Benny Rage against the dying of the light, and you my father curse bless me now with your fierce tears I pray, do not go gentle into that good night.
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Motivation for nurses
Wednesday, January 11, 2012
An old myth about nursing is that is a vocation, a calling based on the desire to help and care for each other. Currently nurses are being criticised for being too educated to care, that they have lost their compassion. I don’t think these things are true. Nurses come to work for a variety of reasons, chief among them of course is paid employment. However, pay itself is not the issue either. Managers and governments need to address more fundamental issues if they want nurses in the NHS to fulfil their mission to provide high quality complex care.
The first thing to do is to dump old ways of thinking regarding motivation. The theory that if you reward good performance then you will get more if it and the converse that punishment of poor performance reduces it, is flawed. Daniel Pink (2009) reviewed the science and based on a good deal of research in both private sector and public sector organisations, criticises the carrot and stick approach.
First the pay issue, the carrot and stick method works when the task is mechanical in nature needing little or no thought. Then rewards for good performance works. Tasks requiring more than rudimentary cognition are different. The globally replicated research indicates that staff who were extremely well remunerated actually performed poorly which might explain why the global finance sector crashed. High pay does not lead to high performance. Pay has to be set, though, to remove it from the table as an issue, so there is a baseline to be achieved where staff no longer worry about their salary. Beyond that level there are there are three other factors at work: Autonomy, Mastery and Purpose.
We need Autonomy to perform well and to be creative. Second we like Mastery. It appears that we like to get better at things, we like to practice to master our skills and finally we need Purpose (or vision) over and above the profit motive. If profit (or cost cutting) is the only goal things go pear shaped. Successful organisations want to make a difference and they develop a transcendental purpose.
The lesson for the NHS is clear. Calls for more nursing leadership to address poor care will fail unless nurses are given or allowed to develop these three things: Autonomy, Mastery and Purpose…that is what will get the nurse leaders of tomorrow really making a difference. Are our organisations up to the task of setting staff free or will they not take the risk and do more of the same? Bureaucracy, managerialism and petty fogging quality processes will kill this initiative. Identify your key members of staff and then give them autonomy to be creative and to master their skills and knowledge, ‘sell’ to them a higher purpose, let them develop their own purpose, and if you don’t know what that is you have work to do. Hands up those of you who can clearly articulate that these three things are your daily experience?
Pink, D. Drive. (2009) The surprising Truth about what motivates us. Canongate. Edinburgh.
What are nurse academics for?
Friday, December 02, 2011
“What are nurse academics for?”
Having pondered on the future of nursing education given various issues such as public concerns about poor quality care, NHS restructuring, funding cuts to humanities, challenges to public sector funding, global health issues linked to sustainability and the challenges of climate change, the commodification of education and its concomitant challenge to critical thinking, the triumph of neoliberal ideology in all areas of social, health and education policy, and an instrumental/vocationally oriented educational philosophy, it occurs to me that we could do with some coordinated critical thinking and action in response.
The literature suggests that some (nurse) academics are very uneasy about the direction that education practice is taking (Thompson 2009, Walker, 2009, Morrall 2010, Shields et al 2011). Darbyshire (2011) suggests that many colleagues say they are too busy to research, publish, present or otherwise engage in scholarship, I have suggested similar (Goodman 2011). The main reason put forward (he writes) is that they see their job is primarily to teach and support students. However, I would add to that growing managerialism and bureaucracy of modern university life (and not just in the UK) allied to the overemphasis on reproducing ‘cognitive capitalism’ in which universities are becoming factory like, (Roggero 2011) turning out fodder for the ‘knowledge economy’ which undervalues critical thinking (Morrall, 2010).
For nursing, our partners in the NHS are so stretched in many clinical areas that student support is at breaking point in terms of their educational development in practice. Clinical practice for too many resembles nothing more than old style apprenticeship experiences where intellect withers, let alone flowers, and the tension between getting the work done and education that Kath Melia identified in the 70’s is as strong as ever.
