Feminist Narrative Interpretations: Chachenges, Tensions and Opportunities for Nurse Researches
Recibido: el 4 de marzo de 2004
Aprobado: el 29 de abril de 2004
DeAnne K. Hilfinger Messias1, Jeanne F. DeJoseph2
1 Ph.D., RN Associate Professor College of Nursing and Women’s Studies Program University of South Carolina Columbia, SC Corresponding Author Information: Office Phones: 803 –777-0410; 803 -777-8423 E-mail: firstname.lastname@example.org
2 Ph.D., CNM, FAAN Professor Emeritus School of Nursing University of California San Francisco, San Francisco, CA
La afinidad por la narrativa la comparten los investigadores de muchas disciplinas. Los estudios sobre narrativa son una opción para las enfermeras investigadoras interesadas en utilizar métodos cualitativos, para analizar sus experiencias en enfermería, salud y enfermedad. En este trabajo discutimos los retos metológicos y epistemológicos, las tensiones y oportunidades que hemos encontrado en el proceso para desarrollar interpretaciones de una narrativa feminista, y la aproximación de los estudios de narrativa, basados tanto en perspectivas feministas como en enfermería.
Investigación feminista, narrativa, narrativa interpretativa, investigación en enfermería, métodos de investigación cualitativa.
An affinity for narrative is shared by researchers across a broad range of disciplines. Narrative inquiry is an option for nurse researchers who are interested in using qualitative methods to explore experiences with nursing, health and illness. In this paper, we discuss the methodological and epistemological challenges, tensions and opportunities we encountered in the process of developing feminist narrative interpretations, an approach to narrative inquiry grounded in both nursing and feminist perspectives.
Feminist research, narrative, narrative interpretation, nursing research, qualitative research methods.
Storytelling is at once an ancient human tradition and a postmodern art. At the beginning of the last century Virginia Woolf reflected the spirit of postmodern literary criticism when she pronounced the death of storytelling and the familiar features of plot, character, and narrative, because “real life was too complex and elusive to be captured in a conventional story” (Buford, 1996, p. 11). In contrast, at the beginning of the twenty-first century there is evidence of increasing interest in storytelling across diverse disciplines, including nursing and other health professions. Commenting on this renewed attention to the narrative nature of human beings, Buford suggested that:
Implicit in the extraordinary revival of storytelling is the possibility that we need stories – that they are a fundamental unit of knowledge, the foundation of memory, essential to the way we make sense of our lives…We have returned to narratives – in many fields of knowledge – because it is impossible to live without them.” (p. 12).
Despite the ubiquitous nature and renewed scholarly interest in narratives and stories, there is little agreement about what constitutes either. Among researchers who engage in narrative inquiry, there are also definitional and methodological differences. Accordingly, researchers from different disciplinary perspectives have constructed multiple approaches to the analysis and interpretation of narratives.
Through both our nursing and feminist connections, we discovered an affinity for narrative and began to explore the possibilities of narrative within our research interests in the areas of women’s health, work, and transitions (Messias, 2001; 2002; Messias & DeJoseph, 2002a; 2002b). In the process, we drew on our previous experiences with other methods of qualitative analysis (Lincoln & Guba, 1985; Strauss & Corbin, 1998) and on the work of other narrative analysts (Bell, 1988; Labov, 1972; Riessman, 1993; Stevens, 1995). At the same time, we struggled to find methodological approaches that fit our philosophical and disciplinary perspectives. Although we were clear about our nursing and feminist bearings, we constantly challenged ourselves to incorporate these multiple perspectives and standpoints into the research processes. The approach we developed is characterized by the co-creation, re-presentation, and interpretation of women’s stories and informed by the multiple perspectives of nursing, feminism, and qualitative/naturalistic research methods we bring to our research. We consider this approach a form of feminist narrative interpretations.
The purpose of this paper is to discuss our responses to the various methodological and epistemological challenges, tensions, and opportunities we have encountered as we explored and developed our approach to feminist narrative interpretations. We begin with a brief discussion of the connections and challenges to narrative research posed by both nursing and feminist perspectives, then proceed with a more detailed description of how we addressed these challenges.
