combined effect of the medical model of care and a philosophy of health care as a business is threatening the complex human interactions that are essential to nursing. In the United States, nursing in 1999 is practiced in an environment that restricts understanding of its value and purpose.

Presence, physically being there and psychologically being with another, is a nursing ideal that is essential to nursing (Gardner & Mohnkern cited in Rogers, 1996). Being physically and psychologically present are components of effective nurse-patient relationships (Rogers, 1996). Unfortunately, creating affirming interpersonal relationships is often not considered efficient or effective by corporate managers. As a result, nurses and patients are marginalized within a profit-driven system that reduces individuals to mere commodities.

A study was undertaken to explore nurses' experience with the ideals of nursing and the reality of health care. Ethnography was used as the method to examine cultural power relations. In-depth interviewing, participant-observation, and document analysis were the methods of data collection. Interviews with a key informant and coworkers were transcribed verbatim and became part of the field notes recorded during participant-observations; 58 pages of organizational documents were reviewed to improve understanding of the service culture. Data collected in 6 months, on different days of the week, and at varying times of day, provided a description of participants and the context of one 49-bed pediatric unit in a 774 bed not-for-profit hospital in southeastern United States.

Narrative content analysis was done on the interview transcripts, documents, and field notes using procedures described by Strauss and Corbin (1990). The entire ethnographic record was read line-- by-line searching for words that describe the culture of nursing practice. Codes were continually compared, action with action, across all sources of data, through higher levels of abstraction until categories were identified for the conflicts nurses experience in practice. Findings were reviewed by the participants who confirmed that the emergent cultural characteristics and conflicts accurately and adequately described their experiences.

The four