Impersonal trust and professional authority: exploring the dynamics

AIM: The aim of the study was to explore the relationship between impersonal trust, governmentality and professional activity through an analysis of professional discourse. BACKGROUND: This study emerged from an earlier paper that described a four-dimensional model based on Luhmann's definition of trust as "reducing complexity and managing expectations". Linking trust with the Foucauldian notion of governmentality develops this further. Governmentality raises the question of how professional authority is constituted through the practice of nurses and other health and welfare professionals. METHOD: Discourse analysis was used to explore the text from two genres--academic literature and interview material (n = 17)--in the context of community residential services for people with learning disabilities. Findings. The study provided evidence to support claims that trust is produced through impersonal systems. Trust is contested in a dynamic process where there are gains and losses. Professionals in organisations actively promote trust, often through systems of distrust. The study also built on the four-dimensional model of impersonal trust--trust, mistrust, abuse and hope--and re-conceptualized the trust-hope dimension. CONCLUSION: There are theoretical links between governmentality and trust. Similarly, in order to understand trust nurses need to understand the dynamic nature of the systems in which they operate. The proposition that trust could frustrate hope adds an element of controversy to the discussion of hope in the nursing literature.     

An audit of clinical supervision in primary care

This article reports on an audit of clinical supervision in one primary care trust (PCT). Data were collected by telephone interviews with 44 respondents from a range of professions occupying different clinical and managerial grades in the organization. Clinical supervision was varied both in terms of its availability and management between different professional groups and teams reflecting, in part, differing levels of motivation towards supporting clinical supervision by individual practitioners and managers as well as a perceived lack of trust leadership. Respondents also reported several potential and actual benefits of clinical supervision, including the improvement and standardization of practice and the facilitation of learning and professional development, although there was no consensus regarding the most appropriate format (e.g. individual, group or team) or structure (e.g. uni-professional or multi-professional) for clinical supervision. It was widely agreed that the introduction of mechanisms for monitoring both the process and outcomes of supervision, greater protection of time allocated for supervision and more training opportunities to increase the skill and number of available supervisors were needed.     

Discourses of collaborative failure: identity,role and discourse in an interdisciplinary world

Discourses of interdisciplinary health‐care are becoming more centralised in the context of global healthcare practices, which are increasingly based on multisystem interventions. As with all dominant discourses that are narrated into being, many others have been silenced and decentralised in the process. While questions of the nature and constituents of interdisciplinary practices continue to be debated and rehearsed, this paper focuses on the discourse of interdisciplinary collaboration using psychiatry as an example, with the aim of highlighting competing and alternative discourses. The fundamental premise of this paper is that collaborative relationships form the basis of interdisciplinary practices in psychiatry. Through a critical engagement and a deconstructive reading of the pretext, context and subtexts of interdisciplinarity, we interrogate the concept of interdisciplinary practice within psychiatry. We contend that an important part of understanding and further conceptualising the discourse is through fracturing it. This process is illustrated in the successive stages of our conceptual map of discourse development: establishing, maintaining and developing discourses. An understanding of interdisciplinary practice is not only critical for psychiatry, but also offers important insights into the performance of collaborative failures and indeed successes across nursing and allied health professions.     

Patient or consumer? The colonization of the psychiatric clinic

Information is given a privileged place in the psychiatric clinic, as illustrated by the prevalence and volume of data to be collected and forms to be completed by psychiatric nurses. Information though is different to knowledge. The present paper argues that information is part of a managerial discourse that implies commodification whereas knowledge is part of a clinical discourse that allows room for the suffering of the patient. Information belongs to the discourse of managerialism, one that positions the patient as customer/consumer and in doing so renders them unsuffering. The patient's suffering is silenced by their construction as a consumer. The discourse of managerialism seeks a complete data set of information. By way of contrast, another discourse, that of psychoanalysis offers the institution the idea that there are always holes, gaps, and uncertainty. The idea of uncertainty, gaps, things remaining unknown and a limit sits uncomfortably with the dominant discourse of managerialism; one that demands no limits, complete data sets, and many satisfied customers. This market model of managerialism denies the potential of the therapeutic relationship; that something curative might be produced via the transference. In addition, the managerialist discourse potentially positions the patient as both illegitimate and unsuffering.     

