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Nursing education: the marriage of two normative worlds — creating a sustainable relationship?
Nursing education: the marriage of two normative w o r l d s creating a sustainable relationship? Frances A Sutton
INTRODUCTION
Frances A, Sutton RN, RPN, DipT (Ns Ed), BEd, MEdAdmin, FRCNA, Associate Professor, Faculty of Nursing, University of South Australia, Smith Road, Salisbury East, South Australia 5109 (Requests for offprints to
FAS) Manuscript accepted 12 July 1995
Nursing has had a presence in Australian higher education since 1975 however, during the past 19 years this area of endeavour has seen a number of significant changes. The most significant change being that of relocating all pre-registration nursing education from its traditional hospital base into the higher education sector, This transfer however, has not been without problems, some of which relate to the lack of nursing's effective adjustment to higher education and the changes in higher education itself. Antecedent to these factors are other elements which include fundamental changes to western ways o f life and thought and the lack o f adequate preparation o f nurses for the experiences and roles they would encounter in the higher education sector as a result of their occupational experiences as nurses and women. These antecedent factors require nurses therefore, to not only understand the significance o f the changes occurring in the western world but also the need on the part o f nurse academics to work in, understand and acknowledge two normative organisations and the impact these organisations are experiencing as the result of the social and cultural changes occurring in the western world. A normative organisation is one in which the exercise o f power is undertaken in such a way so as to gain the commitment to and personal involvement in the organisation's goals by the individuals working in the organisation. The two organisations associated with nursing education, universities and health care organisations, are as such normative organisa-
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tions. These organisations however, while being normative, differ markedly in a number o f ways. This includes their historical origins, goals, organisational structures and processes established to achieve their goals and the expectations they have o f the individuals who work in them. In this sense, nurse academics work between two normative organisations that generate, as a consequence o f their differences, a number of significant difficulties. Additionally, changes in the health care structures, increasing cost containment and the historically generated values o f nursing itself combine to create a range of difficulties that will potentially have a deleterious effect on nursing and which are impossible to overcome unless nursing acknowledges its current difficulties and takes specific steps toward their resolution. Changes being experienced in these normative organisations are however not occurring by chance but as the result of a much wider set o f circumstances. Rather, I suggest that these changes have their genesis in history with the rise o f science and the subsequent advances in knowledge and technology. These innovations gave rise to the industrial revolution and the modern age. In turn, advances in science, knowledge and technology generated a range o f circumstances that has led to a weakening of the traditions and social structures associated with the modern age and a resultant lack of social and cultural stability. This lack of social and cultural stability, the emergence ofmultiplicities and the associated trends o f internationalisation; increasing technologisation; privatisation; commodification and vocationalisation o f education has resulted, in turn, in greater cultural fragmentation, pluralism, diversity and change that collectively is referred to as postmodernity (Lyotard 1986). The forces generated by postmodernity are currently placing pressures on both universities and hospitals and in turn impact on the nature o f and processes associated with nursing education. These are clearly evident in the role and function o f nurse academics and the problems they currently experience. This paper offers some beginning thoughts about these issues and in so doing hopes to stimulate discussion between all persons involved in nursing education. Throughout this paper I use the word hospital to refer to all health care organisations. While in terms o f structure and broad philosophical orientation a difference has been made between hospitals and community agencies, in terms o f their normative function and associated expectation of the individuals who work in them there is minimal difference.
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HIGHER E D U C A T I O N ORGANISATIONS The higher education sector in Australia has until recently been a binary system which reflected values seen in both the American college system wherein the emphasis was on teaching, and the traditional European mziversity system wherein the emphasis was on the development of knowledge, hence research. In recent years the Australian Federal government has attempted to remove the major structural differences between universities and colleges. As a result virtually all colleges and institutes merged with each other to form new universities or merged with existing universities. This has resulted in the establishment of a higher education system in which traditional perspectives of university life have been coupled with the philosophy of pragmatism. Additionally, increasing pressure for cost-containment have added the influence of economic rationalism. It is important to remember however, that universities emerged early in the middle ages with a way of functioning and emphasis different to that seen in contemporary western society. Interested in discovering knowledge and establishing truth, universities sought this in the empirical truth of science, the aesthetic truth of the arts and the spiritual truth of theology. As time passed the forces and pressures of modernism saw them become increasingly aligned with discovering knowledge and establising truth as determined and perceived from the perspective of science. In pursuing this truth the university appointed academic staff and established Chairs (the hallmark of scholarshp) as a means of support for esteemed academics to pursue their intellectual interests. Incumbents of such Chairs attracted students with w h o m they could share their ideas and transmit the same enthusiasm for knowledge and who would extend their research endeavour. Education of these students however, was not the academic's primary area of interest, neither was the development of a formalised curriculnm. The Federal government, and society, as a result of postmodern pressures now require universities, to not just discover knowledge but to discover knowledge which is useful, not just to transmit knowledge but to transmit it in such a way that individuals are prepared for specific occupations and professions. This demand minimally alters the fundamental goals and processes of the university in that it requires them to become more specific with respect to them. The advent of the new university system in Australia has seen the introduction of new fields of endeavour into universities, such as
teaching and nursing, that are concerned with the practical application of knowledge. In incorporating these fields the university has not changed its primary mission but suggests that the service delivered by these professions to the community will be enhanced by the pursuit of the university's basic goals of research and scholarship. Additionally, the ethos of universities is such that the original norms ofbehaviour established for those functioning in universities are expected for new participants in the organisation or for those universities which have recently been established. However, these norms of behaviour are contrary to those demanded of academics as the result of postmodernism. Traditionally, an academic is expected to search for the generalised knowledge in the specific field of endeavour in which they function; to have an attitude of scepticism enabling them to critique their own and others work; to share their findings through publication and discourse and to pursue their work so as to achieve the organisational goals of the university rather than simply serve self interest. A major criticism of the academy and post compulsory education generally however, was that it was too distant from the 'real world'. This led to a number of initiatives such as education becoming 'engaged' and allowing students to experience work, others argued for society to be 'de-schooled' (Illich 19). This criticism was unable, for many subjects, to be defended but resulted in a broad reorientation to education which resulted in an emphasis on students 'learning h o w to learn' rather than learning about specific areas of knowledge. In turn the teacher as teacher was transformed into the teacher as facilitator (Hinkson 1991, p.29). These two sets of pressures are not however, incompatible in that they both require the individuals involved to become creative and able to function somewhat autonomously while acknowledging the reality of interdependence. Thus, with the significant social changes that are occurring universities are changing. These changes are moving toward dividing the functions of higher eduation into two broad categories, the first being that of providing professional training during which the competencies considered necessary by each profession is transmitted. The second category relates to establishing the newly emerging fields of knowledge associated with the new techniques and technologies (Lyotard 1986, p. 60-61).
