The use of metaphor in district nursing: maintaining a balance

NURSING THEORY AND CONCEPT DEVELOPMENT OR ANALYSIS

The use of metaphor in district nursing: maintaining a balance

Claire Goodman BSc MSc PhD RN DNCert

Senior Lecturer, Post Registration Nursing, University of Hertfordshire, Hat®eld, Hertfordshire, UK

Submitted for publication 18 April 2000

Accepted for publication 15 August 2000

Introduction

The use of metaphor within language enables understanding

of a situation or experience to be conveyed through likening

it to one that is known in a different context (Lakoff &

Johnson 1980). Giving attention to how individuals talk

about their experiences as well as what they say acknow-

ledges that language is a symbolic medium in its own right.

As Savage (1995, p. 81) comments:

If the experience of the world is linked to our choices of metaphor,

the study of metaphor would seem an important way of rendering

our experience of the world more accessible¼Metaphor, then, may

be particularly helpful where we wish to understand what is inchoate

and dif®cult to articulate in a literal form.

The ®rst part of the paper will discuss some examples of the

use of metaphoric language within nursing writing and

research. Then, using the example of a study on district

nursing (nursing in the home), it will focus on how data from

interviews and periods of observation revealed that practi-

tioners and colleagues used a shared group of metaphors to

try to capture the nature of district nursing work (Goodman

1998). In particular, it will propose that the metaphors used

106 Ó 2001 Blackwell Science Ltd

Correspondence:

Claire Goodman,

Post Registration Nursing,

University of Hertfordshire,

Hat®eld AL10 9AB,

UK

E-mail: [email protected]

G O O D M A N C .G O O DM A N C . ( 2 00 1 )(2 00 1 ) Journal of Advanced Nursing 33(1), 106±112

The use of metaphor in district nursing: maintaining a balance

Aim of the study. To explore with practitioners and others, their priorities for and

de®nitions of district nursing.

Background/Rationale. This paper discusses whether the use of metaphor in nursing

literature and research can offer particular insights about the situation and

experiences of nurses.

Design/Methods. A case study approach was used to examine district nursing

during a time of policy change. The study was undertaken in two stages using a

range of qualitative methods of enquiry. Participants of the study were district

nurses, General Practitioners (GP) and Community Nursing managers.

Results/Findings. Qualitative data from interviews and periods of observation

revealed that district nurses, and to a lesser extent General Practitioners and nurse

managers used a shared group of metaphors to try and capture district nursing work.

The paper suggest that this recurring group of metaphors demonstrated coherence

between the language used, observed practice and accounts of how district nurses

worked which provided useful insights for district nursing. The metaphoric language

revealed both negative and positive dimensions of district nursing work. It

illuminated the context dependent nature of district nursing work and the con¯icting

interests they had to accommodate. It also revealed the emotional work, skills and

strategies district nurses employed in order to achieve their work.

Conclusions. The paper concludes that an examination of metaphoric language

offers an opportunity to examine what otherwise would be tacit or even misun-

derstood in nursing work.

Keywords: district nursing, metaphor, emotional work, power, primary health care,

new NHS.

illuminated the context dependent nature of the work,

elements of powerlessness and skilled practice that are

inherent in district nursing work but not always evident to

others or to the practitioners themselves.

The use of metaphor to describe nursing work

The relevance of recurring metaphors to describe nursing

work can be examined from several perspectives. For

example, metaphors can be discussed in terms of how they

capture the moral pre-occupations of nursing, to describe

nursing as a professional activity or, when employed by

practitioners, to provide insights into practice. Some exam-

ples of how metaphoric language has been used in these

different ways illustrate how a consideration of their use can

provoke thought and provide new perspectives that extends

beyond understanding metaphor as a form of verbal embel-

lishment (Turner 1974).

Wurzbach (1999) has argued that throughout the history

of nursing, different metaphors have emerged to describe the

moral imperatives that provide guidance to the purpose and

understanding of nursing work. So, from the turn of the

century, the identi®cation of nursing work with military

action, the attendant values of loyalty and obedience have

changed to metaphors that represent nurses as patient

advocates espousing the needs and rights of the individual,

to more recently as agents who promote and participate in a

caring community. Wurzbach (1999) suggests that these

changing moral metaphors of nursing re¯ect how nurses

interpret their ethical responsibilities and service priorities.