Narrative: Nursing and Feminist Connections and Challenges
Nursing “is no stranger to narrative; it has always been a part of how we have explored the shared world of our patients” (Vezeau, 1993, p. 213). Patients and clients often use stories to inform nurses about their experiences with health and illness. Storytelling helps patients to find meaning in their experiences, gives them the opportunity to reconstruct their lives, and can promote health and healing (Bartol, 1989; Sandelowski, 1994). By listening to patients tell their stories, nurses gain an insight and understanding of the human experience with illness that is different from the knowledge of illness conveyed through decontextualized abstract labels or disengaged, analytical reasoning (Benner, Tanner, & Chesla, 1996). Nurses not only listen to patients’ stories, they also are storytellers. In communicating with each other about their experiences with patients, their families, and other health care professionals, nurses commonly use stories. They also incorporate storytelling into health education and in helping patients and families explore ways to identify and cope with illnesses. We were attracted to a narrative approach to research because searching for and sharing stories was a natural extension of our clinical nursing practice.
Feminism supports diversity in extending the methods of the qualitative traditions. Experimentation with different forms and texts is one way feminists have found to express more fully the insights arising from transformations in research practice (Devault, 1990). Although there is no definitive, singular feminist research method, there are certain features that characterize research processes as feminist (Bloom, 1998; Devault, 1990; Hall & Stevens, 1991; Harding, 1987; Reinharz, 1992). Feminist methodologies allow for more interpersonal and reciprocal relationships between researchers and the individuals whose lives and experiences constitute the focus of the research (Bloom, 1998; Lawless, 1991; 1993). These are similar to the relationships that nurses strive to develop with their patients and clients.
The context for this paper is our qualitative research exploring women’s work during pregnancy. Because we were interested in exploring women’s work during pregnancy within multiple contexts, the women we invited to participate were situated in different contexts across multiple continua of weeks of pregnancy, age, race, education, national origin, partnered status, and current employment, economic and living circumstances. Rather than impose our definition of women’s work during pregnancy, we simply asked participants to define work and to share their perceptions and experiences concerning work during pregnancy. We interviewed 29 women at all stages of pregnancy and with diverse ethnic, socioeconomic, cultural, and demographic characteristics. (Three of the interviews were conducted with the women and their male partners, interjecting other dimensions into the research dialogues.) We anticipated, and found, that these women defined, conceptualized, experienced, and interpreted work differently, and in diverse personal and social contexts and environments. Staying open to the possibility of “uncovering” or “discovering” diversity in women’s experiences with work during pregnancy was a key underlying assumption of the study.
The recognition of diversities among women, (e.g. age, economic status, sexual orientation, reproductive status, social position or status, health status, race, ethnicity, political, and religious persuasion) is another of the generally accepted characteristics or criteria of feminist research (Reinharz, 1992). Much of the mainstream research in all disciplines (including nursing) has been blind to such diversities among women. We agree with Anderson (1985) that sound feminist analysis must entail an understanding of race, class, and gender, and other axes of inequality, as researchers seek both the commonalities and the differences across women's experiences. However, narrative researchers differ in the extent to which they include and consider the larger social context in which narratives are embedded (Riessman, 1993). At one end of the spectrum, conversation analysts limit their focus to what participants say and do in a particular interaction. We situate ourselves more closely with other feminist narrative analysts such as the Personal Narratives Group (1989), in making a conscious effort to consider how race, class, gender, sexuality, ability, immigration status, and other contexts of diversity and inequality surface in research participants’ multilayered daily life experiences, their telling of their stories, and the multiple contexts within which these stories may be represented and interpreted.
Like other feminist researchers who embrace interpersonal and reciprocal relationships with those they study, we were challenged by “concerns about ethics, reflexivity, emotions, positionality, polyvocality, collaboration, identification with participants, intersubjectivity, and our own authority as interpreters” (Bloom, 1998, p. 2). Some of the tensions we had encountered in other qualitative approaches led us to experiment with different forms of narrative analysis, which we found posed other challenges as well as opportunities. Heeding Sandelowski’s (1991) forewarnings, as nurse scholars engaged in exploring narrative inquiry, we understood the need to address
the ambiguous nature of truth, the metaphoric nature of language in communicating a putatively objective reality, the temporality and liminality of human beings’ interpretations of their lives, the historical and sociocultural constraints against which individuals labor to impart information about themselves to other individuals, who, in turn, labor to listen. (p. 161).
