In this paper, I discuss nurses' ongoing difficulty in engaging with politics and address the persistent belief that political positioning is antithetical to quality nursing care. I suggest that nurses are not faced with choosing either caring for their patients or engaging with politics. I base my discussion on the assumption that such dichotomy is meaningless and that engaging with issues of relationships firmly grounds nursing in the realm of politics. I argue that the ethical merit of nursing care relies (...) instead on positioning nurses squarely at the centre of care activities, experiences, and functions. Such positioning makes possible what Foucault called ‘practices of self‐formation’, that is, micro‐level processes that balance out the ubiquitous economic, cultural, legal, and scientific technologies that steadily constitute subjects in this era of modernity. Nurses, then, become not a group that needs to be controlled and governed, but individuals who must care for their self before they may care for anyone else. (shrink)

Change is inevitable, and increasingly rapid and continuous in healthcare as organizations strive to adapt, improve and innovate. Organizational change challenges healthcare providers because it restructures how and when patient care delivery is provided, changing ways in which nurses must carry out their work. The aim of this doctoral study was to explore frontline nurses’ experiences of living with rapid and continuous organizational change. A critical hermeneutic approach was utilized. Participants described feeling voiceless, powerless and apolitical amidst rapid and continuous (...) organizational changes which fuelled apathy, cynicism and disengagement from the organization. However, critical analysis of the data showed that nurses actively engaged with power, voice and politics through resistant and transgressive behaviours in micro‐ethical moments of practice. There is a need to reconceptualize the concepts of voice, power and politics in nursing as there is dissonance between nurses’ beliefs about these concepts and what they are enacting in practice. Recognizing their enactment of power, voice and political agency at the micro‐level may empower nurses. Empowerment would mitigate the high levels of reports of powerlessness experienced in practice during organizational changes. (shrink)

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. (shrink)

This article is part of a wider study entitled Value of Nursing, and contains the literature search from electronic databases. Key words for the search included `values of nursing', `values in nursing', `organisational values' and `professional identity'. Thirty-two primary reports published in English between 2000 and 2006 were identified. The findings highlight the importance of understanding values and their relevance in nursing and how values are constructed. The value of nursing is seen to be influenced by cultural change, globalization, and (...) advancement in technology and medicine. These factors are crucial in providing a more structured and measured view of what nursing is, which will result in greater job satisfaction among nurses, better nurse retention and enhanced patient care within a supportive and harmonious organization. The findings of this review have implications for policy makers in recruitment and retention in determining the global value of nursing. (shrink)

The concept of non-domination is an important contribution to the study of freedom but it does not comprehend the whole of freedom. Insofar as domination requires a conscious capacity for control on the part of the dominant party, it fails to capture important threats to individual freedom that permeate many contemporary liberal democracies today. Much of the racism, sexism and other cultural biases that currently constrain the life-chances of members of subordinate groups in the USA are largely unconscious and unintentional, (...) and they do not always involve control. Although they constitute real barriers to freedom, these forms of influence are not accurately characterized as domination, and they will require different mechanisms to overcome them. To achieve the more capacious freedoms that liberal democracy promises, we will need to go beyond non-domination and to come to terms with the non-sovereign, socially distributed character of human agency. (shrink)

The concept of social structure is ill defined in the literature despite the perennial problem and ongoing discussion about the relationship between agency and structure. In this paper I will provide an outline of what the term social structure means, but my main focus will be on emphasizing the value of the concept for nursing research and demonstrate how its erasure in some research negatively effects on our understanding of the nurses' role in clinical practice. For example, qualitative research in (...) nursing has largely focused on agency through such theories as phenomenology, hermeneutics, and symbolic interactionism. The result is that social structure may be erased or seen as epiphenomena of agency. My purpose is to provide a theoretical discussion of social structure and how such a discussion can help us to understand how nurses live and experience clinical practice. While not denying the importance of agency, I will argue that the thinned out approach to social structure places limits on our understanding of the constraints nurses experience in their working lives. The result is that nurses' attitudes and clinical failings are individualized, resulting in ever more calls for improved education, when a more thorough examination of structural issues may elucidate more fundamental problems. (shrink)