They act as organizing themes, principles and goals for nurses

and, Wurzbach argues, as a standard that nurses can use to

evaluate their practice. She concludes that these metaphors

have a use in helping to shape and de®ne nursing aspirations

and understand retrospectively how nursing has understood

its role within society. However, she argues there is also a

danger that in relying on certain metaphors, nursing can

oversimplify the moral complexities they encounter and the

solutions they identify as appropriate.

The contribution of nursing and its underlying knowledge

base have frequently been described as `invisible'. The Royal

College of Nursing report on the value of nursing (Royal

College of Nursing 1992) compared skilled nursing to

invisible mending, not noticeable when performed well.

Feminist critiques of nursing have also argued that nursing

as work is invisible within society because social concepts of

work and profession re¯ect dominant masculine views of

what their characteristics should be (Davies 1995, Colliere

1986). Robinson (1993) described how during a time of

major policy change in the National Health Service (NHS)

the implications for nursing were not considered by managers

or doctors. This ®nding she attributed to nursing's internal

pre-occupations, divisions and confusions that prevented it

from engaging meaningfully with the wider policy debate.

Robinson likened this predicament for nursing as equivalent

to a `black hole'. A very graphic metaphor that captured not

only the absence of recognition but also the internal forces

that helped to create such a situation. In the case of district

nursing the metaphor of invisibility is often used to express

multiple truths about the nature of its practice. It has been

used to encompass both the fact that the majority of the work

is out of sight in patients' homes and the general lack of

understanding as to what district nursing work entails. It also

acknowledges that because the majority of the district nurses'

caseload are older people who are themselves an invisible and

marginalized group in society, district nursing by association

is often invisible (Smith et al. 1993, Fox 1994, Timmons

1994, Scholes 1995, Grif®ths 1996, Hiscock & Pearson

1996, McIntosh 199633 ). The consistency of the use of the

word invisible and related metaphors by researchers and

writers on nursing indicates two consistent themes. How

intangible much of nursing work is and, more importantly,

the lack of recognition that nurses have as an occupational

group. It is suggested that invisibility as a metaphor for

powerlessness, captures an ongoing predicament of nursing

and district nursing in particular. The only concern is when

the invisibility of nursing is presented as a fact rather than as

an acknowledged metaphor for a range of experiences and

patterns of belief and behaviour.

If an analysis of how nurses through metaphors represent its

values and its overall characteristics, then how practitioners

explain their experiences can offer insights on the details of

practice and the emotional work that informs it. For example,

different research studies have explored how nurses use

metaphors to articulate intimacy, caring in critical care and

the emotional consequences of hospice work (Savage 1995,

Jenny & Logan 1996, Froggatt 1998). Froggatt (1998) in her

study on hospice nurses argued that their use of particular

metaphors enabled them to talk about sensitive subjects such

as death and emotions in a way that was not threatening to

them. She further suggested that there was coherence between

the practical activities of the nurses and the metaphorical

concepts they chose to describe their actions. Thus, when they

talked about `switching off', `standing back' and `hardening',

these concepts were mirrored in the practical strategies used

by the hospice nurses to deal with the negative emotional

consequences of their work.

Lakoff and Johnson (1980) argue that metaphors are

grounded in the physical and cultural experience of those

who use them. Metaphors are conceptualized as a creative

Nursing theory and concept development or analysis Use of metaphor in district nursing

Ó 2001 Blackwell Science Ltd, Journal of Advanced Nursing, 33(1), 106±112 107

force that re¯ect and create reality (Froggatt 1998). There is

an assumption that because situations and experiences are

conceptualized and recognized through the medium of meta-

phors, their use illuminates the understanding and response

that individuals have to those situations. However, it is

possible that metaphors are individually rather than collec-

tively determined and that their interpretation should focus

on the wider social environment rather than how a particular

group in society such as nurses, use them. Nevertheless as

Turner (1974, p. 31) re¯ects:

¼the implications, suggestions and supporting values entwined with

their literal use, enable us to see a new subject matter in a new way

Examining how district nurses use metaphors therefore offers

another way of understanding how they describe and prior-

itize their work. The second part of this paper will present

some ®ndings from a study on district nursing and discuss the

extent to which their use of metaphor offered insights on

practice and their experience of a major policy change.

