Redescribing reflective practice and evidence-based practice discourses

This paper provides an analysis on the discourses of reflective practice and evidence-based practice. It commences by examining the role of discourse in describing and defining our beliefs and attitudes. Consequently, it argues that each discourse is based on a certain epistemology, which in effect are language constructs that create realities and like all language constructs, the epistemology of each discourse is open to the possibility of being restructured. Sequentially, any discourse can (re)describe a different type of reality by providing a set of different words, values and beliefs. Eventually, by exposing the language play and the engineered binary of the reflective practice and the evidence-based practice discourses it is concluded that these discourses are not mutually exclusive as they have been portrayed by most of the literature, but complementary ones. Finally, reflective practice and evidence-based practice are re-described as supplementary discourses and practitioners can simultaneously utilize both through the process of critical reflexivity.     

Trust and managerialism: exploring discourses of care

AIM: This paper reports a study that explored the relationship between trust and managerialism through an analysis of professional discourse. BACKGROUND: Managerialism is a distinct set of discourses and practices related to managerial effectiveness, flexibility and consumer responsiveness that have come to characterize debates over the provision of health and welfare services across the developed world. At the same time, trust has attracted increasing academic and political interest. Managerial discourses are critical of healthcare professions and the way they operate. Professional opinions are challenged as representing the interests of professions rather than service users; as a consequence trust is contested. However, where practitioners are both professionals and managers, the boundaries between these discourses become blurred. Moreover, paradoxical development occurs where increasing autonomy for practitioners is accompanied by a strengthening of managerial controls over their activity. METHOD: Discourse analysis was used to explore the text from two genres, academic literature and interviews (n = 17), in the context of community residential services for people with learning disabilities. The study was conducted in 2001. FINDINGS: Two broad themes were identified, each with a number of sub-themes. The first focuses on the relationship between managerialism and trust located around the management of expectations. The second, 'the politics of care', explores the way professional and managerial discourse articulate to produce complementary and contradictory positions. CONCLUSION: The colonization of professional activity by managerial discourse has produced a context where professional activity is defined by a series of managerial imperatives; trust, which was once the product of intimate social activity is now shaped through techniques based on distrust such as audits and quality monitoring. Nevertheless, the persistence of tensions between trust and managerialism suggest an ongoing struggle for professional autonomy in the face of increasing managerial controls.     

Exploring nursing expertise: nurses talk nursing

It has become increasingly important for practitioners to articulate their expertise in modern healthcare settings that demand high levels of accountability and evidence-based practice. The material presented within this article has been interpreted drawing from discourse analysis1 to help explore the discourses that shape and influence understandings of nursing practice. What we present are extracts from four of the 35 participant nurses who applied to take part in the Royal College of Nursing Institute's Expertise in Practice (pilot) Project (EPP). The material presented is used to provide a starting point for exploring how nurses talk about and construct expertise in nursing practice. The four nurse participants' clinical practice areas cover palliative care, mental health, intensive care and fertility care. The material reveals high levels of intensity in the nurse-patient relationship, 'maverick' nursing practices and ongoing reflexivity. All of these aspects appear to capitalize on expertise as a 'catalyst' that alters treatment pathways and maximizes patient-centred outcomes. Exploring a discourse of nursing expertise exposes the tacit situated nature of professional practice that is heterogeneous and most difficult to articulate and explain. It is proposed that expertise tends to be understood from traditional and dominant discourses of medicine, management and technology. Explaining expertise in practice exposes non-conventional practice that in itself can be isolating and challenging to the status quo of contemporary health-care.     