HEALTH CARE O R G A N I S A T I O N S There is no doubt that the western world's
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dedication to the scientific approach of logical positivism, rationality and reductionism led to the emergence of a scientific study of work which resulted in the development of new occupational categories and forms of worker management. One of the forms of worker management, derived from the work of Frederick Taylor (1947) and Max Weber (1947) generated the need for centralisation of all levels of decision making and established a management style and process known as bureaucracy. This form of management became firmly established as the most 'natural' way to organise business and its effectiveness led to it being adopted by governments. The adoption of bureaucratic organisational forms is most markedly seen in hospitals. While hospitals are many and varied they all share a common history and tend to have three distinct characteristics. The first such characteristic is that historically the growth of the modern hospital was strongly influenced by two social forces - expansion of knowledge and advances in technology, neither of which developed in the hospitals but generally in the university and in industry. The second characteristic is the essentially bureaucratic organisational structure and processes evident in hospitals. Bureaucracies, in order to accomplish their specific organisational objectives, are organised in orderly and stable hierarchies and have established rules and procedures for decision-making and employee functioning. Finally, the third characteristics of hospitals is that they reflect the dominance and influence of the philosophy and ideology of the medical profession. This effects both the range and type of services offered and the role and function of other groups of health care workers (Street 1992). Nursing also has bureaucratic structures in which the work of individual nurse practitioners in determined not only by the work of more dominant professions but also nurses who hold greater hierarchical authority (Sutton 1988, p. 65; Silver 1986, pp. 38-41). The goals of hospitals are such that they require a highly specialised range of activities. The work undertaken by such organisations is however, irregular and in part unpredictable. This lack of predictabiity reinforces the importance of the need for quality and control. This emphasis leads to these organisations being perceived as controlling and authoritarian with respect to the activities and behaviours of the individuals they employ. The desired behaviours of persons working within the health care system include delivering high quality care, loyalty, selflessness and hard work.
V A L U E S A N D A T T I T U D E S OF NURSING AND NURSES Colliere (1986) indicated that women have always been the primary providers of care within any society and that in the early development of society the value accorded to these activities was high. This perception changed with the development of writing. It was via this innovation that men, priests initially, started to confiscate or annex women's knowledge, transferring what they could collect and assimilating it for their own understanding. In the process of annexing this knowledge its meaning was frequently changed. The innovation of writing enabled the more rapid accumulation and dissemination of knowledge by men which in turn led to the development of a visible knowledge base. Because women were actively barred from learning to write and read their knowledge remained invisible and was transmitted orally. These characteristics of women's knowledge, coupled with the area on which it focused, led it to becoming seen as menial, unscientific and of no value. The influence of the church and the work of its nuns however, provided a model for women's care-giving. Functioning in the then male dominated church meant obedience and non-questioning of the instructions given to them which generated the 'to obey - to serve' ethic. The establishment of nurse training in the late 19th Century developed around two dominant perspectives which played significant parts in determining the manner in which nurses enacted their role and which I suggest influences nurses to this day. The first perspective is that referred to as the moral perspective and provided direct links to the legacy of the nuns and the church and included such values as dedication, devotion, assistance, mission and vocation. Subordination to others' thought and knowledge and not to question became the primary obligation (Davies 1980, p. 104). The second perspective, referred to as the technical perspective developed as a result of nursing's direct association with medicine. Given this annexation of nursing knowledge by men and the resultant perception that nursing had 'no knowledge', nurses looked toward medicine and attempted to acquire knowledge from this source. The resultant dependency on medicine for knowledge and direction became a major hegemonic force in health care which was reinforced by nurses predominant 'femaleness' and lack of capacity to practice in their own right. These factors established the genesis of nursing's focus and emphasis on treatment and procedures which resulted in nursing becoming understood as synonmyous with activity,
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taken-for-granted and regarded as without value. These perspectives and views are reinforced in the writings of many feminists. Within the MalT~ist feminist group the primary belief is that women's oppression had its genesis in history wherein, via the establishment o f private ownership, men acquired wealth and therefore the means to produce more (Tong 1989). Historically, the majority o f women were excluded from the opportunity to accrue wealth and instead became part of what was owned, used and oppressed. As nursing has a predominantly female composition this group underwent similar experiences. Feminists argue that the power of men has created a well-established patriarchal system that in turn has influenced the nature and structure of social and cultural institutions in western society. This system is pervasive throughout all areas and levels of social activity resulting in the establishment o f systems o f dominance, power, competition and oppression (Weedon 1991). Weedon suggests that existing power relations, having their genesis in history, between men and w o m e n structure all areas o f life: they determine who does what and for whom, what we are and what we might become ... It is concerned with the way in which the oppressions of patriarchy are compounded for many w o m e n by class and race. (1991, p. 1) This fundamental issue is the foundation stone o f patriarchy in that this concept can be best understood as power relations in which women's interests are subordinated to the interests o f men. These power relations may take many forms ranging from the sexual division of labour to the internalised norms of feminity held by western women. Patriarchal power therefore is founded on the social meaning given to biological sexual difference. Importantly, the nature and role o f w o m e n is defined in relation to a male norm (Weedon 1991, p. 2). Patriarchy therefore, implies a fundamental organisation of power on the basis o f biological sex, an organisation which, from a feminist and poststructural perspective, is not natural and inevitable but socially produced. Thus, nursing's status within the health care system arises from its femaleness and its historical oppression o f nursing and subsequent devaluation.
