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.     

Development of an instrument to determine competencies of postgraduate ICU nurses in Cyprus

Aims and objectives: The study sought to explore the expected competencies for postgraduate intensive care unit nurses aiming to develop a future competency-based curriculum. The aim of this part of the study is to develop a new instrument to determine what competencies are expected of postgraduate critical care nurses. Background: Despite existing competency frameworks that emerged from research in the area of critical care, globally and within countries there is diversity and an ongoing debate regarding level of critical care education, outcomes and competencies acquired. Design and methods: A combination of qualitative and quantitative approach was used. In first stage (qualitative), focus groups and interviews were used aiming to explore critical care nurses views concerning expected competencies of postgraduate critical care nurses. In second stage (quantitative), an 81 items Likert scale questionnaire, which was designed based on qualitative data and literature, was distributed among critical care nurses in Cyprus (n: 234, response rate 66%) aiming to receive feedback from clinical nurses and validate the instrument. Psychometric approaches such as internal consistency reliability using Cronbach's α and construct validity were used to validate the instrument. Results: The final questionnaire includes 72 items and has a four-dimensional structure. The four dimensions are (1) leadership/management and professional development, (2) decision-making and management of emergencies, (3) provision of care and professional practice and (4) ethical practice. All factors were highly reliable, with Cronbach's α ranging from 0·895 to 0·974. Conclusions: A new instrument to determine what competencies are expected of postgraduate critical care nurses was generated from this study. A new framework of competencies is grounded on this study that addresses the holistic, individualized and ethically informed quality care of critically ill and may inform educational strategies. Relevance to clinical practice: Critical care nurses competencies need to be determined for quality care and speciality development.     

Nurses' and doctors' knowledge of pain after surgery

AIM: To analyse the links between levels of acute pain management knowledge, perceptions of clinical skills and the acute pain management education history of doctors and nurses working in orthopaedics and general surgery in an acute hospital. METHOD: Questionnaires were sent to 101 doctors and nurses. Eighty two were returned. Questions were derived from an abridged version of McCaffery and Ferrell's (2002) Nurses' Knowledge and Attitudes Survey Regarding Pain, acute pain literature and the trust's clinical standards and protocols. RESULTS: The results identified the most useful sources of acute pain management education and who accessed these; barriers to good acute pain management, other than a lack of education; differences between doctors and nurses in standards of education, levels of perceived competence and knowledge in assessment, pharmacology and analgesic delivery systems. CONCLUSION: Staff and patient misconceptions, inadequate sources of learning and professional traditions continue to affect the quality of acute pain management. However, progress has been made in the trust to overcome these factors through collaborative practice, review of education programmes and specific practice development initiatives.     

The relationship between continuing professional education and commitment to nursing

Nurses have a responsibility to undertake continuing professional development to enable them to keep abreast with changes in health care. Acquiring new knowledge and skills is essential for nurses to practice safely in new and extended roles. Opportunities for continuing professional development are thought to increase retention. The aim of this study was to explore the relationship between undertaking continuing professional development and commitment to the profession and the employing National Health Service trust and to explore any differences between nurses in standard and extended roles. A questionnaire survey was undertaken with 451 nurses employed in three contrasting trusts. The questionnaire incorporated a validated scale to measure organisational and professional commitment. Three hundred and eighteen (70.5%) of the nurses had undertaken continuing professional development over the previous 12 months. Ninety nine nurses (22%) had received only mandatory training over the same period. There was no evidence of a relationship between professional and organisational commitment and undertaking continuing professional development. There was no evidence that specialist nurses in extended roles had undertaken the developmental continuing professional development that would be expected in order for them to acquire new competencies and skills.     

Enhancing patients' trust in the virtual home healthcare nurse

Typically, patients develop trusting relationships with their nurses through a variety of face-to-face, often hands-on, interpersonal interactions that convey the nurse's ability, integrity, and benevolence. However, in telehome care, face-to-face interaction is limited, so nurses must learn to use different strategies to convey those professional characteristics that promote patients' trust. This study explores the nature of trust and the way it develops, and suggests strategies that can be used by telehome care nurses to counter any barriers to trust imposed by the technology.     

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.     

