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.     

Caring holistically within new managerialism

This article explains the attempts of nurses to practice humanistic, holistic care in line with their professionalizing strategy. Ideally, the intention of nurses is to broaden their concerns beyond the physiological needs of patients, thereby circumventing biomedical control over their work. However, the author argues that resource constraints, and the coalescing of biomedical and managerial definitions of patients, suggest that holistic notions of care are subjected to a new form of calculus and normalizing technology. Critically, nurses are more preoccupied with the day-to-day struggle to free up resources for healthcare, in particular bed spaces, and to pre-empt the problem of bed blocking. Such work suggests that the "emptying of beds" is not just a symbol of accomplishment for nursing work. From the governmentality theory of Foucault, the administration of "beds" has become part of the managerial power/knowledge discourse and an instrument for making nurses toe the financial bottom-line.     

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.     

Neoliberalism and the government of nursing through competency‐based education

Competency has become a key concept in education in general over the last four decades. This article examines the development of the competency‐based movement with a particular focus on the significance it has had for nursing education. Our hypothesis is that the competency movement can only adequately be understood if it is analyzed in relation to the broad societal transformation of the last decades—often summarized under the catchword neoliberalism—and with it the emergence of managerial models for Human Resource Management (HRM) for the reorganization of social services. Classical professions, which were characterized under welfarism by an esoteric knowledge based on ethical norms, have now become marketable commodities that can be evaluated in the same way as other commodities. We want to underline that while this development is still under way, it is the concept of competency that was the decisive political instrument enabling this profound change. With the widespread implementation of competency‐based education that now governs nursing knowledge, the development of a critical, oppositional perspective becomes more challenging, if not entirely impossible. We will be focusing primarily on nursing education in Canada, although we maintain that it has relevance for nursing internationally.     

Diagnoses and Interventions Pertinent to Intellectual Disability Nursing*

PURPOSE. The field of intellectual disability care in Ireland has been undergoing significant change, and this has called into question the role of specialist intellectual disability nursing. This review aims to identify the diagnoses and interventions that are employed by intellectual disability nurses. DATA SOURCES. Exploration of the relevant professional literature, drawing on a broad scope of sources, was completed. DATA SYNTHESIS. Examination and discussion within the taxonomic structure of the Nursing Interventions Classification. CONCLUSIONS. Initial data set of diagnoses and interventions identified as a basis and justification for further systematic examination of specialist intellectual disability nursing practice. IMPLICATIONS FOR NURSING PRACTICE. Explication and elaboration of the contribution of specialist nursing within intellectual disability care settings.     

Primary health care provision for adults with a learning disability

BACKGROUND: During the last decade, primary care has been designated as the main provider of health care to people with learning disabilities. Practice nurses based in primary care teams are increasingly the first points of contact with health services. They make an important contribution to promoting good health, with health screening and illness prevention work being a significant part of their role. However, little is known about their views or involvement regarding the provision of primary care for people with learning disabilities. There is therefore a need to explore the nursing perspective, from within primary care, on the current provision of care for people with a learning disability. RESEARCH AIM: To inform the learning disability service of the role of primary care in current service provision for people with learning disabilities. RESEARCH METHOD: A survey of all practice nurses currently employed by Grampian Health Board in Aberdeen was conducted in June 2001. An initial pilot study was conducted in primary care and learning disability services. Data collection took place during June and July 2001. All practice nurses working in the geographical region of Grampian were invited to participate. RESULTS: Communication barriers exist, preventing access to health screening and treatment for some people with learning disabilities. Independent living skills, for example dietary management and budgeting, require additional community support. These conditions pose complex problems for practice nurses and other members of the primary care team. CONCLUSION: This study indicates a need for closer support and partnership with the learning disability service. The factors necessary for providing health care to people with learning disabilities extend beyond the domain of primary care teams. The findings of this survey have important implications for education and support to enable carers and professionals to provide a high standard of care.     