In addition to grappling with issues of ownership, truth, temporality, and the social and environmental issues surrounding the creation and interpretation of stories within nursing research, underlying our ongoing collaborative efforts to develop this feminist narrative interpretative approach were several questions we felt compelled to attempt to answer: How does this approach to narrative reflect both nursing and feminist perspectives? What is our “working definition” of story? What is the position of the researcher in the co-creation of women’s stories? How useful are narrative analysis techniques in feminist narrative interpretations? What are possible forums and formats for adequately and ethically re-presenting these cocreated stories? In the remainder of this paper we discuss how we have responded to these tensions, challenges, and opportunities in developing our approach to feminist narrative interpretations.
Developing a Working Definition of Story
In colloquial usage, “story” can mean fantasy, truth, lie, or almost anything in between. The terms story and narrative are frequently used interchangeably and there are no definitive definitions of either (Poirier & Ayres, 1997; Polkinghorne, 1988). Therefore, one of our main challenges has been to develop a working definition for “story” within the context of feminist narrative interpretations. How we defined “story” was a key to the way we approached both the collection and interpretation of qualitative data. In developing our working definition, we dealt with the processes of eliciting stories in the context of research, the structure and function of stories, and the gendered nature of narratives.
Some qualitative researchers and narrative analysts ask participants to construct a story in response to a specific research question; others elicit the telling of a person’s life story (Benner, Tanner, & Chesla, 1996; Bloom, 1998; Lawless, 1991; 1993). We felt that because each individual can have their own unique definition of “story,” requesting a research participant to “tell a story” could miss some of the richness of their experiences around particular topics. Bell (1988) suggested that within an indepth interview, “people spontaneously tell stories to tie together significant events and important relationships in their lives, and to ‘make sense’ of their experiences” (p. 10). Therefore, rather than asking for specific stories, we encouraged participants to talk about their work during pregnancy in whatever way they chose. The conversations that occurred in the course of research interviews were the direct result of shared moments and experiences that occurred between a storyteller and listener-researcher- interpreter. Because we found their experiences were more naturally expressed and more clearly understood during guided conversations, we moved from a more traditional interview format to a style that resembles more a “conversation” (Riessman, 1992, p. 58). We found that having a focused conversation allowed for a free flow of thoughts and encouraged participants to participate more fully in the research by offering their own interpretations of their life experiences and contexts.
In both our research and our nursing practice, we have come to view women’s stories as representations of their experiences. We approach stories as interpretations of experience, reinterpreted with each telling-hearing-reading. Therefore, we were not comfortable with the notion of story as an “accurate” or “true” account of what “really” happened. In each co-created research conversation a woman can only share what is “real” and “true” for her at that very moment. That reality can be shaped by, for example, her physical feelings, the weather, what she had for breakfast, how she reacts to the researcher, what she perceives the researcher wants to know, or any number of other environmental or contextual factors. Likewise, the researcher may be affected by similar factors. These resulting research narratives are conversations bounded by the context (i.e., persons, place, time, interactions, and imbued meanings) of the research interview. We view stories as socially constructed tapestries that weave together unique threads of personal, relational, and cultural realities, perceptions, and experiences, in the process of facilitating the creation of fluid meaning (Bruner, 1986; Riessman, 1989; Richardson, 1990).
As other narrative analysts (Poirier & Ayres, 1997; Lawless, 1993) have noted, people do not necessarily tell their stories in chronological or thematic order within the narrative texts of research conversations. Within the narrative texts transcribed from our research conversations, only rarely have we identified a temporal sequence of plots or found stories that were plainly bounded or had clear indications of a beginning, middle, and end (Riessman, 1993). Therefore, a definition based on the expectation that stories told within the context of research interviews necessarily have a pre-existing structure was not appropriate for feminist narrative interpretations.
