Craig Dale is no stranger to the complexities of nursing care, and the opportunities for clinical practice improvement that lie within innovative research methods. Dale graduated with a nursing diploma, and later returned to school to complete his baccalaureate degree in nursing. “Much to my surprise, I was hooked by academia,” says Dale. “Reading, reflecting and working with an inspiring group of clinicians and researchers energized my practice. I eventually made my way to graduate studies to capitalize on this vital connection.”
Dale completed his doctoral dissertation, entitled Locating Critical Care Nurses in Mouth Care: An Institutional Ethnography, in 2013. Dale’s dissertation focuses on the mouth care of critically ill, mechanically ventilated or intubated adult patients. With clear links between the development of ventilator-assisted pneumonia (VAP) and the level of mouth care these patients receive, Dale investigated the social organization of mouth care on a critical care unit. His methods were particularly innovative, directly observing mouth care in a hospital setting. “This kind of research isn’t common, partly due to how time-intensive it is,” says Dale. His work uncovered a disconnect between the ideals of preventing VAP and the realities of mouth care delivery.
Completed under the supervision of Bloomberg Nursing Associate Professor Jan Angus, with committee members Drs. Eric Mykhalovskiy and Taz Sinuff, Dale’s dissertation has earned accolades from a number of sources. Recently, Dale has received two awards for his doctoral work: the Centre for Critical Qualitative Health Research (CQ) at U of T’s Dalla Lana School of Public Health awarded him the CQ Award for Methodological Excellence in a Qualitative Doctoral Dissertation, and he received the Doctoral Dissertation Award from the Council of Ontario University Programs in Nursing (COUPN).
“I knew I had to study at Bloomberg Nursing,” states Dale. “It is internationally recognized for research innovation and productivity, and I knew that I could receive very special support and direction to complete my study, especially in the highly contentious subject area of health care acquired infection. Bloomberg Nursing was the best place to undertake a novel approach to a longstanding problem.”
We sat down with Dale to learn a bit more about his research, its importance, and most importantly, its impact.
You’ve received two dissertation awards – one from CQ and the other from COUPN. What makes your work stand out?
My interest is fundamental nursing practice. This is an umbrella term that comprises direct care of the patient’s body – care only nurses undertake. In my doctoral research I worked alongside nurses to learn more about the delivery of mouth care for patients with breathing tubes and ventilators. Believe it or not, this direct approach to inquiry is rarely executed – some even consider it radical to place the researcher in the care environment! To me, it is the logical place to start. My work demonstrates how researchers are missing important problems. Inattention to everyday practice can sustain erroneous assumptions about essential nursing care being simple or easy.
What are the specific/potential impacts of your findings on patient care?
Most of us brush our teeth daily and visit dentists or hygienists to avoid oral health problems. We don’t think of pneumonia prevention as a rationale for mouth care. In critical care settings, mouth care has evolved from the provision of patient comfort to the prevention of serious respiratory infection. Interestingly, critical care nurses do not receive special training in complex oral health intervention. To enhance patient care, I will be working with health stakeholders to create nursing opportunities for oral health training, access to better tools and documentary resources in the critical care unit.
CQ specifically spoke about how your dissertation takes a small aspect of care and problematized it to show wider implications. It seems as though problematizing the smaller aspects of care is something that nursing research should be exploring further. What are your thoughts?
Focusing on things we consider mundane can be incredibly productive. Today, we hear a great deal about practice – Advanced practice, evidence-based practice, best practice and even interdisciplinary practice. Much attention is focused on ‘choosing’ effective treatments for optimal patient outcomes. This positions high-level decision-making and policy as the cutting edge of practice. On the other hand, patients and families will tell you the sharp point of care is the clinician-patient interface. How to best apply efficacious therapies across different patients and settings is a big nursing challenge. Effective therapies do not apply themselves. Problematizing the smaller aspects of care draws us beyond good ideas into the real world.
What brought you to nursing research as opposed to practice?
Nurses are the largest group of health providers. They activate the vast majority of medical care. Puzzlingly, health research often steps over this important fact. Despite intensifying expectations to deliver efficacious therapies, nurses are rarely invited to describe the skill and dexterity required to do so.
Unexpected problems and innovative work-arounds are an everyday facet of nursing. As a researcher I want to work with clinicians to bring clinical difficulties forward for investigation and resolution. I see this as a natural extension of my nursing practice.
If you had to list a favourite aspect of this research, what would it be? What is the reward?
My favourite part of this research was the time I spent in direct practice observation. I worked alongside 12 nurses over the course of several months. This enabled me to see mouth care applied in real time and under different conditions. Observation offers many rewards. Even though I had devoted years to frontline nursing, the ability to focus so specifically on mouth care rendered this work anew. The creativity and timing that nurses deploy in direct practice is awe-inspiring.
Winning two awards for your dissertation is no small accomplishment. Can you talk a little bit about the process, supervision and guidance you received while completing your dissertation?
I could not have produced my dissertation without the extraordinary guidance of my doctoral supervisor Dr. Jan Angus, in addition to my committee members Drs. Eric Mykhalovskiy and Taz Sinuff. Like other students, I found the writing process to be challenging. Today, the style and content of health writing is standardized – everything looks and sounds the same. One’s sense of people and activity is often muted. My dissertation addresses the invisibility of nursing work and knowledge in mouth care. The direction I received was to make this invisibility conspicuous. I had to learn how to write people, activity and even myself back into the account.
With his doctoral work behind him, Dale continues to work with the faculty at Bloomberg Nursing. In January 2014, he began a period of post-doctoral study under Associate Professor Louise Rose, undertaking a pilot study that follows problems nurses demonstrated in the course of Dale’s doctoral research. “Our shared interest in ventilated patients poses an exciting synergy,” says Dale. “The long-term plan is to devise nursing strategies for oral care barriers in addition to the creation of knowledge-translation tools.” Dale and Rose will use video as a method to bring mouth care delivery problems forward for analysis.
“Video is a powerful tool – what takes an hour to explain verbally can be transmitted in a 30-second video,” he explains. “I am very excited to have this extended opportunity collaborate with researchers at Bloomberg Nursing. The recognition I’ve received from CQ and COUPN are evidence of the exemplary guidance available at U of T Nursing. The awards also demonstrate how it remains the best choice for doctoral nursing training in Canada. I cannot imagine being anywhere else.”