It may be the case that the most challenging moral problem of the twenty‐first century will be the relationship between the individual moral agent and the practices and institutions in which the moral agent is embedded. In this paper, we continue the efforts that one of us, Joan Liaschenko, first called for in 1993, that of using feminist ethics as a lens for viewing the relationship between individual nurses as moral agents and the highly complex institutions in which they do (...) the work of nursing. Feminist ethics, with its emphasis on the inextricable relationship between ethics and politics, provides a useful lens to understand the work of nurses in context. Using Margaret Urban Walker's and Hilde Lindemann's concepts of identity, relationships, values, and moral agency, we argue that health care institutions can be moral communities and profoundly affect the work and identity and, therefore, the moral agency of all who work within those structures, including nurses. Nurses are not only shaped by these organizations but also have the power to shape them. Because moral agency is intimately connected to one's identity, moral identity work is essential for nurses to exercise their moral agency and to foster moral community in health care organizations. We first provide a brief history of nursing's morally problematic relationship with institutions and examine the impact institutional master narratives and corporatism exert today on nurses’ moral identities and agency. We close by emphasizing the significance of ongoing dialogue in creating and sustaining moral communities, repairing moral identities, and strengthening moral agency. (shrink)

Moral distress has been written about extensively in nursing and other fields. Often, however, it has not been used with much theoretical depth. This paper focuses on theorizing moral distress using feminist ethics, particularly the work of Margaret Urban Walker and Hilde Lindemann. Incorporating empirical findings, we argue that moral distress is the response to constraints experienced by nurses to their moral identities, responsibilities, and relationships. We recommend that health professionals get assistance in accounting for and communicating their values and (...) responsibilities in situations of moral distress. We also discuss the importance of nurses creating “counterstories” of their work as knowledgeable and trustworthy professionals to repair their damaged moral identities, and, finally, we recommend that efforts toward shifting the goal of health care away from the prolongation of life at all costs to the relief of suffering to diminish the moral distress that is a common response to aggressive care at end-of-life. (shrink)

This article presents a relational criticism of the "morphogenetic theory" of M. Archer. This theory is founded and representative of the most influential mode of perception of the social universe of the last few decades: co-determinism (structure ↔ agency). Co-determinism's influence can be explained by its integration of modern general presuppositions like freedom, individualism, and the quest for a new social order. By identifying five basic principles of relational sociology, we see that Archer's co-deterministic theory offers a complicated solution to (...) avoid voluntarism and co-determinism, limits the potential of sociological imagination, cannot adequately see the fluidity of social processes, produces a certain reification of social structures and agency, and is based on an inconsistent use of egocentric and relational perspectives. These problems can be avoided if we use a relational approach (actor ↔ actor ⇒ structures) based on the study of complex and empirical trans-actions. (shrink)

Anthony Giddens’ theory of structuration is a theory of social action, which claims that society should be understood in terms of action and structure; a duality rather than two separate entities. This paper introduces some of the central characteristics of structuration theory, presenting a conceptual framework that helps to explore how people produce the systems and structures that shape their practice. By understanding how people produce and reproduce structures, then there is the potential for changing them. Criticisms that have been (...) raised about the theory are introduced, followed by examples of how the theory might be useful to nursing research. Structuration theory can be employed to explore how nurses produce, reproduce, and transform nursing practice through social interaction across time and space. (shrink)

Nursing professionalization is both ongoing and global, being significant not only for the nursing workforce but also for patients and healthcare systems. For this reason, it is important to have an in‐depth understanding of this process and the factors that could affect it. This literature review utilizes a welfare state approach to examine macrolevel structural determinants of nursing professionalization, addressing a previously identified gap in this literature, and synthesizes research on the relevance of studying nursing professionalization. The use of a (...) welfare state framework facilitates the understanding that the wider social, economic, and political system exercises significant power over the distribution of resources in a society, providing a glimpse into the complex politics of health and health care. The findings shed light on structural factors outside of nursing, such as country‐level education, health, labor market, and gender policies that could impact the process of professionalization and thus could be utilized to strengthen nursing through facilitating increased professionalization levels. Addressing gender inequalities and other structural determinants of nursing professionalization could contribute to achieving health equity and could benefit health systems through enhanced availability, skill‐level, and sustainability of nursing human resources, improved and efficient access to care, improved patient outcomes, and cost savings. (shrink)

