which ethnography can provide insight into students’ experience, quoting one student who told her “you have to be a chameleon to get a good [placement] report”. She highlighted the need for creativity in nursing education – and in nursing practice more generally. However, she questioned the loss of staff rooms and the implications for both the support networks nurses are able to create within the ward environment and the space to encourage creative thinking.

Culture matters

Professor Gillian Hundt delivered the first of the afternoon’s two papers. Here she related her own experiences of conducting ethnographic research with Bedouin communities. Her paper emphasised the way through which an appreciation of culture aids our understanding of individuals’ actions, particularly in relation to help-seeking behaviour. She recollected a story of a mother of a boy with diarrhoea who felt needed to ask for permission to attend hospital from her husband who was working away at the time. Taking her son to hospital would have implications for her family, not least financial. That the mother delayed seeking help led to accusations of blame from hospital staff who made their own assumptions about why the mother had not sought help for her son immediately. In reference to this story, the crucial point made by Professor Hundt was that developing an understanding of culture by spending time with others can help to challenge such assumptions and prejudices. Professor Hundt then continued by discussing a programme she established where nurses had been given opportunities to spend time with Bedouin communities, going into people’s homes and learning more about their lives. The programme also funded individuals from Bedouin communities to become nurses. In short, cultural understanding developed through close engagement with people’s lives served to challenge prejudices and assumptions easily held by distant others.

Embedded in communities

Professor Gill Furze then acted as discussant. She spoke of the importance of encouraging student nurses to engage with the communities that they will ultimately serve during their training. She highlighted models that had been used in midwifery that enabled engagement with communities but questioned how this might be translated to nurse education given greater numbers of students pursing nurse training. She closed by suggesting that a useful starting point to encourage increased engagement with ideas around culture was to provide opportunities in the curriculum for them to reflect critically upon the culture to which they belong and the assumptions and practices that include and exclude.

Recognising Complexity

Finally, rounding out the day and in some way returning to our starting point, Professor Frances Griffiths talked of the use of the social sciences in ‘Understanding complexity and health using a social science approach’. Her paper discussed the importance of time and context in understanding outcomes of complex interventions. She talked about a longitudinal study of people with a chronic disease in which a typology was identified with regards to the situations of patients, specifically being ‘past reminders’, ‘stuck and struggling’, ‘becalmed’ and submerged’. She contended that identifying the current situation of a patient may open up different options of treatment by GPs.

The seminar drew to a close with participants discussing in small groups the key take-home messages from the day and the challenges and potential routes forward for the integration of the ideas shared during the seminar for nurse education.

Take-home messages
* Students should be given opportunities to wrestle with wicked problems as a means of developing critical thinking, communication and reflective skills among students
* Students should be given space to recognise the cultural values of patients

Challenges
* overloaded curricula
* lecturers’ skillsets
* large classes
* lack of space in our campuses and curricula for students to develop critical thinking ability

Routes forward
* Listening to service users’ experiences living in different cultural contexts directly or through ethnographic accounts of social scientists
* Storytelling as a means to hear and share experience
* Photography to encourage students to reflect on their own lives to better understand the lives of others

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