Engaging in this research process from a feminist perspective presented us with the challenge of recognizing and rupturing of our pre-conceived notions of story and narrative. Although feminist scholars have embraced narrative forms and inquiry, they have not done so uncritically. Smith (1987) and de Lauretis (1987) both expressed misgivings about autobiographical narrative forms based on their association with patriarchal culture. Other feminist scholars have proposed that because stories are gendered, the structure, style, form, and content of women’s stories need to be considered differently from those of men. A major hurdle is recognition of the distinct characteristics of women’s stories. Lawless (1993) suggested women’s difficulties in identifying and constructing their own stories as women’s stories stemmed from the application of male constructs to women’s stories, noting the critical need for models and scripts that would fit the wholeness and complexity of women’s lives as they experience them. As one of the participants in Lawless’s study of women clergy noted, “We don’t know what a woman’s story sounds like because we’ve never heard one…we can’t even tell them” (p. 79). Another woman reflected a similar state of unknowing, but welcomed the challenge and opportunity to explore her own gendered stories: “I must say, I don’t know what a woman’s story sounds like…I’m sitting here saying I can’t believe I told my story that way. On the other hand, I’m glad I was asked to” (p. 57).
One of the ways in which we have attempted to create the opportunity for women’s stories to surface in our research is not anticipating or imposing a pre-conceived structure or form on the stories women tell us. For the purpose of our research, we have come to identify stories as the unfolding of a description of a particular woman’s experiences around a focused topic of the research (e.g. her health, pregnancy, work, employment, or migration). Each story is a dynamic representation of a particular woman's experiences around a focused topic as identified and interpreted by both the woman and the researchers. These stories unfold within the original narrative of the research conversation, but not necessarily in any particular order or format. The focus of these stories may be events, relationships, emotions, or environments. Some stories are more “factual” accounts, others more personal reflections. Throughout the research interviews there are also fragments of stories, some of which are unfinished, others which serve as support or corroboration. The stories that provide us insight into our research interests and questions exist within the various contexts of each particular woman’s experience, the researchers’ research context, and the shared context of the research interview. This contextual definition takes into consideration the temporal and transitory nature of stories created in the process of our research.
The Co-Creation and Interpretation of Stories: The Interconnectedness of Researchers and Research Participants
As Reinharz (1992) noted, there is a broad continuum of the degree of feminist researcher involvement in the lives of the people they study. Feminist narrative interpretation shares with other qualitative and interpretative research the assumption of intersubjectivity between researcher and participant and the mutual creation of data. We agree with Olesen’s (1994) notion that the women who participate in research are actually doing research in their daily lives, as they construct the meanings of the experiences that later become the data that researchers interpret. This approach is also based on the premise that storytelling is a mutual process (Bruner, 1986, Griffin, 1994).
We approach each research interview opportunity as a challenge to create an interpersonal environment of respect, shared information, openness, and clarity of communication. We also assume that each study participant has experiences concerning the focused area of interest, viz. work during pregnancy, and thus, has stories of interest to us in our research endeavors. However, we acknowledge that the women we interviewed may not have considered or conceptualized their experiences either as “work” or as “stories” that they would tell others or that others would want to hear. We also recognize that some participants may be more willing or comfortable in telling their stories, and that we might perceive them as “better” storytellers. Similarly, some women may be more at ease with the interviewer as “listener” than others.
In any case, the quality and substance of the data produced at the moment of each researcher-participant interaction is dependent on the interpersonal quality of that interaction, as well as the participant’s perceived value of the experience and its retelling. Mutuality refers to the efforts taken to identify and reduce the power inequalities among researchers and participants (Hall & Stevens, 1991). In creating spaces for women’s stories through our research, we have found that we are inviting anticipated, as well as unanticipated, disclosures (e.g. regarding sexuality, race, immigration status, physical or emotional health, and personal and family relationships). Disclosure is a quality of researcher engagement related to mutuality and trust, and refers to the authentic revelation of the marginalized identities and experiences of research participants, in ways that are understandable to the research audience (Meleis, 1996).
Our approach to the interactions and “data” produced by researchers and research participants reflects our ontological and epistemological standpoints (Guba & Lincoln, 1994). Our ontological position is that realities are multiple, multilayered, and fluid; as such, they are constantly shaped by perceptions and contexts that include, but are not limited to, gender, class, culture, race, politics, and economics. Our epistemological stance is based on the premise that the relationships between knower and what is to be known are subjective and interactive. We recognize that our values, as well as those of the women we interviewed, inevitably influence the inquiry. Therefore, the resultant knowledge (e.g. the “findings” of the research) is mediated by and inextricably intertwined with the interactions between and among the investigators and the women who participate in the study. In essence, ontology and epistemology are fused.
