Critical Approaches in Nursing Theory and Nursing Research: Implications for Nursing Practice [1 ed.] 9783737005128, 9783847105121

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Critical Approaches in Nursing Theory and Nursing Research: Implications for Nursing Practice [1 ed.]
 9783737005128, 9783847105121

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Pflegewissenschaft und Pflegebildung

Band 14

Herausgegeben von Prof. Dr. Hartmut Remmers

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Thomas Foth / Dave Holmes / Manfred Hülsken-Giesler / Susanne Kreutzer / Hartmut Remmers (eds.)

Critical Approaches in Nursing Theory and Nursing Research Implications for Nursing Practice

With 2 figures

V& R unipress Universitätsverlag Osnabrück

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Bibliografische Information der Deutschen Nationalbibliothek Die Deutsche Nationalbibliothek verzeichnet diese Publikation in der Deutschen Nationalbibliografie; detaillierte bibliografische Daten sind im Internet þber http://dnb.d-nb.de abrufbar. ISSN 2198-6193 ISBN 978-3-7370-0512-8 Weitere Ausgaben und Online-Angebote sind erhÐltlich unter: www.v-r.de Verçffentlichungen des UniversitÐtsverlags Osnabrþck erscheinen im Verlag V& R unipress GmbH.  2017, V& R unipress GmbH, Robert-Bosch-Breite 6, D-37079 Gçttingen / www.v-r.de Dieses Werk ist als Open-Access-Publikation im Sinne der Creative-Commons-Lizenz BY-NC-ND International 4.0 („Namensnennung – Nicht kommerziell – Keine Bearbeitungen“) unter dem DOI 10.14220/9783737005128 abzurufen. Um eine Kopie dieser Lizenz zu sehen, besuchen Sie http://creativecommons.org/licenses/by-nc-nd/4.0/. Jede Verwertung in anderen als den durch diese Lizenz zugelassenen FÐllen bedarf der vorherigen schriftlichen Einwilligung des Verlages.

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Contents

Acknowledgements . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

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Thomas Foth / Hartmut Remmers / Dave Holmes / Susanne Kreutzer / Manfred Hülsken-Giesler Introduction: Critical Approaches in Nursing Theory and Nursing Research: Implications for Nursing Practice . . . . . . . . . . . . . . . .

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David Mercer / Maria Flynn Chapter One: Neoliberal Demolition of the NHS: Challenges of Caring in a Corporate Culture . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

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Christine Ceci / Jeannette Pols / Mary Ellen Purkis Chapter Two: Privileging Practices: Manifesto for “New Nursing Studies”

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Hartmut Remmers Chapter Three: Care: Existential Assets and Nonpartisan Justice. On Several Ethical Aporiae of Care Professions . . . . . . . . . . . . . . . . .

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Heiner Friesacher Chapter Four : Nursing and Critique: Elements for a Theory in Nursing .

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Thomas Foth / Kim Lauzier / Katrin Antweiler Chapter Five: The Limits of a Theory of Recognition: Toward a Nursing Ethics of Vulnerability . . . . . . . . . . . . . . . . . . . . . . . . . . . . 113 Dawn Freshwater / Jane Cahill Chapter Six: Professional Responsibility and Technologically Informed Decision Making: The Rise and Demise of the Compassionate Algorithm

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Manfred Hülsken-Giesler Chapter Seven: Mimesis in Nursing Practice: The Hermeneutical Potential of the Body to Understand Patients’ Lived Experiences . . . . . 151 Gary Rolfe Chapter Eight: The Reflective Practitioner as Critical Theorist . . . . . . 169 Ulrike Greb Chapter Nine: A Nursing Didactics Model based on a Constellational and Critical Identity Perspective . . . . . . . . . . . . . . . . . . . . . . . . . 187 Susanne Kreutzer Chapter Ten: Rationalization of Nursing in West Germany and the United States, 1945–1970 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 209 Pawel J. Krol Chapter Eleven: Nietzsche and the Right to Die: A Critical Dialectic of Access to Euthanasia or Medical Aid in Dying . . . . . . . . . . . . . . . 229 Contributors

. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 245

Index of Names . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 249 Index of Subjects . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 251

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Acknowledgements

Special thanks go to Jayne Elliott who edited, critically read the chapters, and assisted in the translations. We also want to thank Jette Lange for the final editing and the creation of the indexes.

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Thomas Foth / Hartmut Remmers / Dave Holmes / Susanne Kreutzer / Manfred Hülsken-Giesler

Introduction: Critical Approaches in Nursing Theory and Nursing Research: Implications for Nursing Practice

Cet ouvrage produira s0rement avec le temps une r8volution dans les esprits, et j’espHre que les tyrans, les oppresseurs, les fanatiques et les intol8rants n’y gagneront pas. Nous aurons servi l’humanit8; mais il y aura longtemps que nous serons r8duits dans une poussiHre froide et insensible, lorsqu’on nous en saura gr8. (Denis Diderot / Sophie Volland)1

Nurses and nursing scientists have long applied a form of critical thinking that follows the rationality of the nursing process and of decision making based on means-end analyses (Bandman & Bandman, 1995). Critical thinking, understood in this way, is reduced to a critical questioning of existent quantitative evidence for a specific intervention and construes nursing as a rational choice process. In this book we want to advocate for a more unusual understanding of critical thinking, what we might even call a disruptive mode of thinking. Critique, as we understand it, is philosophically justified and developed out of the long but ever-changing history of science, leading to a specific scientific culture that uses the social sciences as societal critique. For this purpose we would like to open up two perspectives: one from a historical point of view and another from an analysis of the present.