Palliative care in nursing homes: exploring care assistants' knowledge

Aim.  To explore the level of palliative care knowledge and to identify educational needs of care assistants (CAs) working within a nursing home context.
Background.  In the United Kingdom (UK) many patients at the end-of-life are admitted to (or reside in) nursing homes, where they receive care from unqualified CAs who have little formal training. Mandatory training in specific skills to meet palliative care needs are absent.
Method.  Questionnaire to CAs in 48 of 91 private nursing homes in one UK region.
Findings.  A population of 1135 CAs were targeted with a response rate of 45% ( n  = 508). A high proportion of CAs in this sample required information about the philosophy and principles of palliative care. Results support the need for an educational initiative to improve palliative care in nursing homes.
Conclusion.  Although recognized as a common place of death for older people, CAs are often unprepared to provide end-of-life care to nursing home residents. It is recommended that attention be given towards developing the skills and knowledge of this staff group.     

Effective health care for people with learning disabilities: a formal carers' perspective

This paper explores the perceptions and experiences of formal carers, working in three different geographical locations in the south of England, in accessing primary health care for people with learning disabilities. The sample included six multidisciplinary, community learning disability teams and 11 managers of small homes for residents who had learning disabilities. Data were collected through focus group and individual semistructured interviews. Levels of collaboration between primary health care groups and the community learning disability teams and the managers of small homes were assessed. Questions were focused upon the importance of primary health care and the key care provider within the community setting. Although some good experiences were recorded, the overall levels of collaboration were poor. Health care was perceived as very important by all of the respondents. The general practitioner (GP) as the coordinator of health care was perceived as the normal model within our health care system but the majority of respondents questioned the effectiveness in relation to their own experiences of accessing health care for people with learning disabilities. The relocation of this role to the learning disability nurse was perceived as a possible solution.     

Service user involvement in care planning: the mental health nurse's perspective

A dissonance between espoused values of consumerism within mental health care and the 'reality' of clinical practice has been firmly established in the literature, not least in terms of service user involvement in care planning. In order to begin to minimize such dissonance, it is vital that mental health nurse perceptions of service user involvement in the core activity of care planning are better understood. The main findings of this qualitative study, which uses semistructured interviews, suggest that mental health nurses value the concept of user involvement but consider it to be problematic in certain circumstances. The study reveals that nurses hold similar views about the 'meaning' of patient involvement in care planning but limited resources, individual patients characteristics and limitations in nursing care are the main inhibiting factors. Factors perceived as promoting and increasing user involvement included: provision of accurate information, 'user-friendly' documentation, mechanisms for gaining service user feedback, and high staff morale.     

Struggles for autonomy in self-care: the impact of the physical and socio-cultural environment in a long-term care setting

Self-care has great significance in individuals' lives because it has been shown to support one's health and well-being in old age. This qualitative study of daily life in a nursing home ward employed an ethnographic design to observe routines and daily activities in the ward. Narrative interviews with the residents and staff were also conducted in order to learn about the environmental experience. The aim was to generate a deeper understanding about how the physical and socio-cultural environments and residents' cultural beliefs influenced participation in their own personal-care activities. The findings demonstrate how the physical and socio-cultural environment in the nursing home actually required older residents to overcome greater physical and cognitive challenges to maintain their participation, autonomy, and dignity in toileting, bathing, and dressing than would have been expected had the resident been living at home.     

Consumerism and health care: the example of fertility treatment

This paper discusses the concepts of consumerism and the consumer of health care, and applies them to the example of fertility treatment, drawing on the health policy literature and data from a study of couples undergoing fertility treatment. It is argued that the concept of the consumer is a slippery one, that it provides only a partial view of being a patient, and that in particular it neglects emotional issues.     

