Disability, connectivity and transgressing the autonomous body

This paper explores the interconnectedness of persons with disabilities, technologies and the environment by problematizing Western notions of the independent, autonomous subject. Drawing from Deleuze and Guattari's reconfiguration of the static subject as active becoming, prevailing discourses valorizing independence are critiqued as contributing to the marginalization of bodies marked as disabled. Three examples of disability "dependencies"-man-dog, man-machine, and woman-woman connectivities-are used to illustrate that subjectivity is partial and transitory. Disability connectivity thus serves a signpost for an expanded understanding of subjectivity and suggests a radically altered ethics that is no longer premised on individual rights.

Towards understanding the unpresentable in nursing: some nursing philosophical considerations

While nursing practice embodies certain observable and sometimes habitual actions, much inheres in these actions that is not immediately discernible. Taking on Lyotard's exegesis of the unpresentable, I undertake an analysis of the unpresentable as it occurs in nursing practices. The unpresentable is a place of alterity often excluded from dominant discourses. Yet this very alterity is what practising nurses face day after day. Drawing from two nursing situations, one from a hermeneutic phenomenological study and the other from the literature, I elucidate the unpresentable from a nursing point of view. Evoking Lyotard as well as selected philosophers from the continental philosophical tradition, I also question whether nursing in its present discourse is capable of responding to the unpresentable in nursing situations. Through the philosophical stance of presentation and representation, I delineate the urgent need to bring the otherness of the unpresentable into our nursing discourse. Nurses in practice confront a wide array of human differences and diversities and come to the realization that no framework alone can ever really have primacy over the multiform presentations of human suffering that so strikingly evoke alterity.

Family health nursing and empowering relationships

PURPOSE

To examine how empowerment, as an ideology and a practice of teaching and learning, was understood and applied by public health nurses (PHNs) in health education with child bearing and child rearing families.

METHOD

Feminist poststructuralism was used to guide data collection and analysis. In-depth, individual interviews were conducted with three mothers and three PHNs and explored the different perspectives held by mothers and PHNs during a home visit.

FINDINGS

Moments of conflict, contradiction, affirmation, and agreement highlighted various empowering relations. Individual choice and recognition of knowledge and power exemplified how both mothers and PHNs used their "agency" to position themselves into a particular relationship. The analysis includes five sections: (a) mother's perceptions of PHNs, (b) normalization as problematic: the good/bad dichotomy, (c) professional/expert: the balance of power, (d) working the relationship, and (e) reflections on empowerment.

CONCLUSION

The information gathered from this studyprovides a rich understanding of the nurses' educational practices with new mothers.

Constructions of self: ethical overtones in surprising locations

Little discussion has occurred in the health profession literature with respect to how the "self" is constructed, despite the imagination and attention it has garnered from philosophers and theorists in various other disciplines. Yet this subject has surprisingly ethical overtones for health professional education and practice. In this paper notions of the self are briefly considered and it is suggested that a narrative and dialogic view of self can contribute to insights about ethical practice in the health professions. Subtle issues with respect to how relationship and language may be used to wield power are revealed and discussed; and awareness about how such power is used in practice is highlighted as a crucial issue. The assumptions practitioners make with respect to constructions of self are ethically important and this topic warrants consideration in the medical humanities.

Alternative futures for health economics: implications for nursing management

As nursing has been subject to successive waves of 'managerialism' there has been a drive on the part of government and elements within the profession to enhance the science base and promote cost-effective health care interventions. This has generated new interest in the 'economics of nursing' as efficiency and 'value for money' are viewed as necessary precondition for the provision of a high quality nursing service. As an academic subject health economics has brought an elegant set of theories to bear on the topic of health and health care. However, mainstream health economics is premised on a series of simplifying assumptions that, if applied uncritically, can induce a range of unintended and adverse consequences. This paper asks how ideas developed in one sphere (health economics) can be become influential in another (nursing management and practice) and it seeks explanations in the theories of Michel Foucault, specifically in his exploration of the reciprocal relationship between power and knowledge. How are our assumptions about what is possible and desirable shaped, how far do mechanisms of surveillance and self-subjugation extend? A range of alternative economic approaches have been developed which challenge many mainstream health economics assumptions. Some of these are better suited to the complex social environment present within health care. Nurses, nurse managers and researchers should question the assumptions of dominant economic models and explore a range of economic frameworks when planning services and evaluating their practice.