DISCUSSION The transfer of nursing education in Australia
initiated a period of rapid and intensive growth in the number o f nursing programmes offered from the higher education sector. During this same period o f time, an unprecedented number o f new academic appointments were made in order to implement the programmes developed. The majority o f appointments were o f w o m e n holding both nursing and academic qualifications, with little or no employment experience in higher education. The majority of these w o m e n came from positions as nurse educators within the traditional hospital setting or were experienced clinicians from hospital or community settings. These nurses had expertise and knowledge of nursing but little understanding of the higher education sector (Sutton 1993). This was a time of great excitement in nursing and we believed the changes heralded a new era however, we were not aware of the effect that our previous socialisation as nurses and women would have on our capacity to accommodate the many changes that confronted us. Neither did we fully recognise the relationship o f the social changes we were experiencing with those also occurring in higher education. Thus, these primarily female academics entered higher education shaped by their experiences as nurses, members of hospitals and women functioning in larger society. As part o f their academic responsibilities these women engaged in rapid programme development and redevelopment of undergraduate pre-registration nursing education programmes. The structure, content and processes established in each of these programmes were heavily influenced by the idividuals and groups developing them. These, in turn, as I have stated were shaped by their experiences as women and nurses and by increasing pressures from the profession for certain processes and activities to be included. The increasing involvement of the profession in determining curriculum content has largely arisen as the result of attempts to link traditional knowledge and values, authority and standards with an emphasis on market driven principles. In creating this situation those in power appeal to notions o f curriculum 'modernisation' and the development of 'better' people able to withstand the temptations of contemporary society (Apple 1990). Thus, postmodernity has produced a demand for graduates of educational programmes who can satisfy the new forms and patterns of work. These forms and patterns of work have developed in response to the changed needs in industry which demand workers who have the capacity to work in a variety of roles within the same occupational category. Thus, business and industry leaders refer to the need for multiskilled workers and seek to broad-band jobs.
Nursing education: the marriage of two normative worlds
The development of individuals with the capacity to function in this way resides, in the western world, primarily in schools (Watkins in Kenway 1994). As the nature and forms of work have undergone change and education has become increasingly linked to the world of work a number of changes have occurred with respect to the nature of knowledge and education. With the deindustrialisation of western work and the subsequent labour-force redundancies individuals are seeking to maximise their capacity to obtain employment. As a consequence, employers have been able to gain significant influence over the educational preparation of individuals. Thus, courses of study are n o w becoming more dearly directed toward assisting individuals gain employment and content within such programmes is included on the basis of functionality rather than the broad educational virtue that has traditionally been seen. In addition to the occupational oppression experienced by nurses a second outcome of both the socialisation of w o m e n and enculturation as nurses has been frequent conflict between a nurse's career and personal aspirations relating to the role of wife-mother. While this is a dilemma c o m m o n to all female academics (indeed all working mothers) it is particularly problematic for nurse academics entering higher education with a strongly reinforced stereotyped model of appropriate female behaviour, That is, their primary socialisation into the female role has been reinforced by the context, mode of work and the role of nurses in the health care services. It is with this background and experience that nurse educators entered the higher education sector. Combined with the differences generated by the two normative organisations with which they had to work provided the major source of difficulty encountered by them and to which they had to adjust. The process of adjustment to work in the higher education sector required the novice academic to examine the values, attitudes and beliefs they held; identifying those that were relevant, removing those that were redundant and acquiring ones which were more approprite to their new role (Cameron-Traub 1986). This required them to shed deferential, submissive and subordinte behaviours and to develop abilities and attitudes closer to those valued by the university. In particular such academics were required to develop more positive perceptions of themselves flexibility, relationships and partnerships based on equal participation, a sense o f collegiality and the ability to be self directed. Changes made by these novice academics also needed to include the acceptance of an
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organisational structure based on meritocracy and collegialism rather than seniority. The subsequent need to develop a focus on research and publication and use this as a basis for teaching and future promotion also needed incorporation into their role while maintaining a focus on nursing practice and clinical expertise. Additional responsibilities such as subject or course coordination, and increased committee participation also had to be addressed. Thus, the major area of adjustment involved them transferring their loyalty from the hospital to the university. This range of adjustments was limited by the introduction of nursing into Colleges of Advanced Education in that the culture within such higher education organisations reinforced an ethos of 'teaching without research'. As part of the transfer of loyalty, nurse academic groups were also required to establish credibility with a second professional reference group (academics) while maintaining credibility with their first (nurse practitioners). Adjustment to this difficulty was handicapped and limited on one hand by their lack of research and on the other by the assumed negative effect of distance from the place of clinical practice held by nurse clinicians. In this situationit has become increasingly apparent that one belief held in nursing is that to be a nurse and to teach nursing effectively one must be constantly engaged in clinical practice or at the very least be located in the practice venue. This has recently reached a point in which nurse academics are being perceived as clinically inadequate and their need to engage in clinical teaching is being restricted by hospitals unless they can demonstrate, in a variety of alternative ways, their clinical competence. Such circumstances and demands have been assisted and in part generated by a number of other dynamics which in my view include: • nursing's general lack of understanding of higher education • nursing's acceptance o f minimum competencies for practice and the subsequent development of field and hierarchical level-specific competencies • reluctance on the part of nursing service to 'let go' o f nursing education • continuing service pressures influencing nursing practice and also education • introduction of casemix and the resultant pressures on staffing nursing services • conflict between the norms of hospitals and universities for staff and students • reluctance on the part of the nurse academic to perceive themselves as an academic and to let go of the norms related to practising clinician