Nursing as means of governmentality

BACKGROUND: This paper conceptualizes nursing as a health profession in transformation at the beginning of the 21st century. We frame our analysis using Michel Foucault's concept of governmentality. While extensively quoted and used in other disciplines, the work of the late French philosopher has been cited infrequently in the nursing literature. Yet a closer look at his work reveals how Foucault offers a relevant entry point for revisiting nursing theory and nursing practice. AIM OF THE PAPER: aim of this paper is to reflect on nursing practice as it is inscribed within the state's modus operandi. We discuss the prevalent notion that nurses are powerless and suggest they do exercise power in many ways and that they are a powerful group. RESULTS: In this paper we show how nursing is a means of governmentality of individuals and of the population because its practices contribute to the management of society through a vast range of power techniques. These techniques range from disciplining individuals to promoting discourses that construct desirable subjectivities. Within this perspective, the emergence of political aspects of nursing theory and nursing practice are made explicit. CONCLUSION: We explore the limits and potentials of the concept of governmentality to the understanding of nursing as a health profession. This concept can generate a form of critical immobilism, but also promotes a more politically complex understanding of nursing practice.     

Developing expertise - the contribution of paediatric accident and emergency nurses to the care of children,and the implications for their continuing professional development

AIM: The purpose of this paper is to explore the contribution of paediatric accident and emergency nurses to the care of children. METHOD: Using a case study approach, the paper focuses on the experiences of three nurses working in this setting, obtained through working alongside the nurses and discussing and observing their experiences. FINDINGS: It became apparent that the nurses were regarded as "experts" in the care of children in this setting. The nurses themselves however, did not share this perception. Their experiences are analysed with reference to literature on expertise, focussing specifically on published accounts of children's nurses' experiences, and research which has explored the concept of expertise within the context of accident and emergency work. The implications for continuing professional development needs are discussed within the context of recent government reports, which make recommendations in respect of access and delivery of on-going professional education. To this end it is advocated that a multi-professional approach is adopted, with children's nurses sharing learning and thus access to, courses customarily provided to adults nurses working in this setting.     

中国护士与非洲护士专业价值观的调查研究

[目的]调查了解不同地区护士专业价值观的差异及其原因。[方法]运用护理人员专业价值观量表(NPVS-R),采用便利整群抽样的方法,对117名非洲护理人员和142名中国护理人员进行问卷调查。[结果]中国护理人员专业价值观得分与非洲护理人员专业价值观得分差异有统计学意义;中国护理人员信任和照顾维度排在前两位,非洲护理人员行动主义和信任维度排在前两位。[结论]不同的文化背景对护理人员专业价值观具有一定的影响作用,加强文化交流,积极学习借鉴,是提升我国护士专业价值观的有效途径。     

应用Q方法论分析韩国护士对举报的感知类型

目的探索护士对举报的主观意见类型,确定每种主观意见类型的特点。方法以Q方法论为理论依据,设计能够认定临床护士对举报感知类型的方案,进行访谈调查,访谈资料采用Q-因素分析。结果大多数专业护士对举报持肯定态度,认为举报可以防止不专业和不道德的护理行为给患者带来的损害;同时她们要求能按合法的程序举报以增加同事间的相互信任;也有一些护士对举报持抵制态度。结论举报能否达到应有的目的,要看护士对举报所持的态度。韩国护士多数支持举报,只要采取合法的程序举报,可以起到保护患者免受不道德和不专业护理行为的损害。     

Engagement between adults in suicidal crises and nurses in mental health wards: a qualitative study of patients' perspectives

ObjectiveTo understand how patients in suicidal crises perceive their engagement with nurses in mental hospitals.MethodsA qualitative study based on grounded theory was conducted. Semi-structured interviews were used with 11 hospitalised adults living through suicidal crises. The data were analysed by multiple researchers, using the constant comparison method, coding, and memo writing.FindingsThe core process was: ‘Feeling nurtured through an interpersonal engagement’. This process underpinned two categories: ‘Feeling safe and cared for while struggling to trust’ and ‘Working toward alleviation and change of my suicidal ideation’. The patients valued nurses who integrated caring approaches of building trust, demonstrating compassion, and promoting safety, with healing approaches of helping them to express and explore their suicidal ideations, and develop new insights and ways of coping. This interpersonal engagement could nurture patients' feelings of being accepted and understood, and being hopeful and capable of overcoming their suicidal ideations.ConclusionThe conceptual insights can inform strategies to reframe overly instrumental approaches to prevent suicide and treat suicidal ideation, and instead promote an interpersonal orientation in nursing practice that integrates caring-healing approaches.     