Foundation Trusts: economics in the 'postmodern hospital'

Foundation Trust Hospitals are community-controlled health care providers which have increased autonomy about how they produce outcomes for the British National Health Service. Although there is a literature on hospital economics it is unclear how these innovative providers will behave, if they have to compete for scarce resources with other hospitals. This paper reviews some of the earlier theories, such as the neoclassical theory of the firm, and discusses their relevance along with 'newer' economic theories such as the transaction costs and evolutionary theory of the firm, plus organizational and human resources theory, to the performance of Foundation Trusts. Much contemporary health care provision is shaped along modernist lines, using scientific endeavour to maximize the impact on health outcomes and technical and social efficiency. However, there is an increasingly postmodern standpoint--critical of modernity--being taken by both patients and hospital staff, to deconstruct processes in the organizations that serve them. Foundation Trusts are postmodern hospitals insomuch as they (to attract scarce resources in a competitive environment), need to marshal the diverse theories of the firm together in order to provide a mass-customized, quality experience, transparently and at least cost--whilst maintaining a stable organizational culture for staff.

Stepping out of the box: broadening the dialogue around the organizational implementation of cognitive behavioural psychotherapy

The dissemination and uptake of cognitive behavioural interventions is central to the evidence-based mental health agenda in Britain. However, some policy and related literature, in and of itself social constructed, tends to display discursive naïvety in assuming a rational basis for the dissemination and organizational integration of cognitive behavioural approaches. Rational constructions fail to acknowledge that the practice settings of key stakeholders in the process are likely to be socially constructed fields of multiple meanings. Within these, the importance of evidence-based interventions may be variously contested or reworked. To illustrate this, a case example from the first author will discuss the hypothetical introduction of a cognitive behavioural group for voice hearers in a forensic mental health unit. This will highlight contradictions and local organizational problems around the effective utilization of postgraduate cognitive behavioural knowledge and skills. A synthesis of social constructionist with organizational theory will be used to make better sense of these actual and anticipated difficulties. From this basis, specific ways in which nurses and supportive stakeholders could move the implementation of cognitive behavioural psychotherapy agenda forward within a postmodern leadership context will be proposed.

Said another way. My definition of nursing

The definition of nursing has evolved since the introduction of the definition by the American Nurses Association in 1980. The society we nurses serve has changed significantly and members of the society demand quality health care and respect for their individual decisions regarding their health care. As a profession, we must keep our fingers on the pulse of society and be ready to respond to the changes of society's needs. Being diligent in defining our position in society is imperative for the preservation of the nursing profession. This paper supports the current definition of the ANA (2003) within the domains of the art, science, and practice of nursing.

Mediating the meaning of evidence through epistemological diversity

Nursing's disciplinary recognition of 'multiple ways of knowing' reflects an epistemological diversity that supports nursing praxis. Nursing as praxis offers a conceptual way to explore what it is about the interface of practice, knowledge and evidence in nursing that distinguishes us as a discipline. I suggest that the relationship between evidence and knowledge is defined and mediated by the same epistemological diversity that supports nursing as praxis. Just as the meaning and truth-value of evidence is evaluated from within the body of existing disciplinary knowledge, new evidence may prompt an evaluation of the meaning and truth-value of extant nursing knowledge. Nursing practice that relies on scientific evidence as a singular basis of practice knowledge is susceptible to exploitation by the diverse agendas operating within an ideology of evidence-based practice and the healthcare system. Mediating the meaning of evidence for nursing practice through acknowledgement of the diverse epistemologies that underpin nursing knowledge will contribute to a disciplinary-specific definition of what constitutes evidence for nursing, and will better direct how evidence is integrated into a disciplinary body of knowledge.