In this context, Gary Rolfe (2010 p 703) recently noted:
“If the discipline of nursing is to survive and flourish as anything more than a provider of vocational training, it is imperative that we make connections and find our place in the wider community of academics and scholars in what remains of the modern University”.
Darbyshire (2011) goes further:
“nurse educators need to do what they should have been doing the moment nursing moved from the old ‘college of nursing’ world into the university sector and that is connecting with and embracing the world of scholarship that did, and hopefully still does, characterise university life”…..“As a nurse educator, you are not in the business of ‘giving lectures’, ‘marking papers’, ‘supporting students’. ‘facilitating tutorials’, ‘designing curricula’ or the like. You are in the transformation business” (Darbyshire 2011 p 723).
I think this is deliberately provocative and needs to be read in its context. My personal feeling is that we are ‘in the business’ as described but without the transformation bit and struggling to juggle the competing demands placed upon us. However, I also think that some demands maybe self-inflicted, and result from acquiescence, tiredness and apathy which result from disempowerment flowing from treadmill like educational processes.
He then goes on to describe what transformation might mean. While I think his points have merit, there is just a tad too much emphasis on the utility of academic work as a criterion for assigning value, thus omitting the liberal humanistic approach to education which sees it as a ‘good in itself’. That being said the challenge is then put:
“if you are not actively engaged in the research and scholarship of nursing education then be prepared to face the question, “what business do you have being part of a University?” (Darbyshire 2011 p 723).
Good question.
What to do?
I think there is a debate to be had here about the meaning and value and purpose of nursing education. I mean a real debate informed by philosophies, reason and evidence that informs and creates the cultural edifice in which we work. We need to examine the organisational culture which forms the scaffold for our educational values and priorities. There may be taken for granted assumptions which upon examination do not hold water. For example, that we have to account for every hour a student spends in theory and that this is achieved through attendance registers. Another assumption may be about research being too time consuming or too constrained by faculty priorities, there may be assumptions about scholarly activity v teaching or what ‘teaching’ actually means. We may consider whether (Nursing?) Theory informed education as well as research informed education itself may have disappeared from curricula replaced by narrowly defined epistemologies that close down evidence based practice into the confines of ‘empiricalitis’ and the tenets of positivistic science. There may be some bureaucratic processes that actually do not enhance the quality of the student experience at all (the standard module evaluation forms?) either because they do not have robust evaluation or because they are gathering the wrong data. This matters because every minute spent on administrative action is a minute not spent on intellectual sharing and development. The next generation of nurse educators needs mentoring, but they need the intellectual freedom to challenge orthodoxy which requires intellectual spaces or ‘liberated territories’ (Zizek 2008) which are havens of thinking into which all thinkers can migrate and from which thoughts can proliferate and social change can reify.
The reason not to discuss this will of course be time, the treadmill can’t be switched off, can it?
Benny Goodman
refs available on demand)
Nursing, Care scares and Moral Panic.
Thursday, November 17, 2011
Nursing, Care scares and Moral Panic.
The number and tone of reports of poor quality care (e.g. Simmons 2011) especially, since the Mid Staffs NHS trust inquiry but by no means is defined by it, may be described as a moral panic and has been described as a crisis in care (Hari 2011, Phillips 2011a, 2011b) and “reveal a moral sickness in the professional ethic of nursing, and more particularly nurse training…” (Phillips 2011b) .These media reports over poor quality care (Marrin 2009, 2011, Shields et al 2011) and the identification of graduate nurses as folk devils who are “too posh to wash”, lead us to ask why this moral panic over graduate nursing has arisen?
A ‘moral panic’ is when a population feels the ‘social order’ is threatened, and that this threat is felt intensely, it is a certain reaction to a perceived social problem. A moral panic may be characterized by irrational, inappropriate overreactions to problems. Stanley Cohen (1972) applied the term to press reports and establishment reaction to the phenomenon of ‘Mods and Rockers’, a moral panic arises when:
“a condition, episode, person or group of persons emerges to become defined as a threat to societal values and interests” (Cohen 1973 p9). The scathing criticism of graduate nursing in the press looks very similar to this sort of description. So, what societal values and interests are thought to be threatened by graduates?
