Preparatory, instant and integrative overviews

SUMMARY

The article examines the concept of getting an overview, a term used indiscriminately in nursing practice. Getting an overview was one of six themes that were phenomenologically identified in an empirical study of the experiences of nurses during the transfer of young children to or from intensive care. Getting an overview was a complex process. According to the philosopher, Bengt Molander, one is able to get an overview using what he refers to as orientation points in order to carry out competent appropriate actions, which are determined by practice. The idea that practice often, but not always, defines appropriate actions is clearly illustrated in the stories told by the nurses who took part in the study.

In conclusion, a nurse's complete overview of the transfer situation can be compared to a three-stage rocket, which comprizes the preparatory, instant, and integrative overview. Appropriate actions vary according to each of the three overview phases. This is important to recognize in order to understand nursing practice, a practice that finds itself in a position between the patient, the family and other professional groups; in other words, with orientation points taken from several traditions of scientific theory.

The preparatory overview was a mental and practical preparation. The instant overview had medical and technical orientation points: the team around the child should quickly, quietly and calmly carry out appropriate actions in order to ensure a successful transfer. When the acute phase of the child's transfer was over, thoughts turned to the family and another context, and one carried out an integrative overview using social and practical orientation points. Transfer was therefore seen in terms of teamwork where the complete overview was achieved through co-operation. The article ends with a discussion of the relevance of these findings for nursing care, together with outlined proposals for continued research on the concept of overview.

Introduction

This article represents part of a larger study concerning the experiences of nurses in connection with the transfer of young children to or from intensive care. The study identified six themes1, one of which was getting an overview, which has proved to be of particular importance to nurses. Having noticed that many people nodded their heads in agreement during lectures on this subject around Denmark, I have chosen to publish this part of the study in a revised form in 'Sygeplejersken'.

The basic aim of the study was to identify the experiences of parents, grandparents, doctors and nurses in connection with the transfer of young children between an intensive care unit and a paediatric unit. The article seeks to identify and analyse the theme of getting an overview, to present the new knowledge developed phenomenologically and put forward proposals for continued research on the issue of overview.

The background for the whole study was first and foremost the growing tendency in the health service to put the patient in the centre and the tendency towards a user-friendly society in general. Secondly, I have worked for many years in the field of paediatric nursing. From my years as a nurse on a paediatric unit, I knew that transfer was a difficult and complex situation, as well as confined. A third background factor concerns the widespread view in nursing that the child and the family are interdependent and mutually affect each other. When someone in the family becomes ill, the whole family becomes unbalanced. The illness together with the unfamiliar environment of the hospital affects not just the child but the whole family as well (1). It is at this point when the family is in a state of unbalance due to the illness of one of its members that the nurse finds herself faced with the responsibility of having to care not just for the sick child but the family as well. When the child becomes so ill as to require intensive care, the child's life is clearly in danger. The transfer to an intensive care unit therefore places extra demands on the nursing staff. It is often an emergency situation requiring prompt action and an ability to get an overview of the situation (2:53). The nurses that were interviewed talked a great deal about either being able or unable to get an overview of the situation (the transfer). An ability to get an overview was crucial for determining what action would have to be taken in order to ensure the successful outcome of the transfer.

Methodology and method

Phenomenology is philosophy

The study interpreted its findings from a phenomenological perspective. This should seem natural in a study that seeks to identify experiences of a phenomenon2. Modern phenomenology, founded by

Side 53

the German philosopher Edmund Husserl (1859-1938), is the philosophy on which the modern qualitative research tradition is based (3:78). Husserl's writings and thoughts have been of great importance to subsequent phenomenologists within many disciplines, and have provided the impetus for a phenomenological movement (4, 5).

The crucial aspect of phenomenological research is to reflect on what is of importance in lived experiences in a life-world, expressions taken from Husserl and one of his pupils, the French philosopher Maurice Merleau-Ponty (6). Merleau-Ponty's life-world is described as ''the world which is present in our perceptions, and which is therefore inextricably bound to the perceptive subject (4:66).'' It is the world in which we live daily, the world where we first discovered what constituted a wood, a field or a river. Merleau-Ponty is referred to as the body's philosopher, because he regards the human body as a duality: the human both is and has body, which accounts for the term lived (embodied) experiences.

The methodical approach in this empirical study is inspired by Spiegelberg (5). The method, which closely resembles Husserl's philosophy, has been described earlier (8).

The phenomenological method is one of many qualitative research methods that during the last decades have contributed to the development of knowledge in social science and humanistic research, including nursing. The method and the study of method, methodology, are relevant for humanistically-inspired nursing research, because one attempts to interpret human experiences; the meaning of life and the experiences of life. Research findings are illustrative and open the reader's eyes to the patient's experience of health and sickness (9, 10) or reveal the inner workings of nursing practice (11). The method has become known as phenomenological clinical nursing research, precisely because of its close link with practice (12).