The deconstructing angel: nursing, reflection and evidence-based practice

This paper explores Jacques Derrida's strategy of deconstruction as a way of understanding and critiquing nursing theory and practice. Deconstruction has its origins in philosophy, but I argue that it is useful and relevant as a way of challenging the dominant paradigm of any discipline, including nursing. Because deconstruction is notoriously difficult to define, I offer a number of examples of deconstruction in action. In particular, I focus on three critiques of reflective practice by the meta-narrative of evidence-based practice (EBP) and attempt to show how those critiques can be directed back at EBP itself. I conclude with the observation that EBP is open to many of the criticisms that it directs at other discourses, including problems of a lack of empirical evidence, of distortions due to memory, and of falsification of the 'facts'.

The language of 'experience' in nursing research

This paper is an analysis of how the signifier 'experience' is used in nursing research. We identify a set of issues we believe accompany the use of experience but are rarely addressed. These issues are embedded in a spectrum that includes ontological commitments, visions of the person/self and its relation to 'society', understandings of research methodology and the politics of nursing. We argue that a poststructuralist understanding of the language of experience in research opens up additional ways to analyze the relationship between the conduct of nursing research and cultural/political commitments.

Modes of rationality in nursing documentation: biology, biography and the 'voice of nursing'

This article is based on a discourse analysis of the complete nursing records of 45 patients, and concerns the modes of rationality that mediated text-based accounts relating to patient care that nurses recorded. The analysis draws on the work of the critical theorist, Jurgen Habermas, who conceptualised rationality in the context of modernity according to two types: purposive rationality based on an instrumental logic, and value rationality based on ethical considerations and moral reasoning. Our analysis revealed that purposive rationality dominated the content of nursing documentation, as evidenced by a particularly bio-centric and modernist construction of the workings of the body within the texts. There was little reference in the documentation to central themes of contemporary nursing discourses, such as notions of partnership, autonomy, and self-determination, which are associated with value rationality. Drawing on Habermas, we argue that this nursing documentation depicted the colonisation of the sociocultural lifeworld by the bio-technocratic system. Where nurses recorded disagreements that patients had with medical regimes, the central struggle inherent in the project of modernity became transparent--the tension between the rational and instrumental control of people through scientific regulation and the autonomy of the subject. The article concludes by problematising communicative action within the context of nursing practice.

Postmodernising clinical supervision in nursing

Clinical supervision (CS) has been organised and conducted around specific modernist principles, despite claims of the need for, or existence of, heterogeneity. A postmodernist perspective is used to challenge the idea that there is a correct structure (hierarchical) and function (developing supervisee self-awareness, detecting and resolving "real" problems) for CS. The meaning of CS can be locally constructed. In an egalitarian consultation, expertise is shared and multiplicity in clinical stories is celebrated. Practitioners are liberated in relation to deciding what approaches fit for the person in context. They feel strengthened by the cohesion of a group with a flattened hierarchy and, within limits, able to challenge existing policy and practice.

[Postmodernism and the issue of nursing]

PURPOSE

The purpose of this study was to illustrate the main stream of postmodernism which has influenced theory and research in the nursing science, and then to consider the meaning and value ofwhat the postmodern perspective has meant to nursing science in the 21st century.

METHOD

Derrida and Foucaults philosophical thoughts that characterized postmodernism through the interpretation of their major literature was studied. Based on their philosophy, it was shown how Derrida's idea could be applied in deconstructing the core paradigm in modern nursing science. In terms of Foucault's post-structuralism, reinterpretation of the nursing science in relation to power/knowledge was completed.

RESULT

Postmodernism created multiple and diverse paradigms of nursing theory as well as nursing research. This was accomplished by deconstructing the modernism of nursing science which was based on the positivism and medical-cure centralism. Specifically, the post-structuralist perspective revealed issues around the relationship of power and knowledge, which dominated and produced modern nursing science. Contemporary nursing science accepts pluralism and needs no unitary meta-paradigm, which can reintegrate multiple and diverse paradigms.