The Historical Relationship between Critique and Crisis The political regulatory forces of the European Middle Ages justified and preserved themselves for many centuries through a catholic universalism. The disaggregation of the medieval ordo was influenced by many factors, primarily through an intertwining of new forms of thinking and cultural styles, which were 1 “This work will surely lead to a revolution of the minds and I hope that the tyrants, the oppressors, the fanatics and the intolerants will not succeed. We will have served humanity ; but we will have been reduced to a cold and insensible dust for a long time, before people are grateful.” (Diderot 1992, p. 148, our translation)

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for their part expressions of the powerfully emerging social layer of merchants. In this historical turn, which has been called the “early modern era,” the renaissance of pre-Christian thought traditions played a decisive role and was perceived as liberating because of an unconstrained analytical access to nature that was no longer restricted by church dogma. In a way, these new explanatory hypotheses in the natural sciences provided the foundation for the development of mechanics as a sub-discipline of physics that would trigger a major boost in technological innovation. Technological inventions, made possible through new scientific insights, undoubtedly contributed in a revolutionary way to the increase in trust that human beings developed in their own abilities. The incomprehensible power of God, as regent of everything that happened, was replaced by the constructive abilities of the human, and was obviously what philosopher and natural scientist Francis Bacon envisaged in his 1650 epochal work, Novum Organum Scientiarum. During this historic era of upheaval a new type of human being took shape who, by virtue of newly discovered capabilities, not only became the potential master over nature but also understood himself or herself as an active creator of social and political life. Thus, to the extent that humans perceived themselves as constructors of their living conditions in peaceful interplay with others, all heteronomous orders were exposed to fundamental critique. Since then, critique, which was understood in the classical Roman era as a magisterial ability to judge,2 has been transformed into virtually a dutiful behaviour. Critique is the medium through which medieval concepts of social order were detached. Nevertheless, this form of specific epistemological knowledge was demarcated from Descartes’ institutionalized doubt about normative postulates. For example, French philosopher Pierre Bayle distinguished sharply between the sphere of reason and the sphere of revelation. According to Bayle, human “reason … is a principle of destruction and not of construction” (Bayle, 1715, as cited in Röttgers, 1990, p. 891, our translation). Another epistemological demarcation resulted from the insight that facts of an objective world were always mediated through human interventions. It is not coincidental that reflection, understood as an intellectual accomplishment rooted in radical doubt, replicated the kind of action found in craftsmanship: the tentative handling of an object in regard to its material properties, its purposeful manipulation that finds its limit in the materiality of the object. In the course of the revolutionary passage to the modern scientific era, the 2 The original meaning of critique derived from the Greek word krinein: dividing, separating, judging, accusing. Aristotle departs in his Politeia (1275b, pp. 18–25) from the assumption that the citizen as a citizen is qualified to be a judge (able to judge). During the fifteenth and sixteenth centuries this old understanding of the term critique underwent a resurgence (see, for example, Röttgers, 1990, p. 890).

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idea of science as pure theoria that is distant from practice thus could no longer be justified. With the dissolution of the dichotomy between bodily and intellectual labor, the opposition between science and social practice also disappeared. Science, with its increasing potential for innovation, became increasingly perceived as a social practice sui generis, and experimental sciences and theories came to be understood as factors in societal developmental processes. One could even state that the historical break of the modern era led to an expectation that science should contribute productively to the evolution of society. Bacon (1650) was the first scholar who saw societal usefulness of science as a way to justify a new science. The center of his argument targeted the scholastic tradition of an authoritatively protected knowledge and the theological claim that the study of nature should legitimize the religious worldview. His position was epistemologically supported 100 years later through Giambattista Vico’s Scianza Nuova, which represented a constructivist understanding of science that was directed against Descartes. Vico’s central doctrine, “Verum quia factum,” meant that one could only perceive what has been made. Importantly, the constitutive characteristic of scientific perception was that it was implicitly intertwined with labor and production. As is well known, these categories historically became the center of philosophical theory constructions aimed at social emancipation. At the beginning of the merchants’ awakening, the sciences that were conceptualized by representatives of this social class were guided by emancipatory interests. They became fertile ground for the philosophical and scientific Enlightenment that began in this era and that was characterized as a form of critique (Hampe, 2009). Kant has systematized this connection between the Enlightenment and critique. With Kant, critique became a task of reason, which cannot be conceptualized as other than critical. In the style of classic Greek thought, critique was conceptualized on the model of a court of justice, and Kant generalized it to all areas and institutions of social life. Therefore, he understood the contemporary era of the Enlightenment as “the actual era of critique under which everything must be subsumed,” including religion and its claim of “holiness,” as well as politics understood as the “making of law” and legitimatized by a “sovereign” (Kant, 1781, A XI, comments). This understanding of critique was definitely restricted to the intellectual arena of the “republic of scholars” [Gelehrtenrepublik] (Röttgers, 1990, p. 892). The question therefore becomes how critique, and how a theory that is conceptualized as a critical theory, could become practical, meaning that it was not restricted to an epistemological critique as in Kant, but rather could be connected with societal emancipatory movements. It seems that for the revolutionary turn of the early modern era, Reinhart Koselleck’s (1973) theorem is correct in assuming the same linguistic root for the

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terms crisis and critique. It seems that this assumption also holds for the crisisladen context of the turn toward modern industrial capitalism. This turn was a historical phase in which the life context of a merchant society was destroyed through technological developments and dramatic socio-structural distortions. From this perspective societal function and practice of science appeared in a new light. The sciences of social action in particular had to clarify the multiple interrelations between their work and the life processes of society as a whole. This necessity implied questioning the transparency of their knowledge interests and to what extent these sciences themselves were a constitutive element of society. This aspect was important because society was a social field that resulted from relations of power and domination (modern capitalism). The crisis of the old world set forces free that came together under the banner of critique and were driven by the aspiration of a scientifically led emancipation from dominance. How can this substantial correlation of crisis and critique in the era of industrial capitalism, with its distinctive dynamics of social crisis, be captured theoretically?

