Nursing Inquiry 1996; 3: 61-64

CONFERENCE REVIEW The Future of Nursing: the critical path toward the year 2000 Canberra, 31 July-1 August 1995

The papers selected for this conference on nursing and its critical path toward the year 2000 promised insights into the political and organisational influences to which nurses and the collectivity of nursing will have to respond or shape in the five years leading up to the end of the century. It was aimed towards nurses who are responsible for decisions that could affect the future of nursing, and in two days cov- ered a wide range of current influences from political and economic to technological, and nursing practice from hos- pital and community to education and research.

With a program of such scope it would be a difficult if not impossible task to provide a coherent critique, let alone maintain the interest of the participants. The latter was cer- tainly achieved, with delegates staying to the very last paper. This was illustrated by those from Western Australia and Tasmania who petitioned for afternoon tea to be cur- tailed so that they could hear the last speaker before leav- ing to catch their flights.

The importance of critical theory in reassessing the relationship between theory and practice was emphasised in relation to nursing education and nursing work. Facul- ties should be aware of the gap between those at university and those who work in practice settings, and what happens when graduates go into ‘traditional’ hospital settings. Will tertiary graduates counter the masculinecentred view in the hospital? The tools of performance appraisal used in TQM and designed to prepare nurses for challenges in the workplace, for example, are reductionist and do not bridge the theory/practice chasm. The art of nursing as caring which is difficult to subject to ‘scientific rigour’ has disap peared under objective measures which report only what can be seen and fail to show nursing as more than the sum of a few tasks or roles (Lawson).

This theme, if not always explicit, was taken up in a number of papers which referred to the erosion of ‘time to

think about what you were doing’, and for staff develop ment and collegiality (JSilley), the importance of reflection in study and clinical work (Browning), and the need to

reflect on the attitudes of universities and hospitals to the advent of nursing students Uames). Nursing research as centra1 to nursing theory should serve practice, but there

are problems of nurses hindering research being done by nurses, of physician approval (‘do they own the patient?’), of incentives, and of resources and skills (Proctor; Hogan). Research, for example, could be carried out to ascertain whether critical thinking does exist among tertiary edu- cated nurses. Once completed where do nurses publish and disseminate their research was the question posed by Wellings. James argued that the national review of nursing education would drive nursing education and practice for the next five years.

The second main theme was nursing and patients in a period of economic rationalism when casemix, case man- agement, coordinated care and the technological impera- tive might work for or against appropriate care. As Russell asked: ‘Can we afford fast health with fast food and fast liv- ing?’ Health policies at state and federal levels were analysed critically by most speakers (Beaumont; Gardner; Keane; Power), but the conclusions shared by them appeared to be that the future critical path for nursing depended on collectively taking advantage of the opportu- nities provided and of convincing policymakers and service providers of the value of nursing to patients, whether it is in the community, in the acute sector, in long term and pal- liative care, or in independent or employed practice. In pain management, Just asked why is it that so often the nurse is brought in as ‘the last resort’ when other approaches have failed, implying that the nurse is an expert who might succeed. Russell would have responded that in the current dominant discourse, it is difficult to challenge accepted beliefs because they appear to be rational.

Russell’s critique included nurses and nursing and focused on the patient as powerless:

Health practice is changing through its discourse. Di s course produces truths which mobilise and create power. Such truths, because they appear rational, are believed by bureaucrats, consumers and even service providers. If one questions [their] validity . ... one immediately falls outside the norm and becomes marginalised to the periphery of health analysis. After all, it is difficult to exist outside the dominant discourse just as it is difficult to debate if cus- tomer focus means patient empowerment because sym- bolically it represents power in the marketplace, but does it produce power for the patient in health care?

The participants were from every state and territory in Australia, and their number (50) allowed the conference to develop its own informal dynamic for the exchange of

Reviews

ideas and ‘internal bonding’ (Gendek) between presenta- tions. Although many of the issues discussed do have seri- ous implications for nurses and clients, the papers were presented in ways which showed how nurses and nursing could develop positive critical paths to 2000.