A story is not the work of the storyteller only, but requires that there be a listener or reader, unless it is to remain an “untold” story. Audience is crucial to the story and influences how stories are told; it is, therefore, a key element in narrative research. For example, the story a woman tells an investigator in the context of a research interview will not necessarily be the same story that she would tell her best friend, a prospective employer, or a relative. When stories are co-created in the process of research, the initial audience consists of the actual investigator(s). However, by giving her consent and participating in a research interview, the study participant agrees to her stories about a focused research question being shared with a broader audience (e.g. other women, researchers, nurses, health professionals and the general public). Although we recognize the potential value in taking qualitative data “back” to research participants, we have opted to take the stories from our research “forward” to these other audiences.
Challenges and Opportunities in Narrative Analysis, Interpretation, and Representation
As we developed our approach, we found feminist narrative interpretations well suited to collaboration. Other methodological challenges and opportunities we experienced included sorting through and critiquing the appropriateness and fit of various narrative analysis techniques and experimenting with diverse forms and venues for presenting the results of our research.
Interpretation as a collaborative effort. Although the process is more complex, having more than one interpreter involved in the research process broadens the dialogue and enriches the process and the products. As co-interpreters, we often initially review the research texts independently, then meet together to direct our focus to the stories. This collaborative process of identifying and locating stories contained in each interview text occurs not only in interaction with the texts but also as a result of the dialogue between interpreters/researchers. When we meet, we share with each other the stories we noticed or created, and compare how story lines are similar or different within each participant’s narrative and across several participants’narratives. We periodically return to the interview transcripts to refine the stories we have already identified and to locate other stories. While each story can stand alone, we also look for connections or contrasts between stories within each narrative and across groups of narratives. Together, we then examine ways in which these stories expand or challenge our current understanding of the phenomenon of interest. In developing our “findings,” we challenge ourselves and each other to bring multiple perspectives to our interpretations. This process of co-creation recognizes the active, participatory relationship between and among researchers. Each time we revisit the data individually or together, the possibility exists for the discovery of new stories or new interpretations of stories previously identified.
Sorting out techniques of narrative analysis. Another methodological challenge was to determine the usefulness of narrative analysis techniques for feminist narrative interpretations. Similar to other approaches to narrative analysis, searching for story lines is key to our interpretive approach. Some narrative researchers analyze one story within an interview, others look for and analyze sequences of stories. Bell (1998) extended story analysis by considering how sequences of stories can provide insight into personal experience. This process involves reducing the interview data to a core or skeleton narrative, then restoring a complete version of the stories. In the process, the storyteller becomes the analyst and the stories are told in the third person (Bell, 1998). Other approaches to narrative inquiry include within- and across-case identification of common or prime story lines (Bottorff, Johnson, Irwin & Ratner, 2000) or types of stories (Ayres, 2000).
We differ from those narrative analysts who define stories in terms of structural elements such as orientation, episode, coda, abstract, evaluation, and/or resolution. Our approach to analysis and interpretation began to flow from our working definition of story as unfolding around a focused topic. Not surprisingly, because we did not define story in terms of structure, we chose not to adopt analytic approaches that focused on structural forms or components of narratives. However, for some of our initial analyses, we did experiment with a more structural approach, based on Labov’s (1972) functional categories, but found such techniques to be reductionistic in both process and results.
Like others who have used narrative analysis in health research, we concluded the use of certain structural narrative analysis techniques contributed little in terms of illuminating our understanding of the stories (Crepeau, 2000). We decided these structural analytic techniques were analogous to diagramming sentences: although they may be useful to narrative researchers in the process of identifying the structure or function of stories, they contribute little to furthering understanding of the underlying meanings. Similarly, some qualitative and narrative analysts reduce and decontextualize the stories that participants tell through coding and categorizing schemes. Rather than override the women’s experiences with our own codes and categories, we strove to preserve the saliency of women’s own words in the presentation of their stories. As listeners/interpreters, co-storytellers, in the processes of cocreating and re-presenting these stories, we identify the story lines and weave together the stories that we have identified as providing insight to our research questions. In the process, we actually may introduce some elements of structure (e.g. order of presentation) into these stories. For example, in re-presenting stories in written form, we occasionally “edit out” certain repetitive aspects of oral speech (e.g. um, like, you know) and also impose conventions of written speech, such as punctuation.
