By Catherine Kelsey, University of Bradford
It is argued that nursing is controlled by a number of hegemonic influences including political reform and societal expectations, the constant call for evidence-based practice and the all-pervading management-led changes that seem to be a constant. And yet nurses are considered to be autonomous and accountable practitioners (Hilton, 2005), who have the capacity to initiate change, improve patient outcomes, deliver high quality service provision, and to achieve this within a framework of prolonged austerity. Furthermore, nurses are also now in a strong position to ensure the self-regulation of personal performance, through the newly-developed process of revalidation, which for some has the potential to facilitate a commitment to lifelong learning and for others presents a significant and particularly unwelcome challenge.
Revalidation has the capacity to improve patient care (NMC, 2015) and yet this process it could be argued, exerts not only a strong influence on the way in which nurses learn, but also ensures a level of endless scrutiny as the process requires a third party to confirm that the nurse or midwife revalidating has complied with the agreed standards. Whilst much of nursing is delivered using an evidence-based approach it is argued by Goodman (2013) that revalidation lacks an evidence base for its implementation. Furthermore, in his work on governmentality Foucault (1991) warns against the culture of a surveillance society and others have reviewed this with reference to medicine (Waring, 2007, Archer et al, 2012).
Although the onus is on the NMC to confirm fitness to practice, it could be considered that this framework is not only about self-regulation but the injection of further hegemonic influences on a profession that already concedes to its domination. Hegemonic influence, essentially power used by the ruling to create ideas accepted by the ruled, is a process through which social stability can be maintained (Wilkinson, 1999). Hegemonic influence describes the somewhat dominant position of an established set of thoughts that become entrenched within society, ultimately preventing the diffusion of alternative thought (Rosamond 2016) and is considered by Wilkinson (1999) as being a conduit through which social stability can be achieved. This influence however is about control and the way in which this can be challenged is by adopting an understanding of critical consciousness or conscientisation (Freire, 2012). Critical consciousness focuses on persons acquiring a wide-ranging appreciation of the context in which they live, recognising the social and political constraints that exist, and through this understanding take action to reduce their impact (Mustakova-Possardt 2003). However, nurses have failed to respond in this way and therefore it could be argued are simply the protagonists of their own fate.
In his work Fay (1987) describes the phenomenon of false consciousness, which he contends is concerned with the ignorance that people have about themselves and the society in which they live. Through the analysis of this notion, it could be argued that nurses are simply unaware of their oppressed state and the controlling influences under which they practice. For example, front-line nurses may be dominated or influenced by the expectations that society has on their ability to provide high quality patient care. Likewise, nurse leaders and nurse educationalists may state that they have little time to challenge the controlling paradigms that exist as the challenge to ensure the wards are staffed adequately and safely take precedent. All is not lost however, for despite these challenges revalidation with its emphasis on reflection (NMC, 2015) if used wisely, could be a platform for political change and nursing reform that puts nurses back into the driving seat.
Revalidation as a platform for political change
Despite the challenges raised towards revalidation in this article it could be argued that having the ability to critically reflect and act, a process known as praxis (Chinn and Kramer, 2011), has the potential to propel nursing towards becoming a more enlightened profession, one which has the potential to empower future practice, and support the move towards emancipation, social equity and empowerment.
Taylor (2010) argues that emancipatory reflection has the capacity to enable nurses to critique workplace power relationships and through this process inspire a new sense of informed consciousness that has the ability to bring about political and social change. Emancipatory knowing (Chinn and Kramer, 2011) encourages action that aims to reduce or eliminate inequality and injustice in all its forms. It requires an understanding of the power dynamics that create knowledge and of the social and political constructs that sustain advantage for some and disadvantage for others. Understanding this process can become a catalyst for nursing and government reform that puts the profession in the driving seat of its own destiny.
Nurses should no longer be the oppressed protagonists of their own narrative. Nursing continues to be let down by those who fail to recognise, or fail to respond with conviction, to the significant contribution nurses make to providing high quality patient care. Many within the profession including nurses themselves, however, have failed to challenge the increasingly dominant paradigms that exist and instead have continued to collude, perhaps unknowingly, to maintain the oppression of nurses.
Demonstrably, nursing has undergone many changes in recent years and the impact of the failings within healthcare have done little to reinforce the idea of nurses as a humanitarian, well-supported workforce able to challenge poor practice and ensure the provision of high quality compassionate, evidence-based care. As early as 1996, Harden (1996) proposed that by adopting critical consciousness as an educational framework, nurse educationalists can develop the capacity to expose the oppressive structures that limit nurses’ experiences; structures defined by Freire (2012) as being related to economic, social and political domination, and through their actions ensure that truly humanistic and compassionate care can be delivered.
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