Over the past two decades, the competency movement has been gathering momentum internationally within the ranks of professional nursing. It can be argued that this momentum is in response to government initiatives aimed at improving consistency in workforce training and accreditation, and fostering national and international portability of qualifications. At the same time, the competency movement has provided the opportunity for regulators, service providers and government to develop mechanisms to reconstitute competent nurses as accountable, self‐regulating subjects and to monitor this (...) transformation in particular ways. The ways in which competencies have been taken up to do this transforming work in Canada are unique and deserving of some detailed description and analysis.We argue that Canadian nursing regulatory authorities have chosen to view competence as the rehearsal of ethical attributes consonant with the professional role,as opposed to the enactment of skilled conduct. As a result, reflective practices rather than skill and knowledge have become the cornerstone of nursing competency formulation and review. We argue that this distinctly Canadian approach to competency serves three ends. First, it privileges the ‘attribute’ element of the nursing competency model and side steps the ever‐problematic ‘nursing knowledge’ issue; second, self‐surveillance by nurses shifts the onus for professional development from industry to the individual; and third, it concedes responsibility for skill assessment by the regulatory authorities to industry control, leaving employers free to determine skill base and skill mix requirements for practice. Finally, we argue that the reflective component of the regulatory framework for Canadian nurses radically fails as a tool for auditing quality and assessing competency. Rather, it functions as a governmental practice that furthers the deregulatory and economic rationalist aims of the Canadian health reform agenda. (shrink)

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. (shrink)

‘Client involvement’ has been a mantra within health policies, education curricula and healthcare institutions over many years, yet very little is known about how ‘client involvement’ is practised in home‐care services. The aim of this article is to analyse ‘client involvement’ in practise seen from the positions of healthcare professionals, an elderly person and his relative in a home‐care setting. A sociologically inspired single case study was conducted, consisting of three weeks of observations and interviews. The study has a focus (...) on the relational aspects of home care and the structural, political and administrative frames that rule home‐ care practice. Client involvement is shown within four constructed analytical categories: ‘Structural conditions of providing and receiving home care’; ‘Client involvement inside the home: performing a professional task and living an everyday life’; ‘Client involvement outside the home: liberal business and mutual goal setting’; and ‘Converting a home to a working place: refurnishing a life’. The meaning of involvement is depending on which position it is viewed from. On the basis of this analysis, we raise the question of the extent to which involvement of the client in public home‐care practice remains limited. (shrink)

This paper provides an analysis of nursing as a knowledgeable discipline. We examined ways in which knowledge operates in the practice of home care nursing and explored how knowledge might be fruitfully understood within the ambiguous spaces and competing temporalities characterizing contemporary healthcare services. Two popular metaphors of knowledge in nursing practice were identified and critically examined; evidence-based practice and the nurse as an intuitive worker. Pointing to faults in these conceptualizations, we suggest a different way of conceptualizing the relationship (...) between knowledge and practice, namely practice as being activated by contextualized knowledge. This conceptualization is captured in an understanding of the intelligent creation of context by the nurse for nursing practice to be ethical and effective. (shrink)

The paradox of the Aged Care Act 1997: the marginalisation of nursing discourse This paper examines the marginalisation of nursing discourse, which followed the enactment of the Aged Care Act 1997. This neo‐reform period in aged care, dominated by theories of economic rationalism, enshrined legislation based upon market principles and by implication, the provision of care at the cheapest possible price. This paper exposes some of the gaps in the neo‐reform period and challenges the assertion that the amalgamation of nursing (...) homes and hostels in such an environment can provide better quality of care and life for residents. It argues that this amalgamation entails a transformation towards a social model of care and fails to address the professional healthcare needs of the acutely sick and complex extreme old person and makes evident new gaps in the provision of aged care services. The paper proceeds to present strategies where the future for nursing practice in aged care necessarily involves a judicious balancing of individual cases alongside economic prescriptions of care and ever‐changing public policy initiatives. It concludes that this can be achieved through a more interactive public, professional and advocacy discourse. The methodology involves extensive analysis of public documents including media, academic journals, government reports and interviews with recognised leaders in the field of aged care. The study utilises a critical interpretative framework consistent with the logic of Michel Foucault. (shrink)

This article examines field studies of nursing work published in the English language between 1993 and 2003 as the first step towards an empirically based reformulation of the nursing mandate. A decade of ethnographic research reveals that, contrary to contemporary theories which promote an image of nursing work centred on individualised unmediated caring relationships, in real‐life practice the core nursing contribution is that of the healthcare mediator. Eight bundles of activity that comprise this intermediary role are described utilising evidence from (...) the literature. The mismatch between nursing's culture and ideals and the structure and constraints of the work setting is a chronic source of practitioner dissatisfaction. It is argued that the profession has little to gain by pursuing an agenda of holistic patient care centred on emotional intimacy and that an alternative occupational mandate focused on the healthcare mediator function might make for more humane health services and a more viable professional future. (shrink)

STAJDUHAR K, FUNK L, JAKOBSSON E and ÖHLÉN J. Nursing Inquiry 2010; 17: 221–230A critical analysis of health promotion and ‘empowerment’ in the context of palliative family care-givingTraditionally viewed as in opposition to palliative care, newer ideas about ‘health-promoting palliative care’ increasingly infuse the practices and philosophies of healthcare professionals, often invoking ideals of empowerment and participation in care and decision-making. The general tendency is to assume that empowerment, participation, and self-care are universally beneficial for and welcomed by all individuals. (...) But does this assumption hold for everyone, and do we fully understand the implications of health-promoting palliative care for family caregivers in particular? In this study, we draw on existing literature to highlight potential challenges arising from the application of ‘family empowerment’ strategies in palliative home-care nursing practice. In particular, there is a risk that empowerment may be operationalized as transferring technical and medical-care tasks to family caregivers at home. Yet, for some family caregivers, a sense of security and support, as well as trust in professionals, may be equally if not more important than empowerment. Relational and role concerns may also at times take precedence over a desire for empowerment. The potential implications of ‘family empowerment’ are explored in this regard. ‘Family empowerment’ approaches need to be accompanied by a strong understanding of how to best support individual palliative family caregivers. (shrink)

From the state to the family: reconfiguring the responsibility for long‐term nursing care at homeThis paper discusses the implications of the shift in the location of the provision of healthcare services from healthcare institutions to the home, which has occurred or is projected to occur in coming years. It is argued that the responsibility for the provision of care and assistance needed by the elderly living at home and people with long‐term conditions living at home has shifted from public services (...) to the family. Studies of care‐givers have shown that in many situations they experience tremendous burdens, financial difficulties and health problems. Their social lives have been confined to the home, and contacts with friends and neighbors have been significantly reduced. This situation needs to be addressed by nurses, who in many cases serve as the bridge between the home and the official healthcare system. Using Foucault’s exploration of power, particularly his idea of governmentality, a genealogy of care‐giving in the home in Iceland’s health‐care has been constructed. The main findings were that, although this is occurring somewhat later than in many other countries, the state is withdrawing from its previously defined responsibility for the health and well‐being of the nation. At the same time the citizen’s responsibility for maintaining health is emphasized. Based on these findings, the argument is made that nurses in Iceland can have a profound influence on policy‐making in relation to the organization of services provided in those homes. Suggestions are made as to how this can be done, which may be of interest to nurses in other countries. (shrink)