The construction of composite narratives is another approach to narrative analysis (Stevens, 1995; Stevens, Hall, & Meleis, 1992). One of the advantages of such an approach is that the researcher does not have to worry about confidentiality or identity disclosure in a composite story, because there is no “real person” behind the story. Although we have not adopted the composite narrative approach, we did experiment with synthesizing the various stories contained in an interview narrative into one integrated “core narrative” for individual participants. However, the resulting synthesis often proved too long and unwieldy. One of the ways in which we have addressed this challenge is to identify several story lines within each participant’s narrative, recognizing that there often are connections and overlap within these story lines, because they are part of women’s “larger” life stories.
Representing results. The challenge of large texts is one that is not unfamiliar to qualitative researchers in general, across disciplines and methodological persuasions. The intent of our approach to stories is to display the results of our interpretive research processes in a form that more closely reflects the participants whose stories the research is intended to present. Sometimes we weave the cocreated stories and narrative interpretations together, alternating stories and interpretations. Different stories or different storytellers may lend themselves to different forms of re-presentation. By re-presenting both the co-created stories (which preserve individual women’s words) and our interpretations of the contexts and meanings of those stories, we allow other audiences the opportunity to follow, challenge, or extend our interpretive weavings.
In representing women’s stories, maintaining a balance between the voices of researchers and participants is an ongoing challenge in feminist narrative interpretations. The ways we choose to re-present women’s stories involve complex issues of “ownership.” We specifically want to privilege the women who shared their experiences and perspectives with us in the course of our research, rather than totally privileging our “overwriting” of their words and expressions. At the same time, we need to acknowledge our role and active engagement in the co-creation and interpretation of these stories, and the re-presentation of these stories to other nurses, researchers, and women, in furthering women’s health and well-being. Another challenge is not to privilege one type or format of story over another. The choices of whose stories to “move forward” and re-present to other audiences has implications in terms of our role as feminist researchers with an obligation to combat the social and interpersonal structures that perpetuate the oppression of women. Inherent in the process of women researching other women is the danger of reproducing existing structures of inequality and power (Patai, 1988).
We have had the occasion to re-tell participants’ stories in several different formats and forums. These include the more conventional format for research, in which we re-presented individual women’s stories within published research reports. However, we have also re-presented women’s stories orally at research conferences, in classroom presentations, and as case studies for health care providers. From both our personal perspectives and our observations of the reactions of our audiences, telling stories has been a meaningful and effective way to re-present the results of our research.
Summary and Conclusions
Virginia Wolff had a point in contending that life is complex. An illustration of that complexity is the way health issues are embedded in the multiple contexts of women’s lives and work. We believe that stories can help nurse researchers make sense of and interpret the meaning of women’s health and illness related experiences. In this paper we have described and illustrated an approach to research that incorporates both nursing and feminist perspectives in the co-creation, representation and interpretation of stories. Feminist narrative interpretation is a complex and dynamic research process that involves asking, listening, reading, looking for, identifying, locating, co-creating, re-presenting, and interpreting stories. These interpretive processes begin with development of the research project and continue with guided research conversations around a focused topic, viz. the research question(s). Our approach to women’s stories is predicated on several underlying assumptions. We situate ourselves in the position of listener/conversationalist/ interpreter to collect our research narratives. We define stories in terms of the interpretive interaction of researcher(s) and narratives, not in terms of form or structure – a distinction from other forms of narrative analysis. Each story is a dynamic, unfolding representation of a particular woman’s experiences. How a story unfolds is a function of the interaction of the past and present experiences, perspectives, interests, and perceptions of both the narrators and the listeners. The resulting co-created stories are reproduced and re-presented in other moments and other forms through the researchers’ analyses, synthesis, and interpretations. Like other methodological standpoints, feminist narrative interpretation is, “by definition, partial, incomplete, and historically contingent” (Riessman, 1993, p. 70).
Research approaches such as feminist narrative interpretations both confirm and expand the applications of stories in nursing practice and research. Boykin and Schoenhofer (1991) suggested that stories are valuable as an approach for illuminating “the uniqueness, subtlety and depth of nursing knowledge” (p. 245) generated through nursing practice. The opportunity to witness, interpret, and represent other women’s stories certainly is a privilege. Through research that furthers the sharing of cocreated and re-presented stories, nurses may also find knowledge, inspiration, and guidance for the transformation of nursing practice.