Some constitutive elements of Max Horkheimer’s critical theory Not without good reason the decade following World War I in Europe has been characterized as being in permanent crisis. An academic reaction to the loss of socially meaningful synthesizing forces and powers was Sheler’s sociology of knowledge and its offspring of critiques of different forms of ideology. Although critique of ideology was already widespread in the era of the early Enlightenment through Francis Bacon, for example, in the post-bourgeois era it transformed into a critique of an inevitable false consciousness. Consciousness was labeled as inevitably false when it became the functional representation of dependence from opaque dominance. Another form of ideology critique was one that conserved revolutionary ideas of the bourgeoisie that had not been historically realized. It was thus not only about confronting the representatives of a bourgeois order with their original ideas and with their own history, but also about analyzing the causes for the failure of an emancipatory process that was originally intended as revolutionary. Merging these two aspects provided a measurement for the critical function of science in regard to society and the political morality of its representatives. In what follows, we will focus on Horkheimer as an exponent of a critical social theory that became a philosophical school. For Horkheimer, the catastrophe of World War I was actually one of the first breaches of civilization and was an imperative reason for the relevancy of a social revolution. In his opinion, the failure of the 1920s’ revolutionary movement needed to be analyzed through broadly laid-out, theoretically well-funded, in-

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stitutionalized interdisciplinary social research. This theoretical and empirical task consisted of studying not only the backlash of historical emancipatory movements, but also the authoritative destruction of a weakly developed liberalpolitical culture in Europe. This epochal context of a self-destroying bourgeois culture and morality in the political violence unleashed in the 1930s needed to be critically and theoretically analyzed. The difficulties of a scientific empirically informed critique was that its partisan assertion (Horkheimer talks about the “needs of a coming humanity” (1933, p. 149)), could not claim addressees capable of acting politically. Rooted in a materialist thought tradition, for Horkheimer it was without question that a practical claim to the validity of truth needed to be defended. Under the concept of a pure, timeless, and uninterested theoria, this claim could not be realized. Under a critique of illegitimate dominance the original bourgeois principle of the autonomy of spirit and action should likewise be conserved. Only on these grounds could also the false consciousness of oppositional social movements be criticized. A critique merely of power does not suffice but must be complemented by a critique of a power that dominates the consciousness of the people who want to break free from it. One of the most important concerns of Horkheimer’s critical theory was a critique of reification, which had to be developed in terms of a critique of science and of consciousness. Traditional theory is a quasi-classification of a “bourgeois way of thinking” (Horkheimer, 1974, pp. 257, 269). This way of thinking is unable “to realize that existence is the result of social life processes in which the individual participates” and leads to hypostatizing both concepts and the reality that they describe (Horkheimer, 1937, p. 131; Horkheimer, 1935, p. 289). In contrast, critical theory exposes the unrecognized conditions, which are also part of false consciousness, of failed social struggles for emancipation (Horkheimer, 1937, p. 204). Basically, the critical scientist, in the role of a committed intellectual, and social emancipatory movements are struggling for autonomy from heteronomy and external power in an era of unleashed capitalism. In this respect, alliances emerge between the activities of a critical scientist and those social forces that work towards changing the social situation; these alliances must be perceived as “dynamic units” (Horkheimer, 1937, p. 189; see also Jaeggi & Wesche, 2009). After the experiences with fascism and Stalinism the pragmatic possibilities of enforcing a critical social theory dramatically changed. Even the democratization of Western-European societies did not change the fateful and inescapable fact that the technologic-industrial world was spreading globally (Max Weber). Horkheimer diagnosed this global spread as a manifestation of instrumental reason, which was in its core self-destroying (Horkheimer & Adorno, 1972). Henceforward, it appeared to critical theorists that interventions in society were only possible if they practiced sociological Enlightenment [Aufklä-

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rung] based on advanced empirical social research. Theoretically, Horkheimer assumed that it was necessary to tie critical theory to a transcendent-religious content of a non-affirmative theology in order to remain conscious of the moral difference in the existing technological-instrumental solidified order of dominance. Horkheimer asserted in his Critique of instrumental reason [Kritik der instrumentellen Vernunft] that “economic and cultural mechanisms of modern industrialism” provoked the “decay of individual thinking and resistance” (Horkheimer, 1974, p. 148). Nevertheless, the history of this decay seems to imply a dialectic relation: through “forms of a highly developed industrialism,” through the “influence of the all encompassing machinery of mass-culture,” the “idea of the individual” indeed deteriorates, but, at the same time, conditions are created that become “prerequisites for the emancipation of reason” (Horkheimer, 1974, p. 166). Thereby, critical thinking assumes the role of the lonesome leader of social liberation. The critical gaze is directed toward the social conditions of researchers’ work and their “meaningless hustle” within research institutions that are transformed more and more into industrial enterprises, leading to caricatures of academia and science. Scientists appear merely as “experts” and “servants of the apparatus” (Horkheimer, 1974, p. 85). A complementary phenomenon is the alarming connection between “expert knowledge and obscurantism” (Horkheimer, 1954, p. 446). The situation of the intellectual has been changed fundamentally since the industrial revolution and has increasingly led to conformism. Against this backdrop, it is important to remember that scientific work, due to its formalized-procedural character, holds a liberating potential. Since the intellectual work of the researcher is performed as a form of reflection, he or she ultimately stays, in Lepenies’ words, “alienated from power” (Lepenies, 1992, p. 60). Not expected by Horkheimer, starting in the 1960s the role attributed to the researcher as the leader of critical reason led to a reform movement within education and science. This movement had relatively stable political effects. Not foreseeable was the strengthening in the Western world of a neo-conservatism in alliance with an economic neoliberalism that began in the 1970s. Through these powerful streams the developing alliance between critical intellectuals and social emancipatory movements came under pressure. The dominance of the market, freed from the constraints of the welfare state, has since led to an unimaginable dynamic that is characterized by penetration of instruments of dominance into the biological substratum of human life. To sufficiently grasp this tendency confronts the project of critical theory with completely new challenges.

