Tres uniones proyectadas antes del Mercosur: Castañeda, Sarmiento y Perón

So in asking whether nurse education is a form of social (re) engineering a picture has emerged of nurses engaged in a definitional struggle influenced from both within and outside of the profession. It has been argued before that the history of nurse education can be seen as a continual attempt to reconcile the interest of politicians, the institutes that employ nurses, those who work alongside them (e.g. medics) and the aspiration of the profession to build their professional role (Cockayne 2008), alongside issues of introduced managerialism into the NHS and demographic changes/ societal changes e.g. changes in the employment of females. This inquiry however is focussed on a particular ‘historic’ event which is the introduction of educational standards for nurses that mean all nurses will be graduates. Asking what ‘difference;’ is imagined or will be seen in the profession by implementing this change.

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By undertaking this research both the discursive (Semiotic) representations of the actual world, on the one hand and imaginaries, as discursive (Semiotic) representations of a possible, non-actual (or not yet actual) world on the other have been explored through examining both policy and professional texts and the ‘stories’ of individual nurses. The world of the professional nurse who is well educated and equal to medics (and other health care professionals) in cultural and social capital is imagined. The current reality is constructed as problematic and the nurse is debated as central to that ‘problem’ but importantly key to avoiding the pending ‘carequake’ (Department of Health 2010). Policy and professional discourse establishes changing role as key required action to solve the ‘problem’ and as the goal premise such an imaginary has the power to give people reasons for action, they simply are reasons for actions. This confers (if collectively recognised), a deontic system of obligations (it is the nurses obligation to be educated as this is the only way to be better and meet the challenge), therefore enabling and constraining human activity. In this way being able to declare a certain imaginary as a fact, then working to enforce its collective recognition and furthermore imposing deontic action, is one of the manifestations of power in society (Fairclough and Fairclough 2012). This is achieved in this example (nurses becoming graduates) through legitimation- politicians declare that we have ‘this problem and the answer is ‘this’; the professional body respond and legitimates the claim. This judgement of legitimation is made in relation to a background of norms beliefs values that are themselves legitimate in some way and so justification of action in virtue of some reason and justification in virtue of a publically recognised system of norms values and belief (Fairclough and Fairclough 2012).

Important here is that this discourse is more rationally persuasive than the discourse that is the object of critique (Fairclough and Fairclough 2012). The object of critique is the role of nurses as bed side carers, the angel by the bedside, ‘mopping the brow’ and ‘caring’. The persuasive argument is nurses as professionals moving towards the management of care through the persuasive role of manager, planner, thinker, delegator of care roles. The only basis for

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claiming superiority of position (nurses as graduates, as managers of care) is providing explanations which have greater explanatory validity or power and greater predictive power. Within nursing (still struggling to establish itself as a legitimate profession) it seems that the persuasive argument that is being waged concerns improving care through the quality assurance of efficient and effective practice and the importance of measureable clinical outcomes. People lay claim to being ‘professional’ through commitment to being ‘better’, that is as defined by government policy committed to being outcome focussed measured through quality matrix , audited and through convictions about what constituted ‘good practice’, and so on. Many of the nursing roles undertaken at the bedside can now be legitimately undertaken by well trained (and cheaper) health care assistants, while the ‘important’ and professional work of managing, auditing, quality assurance, planning etc. can be undertaken by the educated and professional graduate nurse.

However data generated through the professional discussion boards and blogs demonstrate a tension for nurses as contradictions, dilemmas, compromises exist between the ‘nature’ of nursing care and what they now experience for themselves as professionals. The job of exploring the response of nurses to these changes involved uncovering these tensions. It seems that nurses are locating their ‘professional’ experiences between their affiliation to both externally declared expectations of quality and changing role and their understood role as bedside carers. There seems to be a kind of overlapping ecology of practice which is creating a tension between the practice of care and the management of it. This supports what Stronach et al (2002) described as professional uncertainty, about the nature of ‘good practice’ or the adequacy of long held ideals such as hands-on client care and holistic practice which through this re-engineering become ‘symbolically vulnerable’ (Stronach, Corbin et al. 2002). As values are embedded in the paradigms and pedagogues of the nursing profession this new paradigm of health care has initiated new challenges to the profession: central is the need to balance nurses’ humanistic commitment to patient advocacy with a realistic/pragmatic approach to patient care owing to resource limitations and the need to remain profitable (Hendel

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and Traister 2006). There exists therefore a tension between what has been referred to as inside out ethics (Dawson 1994), based on the Aristotelian notion of the virtuous person which can be at odds with outside in ethics which bound professional nurses to follow the institutional rule or guideline (Dawson 1994), or externally driven expectations of self-improvement through education and government and professionally defined ‘betterment’.