Use of complex adaptive systems metaphor to achieve professional and organizational change

AIM: This paper uses the experiences of a programme designed to bring about change in performance of public health nurses (health visitors and school nurses) in an inner city primary care trust, to explore the issues of professional and organizational change in health care organizations. BACKGROUND: The United Kingdom government has given increasing emphasis to programmes of modernization within the National Health Service. A central facet of this policy shift has been an expectation of behaviour and practice change by health care professionals. METHODS: Change was brought about through use of a Complex Adaptive Systems approach. This enabled change to be seen as an inclusive, evolving and unpredictable process rather one which is linear and mechanistic. The paper examines in detail how the use of concepts and metaphors associated with Complex Adaptive Systems influenced the development of the programme, its implementation and outcomes. FINDINGS: The programme resulted in extensive change in professional behaviour, service delivery and transformational change in the organizational structures and processes of the employing organization. This gave greater opportunities for experimentation and innovation, leading to new developments in service delivery, but also meant higher levels of uncertainty, responsibility, decision-making and risk management for practitioners. CONCLUSION: Using a Complex Adaptive Systems approach was helpful for developing alternative views of change and for understanding why and how some aspects of change were more successful than others. Its use encouraged the confrontation of some long-standing assumptions about change and service delivery patterns in the National Health Service, and the process exposed challenging tensions within the Service. The consequent destabilising of organizational and professional norms resulted in considerable emotional impacts for practitioners, an area which was found to be underplayed within the Complex Adaptive Systems literature. A Complex Adaptive Systems approach can support change, in particular a recognition and understanding of the emergence of unexpected structures, patterns and processes. The approach can support nurses to change their behaviour and innovate, but requires high levels of accountability, individual and professional creativity.     

Work narratives: gender and race in professional personhood

An ethnographic study was conducted to explore how nurses construe and understand their professional culture and their professional personhood. The sample was 36 nurses ranging in age from 26 to 63 (12 African American women, 11 White women, 13 men 12 White and 1 Caribbean Islander). Data were gathered through participant observation, audiotaped individual conversations, a process of seven consecutive group sessions, and short narratives written by the nurses in group sessions. The data were analyzed: (a) by a coding system that focused on the formal and informal roles, rules, and relationships in work and school settings; and (b) by examining the changes in participants' narratives about their professional identity during the process of the group meetings. All the nurses in the sample had been profoundly affected by the socially accepted "feminine" images of nursing. The findings also revealed racial issues in the nursing profession. The implications of this study point to the need for new models of nursing education and nursing leadership to overcome old images and to make nursing attractive to those from diverse backgrounds.     

Creating a new whole: helping families of people with schizophrenia

Collaboration between psychiatric nurses and family members is considered an important part of caring for people with schizophrenia either in hospital or at home after discharge. Studies have demonstrated family involvement in terms of caring for patients who have been discharged early from hospital. An extensive review of the literature and related studies regarding nursing interventions have been done, but there have been limited studies on what psychiatric nurses actually do when working with the families of people with schizophrenia in Thailand. The purpose of the present study was to explore relationships between Thai psychiatric nurses and families in terms of administering nursing care to patients. Grounded theory methodology was used to examine the processes through which psychiatric nurses work with families. Data were collected by 16 psychiatric nurses through in-depth interviews, observations, and field notes. Data were analyzed using constant and comparative methods of other studies, which revealed the process by which nurses can create a new whole between families, patients, and Thai psychiatric nurses. The process consists of four major stages: establishing trust, strengthening connections, promoting readiness to care, and supporting family.     

Issues of trust and ethics in computerized clinical decision support systems

Clinical decision support systems are computer technologies that model and provide support for human decision-making processes. Decision support mechanisms facilitate and enhance a clinician's ability to make decisions at the point of care. Decisions are facilitated through technology by using automated mechanisms that provide alerts or messages to clinicians about a potential patient problem. A clinician's level of trust in these technologies to support decision making is affected by how knowledge is represented in these tools, their ability to make reasonable decisions, and how they are designed. Furthermore, ethical tensions occur if these systems do not promote standards, if clinicians do not understand how to use these systems, and when professional relationships are affected. Issues of trust and ethical concerns will be examined in this article, using a research study of midwestern nursing homes that implemented a clinical decision support system.     