The first aspect is that some feel a loss of ‘the proper place of women/nurses as mother archetypes’ which is part of the longer term process of female entry into the labour market and the break from domestic duties. Feminism has been blamed for this process (however the requirements of consumer capitalism and the need for labour has also had its effects).
The second is the ambiguities felt over the care of elderly people which increasingly has been seen to be the State’s proper role since the introduction of the Welfare State. Although the expressed social order demands that care of the elderly be done within families, the economy demands labour mobility resulting in geographically fragmented families unable to care for elderly relatives. The loss of the family wage and the rise of consumer culture also affects our abilities to care for both children and the elderly as both parents work. The actual social order is that elderly people are, en masse, in institutions and that allows us to abrogate our responsibilities. Although no one expresses a wish to be in a nursing home, no-one either wants (or is able) to take responsibility for elder care.
The third aspect is that body work which involves intimacy, closeness as well as dirt and disgust, is again seen as female caring work which does not attract any social value or support beyond expressions of stoic heroism on behalf of carers.
Graduate nurses challenge these conceptions by being women who are educated, who work and expect like any other professional to be rewarded for their efforts, there is then a cognitive dissonance between on the one hand a vision of nursing as self sacrificial angels and as professionals requiring proper education and reward as professionals. One way to solve this dissonance is to reframe professional nursing, i.e. ‘train’ them in hospitals (putting them in their ‘proper place’).
However, the place of women, and women as nurses, the ambivalence towards care and its meaning, the increasing marginalisation of the elderly and their devaluing may be manifestations of society’s turn from solid to ‘liquid modernity’ (Baumann 2000). Social values, aspirations and expectations are played out within the themes of globalization, individualization, marginalisation, poverty and consumerism. These are the actual social threats that this moral panic cannot actually name and identify. ‘Folk devils’ have to be found to explain these new forms of alienation. Poor care has been around as long as there have been carers, and so we need to be careful not to argue that liquidity causes poor care, rather it may the case that liquid social conditions predispose individuals to perform in particular ways and for their actions to be interpreted in particular ways. The folk devils are in, this instance, graduate nurses. However, blaming nurses refocuses attention away from more difficult problems and gives easy solutions (‘return training to hospitals and all will be well’).
Liquid modernity, according to Baumann, involves community fragmentation, eroding social bonds, atomized relationships and individualistic expectations all in the context of the globalization of capital and markets which dislocate communities. Workers have to respond to calls for mobility and flexibility or face redundancy. Communities struggle to reconcile competing demands especially with the increasing numbers of elderly people and costs of care. Nurses and midwives find themselves caught between all of these competing demands unable to make the links between their individual experiences and larger social conditions,
If only one nurse abuses a patient we should properly look to the character of the individual nurse for reasons. When cases of reported abuse become legion then the personal troubles of the patients should be seen in the context of the public issues of society. To fully comprehend the position of the abuser we need to address their personal biography and history and the relationship between the two in society. Anyone wishing to analyze why there is poor care needs to avoid simplistic knee jerk moral panic type reactions and grab the idea that nurses can understand their experiences and gauge their fates only by locating themselves within their period, that they can know their own lives only by becoming aware of all those nurses in the same circumstances. Focusing on the personal accountability of care staff without addressing the structural conditions in which they work simply will not do.
So what then is the answer?
Care has to be really valued, and in current society the main way value is ascribed is to place a monetary value onto it and bring it centrally into business planning. Therefore the cost of care has to be brought into all accounting. Capitalist production currently does not take into account the care (and environmental) costs that society bears for that production. However caring still has to be done or else production cannot continue in its current form. This is not a new argument, feminists and environmentalists have been arguing this for years. If society wishes to value care then it has to pay for it. That means increasing the number of staff and paying them a competitive wage so that good quality staff are educated, retained, supervised, developed and valued. Or, as Sue Gerhardt (2010a) agues we should refocus on caring as a real social value and perhaps introduce a ‘caring wage’ (2010b) say £12,000-£16,000 per year? Society has to value care with more than lip service and the stoic angels tag, but in the current economic setting social values are not strong enough to ensure we will do this.
