Whither nursing? Discourses underlying the attribution of master's level performance in nursing.

AIM: Drawing upon the selected findings from a multidisciplinary study that sought to explore the meaning of master's level performance in health professional practice, the characteristics which nurse educators attributed to the practice of master's level nursing graduates are analysed to reveal underlying discourses. BACKGROUND: Although master's level programmes for nurses have been available in the United Kingdom (UK) for the past three decades and current heath policy directives link master's level qualifications with senior clinical nursing roles, the contribution that master's level education might make to the future direction of nursing is unclear. RESEARCH DESIGN AND METHODS: In-depth interviews were undertaken with a purposive sample of 18 nurse lecturers drawn from eight universities in the UK who were responsible for master's level programmes in nursing. The interview agenda explored participants' perspectives of the characteristics of master's level performance. Drawing upon the methodology of discourse analysis, interview transcripts were interpreted in such a way as to show the implicit discourses underlying the participants' claims regarding their graduate's attributes of professional practice. FINDINGS: The characteristics attributed to master's graduates were categorized under (a) cognitive competencies, (b) practice-related competencies, (c) research orientation and (d) personal dynamism. However, these attributions are not empirical generalizations, developed inductively. Rather, they draw on socially available discourses regarding the future direction of the profession. CONCLUSION: The nurse educators drew on the following socially available discourses: (a) a discourse in which nursing is construed as involving great competence in practice, but without radicality of thought. Associated with this is a pervasive rhetoric of pragmatism; (b) a discourse of interprofessional practice in which nursing has a role of leadership. This is associated with a view of the location and power of nursing within the structure of the National Health Service and (c) notably lacking were discourses of care-giving, and of academic/intellectual aspiration. The implications of these discourses for the future direction of nursing are considered.

Some dilemmas of master's level nurse education.

Despite an increase in the growth of master's level provision for qualified nurses in the United Kingdom uncertainty exists regarding the characteristics of master's level performance in respect of professional practice. This paper presents selected findings from a multidisciplinary study that sought to examine the characteristics of master's level performance in health professional courses that had an expressed practice orientation. It focuses specifically on dilemmas nurse educators encountered in relation to British master's level nurse education. Following an initial pilot stage involving focus group interviews with separate groups of nurses, occupational therapists and physiotherapists, an interview agenda was developed to explore participants' perspectives of the characteristics of master's level performance. Individual in-depth interviews were undertaken with a purposive sample of 18 nurse educators drawn from eight universities in England. Interview transcripts were coded and thematically analysed. Six kinds of dilemma emerged from the interviews. These were breadth vs. depth in the conceptualization of master's level for nursing, relevance to practice vs. academic detachment, facilitating creative thinking vs. reinforcing rigidity, encouraging or suppressing different modes of critical thinking, postgraduate nurses as loyal change agents vs. the problem of well-qualified mavericks, and professional experience as facilitating or hindering master's level performance. These dilemmas raise important questions about course design and the role of stakeholders in determining curriculum content. Moreover, a pervasive tension between a utilitarian emphasis on the application and utility of knowledge on one hand, and aspirations to promote creativity and critical thinking which look to alternative possibilities on the other hand, suggests that nurse educators exercise a degree of conservatism in relation to master's level. It is concluded that this apparent quest to maintain a safe variant of the status quo as the best way of promoting the wellbeing of patients should be subject to profound questioning.

'Levels' of attainment in nursing practice: reality or illusion?

In earlier research based on an analysis of course documentation, it had been found that there was little consensus among nurse educators concerning the parameters which distinguish levels of practice skills, particularly those which differentiate diploma and degree qualifications in the United Kingdom. This result was confirmed and strengthened in the current study. Lecturers in nursing, when presented with a sorting task using 40 statements derived from course documentation selected from the earlier study, were unable to distinguish statements describing diploma level from those describing degree level practice. Possible reasons for the difficulty are discussed. It is concluded that the attempt to represent practice skill in a hierarchy of assessment for degree or diploma qualifications is premature since the parameters of practice remain unreliably specified.

Psychological effects of aesthetic dental treatment.

OBJECTIVE: To demonstrate that aesthetic restorative dental treatment, using the porcelain laminate veneer, has a positive effect on the self-esteem of a patient. METHODS: A study group of 17 patients, unhappy with their dental appearance, were assessed psychologically at the pre-operative, immediate post operative and 6 month review stages. Porcelain laminate veneer restorations were used to improve the dental aesthetics for the patients in the study group. A comparison group of 27 subjects, without a dental appearance problem, were also psychologically assessed at comparable intervals. The assessments included Cattell's 16PF Personality Inventory, a Body-Esteem index, a computer administered version of the Repertory Grid technique and semi-structured interviews. RESULTS: The results showed that there were no significant differences between the study and comparison groups on any first or second-order factor of the 16PF. However, highly significant changes in a positive direction (p < 0.005) were observed in the study group in responses to a Body-Esteem questionnaire at each stage in the procedure. Comparison group changes were not significant. Repertory Grid analyses showed a significant overall convergence in the study group compared with the comparison group. There were also significant positive shifts amongst the study group in the normalised ratings of "self' on several of the constructs. Interviews confirmed the Repertory Grid findings. CONCLUSIONS: The study shows that aesthetic restorative treatment has a positive effect on patients' self-esteem.

