By Cynthia Sylvia, D NURS, MSc, MA, RN, CWCN
In this first installment of my new WoundSource video blog series, I will be sharing my doctoral research on exploring the identity of the certified wound ostomy continence nurse in industry. The video and full transcript are available below, as well as a link to my poster on the same topic that was presented recently at the WOCNext conference. Please feel free to leave comments or suggestions for future vlog series topics!
Moderator: Hello and thank you for visiting the WoundSource blog. My name is Emmie McCalley, Editorial Associate for WoundSource. Today, Cynthia Sylvia will be sharing her doctoral research on exploring the identity of the certified wound ostomy continence nurse in industry as her introductory WoundSource vlog. Cindy, thank you so much for being here.
Cynthia Sylvia: Thank you, Emmie, for offering me this venue. What do I mean by professional ecology? I define it as the study of interactions among individuals and their environment, in this case, focusing on the professional social environment. How am I framing this study? By descriptively examining discourse among a sample of nurse individuals who share common bonds within a professional niche that happens to be a non-traditional role. I'm going to share the motivation behind my study, what led me to this place and the surprising process that has emerged up to this point in time.
Before I begin, let me share a bit about myself since who I am in relation to this study is significant. I knew exactly where I was headed when I began my journey to my nursing doctorate. My desire to seek an answer to my research question was the rationale for pursuing my degree. As a WOCN and member of the WOCN Society for many years, my career path took me from the bedside to the medical device industry. My experience generated an urgency to explore the identity of nurses who venture beyond the traditional boundaries. The journey started for me over 20 years ago, when I made the transition from direct patient care to a role in industry. At that time, the transition was a novel one. I lived the journey and wish to share. I believe that this work can make a difference by contributing evidence to the gap that currently exists. Evidence for what it is that these individuals do, and the role they perform.
We as nurses have been less than vocal about what we do even in the most traditional areas of practice. Transitioning to a non-traditional role from a role that is shaded in mist to begin with adds layers of complexity. It has always been about the journey and being able to legitimatize a new role. It was my intent to identify the knowledge and skill set that these nurses embody. I wanted to understand their role and define the boundary of this emerging subculture. Finally, I wish to provide a safe platform for these nurses to speak out.
I love this quote by Leon Edel from Writing Lines. Nurses have been less than vocal about telling stories. Some say it is the often taboo nature of what it is that we do with and for our patients on a daily basis. Now I've taken the opportunity to expand discourse on a non-traditional role. Edel speaks of how the public facade is the mask behind which a private mythology is hidden. Through iterative interpretation, and from a position of familiarity, I interpret the story of my peers. My dilemma is that I placed myself in a position as a researcher among colleagues; an insider. It is my responsibility to reconcile these two roles.
Familiarity greatly influenced my work, and I was fortunate to have been taught by two experts, Sara Delamont and Paul Atikinson, during my studies at Cardiff University. Their work, Fighting Familiarity, greatly impacted my research. Familiarity is described as a commitment to making the familiar strange, to bring reflexivity to both descriptive and interpretive process. The problem of familiarity manifested itself in the duality of my role. First, am I recognizing what is actually happening? Have I described what my participants are saying, or am I unintentionally describing what I am experiencing? Second, am I missing something that is staring me in the face, because it is so much part of everydayness to me? I have concluded that I can never truly know the answer for sure. I think of my own perception as a filter that enables me to describe and interpret the story of my participants in a way that would not be possible from an outsider's perspective.
The theoretical framework of my study is Symbolic Interactionism. These are three of the most influential researchers. Symbolic Interactionism is a theory espoused by Herbert Blumer that describes how meaning is associated with a distinctive sociological phenomenon. The three principles guided me in my descriptive analysis of how these nurses perceive themselves. These principles provide a cycle of feedback for evolving interpretation. Goffman examines role performance and has explored the "dirty work of nurses." The context of this study is performing a new role on a stage that is still being constructed. Tuan writes about space and place and differentiates them. The impact of geography upon the role focuses on new contextual experience. His work took on meaning within the context of this study because of the mobility of these nurses.
My method was qualitative interpretive analysis, using two forms of data collection for triangulation. Here, you see the procedures I employed to perform my study. To be chosen as a participant, my colleagues had to be currently employed within industry for at least two years and to have been previously employed as WOCN in direct patient care. I employed both a focus group and a series of semi-structured interviews. The data differed according to source. The focus group allowed for social interaction of participants where responses were generated and triggered from other participants. In the interviews, the responses were solely those of the nurse participants.
The descriptive analysis from the focus group was complex to the extent that I had to unravel multiple threads of conversation. With the descriptive analysis of the interviews, I was able to follow the monologue more easily. A focus group was implemented in 2014, and a series of six interviews were conducted the following year. The focus group provided a micro environment for sharing, while offering me the opportunity to mine a significant amount of data early on. By the end of this journey, I organized findings under four primary themes, but each data collection method yielded broad themes and multiple sub themes. Emergent themes from my focus group were process of career change, how they see themselves, how they feel they are perceived by others, what sets them apart, and network of support.