The qualitative research interview and phenomenology

The study's empirical data-collection method took the form of the qualitative research interview. This is an investigative form of research designed to gather descriptions from the informant's life-world, and then to interpret the meaning of these exeriences, which are phenomenologically referred to as lived experiences (7:13). It is an interview where the informant speaks freely without structured questions, albeit loosely controlled by the interviewer and an interview guide. The object is to search for a deeper understanding of the meaning of a phenomenon with which one assumes everyone is familiar. Transfer – how is this really experienced? What is the meaning of this phenomenon? What lies hidden behind it? One can have notions of something without having an idea about what something contains (14:7).

The unstructured qualitative research interview is a form of communication that includes elements of both general conversation and therapy (15, 16). The relationship between the interviewer and the informant is therefore of crucial importance for the success of the interview (17). The interpreting researcher and interviewer engages in ''a true dialogue'' with the informant in an analytical and reflexive exercise (18). The researcher's assumptions and presuppositions about the phenomenon in question are challenged, broadened and altered. The method chapter in a qualitative study contains therefore more than just a brief explanation of the method's use. Methodological considerations of all different kinds strengthen the validity of the study.

Setting and primary empirical data

The study was conducted at a Danish university hospital between August 1993 and April 1995. A group of 19 Danish nurses participated in the study as primary sources: 10 worked in intensive care, 5 on the neonatal unit and 4 on the paediatric unit. Although the three units belonged to the same hospital, they were located in different buildings. A transfer was therefore both difficult and time-consuming. It was carried out either by crossing a busy major road in an ambulance or by using a one-kilometre long underground hospital tunnel. The median age of the nurses (N= 18, one unknown) was 32.3 (range 26-47). There were 18 females and 1 male, of whom 11 were married and 9 had children. The median time since the nurses had completed their training was 5.75 years (range 1.5-25) and the median period of attachment to the unit was 2.25 years (range 0.4-10).

The participants, who came from intensive care and the neonatal and paediatric units, differed in their experiences of a transfer. They were given complete freedom to recount their own experience of a transfer situation in which they had taken part – a transfer to or from an intensive care unit. Most of the nurses chose to talk about children they had transferred,

Side 54

while a few talked about children they had received on their unit.

Secondary empirical data

In order to describe the experiences of the family and nursing staff involved in the transfer of young children to or from intensive care, the interview data was originally collected from two professional groups and two family groups: nurses and doctors who had participated in the transfer of young children, and parents and grandparents whose child or grandchild had been admitted to both intensive care and either a paediatric or neonatal unit.

Whilst processing the data collected, I realized it would be necessary to limit the scope of the project. Although I intended to carry out a phenomenological study, my inexperience as a phenomenological researcher led me to underestimate the time it would take to closely examine, organize and theorize the data collected from the interviews.

A partial analysis of the interviews with parents, grandparents and doctors was carried out. These interviews were thereafter incorporated as secondary sources in the thesis, in the sense that they were included in order to shed light on the primary empirical data: the experiences of the nurses. This article includes an interview with an anaesthetist as secondary empirical data, which will be juxtaposed with the statements of nurses on the issue of overview.

Selection of participants

The selection process of participants was based on certain criteria, where the nature of the study determined which nurses could take part (20). These criteria required previous involvement in the transfer of a young child to or from an intensive care unit as well as a willingness and interest to talk about this experience. The quality of the transfer was considered irrelevant and not a criterion for participation. The selection procedure was carried out either by the relevant unit sister or by the author.

The interview

Each nurse was interviewed once. The interview lasted for approximately one hour and was conducted on the unit either during or immediately after work. An interview guide determined the direction of the interviews, which were recorded on tape and later transcribed word-for-word and analyzed.

The participants were asked to talk about a transfer in which they had taken part: ''What happened?,'' ''What did you do?,'' ''What thoughts crossed your mind?'' and ''What were your feelings?'' As interviewer I focused their attention on the following questions: ''What did you do, then?,'' ''What thoughts crossed your mind at that time?'' and ''What were your feelings at that time?'' The conversation kept reverting to what had been said earlier and we reflected once more on the matter. The qualitative interview includes both experience and reflection (21). After the participant had talked about the child they had been involved in transferring, we broached the subject of transfer and nursing in general. The interview ended with my question: ''Is there anything else which comes to mind about the transfer which you would like to tell?'' It was often at this point, that is, towards the end of the interview, that participants offered insights, recognitions and opinions about the transfer they had discussed. Metaphorically, this process or deeper insight that came to the surface can be compared to peeling an onion layer by layer, in an attempt to penetrate the core, the deeper meaning, the lived experience. The phenomenological reflection gave both the interviewer and the informant new insights. As we peeled away the old ideas and reflected we gradually realized what lay at the heart of the matter.

Ethics

The ethical guidelines followed were based on those laid down by the Northern Nurses' Federation (22) in connection with informed voluntary consent, verbal and written information, confidentiality, etc. Permission to carry out the study was obtained before data was collected, and a number of orientation meetings were held at the hospital units implicated. A description of the project was sent to the Regional Committee on Scientific Ethics, and once the interview data had been transcribed the Data Surveillance Authority was informed.

