A birth centre's encounters with discourses of childbirth: how resistance led to innovation

An ethnographic study of a free-standing birth centre uncovered a site of intense contestation. Two prominent childbirth discourses attempting to inscribe their orthodoxies on staff and women users encountered stern and persistent resistance. Using postmodern theory, this resistance is conceptualised as nomadic activity, as space is made at the margins of discourse for a difference and diversity to manifest. The relationship between discourse and women's agency is layered and non-linear as the presence of dissonant data indicates. The birth centre, however, actualises a number of contrasting ways of 'being' and 'doing' that appear to serve the interests of staff and women well. In particular, 'nomadic' midwifery practice and a 'care as gift' orientation challenges the biomedical model that defines the parameters of normal and the 'vigil of care' discourse that regulates the professional/patient relationship. Birth centres may encourage novel and eclectic ways of providing childbirth care.

Setting the space for sex: Architecture, desire and health issues in gay bathhouses

This aim of this study was to describe and compare the physical design, as well as the atmosphere of urban gay bathhouses, and reflect on how desire operates within these premises when it intersects with the bathhouse environment and health imperatives. Three bathhouses were studied for a total of 147 h of observation. Men's desire for other men has created a landscape of spaces (real and virtual) where sex takes place in parks, alleys, restrooms, rest stops, adult theatres, video arcades, bookstores, bars, gay bathhouses and finally, the Internet. Although the Internet is perceived as an easy way for encountering sexual partners, gay bathhouses remain the most popular and convenient way, for men having sex with men to meet for regular or casual sex. This paper presents the descriptive results of an ethnographic nursing study that took place in three gay bathhouses located in two Canadian metropolitan areas. Gay bathhouses offer patrons a space within which a wide range of interactions, sensations and pleasure can be experienced. This paper highlights the specific features of three gay bathhouses, compares settings according to their specific architectural features and related sexual activities, and finally, proposes some changes in light of certain health issues.

Considering alternatives: student nurses slipping directly from lay beliefs to the medical model of mental illness

When student nurses enter higher education establishments to commence their nurse education it is expected that they would hold lay beliefs of mental health and mental illness. Lay beliefs are generally informed by the medical model of mental health. It is argued that there are many other beliefs and approaches to mental health that student nurses (of all branches) should consider before graduating into the health care world dominated by the medical model of mental health and mental illness. A number of other approaches and theories are summarised and offered as examples to student nurses for their consideration.

High theory/mass markets: Newsweek magazine and the circuits of medical culture

Medicine is driven by much more than science and reason (ethics); it is also driven by the circuits of culture within which it operates. This article examines how postmodern theory deconstructs standard ideals of science and reason and allows medical humanities scholars to better contextualize the world of medicine. As such, postmodern theory provides an invaluable tool for understanding the circuits of popular culture and medicine's place within these circuits. Using a recent issue of Newsweek magazine devoted to health and technology to illustrate the main points, this essay argues that contemporary popular influences on medicine are deeply problematic, and that through an appreciation of the dynamics of culture, medical humanities scholars can join the struggle over medical culture. This perspective allows medical humanities to make important contributions toward alternative circuits of medical representation, consumption, and identification.

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".

Separation of conjoined twins and the principle of double effect

This article examines the relationship between the principle of double effect and justification for separation surgeries for conjoined twins. First, the principle of double effect is examined in light of its historical context. It is argued that it can only operate under an absolutist view of good and evil that is compatible with the Bible. Given this foundation for application, scenarios for separating conjoined twins are considered against the criteria for the principle of double effect. It is concluded that the principle of double effect cannot be applied to cases wherein one of the twins must be killed. However, it is noted that this does not leave decision makers without options.

Getting a visit: how district nurses and general practitioners 'organise' each other in primary care

This paper examines the ways in which district nurses and general practitioners interacted and influenced each other's work within primary care services. The data presented here examine how the developments in the organisation of primary care affected the work of district nurses during a time of turbulent change. Qualitative data from 300 hours of participant observation and 40 semi-structured interviews with 33 district nurses were analysed using grounded theory, after which a literature review was undertaken. The findings from this study were interpreted using a Foucauldian notion of power and Fox's (1995) analysis of 'organisation'. The shift in power to general practitioners (GPs) has meant that they can exercise ever-increasing authority over nurses in their employ. Strict rules governed the process of inter-professional work and nurses and doctors used creative strategies to overcome the problems that existed between them. The data show that nurses could and did resist the power of GPs but this resistance generally elicited other more punishing forms of authority. Direct and indirect threats were commonplace. The data suggest that district nurses were moving into a closer, more business-like and tightly-controlled working relationship with general practitioners, through which competing discourses interplayed and circulated between GPs and district nurses in the organisation of primary care services.