A study into the de®nition and experienceof district nursing work during a timeof policy change

A case study of district nursing work that drew on qualitative

methods of inquiry was undertaken during a time of policy

change within the British National Health Service (Goodman

1998). The policy change was the introduction of purchasing

of district nursing services by General Practitioner (GP)

fundholders who received devolved budgets to purchase

services on behalf of their patients (NHS Management

Executive 1992a). Primary Care Groups and Primary Care

Trusts whose membership consists of representatives from

health and social care have since superseded this particular

approach to the organization of services in primary health

care (Department of Health (DoH) 1997). Many of the

principles that were developed within fundholding have been

incorporated into the new structures. In particular, the

importance of basing resources and services around the local

populations' health needs and using local practitioners and

colleagues knowledge to inform that process. A more detailed

description of the policy background, research approach,

data collection methods and analysis is provided elsewhere

(Goodman et al. 1998). The research aims of the study that

are relevant to this paper were:

· To describe the experience of district nursing within GP

fundholding settings

· To explore with district nurses, managers and GP fund-

holders, their de®nitions of and priorities for district nursing

from the introduction of GP purchasing

The study was undertaken in two phases. In the ®rst phase

61 semistructured interviews were undertaken with district

nurses, NHS managers and GP based in 12 different sites

across England and Wales. Thirty-six of these participants

were quali®ed district nurses. These interviews explored with

participants their understanding of district nursing work, its

de®nition and how they perceived the policy change of GP

fundholding. From each site a contract/service agreement

held by a NHS Trust with a GP fundholder for the purchasing

of district nursing services and relevant NHS Trust literature

was also examined. The second phase of the study involved a

period of observation over 3 months and further interviews.

These involved two district nursing teams (eight nurses and

three health care assistants) and their fellow primary health

care team members, based in two of the sites that participated

in phase one of the study.

The need for balance

Throughout the study district nurses used a group of

metaphors to describe their work that were pre-occupied

with the need for balance interlinked with images of sailing or

sea travel. District nurses used phrases that were concerned

with keeping a situation steady and not causing disruption.

They were used to describe what was required to ensure the

work was performed, so that the district nurses were not

de¯ected from their purpose of patient care. District nurses

spoke of the importance of `not rocking the boat' or `not

making waves'. The uncertainty of how, for example GP

might react, particularly as the policy change of GP

purchasing of district nursing services, meant that raising

questions or objections could jeopardise something, that in

the district nurses opinion was going well. As this quote from

phase one of the study demonstrates, the risk of unsettling a

situation and relationships were too high especially when

others were busy and pre-occupied:

But you feel you can't be too dif®cult and create too many waves

because if they (General Practitioners) wanted to, they could say `I

am sorry I just can't work with that system

`Not making waves' was a phrase used frequently by one of

the district nurses during the time of observation. She used it

in terms of maintaining steady relationships with colleagues

within the district nursing team, the GPs, her manager and

patients. If she was unsure or unhappy about a situation she

preferred to `go with the ¯ow' rather than make a direct

challenge. Similarly, district nurses spoke of work and

relationships with GPs whether they were going smoothly

or not. Extra work or external changes were characterized as

a `bumpy time', the balance was lost. In these examples, the

1C. Goodman

108 Ó 2001 Blackwell Science Ltd, Journal of Advanced Nursing, 33(1), 106±112

picture is one where the district nurse is accommodating

pressures to avoid unpleasantness and a change of direction.

However, it was also used to represent for what the district

nurse was appropriate, the correct balance of work. Here a

district nurse from the ®rst phase of the study uses the idea of

travel and extends the seagoing metaphor in describing how

she views her caseload. To do something new she would have

to lose some other aspect of her work:

It's a question of what you have got and where could it go. I mean at

the moment I think we are fairly well doing what I see as what our

job ought to be¼I think at the moment we are on a fairly even keel,

and I can't think of anything that we could jettison.

