The aim of this paper is to re‐examine nursing work from a Marxist perspective by means of a critique of two key concepts within nursing: autonomy and caring. Although Marx wrote over 150 years ago, many see continuing relevance to his theories. His concepts of capital, ideology and class antagonism are employed in this paper. Nursing's historical insertion into the developing hospital system is seen in terms of a loss of autonomy covered over by the development of cults of loyalty (...) toward those institutions, while the concept of emotional labour is used to re‐examine nursing's high valuing of “caring” and to understand it as potentially exploitative of nurses. Raising awareness of this alternative way of understanding nursing work can become a first step toward change. (shrink)

Compassion in healthcare has received significant attention recently, on an international scale, with concern raised about its absence during clinical interactions. As a concept, compassionate care has been linked to nursing. We examined historical discourse on this topic, to understand and situate current debates on compassionate care as a hallmark of high‐quality services. Documents we looked at illustrated how responsibility for delivering compassionate care cannot be consigned to individual nurses. Health professionals must have the right environmental circumstances to be able (...) to provide and engage in compassionate interactions with patients and their relatives. Hence, although compassionate care has been presented as a straightforward solution when crisis faces health services, this discourse, especially in policy documents, has often failed to acknowledge the system‐level issues associated with its provision. This has resulted in simplistic presentations of ‘compassion’ as inexpensive and the responsibility of individual nurses, a misleading proposal that risks devaluing the energy and resources required to deliver compassionate care. It also overlooks the need for organisations, not just individuals, to be charged with upholding its provision. (shrink)

Background:Research suggests that nurses generally do not participate in ethical decision-making in accordance with ethical guidelines for nurses. In addition to completing their training, nurses need to reflect on and use ethically grounded arguments and defined ethical values such as patient’s dignity in their clinical work.Objectives:The purpose of this article is to gain a deeper understanding of how nurses deal with ethical decision-making in daily practice. The chosen research question is “How do nurses participate in ethical decision-making for the patient?”Design (...) and method:We use Gadamer’s philosophical hermeneutics as well as Kvale and Brinkmann’s three levels of understanding in interpreting the data material. Nine registered nurses were interviewed.Ethical considerations:The Ombudsman of Norwegian Social Science Data and the head of the hospital approved the investigation. The participants received both oral and written information about the study and they gave their consent. We informed the participants that the participation was voluntary and that they were free to withdraw at any point in the course of the study. The requirement of anonymity and proper data storage was in accordance with the World Medical Association Declaration of Helsinki. The participants were assured that privacy, and confidentiality would be duly protected.Results:Four key themes emerged: confusion in relation to professional and operational expectations of role, ideal somnolence, inadequate argumentation skills, and compound pressure.Conclusion:Ethical ideals appear to be latent in the mindset of the participants; however, the main finding of this investigation is that nurses need to activate the ideals and apply them into practice. Furthermore, management needs to initiate professional reasoning and interdisciplinary discussions leading to common goals for patients. (shrink)

SARGENT A. Nursing Inquiry 2012; 19: 134–143 [Epub ahead of print]Reframing caring as discursive practice: a critical review of conceptual analyses of caring in nursingThis study critically examines the way in which the concept of caring is presented in the nursing literature through conceptual analytic approaches. A critical reflection on the potential consequences of representing a concept of caring as vague and ambiguous, yet central to ontology and epistemology in professional nursing is presented drawing on comparisons between the conceptual analyses (...) of caring, and of structuralist perspectives of language, and how this potentially limits scholarship in this area. A search of the literature revealed nine conceptual papers. These papers highlight the self‐referential characteristics of the concept of caring, and of analytical methods in general. It is proposed that this is the result of a systematic adherence to a rigid, structuralist view of language, whereby stable relationships between words and their meanings are assumed. An alternative perspective is offered by viewing caring as a discursive practice rather than a fixed conceptual entity, calling into question the role that the concept plays in nursing practice. A poststructuralist perspective requires caring to be perceived as a discourse of nursing that is fluid and contingent, rather than a central and guiding concept, opening up a new orientation for nursing scholarship in caring research. (shrink)

The purpose of this contemporary history study is to analyse nursing strategy documents produced by NHS Trusts in England in the period 2009–2013, through a process of discourse analysis. In 2013 the Francis Report on the Mid-Staffordshire NHS Foundation Trust was published. The Report highlighted the full range of organisational failures in a Trust that valued financial efficiency over patient care. The analysis that followed, however, dwelt heavily on the failings of the nurses. Nursing strategy documents at that time served (...) to set the future direction for NHS Trusts, prescribing specific value frameworks for each nursing workforce. However, the values chosen frequently conflicted with each other pitting nursing values against a managerial trope. It is argued that documents provided a response to wider NHS concerns and high-profile failures in care, particularly the Francis Report, paying lip service to staff engagement whilst maintaining a corporate focus. Nursing values were placed firmly within a managerialist discourse, one that has needed to be re-evaluated in the current Covid-19 pandemic. Wider implications of the research suggest discussion of value conflict may be beneficial within nursing education and a truly local approach to strategy creation would potentially promote staff buy-in to strategy documents. (shrink)