The relationship between interviewer and informant

It is often said that the interviewer is his or her own instrument (15). To be one's own instrument requires considerations on various levels, so that the relationship between interviewer and informant is

Side 55

optimal; in other words, the most productive for the interview (17). First of all there is a demand for self-awareness: an awareness of oneself as a professional and as a human being; an awareness of one's prejudices and presuppositions influenced by professional experiences and human life experiences; and finally an awareness of one's knowledge and influence in terms of professionalism and position in society. Secondly, demands are made in terms of evaluating oneself as an interviewer. The ideal interviewer is a person who listens and is sensitive, who puts questions that can easily be understood, who is open and yet guides the interview so that it moves in the right direction. In addition, the interviewer should consider the relationship in the interview situation itself.

A qualitative research interview can therefore be said to be both a monologue and a dialogue. It is an intense communicative situation, which inevitably contains therapeutic elements. The qualitative interview is similar to the therapy situation, which is a professional form of communication. Both situations are unique in character, incorporating a reasonable, albeit asymmetric, degree of trust where the interviewer purposefully and in a limited space of time persuades the informant to talk about himself (15:59). Participating in a research interview is, in an empirical study (23), described as a therapeutic and positive experience, partly because the interviewer listens intently.

In this study there were also nurses who openly admitted that during the interview they had been able to resolve certain unanswered questions, or had thought of something that had not occurred to them earlier. Although the interview was a research interview, it must be said to have contained therapeutic elements (15) without being considered therapy.

FIGURE 1. THE STUDY'S ANALYSIS LEVELS 

Analysis level	Description
1st Level	Identifying themes based on the participants' own words
2nd Level	Essential themes in each interview
3rd Level	Universal basic themes
4th Level	Development of central expressions

Analysis

The phenomenological analysis was carried out on several levels (see Table 1). The first level focused on identifying themes from the transcripts of the participants' experiences as they were told and close to the participants' own words. On the second level I looked for essential themes in each interview. Which of the themes described did the nurse revert to during the interview? What emerged as being important? If the nurse repeatedly reverted to a theme, it was regarded as important for her.

On the third level I looked for universal basic themes, essential themes that were common for all the interviews and fundamental for not only the phenomenon but also the context in which the phenomenon occurred: nursing care. During the analysis I discovered further connections within and between the universal basic themes. The analysis confirmed that ''the phenomenological methodology resembles more an acquired reflection than a technique'' (13:131), and that the problem with qualitative research is not data collection but data reduction (24).

A fourth level evolved itself from the written phase. Certain expressions stood out as central within each theme. For example, the expressions getting an overview or lacking an overview were frequently used in the empirical data. These were words used indiscriminately without thought to their meaning. It became phenomenologically important to highlight these expressions in the universal basic themes. What did the nurse mean precisely when she said, ''I need to get an overview of the situation?'' What do philosophers think? What do nurse theorists think? What can we learn from empirical data and theory, and how can theory and empirical data be combined?

Validation

The whole research process incorporated considerations aimed at strengthening the scientific reliability and validity of the study. These considerations adopted Kvale's recommendation regarding communicative validation (16, 25): to avoid too much intersubjective validation. The researcher must

Side 56

trust his own conclusions. Kvale rejects the notion of the researcher going back to the informants to ask for ''a second look.'' Validation is a quality of the research-oriented handicraft for which the researcher must accept full responsibility.

Generalizability

Generalizability, meaning to transcend time and place, is a serious problem with qualitative studies (26, 27). One of the difficulties is that the small number of participants, the selection criteria and analysis process are undertaken within a specific meaningful context. ''How is it possible to adhere to the context and thereby the specific, the living and the narrator, and at the same time transcend precisely this context to generalize one's insights (27: 315)?''

The suggestion is an analytical and theoretical generalization formed in the deeper understanding that the analysis offers on the basis of the empirical data (27: 315).

In this study I was able to achieve generalizability on the fourth analysis level. It was not until this stage of the analysis that I was able to surpass time, place and subjective interpretation. It was on this level that expressions clearly evident in the themes were selected and illuminated with the help of philosophy, theories and research findings. An intersubjective interaction occurred between the empirical data, the researcher and the theories – also referred to as the third person approach (28) – and this led to the development of new expressions. In other words, the findings from the internal transfer were conceptualized in such general terms that they could be related to all kinds of transfer.

Presentation and discussion of the findings

What did the nurse mean precisely by being prepared for the transfer and reception, and getting an overview of the situation? The quotations below from three nurses and a doctor offer a representation of the continued analysis.

''First of all I have to get an overview of the situation and the patient who's arriving... what's wrong with the child, how many bags are attached to the drip, where is the IV-access, what drugs are being given... just so I know what kind of child I am dealing with and what is going to happen and what there is... because I also feel it's important that outwardly we appear in control of the situation.''

This nurse (hereafter referred to as L) wanted to know what was wrong with the child, what kind of intravenous fluid and other drugs the child was receiving, and what was going to happen. As long as she knew these things, she felt she had an overview of the situation. She used her senses in order to get an overview. She observed the child and the equipment used, she listened to the report, and she wished to appear outwardly in control of the situation.

Another nurse (hereafter referred to as K) felt vulnerable in the presence of parents if she did not have an overview of the situation with regard to equipment and instrumental nursing care.

