In my previous post, I highlighted an attribute essential to effective leadership in nursing: sensitivity to complexity. I noted that sensitivity to complexity involves an awareness of relationships, including one’s place among those relationships. I further mentioned that it requires the ability to understand alternate perspectives and interpretations of information. In this post, I would like to begin to examine the notion of interpretation and explore important applications to nursing practice.
During my years in research, I had numerous opportunities to engineer databases of various kinds. Some have been hard copy collections of documents stored in file cabinets or three-ring binders. Others have been electronic in nature, consisting of archived electronic storage media or repositories of electronic data stored within well-organized directory structures. Some of the databases I have engineered have involved electronic applications such as Microsoft Access, with data entry forms and reporting functions.
Having developed these databases at various times in my research career, it is obvious that one of the most daunting barriers to the successful development and use of any database is the problem of differentiation between the data depositor and the data retriever. Most databases seem to be developed with the retriever in mind. They are developed to fulfill a need for information, but data entry functions are often excessively complicated and unwieldy. On the other hand, some databases are engineered with the depositor in mind. It is easy to obtain information and enter it into the database, but extracting that information may be nearly impossible to accomplish efficiently.
This dilemma, which affects virtually all databases, is also an obstacle to the use of electronic medical records. Why is this so? What is the meaning of electronic medical records? Of electronic records? Of medical records? Of records?
The problem of the meaning of records is the problem of interpretation. By interpretation, I mean the act of and product of explanation of the meaning of something based on a view of that thing. The field of scholarship that deals with interpretation is sometimes referred to as hermeneutics. Most scholarly applications of hermeneutics have traditionally related to literature or theology, although the study of interpretation has applications far beyond those two fields.
We are all acquainted with disagreement in interpretation. In fact, one of the most obvious features of interpretation is the potential for disagreement due to differences of meaning derived from different perspectives on the “something” in question. For nurses, understanding these differences and handling them wisely can benefit nursing communities as a whole.
As a nursing student, I was sometimes required by my clinical instructors to revise my charting. I know in some cases this was because my skills of perception were not yet honed, so that my charting did not reflect the perceptions of a competent practicing nurse. In other cases, my charting did not reflect institutional policies related to charting expectations.
As a new nurse on orientation, I was also sometimes required to revise my charting to reflect the perceptions of my preceptors. After all, a newly licensed registered nurse does not, by virtue of having passed a standardized test, receive either competence or experience. The test is only an instrument validated for the purpose of judging the general competence of prospective licensees. Of course, there were also revisions to conform to institutional charting policies and expectations, which I was still learning.
As I look back at my nursing career, I can see clearly that the primary method of charting instruction I received during nursing school as well as my orientation as a new nurse involved intra-shift review of my charting with an instructor or preceptor, with revisions required based on the judgment of the reviewer. This seems reasonable at a glance, but what are the vulnerabilities of this method? Is nursing only strengthened by this practice, or is there a downside?
With respect to knowledge in healthcare in general and in nursing communities in particular, hermeneutic principles challenge us to consider the importance of how we curate input to the records of our knowledge, observations, and activities. Are medical records to be viewed as presumably errorless and comprehensive or as potentially erroneous and incomplete? Aren’t the human perceptions contributed for posterity those of individuals deemed competent to do so but always potentially incompetent?
It is easy to see that the curation of input to our records involves the curation of information. To the extent that we utilize those records to convey knowledge to others, we must recognize that when we curate information, we are engaged in the curation of meaning.
The number of individuals involved in the curation of input can influence the meanings conveyed in the records. In my case, orientation involved a total of 18 shifts on the unit working with at least eight different preceptors. Therefore, I experienced the influence of at least eight different perspectives on nursing, including at least eight different charting styles. I recall the personal hermeneutic crisis, the crisis of interpretation, this caused.
I would like to explore this further in later posts. In the meantime, what instructional practices did you experience either in nursing school or during orientation? How have they influenced you?