The metaphor of a boat is one of a shared enterprise where

the interdependence of the district nurses, GPs, nurse

managers and patient need have to be carefully balanced. It

evokes a picture of district nursing work where judgements

are made so as to ensure a smooth passage. The least the

disturbance, the easier it is for the work to be performed and

collaborative patterns of working to be maintained. Deci-

sions to challenge GP or manager decisions or make-known

areas of practice that were potentially contrary to the

expectations of others were weighed against the probable

disruption it would cause.

Another way in which district nurses used metaphors that

were related to the idea of balance was in their descriptions of

how they dealt with the competing demands of the organi-

zations with whom they worked. When discussing the intro-

duction of the policy change most of the participants in both

phases of the study discussed or alluded to the potentially

awkward (and unstable) situation in which district nurses

found themselves. This was characterized by the district

nurses as being `caught in the middle', `sandwiched between

the doctors and management', `a foot in each patch', `torn

between the two'. It was a situation that others also recog-

nized and used similar language to describe. One GP described

the district nurses she worked with as engaged in a `tactful

balancing act' between herself and the nursing managers.

District nursing strategies for ensuring balance

How the `balancing' process was undertaken was apparent

when district nurses talked of how they responded to

different pressures on their workload, most notably medically

related tasks. One district nurse described requests for her to

do venepuncture or in¯uenza (¯u) vaccinations as minor

irritations that were not worth resisting. These kind of tasks

did not interfere as one district nurse put it with her work the

`real' business of patient care. Consequently, it was often not

the task that indicated whether a district nurse would

perform it or not, but its effect on the balance and direction

of the caseload, that is how it in¯uenced her overall ability to

get the work completed. Working in the community meant

that district nurses appeared to have a high threshold for

what they would absorb and cope with. The time involved in

re-negotiating who would perform certain tasks or devel-

oping clear criteria as to when they would be involved was

time away from their work with patients. District nurses

would describe how they would accept referrals that did not

feel were appropriate and then over time remind the GP why

these patients could be seen at the practice or referred directly

for social support. Restoring the right `balance' of the

caseload on these occasions was a gradual process that

maintained a sense of co-operation with GPs and other team

members. Many of the practitioners interviewed had devel-

oped strategies they could describe that ameliorated situa-

tions which threatened to unbalance and re-order their

priorities of care. A reluctance to upset and cause disturbance

however, could mean that district nurses accepted work

which then unbalanced their caseload. In these situations it

was apparent the metaphors of disturbance and being

overwhelmed referred to their perceived inability to control

their work. One district nurse linked this experience, to her

lack of power in determining whether certain activities were

district nursing work:

Well I don't know how much power we have this is the thing; we

don't know our own power you see we don't feel as if we have

enough power

Balancing work has been identi®ed as an attribute of nursing

work in general, and one that is symptomatic of its accom-

modation of others needs and demands to its own detriment

(De Raeve 1994). For district nursing although there was an

added signi®cance. It was not only an expression of how

different patient needs and GP demands were accommodated

and the caseload kept manageable, it was also a guiding

principle that could be observed in clinical practice. District

nurses worked with and around patients' needs and situa-

tions. It was prerequisite of the job that they accepted their

`rights' to provide care were dependent on their patients'

`rights' to decide whether they would accept it as offered or

not. Their pattern of working was one of compromise, ®tting

patients' demands with those of the caseload. During the

observation, district nurses were observed accepting patients

demands that were not seen by them as clinically justi®ed in

order to keep a relationship open, avoid upset and time

consuming discussions:

In one situation the parents of an adult patient who was in the

advanced stages of Multiple Sclerosis and receiving daily visits,



insisted only quali®ed nursing staff visit their daughter. The parents

also `supervised' the district nurses and were perceived by the team as

highly critical and unappreciative of what they did for the woman.

Over the year the district nurses re-negotiated the pattern of visiting

and reached an agreement with the parent that health care assistant

when appropriate could visit as well as the nurses. The demands and

expectations this family placed upon the service were resented by the

team especially when they were busy but it was felt necessary to

ensure they could provide care to the daughter in as amiable an

atmosphere as possible (Team one ®eld note summary).