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Critique in the Era of Neoliberalism This book appears in a time of hostility to any form of critique amid a growing anti-intellectualism in many Western societies. It seems that we are yearning for certainty, security, and stability rather than for critical and political analysis or theoretical debates. Neo-conservatives are on the rise in most Western societies. National governments in many countries in Central and Eastern Europe and in former liberal countries such as Scandinavia or the Netherlands are openly supporting neoconservative agendas. Populists like Donald Trump in the US, the “Brexit” proponents in the UK, far right “movements” like the Front National in France or the Alternative for Germany are examples of a worrying development in our current societies. Supported by think tanks generously funded through corporate structures, neoconservatives like Leo Strauss in the US nurtured very early on a particular mistrust of democracy (Drury, 1999, p. 705) and the need for authoritative social orders, militarization, and an educational system based on moral values centered on “cultural nationalism, moral righteousness, Christianity (of a certain evangelical sort), family values and right-to-life issues” (Harvey, 2007, p. 84). Accused of undermining the moral fabric of society, intellectuals and academics are more often than not attacked as a latte-drinking urban elite who have lost any connection to the issues concerning hard-working men and women. The recent election campaign and the result of the election in the US are blatant examples for this line of thinking and make clear how huge numbers of voters can be directed into this line of thought. The concept of intellectual critique, it seems, is outmoded and under scrutiny, and research and study programs are themselves under surveillance. In various disciplines in the humanities and social sciences, and in nursing science in particular, recourse has been made to scientific models of investigation that tend to eliminate subjective assessments and replace them with solid “facts.” It is increasingly difficult to develop theories that encourage innovation due to the imposition of orthodoxy. Personal expressions of opinions or points of view by researchers and classroom teachers are often frowned upon, and programs and courses that take up questions of inequality or social justice may be deemed superfluous. This hostility to critique persists at a time that is particularly challenging for nursing as a profession and for the conditions under which nursing care is delivered. In the more than 50 years since the onset of the neoliberal revolution, neoliberalism has taken shape in very different forms depending on national contexts (Harvey, 2007; Mirowski, 2015; Peck, 2010; Stedman Jones, 2012). However, all the different neoliberal varieties share similar aspects in targeting segments of the population who rely on state services. In the healthcare sector, government attempts to reduce the costs of healthcare systems have had devastating effects

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on vulnerable parts of the population, and on the nurses who care for them. Frontline clinical and nursing services have been cut and many public healthcare servants have suffered wage freezes, with pay running well behind the rate of inflation. Pensions have been cut and retirement ages have risen. Forced flexible working hours have led to what has been called a “casualization of the hospital workforce” (for the Canadian context see, for example, Rankin & Campbell, 2006). These developments have left many nurses in precarious living conditions. At the same time governments began to systematically cut support for the vulnerable in order to break “welfare dependency.” Healthcare services have been increasingly privatized by returning public services to private corporations, leading to the implementation of profit-making in healthcare – developments that have only been accelerated by the “free trade treaties” of TTIP, CETA, NAFTA, and others. Catchword phrases include the increasing economic pressure on healthcare systems, leading to profound transformations that are realized by making nurses responsible for the economization of their services at the bedside; the replacement of RNs through unlicensed assistants or under-qualified personnel; the increasing privatization of formerly publicly funded and administered social and healthcare services, etc. The search for security in nursing is characterized by an emphasis on empiricism and quantitative analysis, like evidenced-based nursing (EBN), best practices (BP), procedural guidelines, etc. Furthermore, a long-standing discourse positions nursing in opposition to philosophy. Theory, the argument goes, must serve the solution of clinical problems, and research in nursing sciences should be restricted to developing economically efficient tools that can be used in practice. Critical theory would distort the empirical truth and unacceptably distance nurses from the pure facts that need to be discovered. Nursing science in its current state is about knowledge transfer, decision making, and interventions based on best available evidence – everything beyond this is pure speculation and a waste of time. This situation can be partially explained by the fact that nurses are traditionally rather hostile to theory, perceiving themselves as members of a practice profession in which theoretical discussions are rather relics from the beginnings of the profession. From this perspective, it would seem that nursing is apolitical, that it abstains from political interventions. However, this unwillingness to engage in political struggles can also be seen as an expression of what Stuart Hall (2011) called the “neoliberal conjuncture” or the unresolved rupture of our epoch, which we can define as “the long march of the Neo-liberal Revolution” (Hall, 2011). As we will discuss in more detail, this “revolution” has transformed our understanding of what democracy and with that, critique, implies. Neoliberalism, we claim, has transformed the very idea of democracy and democratic struggles and made it even more difficult for nurses, who historically have

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Introduction

more or less been excluded from political decision-making processes, to intervene or to initiate political struggles. This collection is about critical theories that inspire the practice of nursing science as critique, a practice that needs to be protected and reinforced “in the face of a conservative revolution that, in the academy as in politics, seeks to discredit critique as disruptive, discordant, even disloyal” (Scott, 2007, p. 21). The different contributions to this volume demonstrate that critical theory in nursing is not only possible, but also necessary – today even more than ever. Before introducing the different chapters in our collection, we want to briefly outline the societal context that constrains the practice of critique. Neoliberalism as a political rationality cannot be understood merely as the economization of the social, but must rather be analyzed as a specific rationality about how to govern our societies, with far-reaching consequences for populations on a global scale. While this book is not about neoliberalism per se, many of the chapters discuss the repercussions of the ongoing transformations in our neoliberal societies on nursing. What rather concerns us here is the question of why it is increasingly difficult to meaningfully criticize these transformations in general and to develop critical perspectives for nursing in particular. We argue that the implementation of new governance models has permeated all aspects of life, including nursing and health care, making it increasingly difficult for nurses to critically and actively intervene in political processes. What could critique and critical theory for nursing mean in these neoliberal times?

Neoliberalism as political rationality The term neoliberalism as such is controversial because, as many critics argue, the “term lumps together too many things to merit a single identity ; it is reductive, sacrificing attention to internal complexities and geo-historical specificity” (Hall, 2011, p. 206; see also Peck, 2010). Despite these justified objections, we agree with Stuart Hall that “naming neo-liberalism is politically necessary to give the resistance to its onward march content, focus and a cutting edge” (ibid, 706). Although neoliberalism as a theoretical and political approach has existed in Germany [Ordoliberals] from the early 1920s where it became the foundational rationality for the instauration of a German state after World War II, and in the US with the Chicago School since the mid-1940s, it was not until the mid-1970s that it made headway against welfarism in North America (Foucault, 2004; Ptak, 2015; Stedman Jones, 2012). Neoliberal economists began to deplore the huge bureaucratic apparatus needed to manage the welfare state (Friedman, 2011). No longer was the state to accompany the citizen “from cradle to grave.” The state