''I become anxious if there is something that I don't know, if there is some technology or some aspect of instrumental nursing care that I'm uncertain about. I feel vulnerable, especially if a child's parents are standing behind me looking over my shoulder. In this situation I invest a lot of effort telling myself to stay calm and not to get flustered. Then it's simply a question of approaching one's colleagues and getting some help about how to do this and about certain procedures. But it takes a lot of energy and effort to keep in control of this situation. It's much easier for the parents to ask those specific questions. If one doesn't have an answer ready, then I think it's difficult.''

Both nurses felt that it was important for the level of trust between nurses and patients to have an overview of the situation, as well as have colleagues and procedure manuals on hand in order to have access to information regarding uncertainties about the child's care and the equipment being used.

A third example of getting an overview is illustrated by an anaesthetist (hereafter referred to as A).

''(...) I was called to a child who had been admitted to the paediatric unit, who was extremely poorly, in a state of confusion and almost unconscious (...). We had to get her stabilized and transferred (...). One comes down to a child who is quiet, limp, has bradycardia, is delirious and distant (...). It's clear that the first thing one has to do is concentrate on finding out what physically needs to be done in the emergency situation. After consulting with the paediatrician, who is waiting to receive us, it becomes clear that there is an urgent need for artificial respiration. In other words, the patient has to be intubated (...). This is fairly straightforward. The child is put on an

Side 57

intravenous drip and given a drug to help him sleep, and a tube is also inserted in the trachea. A certain stability is gradually achieved as the air passages are opened (...). One should be a little anxious before attempting to handle the situation; in other words, try to get an overview of the situation and determine what needs to be done if a critical situation arises, for example, in connection with blocked air passages (...) When it's all over and things have turned out all right, one winds down a little and concentrates on the peripheral things. There are a number of practical things that have to be taken care of. Have porters been ordered? Is transportation on the way? Banal things such as having to push the bed up ourselves. We also have a lot of equipment. All those practical things. Then one talks to the paediatrician about this and that, and, of course, makes sure the family has been informed about why certain actions have been taken.''

A first of all got an overview of the situation. Next he decided what needed to be done with the child, and then after consulting with the paediatrician he performed those actions on which they had agreed. For him, getting an overview meant having a basis on which to act. He made no specific mention of the importance of getting an overview for gaining the parents' trust. On the contrary, he referred only to the importance of an overview for determining appropriate treatment of the patient. In this respect, he regarded the parents as a lower priority. Not until after the intubation and stabilization of the child did he think of the parents and of keeping them informed.

Overview as knowing-in-action

For a thorough explanation of what it means to get an overview, it is important to incorporate the interpretation of the Swedish philosopher, Bengt Molander (29). He is one of the few philosophers who has interpreted the concept of overview3. He defines the ability to get an overview as knowing how to act or ''knowing-in-action,'' which leads one in an acceptable direction. He speaks of an overview or knowing one's way about4, as a prerequisite for appropriate actions. Molander's starting point is pragmatic knowledge, in the sense that actions are key concepts and knowing-in-action acceptable in any social community of knowledge. Molander sees human beings as action-taking people, who participate in social activities, where it is important to perform at one's best and to progress in a reasonable way. Human beings act and function together, but not all can be expected to be experts. Theoretical knowledge becomes, in relation to knowing-in-action, a marginal knowledge, albeit still important. However, Molander, like Kirkevold (2), relegates theoretical knowledge to a seat on the sideline in relation to everyday situations in practice. In other words, there is more at stake for both doctors and nurses than theoretical knowledge when, for example, a young child must be intubated and transferred.

Appropriate actions

Molander believes that appropriate actions are an inherent human characteristic, in the sense that they cannot be reduced further. People cannot fail to act because this is part of human nature. In the event of lacking an overview, a person will find appropriate action to take in order to move on. One discusses questions and reasons, lays strategies and asks questions about what is relevant, who is responsible for what, and so on. Appropriate actions are present in practical knowledge in the individual situation.

In getting an overview or ''knowing one's way about,'' questions beginning with ''what'' and ''why'' should represent a fundamental unit and always be present in practical knowledge. This, however, is insufficient. Appropriate actions and Molander's knowing-in-action are embedded in established patterns of action in practice. What and Why are present before us. Therefore we do not have knowledge. Instead, we participate in that knowledge, which is in practice before us. Patterns of action or orientation points are acquired in practice through knowledge and professional traditions. Despite providing stability and continuity, the dynamics cause traditions to be broken, not in defiance or revolt but as a movement, ''a growing past.''

Performing reasonably well

Getting an overview of the situation is not synonymous with having everything under control (29). Orientation points are required. One has to know which questions, studies and discussions are required in order to proceed. In other words, one has to be able to perform reasonably well in the situation, and strive towards development and growth, but not total control. Not everything can be under control.

Side 58

When a critically ill young child was admitted to intensive, L felt that ''performing reasonably well'' meant being able to obtain the essential information about the child, their care and treatment. L defined the essentials in physical, instrumental and disease-related terms. What was wrong with the child? What drugs was the child being given? Where was the IV-access? What was going to happen now? These questions represented her orientation points.