Discourse analysis: towards an understanding of its place in nursing

AIM: This paper describes how discourse analysis, and in particular critical discourse analysis, can be used in nursing research, and provides an example to illustrate the techniques involved. BACKGROUND: Discourse analysis has risen to prominence in the 1980s and 1990s in disciplines such as the social sciences, literary theory and cultural studies and is increasingly used in nursing. This paper investigates discourse analysis as a useful methodology for conducting nursing research. Effective clinical reasoning relies on employing several different kinds of knowledge and research that draw on different perspectives, methodologies and techniques to generate breadth of knowledge and depth of understanding of clinical practices and patients' experiences of those practices. DISCUSSION: The steps in a discourse analysis include: choosing the text, and identifying the explicit purpose of the text, the processes used for claiming authority connections to other discourses, construction of major concepts, processes of naming and categorizing, construction of subject positions, construction of reality and social relations and implications for the practice of nursing. The limitations of discourse analysis, its relationship to other qualitative approaches and questions for evaluating the rigour of research using discourse analysis are also explored. The example of discourse analysis shows how a text influences the practice of nursing by shaping knowledge, values and beliefs. CONCLUSION: Discourse analysis can make a contribution to the development of nursing knowledge by providing a research strategy to examine dominant discourses that influence nursing practice.     

What mental health nurses have to say about themselves: A discourse analysis

Mental health nursing is largely invisible within public discourse. When mentioned at all in news media, it is usually a signifier of an occupation connoting where a nurse works. There is rarely a presumption of expertise in any sphere or articulation of a unique skill set or defining features which differentiate the mental health nurse from other nurses. This paper sought to examine the professional discourse around mental health nursing as inferred from a review of papers published in the International Journal of Mental Health Nursing in 2019. A discourse analysis of full‐text papers (n = 117) was undertaken exploring references to mental health nurses or nursing and what this communicated about the field. The discourse clustered around three themes: The invisible or absent mental health nurse, ambiguous and blended identities, and a group of low attributed value and sophistication. There were few examples of authors presenting mental health nurses in a way which counters stereotypes of the dominant discourse about mental health nurses as a lesser skilled occupational group. Academics, editors, authors, and practitioners are urged to contribute to the construction of discourse around mental health nursing expertise which differentiates it from other branches of nursing and other distinctive disciplines.     

A discursive exploration of the practices that shape and discipline nurses' responses to postoperative delirium

A discursive exploration of the practices that shape and discipline nurses' responses to postoperative delirium Although delirium is classified as a medical emergency, it is often not treated as such by health care providers. The aim of this study was to critically examine, through a poststructural, Foucauldian concept of discourse, the language practices and discourses that shape and discipline nurses' care of older adults with postoperative delirium (POD) with a purpose to question accepted nursing practice. The study was based on data collected from face-to-face, in-depth, personal interviews with six nurses who work on an acute postoperative patient care unit. Five analytic readings of the data identified two prominent discourses at work in nursing practice which influenced the care of patients with POD. These were identified as discourses of legitimacy/illegitimacy and discourses of nursing work. Through the process of poststructural analysis it became evident that one overriding discourse - the biomedical/scientific discourse - served to direct, legitimize and govern all other discourses. The findings of this study have implications for nursing knowledge and practice, length of hospital stay and improved patient outcomes. This study builds on previous work and is the first study to conduct a discourse analysis illuminating nurses' responses to POD through comparison with other acute medical emergencies from a poststructural perspective.     

'Inductions of labour': on becoming an experienced midwifery practitioner in Aotearoa/New Zealand

This paper analyzes and explores varying discourses within the talk of new practitioner direct entry (DE) midwives in Aotearoa/New Zealand. In Aotearoa/New Zealand, midwifery is theorized as a feminist profession undertaken in partnership with women. Direct entry midwifery education is similarly based on partnerships between educators and students in the form of liberatory pedagogies. The context for the analysis is a large ethnographic study undertaken with a variety of differently positioned midwives based mainly in one city in New Zealand. I interviewed and observed over 40 midwives in their different practice settings in 2003. Complex and contesting forms of knowledge production are analyzed in this paper drawing on methodological insights from Foucauldian discourse analysis. New practitioners engage in techniques of self-monitoring and surveillance as they move towards becoming established practitioners. New midwifery subjectivities and forms of knowledge production which contest authoritative forms of knowledge are produced. Midwives in New Zealand are seen to inhabit a complex and liminal space of midwifery praxis. Paradoxically, they are exhorted to remain the 'guardians of normal birth' in a time of increasing interventions into birth both locally and internationally. Paradoxes encountered by new midwifery practitioners in New Zealand as they struggle to maintain ideals of 'normal' birth may be paralleled by the constraints inadvertently produced through governing discourses of emancipatory or liberatory pedagogies. The relevance of this is also highly critical for midwifery and birth practices internationally.     