Graduates’ development of interprofessional practice capability during their early socialisation into professional roles

Graduates entering the healthcare workforce can expect to undertake interprofessional practices, requiring them to work at the intersection of knowledge and practice boundaries that have been built over years of socialisation in their respective professions. Yet, in complex health environments, where health challenges go beyond the knowledge and skills of any single profession, there is a growing concern that healthcare practitioners lack capability to collaborate with each other. This article presents the findings from a year-long hermeneutic phenomenological study of graduates’ temporal experiences of practice roles in their respective fields of healthcare and in collaboration with other professions. Research findings emerged through an inductive analytic process using thematic analysis techniques and provides an insight into graduates’ early professional practice in contemporary healthcare contexts and the development of their professional practice at the interface of professional boundaries. The 18 graduates from six health professions developed their professional practice in working contexts where intersecting professional boundaries resulted in strengthening professional identity in their chosen professions, through articulating distinct knowledge and skills to other professions during collaborative work. Concurrently they established flexible working relationships with members of other professions, resulting in expanding health perspectives and extending practice knowledge and skills beyond their distinct professions. The study provides new understanding of the relationship between areas of professionalism, identity, and collaborative practice in an evolving health workforce, through the experiences of graduates in their early work as registered health practitioners.     

The meanings of autonomy for physical therapy

The purpose of this article is to explore the social context and meanings of autonomy to physical therapy. Professional autonomy is a social contract based on public trust in an occupation to meet a significant social need and to preserve individual autonomy. Professional autonomy includes control over the decisions and procedures related to one's work (technical autonomy) and control over the economic resources necessary to complete one's work (socioeconomic autonomy). Professional autonomy is limited and weakened by the relationship of one profession to another (dominance), by the influence of other social institutions (rationalization and de-professionalization), and by the internal disposition of the profession itself (insularity). Professional autonomy for physical therapists is increasing as medical dominance has declined but is limited by the trends of rationalization and de-professionalization in health care. Physical therapists must recognize that professional autonomy represents a social contract based on public trust and service to meet the health needs of people who are experiencing disablement in order to maintain their individual autonomy.     

我国专业化养老服务现状及对策研究

通过对我国养老服务队伍、养老服务相关专业学历教育及从业人员的资格认证现状进行分析,提出专业化养老服务队伍发展对策,即加强老年服务工作者的培训力度,大力发展养老服务相关专业的学历教育,建立养老服务从业人员的资格认证制度.     

Patient autonomy and the politics of professional relationships

Debate in the health care professions about the politics of interpersonal relationships between professionals and their patients or clients is increasingly organized around proxy measures of the quality of professional services such as patient satisfaction, or the extent to which the provision of care avoids routines and is genuinely individualized This paper explores some of the problems which arise from this in relation to patients' autonomy and nurses' authority     

Mental health care: trust and mistrust in different caring contexts

Aims and objectives. To identify the factors that make trust within the context of public mental health possible. We also consider the question of patients’ trust in the whole caring system. The study is based on individual interviews with 22 psychiatric patients, who were also users of social services. Background. There are theoretical studies concerning trust between human beings in several disciplines within psychiatry and social services but few studies investigate how trust can be created and what makes it possible. The literature reveals that there is need for research concerning trust in psychiatry. In this study we examined two different caring contexts and investigated what makes trust possible in these contexts. The contexts are termed the Integrated Network and Family Model and the Traditional Model. Design. A qualitative method based on the grounded theory approach was used. Methods. The main focus in the analysis was on how the patients had experienced the contexts of the caring systems and how trust was created or not within them. Results. Three categories creating trust were found in the Integrated Network and Family Model and two in the Traditional context. Acceptance of the patient’s expertise concerning his/her life situation, openness and joint discussions concerning knowledge are important. Trust is closely connected to autonomy and power: patients feel that trust increases as their experience of autonomy increases and in such situations power is not owned by any one person. Conclusions. Trust between psychiatric patients and personnel can be created in both the Integrated Network and Family Model and traditional context, but in different ways. Relevance to clinical practice. Clinical workers and nursing personnel can use our findings in their practical work with psychiatric patients. Our findings support theoretical considerations concerning trust and can be used as guidelines for nursing personnel in their work.     

