In the Margins of the Mind: Development of a Projective Research Methodology for the Study of Nursing Practice

Article excerpt

This article presents an original research method derived from the Thematic Apperception Test used in clinical psychology to understand human motivation and action. The research method is derived from the theory of projection, which states that humans will perceive stimuli in terms of their own expectations and motives and will credit others with their own attitudes, beliefs, traits, and dispositions. Projective techniques are one of a handful of methods that provide access to this type of knowledge since it resides below the level of consciousness. Use of this type of method in nursing research may be fruitful because of its capacity to make apparent the complex interplay between a clinician's beliefs and the interpretation of meaning that motivates clinical action.

Keywords: nursing practice; qualitative research method; narrative analysis; methodology; projective method

In this article, we describe a research method used in a study the aim of which was to identify and document practicing obstetrical nurses' cognitive orientations to childbirth to infer how they might influence the utilization of cesarean section (CS). The method is a projective technique, specifically a variant of the Thematic Apperception Test (TAT). The underlying assumption of projective methodologies is that they provide access to attitudes and beliefs that motivate human action and reside outside of consciousness (Aronow, Weiss, & Reznikoff, 2001; Cramer, 2004; Funder, 2001; Teglasi, 2001). The technique is commonly used in psychology for both clinical and research purposes, but to the best of our knowledge it has not been used to study the implicit motivations that shape nursing practice. For this reason we present the method to initiate a discussion among the nursing research community. In the remainder of the article we provide the rationale for using the method, a description of how it was used, and the strengths and limitations in the context of this study. Where appropriate we have illustrated use of the method with findings from the study that are reported in full elsewhere (see Regan & Liaschenko, 2007).

The central aim of the study that used the projective method presented here was to understand how nurses might influence the utilization of CS. The study was designed to ascertain how nurses think about childbirth with the idea that their cognitive orientations shape clinical action in ways that could influence the utilization of CS. CS currently accounts for approximately one-third of all births in the United States, and utilization has increased 40% over the last decade and a half (Declercq et al., 2007). A significant body of research has addressed a variety of factors that might account for this, including the role of nurses. Although nurses have been implicated in the rising utilization of CS, limited research demonstrates precisely how or why they could act in ways that might increase the use of this surgical intervention. One possible explanation is the "powerful influence . . . [of] organizational culture, characterized by high rates of routine medical interventions" on nursing practice (Hodnett et al., 2002, p. 1380). While plausible, this explanation fails to account for anecdotal evidence that some nurses "consistently have low cesarean delivery rates, low intervention rates, [and] good neonatal outcomes . . . regardless of [the woman's] risk level or the obstetrician in charge of their care" (Bowes, 2003, p. 161). We sought to account for these differences by examining how nurses cognitively frame childbirth in order to generate testable hypotheses about how nurses might act in ways that could influence the utilization of CS.

The problem of conducting research about how individuals cognitively frame an issue is that these belief systems exist outside of consciousness and therefore are not readily accessible (Aronow et al., 2001; Funder, 2001; Morgan & Murray, 1935; Teglasi, 2001). A projective method, specifically an adaptation of the TAT, was selected for this research because of its capacity to access unconscious or implicit knowledge structures (Morgan & Murray, 1935). …

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