CONCLUSION

In considering the issue of nursing science in postmodernism, it can be summarized as follows: the postmodern thinking discovers and reveals diverse and potential nursing values which were veiled by the domination of western modern nursing science. These were motivated to create nursing knowledge by conversation in interpersonal relationships, which can contribute to practical utilities for the caring-healing situation.

The implementation of Narrative Pedagogy into nursing education in Japan

The conventional approach to nursing education has been dominant in the teaching and learning environment in Japan. Some teachers are now seeking alternative approaches that can offer new ways of practice for reforming nursing education. Narrative Pedagogy can be used to guide the reconstruction of nursing education in Japan. The author reviews contemporary approaches to nursing education in Japan and discusses the strategies for implementing Narrative Pedagogy into the nursing education environment.

Narrative ARTifice and women's agency

The choice to pursue fertility treatments is a complex one. In this paper I explore the issues of choice, agency, and gender as they relate to assisted reproductive technologies (ARTs). I argue that narrative approaches to bioethics such as those by Arthur Frank and Hilde Lindemann Nelson clarify judgments about autonomy and fertility medicine. More specifically, I propose two broad narrative categories that help capture the experience of encounters with fertility medicine: narratives of hope and narratives of resistance. This narrative typology captures the inevitable conflict that women feel when they become subjects of fertility medicine. On the one hand, they must remain hopeful; on the other, they must not surrender themselves completely. Nelson's account of counterstories as narratives of resistance helps us see how women can reconcile the experience of a strong desire to have children with the desire to remain authentic and whole.

Evidence-based practice: a deconstruction and postmodern critique: book review article

This paper discusses the significance of postmodernism for healthcare practice, specifically the discourse known as 'evidence-based practice'. It considers two texts, both of which present postmodern analyses of contemporary issues. One text presents a deconstruction of evidence-based practice in an attempt to reveal its 'true' nature, which is portrayed as one that does not respect research paradigms other than the randomised controlled trial, merely pays lip service to expertise and fails to connect with the real nature of clinical practice. The second text considers the accusation that absolute relativism implied by postmodern approaches may permit an 'anything goes' mentality and provide succour to those advocating unacceptable practices. A 'defence' of postmodernism in relation to the accusation that it encourages holocaust denial is used to consider further the nature and limitations of postmodern critiques of evidence-based practice. This review concludes that postmodernism fundamentally challenges the apparent 'objectivity' of evidence-based practice but it does not challenge the fundamental rules for acquiring and testing evidence. Rather it is the selection of questions to be asked and answered by evidence-based practice/practitioners that is the true limitation. This is the ground upon which fruitful argument can be had about the significance of evidence without undermining the requirement that there be evidence and standards to judge such evidence.

Nursing scholars appropriating new methods: the use of discourse analysis in scholarly nursing journals 1996-2003

Nursing scholars appropriate the analysis of discourse. "Discourse analysis" covers a wide spectrum of approaches to analysing meaning and language and there is no widely accepted definition of either a concept or an analysis of discourse. A sample of the discourse analyses indexed in the CINAHL database was analysed in order to identify what notions of discourse and discourse analysis are preferred by nursing scholars. The results showed that nursing scholars prefer approaches to discourse that resemble mainstream qualitative research avoiding social life and interaction. Explanations for these findings are briefly outlined.

Regulating hospital use: length of stay, beds and whiteboards

This paper presents part of a larger study of contemporary nursing practice and the rationalisation of hospital length of stay. Informed by Michel Foucault's work on governmentality, length of hospital stay and the re-engineering of surgical services are examined, not in terms of numerical representations of hospital use, but as part of social and political processes through which certain concepts are made susceptible to measurement and practices are organised. Using data generated through fieldwork in a hospital surgical division this analysis offers understandings of how social practices around length of hospital stay are translated and how they pattern contemporary hospital nursing practice. Nursing practice is explored through the reconstitution of hospital beds and the demands of local administration of hospital length of stay.