It was a situation the nurse manager of the district nursing

team described as `tiring' for the district nurses and indic-

ative of the emotional labour involved in maintaining a

balance in patient, carer and nurse relationships. In this

sense then a need to maintain balance for district nurses was

not only a symptom of powerlessness but also an expression

of the tortuous and skilled nature of district nursing practice

itself.

Discussion

Although district nurses and colleagues de®ne their work by

the individual experience of caring (Traynor 1996), they

achieve it through the negotiation and balancing of many and

often con¯icting demands. This was demonstrated in the

metaphors that they used to outline their work and the

strategies they described and were observed to employ in

practice. There were three dimensions to interpreting what

district nurses meant when they used the metaphors of

keeping a balance and related images of sea travel. First their

use re¯ected a sense of purpose, the imperative to get the

work completed and the need to avoid the kind of upset and

de¯ection that slowed the process down even if it meant

accommodating the peripheral demands of others. District

nursing work was not seen as something that could be easily

deferred. Second, it was an expression of the nature of district

nursing work itself and the necessity for negotiation and

juggling of demands to maintain therapeutic relationships

with patients as well as a manageable caseload. It is suggested

this approach to working in the clinical environment was

often translated into relationships with managers and GPs. It

was a natural extension of practice. District nurses work in a

multiprofessional environment where it is dif®cult to have a

discrete role and they often compensate for the inadequacies

of other services (Audit Commission 1999). As one study

revealed they are frequently called on to ®ll the gaps in service

provision (Grif®ths 1996). This kind of balancing work

involves accommodating a range of demands which, if too

many, always have the potential to overwhelm them. Third, it

was a manifestation of the powerlessness of district nurses to

be independent of the expectations of others and direct their

own work. A ®nding that links directly with how it is an

everyday experience of women's' lives to perform `balancing

acts' (Gieve 1989, Neal et al. 1993) and how nurses have

traditionally related to doctors and colleagues (Abbott &

Wallace 1990, McDowell & Pringle 1992, Sweet & Norman

1995).

Where the balancing work of district nurses extended

beyond the accommodation of the interests of medicine and

management and re¯ected strategies for care and caseload

management, parallels exist with the emotional and hidden

work of nursing described by Smith (1992) and James (199244 ).

The ®ndings of this study revealed that activities such as

negotiating access to patients' care given in partnership with

family carers, methods to ameliorate the de®ciencies of the

skill mixed team, and how individual responsibilities and

patient demands were judged against the overall needs of the

caseload, all demonstrated an interest in maintaining an

integrated approach that matched resources and expertise to

the situation encountered. This too, was skilled balancing

work that acknowledged the context dependent nature of

district nursing and primary health care and the need to co-

ordinate different networks of support that exist (Hockey

1979, Flynn et al. 1996, Ryan et al. 1997). This balancing

work was a very different expression of powerlessness to that

which is gender related and organizationally determined. It

related to the nature of primary care working itself and the

fact that the outcomes of care will always be dependent on

negotiation and accommodation. It was the absence of

suf®cient resources, the unpredictability of the work, patient

situations that failed to ®t categories of care and the variation

in the caseload that made balancing skills so important. This

situation encompassed a reality that district nurses felt they

had no choice but to work with. The indirect approaches,

which often involved negotiation and accommodation often,

were perceived as the only ones that would work. In this

respect the metaphors of balancing re¯ected how outcomes

from district nursing interventions were as much a product of

how the situation of care was managed as the actual care

provided.

Conclusion

District nurses do not work in an environment that is pliable.

There is a sense in which providing patient care becomes

something which is achieved against the odds. It is argued

that their choice of metaphors illuminates that experience. It

also helped to explain why were apparently irrational or

inconsistent decisions were made so that care could be

1C. Goodman


achieved or relationships sustained (Badger et al. 1989).

There were positive and negative attributes to the group of

metaphors used. They con®rmed the persistent nature of the

hierarchical and gender/role in¯uenced structures that

district nurses have worked within for decades (McIntosh

& Dingwall 1978). They also revealed the skills district

nurses employ to integrate and accommodate con¯icting

demands and needs into their daily work for ultimate patient

bene®t; skills that have not been recognized (NHS Manage-

ment Executive 1992b). Within a NHS that emphasizes

partnerships and collaborative working (DoH 1997), it may

be helpful to discuss further how balancing strategies that

maintain co-operation and interdependence may achieve

healthy outcomes or shared goals.