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was now to maintain the infrastructure of law and order and the people were to promote individual and national well-being by their responsibility and enterprise (Thatcher, 1980, as cited in Eccleshall, 2002, pp. 242–244). This reconceptualization of the role of the state was based on the rationale that it had grown too large and that it was undertaking projects that could better be accomplished by the private sector. The welfare state, it was thought, eroded personal responsibility, thereby jeopardizing the moral fiber of the nation. As Thatcher underlined, “[t]here is no such thing as society … [t]here is only the individual and his [sic] family” (Eccleshall, 2002, p. 240). Instead, the neoliberal model was based on the idea of free, entrepreneurial, self-governing individuals with the state having no right to prescribe how these individuals manage their property. According to neoliberals, Keynesian attempts to engineer the social must also under no circumstances dominate corporate interests. The state should never intervene in the natural order of the free market; rather, it was only to safeguard the conditions for profitable competition. Neoliberal politics target union power and support individualized, competitive solutions, and entrepreneurship. Thatcher coined the “key neo-liberal ideas behind the sea change she was imposing on society : value for money, managing your own budget, fiscal restraint, the money supply and the virtues of competition” (Hall, 2011, p. 712). All these aspects are important effects of neoliberalism but it is more than a mere cluster of economic politics. Neoliberalism must be understood as a political rationality that “both organizes … policies and reaches beyond the market” (Brown, 2003, p. 2); neoliberalism is Undoing the Demos (Brown, 2015) and radically transforming liberal democracies by submitting every dimension of our existence to an economic rationality, including the political sphere. Brown has called claims that markets and market laws are “naturally given” as “normative rather than ontological,” because rational actors must be produced and market rationale for decision making must be imposed (Brown, 2015, p. 45). Neoliberalism is a “constructivist project” because it is organized through laws and the institutionalization of a rationality that directs the economy and protects it through laws and other regulations. As social theorist Thomas Lemke put it, “the market [must] be constituted by dint of political interventions” (Lemke, 2001, p. 193). The state must orient its politics to the needs of markets by adapting its monetary policies, its tax regimes, its organization of social services and healthcare, etc., instituting a new form of legitimation for the state, which is now evaluated by its ability to maintain and strengthen “free” markets. An individual is conceived as homo oeconomicus, one who organizes all areas of life according to this market rationality – every individual becomes an entrepreneur of itself, organizing life according to the model of the firm (Rose, 2005). Individuals are conceptualized in terms of human capital and like any other kind of capital, “are constrained by markets in both inputs and outputs to comport

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themselves in ways that will outperform the competition and to align themselves with good assessments about where those markets may be going” (Brown, 2015, p. 109). The human understood as human capital is responsible for itself and at the same time, becomes a dispensable asset because the neoliberal state grants no guarantee for the life of the individual. The neoliberal state itself must behave as a market actor and is responsible only for safeguarding the conditions for profitable competition. Homo oeconomicus and the neoliberal “economization” of the political convert both state and citizen “in identity and conduct, from figures of political sovereignty to figures of financialized firms” (Brown, 2015, p. 109). In classical liberalism, homo politicos was based on the idea of freedom, which was understood as the minimum necessary for self-rule and participation in liberal democracy for the common good. Under neoliberalism, freedom is “linked with a normative diminished conception of the person. The concept of the person as a ‘rational decider’ is not only independent of the idea of the moral person who determines her will through an insight into what is in the equal interests of all those affected; it is also independent of the concept of the citizen of a republic, who participates in the public practice of self-legislation” (Habermas, 2001, p. 94). Democracy is no longer about “dissent” but rather reduced to formal rights like that of property and the right to vote. Democratic rights become something that can be consumed in the same way as other goods. “Neoliberalism also calculates that the use-value of civil liberties is consumed in the enjoyment of private autonomy …[i]t does not add political autonomy as further dimension of freedom” (Habermas, 2001, p. 94). Civil liberties understood in this way can easily be suspended, as is the case in many current societies where a kind of permanent “state of exception” is established (Agamben, 2005). But in this constellation the subject that is human capital for itself and for the state can easily be abandoned. As sociologists Pierre Bourdieu and Robert Castel highlighted at the end of the 1990s, we live in times of generalized precarity, both in the public and in the private sector (Bourdieu, 1998; Castel, 1995, 2003; see also Lorey, 2015). Castel emphasized in particular that the neoliberal demolition of the collective security system and the rise of precarious working conditions have led to unemployed individuals being excluded from any possibility of meaningfully participating in collective life, and collective forms of resistance are increasingly difficult to organize.

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New Governance or the Demolition of Liberal Democracy By eliminating political life, neoliberalism ridicules critique and reduces its practice ad absurdum. In order to better understand how liberal democratic principles have been abandoned, one important aspect of the neoliberal critique of the welfare state was the state’s inability to manage all of the information necessary to evaluate each micro-event in a free market society. Proponents of neoliberalism claim that only the individual economic actor is “empowered” to analyze risks and benefits in order to make the best choices; local actors must be free to choose according to the natural law of the market and to human nature. The technology neoliberalism implemented to govern free market societies is what has been described as new governance. Governance has become a central concept in all areas of society, not only in politics, but also in private enterprises, in public institutions like universities, in healthcare systems like hospitals, in NGOs, and in other associations and institutions. The concept is linked to the idea of “governing without Government,” and the “minimal state” (Rhodes, 1996). While there is no one definition of governance, all recognize that proliferating social demands have made societies more complex. Supported by the development of communication technologies, political authority has evolved as polycentric and multidimensional. Regulation no longer functions in a “top-down” manner, as was the case in the welfare state, but rather “bottom-up” through complex relations within a field composed of both public and private actors. The demarcation between public and private has thus become blurred (Jessop, 1995; Walters, 2004). New governance is closely related to technologies like New Public Management, which was introduced in countries like Britain and Canada in the 1980s with the aim of implementing management methods developed in the private sector for the efficient organization of public services. Therefore, governance introduces a new and specific relationship between the state, civil society, and the markets – “governance of politics without a centre” (Della Sala, 2001). Governance, and especially good governance, puts emphasis on processes and is no longer concerned with institutions. Thomas Lemke summarized that “governance involves a shift in the analytical and theoretical focus from institutions to processes of rule” and leads to the “erosion of state sovereignty” (Lemke, 2007, p. 62). Its declared aim is the mobilization and the engagement of non-state actors leading to new political cultures by “inciting new arrangements and practices that include sharing public power among different tiers of regulation, privatizing the provision of utilities and services, and above all, increasing reliance on partnerships, networks, and novel forms of connection and communication about policy design and delivery” (Brown, 2015, p. 125). Governance conceptualizes democracy in a new way and is more than a

