Breaking the silence: nurses' understandings of change in clinical practice

Aim. This paper reports a study exploring critical care nurses' understandings of change in their practice. Background. In contemporary nursing literature, change in clinical nursing practice is generally understood to be a rational process, synonymous with progress. It is seen as invariably contested, and hence difficult to achieve. It is represented as occurring infrequently. This literature effectively silences clinicians as this discourse of change does not recognize or incorporate their views or practices. Methods. This study was informed by a Foucauldian poststructuralist framework. The participants were 12 critical care nurses who engaged in three individual in-depth, focused interviews. The transcripts were deconstructed to reveal participants' discourses of change and the implications of these discourses for nursing work. The data were generated between 1996 and 1998 as part of a study whose in-depth analysis was completed in 2003. Findings. Change was revealed as a highly complex phenomenon, closely intertwined with understandings of clinical nursing work. Participants showed difficulty in identifying or recalling clinical changes. Several dichotomies shaped their understandings of change, including change/stasis, formal/informal and dramatic/subtle. Their experiences of change frequently conflicted with prevailing dominant understandings, but they did not openly challenge them. Rather, they employed dichotomies, such as abstract/concrete and other/self, to enable them to work with these conflicts. As a result, they engaged in practices such as naming other nurses as 'irrational'. Conclusion. The data provide new understandings of change in clinical nursing practice, some of which challenge many widely held views (for example, that such change is a rare occurrence). It is argued that a lack of open challenge by clinical nurses contributes to their silencing, promotes disharmony amongst nurses and, hence, works against a collaborative approach to decisions about clinical practice.