Predictors of professional nursing practice behaviors in hospital settings

BACKGROUND: Many hospital nurses perform isolated, routine tasks, rather than use their professional training, because they are subject to control by organizational and medical divisions of labor. The environment may interfere with a nurse's ability to practice autonomously and according to professional standards. OBJECTIVES: The purpose of the study was to explore how certain factors in the environment and personal characteristics interact to affect hospital nursing practice behaviors. METHODS: The study used a nonexperimental, comparative design. Surveys were sent to a random sample of 500 nurses throughout the state of Michigan. Three instruments, measuring structural empowerment, self-efficacy for nursing practice, and professional practice behaviors, were included. Path analysis was used for statistical analysis. RESULTS: Three hundred sixty-four nurses responded (73%), of whom 251 provided usable protocols for the final analysis. Environmental factors (structural empowerment) contributed both directly to professional practice behaviors as well as indirectly through self-efficacy. Self-efficacy mainly exerted its effect as a mediator in the relationship between environmental factors and practice behaviors. Support for the proposed theoretical model was mixed, although the proposed model fit the data well (chi = 11.02 [(5, N = 251), p < .05, CFI = .999, NNFI = .991, RMSEA = .069]). An alternative model emerged from the data analysis. DISCUSSION: Nurses may practice more professionally when the environment provides opportunities and power through resources, support, and information. Self-efficacy may contribute to professional practice behaviors, especially in an environment that has the requisite factors that provide empowerment.     

The knowledgeable practice of critical care nurses: a poststructural inquiry

BACKGROUND: Contemporary nursing literature emphasises the desirability of clinical nurses being "knowledgeable". However, the need for nurses constantly to acquire more knowledge is reiterated. Lack of knowledge is seen to underlie an array of professional problems. Little is known of how nurses themselves understand what it means to practise knowledgeably. OBJECTIVE: To explore critical care nurses' understandings of knowledgeable practice and its relationship to being a "good nurse". METHODOLOGY: A poststructuralist framework informed the study. The study participants were 12 critical care nurses. Data were generated through three individual focused interviews with each participant. Data analysis involved deconstruction of the interview texts to reveal participants' discourses of knowledgeable practice and the implications of these discourses for their subjectivity and for their work. FINDINGS: A discourse of knowledgeable practice was revealed as central to participants' sense of identity as "good nurses". Participants believed their knowledge resided in their heads ("knowing why") and in their hands ("knowing how"). Fluency of action, which was achieved and maintained by frequent repetition of activities, contributed to their sense of being knowledgeable. Participants described being excluded from knowledge in some instances. In general, however, "actual" knowledge was of less importance than was being positioned, by themselves and others, as knowledgeable. This positioning was frequently undermined by other staff, both medical and nursing. Analysis revealed that the discourse of knowledgeable practice was underpinned by a dichotomy of ignorant/knowledgeable, in which "ignorant" was the dominant category; hence, nurses were assumed to be ignorant until they could "prove" otherwise. CONCLUSIONS: The findings contest the notion, espoused in nursing literature, that acquisition of knowledge can "empower" nurses, thus providing the solution to problems they may experience. Rather, strategies are required that challenge and disrupt relations of power that construct nurses as "ignorant".     

Personal resilience as a strategy for surviving and thriving in the face of workplace adversity: a literature review

AIM: This paper is a report of a literature review to explore the concept of personal resilience as a strategy for responding to workplace adversity and to identify strategies to enhance personal resilience in nurses. BACKGROUND: Workplace adversity in nursing is associated with excessive workloads, lack of autonomy, bullying and violence and organizational issues such as restructuring, and has been associated with problems retaining nurses in the workforce. However, despite these difficulties many nurses choose to remain in nursing, and survive and even thrive despite a climate of workplace adversity. DATA SOURCES: The literature CINAHL, EBSCO, Medline and Pubmed databases were searched from 1996 to 2006 using the keywords 'resilience', 'resilience in nursing', and 'workplace adversity' together with 'nursing'. Papers in English were included. FINDINGS: Resilience is the ability of an individual to positively adjust to adversity, and can be applied to building personal strengths in nurses through strategies such as: building positive and nurturing professional relationships; maintaining positivity; developing emotional insight; achieving life balance and spirituality; and, becoming more reflective. CONCLUSION: Our findings suggest that nurses can actively participate in the development and strengthening of their own personal resilience to reduce their vulnerability to workplace adversity and thus improve the overall healthcare setting. We recommend that resilience-building be incorporated into nursing education and that professional support should be encouraged through mentorship programmes outside nurses' immediate working environments.