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simple shift in emphasis. It is about implementing a different way to disseminate power ; through this decentralization, power is rather “ ‘conducting’ and not only constraining or overtly regulating the subject” (Brown, 2015, p. 125). These changes transform politics into an area for management and administration and the public arena into a “domain of strategies, techniques and procedures through which different forces and groups attempt to render their programs operable” (Meehan, 2003, p. 3). Government is replaced with governance and the public sphere is reduced to problem-solving processes. Governance’s emphasis on consensus hinders the expression of different political positions and desires, thereby hollowing out the very idea of democracy, which is more about dissensus than consensus (RanciHre, 2013). Any debates are not about questions related to justice or the common good. There are few deliberations on societal values and no struggles around power and the pursuit of ideas about what may be in the best interest of society in general. Participants are integrated into decision making through benchmarking (the practice of an agency basing internal reform on the successful practices of another enterprise), consensus building, private-public partnerships, etc. “‘Stakeholders’ replace interest groups or classes, ‘guidelines’ replace law, ‘facilitation’ replaces regulation, ‘standards’ and ‘codes of conduct’ disseminated by a range of agencies and institutions replace overt policing and other forms of coercion.” These processes also replace “a vocabulary of power, and hence power’s visibility, from the lives and venues that governance organizes and directs” (Brown, 2015, p. 129). These consequences are particularly visible in healthcare systems in places like Ontario, for example, where the 14 Local Health Integrative Networks (LHINs) are a paradigmatic example of this transformation. With a clear mandate of making the healthcare system more “efficient,” business managers on the boards of the LHINs are in essence “steering” the provincial healthcare system. Struggling with the goals of managing and distributing constrained resources, these local structures are making decisions on hospital closures and the provision of services based on economic considerations. The LHINs were implemented in 2007 with the promise that they would be closer to the community level, and people would then have a say in decision making. However, decisions are actually made behind closed doors, and patient advocacy groups who, like the Ontario Health Coalition, are critical of the LHINs’ policies, are systematically excluded. In 2010, the ombudsman in the Ontario provincial government complained about the lack of transparency (Marin, 2010) and even though the LHINs are obliged to deliver regular audits and assessments on their effectiveness and efficiency, no such report has yet been completed (Ontario Health Coaltion, 2016). The effects of this new governance approach have been devastating in some

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areas. In the region of Niagara, for example, one hospital has been closed despite the resistance of the local population, and four more closures are planned (Ontario Health Coalition, 2015b), resulting in markedly decreased access to medical care for a largely elderly population in a rural region with insufficient public transportation options. And the Kingston General Hospital was on “code gridlock” for 25 days in 2014, meaning that it was unable to accept emergencies or even regular admissions because of overcrowding This happened “despite the hospital meeting or exceeding provincial benchmarks for so-called efficiencies like throughput or length of stay (how fast the hospital pushes patients through)” (Ontario Health Coalition, 2015a, n.p.). Benchmarking, evidence-based nursing (EBN), and best practices (BP) are important technologies in new governance, and those working in the healthcare system have also been affected by their hegemonic influence, transforming their practices and rendering them increasingly unable to critique new technologies. These important technologies are claimed to be based on neutral and objective research, and in combination with the strong emphasis on consensus, are especially hard to resist. Not only are these approaches used in every sector of our societies such as social services, government agencies, police forces, and hospitals, etc., but they also implement an endless circle among researchers, clinicians, and institutions. This circle allows combining the distinctive efforts of different societal sectors like private enterprises, schools, hospitals, government, etc. A practice based on BP appears as neutral because it is not based on political intentions. Criticizing BP is only acceptable if one proposes “better” practices, but there is no possibility of radically criticizing the approach as such. Successful practices can also be transferred from one industry to another. One recent example in healthcare is the implementation in Canadian hospitals of the LEAN concept, originally developed in the 1960s by Toyota for more efficient car production. LEAN is the realization of the idea of new governance at the mesolevel, the institution. Its resemblance to the adjective “lean” is no coincidence because the basic idea of this model is to shorten the distance between the decision-making centers of an enterprise and front-line workers. Proponents of LEAN contend that a manager acting in isolation of employee input is not able to make the right decisions. The Toyota model therefore emphasizes that it is necessary to constantly include employees in decision-making processes and to elicit the total engagement of each and every member of the enterprise. LEAN depends on a concept derived from psychology called Kaizen. This concept aims to motivate employees to work together to constantly improve efficiencies in the enterprise – efficiencies that are based on the idea of just-in-time production. To achieve greater efficiency, employees are called upon to continuously engage in the search for absolute quality and to realize the objectives of the enterprise at

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every moment in their work processes. In order to motivate and mobilize employees, employers use the instruments of Kaizen, which, among others, consist of holding team meetings or focus groups and encouraging reports about processes that are not functioning smoothly or in which delays are occurring. Employees are invited to pinpoint problems in their work processes and to propose solutions. However, the objectives are preset – Kaizen is not meant to lead to innovations but rather to modify and to better standardize or streamline existing processes. Employees’ proposals are only retained if they contribute to those narrowly defined objectives that are compatible with increasing client satisfaction. Under the cover of egalitarian participation, the LEAN model modifies and reaffirms power relations in the workplace. Without overt coercion, employees are meant to internalize the objectives of the enterprise. LEAN and Kaizen are a means of implementing a kind of auto-control performed by employees themselves over their work and they encourage surveillance of every employee over the work of his or her colleagues. Since discussions take place in small team meetings without union involvement, excluded from this “democratization” of the work environment and the horizontal hierarchy of employer and employees searching together for solutions is the development of a collective voice around issues of workplace security, decent salaries, healthcare benefits, etc. Because the concepts underlining best practices and benchmarking can be exported from one sector to another, public sector organizations cannot claim specific or even traditional practices and norms. Through the implementation of these technologies, questions around provision of equal access to healthcare, or care defined as advocacy for patients’ rights, or calls for justice in public healthcare systems, are no longer permissible. Instead, the delivery of healthcare is construed as no different from the production of a car, with the assumption of an unquestionable claim for efficiency on which all these technologies are founded. Thus, debates are framed in such a way that real dissent cannot emerge; the preferred technologies of BP and benchmarking in new governance have a quasi-consensus built in.