The discourse of speech-language pathology

As speech-language pathologists we seek to understand the communication of others, but rarely turn our attention to how we communicate. In this paper I consider what our discourse about our own profession may communicate about the culture of speech-language pathology. To consider our professional discourse, I use the approach of critical discourse analysis to examine the discourses produced about and by those involved with communication difficulty as “artefacts” of the cultural ideology in which they are embedded. Through analysing discourses and the contexts in which they are produced, we can begin to identify the underlying socio-cultural forces that are instantiated and maintained through such discourses. This paper introduces the concepts central to critical discourse analysis, and examines some key examples of the discourse artefacts of speech-language pathology in relation to scope of practice in order to reflect on what these discourses may tell us about our professional culture.     

Exploring nurse learner wastage/persistence using a discursive approach: towards a theoretical understanding of the subject

RATIONALE AND AIMS OF THE STUDY: This article summarizes the findings of an exploratory study of nurse learner wastage/persistence conducted in England between 1996 and 2000. Given the lack of theorizing in much of the literature on nurse learner wastage/persistence, this study sought to generate a theoretical standpoint from which to explore voluntary nurse learner wastage. DESIGN/METHODS: The theoretical standpoint developed drew together the theme of integration, derived from the work of Tinto, with the themes of identity and discourses, as conceptualized by Foucault. Accordingly, integration was defined in terms of how well the learner was able to subscribe to the subjectivities made available by the institutional discourses. One of the chief strengths of this approach was that it facilitated an understanding of the interaction between the individual and the institution in relation to wastage/persistence. A multiple case study strategy was used which focused on learners in the first year of a Project 2000 course. The case study strategy utilized a range of qualitative research methods. FINDINGS AND CONCLUSION: The findings indicated that the institution was constituted by two major discourses: the 'apprentice' discourse and the 'autonomous' discourse. It was found that the stayers were much more integrated into the institution, hence they were able to persist on the course, by virtue of being able to manage the contradictions in their identity as a nurse and a learner that these two discourses engendered.     

Discourses on empowerment.

The discourse community of British psychiatric and mental health nursing is a contested realm. The 'Big Stories' of policy and planning of services are clearly articulated in disputes in journals, but the 'Little Stories' of nurses' work and patients' or users' experiences may be ignored or under-valued. This paper illustrates how the Big Story of a central theme in current policy--empowerment--is articulated in the realm of research funding and design, and how it is articulated by practitioners. The paper focuses attention on the responsibilities faced by researchers, in relating the Little Stories of practice and the Big Story of policy. It reports early and tentative findings from a study of community psychiatric nurses' empowerment of people with enduring mental disorders. The paper suggests ways in which strategies for analysis of qualitative data from interviews with CPNs may be informed by ideas drawn from the field of discourse analysis; reflexively examining how researchers' discourses relate to those of policy makers and mental health nursing practitioners. This paper is based on a presentation at the Network for Psychiatric Nursing Research Conference, Napier University, Edinburgh, 17 September 1997.     

Social inclusion/exclusion as matters of social (in)justice: a call for nursing action

Social inclusion/exclusion involves just/unjust social relations and social structures enabling or constraining opportunities for participation and health. In this paper, social inclusion/exclusion is explored as a dialectic. Three discourses – discourses on recognition, capabilities, and equality and citizenship – are identified within Canadian literature. Each discourse highlights a different view of the injustices leading to social exclusion and the conditions supporting inclusion and social justice. An Integrated Framework for Social Justice that incorporates the three discourses is developed and used to critique the dominant focus on distributive justice within foundational Canadian nursing documents. We propose a broader conceptualization of social (in)justice that includes both relational and structural dimensions. Opportunities for multilevel interventions to promote social justice are identified. This framework is congruent with nursing's moral imperative to promote health equity and with the multiple roles played by nurses to promote social justice in everyday practice.     

