Distal nursing

doi:10.1016/S0277-9536(02)00230-7

Social Science & Medicine

Volume 56, Issue 11, June 2003, Pages 2317-2326

https://doi.org/10.1016/S0277-9536(02)00230-7 Get rights and content

Abstract

This paper considers the spatial dynamics of nurse–patient relationships within hospitals, primarily in the USA, under conditions of organizational restructuring, and situates them within social theoretical perspectives on space. As a human practice to which relationship is considered essential, nursing depends upon sustaining an often taken-for-granted proximity to patients. But hospital nursing, I argue in this paper, is increasingly constrained by spatial–structural practices that disrupt relationship and reduce or eliminate such proximity. Three kinds of proximity are threatened: physical, narrative, and moral. Examining these proximities through a place–space lens suggests that nursing is increasingly “distal” to patient care. There are potentially dangerous implications in this loss of proximity.

Section snippets

Theoretical perspectives: space and place

At least two broad strands of discourse are relevant to this discussion: phenomenological perspectives on space and place in philosophy, which suggest that place grounds our subjective, embodied experience and can only be understood through experience (Casey, 1993; Malpas, 1999), and critical geographical and historical perspectives which draw attention to the power relationships instantiated in places and spaces (Foucault (1975), Foucault (1979); Lefebvre, 1992/1974; Malpas (1994), Massey

Nested proximities in nursing

Within nursing, Tanner, Benner, Chesla, & Gordon (1994), Liaschenko (1997) was perhaps the first to suggest that geographical concepts are relevant to understanding the nurse–patient relationship at all levels. Liaschenko argued that although ethical concerns are commonly considered to arise out of the local, intimate aspect of nurse–patient relationship, they often originate at a larger structural scale. Liaschenko suggested that patients, by virtue of their social positions, have different

Structural–spatial changes affecting proximities

During the past decade, an unprecedented cluster of structural changes has occurred within the health care sector in general; the effects of these changes have been especially pronounced within United States hospitals (although similar scenarios are unfolding across Canada and Western Europe as cost-cutting pressures increase) and upon nurses specifically (Norrish & Rundall, 2001; Sochalski, Aiken, & Fagin, 1997). Discussion of the larger, interrelated economic and social factors that have

Distal nursing: Dangers

There are potential dangers in making nursing distal, not the least of which is that as nurses lose their proximities with patients and with one another, and see their work in terms of fulfilling extralocal demands for categorical and procedural efficiency and uniformity, they will likewise lose their sustaining narrative and moral traditions and will take up their work as mere technicians. This may reshape nursing as a “we’re just running the trains” occupation (Lifton, 1986, p. 400). Under

Spatial–structural power dynamics

Distal nurses fit perfectly within a spatial–structural ordering for health care that preserves and reinforces existing economic and power relations. Scholars from Heidegger (Heidegger, 1977) to Foucault (Foucault (1975), Foucault (1979); Rabinow, 1984) and others have called attention to the technologically totalizing and rationalizing character of modernity, which emphasizes an instrumental “ordering for ordering's sake”. Malpas (2000) describes how this technological understanding tends

Conclusion

This paper has argued that spatial–structural ordering procedures at work in US hospitals increasingly reshape nursing as a “distal” practice, disrupting nurses’ physical, narrative, and moral proximity to patients. Loss of proximity threatens nursing's traditional appreciation for the particular in clinical and moral decision making and may create a distanced, “we’re just running the trains” mentality. Nursing's power lies in its honoring of the particular and relational; it is thus important

Acknowledgements

Work on this paper was supported by a residential research fellowship at Irvine, California funded by the University of California's Humanities Research Institute. I would like to express my appreciation to HRI director David Goldberg, assistant director, Debra Massey Sanchez, and the HRI staff who helped make our visit such an intellectually renewing and productive experience. My gratitude also to the members of the HRI group: Carolyn Cartier, Edward Casey, Sharon Kaufman, Jeff Malpas, Sara

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Distal nursing

Abstract

Section snippets

Theoretical perspectives: space and place

Nested proximities in nursing

Structural–spatial changes affecting proximities

Distal nursing: Dangers

Spatial–structural power dynamics

Conclusion

Acknowledgements

Social Science & Medicine

Evaluating the consequences of hospital restructuring

Medical Care

Downsizing the hospital nursing workforce

Health Affairs

Social spacesCognitive, aesthetic, moral

The quest for control and the possibilities of care

Clinical wisdom and interventions in critical careA thinking-in-action approach

From beginner to expertgaining a differentiated clinical world in critical care nursing practice

Advances in Nursing Science

Expertise in nursing practiceCaring, clinical judgment, and ethics

The primacy of caringStress and coping in health and illness

Moral perception and particularity

Ethics

Sorting things outClassification and its consequences

Performance improvement with patient service partners

Journal of Nursing Administration

Getting back into placeToward a renewed understanding of the place-world

The birth of the clinic

Can we research suffering?

Qualitative Health Research

Scientism and economism in the regulation of health care

Journal of Health Politics, Policy and Law

Existential advocacyPhilosophical foundation of nursing

Narrative and exploration

Nursing Inquiry

Relational narrativeThe postmodern turn in nursing ethics

Scholarly Inquiry for Nursing Practice

In a different voice

Narrative, literature, and the clinical exercise of practical reason

Journal of Medicine and Philosophy