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• instances of inadequate clinical teaching and supervision by nurse academics • lack of leadership in nursing. It is fair to say that not all problems are generated by the hospitals and their norms. A number of significant problems are also generated by the university, which include: • pressure to retain failing students, via overly liberal and generalised student grievance and appeal processes • admission o f students who have clear limitations in functioning successfully as registered nurses • pressure on academics to research and publish and lack of recognition to equate clinical practice with these traditional academic activities • pressure to engage in other activities such as internationalisation and externalisation o f nursing programmes • pressure to rationalise programmes and university structures as a result o f the introduction o f the relative funding model • increasing cost containment and the pressure to rationalise subjects, programmes and staffing. The process of adjustment, as identified, is difficult for novice nurse academics and are generated from three major dichotomies they experience (Sutton 1989). These comprise the traditional-contemporary dichotomy created by their femaleness and primary and occupational socialisation toward enacting female stereotypes. The normative contradictions subsequently experienced in the academic role with its pressure for them to be independent, assertive, innovative and career conscious is the primary dichotomy to be resolved. The second dichotomy is that of professional practitioner academic. This involves the dilemmas created by their professionally driven ideal to serve others and address tangible, concrete issues and the academic ideal to inquire into less concrete but equally practical issues, engage in research and development o f theoretical abstractions. The third and final dichotomy is that of the professional - bureaucratic, which generates conflicts associated with the clinical component of nursing education programmes. These conflicts relate to the possible clash o f hierarchical authority with professional expertise or professional judgements with economic judgements. This latter dichotomy is becoming increasingly problematic for nurse academics. Thus, in nursing education at present we can identify a number of significant pressures on nurse academics. Further pressures are arising from within nursing itself This has most notably been from clinical colleagues who
practising within the relative comfort of one normative world criticise nurse academics failure to maintain a full focus on the goals o f the hospitals. In making this criticism they concentrate on matters firmly linked to their own normative world, namely as they perceive it, nurse academics inability to function as clinicians. Whether this is real or not is inconsequential on one level. Importantly, it indicates a failure on the part of nurse academics to convey their dilemmas and difficulties to their clinical colleagues. It also indicates a failure on the part o f clinical colleagues to understand that in any situation more than one set of dynamics is in operation. This situation however, reflects theinfluence of the occupational culture of nursing and that of the hospital and its current potential to separate nurses rather than unite them. In addition, it may also be reflecting an increasing gap between service and education which in turn reflects a gap between those located in the clinical setting and those located in the university. While there has always been some tension between service and education, the relocation of education into the higher education sector promised a unification o f these areas o f nursing work in order to ensure the most effective programmes possible. Nursing seems in great danger o f losing this unified approach and must seek to develop strategies that will strengthen unification. The first step in working together is to identify the various pressures on each group o f nurses and in so doing also identifying what norms they must accept, what norms they do not want and what norms they want to incorporate. One such norm that I suggest is required is that of open, honest communciation and the development of true collaborative relationships. Weedon (1991) argues that feminists need to develop feminist theory and a concept o f feminist rationality which is different from the rationality of patriarchy and which no longer subordinates feminine qualities as they are currently defined. She suggests that post-structuralism offers a useful, productive framework for understanding the mechanisms of power in our society and the possibilities of change (Weedon 1991, p. 10). This perspective's usefulness resides not only in its capacity to inform us about the relation between social language, subjectivity, social organisation and power but also relates to its complementarity to postmodernism. This latter point is o f importance in this discussion because I am suggesting that many of the problems being experienced by nurse academics and nursing generally relate to postmodern pressures. Because we need to understand why nurses tolerate social relations which subordinate their interests to those o f medicine
Nursing education: the marriage of two normative worlds
and we also need to understand the mechanisms whereby nurses adopt particular discursive positions as representative of their interests both the theoretical perspectives of postmodernism and poststructnralism are useful. This usefulness resides in postmodernism offering insights into the broad social and cultural changes that are occurring and poststructuralism offering a framework for understanding the relation between persons and their social world and for concepmalising social change (Davies 1989, p. xi). W i t h i n poststructuralism the structures and processes of the social world are recognised as having a material force, a capacity to constrain, to shape, to coerce, as well as to potentiate idividual action. The processes whereby individuals take themselves up as persons are understood as ongoing, thus individuals are constituted and reconstituted through a variety of discursive practices (Davies 1989, p. xi). It is the recognition of the ongoing nature of the constitution of self that offer useful insights about the situations nursing faces and the action they take in response to them. To explain further, individuals through learning the discursive practices of a society, are able to position themselves within those practices in multiple ways. As a result they develop subjectivities, that is ways of being, which are both in concert with and in opposition to the ways in which others choose to position them, By developing an tmderstanding of this fundamental contradiction we are able to acknowledge the complexity and changing nature of humans. In addition, by being able to acknowledge individuals as being in a constant process of construction and deconstruction as a result of discursive practices then it is also possible to see the power of those practices. While this assists in understanding how the social world is created and sustained it also assists in understanding how the social world can be changed. That is by n o n support of certain discourses which are limiting and oppressive and by the creation of new discourses. This development of such understanding will assist nurses and nursing to appreciate the circumstances from the past that still influence their present situation and which could lead to a different and more productive future. This paper is but a beginning position, it has identified a number of the sources of pressure
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and tension. It serves not to provide answers or even to ask the questions, but simply to identify that there is a problem. As nurses we can either choose to ignore this problem or to seek ways to resolve it. Resolution in my view ought to be underpinned by poststructuralist explorations and understanding of the world of nursing and health care. In turn these explorations and understandings can be directed toward establishing a marriage of two normative worlds and thereby creating a sustainable relationship.