For K, ''performing reasonably well'' meant a desire to be in control of more than the technology and instrumental nursing care. This was particularly evident in the empirical data where both L and K gave consideration to the child's parents. Being able to perform reasonably well for them meant that the parents placed their trust in them and believed their child was in good hands.

As regards A, ''performing reasonably well'' meant physically examining the child before treating it. What were the child's reactions like, what was the child's level of consciousness, and what did the child require? He discussed the child's condition with the paediatrician. Those questions and discussions represented his orientation points.

Another nurse (hereafter referred to as B) represents another example:

''The child was so tired that it was having difficulty breathing. Its colour, especially its colour, was a little too greyish. It wasn't due to a heart condition, it wasn't that, but it had a poor colour in comparison with a newborn baby that has a nice pink colour. It looked so tired, and the way it was breathing, the way it was so limp, I didn't like it. I could see the child needed some Salbuvent inhalation, and as it was to be given as required, I administered it as quickly as I could. When I saw that it didn't help, I called the doctor first-on-call (...) The child was having difficulty coughing, and that's what was causing the accumulation of secretion, which needed to be sucked out. Then suddenly, the child turns and takes a turn for the worse, and has apnoea. I just about have time to shake the child before I have to call for help, as I'm new on the unit. (...) Then one of my colleagues arrives and lends a hand. We have to sit with the child to hold it. Then we get the doctor second-on-call to come and have a look and he says, ''We've got to get the child to ICU right away.''

For B, visual and other sense impressions were the most important. Skin colour, breathing, muscle tone, tiredness, accumulation of secretion, and apnoea were symptoms that indicated that the child was sick. B's observations of the child's condition, her colleague and the doctor second-on-call were her orientation points for being able to get an overview of the situation.

Lacking an overview

Being unable to get an overview of the situation is becoming an increasingly frequent occurrence (29). Society is becoming more and more blurred, which is related to the excessive use of abstraction and too much information. One's knowledge becomes clouded, leading to an inability to find orientation points on which to focus. Molander sees two threats that face the action-taking person who lacks an overview of a situation: rigidity and blind actions. Without an overview, actions are carried out blindly, inflexibly and rigidly; in other words, mechanically and automatically. In a social community of living knowledge and knowing-in-action widespread doubt and uncertainty will appear because one oversteps boundaries, understanding and knowledge.

Knowledge leads somewhere, or otherwise it cannot be regarded as knowledge, but instead rigid or blind actions (30). The blind action is a consequence of mechanical and automatic thinking: I know what I am doing because we always do it this way. This indicates the absence of living knowledge. The rigid knowledge is a consequence of a strong conviction and unfounded belief in one's own abilities, an over-confidence guided by a fixed preconception: I know what I am doing because I know what I want. Both actions in my view are blinkered, in the sense that one looks at a situation from only one perspective. At the same time blinkered actions contribute to a sense of security. Unfortunately, they are rigid and restrictive. Actions in living knowledge are neither over-confident nor mechanical, but appropriate (30). Some would say that actions are carried out with competence (2, 31, 32).

Can one argue that K had no orientation points and therefore lacked an overview of the situation? Her experience was that she did not always know enough about the technical side of receiving a young child onto a unit. However, she was able to approach her colleagues for help, who constituted some of her orientation points. K relied on her colleagues and in this way was able to get an overview. She did not act blindly or automatically, nor was she over-confident. Instead she acted appropriately. Among her colleagues was a common acceptance and desire for

Side 59

staff to ask each other for help and advice. According to Molander's interpretation, K therefore performed reasonably well. However, should we not ask ourselves whether K, from a professional point of view, should be able to perform reasonably well in an emergency situation without having to rely on her colleagues? Should she not possess sufficient knowledge to realize what should be observed and how the equipment functions? Should she not be able to act appropriately without hesitation in an emergency situation?

Practice determines appropriate actions

Practice determines which actions are right and reasonable to pursue (29). In any practice there are rules governing appropriate actions. Rules are not instructions though, but rather provide guidance on what needs to be done. One has learnt this and one knows the difference between what is right and what is wrong.

One can ask oneself in which practice the nurses and the doctor found themselves and what dictated their actions. Which questions and answers were reasonably accepted, and which actions provided answers to questions of ''what'' and ''why'' within their respective practice?

It was absolutely clear that the anaesthetist found himself in a ''pure'' medical hospital practice, where the area of focus was the patient's illness. For A, questions of ''what'' and ''why'' primarily meant finding out what was wrong with the patient. Once this had been done, the patient was then treated in accordance with the disease-oriented medical tradition. A was able to get an overview of the situation apparently easily and acted appropriately in line with this tradition.

On the other hand, there was an element of doubt concerning in which practice the nurses found themselves. On the surface one would imagine that the nurses found themselves in a professional nursing tradition, where the area of focus was care and nursing of the patient. However, their statements clearly illustrate that this professional tradition was less ''pure'' or more complex than A's professional medical practice. The nursing practice incorporated elements from medical as well as nursing and social practice. L responded to questions of ''what'' and ''why'' using a disease-oriented paradigm, whilst K used primarily a familiar or rather a compassionate paradigm. It was clearly easier for A and L to get an overview of the situation and act appropriately than it was for K, who would have liked to have acted reasonably acceptably, also in the eyes of the parents. I see nothing wrong with K's efforts, on the contrary. The problem for K was that she simultaneously had orientation points in all directions for both the technology and the child as well as the parents.