In the context of modern nursing practice that is embedded within complex social situations, critical discussions about the contribution of major philosophers are relevant and important. Whilst nurse theorists have advanced and shaped nursing as a discipline, other major philosophers can offer much to advance nursing enquiry. In this paper, we focus on philosopher Roy Bhaskar who, amongst others, developed critical realism, a philosophy for social science which connects with how many of us think about the world. Bhaskar's work focuses (...) our attention on the interplay between structure and agency and on the search for the causative or generative mechanisms that explain the social world. Bhaskar was interested in human emancipation, and we suggest his work is of great importance to advance understanding of complex social situations. Critical realism has already been endorsed by a range of disciplines, especially in research which focuses on real problems and acknowledges the complexities of the social world. In recent evidence from healthcare literature, there has been a surge in research using realist methodology (realist evaluation and realist synthesis), which is underpinned by the philosophy of critical realism and which offers a different perspective to understanding nursing and healthcare problems through the realist lens. However, we suggest that sufficient attention is not always paid to the philosophical roots of this methodology. In this paper, we provide insight into Bhaskar's work and demonstrate how research positioned within critical realism and realist methodology can advance nursing and healthcare‐related knowledge. Through shining a light on Bhaskar, we illustrate how critical realism philosophy is a natural fit with human and health science enquiry, including nursing. (shrink)

The subject of this article is moral agency in nursing, studied by the use of an applied philosophical method. It draws upon nurses’ accounts of how they see intrinsic value in their work and believe that they make a difference to patients in terms that leave their patients feeling better. The analysis is based on the philosophy of Iris Murdoch to reveal how nurses’ accounts demonstrated that they hold a view of themselves and their professional practice that is intrinsically linked (...) to, and dependent upon, their capacity to see good in the work they do. (shrink)

The conceptualization of human agency is one of the oldest and most debated challenges in political theory. This essay defends the continuous relevance of this endeavour against a proliferating theoretical pessimism. Instead of engaging the much rehearsed structure-agency debate, the author conceptualizes agency in relation to discourses. However, such an approach inevitably elicits suspicion. Is discourse not merely a faddish term, destined to wax and wane with fleeting intellectual trends of the postmodern and poststructural kind? Does the concept of discourse, (...) as many fear, suck us into a nihilistic vortex and deprive us of the stable foundations that are necessary to ground our thoughts and actions? Not so, argues this essay, and defends an anti-essentialist stance as the most viable chance for retaining an adequate understanding of how people situate themselves as agents and influence their socio-political environment. The ensuing analysis, which focuses on everyday forms of resistance, demonstrates how the very acceptance of ambiguity, often misrepresented as relativism, is a crucial precondition not only for the conceptualization of human agency, but also for its actual application in practice. (shrink)

The purpose of this paper is to explore how nurses are enrolled into and take part in programmes of efficiency and effectiveness. Using the philosophical theorizing about desire as a force or power, I focus specifically on what is understood as relations between desire and productivity in current Westernized health‐care systems. Use is made of the idea from Spinoza that human emotions consist only of pleasure, pain, and desire as these act as a motive force. This is then linked with (...) more contemporary work on the politics and discourses of desire. A report on the implementation of a productivity programme in the United Kingdom, The Productive Ward: Releasing time to care™, is explored for the ways its developers set about motivating nurses to endorse and enact the programme. In exploring the mechanics of desire in these processes, a view of desire as productive is promoted. Looking at desire as assembling actions, and an assemblage, moves the analysis to an interrogation of actions and practices used to enable and bring nurses to the process. Moreover, in working through the various modalities and operations of desire, the potential and limits of such projects are abstracted. Such potentials and limits are necessarily set by the intensification of power and desire in the capitalist economy, saturating areas of nursing, and health‐care provision. (shrink)

Nursing as normative praxisThe purpose of this paper is twofold. First, it introduces a variety of concepts of ‘praxis’, and argues in support of those which reflect the normative dimension of the critical social perspective. This begins with the Aristotelian concept, and moves through a variety of sources, including Hannah Arendt and Paulo Freire, but focuses primarily, and uniquely in the nursing literature, upon the work of the Yugoslavian ‘praxis Marxists’. Second, specific ways of conceiving nursing as praxis are outlined, (...) including political, aesthetic and ethical forms which have immediate import for nurses. The paper concludes with brief suggestions as to how these ways of conceiving praxis may be used by nurses to develop a more intimate and productive understanding of their own practices. (shrink)

Bourdieu is an important thinker within the sociological tradition and has a philosophically sophisticated approach to theoretical knowledge and research practice. In this paper, we examine the implication of his work for nursing and the health sciences more broadly. We argue that his work is best described as a reflexive realist who provides a space for a nonpositivist approach to knowledge that does not fall into the trap of idealism or relativism. We emphasize that Bourdieu was not an abstract theorist, (...) but only utilized theories to understand and explain the social world in all its empirical complexity. Theory is emphasized over method without denying the importance of method. We then provide a brief overview of some of his key concepts: habitus, field and capital. His work is a scientifically astute practice that has an emancipatory purpose, with particular resonance to the problems of nursing as a social practice. Some have criticized Bourdieu for undermining agency and we briefly address this issue, but argue that his conceptual framework helps us to understand what endures in social practice and why change is often problematic. In short, this paper argues that Bourdieu's work is a fruitful resource for critiquing existing nursing approaches that are preoccupied with agency over structure. (shrink)