REFERENCES Apple M W 1990 Ideologyand curriculum,2nd edn. ILoutledge, London Cameron-TraubE 1986 From tutor sisterto nursing academic. 8th NationalConferenceof the Royal College of Nursing, Darwin,Australia Colliere M 1986 Invisiblecare and invisiblewomen as health care providers. InternationalJournal of Nursing Studies 23 (2): 95-108 DaviesB 1989 Frogs and snailsand feministtales. Alien& Unwin, Sydney Davies C (ed.) 1980 Kewritingnursinghistory. Croom Helm, London HinksonJ 1991 Postmodernity:state and education. Deakin UniversityPress, Geelong,Victoria KenwayJ (ed.) 1994Economisingeducation.:the postFordist directions.DeakinUniversityPress, Geelong, Victoria LyotardJean-Francois1991 The postmoderncondition. In: HinksonJ (ed.) Postmodemity:state and education.DeakinUniversityPress, Geelong, Victoria SilverM 1986A programfor career structure: a vision becomes reality.AustralianNursesJournal 16 (2): 44-47 Sutton F 1988 From hospitalto college:the transferof pre-registrationnursingeducationand the potential effect on nursingas a profession.Unpublished dissertation.Universityof New England Sutton F 1989 Shiftinggears: problemsexperiencedby nurse academicsin their transitionfrom the role of educator to that of academic. HigherEducation, Research and DevelopmentSocietyof Australia1989 NationalConference,Adelaide Sutton F 1993 Occupationalculture,feminismand nursing curriculum.CriticalTheory, Feminismand Nursing Conference,Melbourne Tong T 1989 Feministthought: a comprehensive introduction.Unwin Hyman,London WatkinsP 1994 The Fordist/post-Fordistdebate: the educationalimplications.In: KenwayJ (ed.) Econornisingeducation:tlle post-Fordistdirections, Deakin UniversityPress, Geelong,Victoria Weedon C 1991 Feministpractice and poststructuralist theory. Blackwe11,Cambridge,Massachusetts
INTRODUCTION
Frances A, Sutton RN, RPN, DipT (Ns Ed), BEd, MEdAdmin, FRCNA, Associate Professor, Faculty of Nursing, University of South Australia, Smith Road, Salisbury East, South Australia 5109 (Requests for offprints to
FAS) Manuscript accepted 12 July 1995
Nursing has had a presence in Australian higher education since 1975 however, during the past 19 years this area of endeavour has seen a number of significant changes. The most significant change being that of relocating all pre-registration nursing education from its traditional hospital base into the higher education sector, This transfer however, has not been without problems, some of which relate to the lack of nursing's effective adjustment to higher education and the changes in higher education itself. Antecedent to these factors are other elements which include fundamental changes to western ways o f life and thought and the lack o f adequate preparation o f nurses for the experiences and roles they would encounter in the higher education sector as a result of their occupational experiences as nurses and women. These antecedent factors require nurses therefore, to not only understand the significance o f the changes occurring in the western world but also the need on the part o f nurse academics to work in, understand and acknowledge two normative organisations and the impact these organisations are experiencing as the result of the social and cultural changes occurring in the western world. A normative organisation is one in which the exercise o f power is undertaken in such a way so as to gain the commitment to and personal involvement in the organisation's goals by the individuals working in the organisation. The two organisations associated with nursing education, universities and health care organisations, are as such normative organisa-
NurseEducationToday(I 996) 16, 443449 © [ 996 PearsonProfessional/td
tions. These organisations however, while being normative, differ markedly in a number o f ways. This includes their historical origins, goals, organisational structures and processes established to achieve their goals and the expectations they have o f the individuals who work in them. In this sense, nurse academics work between two normative organisations that generate, as a consequence o f their differences, a number of significant difficulties. Additionally, changes in the health care structures, increasing cost containment and the historically generated values o f nursing itself combine to create a range of difficulties that will potentially have a deleterious effect on nursing and which are impossible to overcome unless nursing acknowledges its current difficulties and takes specific steps toward their resolution. Changes being experienced in these normative organisations are however not occurring by chance but as the result of a much wider set o f circumstances. Rather, I suggest that these changes have their genesis in history with the rise o f science and the subsequent advances in knowledge and technology. These innovations gave rise to the industrial revolution and the modern age. In turn, advances in science, knowledge and technology generated a range o f circumstances that has led to a weakening of the traditions and social structures associated with the modern age and a resultant lack of social and cultural stability. This lack of social and cultural stability, the emergence ofmultiplicities and the associated trends o f internationalisation; increasing technologisation; privatisation; commodification and vocationalisation o f education has resulted, in turn, in greater cultural fragmentation, pluralism, diversity and change that collectively is referred to as postmodernity (Lyotard 1986). The forces generated by postmodernity are currently placing pressures on both universities and hospitals and in turn impact on the nature o f and processes associated with nursing education. These are clearly evident in the role and function o f nurse academics and the problems they currently experience. This paper offers some beginning thoughts about these issues and in so doing hopes to stimulate discussion between all persons involved in nursing education. Throughout this paper I use the word hospital to refer to all health care organisations. While in terms o f structure and broad philosophical orientation a difference has been made between hospitals and community agencies, in terms o f their normative function and associated expectation of the individuals who work in them there is minimal difference.
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HIGHER E D U C A T I O N ORGANISATIONS The higher education sector in Australia has until recently been a binary system which reflected values seen in both the American college system wherein the emphasis was on teaching, and the traditional European mziversity system wherein the emphasis was on the development of knowledge, hence research. In recent years the Australian Federal government has attempted to remove the major structural differences between universities and colleges. As a result virtually all colleges and institutes merged with each other to form new universities or merged with existing universities. This has resulted in the establishment of a higher education system in which traditional perspectives of university life have been coupled with the philosophy of pragmatism. Additionally, increasing pressure for cost-containment have added the influence of economic rationalism. It is important to remember however, that universities emerged early in the middle ages with a way of functioning and emphasis different to that seen in contemporary western society. Interested in discovering knowledge and establishing truth, universities sought this in the empirical truth of science, the aesthetic truth of the arts and the spiritual truth of theology. As time passed the forces and pressures of modernism saw them become increasingly aligned with discovering knowledge and establising truth as determined and perceived from the perspective of science. In pursuing this truth the university appointed academic staff and established Chairs (the hallmark of scholarshp) as a means of support for esteemed academics to pursue their intellectual interests. Incumbents of such Chairs attracted students with w h o m they could share their ideas and transmit the same enthusiasm for knowledge and who would extend their research endeavour. Education of these students however, was not the academic's primary area of interest, neither was the development of a formalised curriculnm. The Federal government, and society, as a result of postmodern pressures now require universities, to not just discover knowledge but to discover knowledge which is useful, not just to transmit knowledge but to transmit it in such a way that individuals are prepared for specific occupations and professions. This demand minimally alters the fundamental goals and processes of the university in that it requires them to become more specific with respect to them. The advent of the new university system in Australia has seen the introduction of new fields of endeavour into universities, such as
teaching and nursing, that are concerned with the practical application of knowledge. In incorporating these fields the university has not changed its primary mission but suggests that the service delivered by these professions to the community will be enhanced by the pursuit of the university's basic goals of research and scholarship. Additionally, the ethos of universities is such that the original norms ofbehaviour established for those functioning in universities are expected for new participants in the organisation or for those universities which have recently been established. However, these norms of behaviour are contrary to those demanded of academics as the result of postmodernism. Traditionally, an academic is expected to search for the generalised knowledge in the specific field of endeavour in which they function; to have an attitude of scepticism enabling them to critique their own and others work; to share their findings through publication and discourse and to pursue their work so as to achieve the organisational goals of the university rather than simply serve self interest. A major criticism of the academy and post compulsory education generally however, was that it was too distant from the 'real world'. This led to a number of initiatives such as education becoming 'engaged' and allowing students to experience work, others argued for society to be 'de-schooled' (Illich 19). This criticism was unable, for many subjects, to be defended but resulted in a broad reorientation to education which resulted in an emphasis on students 'learning h o w to learn' rather than learning about specific areas of knowledge. In turn the teacher as teacher was transformed into the teacher as facilitator (Hinkson 1991, p.29). These two sets of pressures are not however, incompatible in that they both require the individuals involved to become creative and able to function somewhat autonomously while acknowledging the reality of interdependence. Thus, with the significant social changes that are occurring universities are changing. These changes are moving toward dividing the functions of higher eduation into two broad categories, the first being that of providing professional training during which the competencies considered necessary by each profession is transmitted. The second category relates to establishing the newly emerging fields of knowledge associated with the new techniques and technologies (Lyotard 1986, p. 60-61).