Baumann Z. (2000) Liquid modernity. Polity. Cambridge.
Cohen, S. (1973). Folk Devils and Moral Panics. St Albans: Paladin, p.9
Gerhardt S. (2010a) The Selfish Society. How we all forgot to love one another and made money instead. Simon and Shuster. London.
Gerhardt S.(2010b) The Selfish Society. RSA events. 22nd April. http://www.thersa.org/events/audio-and-past-events/2010/the-selfish-so
Hari, J. (2011) The plan to resolve our care home crisis. The Independent January 26th http://tinyurl.com/5ugyond
Hawken P (1994) The Ecology of Commerce. Harper Collins. London
Marrin, M. (2009) Oh Nurse, Your degree is a symptom of equality disease. The Sunday Times. November 15th
Marrin, M. (2011) Our flawed uncaring NHS is a self inflicted wound. The Sunday Times. May 29th
Phillips, M (2011) The moral crisis in nursing, voices from the wards. Daily Mail. October 21. http://melaniephillips.com/the-moral-crisis-in-nursing-voices-from-the
Phillips, M. (2011) How feminism made so many nurses to grand to care. Daily Mail. October 17. http://melaniephillips.com/how-feminism-made-so-many-nurses-too-grand-
Shields, L., Morrall, P., Goodman, B., Purcell, C. and Watson, R. (2011) Care to be a nurse? Reflections on a radio broadcast and its ramifications for nursing today. Nurse Education Today. doi:10.1016/jnedt.2011.09.001
Simmons, M. (2011) Poor Nursing care. NursingTimes.net. 4th July. http://www.nursingtimes.net/poor-nursing-care/398.thread
Leadership for the future. Where do we go from here?
Thursday, November 03, 2011
“Considerable evidence suggests that neocolonialism, in the form of economic globalization as it has evolved since the 1980s, contributes significantly to the poverty and immense global burden of disease experienced by peoples of the developing world, as well as to escalating environmental degradation of alarming proportions. Nursing's fundamental responsibilities to promote health, prevent disease, and alleviate suffering call for the expression of caring for humanity and environment through political activism at local, national, and international levels to bring about reforms of the current global economic order”. (Falk-Rafael 2006)
The theories and issues so far covered in this module are focused on the individual (micro) and organisational (meso) level of analysis. Nurses are asked to examine their personal resources and the culture of the clinical setting and the hospital environment in which they work. The immediate focus is on patient outcomes: their safety, their recovery, their dignity and their comfort. Many of the policy drivers for critical care rightly ask us all to consider the patient’s journey, to see the issues from their perspectives as well as from our own.
You have been invited to consider whether transformational leadership is a style fit for clinical practice, you have been invited to consider how interpersonal and interprofessional relationships affect your work, you have been invited to consider how we add value in a public sector organisation, you have been invited to consider applying CQI as a process in your work.
But you have not been invited to take the next step: The macro analysis.
A macro analysis asks you to see beyond the individual, the clinical unit and the hospital. It asks you to consider wider socio-political issues that impinge on public health and well being. Critical care rightly focuses on the seriously ill individual and the skills and competencies developed for nurses reflect that. However, Nursing is an ethical endeavour, your exercise of leadership reflects your ethical positions. The decisions you don’t take may be as important as the decisions you do. The world view you ascribe to helps to create the world you live in. You have an opportunity for just a moment to raise your eyes above the bedside and think about your vision for the future.
A good deal of discussion in leadership theory is about vision, that leadership is a role, it is a process and can be exercised by anyone. Being a ‘leader’ is a post holder (chosen, elected , appointed), but a formal post may or may not exercise leadership. So I wish to ask, what are you leading for, for you are all potential leaders regardless of the formal title or post you hold. What is your vision? What are your ethics? What do you care about?