This paper will explore the relationship between Mezirow's concept of reflexivity and Bourdieu's theory of habitus in order to develop a more robust framework within which critical reflection can take place. Nurse educators have sought to close the theory practice gap through the use of critical reflection. However, we are not convinced that this has produced the depth and quality of reflection required. Furthermore, the contexts in which critical reflection takes place is often sidelined or erased so that the whole (...) impetus in the literature is to educate nurses in reflection rather than empower nurses to understand the complex circumstances and barriers that obstruct critical reflection. This paper argues that the reason for this position is that nurse education does not always acknowledge the role that personal and cultural values systems have on reflective practices. The literature search was undertaken using CINHAL and MEDLINE. Keywords included: values systems, habitus, and critical reflection. Inclusion criteria were determined by the theoretical approach and included seminal texts, from as far back as 1956, to identify key themes. Although critical reflection is a potentially powerful way of enhancing care it has often failed to do so. It is suggested that this is because nurse educators have frequently used models of reflection without considering the impact that student's personal values systems has on their perceptions of care and subsequently care delivery. The purpose of this paper is to promote deeper levels of reflection and is part of a programme of research aimed at developing a more robust approach to reflection in educational practice. (shrink)

This paper argues that insights into infant emotional development, particularly the capacity to engage with rupture and repair, can be applied to the understanding and promotion of flourishing in later life, individually and socially. Starting with the Queen’s visit to the Republic of Ireland as an example of successful social repair after rupture that enables flourishing, the paper goes on to outline some relevant psychological theory that undergirds this. It then considers some of the practical relevance and problems that apply (...) to rupture and repair in the contemporary world, particularly the world of health care, Amidst the inevitable messiness of life, flourishing and growth can only be achieved with the kind of flexibility implied by creating repair in the face of rupture. (shrink)

Austerity, by its very nature, imposes constraints by limiting the options for action available to us because certain courses of action are too costly or insufficiently cost effective. In the context of healthcare, the constraints imposed by austerity come in various forms; ranging from the availability of certain treatments being reduced or withdrawn completely, to reductions in staffing that mean healthcare professionals must ration the time they make available to each patient. As austerity has taken hold, across the United Kingdom (...) and Europe, it is important to consider the wider effects of the constraints that it imposes in healthcare. Within this paper, we focus specifically on one theorised effect—moral distress. We differentiate between avoidable and unavoidable ethical challenges within healthcare and argue that austerity creates additional avoidable ethical problems that exacerbate clinicians’ moral distress. We suggest that moral resilience is a suitable response to clinician moral distress caused by unavoidable ethical challenges but additional responses are required to address those that are created due to austerity. We encourage clinicians to engage in critical resilience and activism to address problems created by austerity and we highlight the responsibility of institutions to support healthcare professionals in such challenging times. (shrink)

Most current management systems of healthcare institutions correspond to a model of market ethics with its demands of competitiveness. This approach has been called managerialism and is couched in terms of much‐needed efficiencies and effective management of budgetary constraints. The aim of this study was to analyse the decision‐making of nurses through the impact of health institution management models on clinical practice. Based on Foucault's ethical theory, a qualitative study was conducted through a discourse analysis of the nursing records in (...) a hospital unit. The results revealed that the health institution standardises health care practice, which has an impact on professional and patient autonomy as it pertains to decision‐making. The results of this research indicate that resistance strategies in the internal structures of health organisations can replace the normalisation and instrumentalisation of professional practice aimed at promoting patient self‐determination. (shrink)

Background:New graduate transition into the workforce is challenging and can involve managing ethical tensions. Ethical tensions cause new graduates to doubt their capabilities due to their lack of experience. To support new graduates, we need to know what these ethical tensions are.Objectives:To explore the ethical tensions perceived to occur in practice for new graduate health professionals.Research design:This qualitative systematic review involved a search of five databases (Medline, EMBASE, AMED, CINAHL and Scopus) which resulted in the retrieval of 3554 papers. After (...) the two-phased screening process, eight studies were identified that met the inclusion criteria and had rich data on the review question. Articles were read several times, critically appraised and analysed through thematic analysis.Ethical considerations:No ethical approval was required for the systematic review. The review was conducted following well-established reporting guidelines enabling transparency and rigour.Findings:Studies originated from Australia, United States, Iran and China. One study included speech pathologists and seven were with nurses. Four themes included the following: (1) enduring an unknown workplace culture that generates uncertainty without support for new graduates; (2) being vulnerable because of distress from bullying, exclusion and being a scapegoat; (3) constraining systems and institutional restrictions that cause dilemmas; and (4) experiencing disillusionment from lost ideals about ethical practice.Discussion:This review has brought to light the vulnerability of new graduates to negative workplace culture and collegial incivility. In addition, new graduates are subjected to ethical tensions created by institutional constraints which can create dilemmas and uncertainties through practice that does not align with what they anticipated.Conclusion:Understanding ethical tensions experienced by new graduates enables provision of informed support. There needs to be considerable cultural change for orientation and socialisation of new graduates to enable them to learn and manage ethical tensions. (shrink)