HEALTH CARE O R G A N I S A T I O N S There is no doubt that the western world's
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dedication to the scientific approach of logical positivism, rationality and reductionism led to the emergence of a scientific study of work which resulted in the development of new occupational categories and forms of worker management. One of the forms of worker management, derived from the work of Frederick Taylor (1947) and Max Weber (1947) generated the need for centralisation of all levels of decision making and established a management style and process known as bureaucracy. This form of management became firmly established as the most 'natural' way to organise business and its effectiveness led to it being adopted by governments. The adoption of bureaucratic organisational forms is most markedly seen in hospitals. While hospitals are many and varied they all share a common history and tend to have three distinct characteristics. The first such characteristic is that historically the growth of the modern hospital was strongly influenced by two social forces - expansion of knowledge and advances in technology, neither of which developed in the hospitals but generally in the university and in industry. The second characteristic is the essentially bureaucratic organisational structure and processes evident in hospitals. Bureaucracies, in order to accomplish their specific organisational objectives, are organised in orderly and stable hierarchies and have established rules and procedures for decision-making and employee functioning. Finally, the third characteristics of hospitals is that they reflect the dominance and influence of the philosophy and ideology of the medical profession. This effects both the range and type of services offered and the role and function of other groups of health care workers (Street 1992). Nursing also has bureaucratic structures in which the work of individual nurse practitioners in determined not only by the work of more dominant professions but also nurses who hold greater hierarchical authority (Sutton 1988, p. 65; Silver 1986, pp. 38-41). The goals of hospitals are such that they require a highly specialised range of activities. The work undertaken by such organisations is however, irregular and in part unpredictable. This lack of predictabiity reinforces the importance of the need for quality and control. This emphasis leads to these organisations being perceived as controlling and authoritarian with respect to the activities and behaviours of the individuals they employ. The desired behaviours of persons working within the health care system include delivering high quality care, loyalty, selflessness and hard work.
V A L U E S A N D A T T I T U D E S OF NURSING AND NURSES Colliere (1986) indicated that women have always been the primary providers of care within any society and that in the early development of society the value accorded to these activities was high. This perception changed with the development of writing. It was via this innovation that men, priests initially, started to confiscate or annex women's knowledge, transferring what they could collect and assimilating it for their own understanding. In the process of annexing this knowledge its meaning was frequently changed. The innovation of writing enabled the more rapid accumulation and dissemination of knowledge by men which in turn led to the development of a visible knowledge base. Because women were actively barred from learning to write and read their knowledge remained invisible and was transmitted orally. These characteristics of women's knowledge, coupled with the area on which it focused, led it to becoming seen as menial, unscientific and of no value. The influence of the church and the work of its nuns however, provided a model for women's care-giving. Functioning in the then male dominated church meant obedience and non-questioning of the instructions given to them which generated the 'to obey - to serve' ethic. The establishment of nurse training in the late 19th Century developed around two dominant perspectives which played significant parts in determining the manner in which nurses enacted their role and which I suggest influences nurses to this day. The first perspective is that referred to as the moral perspective and provided direct links to the legacy of the nuns and the church and included such values as dedication, devotion, assistance, mission and vocation. Subordination to others' thought and knowledge and not to question became the primary obligation (Davies 1980, p. 104). The second perspective, referred to as the technical perspective developed as a result of nursing's direct association with medicine. Given this annexation of nursing knowledge by men and the resultant perception that nursing had 'no knowledge', nurses looked toward medicine and attempted to acquire knowledge from this source. The resultant dependency on medicine for knowledge and direction became a major hegemonic force in health care which was reinforced by nurses predominant 'femaleness' and lack of capacity to practice in their own right. These factors established the genesis of nursing's focus and emphasis on treatment and procedures which resulted in nursing becoming understood as synonmyous with activity,
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taken-for-granted and regarded as without value. These perspectives and views are reinforced in the writings of many feminists. Within the MalT~ist feminist group the primary belief is that women's oppression had its genesis in history wherein, via the establishment o f private ownership, men acquired wealth and therefore the means to produce more (Tong 1989). Historically, the majority o f women were excluded from the opportunity to accrue wealth and instead became part of what was owned, used and oppressed. As nursing has a predominantly female composition this group underwent similar experiences. Feminists argue that the power of men has created a well-established patriarchal system that in turn has influenced the nature and structure of social and cultural institutions in western society. This system is pervasive throughout all areas and levels of social activity resulting in the establishment o f systems o f dominance, power, competition and oppression (Weedon 1991). Weedon suggests that existing power relations, having their genesis in history, between men and w o m e n structure all areas o f life: they determine who does what and for whom, what we are and what we might become ... It is concerned with the way in which the oppressions of patriarchy are compounded for many w o m e n by class and race. (1991, p. 1) This fundamental issue is the foundation stone o f patriarchy in that this concept can be best understood as power relations in which women's interests are subordinated to the interests o f men. These power relations may take many forms ranging from the sexual division of labour to the internalised norms of feminity held by western women. Patriarchal power therefore is founded on the social meaning given to biological sexual difference. Importantly, the nature and role o f w o m e n is defined in relation to a male norm (Weedon 1991, p. 2). Patriarchy therefore, implies a fundamental organisation of power on the basis o f biological sex, an organisation which, from a feminist and poststructural perspective, is not natural and inevitable but socially produced. Thus, nursing's status within the health care system arises from its femaleness and its historical oppression o f nursing and subsequent devaluation.