Critical realism, a philosophical framework originally developed by Roy Bhaskar in the 1970s, represents a relatively new approach to research generally and to nursing research in particular. This article explores the ontological and epistemological tenets of critical realism and examines the application of critical realist principles to nursing research and practice through a review of the literature. It is evident that few published nursing research studies have, as of yet, utilized critical realism as their paradigm of choice. Both the strengths (...) and limitations of the presentation and use of critical realism in these studies are discussed in this article. Given the varying degrees of success of the authors in explicating critical realism as a philosophical framework, the value of critical realism to the research study, and the ways in which usage of the critical realist framework influenced development of the study and interpretation of findings, it is evident that the quality of future publications espousing the use of critical realism must continue to be strengthened significantly. (shrink)

Nurse practitioners (NPs), as advanced practice nurses, have evolved over the years to become recognized as an important and growing trend in Canada and worldwide. In spite of sound evidence as to the effectiveness ofNPs in primary care and other care settings, role implementation and integration continue to pose significant challenges. This article utilizes postcolonial theory, as articulated by Homi Bhabha, to examine and challenge traditional ideologies and structures that have shaped the development, implementation and integration of theNProle to this (...) day. Specifically, we utilize Bhabha's concepts of third space, hybridity, identity and agency in order to further conceptualize the nurse practitioner role, to examine how the role challenges some of the inherent assumptions within the healthcare system and to explore how development of each to these concepts may prove useful in integration of nurse practitioners within the healthcare system. Our analysis casts light on the importance of a broader, power structure analysis and illustrates how colonial assumptions operating within our current healthcare system entrench, expand and re‐invent, as well as mask the structures and practices that serve to impede nurse practitioner full integration and contributions. Suggestions are made for future analysis and research. (shrink)

A better appreciation of the material, distributed quality of human agency can illuminate subtle dynamics of domination and oppression and reveal resources for potentially liberatory political action. Materialist accounts of agency nevertheless pose challenges to the notion of personal responsibility that is so crucial to political obligation and democratic citizenship. To guard against this danger, we need to sustain the close connection between agency and a sense of selfhood that is individuated, reflexive, and responsive to norms. Yet we should acknowledge (...) that reflexive selfhood is not the whole of individual agency for the sources of agency extend beyond the individual herself. We also need to recognize the ways that both reflexivity and norm-responsiveness are themselves embodied capacities. When properly conceived, a materialist view of agency can increase awareness of our oftenunwitting contributions to systematic inequalities of power and extend our political responsibilities in emancipatory directions, thus holding great promise for democratic life. (shrink)

Background: Nurses and surgeons may experience intra-team conflict during decision making about the use of postoperative life-sustaining treatment in the intensive care unit due to their perceptions of professional roles and responsibilities. Nurses have a sense of advocacy—a responsibility to support the patient’s best interest; surgeons have a sense of agency—a responsibility to keep the patient alive. Objectives: The objectives were to (1) describe the discourse surrounding the responsibilities of nurses and surgeons, as “advocates” and “agents,” and (2) apply these (...) findings to determine how differences in role responsibilities could foster conflict during decision making about postoperative life-sustaining treatment in the intensive care unit. Research design: Articles, books, and professional documents were explored to obtain descriptions of nurses’ and surgeons’ responsibilities to their patients. Using discourse analysis, responsibilities were grouped into themes and then compared for potential for conflict. Ethical considerations: No data were collected from human participants and ethical review was not required. The texts were analyzed by a surgeon and a nurse to minimize profession-centric biases. Findings: Four themes in nursing discourse were identified: responsibility to support patient autonomy regarding treatment decisions, responsibility to protect the patient from the physician, responsibility to act as an intermediary between the physician and the patient, and the responsibility to support the well-being of the patient. Three themes in surgery discourse were identified personal responsibility for the patient’s outcome, commitment to patient survival, and the responsibility to prevent harm to the patient from surgery. Discussion: These responsibilities may contribute to conflict because each profession is working toward different goals and each believes they know what is best for the patient. It is not clear from the existing literature that either profession understands each other’s responsibilities. Conclusion: Interventions that improve understanding of each profession’s responsibilities may be helpful to reduce intra-team conflict in the intensive care unit. (shrink)

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)