Sarah Parkin (2010) argues that much of leadership education does not clearly see the impending crises of unsustainable economic, business and political practice, has failed to see the wider picture and has failed to ask what is leadership for?
We know we live in a messy world (Peccie 1982, Morrall 2009). The financial crisis that started in 2008 continues prompting the indignados movement. Spain has a 46.2% under 25 unemployment rate where young educated people argue:
“juventud sin futero, sin casa, sin curro, sin pension, sin meido.” (The Economist 2011).
We know that economic inequality has direct health effects (Marmot 2010, Wilkinson and Pickett 2009). We know what the under 5 mortality rate in many countries is still far above the stated target of the Millennium Development Goals (MDG 4). The WHO (2008) supports the ‘social determinants of health’ approach which links social, political and environment issues with human health. Climate change is the biggest threat to public health and security in this century (Costello et al 2009, BMA 2008, 2011, Goodman and Richardson 2009, Goodman 2011).
These issues, Parkin argues, require leadership as “positive deviancy”. A positive deviant is:
“a person who does the right thing for sustainability, despite being surrounded by the wrong institutional structures, the wrong processes and stubbornly uncooperative people” (2010 p1).
There is an urgent need for healthcare professionals to address the sustainability of current politics, economics and social practices (Goodman 2011). The exact nature of that response is down to individuals. However, without some macro analysis we are in danger of leading ourselves into the dark. This then leads us to ask about out ethical responsibilities on a globalised world.
Nurses’ ethical responsibility in a globalised world?
Globalization results in large capital flows, labour movement and displacement and the increasing dominance of TransNational Corporations (TNCs) on economic, social and political life. The demise of state power for the public good and its alignment with finance capital (Harvey 2010, Crouch 2011) – results in its increasing withdrawal from public services in many European countries. The TNCs and ‘the markets’ are two voices guiding politics. The current Eurozone crisis illustrates how politicians have to create polices that the international financial institutions feel are acceptable to them. Collier (2008) suggests that we have a bottom billion stuck in poverty, and the WHO acknowledges wide health inequalities. Even for the Rich, threats to survival are not domestic but global. Perspectives are changing from local to global, the ethics of healthcare thus need to be discussed in this context. The WHO’s Millennium Development Goals also set a global policy framework. There is thusa need for another voice to defend global public goods such as health.
Ethical practice (source Austin 2008):
Paul Ricoeur (1992) suggested that ethics are about “aiming at the good life”, and so if this is the case we ought to consider the good for all. If everyone has a right to the opportunity for a good life, what should the Nursing response be?
Consider the codes of Ethics that govern nursing practice. Where are they and what do they say?
Professional ethics:
• http://www.icn.ch/about-icn/code-of-ethics-for-nurses/ International Council of Nurses. Code of Ethics for Nurses.
Acting Ethically as a nurse in a global community requires a need for transformative thinking and leadership as positive deviance.
My frame of reference is that healthy lives depend on a healthy socio-economic and physical environment as outlined in the Social Determinants of Health approach (WHO 2008) which has as its outer layer in the model 'general socioeconomic, cultural and environmental factors', i.e. social and environmental structures. Thus, I largely agree with Peter Morrall (2009) who argues that patterns of illness and disease are largely determined by issues of social structure and increasingly physical environments. Social structures protect some while damning others to misery and poverty as evidenced in the inequalities in health literature. The affluent even in poor countries and difficult environmental conditions live in 'safe' enclaves where they can ensure clean water and a ready supply of food, even in famine stricken countries, money buys food. However, even the affluent will be affected by global changes in certain key environmental limits.
The key power relationships operating at present is the hegemonic stranglehold of advanced consumer capitalism in which the richest 2% own 50% of the world's wealth (Davies et al 2006). Many do not understand or recognise the notions of limits, while others put undue faith on the resourcefulness of humanity to solve the problems but to do so within the frame of reference of 'business as usual' unaware that their selves are interconnected and interdependent within a much wider framework of meaning.