Paradigms of psychiatry: eclecticism and its discontents

PURPOSE OF REVIEW

To assess paradigms of psychiatry, assessing their strengths and limitations.

RECENT FINDINGS

The biopsychosocial model, and eclecticism in general, serves as the primary paradigm of mainstream contemporary psychiatry. In the past few decades, the biopsychosocial model served as a cease-fire between the biological and psychoanalytic extremism that characterized much of the 19th and 20th century history of psychiatry. Despite being broad and fostering an 'anything goes' mentality, it fails to provide much guidance as a model. In recent years, the biological school has gained prominence and now is under attack from many quarters. Critics tend toward dogmatism themselves, usually of postmodernist or libertarian varieties. Three alternate approaches include pragmatism, integrationism, and pluralism. Pluralism, as technically defined here based on the work of Karl Jaspers, rejects or accepts different methods but holds that some methods are better than others for specific circumstances or conditions.

SUMMARY

The compromise paradigm of biopsychosocial eclecticism has failed to sufficiently guide contemporary psychiatry. The concurrent revival of the biological model has led to postmodernist counter-reactions which, though valid in many specifics, promise to replace one ideological dogma with another. New paradigms are needed.

Building moral communities? First, do no harm

As concern for the oral health of vulnerable populations grows, dentistry continues to seek effective ways to respond. In August 2005, Dr. Donald Patthoff and Dr. Frank Catalanotto convened a national workshop at the American Dental Association headquarters on the ethics of access to oral health care. A series of papers were produced for the workshop and subsequently revised for publication. This one responds to the paper by Dr. David Chambers on moral communities and the discursive imperative for building community and consensus around issues affecting equitable access to oral health care. I explore three interrelated issues that ought to be considered when endeavoring to build moral communities: 1) the problem of power relations-a fundamental constituent within discourse that can impede constructive efforts; 2) the discursive disconnect between theoretical ethics and social constructs affecting dentistry; and 3) the bioethical principle of nonmaleficence as a priority in the desire for building moral communities. In essence, this article responds also to the call from ethicists who see a significant need for substantive interdisciplinary contributions to inform how people at different social levels react in ethically problematic situations in its broad social context.

Beauty and art

Definitions of beauty and art have been turned upside down when trying to describe 20th century and postmodern art. The classical sense of beauty looks toward the replication of nature as its inspiration. The development of Impressionist art and modern art forced the rules of aesthetics to be rethought and revised. Old standards of aesthetics were brought into question with each successive artistic challenge. This article endeavors to explore the meaning of beauty and the aesthetic experience as it relates to defining art.

Intelligent nursing: accounting for knowledge as action in practice

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.

Evidence, Virulence, and the Disappearance of Nursing Knowledge: A Critique of the Evidence-Based Dogma

CONTEXT

Within the domain of health care, the new discourse of evidence-based practice has appeared and gained momentum, giving rise to a plethora of correlates such as specialized scientific journals and best practice guidelines. Following the crowd, nursing has jumped onto this trend's bandwagon. Although some scholars and clinicians have tried to expand these notions, few have considered a deconstructive approach to do so.

APPROACH

Drawing on the works of continental postmodern thinkers such as Baudrillard, Deleuze & Guattari, and Foucault, this paper critically examines the rise of the evidence-based nursing (EBN) movement in order to deconstruct the "taken-for-granted" assumption that EBN is in and of itself the favored path to the sound development of nursing knowledge.

DISCUSSION

We argue against the hierarchical differentiation of varied research approaches so as to allow diverse methodologies to guide research and ultimately practice. The status quo is challenged, where research agendas are currently dominated by one paradigm of knowledge development; that of post-positivism in which randomized control trials are portrayed as superior evidence. There is a hazard in excluding many other venues to build nursing knowledge and in oversimplifying the complexity of clinical nursing practice. Furthermore, we argue that this preferred path of knowledge development contradicts nursing academics' efforts to distance itself from the medical model of health care provision and research.