Heather Gardner School ofBehauioura1 Health Sciences

Faculty of Health Sciences La Trobe University

Bundoora, Victoria, Australia

BOOK REVEWS

The Ideology of Cmmunity Care by David Skidmore (1994) 136 pages, $36.95, Chapman & Hall, London.

The author’s principal and unusual aim in this short book is to ‘develop an ideology of community care’. Sensibly rejecting the definition of ideology as ‘science of ideas’, Skidmore offers a modest alternative, namely ‘speculation’. His speculations concern the ‘collection of ideas about care in the community and those themes that are support- ive and/or antagonistic of both care and community’.

Divided into two thematic parts - Community, and Care and caring- the book is about belonging and the nature of the bonds that cement relationships among people. Using the leitmotif of geography as a means of under- standing community, the first part is about the variety of formal and informal social links - such as customs, norms, shared language and tradition - that bind relations and provide persons with security, identity and the means of becoming ‘natives’.

These links however, contain a falsehood. They imply safety and order and, based on an assumption of normality, demand conformity, blind us to difference and deny the individual. Rejection, exclusion and nonconformity remain possibilities and, like acceptance, are influenced by biology, sociology, psychology and politics. The severely nonconformist are those individuals who become exiles, such as the chronically mentally ill, or refugees, such as the deinstitutionalised. Intruding into the private lives of these individuals are the professional carers, whom Skidmore likens to tourists, daytrippers and visitors. Motivated by self- interest, professional carers are portrayed as often viewing their clients in a stereotyped way.

In the second part Skidmore uses the metaphor of fam- ily to develop ideas about how persons connect with one another and the wider world. The family is, Skidmore argues, the basic caring unit of society. Conforming to the

ideal of family, where all members give and receive care and affection in a context of stereotyped roles, is exacting. Therefore, the giving and receiving of care experienced and learnt in the family is not easily transferable to profes- sional relationships, where there is little choice about and possible dislike of clients. The care offered by the profes- sional is depicted as mechanical, artificial and part-time. The mechanisation of care is assisted by diagnosis, which makes the patient and his/her condition predictable. Prc- fessional care is artificial because it is governed by rules specially designed to limit attraction and the possibility of a sexual relationship with a vulnerable person. Professional carers, especially doctors and nurses, are portrayed as per- petuating a parent-child model that makes for passive’ patients.

Rightly crititat of the lack of economic and other resources to provide adequate community care, Skidmore also criticises the wholesale transfer of institutional models of caring to the community and formal care to lay-carers. Distinguishing between care in the community and care b.J the community, Skidmore argues that adequate and effec- tive community care is not a cheap option.

Like most ideologies, the beliefs and values advanced in this text are sometimes inconsistent. Arguing that ‘the cur- rent provision of community care is incongruent with the notion of empowerment’, he urges those he has defined as part of the problem - professional carers - ‘to grasp the nettle of advocacy’. Relying on a linear model to distin- guish and dichotomise between, for example, the natural and the artificial, the ideal and the real, the active and the passive, and the emotional and the mechanical, Skidmore helps stabilise current unequal relations and distribution of resources. It is not that he opposes change, quite the contrary, but in framing the problems of community care as lying along various horizontal continua, there is appar- ently only one way to go - towards the-norm. Finally, in assuming that norms are the basis of the social system rather than its products, the organisational, technical and practical regulation of community care is not scrutinised.

Ruth Elder School of Nursing

Queensland University of Technology Queensland, Australia

Health Cam and the Law: A Guide for Nurses by Meg Wallace (19’35) 471 pages, $45.00, The Law Book Company, Sydney.

The second edition of Meg Wallace’s useful text on law has been expanded to be applicable to all health care workers: doctors, dentists, occupational therapists, pathologists and

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