The nurse's unique position in the middle

If we use Molander to help answer the question concerning what the three participants meant by getting an overview and being in control of the situation, we can say that all three wished to get an overview because it would provide a basis from which to act appropriately. They all recognized that the lack of an overview would mean that their knowledge would be clouded. It was imperative for them to get an overview.

Getting an overview is, however, a professional tradition, stabilized in a professional and cultural community. As a doctor one is able to get an overview of the situation by closely observing the patient's condition and responses to examinations performed. Nurses, however, often complain about lacking an overview of the situation. For example, the situation for K was too confusing for her to be able to act appropriately during the transfer. She felt that she lacked sufficient knowledge.

One explanation for this could be that the nurse traditionally participates in several communities of knowledge, each guided by their own paradigm. One obtains different answers to questions of ''what'' and ''why'' depending on which scientific tradition one's actions are based. This would appear to be the case with regard to the transfer of a young child to an intensive care unit.

The nurse's position in different scientific traditions is constantly debated in the nursing literature. Scheel describes nursing as an international practice at the intersection of natural, social and human science (33). Scheel interprets those philosophies that guide the three scientific traditions. As there is access on a universal level, Scheel sees no problems or options in individual situations.

Hamran sees nursing as an invisible working area, woven together by two cultures; a caring culture and a technological culture (34). The nurses' invisible working area has blurred borders and is riddled with

Side 60

guilty conscience. Hamran questions the ability of nurses to successfully carry out their duties when they are being pulled in different directions from two sides. On the other hand, the nurse's position in the middle has also been described as privileged (11). From an ideal perspective, this position means that the nurse can help encourage joint decisions on how best to promote health. Nevertheless, the nurse can easily become caught in the middle, similar to the nurses' in Hamran's study. What is clear though, is that the nursing profession has a unique position in a clinical practice between doctors, patients and hospital administrators. On a paediatric unit, a neonatal unit or a children's intensive care unit, the nurse finds herself even more in the middle, as parents also become involved in the child's health care and the family's care. This creates both possibilities and constraints.

FIGURE 2. THE PREPARATORY, INSTANT AND INTEGRATIVE OVERVIEW DURING TRANSFER
 

Overview	Orientation points	Competent and appropriate actions
Preparatory Mental preparation		Relax or panic will set in Be prepared for distressed parents
	Practical preparation	Be completely familiar with the technology available Is the apparatus in proper working order?
	Practice knowledge	What do I do/know? Why do I do/know it?
Instant	Physical condition	What is wrong with the child? What does the child need?
	Technology, instruments, medicine, etc	Where is the IV-access? What drugs is the child being given?
	Practice knowledge	What do I do/know? Why do I do/know it?
Integrative	Patient	What does the child need?
	Family	What does the family need?
	Context	What can the unit offer?
	Practice knowledge	What do I do/know? Why do I do/know it?

Conclusion

The analysis of the interview data based on the initial analysis phases pointed to the conclusion that getting an overview of the situation during transfer was significant and complex. A great deal was implicit in practice. The expression I need to get an overview was an incomplete sentence and should continue; in order to take competent and appropriate action.

Side 61

According to Molander, having the ability to get an overview requires finding orientation points derived from answers to questions of ''what'' and ''why.'' Not until then can appropriate – as opposed to rigid and blind – actions be taken. Molander argues that practice defines these appropriate actions. The empirical data clearly illustrates that practice during transfer does not always define appropriate actions in a manner satisfying to all nurses. There were those who felt everything went smoothly during the transfer, while there were others who stated that they were unable to get an overview of the situation. The inclusion of secondary empirical data in the form of a quotation from an anaesthetist highlighted similarities and differences between how doctors and nurses got an overview. Being able to get an overview of the situation in order to take appropriate action was more complex in the professional nursing practice than in the professional medical practice. This is quite understandable and logical, as nurses find themselves in a unique position in the middle. While this can lead to feelings of frustration, nurses are at the same time in a privileged position with many options.

In conclusion the phenomenological analysis provided a detailed explanation of what it means to get an overview of the situation during transfer (see Table 2). The nurses talked of being able to get an overview and of being mentally and physically prepared. Preparation and overview are mutually related. Mental and physical preparation in addition to practice knowledge were orientation points in a preparatory overview, which was built up prior to reception of the critically ill child. Is everything ready for the arrival of the child? Am I mentally and physically prepared to receive the child and the parents? What appropriate action should be taken?

The nurse's and the doctor's ability to get an overview of the situation during the reception itself was referred to as the instant overview. It had medical, technical as well as practice-based orientation points. Appropriate actions were therefore different to those taken during the preparatory overview.

In addition to this, there also existed a third overview stage during the transfer, the integrative overview, which was broad and all-embracing. This stage incorporated further questions and answers to ''what'' and ''why,'' as the child's family and context were included. This offered many possibilities for appropriate actions. A continuous aspect throughout the overview process was practice knowledge. In addition, there were also different orientation points and answers to questions of ''what'' and ''why'' in the preparatory, instant and integrative overview.