Home is a place of comfort, yet space is new terrain and these nurses are continually making place of space. When space becomes familiar, it is place. The social self is one's feelings about the imputed attitudes of others toward oneself. Being on the dark side exemplifies the meaning expressed by participants who have interpreted feelings of being a traitor from social interaction with others. As one of my nurses stated, "Coming into this role, I could find a huge negative. I think it went away for a little while, not as bad as it used to be, but a nurse that moves from patient care into an industry role is seen as a traitor by other nurses who are certified in that area. Many times, you can overcome it with your direct customers, but when you come to a conference or you are working with a Membership Committee, then you aren't treated equally...The thing is that we are judged as leaving our ethical side over here, because now we work for a company. And that's so untrue in this group."
Boots-on-the-ground is a link to empirical experience, ties to earlier clinical experience. It depicts credibility they offer in communication to customers, they are the bridge. During the following year, the interviews were open-ended and I was able to prepare for conversation with each nurse in a way that permitted me to probe more deeply. Here are the emergent themes from the six interviews: how they see themselves, role, impact of role on professional identity, and independence and control. Evolved from thematic analysis was an ever-shifting cascade of themes and sub-themes. Interpretive analysis is an iterative process that involves immersion in the data, first within a descriptive realm and then on an interpretive level with cross verification of contextual data. The process is fluid and the secret becomes how to be comfortable with chaos.
Regardless of geography, themes were resounding, such as being a nurse, which is the legacy that grounded all nurses. As one nurse shared, "We're nurses first. I say I'm a nurse; I don't know that's ever going to come out of me." A sense of adventure, of being autonomous, a love of change, lifelong learning, to teach, to be spontaneous, to share experiences beyond their comfort zone, and to make a difference describes their approach to performance. The nurses see themselves as experts recognized for their unique knowledge and skill set. They feel that a part of their leadership role is being a voice of the bedside nurse. Their practice is mobile and they experience a spectrum of social exchange. The individuals with whom they interface are their role set and those members of the role set interact with the occupants of the role, each in separate lines of action and communication. Role set is a function of social mechanisms and affects the expectations of "others." Role sets reflect the complexity of social structure and relationships within society. The nurse participants see themselves as perceived by others along a continuum. The way that nurses see themselves, and the way they perceive how others see them, is framed by the context of their social interaction and their own unique role set.
Much complex work is done along the journey to professionalization. Part of that work is examining practice of what it is that we do. It takes courage to self examine. As Everett Hughes wrote on frontiers of work. "It is like looking hard in the glass to see if one has wrinkles." My claim is that I've begun that task of studying my own cohort and demonstrating evidence about this new zone of practice, this space between two worlds. This journey has been about defining identity through social interaction and demarcating boundaries. Much to my surprise, my study revealed a model of professionalism, the experience of Boundary Work, with a precedence in the literature. I have mapped the terrain to situate the role solidly within the greater scope of nursing, while establishing a zone of practice.
These are the overarching concepts that emerged. Throughout the process, there has been an undercurrent of tension and resilience fighting against marginalization. These nurses function in isolation, yet they are resilient with a passion for what they do. The process of Boundary Work is contentious, depending upon the stability of the human ecology, the perception of those drawing the boundaries and those being separated out. The participants blend the world of being clinical with the world of business. They cross boundaries, blending language to bring people together. "I know people everywhere, so now it's learning how to talk to different people. It's all a different conversation."
What might the future hold? Mentoring, formation of a formal professional network, options for dissemination about this identity and role, to make the unknown, known. Yet to be defined is the capital expended within this new zone. I propose it is the special knowledge and skill set that these nurses bring to the world of business. I set out to investigate identity; what I found was surprising: a subculture engaged in establishing a territory as CWOCNs in industry. Communication about a new zone demands transparency. Nurses in this subculture are risk takers willing to take on challenges and be assertive, because they feel they are making a difference contributing to the nursing profession and quality patient care. Boundary Work is not new, there is an established body of literature and nursing can benefit from that evidence, while adding to it. Having and amplifying our voice as nurses is a professional priority, requiring a strategic approach and a foundation in evidence. We are a multi-faceted profession and we have only just begun the journey that embraces our potential of human ecology and incorporates all of Nursing.
Here I've shared some of the references that I mentioned during my presentation. My study would not have been possible without the social interaction of my participants and the trust they placed in me to tell their stories. I thank them at every opportunity, and I thank you for listening. I hope this study broadens your perspective on the professionalization of nursing. Thank you.
About the Author
Cynthia Sylvia is the Managing Member of Cynthia Sylvia, LLC, a nurse executive consultant service. With a clinical nursing specialty as a Certified Wound Care Nurse; she is a qualitative researcher, published author and international speaker. As a facilitator of two Consensus Development Initiatives on the Prevention of Pressure Injuries, she has generated multiple global publications and presentations. Cynthia has a broad range of clinical experience with roles in acute and home care and clinical science management in the medical device industry that includes years of service on the Corporate Advisory Council of the National Pressure Ulcer Advisory Panel, in addition to being a founding member of the Support Surface Standards Initiative. Her educational background includes a Master of Arts in Health Promotion Counseling and a Master of Science in Wound Healing and Tissue Repair at Cardiff University in Wales where she was awarded her Doctorate in Nursing.
The views and opinions expressed in this blog are solely those of the author, and do not represent the views of WoundSource, Kestrel Health Information, Inc., its affiliates, or subsidiary companies.