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Subjects of concern: troubling categories

Nursing is described by many as ‘practice based’: an appealing and irresistible phrase, a salve for professional self-doubt, and a position that has great utility when communicating the essence of nursing to others outside the profession. Yet this is also a political position, situated in a particular configuration of relationships, identities and histories. Nursing is a practice-based profession, but it is certainly not unique in this respect. To refuse intellectually diverse scrutiny on the premise that this is somehow incompatible with the ‘art’ of nursing and a ‘practical’ closeness to the patient cannot be defended.

As Dame Jill Macleod Clark recently indicated with concern at RCN conference, there is a great deal of nursing research that concerns itself with a concern for ‘experiences, attitudes and perceptions’ (Macleod Clark 2009). No one appears immune from this. We seek the perceptions of patients, carers, students and their mentors; indeed, everyone it seems. Of course, there is nothing wrong in this. It is always important to listen to what people have to say, ascertain their understandings and allow ourselves to capture and incorporate their memories into ours and gain a sense of their ‘being-in-the-world’. That this is also congruent with the positioning of the patient as a consumer of the services that we offer, and that such studies are often local in their scope, is probably a useful if not intentional convenience.

Critical of basic assumptions

It is also important to ascertain whether we are

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As Dame Jill Macleod Clark recently indicated with concern at RCN conference, there is a great deal of nursing research that concerns itself with a concern for ‘experiences, attitudes and perceptions’ (Macleod Clark 2009). No one appears immune from this. We seek the perceptions of patients, carers, students and their mentors; indeed, everyone it seems. Of course, there is nothing wrong in this. It is always important to listen to what people have to say, ascertain their understandings and allow ourselves to capture and incorporate their memories into ours and gain a sense of their ‘being-in-the-world’. That this is also congruent with the positioning of the patient as a consumer of the services that we offer, and that such studies are often local in their scope, is probably a useful if not intentional convenience.

Critical of basic assumptions

It is also important to ascertain whether we are doing what we are paid by the public to do. We must not forget about evaluating practice, lest we risk delivering care that is not evidence-based, effective, measurable and subject to scrutiny by others. As such, Professor Macleod Clark is correct in emphasising the need for programmatic work, centres of research excellence and the identification of what she describes as ‘meaningful metrics’. More provocatively, however, I would also suggest that we need to concern ourselves critically with the methodologies we choose and, more importantly, with the basic assumptions we make about the subjects and categories of our enquiries.

Nursing, like all professions, requires a stable subject onto which it can confer discipline and control. And, like all good empirical scientists, we must be clear in our characterisations of the subject, be it the family in trauma, the elderly woman with a leg ulcer, the teenager with diabetes or, if we must, ourselves. To be taken seriously as a distinct professional discipline, nursing must, in addition to wide and rigorous programmatic research, demonstrate an intellectual competency by showing a concern for the categories, discourses and presumptions we hold about the nature of our subjects of enquiry.

Remaining too close to practice

Researching ‘perceptions’ may be interesting, but is simply not enough. We need to understand the manner by which we constitute the subjects of our enquiry. Categories such as ‘the patient’, ‘the student’ and ‘the family’, for instance, appear stable enough to be subject to hard empirical enquiry. But perhaps we ought to extend the envelope of our study, step back a little, and think hard about who or what these subjects are, and if our categorisation of them is meaningful or ‘valid’. Our inability to question the nature of the subject in this way is in part because of our expressed need to remain ‘close to practice’, and this has mitigated against taking the longer view of nursing and of the subjects of its research.

Professor Macleod Clark’s position is pragmatic, sensible and, in the current climate, politically astute. Nursing research is located in the mire of an empirical conspiracy that is largely beyond our political control. Research activity in nursing is, for now at least, more vigorous than at any time in the past. But trapped in the politico-economic trinity of government policy, evaluation of service delivery and the metrics and market of higher education research, the empirical landscape is marked by patches of arid land, a drought of epistemic diversity. To firmly characterise the contribution that nursing can make, we need to ensure that we constantly revisit and relearn what the essence of nursing actually is.

Care about methodological tools

Reaching beyond a comfortably-focused definition of the contemporary discipline involves asking sometimes difficult questions about nursing’s raison d’être: for example, its continued subjugated location in political and media discourse or its effective de-politicisation at the level of education and clinical practice. If nursing wishes to remain aligned to the notion of ‘care’ (something that is, by no means, a certainty) then we must remind ourselves what this comforting aspiration means.

I believe that ‘care’ refers to nursing’s capacity to render particular subjects – the sick, the voiceless, the vulnerable and the forgotten – visible, and hence we need to extend our representational concern to the methodological tools we choose to work with and the subjects of our enquiry.

This means our methodologies need to challenge many of the preconceptions that they hold dear, many of which reside deeply embedded in the culture of the profession, out of sight of the more visible gestures that characterise nursing practice. Yes, nursing should be concerned with the ‘science’ of infection control, tissue viability and continence, to use Professor Macleod Clark’s examples. But in the revised vista of nursing practice – public health and health promotion, inter-professional working in mental health, and primary care practice with certain defined groups, for example – we need to ensure that the subjects of our concern in these areas are characterised with the scrutiny and rigour that we also apply to the biomedical aspects of our practice.

Looking beyond the comfort zone

Residing in this ‘revised vista’, much nursing research has been concerned with those subjects and identities that have, in the closing decades of the past century and in the early years of the new, been constituted through political discourse. In their time, they have been important, including women and their health, minority ethnic groups, the very young, and the most senior members of our society. However, unlike the leg ulcer, Waterlow score or urinary infection rate, these are not stable empirical subjects, and their identities will always be contested, no matter how much we or our politicians might wish them not to be.

So while, for purely pragmatic political and economic reasons, nursing research does need to ‘think big’ and act with precision and rigour, nursing theory and methodology also needs to look beyond the epistemological comfort zone of its most popular antecedents. In attempting to establish our own identity, and often for sensible, practical reasons, we have plundered our neighbours: medicine, psychology and a handful of other disciplines, albeit some less deeply than others. We rarely have made deep journeys into history, geography and politics. These too are liberating, practical disciplines, concerned with questioning their epistemic bases and their application in the field. And nursing ought to do the same.

Tackling a political agenda

Nursing resides within a melee of ontological disorder. I believe this can be a valuable characteristic. But with the bureaucratisation of nursing – which has often been, we should remind ourselves, at the request of nurses – we risk neutering the free-spirit and political engagement that should characterise any discipline that concerns itself with the individual and the community. There are – to coin an unfortunate political sound-bite – ‘green shoots’. The recent professional debate on euthanasia, for example, has been a vital illustration of the willingness of nursing to challenge deeply embedded cultural beliefs. Nursing must also think closely about how it might progress this debate and others if it is to avoid the ‘so what?’ response that often, sadly, renders powerlessness the nursing voice.

Nursing – in theory, practice and all locations in between – has promoted a moral disconnect between politics and practice. It is not alone among the professions in doing so, but the effect has been to increasingly anaesthetise practice, subjugate challenge and confine theory and practice to a particular ideological frame and field of methodological thought. Nursing should attempt to ‘compete with the best’, and endeavour to borrow the tools and proficiencies of other academic disciplines. Equally, however, nursing should aim to sharpen its own methodological and political intellect by troubling the very categories that mark the subjects of our concern.

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