The variety of qualitative research. Part one: Introduction to the problem.

For a number of reasons qualitative techniques have taken firm root in nursing research generally and are of growing importance in research undertaken by nurse educators. But there is a great deal of confusion about the nature of the data which are produced by qualitative research, the way such data must be handled, and the use to which such data can be put. The confusion often results from a failure to differentiate between several orientations to qualitative data. Positivist research may use qualitative data (something not always recognized). It presupposes that there is some underlying, true, unequivocal reality, and a theory covering this is to be sought by the research. There must be evidence of validity-in the sense of a match between the data and the reality they are supposed to reveal. Non-positivist research is of a number of kinds, despite often being treated as unified. These will be treated in the second part of this paper.

The variety of qualitative research. Part two: Non-positivist approaches.

For a number of reasons qualitative techniques have taken firm root in nursing research generally and are of growing importance in research undertaken by nurse educators. But there is a great deal of confusion about the nature of the data which are produced by qualitative research, the way such data must be handled, and the use to which such data can be put. The confusion often results from a failure to differentiate between several orientations to qualitative data. In the previous paper Positivist research was discussed. Non-positivist research is of a number of kinds, despite often being treated as unified. Examples are: (a) descriptive ('phenomenological') research-which seeks to give a faithful account of an area of experience or of an aspect of the 'life-world'; (b) interpretative ('hermeneutic') research-which aims to show ways of making sense of experience; and (c) discourse analysis-which draws out the socially available modes of thinking and action which reveal themselves in qualitative data.

Theory and practice: beyond the dichotomy.

Equipping students with the means to bring theoretical understanding to bear on the implementation of practical nursing skills has been an enduring problem for nurse educators. The problem is partly born out of a clinical culture in which the 'merely theoretical' tends to be dismissed. The aim of this paper is to show ways of thinking about theory and practice which actually avoid fruitless dichotomy. Theoretical reflection and practical action are in reality richly interconnected (Heidegger 1962). In the case of the expert practitioner (Benner 1984) theory and practice may be impossible to distinguish. New thinking on this problem is particularly urgent in the light of the Project 2000 initiative. It is hard to see how this new approach to nurse education can be entirely successful if students are allowed to get into the way of contrasting the reality of practice with the 'merely theoretical'.

The meaning of incontinence: a qualitative study of non-geriatric urinary incontinence sufferers.

The meaning of the problem for incontinence suffers is known to be a very significant influence on coping. The present study was based on in-depth qualitative interviews with 28 young or middle-aged women who suffered urinary incontinence. Analysis, aimed at discovering the meaning of their condition for the sufferers themselves, led to the following conclusions. Incontinence is taboo, meaning not only that it is a socially unacceptable topic of conversation (inhibiting the approach of suffers to health professionals), but also that it is difficult for suffers themselves to focus on and think about clearly. Sufferers can react with apathy, or may perpetually teeter on the edge of taking ameliorative action: rational ways of tackling the problem are often not followed. The problem is seen as one of personal control: incontinence is lack of a grip on bodily propriety. Sufferers may feel horribly unique, and also worry that the incontinence is their own fault. They fear a guilty association with despised groups. It is noteworthy that the maintenance of 'normality'--allowing the sufferer to claim that there is no problem and that she is not incontinent--may involve a great deal of work. Although there are indications of defensive denial in sufferers' reactions to the problem, an additional interpretation is that they are fighting to subordinate the problem in favour of other priorities. Implications for practice of each of these features of the meaning of incontinence are drawn out.

Patient participation: its meaning and significance in the context of caring.

The ideal that patients should be participants in their own care has found wide acceptance amongst nurses. Yet within the academic discipline of nursing little has been done to clarify the nature of participation. In this paper, a phenomenology of participation is presented as it applies to the caring work of nursing. Participation requires: (a) attunement to a mutual 'stock of knowledge at hand'; (b) emotional and motivational attunement to the other's concerns; (c) taking for granted (and implicitly assuming the other takes it for granted) that one can contribute worthily; (d) feeling that one's identity is not under threat. Though it is difficult to attain, participation appears to embody many of the ideals central to current thinking in nursing. Moreover, the attempt to build participatory relationships with patients is ethically required of members of a 'caring' profession.