For individual nurses this seems to be the crux of a perceived dilemma. The apparent ‘upgrading’ of education for nurses to graduate level, becoming legitimate participants in academic endeavour, and the gaining of symbolic capital has come for some individuals at the cost of grounding their knowledge in the positivist scientific paradigm in order to provide a decisive step towards gaining autonomy in relation to doctors. The cost is high with the sphere of autonomy being carved out in relation to doctors and the process of professionalisation grounded in ‘Evidence Based Practice’ and academic knowledge being increasingly conditioned by economic factors: ‘economic targets, limited resources, management decisions’ (Marrero and Muller 2009) . This is supported by evidence that restructuring of the welfare state has meant that professionals are being increasingly held accountable for their work with accountability being a major concept in education programmes (Houtsonen and Kosonen 2009). Evidence based guidelines and practice transforms talk of nursing care from the ‘personal touch’ into ‘objective and legitimate procedure’ (ibid p.65) which is perceived by nurses as a crucial feature of professional practice but this is problematic as it becomes a peculiar combination of autonomous professional practice and accountability being based on established (imposed) guidelines. This moves the sight of the nurse from the individual to a Universalist approach. Clinical outcomes are counted and matter in a rush of ‘universalist excess’ (Stronach, Corbin et al. 2002). Professionalism and Evidence Based Practice is perceived therefore as both gaining and losing autonomy.

So individual nurses are being asked (educated) to conclude that they should start acting in different ways or change their identities in certain ways, on the basis of beliefs about what the state of the world is and goals of achieving

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different states of affairs and to decide to do so and actually do so. But such processes do not have a purely individual character. In many cases organisations of various sorts come to such conclusions about changes in ways of acting and identities. This connects practical reasoning with the technologisation of discourse (Fairclough 1992), seeking to bring about changes in discourse in order to engineer social, cultural or institutional change (Fairclough and Fairclough 2012). What the data has revealed is therefore a definitional struggle within nursing with policy and the espoused professional ‘futures’ of nursing seemingly re-engineering the profession in one direction- towards a leaner, more management focused nurse who ensures quality of care whilst not physically providing it personally, within a context of financial constraints, changing roles of medics and health care support workers and…….the list goes on. This is felt and debated by individual nurses with the definitional struggle playing out as claims and counter claims about what nursing is and should be with key interdiscursive narrative regarding financial contexts and nurses as workforce, to be afforded or otherwise. Skill mixed and efficient.

Policy makers and professional leaders therefore appear to be implementing policy within the discourse of economism which as Bourdieu (1990 p.112) suggests ‘recognises no other form of interest’. The discourse of economics constructs the topic and it appears across a range of texts forms of conduct and a number of different sites at any one time (Ball 1999). Processes of restructuring and rescaling across networks of social practices are realised though orders of discourse which constitute imaginaries for new relations of structure and scale in fields and these may become hegemonic and may be re contextualised and be operationalised in new structures practices, relations and institutions. Policy texts are not some superficial embroidery upon political events but are a fundamental constitutive part of them (Fairclough 2010).

There exists currently therefore a battle for identity in nursing, based on conflicting reasons for action and being fought on a number of fronts. Policy and professional text declare (and legitimate as true) a crisis in the health care sector and makes pleas to the nursing profession regarding this forthcoming

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‘carequake’ thus giving deontic reasons to change their actions by leading people to recognise and accept the external (moral, institutional) force (Fairclough and Fairclough 2012). Within the nursing profession nurses align themselves to, or resist the new face of the nursing professional, who is degree educated, directing care rather than delivering it. Nurses appear to be trying as Ewick and Silbey (1995) have described to work out the relations between ‘personal troubles’ and ‘public issues. The personal troubles of the nurse, whose understanding (or aspiration) for their role may be based on personal and therapeutic caring, which conflicts with the political demand for a ‘better’ kind of nurse. Stronach et al (2002 p.109) refer to as this ‘economy of performance’ which are manifestations broadly of the audit culture, and various ‘ecologies of practice’ which are professional disposition’s and commitments, ‘individually and collectively engendered’ (p.109).

Nurses are thus caught in this ‘tension’ which Stronach et al (2002) have described as a ‘theory that is needed’ to describe the discursive dynamics between different pressures. Not a static audit culture or an era of de- professionalisation or indeed professionalisation, or managerialism but a dynamic and changing thing.