Critique and History Assuming that our diagnosis is correct and neoliberal transformations of healthcare systems have led to a veritable immunization against critique, from what standpoint then can a critique be formulated in our current situation? It is in this context that we want to suggest that historical research is an important way to provide a critical perspective in nursing science, which, beyond a reflectivity claimed everywhere, actually questions both the foundations of

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thought and action in nursing science as well as its genesis or genealogy. We are not concerned here with a kind of “antiquarian” history that is about describing the past in order to save it from oblivion, but rather with historical research aiming to study the past in light of the present. Historical research understood in this way demonstrates how that-which-is has not always been, and that our current understanding of ourselves is the effect of processes of problem solving that are embedded in relations of power. Critique is always the history of the present, and we must be careful not to reduce it merely to the pre-history of the present. The question is, then, what does that past tell us about today? (Duden, 2010). Historical research provides an invaluable chance to distance ourselves from, or to destabilize, the taken-for-granted conditions of our current lives. Critique must be able to highlight other realities – to enable highlighting the Other or what appears as foreign to one’s own reality – and provide insights into the contingency of what we have become (Landwehr, 2012). It should be of utmost importance for nurses today to better understand how nursing was conceptualized before its far-reaching economization. Only from a historical perspective is it possible to measure the extent to which economic calculi and management strategies have pervaded nursing practice. The younger generation of nurses, who lack personal experience with the temporality of the organization of nursing, are particularly vulnerable to the imperatives of economic and administrative rationalities. How can they understand, for example, when and in what context economic concepts were implemented in nursing’s area of action, and how did this implementation lead to changes in the everyday provision of care? Who were the important actors in these processes? What mechanisms made it possible to implement the idea of efficiency as a new leitmotiv in the selfimage and organization of nursing? Without a historical perspective, how can these agendas be viewed as not inevitable but the result of decisions, interests, discourses, and relations of power, all of which could have led to different outcomes? This book is an important step in bringing together historical perspectives and findings with social scientific perspectives. Only in this combination is the development of a critical perspective in nursing practice and theory possible.

The Chapters The following chapters will challenge the status quo and are a plea for critique as a disruptive undertaking. This comprehensive collection offers a unique look at nursing practice, theory, research, and nursing history from various critical theoretical perspectives. It aims to initiate an international discussion among

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scholars from diverse countries, particularly Germany and Anglo-American countries, coming from distinctive schools of thought, for example, German critical theory and post-structural approaches, and influenced by their respective histories of sciences. This book analyzes and criticizes nursing theory, nursing research, and practice along several dimensions: Nursing Ethics, Subjectivity, Body and Flesh [Lieb], Technology, Power, History, and Education. Nurses and the practice of nursing play a significant role not only in healthcare in general but particularly in the realization of current transformations in healthcare systems around the world. The purpose of this collection is to critically examine the transformational processes that are characterized by an increased marketization of healthcare and that have a crucial impact on the future of nursing and healthcare in Western societies. To do so it is necessary to question, from a historical perspective, how we have come to be where we are now. Therefore, this collection moves away from the unquestioned assumption that nursing is an apolitical discipline/profession based on benevolent caring, but rather highlights that nursing needs to develop a critical potential and self-awareness in order to influence current political developments. Critical perspectives on nursing have been developed in countries with unique philosophical traditions that have influenced the way nursing is conceptualized. These critical approaches coexist but often seem to be incompatible because transnational theoretical exchanges rarely take place. Sensitive topics in the realm of nursing and healthcare are therefore reconceptualized through the work of philosophers like Adorno, Butler, Foucault, Habermas, Honneth, Horkheimer, Merleau-Ponty, and others. This collection is based on the conviction that critical theory can only be kept alive if one demonstrates its epistemological potential or cognitive interest regarding current contexts and developments. Critical theory should not be discussed in abstract but rather in concreto, that is, related to specific problem areas. A theoretical discussion of critical theory in nursing should proceed ideally using concrete thematic issues to develop a theoretical and critical perspective. This collection will provide numerous theoretical tools to address issues related to nursing practice, research, and theory. By combining different philosophical perspectives in creative and productive ways the book will contribute to helping nursing reach its full critical potential. The first chapter by Dave Mercer and Maria Flynn is directly linked to the neoliberal transformations described earlier. The authors explore the challenges of upholding the caring values of nursing within an increasingly corporatized health economy. In United Kingdom health services, social care is that which is provided to the elderly, people living with long-term health conditions, and those needing rehabilitative care, living in their own homes, and who meet the criteria to “qualify” for the allocation of a personal social-care budget from the

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state. These budgets can only be used for the purchase of essential support in everyday activities such as getting up and going to bed, washing, dressing, or making simple meals. The majority of the social-care workforce are unqualified people, typically earning the minimum wage and working for private care provider companies. Irrespective of the place of employment, the working practices of both qualified nurses and social-care staff are bound by caring and compassionate values, which are accorded a central place as quality markers in current UK health and welfare reforms. The Francis Report and the UK Care Quality Commission, though, highlight concerns about systemic care “failings” and declining compassion. Since publication of these reports, much of the professional nursing research and commentary has focused on understanding care and compassion within the existing framework of healthcare. However, there is little discussion about how neoliberalism itself may be the root of any “compassion failure” in nursing. Chapter 2 by Christine Ceci, Jeannette Pols, and Mary Ellen Purkis is a manifesto for “new nursing studies.” The authors argue that their notions of new nursing studies is intended to both challenge and build nursing knowledge as ways of thinking and studying nursing that highlight the difficulties, for example, of evidence-based movements that claim to have answers to the challenges of practice. It is the authors’ contention that the practices constituting nursing have not been taken nearly seriously enough – and this is especially so in explicitly theoretical writings. This chapter is not about theory of and for nursing. Instead, Ceci et al. articulate an approach to nursing as a set of empirical practices that occur in organizational contexts. Practices inform, and are informed by, those organizational contexts. By taking the study of practices seriously, we are able to think deliberately about the practices that constitute nursing, to theorize them in ways that can strengthen those practices and thus, to be able to talk about practices on their own terms. The authors want to encourage good practices to travel outside of the very particular circumstances where they exist and to make practice better in other locations. In Chapter 3, Hartmut Remmers discusses the ethical aporia between care and justice that characterize care professions. The main focus of this chapter is the ethical self-image of caring professions, in particular, the nursing profession. Principle-based ethics of nursing or medicine (such as respect for autonomy, beneficence/non-maleficence, and justice) play an important role in solving clinical problems. However, when questions that involve more than clinical aspects of practice are concerned, principle-based ethics must make way for meta-ethical considerations. The main concern is how to define a particular overarching ethics specifically for caring professions that is able to consistently justify aspects like the emotional attention that nurses are to provide to others. Using the work of Habermas, Foucault, and L8vinas, Remmers develops a the-

