As novice nursing students we took great pride in "being good at" certain nursing skills that seemed so simplistic yet were expressive of what a "good nurse" does. The simple intervention of giving a back rub to a frail elderly woman helped each of us to value the rituals of nursing and become more comfortable with our inexperience during this time of learning. Role transition often provokes anxiety, and rituals help to alleviate anxiety in this vulnerable transitional period of becoming a nurse. Yet, "A key characteristic of any ritual is that they are a form of repetitive behavior that does not have a direct overt technical effect."1^(p92) Furthermore, rituals in nursing can also be viewed as pejorative in nature. Today, the buzz is, "Where is the evidence to support these rituals?"

Experienced neonatal or advanced practice nurses have had more opportunity (and privilege) to observe the artful and expressive aspects of caregiving. Such observations define practice both positively and negatively. On the positive side, rituals help to portray in symbolic form key values and cultural orientations of a "good" neonatal nurse and/or neonatal nurse practitioner. Turner2 discussed how this expressive aspect is like language in that it can only be understood in context by those with the ability to decode it. Rituals in the form of implicit language include areas that only our neonatal nursing culture can truly understand. For example, during shift-to-shift report we might overhear, "her SATs are trending to the 80s and her pulse pressure is widening [horizontal ellipsis] I don't know why she's acidotic because there is no (flow) murmur yet."

Rituals are often not questioned; they are just there as a constant in the culture. Other rituals of the nursing culture might include the color or design of scrubs to denote doctor versus nurse, or the nurse practitioner wearing a white lab coat over scrubs. Helman1 considers rituals as important features of all societies, the means by which groups celebrate and reproduce their worlds. Rituals establish group cohesion, define the hierarchical nature of formal and informal practice, and protect the physiological and psychological tenets (threads of evidence) of our practice. They also provide a way to pass on personal knowledge that can sometimes be the most difficult to overcome and teach.3

Of course, the negative or pejorative rituals are easily described and include both language and interventions. Examples of language and symbolic expressions of neonatal nursing include what is said during change of shift ("he's looked like that all night"), who is the expert nurse to work with which type of patient, who gets the narcotic keys and checks the monitors and rooms before report, what nursing group rounds include, and what an RN may say RN to RN versus RN to NNP. Walsh and Ford define rituals as "carrying out a task without thinking it through in a logically problem solving way."4^(p26) Neonatal intervention rituals are too numerous to describe, but here is a current list (not in any particular order) for reflection.

* Timing and procedure of the first bath (temperature of water, sponge versus emersion, soap versus no soap, lotion, cracked skin)

* Process of admission priorities/immediate postnatal interventions (When the length and occipital frontal circumference are done [some hospitals will not admit an infant formally until a length is done], what is done first, second, vitamin K injections, eye care, picture taking, etc5)

* Sequence of a series of interventions during one episode (suction first, temperature, then diaper change)

* Use or nonuse of heparin for umbilical and peripheral venous lines

* Where temperature probes are placed and why

* Rate for to keep open for umbilical arterial catheters, peripherally inserted central catheter lines, and intravenous lines

* How we facilitate and "help" during the first few breast-feeding interactions

* Expectations of who does what during admission, resuscitation, and code

* Linen changes on infant bed whether needed or not

* Correlating limb blood pressures with arterial blood pressures

* What we do for intravenous infiltrates, cracked skin, excoriated skin, dry wound care versus moist wound care, and shaving

* Time of day for infant weight, change of total parental nutrition tubing, and bathing (what shift)

* Daily weights, weights every 12 hours, weights every week, electrolytes every 12 hours, electrolytes everyday, use of birth weight for dry weight for the first 7 days

* Making a baby cry at birth

* Using chest physiotherapy or deep suctioning to remove fetal lung fluid secretions

The good news is that these are the things that really do bug us about neonatal nursing practice. They are also good examples of the types of nursing practice that are for the most part understudied, could be studied by nurses, and could effect change (evidence based). It seems strange that a profession that advocates a holistic and developmental approach to care should be so insistent on such a purely technical and rational (or irrational) approach. Schon describes the confines of such an approach and identifies how real professional practice is often within the indeterminate "swampy zone that lies beyond the canons of technical rationality." 6^(p3) For the clinical nurse, rituals can be viewed as a defense against change while the nurse researcher must be careful not to advocate change too strongly on what can sometimes be flimsy grounds. On a final note, Strange noted, "To dismiss ritual simply as irrational, as was implied earlier, is to deny an enormous area of human experience."7^(p112)

Kimberly Horns, PhD, RNC, NNP

Faculty Associate, Arizona State University, College of Nursing, Tempe, Ariz

Jacqueline M. McGrath, PhD, RN, NNP

Associate Professor, Arizona State University, Tempe, Ariz

REFERENCES