Shattered expectations: when mothers’ confidence in breastfeeding is undermined – a metasynthesis

Objectives: Why do mothers give up breastfeeding, even though breastfeeding has great importance to them? This study examines what has affected mother’s confidence in breastfeeding when she gives up breastfeeding. Method: A metasynthesis of seven studies on mothers’ experiences with breastfeeding was conducted using Noblit and Hare’s methodological approach. Results: The metasynthesis shows that confidence in breastfeeding is shaped by shattered expectations and is affected on an immediate level by mothers’ expectations, the network and the breastfeeding experts and on a discourse level by the discourses: breastfeeding as nature, the female body as a machine and the note of caution. Foucault’s concept of discourse is used to discuss how these discourses affect mothers’ confidence in breastfeeding by giving the right to speak about breastfeeding to the breastfeeding experts, by isolating the mothers who do not breastfeed and by organizing knowledge about breastfeeding in a certain way. Conclusions: The individual mother is responsible for the success of breastfeeding and the discourses are hiding that general perceptions of breastfeeding undermines the mothers’ confidence in breastfeeding and leads to shattered expectations.     

Professional caregivers' work with the dying in nursing homes – a Foucault‐inspired analysis of discourses in the last decade in a Danish context

International studies on the death of elderly nursing home residents show the complexity in the understanding of the professionals who care for the dying. The aim of this study is to explore the discourses about professional caregivers caring for those dying in Denmark in the last decade. A discourse analysis inspired by Foucault was constructed. The material consists of different source documents: research articles, newspaper articles, theses, books, websites – 35 sources in total. There are constructed six positions of speech, five discourses and three themes: (1) ‘the work of the professional caregivers – a complex low‐status work’; (2) ‘the education of the professionals – the way to ensure a good death or possessing the right qualifications’ and (3) ‘the vulnerable professionals’. The study concludes that an economical/political discourse is dominating and sets up the frames within which the professionals care for dying residents, although the medical, the social/critical and the religious discourses attempt to speak against it. All positions articulate that the professional caregivers' job has a low status and that it is not possible to provide an optimal care due to lack of time, resources and education. Psychical or mental demands make the professionals vulnerable. The meaning of optimal care varies according to the positions of speech.     

Managing risk: a qualitative study of community-based professionals working with learning-disabled sex offenders

This study reports on research conducted to examine how community practitioners manage the difficulties of risk assessment in relation to people with a learning disability and a history of sexually offensive or abusive behaviour. Semi-structured interviews were conducted with a number of key professionals from various disciplines, all currently involved in the assessment process with the aim of determining potential referral to community settings. Data analysis revolved around a thematic exposition of factors influencing the relationship between the objective science of psychiatric investigation and the subjective interpretation of real-world practicalities in working with this group. Findings surrounded three major themes, frame conflict, relating to the difficulties of decision making in this area, therapeutic performance, whereby professionals were expected to engage in some form of active intervention, and safety outcomes, involving consideration of the problematic nature of judging the likelihood of re-offending.     

Disclosing discourses: biomedical and hospitality discourses in patient education materials

Patient education materials have the potential to strengthen the health literacy of patients. Previous studies indicate that readability and suitability may be improved. The aim of this study was to explore and analyze discourses inherent in patient education materials since analysis of discourses could illuminate values and norms inherent in them. Clinics in Sweden that provided colorectal cancer surgery allowed access to written information and ‘welcome letters’ sent to patients. The material was analysed by means of discourse analysis, embedded in Derrida's approach of deconstruction. The analysis revealed a biomedical discourse and a hospitality discourse. In the biomedical discourse, the subject position of the personnel was interpreted as the messenger of medical information while that of the patients as the carrier of diagnoses and recipients of biomedical information. In the hospitality discourse, the subject position of the personnel was interpreted as hosts who invite and welcome the patients as guests. The study highlights the need to eliminate paternalism and fosters a critical reflective stance among professionals regarding power and paternalism inherent in health care communication.     