The metaphors expressed by district nurses were not

unique to them as an occupational group. Their use can be

linked to an understanding of the role of women in how they

manage their work, and how nurses in general relate to those

in authority. Much of what district nurses described was

indicative of their abilities to absorb and accommodate the

expectations of others. (Gamarnikow et al. 1983, McDowell

& Pringle 199255 , Valentine 1996). Nevertheless, the recurring

group of metaphors demonstrated coherence between the

language, observed practice and accounts of how they

worked, that provided speci®c insights for district nursing.

For practitioners, when it is dif®cult to articulate why they

act as they perform, an examination of their use of metaphor

helps to provide a basis for discussion as to the underlying

rationale and principles of practice. Metaphors offer an

opportunity to give voice to what otherwise would be tacit. In

an environment that increasingly emphasizes evidence based

health care and evaluation of practice (Grif®ths 199966 ), there

is a need to develop a shared understanding of the context

and competing realities of primary health care practice that

combine to shape how district nurses work.

Limitations of the study

The study was undertaken with district nurses and colleagues

in the midst of a particular policy change. It is possible that

the interpretation of and signi®cance attributed to the

metaphors identi®ed were speci®c to the experience rather

than a representation of district nursing work in general.

When the ®ndings were fed back and discussed with district

nurses they con®rmed the explanations offered by the

researcher and did not offer alternative interpretations.

Nevertheless, it would be appropriate for subsequent studies

that involve district nursing to explore whether the group of

metaphors described in this study continue to be employed by

practitioners to describe their work and situation.

There are ethical concerns about a study that through its

®ndings raises the practitioners' awareness of their situation

of powerlessness and the contributory factors, but does not

offer support or the opportunity to explore strategies for

changing the situation. Within the presentation of ®ndings to

participants, examples of how practitioners had asserted their

priorities and the strategies they had used to maintain a

correct balance in their work were discussed. Similarly,

strategies that had perpetuated patterns of working that

meant district nurses were accommodating the needs of others

were considered. It was a limitation of the study that although

there were opportunities to discuss the ®ndings it was not part

of the design to work with practitioners to act upon them.

References

Abbott P. & Wallace C. (1990) An Introduction to Sociology: a

Feminist Perspective. Routledge, London.

Audit Commission (1999) First Assessment: a Review of District

Nursing Service in England and Wales. Audit Commission,

London.

Badger F., Cameron E. & Evers H. (1989) District nurses' patients:

issues of caseload management. Journal of Advanced Nursing 14,

518±527.

Colliere M. (1986) Invisible care and invisible women. International

Journal of Nursing Studies 23, 95±112.

Davies C. (1995) Gender and the Professional Predicament in

Nursing. Open University Press, Buckingham.

De Raeve K.M. (1994) The carrier bag theory of nursing practice.

Advances in Nursing Science 16, 9±22.

Department of Health (DoH) (1997) The New NHS: Modern

Dependable. The Stationery Of®ce, London.

Flynn R., Williams G. & Pickard S. (1996) Markets and Networks:

Contracting in Community Health Services. Open University Press,

Buckingham.

Fox E. (1994) District Nursing and the Work of the District Nursing

Associations in England and Wales 1900±1948. Unpublished PhD

Thesis, University of London, London.

Froggatt K. (1998) The place of metaphor and language in exploring

nurses emotional work. Journal of Advanced Nursing 28, 332±

338.

Gamarnikow E., Morgan D., Purvis J. & Taylorson D. (1983)

Gender Class and Work. Heinemann, London.

Gieve K. (ed.) (1989) Balancing Acts: on Being a Mother. Virago

Press, London.

Goodman C. (1998) The Purchasing and Provision of District

Nursing in GP Fundholding Settings: a Case Study. Unpublished

PhD Thesis,99 University of Hertfordshire, UK.

Goodman C., Knight D., Machen I. & Hunt B. (1998) Emphasising

terminal care as district nursing work: a helpful strategy in a

purchasing environment? Journal of Advanced Nursing 28, 491±

498.

