Earlier today I spoke in a debate about where researchers in nursing should publish their research. The other speakers were rather more focused on the motion that I was. Here’s the text of my talk:

For debate RCN Conference Cardiff, March 2009
I want to talk about ‘impact’ and about ‘nursing’. I want to suggest to you that we may have strongly felt and cherished beliefs about both but that the ‘truth’ about both is more complex than we would like to believe – and perhaps actually rather unpalatable. I’d like to suggest that we are living in a kind of ideological fog when we talk and think about them.
First I’d like to suggest that research may be less important than we think in an activity as complex as healthcare. In healthcare delivery what is far more influential on patient experience, on outcomes and on job satisfaction is the amount of work to be got through, how good the managers are, what our colleagues are like – and alongside every exemplary intelligent and highly motivated nurse there are a few who seem to use work as a kind of therapy sandpit to act out their problems with insecurity and resentment. Also having a huge influence on what happens in healthcare are the contingencies of daily unpredictability (people ringing in sick, agency staff who are lost, students who have fights with each other, medical consultants to be intimidated by, managers to be bullied by) not to even mention the constant distorting effects of a series of bizarre government targets that were invented not to make the health service better for anyone but to solve some short term media embarrassment for ministers. In this context, and yes, this is a negative picture but it it is the context, I think it is fair to say that compared with addressing some of these problems, the potential impact of research is small. We don’t need a stream of new knowledge constantly fed to nurses who are struggling with other factors at the bedside or in the community. Whatever we might like to think, its just not the priority.
Second, no-one can do much about research findings because procedures, assuming they are followed, are decided by organisational committees and handed out in the form of protocols and standard operating procedures. The nurse who wants to introduce anything new needs the skills not so much of understanding arcane research methodology but of political and bureaucratic nous and muscular survival. As one nurse said in a focus group run by a colleague of mine recently ‘If you don’t act by the protocol the repercussions come back on yourself and you stand alone’. The space of healthcare delivery is a space where subjectivity is almost entirely erased in a realm of procedures, where nurses and others crave to act and be seen to act in a way in which they are ‘covered’. Nurses are awkwardly suspended between science and witchcraft. Like the chorus of women in poet T. S. Eliot’s Murder in the Cathedral, their overriding concern is ‘in avoiding notice’, they are ‘Living and partly living’ or like those in the Laodicean church in the book of Revelation who are not passionate but lukewarm and are ‘spewed out’ of God’s mouth. Nurses have been wanting to be ‘covered’ for thirty years at least and the rise of evidence based practice merely provides a new backdrop and a different vocabulary for this fearful and masochistic desire for invisibility and annihilation. So, research, innovation, impact and nursing do not fit easily together without looking through half closed eyes.
I want to return to the particular expectations placed on research within healthcare and then within nursing because it can inform our debate and gives some explanation for why we are all here this morning. Since the 1940s when the medical profession was corralled into the National Health Service in this country, governments have become increasingly bothered by that profession’s ability to eat up whatever resources were thrown into the system. At the same time, roughly – perhaps rather later, a sociology of the professions has recast these apparently altruistic and knowledgeable groups like medicine but also others as self-serving elites who masquerade as motivated by the needs of their clients but whose chief concern is in building up their sphere of influence possibly even at the expense of these clients. Their call for resources – in the case of medicine from the national purse – has been made convincing by the profession’s secret body of knowledge and by the privacy and emotive power of their relationship with individual patients. In the UK, governments have tried a number of approaches to curb this expensive professional power: general management, market forces, for example, but current arrangements look to be the most successful: a nice mixture of inspection agencies, new levels of recording activity and outcome, guidelines for practice, readily available ‘evidence’ and incentives – or rather penalties. So research in the healthcare arena (apart from being a potential money-spinner in the form of turning the NHS into a research field for pharmaceutical companies) is a battleground where various professional groups can demonstrate their effectiveness and be seen to be concerned with issues like treatment and outcome variation.
One strong impulse for nursing to take up the drive for research and evidence based practice is connected to the profession’s ever-present desire for credibility and a little status in a healthcare world dominated by other powerful professions. As soon as talk of evidence based activity was out of the bag it became a currency that was not likely to go away. Back in the late 80s and early 90s in response to a rising managerialism and cost-containment, nurses and others were busy in efforts aimed at demonstrating their ‘value for money’. Then, later in the 1990s, they needed to show that they were acting from a reliable scientific basis. Some looked to ‘evidence’ quite explicitly as another vehicle for demonstrating the so-called ‘value of nursing’, the value of having qualified nurses on the staff. Yet strangely, in recent focus groups that I have run with nurses , the influence of research came very low down on the list of forces affecting practice and decision-making. Organisational protocols featured far more prominently. The strange thing was that the focus group members did not see this kind of circumscribed working as compromising their professional autonomy and image. Quite the opposite. Telling me that the protocols in force in their NHS trusts had been developed from specifically nursing research (rather than medical research) they saw the existence of these instructions as a sign that nursing had finally come of age and as proof of its professional status. These groups also told me repeatedly that when research did influence practice it was through formal decision-making bodies and channels that they were not privy to. Generally, instructions seemed to come down to use this kind of dressing rather than that. So, among a risk-averse and arguably not hugely powerful group, this is perhaps a procedure that suits everyone and has a built-in opportunity to complain a little about being disempowered while actually finding the lack of personal autonomy deeply reassuring because you are ‘covered’.
Finally I want you to entertain the thought that we might share a fond overestimation of the importance of research altogether. Could it possibly be that the whole research enterprise and our belief in its usefulness and its ‘impact’ is part of a pervasive but desperate fantasy? And the fantasy at its most basic is something like this: that we live and breathe and work in a rational world that we can largely take control of through rational examination, planning and action.
In nursing and healthcare this belief has a particular flavour – which I have talked a little about.
The main value of this story is in boosting our morale, as enlightened Westerners, by letting us feel for a moment or two that we are masters and mistresses of our collective destiny. The rational abilities of the human mind have had to take on the roles and responsibilities previously allocated to gods, or God. But what if human events in any realm are largely determined by forces that we are barely aware of whether they be unconscious, as Freud would argue, or ideological, as Marx or Althusser might say? These, just to take two, might be influencing what goes on in healthcare organisations and policy making – and nobody acknowledges it because its in most people’s interests to maintain this pretence that everything important is out in the open.
So, publishing in high impact places? well, not all research in nursing has anything directly to do with practice (and this is worth remembering) and those researchers that are involved in such work, if they have a choice of one or the other, would perhaps be better off spending their time trying to influence decision-making agencies and bodies rather than individual nurses. Of course there will always be some individuals in units that are the exception, but I would argue that the in an increasingly standardised health service, the role of any individual journal-reading nurse in innovating practice is in fact quite small.