DISCUSSION The transfer of nursing education in Australia
initiated a period of rapid and intensive growth in the number o f nursing programmes offered from the higher education sector. During this same period o f time, an unprecedented number o f new academic appointments were made in order to implement the programmes developed. The majority o f appointments were o f w o m e n holding both nursing and academic qualifications, with little or no employment experience in higher education. The majority of these w o m e n came from positions as nurse educators within the traditional hospital setting or were experienced clinicians from hospital or community settings. These nurses had expertise and knowledge of nursing but little understanding of the higher education sector (Sutton 1993). This was a time of great excitement in nursing and we believed the changes heralded a new era however, we were not aware of the effect that our previous socialisation as nurses and women would have on our capacity to accommodate the many changes that confronted us. Neither did we fully recognise the relationship o f the social changes we were experiencing with those also occurring in higher education. Thus, these primarily female academics entered higher education shaped by their experiences as nurses, members of hospitals and women functioning in larger society. As part o f their academic responsibilities these women engaged in rapid programme development and redevelopment of undergraduate pre-registration nursing education programmes. The structure, content and processes established in each of these programmes were heavily influenced by the idividuals and groups developing them. These, in turn, as I have stated were shaped by their experiences as women and nurses and by increasing pressures from the profession for certain processes and activities to be included. The increasing involvement of the profession in determining curriculum content has largely arisen as the result of attempts to link traditional knowledge and values, authority and standards with an emphasis on market driven principles. In creating this situation those in power appeal to notions o f curriculum 'modernisation' and the development of 'better' people able to withstand the temptations of contemporary society (Apple 1990). Thus, postmodernity has produced a demand for graduates of educational programmes who can satisfy the new forms and patterns of work. These forms and patterns of work have developed in response to the changed needs in industry which demand workers who have the capacity to work in a variety of roles within the same occupational category. Thus, business and industry leaders refer to the need for multiskilled workers and seek to broad-band jobs.
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The development of individuals with the capacity to function in this way resides, in the western world, primarily in schools (Watkins in Kenway 1994). As the nature and forms of work have undergone change and education has become increasingly linked to the world of work a number of changes have occurred with respect to the nature of knowledge and education. With the deindustrialisation of western work and the subsequent labour-force redundancies individuals are seeking to maximise their capacity to obtain employment. As a consequence, employers have been able to gain significant influence over the educational preparation of individuals. Thus, courses of study are n o w becoming more dearly directed toward assisting individuals gain employment and content within such programmes is included on the basis of functionality rather than the broad educational virtue that has traditionally been seen. In addition to the occupational oppression experienced by nurses a second outcome of both the socialisation of w o m e n and enculturation as nurses has been frequent conflict between a nurse's career and personal aspirations relating to the role of wife-mother. While this is a dilemma c o m m o n to all female academics (indeed all working mothers) it is particularly problematic for nurse academics entering higher education with a strongly reinforced stereotyped model of appropriate female behaviour, That is, their primary socialisation into the female role has been reinforced by the context, mode of work and the role of nurses in the health care services. It is with this background and experience that nurse educators entered the higher education sector. Combined with the differences generated by the two normative organisations with which they had to work provided the major source of difficulty encountered by them and to which they had to adjust. The process of adjustment to work in the higher education sector required the novice academic to examine the values, attitudes and beliefs they held; identifying those that were relevant, removing those that were redundant and acquiring ones which were more approprite to their new role (Cameron-Traub 1986). This required them to shed deferential, submissive and subordinte behaviours and to develop abilities and attitudes closer to those valued by the university. In particular such academics were required to develop more positive perceptions of themselves flexibility, relationships and partnerships based on equal participation, a sense o f collegiality and the ability to be self directed. Changes made by these novice academics also needed to include the acceptance of an
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organisational structure based on meritocracy and collegialism rather than seniority. The subsequent need to develop a focus on research and publication and use this as a basis for teaching and future promotion also needed incorporation into their role while maintaining a focus on nursing practice and clinical expertise. Additional responsibilities such as subject or course coordination, and increased committee participation also had to be addressed. Thus, the major area of adjustment involved them transferring their loyalty from the hospital to the university. This range of adjustments was limited by the introduction of nursing into Colleges of Advanced Education in that the culture within such higher education organisations reinforced an ethos of 'teaching without research'. As part of the transfer of loyalty, nurse academic groups were also required to establish credibility with a second professional reference group (academics) while maintaining credibility with their first (nurse practitioners). Adjustment to this difficulty was handicapped and limited on one hand by their lack of research and on the other by the assumed negative effect of distance from the place of clinical practice held by nurse clinicians. In this situationit has become increasingly apparent that one belief held in nursing is that to be a nurse and to teach nursing effectively one must be constantly engaged in clinical practice or at the very least be located in the practice venue. This has recently reached a point in which nurse academics are being perceived as clinically inadequate and their need to engage in clinical teaching is being restricted by hospitals unless they can demonstrate, in a variety of alternative ways, their clinical competence. Such circumstances and demands have been assisted and in part generated by a number of other dynamics which in my view include: • nursing's general lack of understanding of higher education • nursing's acceptance o f minimum competencies for practice and the subsequent development of field and hierarchical level-specific competencies • reluctance on the part of nursing service to 'let go' o f nursing education • continuing service pressures influencing nursing practice and also education • introduction of casemix and the resultant pressures on staffing nursing services • conflict between the norms of hospitals and universities for staff and students • reluctance on the part of the nurse academic to perceive themselves as an academic and to let go of the norms related to practising clinician