Instrumentalisation of the health system: An examination of the impact on nursing practice and patient autonomy

Most current management systems of healthcare institutions correspond to a model of market ethics with its demands of competitiveness. This approach has been called managerialism and is couched in terms of much‐needed efficiencies and effective management of budgetary constraints. The aim of this study was to analyse the decision‐making of nurses through the impact of health institution management models on clinical practice. Based on Foucault's ethical theory, a qualitative study was conducted through a discourse analysis of the nursing records in a hospital unit. The results revealed that the health institution standardises health care practice, which has an impact on professional and patient autonomy as it pertains to decision‐making. The results of this research indicate that resistance strategies in the internal structures of health organisations can replace the normalisation and instrumentalisation of professional practice aimed at promoting patient self‐determination.     

Governmentality, student autonomy and nurse education

Title. Governmentality, student autonomy and nurse education. Aim. This paper is a report of a study to explore how governmental practices operated in nurse education. Background. Since the 1980s nurse education internationally has been strongly influenced by educational theories that aim to promote student autonomy by encouraging self‐direction and critical thinking. Newer curriculum models advocate transformative approaches leading to greater emancipation, social equity and inclusion. Although these changes have been positively evaluated there had been limited critical research on how student behaviour is governed. Method. A discourse analytic study was conducted from 2000 to 2004 using interviews (n = 30) with a purposive sample students and teachers in one United Kingdom university. Data were also collated from the course curriculum and student handbook for the students’ programme. Data were analysed to identify how student behaviour is governed. Findings. Two governing practices are described: control and technologies of the self. These practices contribute to an overall system of governing student behaviour that creates tension between the avowed progressive empowerment discourse and taken for granted everyday educational practices. Students are subjected to a range of governmental and disciplinary strategies and, through a process of normalization, ultimately become their own supervisors within the system. Conclusion. The tensions between the demands of a professional outcome‐based nursing programme and notions of empowerment and student autonomy have not been resolved. Instead, present educational practice is characterized by normalizing discursive practices that aim to produce a specific version of a student subject as autonomous learner. Thus, discourses of both empowerment and professional behaviour govern students.     

Multi-sector perspectives on learning for interprofessional practice: lessons for higher education and organisational culture

ABSTRACT

In order to build the evidence base for interprofessional education and practice, it is important to establish how the concepts and theories are understood by higher education providers, policy-makers, managers, and practitioners. Using an interdisciplinary research approach, and facilitated by the use of visual images, we undertook a discourse analysis of interviews and discussions around definitions, competencies, and cultures of learning for interprofessional practice in the context of child health and social care in Scotland. Challenges to interprofessional practice were seen as generated within professional hierarchies and the complicatedness of working with chronic or multisystem disease. In order to work collaboratively, individual practitioners should understand the boundaries of their own knowledge and skills and demonstrate the capacity for interpersonal communication (within and between professions), as well as problem-solving and dealing with uncertainty. While there was agreement on these as key learning needs for collaborative working, the term interprofessional education was rarely used in practice by the interviewees and there was perception of a gap between university and workplace settings in supporting learning for interprofessional practice. It is recommended that educational frameworks acknowledge that the interprofessional learning journey is influenced by context and organisational culture.     

'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.     

Power and confidence in professions: lessons for occupational therapy

BACKGROUND: Powerful professions have the capacity to obtain leadership positions, advocate successfully in the policy arena, and secure the resources necessary to achieve their professional goals. Within the occupational therapy profession, cultivating power and confidence among our practitioners is essential to realize our full capacity for meeting society's occupational needs. PURPOSE AND KEY ISSUES: Drawing from a historical analysis of the medical and nursing professions, this paper discusses the implications of power and disempowerment among health professions for their practitioners, clients, and public image. Theoretical perspectives on power from social psychology, politics, organizational management, and post-structuralism are introduced and their relevance to the profession of occupational therapy is examined. IMPLICATIONS: The paper concludes with recommendations for occupational therapy practitioners to analyze their individual sources of power and evaluate opportunities to develop confidence and secure power for their professional work--in venues both in and outside the workplace.     