To sum up, it can be said that the complete overview within this conceptual framework is a three-stage rocket, where each stage is an independent unit with its own orientation points and appropriate actions. At the same time, the previous stage is a prerequisite for appropriate actions at the next stage. The conceptual framework provides an explanation of what the nurses meant by having or lacking an overview. It was evident from the analysis that the nurse who wished to get an overview of the whole transfer process was easily frustrated. The transfer was achieved through teamwork where the complete overview and the successful outcome of the transfer were performed through co-operation, using orientation points and appropriate actions of a varied form.

The relevance of the study for nursing care

The successful transfer was dependent on a team of nurses and doctors working in close co-operation with detailed knowledge and an ability to get an overview of the situation. They were required to act appropriately and responsibly, showing care and consideration for the child, the family and each other. The study demonstrated the need for continued training in relation to the themes identified, including the theme of getting an overview.

Training in the field of appropriate actions during transfer could use the three-stage rocket as a basis. What does it mean to get an overview of the situation during transfer? The interpretation in this study showed that this overview was achieved in stages each using different orientation points.

Orientation points developed in and for practice are, however, not sufficient in order to take appropriate action during transfer. Practice knowledge can sometimes contain ''contaminated water'' as described in another study (35). The author discovered that nurses in practice do not always learn what they should. Therefore the theoretical training should take place in parallel with learning in practice. Continued training would highlight hidden or missing practice-based orientation points for appropriate actions and attitudes (29).

A concrete suggestion for training is put forward by Benner, Tanner and Chesla (31: 109-113), who discovered

Side 62

that nurses at a competent level were particularly interested in reading nursing literature. At no other level was the interest in purchasing textbooks as high. The authors proposed therefore the creation of small study groups consisting of competent nurses who, with guidance from expert nurses, could complement their theoretical studies with stories from practice.

Further documentation on the concept of getting an overview is, however, necessary. In this respect it would be of particular interest to document how the nurse's ability to get an overview of the situation would help contribute to the patient's recovery. What skills or procedures does the nurse use in order to get an overview of the patient's situation, and how can this overview be of benefit to the patient?

Another proposal for continued research on the issue of overview is narratives, a method related to phenomenology and particularly suited to the development of knowledge in nursing (31: 109-113). On account of the narrative's subjective perspective, which reflects attitudes and is realized through actions, this method is of vital importance for training and management, as well as for care and nursing of patients and their family in different contexts. In reality, there is nothing particularly novel about this area as nurses have a long oral tradition. The novel aspect concerns the collection, the documentation and the use of narratives in research. This opens up a great many possibilities for humanistically-inspired nursing science.

Finally, I would like to stress the importance of continuing phenomenological research in general. Nursing as a profession has a duty towards society. This duty is best undertaken by a reciprocal relationship between nurse theorists, nurse researchers and nurse practitioners, where knowledge is created and developed through unity and diversity of thought (36). Phenomenology as a guiding philosophy offers nurses an ideal way to perform their duties for the benefit of society. 

Keywords: Assessment, Clinical nursing research, intensive nursing care, nursing practice, overview, paediatric nursing, phenomenology, transfer.

Footnotes

1. Other themes: being with the child, offering support to the parents, giving the parents hope, handling responsibility, and experiencing security and insecurity.
2. In the early 1990's the Norwegian nurse and philosopher Kari Martinsen gave lectures on the relationship between phenomenology and nursing. These lectures (7) inspired me to continue my studies in both Denmark and the USA, which, among other things, led me to write an original article on phenomenology and nursing (8).
3. Fog (15:122) also deals with getting an overview as a basis for action. For her, getting an overview of the situation and using intuition are necessary for any interviewer who wants to relate to an interview and use it as a basis for developing conceptual structures.
4. Molander has borrowed the concept knowing one's way about from Anscombe, itself derived from Wittgenstein (29:119). Molander later uses the term generalizability as a translation.