Values‐based practice is deemed essential for healthcare provision worldwide. In England, values‐based recruitment methods, such as multiple mini interviews (MMIs), are employed to ensure that healthcare students’ personal values align with the values of the National Health Service (NHS), which focus on compassion and patient‐centeredness. However, values cannot be seen as static constructs. They can be positively and negatively influenced by learning and socialisation. We have conceptualised students’ perceptions of their values over the duration of their education programme as a (...) ‘values journey’. The aim of this hermeneutic longitudinal focus group study was to explore the ‘values journey’ of student nurses and midwives, recruited through MMIs, across the 3 years of their education programme. The study commenced in 2016, with 42 nursing and midwifery students, originally recruited onto their programmes through multiple mini interviews. At the third and final point of data collection, 25 participants remained. Findings indicate that students' confidence, courage and sense of accountability increased over the 3 years. However, their values were also shaped by time constraints, emotional experiences and racial discrimination. We argue that adequate psychological support is necessary as healthcare students embark on and progress through their values journey, and propose a framework for this. (shrink)

A report suggests that United States’ army officers may engage in dishonest reporting regarding their compliance procedures. Similarly, nurses with espoused high ethical standards sometimes fail to live up to them and may do so while deceiving themselves about such practices. Reasons for lapses are complex. However, multitudinous managerial demands arising within ‘technical and instrumental rationality’ may impact on honest decision‐making. This paper suggests that compliance processes, which operates within the social structural context of the technical and instrumental rationality manifest (...) as ‘managerialism’, contributes to professional ‘dishonesty’ about lapses in care, sometimes through ‘thoughtlessness’. The need to manage risk, measure, account, and control in order to deliver efficiency, effectiveness, and economy (technical rationality) thus has both unintended and dysfunctional consequences. Meeting compliance requirements may be mediated by factors such as the ‘affect heuristic’ and ‘reflexive deliberations’ as part of the ‘structured agency’ of nurses. It is the complexity of ‘structured agency’ which may explain why some nurses fail to respond to such things as sentinel events, a failure to recognize ‘personal troubles’ as ‘public issues’, a failure which to outsiders who expect rational and professional responses may seem inconceivable. There is a need to understand these processes so that nurses can critique the context in which they work and to move beyond either/or explanations of structure or agency for care failures, and professional dishonesty. (shrink)

The espousal of organizational values with an expectation of primarily positive consequences in leadership, employee performance and organizational change has often been recognized as overly simplistic, but giving a more complete and critical account of the interrelations between values and behaviour has proven challenging. This article describes a balanced and integrated positive, ambivalent and negative approach. The use of this PAN approach is described in the case of a health care organization. Evidence is given from a survey of 96 staff (...) perceptions of their current organizational values, staff evaluations of their colleagues’ demonstration of the organization’s espoused values and content analysis of 35 ‘memorable moments’ regarding what staff had experienced. Using the PAN framework in this case suggests a picture of staff reporting experiences as 50–30–20, respectively, for the PAN approach. The implications of this framework for leadership, employee performance and organizational change are discussed. (shrink)

Background:Ethics is a founding component of the nursing profession; however, nurses sometimes find it difficult to constantly adhere to the required ethical standards. There is limited knowledge about the factors that cause a committed nurse to violate standards; moral disengagement, originally developed by Bandura, is an essential variable to consider.Research objectives:This study aimed at developing and validating a nursing moral disengagement scale and investigated how moral disengagement is associated with counterproductive and citizenship behaviour at work.Research design:The research comprised a qualitative (...) study and a quantitative study, combining a cross-validation approach and a structural equation model.Participants and research context:A total of 60 Italian nurses involved in clinical work and enrolled as students in a postgraduate master’s programme took part in the qualitative study. In 2012, the researchers recruited 434 nurses from different Italian hospitals using a convenience sampling method to take part in the quantitative study.Ethical considerations:All the organisations involved and the university gave ethical approval; all respondents participated on a voluntary basis and did not receive any form of compensation.Findings:The nursing moral disengagement scale comprised a total of 22 items. Results attested the mono-dimensionality of the scale and its good psychometric properties. In addition, results highlighted a significant association between moral disengagement and both counterproductive and citizenship behaviours.Discussion:Results showed that nurses sometimes resort to moral disengagement in their daily practice, bypassing moral and ethical codes that would normally prevent them from enacting behaviours that violate their norms and protocols.Conclusion:The nursing moral disengagement scale can complement personnel monitoring and assessment procedures already in place and provide additional information to nursing management for designing interventions aimed at increasing compliance with ethical codes by improving the quality of the nurses’ work environment. (shrink)