Grif®ths J. (1996) An Ethnographic Study of District Nursing Work.

Unpublished PhD Thesis, University of Liverpool, Liverpool.

Grif®ths J. (1999) Group clinical supervision in district nursing.

British Journal of Community Nursing 4, 90±93.



Hiscock J. & Pearson M. (1996) Professional costs and invisible

value in the community nursing market. Journal of Interprofes-

sional Care 10, 23±31.

Hockey L. (1979) A Study of District Nursing; the Development and

Progression of a Long Term Research Programme. Unpublished

PhD Thesis,1010 City University, UK.

James N. (1992) Care, work and carework: a synthesis? In Policy

Issues in Nursing (Robinson J., Gray A. & Elkan R. eds), Open

University Press,1111 Milton Keynes.

Jenny J. & Logan J. (1996) Caring and comfort: metaphors used by

patients in critical care. Image: Journal of Nursing Scholarship 28,

349±352.

Lakoff G. & Johnson M. (1980) Metaphors We Live by. University

of Chicago Press, Chicago.

McDowell L. & Pringle R. (1992) De®ning Women: Social Institu-

tions and Gender Divisions. Polity Press in association with Open

University Press, Buckingham.

McIntosh J. & Dingwall R. (1978) Teamwork in theory and practice.

In Readings in the Sociology of Nursing (Dingwall R. & McIntosh

J. eds), Churchill Livingstone, Edinburgh.

McIntosh J. (1996) The question of knowledge in district nursing.

International Journal of Nursing Studies 33, 316±324.

National Health Service Management Executive (NHSME) (1992a)

Guidance on the Extension of the Hospital and Community

Services Elements of the GP Fundholding Scheme from 1 April

1993. EL (92) 48 NHSME Health Care Directorate, Portland

Place, London.

National Health Service Management Executive (NHSME) (1992b)

The Nursing Skill Mix in the District Nursing Services. Value for

Money Unit, HMSO, London.

Neal B., Chapman N.J. & Ingersoll-Dayton A.C. (1993) Balancing

Work and Caregiving for Children, Adults and Elders. Sage

Newbery Park, CA.

Robinson J. (1993) Problems with paradigms in a caring profession.

In Nursing Art and Science (Kitson A. ed.), Chapman & Hall,

London, pp. 72±84.

Royal College of Nursing (1992) The Value of Nursing. RCN, London.

Ryan D., Tilley S. & Pollock L. (1997) Review of Literature on the

Effectiveness of Community Psychiatric Nurses in Achieving

Health Outcomes for People with Mental Illness. Department of

Nursing Studies, University of Edinburgh, Edinburgh.

Savage J. (1995) Nursing Intimacy: an Ethnographic Approach to

Nurse Patient Interaction. Scutari Press, London.

Smith P. (1992) The Emotional Labour of Nursing: How Nurses

Care. Macmillan, Basingstoke.

Smith P., Mackintosh M. & Towers B. (1993) Implications of the

new NHS contracting for district nursing. Journal of Interprofes-

sional Care 7, 115±124.

Scholes J. (1995) Making the Invisible Visible: an Evaluation of the

Care Management Role of the District Nurse as Part of a NDU

Initiative. Unpublished report, Brighton University, Falmer, Sussex.

Sweet S.J. & Norman I. (1995) The nurse-doctor relationship: a

selective literature review. Journal of Advanced Nursing 22, 165±

170.

Timmons A. (1994) Discharge Dilemmas. Unpublished MSc Thesis,

University of Nottingham, Nottingham.

Turner V.W. (1974) Dramas, Fields and Metaphors: Symxbolic

Action in Human Society. Cornell University Press, New York.

Traynor M. (1996) Rhetoric and Rationality: a Deconstruction of

Managerial and Nursing Discourse in the New NHS. Unpublished

PhD Thesis, University of Nottingham, Nottingham.

Valentine P.B. (1996) Nursing a ghettoised profession relegated to

the women's sphere. International Journal of Nursing Studies 33,

198±106.

Wurzbach E.M. (1999) The moral metaphors of nursing. Journal of

Advanced Nursing 30, 94±99.

1C. Goodman


The use of metaphor in district nursing: maintaining a balance

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