A discursive exploration of nursing work in the hospital emergency setting

Emergency nurses apply specialist knowledge to the practice of emergency care. This paper discusses the ways in which three emergency nurses understand the nature of their care from their own frames of reference and experiences and presents some of the data collected in a larger study. Various discourses, which compete to inform emergency nurses' understandings of practice, are linked with the notion of nurses as subjects; that is, each discourse may inform, shape and constitute the practice of the nurse and, in turn, the ways in which the patient comes to be known and understood. I will examine the ways in which emergency nurses come to experience or position themselves vis-à-vis extant forms of knowledge of emergency care and the extent to which they articulate new or distinctive formulations of emergency care. This paper illuminates the commonalities that constitute the discourses of emergency nursing care, and also analyse nurses' language which demonstrates that within each discourse variations, contradictions and resistances exist. Emergency nursing care occurs in a context of a biomedical discourse that dominates, or tends to dominate, the work of the emergency setting and so to determine acceptable or possible practices. Nevertheless, nurses contest in various ways the 'truths' that they understand to underpin their practice. Challenges to biomedical discourses are revealed, to some extent, by drawing attention to specific situations and particular struggles encountered in emergency nurses' everyday practice.     

Constructions of spirituality in contemporary nursing theory

BACKGROUND: The nursing literature on spirituality tends to agree that modern science is relatively powerless to address the loss of personal meaning experienced by people facing death, suffering and loss. As a remedy, the literature recommends addressing patients' spirituality. The typical analytical move is to distinguish spirituality from religion and consider it a part, dimension or property of the patient. AIM AND METHOD: This paper uses discourse analysis to identify the formal properties of scientific and religious discourses and their social and political implications. The nursing literature is then investigated to detect the use of such discourses in constructing the object spirituality and to consider any implications for nursing as a social practice. FINDINGS: Far from escaping science and religion, the literature constructs spirituality by means of scientific and religious discourses. These discourses have characteristic strengths and weaknesses that the nursing literature seems to miss. Accordingly, its use of religious discourse lacks coherence and depth, and risks merging human with transcendent authority. Its use of scientific discourse lacks precision and clarity and risks intensifying those features of modernity which contribute to a loss of personal meaning in the face of death, suffering and loss. CONCLUSION: Nursing literature on spirituality raises important questions but is limited in its capacity to address them. This paper provides an alternative perspective. First, it draws on an analysis of the modern institutional environment and its existential dimension. Secondly, it applies discourse analysis to the task of helping people experiencing illness and injury. This approach respects the strengths and limitations of both scientific and religious discourses.     

An emerging discourse: toward epistemic diversity in nursing

Grounded in a postmodern feminist methodology, this article undertakes an initial analysis of a newly emerging discourse in contemporary nursing academia in the United States. Two currently prominent discourses in nursing, a dominant discourse informed by the processes and values of "science" in the Enlightenment sense and a concurrent marginalized discourse informed by postmodernism, are described as a context for the emerging discourse. A genealogy informed by the work of Foucault is presented as a basis for an analysis of the power effects resulting from the conflict between these 2 discourses. Finally, 3 recent texts in nursing are analyzed and common themes identified as indicative of a new intertextual discourse, termed "epistemic diversity," emerging from this discursive conflict.     

Decrepit death as a discourse of death in older age: implications for policy

Background.  In Australia, care of the older person dying in residential aged care is contentious. This paper reports on selected results of a study of aged and palliative care policies, undertaken to elicit discourses of dying in aged care environments.
Aims.  To gain understanding of the relationship of policy to practice and to highlight commonalities and differences between aged and palliative care policies.
Design and method.  Utilizing discourse analysis, a range of palliative care and aged care documents were analysed, to explicate layers of complexity. Two divergent discourses emerged in the data organization.
Results.  The dominant palliative care discourse about dying decries an 'undeserved death'; the discourse about an older dying person is described as 'decrepit death'. These competing discourses provide a framework for examining emerging national policy work to improve care of the dying.
Conclusions.  Dying in residential aged care has been hidden and unacknowledged by the community. The challenge of providing more equitable care has recently received significant government policy attention.
Relevance to clinical practice.  Policy influences practice; both aged care and palliative care nurses, could benefit from understanding the place of policy in implementing changes on behalf of those in their care.