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• instances of inadequate clinical teaching and supervision by nurse academics • lack of leadership in nursing. It is fair to say that not all problems are generated by the hospitals and their norms. A number of significant problems are also generated by the university, which include: • pressure to retain failing students, via overly liberal and generalised student grievance and appeal processes • admission o f students who have clear limitations in functioning successfully as registered nurses • pressure on academics to research and publish and lack of recognition to equate clinical practice with these traditional academic activities • pressure to engage in other activities such as internationalisation and externalisation o f nursing programmes • pressure to rationalise programmes and university structures as a result o f the introduction o f the relative funding model • increasing cost containment and the pressure to rationalise subjects, programmes and staffing. The process of adjustment, as identified, is difficult for novice nurse academics and are generated from three major dichotomies they experience (Sutton 1989). These comprise the traditional-contemporary dichotomy created by their femaleness and primary and occupational socialisation toward enacting female stereotypes. The normative contradictions subsequently experienced in the academic role with its pressure for them to be independent, assertive, innovative and career conscious is the primary dichotomy to be resolved. The second dichotomy is that of professional practitioner academic. This involves the dilemmas created by their professionally driven ideal to serve others and address tangible, concrete issues and the academic ideal to inquire into less concrete but equally practical issues, engage in research and development o f theoretical abstractions. The third and final dichotomy is that of the professional - bureaucratic, which generates conflicts associated with the clinical component of nursing education programmes. These conflicts relate to the possible clash o f hierarchical authority with professional expertise or professional judgements with economic judgements. This latter dichotomy is becoming increasingly problematic for nurse academics. Thus, in nursing education at present we can identify a number of significant pressures on nurse academics. Further pressures are arising from within nursing itself This has most notably been from clinical colleagues who
practising within the relative comfort of one normative world criticise nurse academics failure to maintain a full focus on the goals o f the hospitals. In making this criticism they concentrate on matters firmly linked to their own normative world, namely as they perceive it, nurse academics inability to function as clinicians. Whether this is real or not is inconsequential on one level. Importantly, it indicates a failure on the part of nurse academics to convey their dilemmas and difficulties to their clinical colleagues. It also indicates a failure on the part o f clinical colleagues to understand that in any situation more than one set of dynamics is in operation. This situation however, reflects theinfluence of the occupational culture of nursing and that of the hospital and its current potential to separate nurses rather than unite them. In addition, it may also be reflecting an increasing gap between service and education which in turn reflects a gap between those located in the clinical setting and those located in the university. While there has always been some tension between service and education, the relocation of education into the higher education sector promised a unification o f these areas o f nursing work in order to ensure the most effective programmes possible. Nursing seems in great danger o f losing this unified approach and must seek to develop strategies that will strengthen unification. The first step in working together is to identify the various pressures on each group o f nurses and in so doing also identifying what norms they must accept, what norms they do not want and what norms they want to incorporate. One such norm that I suggest is required is that of open, honest communciation and the development of true collaborative relationships. Weedon (1991) argues that feminists need to develop feminist theory and a concept o f feminist rationality which is different from the rationality of patriarchy and which no longer subordinates feminine qualities as they are currently defined. She suggests that post-structuralism offers a useful, productive framework for understanding the mechanisms of power in our society and the possibilities of change (Weedon 1991, p. 10). This perspective's usefulness resides not only in its capacity to inform us about the relation between social language, subjectivity, social organisation and power but also relates to its complementarity to postmodernism. This latter point is o f importance in this discussion because I am suggesting that many of the problems being experienced by nurse academics and nursing generally relate to postmodern pressures. Because we need to understand why nurses tolerate social relations which subordinate their interests to those o f medicine
Nursing education: the marriage of two normative worlds
and we also need to understand the mechanisms whereby nurses adopt particular discursive positions as representative of their interests both the theoretical perspectives of postmodernism and poststructnralism are useful. This usefulness resides in postmodernism offering insights into the broad social and cultural changes that are occurring and poststructuralism offering a framework for understanding the relation between persons and their social world and for concepmalising social change (Davies 1989, p. xi). W i t h i n poststructuralism the structures and processes of the social world are recognised as having a material force, a capacity to constrain, to shape, to coerce, as well as to potentiate idividual action. The processes whereby individuals take themselves up as persons are understood as ongoing, thus individuals are constituted and reconstituted through a variety of discursive practices (Davies 1989, p. xi). It is the recognition of the ongoing nature of the constitution of self that offer useful insights about the situations nursing faces and the action they take in response to them. To explain further, individuals through learning the discursive practices of a society, are able to position themselves within those practices in multiple ways. As a result they develop subjectivities, that is ways of being, which are both in concert with and in opposition to the ways in which others choose to position them, By developing an tmderstanding of this fundamental contradiction we are able to acknowledge the complexity and changing nature of humans. In addition, by being able to acknowledge individuals as being in a constant process of construction and deconstruction as a result of discursive practices then it is also possible to see the power of those practices. While this assists in understanding how the social world is created and sustained it also assists in understanding how the social world can be changed. That is by n o n support of certain discourses which are limiting and oppressive and by the creation of new discourses. This development of such understanding will assist nurses and nursing to appreciate the circumstances from the past that still influence their present situation and which could lead to a different and more productive future. This paper is but a beginning position, it has identified a number of the sources of pressure
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and tension. It serves not to provide answers or even to ask the questions, but simply to identify that there is a problem. As nurses we can either choose to ignore this problem or to seek ways to resolve it. Resolution in my view ought to be underpinned by poststructuralist explorations and understanding of the world of nursing and health care. In turn these explorations and understandings can be directed toward establishing a marriage of two normative worlds and thereby creating a sustainable relationship.
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