Living on dialysis: concerns of clients in a renal setting

Background. This article reports a study that sought to understand the experience of a group of Caucasian men with end stage renal failure managing their own haemodialysis therapy in their homes. Methodology. The study used a critical interpretive methodology. The renal setting was critically viewed as a specialized health care context constituted by several interrelated discourses. Although established by the dominant professional discourse, it also includes a number of others, in particular an obscure client discourse that is a response to the dominant discourse. Methods. Initially participants' own interpretations of their individual experiences were outlined. These were then collectively reinterpreted by contextualizing them in terms of the critical view of the renal setting, in order to discern their own views as renal clients that were obscured by the language and ideas of the dominant discourse with which they had been enculturated. Findings. From an analysis of the set of accounts derived from interviews with six participants, four concerns of the renal client discourse were identified. Together these model their shared perspective, which underlies each of their individual accounts of their experience of illness and therapy. These concerns were: (1) suffering from continuing symptoms of end stage renal failure and dialysis; (2) limitations resulting from negotiating dialysis into their lifestyle; (3) ongoingness and uncertainty of life on dialysis; and (4) altered relationship between autonomy and dependence inherent in living on dialysis. Conclusion. One specific implication of this study is that the distinctive potential of the nursing role in renal settings lies beyond the performance of a range of technical tasks, in addressing the experience of people living on dialysis, described here as the concerns of the renal client discourse.     

A discourse analysis of debates surrounding the entry of nursing into higher education in Ireland

BACKGROUND: It was only at the start of the 21st century that the nursing profession in Ireland gained full entry to the academy, joining the ranks of the graduate professions in healthcare. Up to that time, the system of professional training of nurses in Ireland was based on the apprenticeship-training model. AIM: This paper critically analyses discourses opposing advanced educational preparation for nurses and the entry of nursing to higher education in order to reveal the discursive work they perform. METHODS: The study analyses historical and contemporary texts using a critical discursive approach. FINDINGS: The study uncovers common themes and continuities embedded in discourses concerning the role of the nurse and nurses' professional training. Through professional and popular debate, a particular and enduring set of images of the nurse was constructed, which was antithetical to the idea of a nurse receiving professional training in the academy. The debate was conducted by doctors, journalists, public officials, and by nurses, some of whom were ambivalent or even hostile to the notion of the educated nurse. Much of the debate concerned the role of the nurse and the relationship between knowledge/intelligence and practice/caring. CONCLUSIONS: As outsiders looking into the academy, nurses were required to justify their case for entry into higher education against a discursive backcloth that constructed a dichotomy between the mental and the manual and positioned nursing as a practical and commonsense occupation unworthy of academic study. In consequence, nursing was and continues to be challenged to expose, resist and counter the values and assumptions embedded in this backcloth as they strive to establish, maintain and consolidate their foothold in academia.     

Professional discourse and service cultures: an organisational typology developed from health and welfare services for people with learning disabilities

This study focuses upon the effect of social policy upon a particular area of service provision. It is influenced by the Foucauldian concept of governmentality and the proposition by Lewis et al. that social policy needs to be understood in local contexts. Only through understanding the partial and fragmented impact of policy can we gain a clear insight into the outcomes for users. The study is undertaken through an exploration of the micro politics of organisations providing health and welfare services for people with learning disabilities. It involves an approach to discourse analysis that focuses upon text developed from interviews with service providers, which is brought into contact with published literature in an iterative process. The interpretation of the text produces four themes: power, trust, citizenship and managerialism. The development of these themes and a further holistic interpretation of the text suggest an emerging organisational typology. A typology based upon different articulations of the themes noted that work to produce particular outcomes for service users.