Towards a geology of evidence-based practice—A discussion paper

We begin this paper with a consideration of the significance of a historical perspective in presentations of evidence-based practice in the nursing and medical literature. We suggest that whereas writers often produce coherent historical narratives as justification for particular views of the nature of EBP, an examination of its origins reveals no such signs of historical development or progress in our conception or understanding of it. We then explore alternative modes of thought for attempting to understand and critique the variety of definitions and descriptions of EBP to be found in the literature. We eventually reject the linear mode of historical thinking in favour of Deleuze's notion of rhizomatic thought and the metaphor of geology. Finally, we employ the rhizomatic mode of thinking and writing to construct a geology of evidence-based practice which attempts to expose and embrace contradictions in definitions and uses of the term rather than discount them in an authorised historical narrative written from the perspective of the dominant discourse.

Troubling 'insight': power and possibilities in mental health care

This paper critiques the conventional concept of 'insight' within the mental status assessment, seeking to unseat its taken-for-granted definition and the status it has acquired in research and practice. Drawing on social theory, consumer perspective and interdisciplinary research, the paper focuses on the impact of 'thin' biomedical understandings of insight, in disqualifying and demoralizing persons subjected to assessment and at the same time creating punitive scrutineers out of well-intentioned practitioners. Nurses and their mental health colleagues are encouraged to reconsider their reliance on the concept of insight. We entertain the alternative idea that insight is a quality of perception that mental health practitioners can cultivate, to more deeply understand their work, culture and the self.

Transcending transculturalism? Race, ethnicity and health-care

This paper offers a critical commentary on the essentialist concept of ethnicity, which, it is argued, underpins the discourse of transcultural health-care. Following a consideration of the difficulties that ensue from the way in which ethnicity has been theorised within transcultural nursing in particular, the paper turns to a consideration of alternative ways of thinking about ethnicity, which have emerged from more recent social anthropology and postmodernism. It addresses the question of how to therorise ethnicity in a way that does not entail its reification as a set of fixed cultural properties, and makes some tentative suggestions for the possibility of a critical culturalist approach to difference and healthcare practice, which must include a consideration of racisms.

Patient characteristics of women and men cared for during the first 10 years at an inpatient hospice ward in Sweden

The hospice philosophy with focus on the patient's autonomy and the ideal of a good death are the overall objectives of palliative care. Often-raised questions, when discussing hospice, are for which of the incurable ill inpatient hospice is the most optimal care alternative together with who are making use of hospice. The aim of the present study was to describe patient characteristics such as age, marital status, diagnosis, referral source and length of stay (LoS) in relation to gender, during the first decade at an inpatient hospice ward (1992-2001). Data, obtained from medical register, were analysed by using descriptive statistics and the chi-square test. The number of patients was 666 women and 555 men, and most of them were elderly. In some respects significant differences were observed between women and men. More women than men were single, had cancer with relatively rapid trajectory and were referred from the oncology department. Men, more often than women, were diagnosed with cancers with a somewhat longer trajectory. Despite the longer trajectory, the LoS was shorter for men (median =13 days) than for women (median = 17 days). The most frequent referral source was hospital, though men, younger men in particular, were more often referred from home-based hospice care than women. During the last 3 years self-referrals were documented. Self-referrals can be seen as one distinct expression from a standpoint of one's own active choice compared with other referrals. Altogether, self-referrals were less frequent among women than men but in relation to age, self-referrals were more common among the youngest (<60 years) and the oldest women (>85 years) than men in the same age groups. Further studies illuminating a gender perspective can broaden the understanding of what these differences may imply for women and men.

Prenatal diagnosis and selective abortion: a result of the cultural turn?

There is a growing trend in obstetric medicine of prenatal diagnosis and the selective abortion of foetuses that are likely to be born with a disability. Reasons commonly given to explain this trend include the financial implications of screening and testing policies, the disruption to families caused by the birth of a child with a disability, and the potential quality of life of the unborn child. This paper reflects upon another possible reason for this. It is argued that it is, in part, a consequence of our attitudes towards disability and a pursuit of aesthetic perfection. These attitudes arise from a social context that may be explained by considering the effect on the disabled community of the transition from modernity to postmodernity. This shift is demonstrated by inspecting some of the synonymous developments in art history. It is suggested that this "cultural turn" may have both helped and hindered people with disabilities, but the hypothesis requires further testing. This could best be achieved with a qualitative study of what motivates parental decision making in the obstetric unit.