Developing an understanding of gender sensitive care: exploring concepts and knowledge

BACKGROUND: In the United Kingdom (UK), concern about inequalities in health and health care has led to interest in gender sensitivity in health policy and practice. AIM: To develop an understanding of possibilities for gender sensitive care through exploring the concepts of gender and gender sensitivity and through reviewing relevant knowledge about gender and health. METHODS: The dimensions of the concept of gender and theories explaining gender relations are explored through a review of key social science texts. A discussion of gender sensitivity draws on Bowden's analysis of gender sensitive ethics. A literature review of evidence about gender and health identifies relevant knowledge for gender sensitive care. FINDINGS: Seven features of the concept of gender are identified. Gender sensitivity involves an understanding of the socio-political context of experience and relationships. The social context also affects health. Differences in male and female mortality and morbidity rates are likely to be related to differences in economic resources, differences in men and women's position in public and private worlds, to power in social relations and to sexuality and body image. Possibilities for gender sensitive care may be supported through feminist approaches and through a postmodernist understanding of the manner in which discourses shape our understanding of gender and gender relations. Valuing care is a feature of gender sensitivity. CONCLUSION: Gender sensitive care involves recognizing the significance of research related to social influences on health and understanding nursing in its socio-political context, and care in the context of gender relations. Experiential learning can synthesize learning across varied learning modes, bridging learning through experience and formal analysis. Exploring concepts, evidence about gender and health and personal experience will all be important in the development of gender sensitive care.     

Facilitating best practice in aged care: exploring influential factors through critical incident technique

Aim.  The focus of this study is on the perspective of facilitators of evidence-based aged care in long-term care (LTC) homes about the factors that influence the outcome of their efforts to encourage nursing staff use of best practice knowledge.
Design.  Critical incident technique was used to examine facilitators' experiences.
Methods.  Thirty-four participants submitted critical incident stories about their facilitation experiences through face-to-face interviews, telephone interviews, and/or a web-based written questionnaire. The resultant 123 stories were analysed using an inductive qualitative approach.
Results.  Factors at individual and contextual levels impacted the success of facilitators' work. The approaches and traits of facilitators as well as the emotionality and intellectual capacity of nursing staff were the individual factors of influence. On a contextual level, the inherent leadership, culture, and workload demands within LTC homes, as well as externally imposed standards were influential.
Conclusions.  Primary factors influencing the facilitation of best aged care in LTC homes appear to be largely relational in nature and intimately connected to the emotionality of those who work within these settings. Enhancing the interactional patterns amongst staff and leaders as well as promoting a positive emotional climate may be particularly effective in promoting better aged care nursing practice.     

Governing nursing conduct: the rise of evidence-based practice

Drawing on the Foucauldian concept of 'governmentality' to analyse the evidence-based movement in nursing, we argue that it is possible to identify the governance of nursing practice and hence nurses across two distinct axes; that of the political (governance through political and economic means) and the personal (governance of the self through the cultivation of the practices required by nurses to put evidence into practice). The evaluation of nursing work through evidence-based reviews provides detailed information that may enable governments to target and instruct nurses regarding their work in the interest of preserving the health of the population as a whole. Political governance of the nursing population becomes possible through centralised discursive mechanisms, such as evidence-based reviews that present nursing practice as an intelligible field whose elements are connected in a more or less systematic manner. The identity of the evidence-based nurse requires the modern nurse to develop new skills and attitudes. Evidence-based nursing is an emerging technology of government that judges nursing research and knowledge and has the capacity to direct nursing practice at both the political and personal level.     

An analysis of the development of adolescent and young adult cancer care in the United Kingdom: A Foucauldian perspective

This paper analyses the development of the specialism of adolescent and young adult (AYA) cancer care via a Foucauldian lens to consider how knowledge and awareness have grown since questions were first raised about unmet needs of AYAs with cancer. The AYA specialism has gathered momentum over the last 30 years in the United Kingdom (UK) and is fast gathering pace internationally. Fundamental to this process has been the combined contribution from nursing and other health professionals, researchers, policy‐makers and philanthropists. From an initial process of problematisation, through a gradual growth in empirical knowledge and resultant shifts in health policy, a new nexus of expertise has emerged that enabled AYA cancer care to become recognised as distinct from either child or adult oncology. Different stakeholders contributed to the discourses that have underpinned this development—a process likely to continue as it expands further. This paper draws on examples from the growth of the AYA specialism, the emergence of new professional roles and a growth in research. It illustrates how the coalescing of multiple perspectives allowed new discourses and, ultimately, new practices to be established that now have global impact.