Thus there is a need to transform thinking. Currently leadership is the problem not the solution because we are not asking what we are leading for.
To encourage and transform leadership there is a need to engage in provocative pedagogy whereby we engage in intellectual critique through being challenged with provocative positions. We need a sociological imagination to connect personal troubles with public issues, to fully understand their personal biographies as related to wider social forces at this point in history.
Medical and nursing disciplines cannot be immune from this process. It is not enough to learn how the body works and what to do when it goes wrong. This is navel gazing of the worse kind. Many doctors and nurses have for a long time been pioneers for social action, acting on behalf of the poor, weak and vulnerable. That is their ethic. That has been their historic mission, the problems of this messy little world may not mean a hill of beans to many but without a reawakening of consciousness and a reconnection of self to others, which includes the biosphere, the future looks grim. Peter Morrall (2009) has argued that we as health professionals and/or academics have an ethical responsibility to take individual, collegiate, and organisational action with regard to the social ills which affect human health and happiness.
However, taking a stand is hard. Ethics is hard. Ethics requires thinking. We may be the only sentient being on the planet who can think and reflect on our existence and the search for ‘truth’ It may be that we have a special responsibility to think about our decisions and why we make them. Damon Horowitz has recently argued (2011):
“ Not only can we think, we must. Hannah Arendt said, "The sad truth is that most evil done in this world is not done by people who choose to be evil. It arises from not thinking." That's what she called the "banality of evil." And the response to that is that we demand the exercise of thinking from every sane person”
But this may lead to ‘Moral distress’ and Moral responsibility - by understanding the disparities in health if we have responsibility what does that mean? We may provoke moral distress, but then what?
Austin, W. Chapter 3 in Tschudin, V. and Davis, A. (eds) (2008) The Globalisation of Nursing. Radcliffe. Oxford.
British Medical Association (2008). ‘Health professionals taking action on climate change’, http://www.bma.org.uk/ap.nsf/Content/climatechange
British medical Association (2011). The health and security perspectives of climate change. October 17th http://climatechange.bmj.com/statement
Collier, P. (2008) The Bottom Billion, OUP. Oxford
Costello, A. et al (2009). Managing the effects of Climate change. Available online at http://www.thelancet.com/climate-change
Crouch, C. (2011) The strange non death of neoliberalism. Polity Press
Davies, J., Sandstrom, S., Shorrocks, A., and Wolff, E. (2006) The world distribution of household wealth. December. UNU-WIDER http://www.wider.unu.edu/events/past-events/2006-events/en_GB/05-12-20
Economist, The. (2011). Left behind. September 10th. http://www.economist.com/node/21528614
Falk-Rafael, A. (2006) Globalization and Global Health: Toward Nursing Praxis in the Global Community. Advances in Nursing Science: January/March 2006 29 (1) p 2-14
Goodman B., Richardson J. Climate Change, Sustainability and Health in United Kingdom Higher Education: The Challenges for Nursing in: Jones P., Selby D., Sterling S (2009). Sustainability Education: Perspectives and Practice Across Higher Education. London, Earthscan.
Goodman, B. (2011). The need for a sustainability curriculum in nurse education. Nurse Education Today [online] http://www.nurseeducationtoday.com/article/S0260-6917(10)00262-5/abstr
Harvey, D. (2010) The enigma of capital and the crises of capitalism.
Horowitz, D. (2011) Calls for a moral operating system. TED.com http://www.ted.com/talks/damon_horowitz.html?utm_source=newsletter_wee
Marmot, M. (2010) .Fair society, Healthy Lives. The Marmot Review. Strategic review of health inequalities in England post 2010. http://www.marmotreview.org
Morrall P (2009a). Sociology and Health. London: Routledge.
Parkin, S. (2010). The Positive deviant. Sustainability leadership in a perverse world. Earthscan . London.
Peccie, A. (1982). One Hundred Pages for the Future: Reflections of the President of the Club of Rome. Futura books.