Litterature

1. Hardgrove C, Roberts BM. The family with a hospitalized child. Gilliss CL (red.), Highley BL, Roberts BM, Martinsen IM. Toward a science of family nursing. Menlo Park, CA: Addison-Wesley Publishing Company 1989, s. 248-261.
2. Kirkevold M. Vitenskap for praksis? Oslo: Ad Notam, Gyldendal 1996.
3. Boyd CO. Philosophical foundations of qualitative research. Munhall PL (red.), Boyd CO. Nursing research. A qualitative perspective. 2nd ed. New York: National League for Nursing Press 1993, s. 66-94.
4. Bengtsson J. Sammanflätningar. Husserls og Merleau-Pontys fenomenologi. 2. udg. Göteborg: Daidalos 1993.
5. Spiegelberg H. The phenomenological movement: a historical introduction. 3rd revised and enlarged ed. Haag: Martinus Nijhoff Publishers, 1982, s. 69-165, 677-719.
6. Merleau-Ponty M. Tegn. Udvalgte essays. København: Rhodos. (fr. Signes) Kapitel 9. Synligt – usynligt 1969, s. 251-282.
7. Martinsen K. Under kærlig forskning. Fænomenologiens åbning for den levede erfaring i sygeplejen. Tiltrædelsesforelæsning. Tillæg til Tidskr Sygepl 1991; 36, 4-15.
8. Hall EOC. Husserlian phenomenology and nursing in a unitary-transformative paradigm. Vard Nord 1996; 16:3, 4-8.
9. Boyd CO. Phenomenology: The method. Munhall PL (red.), Boyd CO. Nursing research. A qualitative perspective. 2nd ed. New York: National League for Nursing Press 1993, s. 99-132.
10. Cohen MZ, Omery A. Schools of phenomenology: Implications for research. Morse JM (red.) Critical issues in qualitative research methods. London: SAGE Publ 1994, s. 136-156.
11. Bishop AH, Scudder JR. The practical, moral, and personal sense of nursing. A phenomenological philosophy of practice. New York NY: State University of New York Press 1990.
12. Cohen MZ. The experience of surgery. Phenomenological clinical nursing research. Omery A (red.), Kasper CE, Page GG. In search of nursing science. London: SAGE 1995, s. 159-174.
13. Van Manen M. Researching lived experiences. Human science for an action sensitive pedagogy. New York: State University of New York Press 1990.
14. Fog J. Om den følsomme fornuft og den fornuftige følsomhed. Psykoterapi som erkendelsesparadigme. Psyke og Logos 1985; 6, 59-84.
15. Fog J. Med samtalen som udgangspunkt. Det kvalitative forskningsinterview. København: Akademisk Forlag 1994.
16. Kvale S. Den sociale konstruktion af validitet. Lunde IM (red.), Ramhøj P. Humanistisk forskning inden for sundhedsvidenskab. København: Akademisk Forlag 1996, s. 295-314.
17. Hall E. Relationen mellem interviewer og informant i det kvalitative forskningsinterview. Lunde IM (red.), Ramhøj P. Humanistisk forskning i sundhedsvidenskab. København, Akademisk Forlag 1996, s. 182-200.
18. Benner P. The tradition and skill of interpretive phenomenology in studying health, illness, and caring practices. Benner P (red.). Interpretive phenomenology, embodiment, caring, and ethics in health and illness. London: Sage 1994, s. 99-128.
19. Maunsbach M, Dehlholm-Lambertsen B. Gyldighedskriterier. Nord Med 1997; 112: 2, 63-65.
20. Maunsbach M, Lunde IM. Udvælgelse i kvalitativ forskning. Lunde IM (red.), Ramhøj P. Humanistisk forskning inden for sundhedsvidenskab. København: Akademisk Forlag 1996, s. 142-153.
21. Jørgensen PS. Om validitet i kvalitative undersøgelser. Nord Psyk 1989; 41:1, 25-41.
22. Sykepleiernes Samarbeid i Norden (SSN). Etiske retningslinier for sygeplejeforskning i Norden 1987.
23. Hutchinson SA, Wilson ME, Wilson HS. Benefits of participating in research interviews. IMAGE, Journal of Nursing Scholarship 1994; 26:2, 161-164.
24. Wolcott HF. Writing up qualitative research. London: SAGE Publ 1990.
25. Kvale S. To validate is to question. Kvale S (red.). Issues of validity in qualitative research. Lund: Studentlitteratur 1989, s. 73-92.
26. Sandelowski M. Rigor or rigor mortis: The problem of rigor in qualitative research revisited. Adv Nurs Sci 1993; 16:2, 1-8.
27. Jørgensen PS. Generalisering i kvalitativ forskning. Lunde IM (red.), Ramhøj P. Humanistisk forskning inden for sundhedsvidenskab. København: Akademisk Forlag 1996, s. 315-328.
28. Collin F. Nursing science as an interpretive discipline. Problems and challenges. Vard Nord 1992; 12:1, 14-23.
29. Molander B. At handla med goda skäl. Bertilsson M (red.), Molander A. Handling, norm och rationalitet. Göteborg: Ariadne Forlag, Daidalos 1992, s. 73-92.
30. Molander B. Kunskap i handling. Göteborg: Daidalos 1993.
31. Benner P, Tanner CA, Chesla CA. Expertise in nursing practice. Caring, clinical judgement, and ethics. New York: Springer Publ 1996.
32. Wackerhausen S. Teknologi, kompetance og vidensformer. Philosophia 1992; 20:3-4, 81-117.
33. Scheel ME. Interaktionel sygeplejepraksis. vidensgrundlag – etik og sygepleje. København: Munksgaard 1994.
34. Hamran T. Pleiekulturen – en utfordring til den teknologiske tenkemåte. Oslo: Gyldendal Norsk Forlag 1992.
35. Heggen K. Sykehuset som 'klasserom'. Praksisopplæring i profesjonsutdanninger. Oslo: Universitetsforlaget 1995.
36. Dean H. Science and practice. The nature of knowledge. Omery A (red.), Kasper CE, Page GG. In search of nursing science. London: SAGE 1995, s. 275-290.

The study was funded by the Danish Medical Research Council.

Accepted for publication March 27, 1998

Elisabeth O.C. Hall, School of Advanced Nursing Education at University of Aarhus, Vennelystparken 8000, Aarhus C, Denmark.