Postmodern feminist perspectives and nursing research: a passionately interested form of inquiry

The challenges posed by postmodern and poststructural theories profoundly disrupt the certainties of feminist and nursing research, yet at the same time offer possibilities for developing new epistemologies. While there are an increasing number of accounts discussing the theoretical implications of these ideas for nursing research, I wish to discuss the practical and the methodological implications of using postmodern feminist theories within empirical research. In particular, I identify the challenges I encountered through an examination of specific aspects of the research process and through examples drawn from empirical research. I conclude that using postmodern feminist theories requires a continuous engagement with, and interrogation of, the modern epistemological and ontological assumptions of qualitative, feminist nursing research and, in so doing, presents the possibility for nurse scholars to begin to develop a 'passionately interested' methodological approach to nursing inquiry.

Postmodern consciousness in psychotherapy

Modern consciousness is a cultural and historical achievement in the West and a developmental task for each person now. Modern consciousness consists in the emancipation from the power of community, animistic nature and the unconscious. It is connected with neurosis and psychotherapy because it has to do with inner conflicts. But today there is an increasing number of cases which are characterized by dissociation and acting out, without the feeling of conflicts. Consciousness seems to be changing toward a new conception which might be called 'postmodern consciousness'. The essence of postmodern consciousness is shown by interpreting two dreams internally. The first dream from a case of depersonalization indicates that it is not necessary to be entangled with the object. There is a different kind of coniunctio in the mode of seeing. The second dream from a case of dissociative disorder shows a world which has neither traces of pre-modern cosmology-high and low, here and the beyond-nor modern interiority. There is only surface and self-reflection without content. The discussion of dreams suggests that postmodern consciousness is not to be understood as premature and pathological. It is therapeutically important to refine and deepen postmodern consciousness.

Masculinity, male development, gender, and identity: modern and postmodern meanings

Modern and postmodern scholars are addressing the crisis in masculinity by questioning the meaning of masculinity and by rethinking masculinity, male development, gender, and identity. This article explicates current modern humanist positions and postmodern positions on these topics. The first section summarizes contemporary theories advanced by scholars in the relatively new discipline of men's studies. The second section presents postmodern positions exploring sex as a biological given, the emerging critiques of differentiating sex and gender, and poststructural psychoanalytic positions on simultaneous production of individual subjectivity (sense of self), masculine identity, and society. Implications of these perspectives are identified.

Whiteness and difference in nursing

This paper uses a semiotic, performative theory of language and post-colonial theory to argue that nursing's representations of 'multiculturalism' need to be grounded in a theory of whiteness, an historicized understanding of how ethnic/cultural differences come to be represented in the ways they are and informed by Foucault's notions of power/knowledge. Using nursing education and 'cultural compentency' as examples, the paper draws on a range of literatures to suggest more critical and politically productive ways of approaching difference from within nursing's largely white interpretive framework.

Mobile subjectivities: positioning the nonunitary self in critical feminist and postmodern research

Most scholarly work is written from the perspective of the author being a unitary subject occupying a sole, rational, and unified position. This article argues that scholarship may be enhanced by the author adopting multiple subject positions as a methodological framework. Such an adoption is advantageous in working against the romance of the notion of a single truth while also maintaining teleological values congruent with critical and feminist agendas. This article outlines the conceptual development of this methodological framework, the rationale for its development, an explication of the concept of multiple subjectivity, and an exemplar of its application within nursing research.

Adopting a constructivist approach to grounded theory: implications for research design

Grounded theory is a popular research methodology that is evolving to account for a range of ontological and epistemological underpinnings. Constructivist grounded theory has its foundations in relativism and an appreciation of the multiple truths and realities of subjectivism. Undertaking a constructivist enquiry requires the adoption of a position of mutuality between researcher and participant in the research process, which necessitates a rethinking of the grounded theorist's traditional role of objective observer. Key issues for constructivist grounded theorists to consider in designing their research studies are discussed in relation to developing a partnership with participants that enables a mutual construction of meaning during interviews and a meaningful reconstruction of their stories into a grounded theory model.