Ricoeur, P. (1992) in Austin (2008) op cit.
Tschudin, V. and Davis, A. (eds) (2008) The Globalisation of Nursing. Radcliffe. Oxford.
Wilkinson R and Pickett K (2009). The Spirit level. Why equality is better for everyone. Penguin. London.
World Health Organisation (2008). Closing the gap in a generation. Health equity through action on the social determinants of health. WHO.
'basic' nursing and nurses responses
Wednesday, October 26, 2011
I was fortunate to be involved last night in a twitter chat on the subject of ‘basic’ care (#nurchat for you tweeters), this followed on from the recent Care Quality Commission’s report on Dignity and Nutrition which does not make pleasant reading. The issues are current and will be for a long time. I have to agree with Colin Holmes’ observation: “My theory is that these are deep-seated archetypes, established and maintained under the influence of powerful but subtle psychological and social forces, and although not completely impervious to change I don’t think that reiterating the facts of the matter will have much impact on them”.
The nursing archetype referred to is the ‘altruistic caring mother figure’ the implcation is that the graduate technically proficient nurse challenges this deep seated view. The archetype is founded upon gendered and class role perceptions and is addressed in the sociological literature (see for example Peter Morrall Sociology and Nursing 2001). Cognitive psychology teaches us about how we think, how we are prone to cognitive biases, Logic in philosophy teaches us the many logical fallacies we engage in when arguing and the advertising industry is accessing new and sophisticated means of persuasion (see George Monbiot on this “Sucking Out Our Brains Through Our Eyes” http://www.monbiot.com/) which bypass our critical reasoning skills. Thus the public understanding and public policy is not founded on clear and reasoned argument.
My perspective on this is that the “subtle psychological and social forces” will continue to work their ‘magic’ upon the public’s imagination because the public lacks the ‘sociological imagination’ required to excise the base gender/class archetypes. What is required is a Khunian paradigm shift within the public’s understanding of nursing, and this will only come about as the anomalies in thinking are constantly revealed in narrative and political action until a tipping point is reached.
This reinforcess my belief that resistance to the dumbing down of entry gates to graduate nursing and educational provision has to continue and that the nursing community must learn new ways of networking and communicating (social media such as twitter?) to build up the body of anomalies to challenge a hegemonic view of nursing practice. The anomalies include the research evidence of course, but this is much more than clearly communicating what we do and what nursing is based on: it requires stories, narratives, emotion etc, it requires political activism as well (I mean politics in the broadest sense).
Thanks to Peter Morrall I am reminded of Antonio Gramsci’s ‘hegemonic dominance’ which relies on a “consented” coercion. Gramsci was of course analysing class relations in capitalist society in an attempt to understand why the working class accepted the values of the capitalist class as “common sense values for all”. Not until the cultural hegemony of these ‘common sense’ values are revealed for being merely class values, do we reach a a “crisis of authority” then the “masks of consent” slip away, revealing the fist of force.
In our context the public holds ‘common sense’ values about what nursing is, many nurses may hold onto those self same values, both groups not realising that these values locate nursing within a particular social construction of gendered and class understandings of work (e.g. nursing as emotional labour, ‘basic’ caring not requiring professional education etc) which are not common sense at all! Society does not value female labour in the same way as male labour, society does not value old age, why else do we shut them away in institutions that struggle to pay for enough expert staff to care for them? Western societies can find trillions to support an ailling financial system but public hospitals and care homes struggle to pay for enough skilled care in a classic Galbraithian ‘Private affluence-Public squalor’ allignment. That is a toxic mix allied to the archetypes Colin discusses.
So to address poor quality care:
1) value and pay for care - women’s care work is not ‘basic, it is not female work it is human work.
2) value and pay for the elderly - the old have intrinsic worth not economic ‘value’. Capitalism must pay for all its members and not focus rewards on (often mythical)’wealth’ creators.
3) develop staff, supervise staff, educate staff
4) sack or retrain failing staff
5) sack or retrain managers
6)….over to you.