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oretical approach that is able to grasp multidimensional perspectives by using historical and theoretical approaches informed by sociological and psychological theories. Remmer’s main assumption for this endeavour is that both the moral orientation of a person as well as that of institutions, which guarantees the functioning of a given society, undergoes continuous change. L8vinas’ approach is fruitful with regards to professional (human-centered) services in the realm of motivational anchoring. It does, however, seem to fall short of two universal standards: respecting a biographically unique history of subjectivation and the creation of fair conditions, in which such biographically unique subjectivation can be realized. To accomplish this, a perspective that ensures distance from affective conditions is needed. Heiner Friesacher’s contribution in Chapter 4 starts from the assumption that the goals of emancipation and political maturity [Mündigkeit] have not been taken up in nursing theories so far. This is surprising because nursing practice takes place in the context of asymmetrical power relations, structures of domination, and conflicts of interests. In nursing, understood as a field of action, the interaction with human life has become increasingly problematic through scientification particularly of the natural sciences, technological processes, and processes of economization. This development actually makes a fundamental, theoretically based, critical perspective in nursing necessary. Friesacher argues for the need for a justified and explicated specific form of critique, which is understood here as an immanent critique (in the form of an ideological critique), whose norms are already immanent in nursing practice, although in a deficient and distorted manner. Friesacher bases his critical theory of the science of nursing on that of critical theory from the Frankfurt School, particularly the most recent on corporality [Leib]. These philosophical-theoretical approaches enable both a critique of the economization of care and the conceptualization of a “normative and profound” definition of nursing action. In chapter 5, Thomas Foth, Kim Lauzier, and Katrin Atweiler critically discuss the concept of recognition developed by critical theorist Axel Honneth and introduced in nursing sciences as a critical perspective on current transformation of healthcare systems. They use the case of Brian Sinclair, a Canadian of aboriginal descent, who died in an emergency room because nurses did not “see” him. Honneth would claim that the nurses failed to recognize, or they misrecognized, Brian Sinclair. However, the authors attempt to demonstrate that Honneth is trapped in a paradox, because even if, as he contends, recognition is extended to all humans, a theoretical pre-condition still exists that excludes a large proportion of people who fall outside the boundaries of being recognizable – those who are unrecognizable. There will always be a remainder or a region of the unrecognizable; even if the parameters of granting recognition are expanded, this region is preserved and extended accordingly. And, as the authors

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contend, recognition is based on power that differentiates, which explicitly and implicitly produces forms of inequality and which will always be reactivated in the process of extending recognition. The authors therefore conclude that recognition, understood through Honneth, cannot avoid mechanisms of inclusion and exclusion. Chapter 6 by Dawn Freshwater and Jane Cahill situates professional responsibility as a potential site of meaning construction for nurses in the development of their professional identity. Their line of argument is directed towards the interrogation of professional responsibility, as this is understood by embodied professionals working in particular clinical contexts. Specifically, the chapter works towards the deconstruction of the dominant model of professional responsibility, which supports practitioners to engage with technological expertise and their cyborgic desires, while maintaining a commitment to provide compassionate and responsive care respectful of patients’ autonomy. Freshwater and Cahill highlight that technical expertise, which aids in decision making, is sometimes perceived as contributing to efficiency, certainty, and rationalization through a logical step-by-step approach to the diagnosis, assessment, and management of a clinical problem. They contend that the translation and implications of technological aids to decision making in relation to professional responsibility in nursing is as yet an under-explored area. In chapter 7, Manfred Hülsken-Giesler introduces the concept of mimesis as a potential core concept for nursing practice. He argues that the scientification of nursing and the gain in empirical knowledge that comes with it provide growing possibilities of interpretation for a broader and general understanding of health problems. However, individual and situational experiences of sickness can barely be accessed through evidence-based findings. Individual experiences cannot be completely generalized and must be evaluated anew in every case in order to access the meaning of the situation for the patient and to draw professional conclusions. The goal here is not to identify seemingly objective facts in the form of nursing diagnoses but to access the immediate experience of the other in order to take their interpretation of their own illness as a starting point for initiating support. It is this reference to the experience of care receivers that legitimizes care work as professional work. With chapter 8 the focus of the book turns slightly turn away from questions around nursing theory and ethics towards nursing education. Gary Rolfe suggests in his chapter that, from the outset of the reflective practice movement, nurse educators and researchers have recognized that any challenges to the dominant technical rational epistemology pose a substantive threat to their own hegemonic power, position, and practice. They have therefore sought, either tacitly or explicitly, to suppress the radical promise of reflective practice by presenting reflection as merely another technical rational tool under their own

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control. Rolfe argues that, if it is to present a serious and sustained challenge to the dominant technical rational approach to nursing, the reflective practice movement must develop a sound epistemological framework. He offers certain elements of Jürgen Habermas’ critical theorist philosophy for consideration, and concludes by exploring the parallels between Habermas’ attempts to develop a reflexive response to positivism and Schön’s call for an anti-positivist epistemology of practice to counter technical rationality. In chapter 9, Ulrike Greb develops a specific didactic using the work of Adorno and other German critical theorists. She claims that within the context of societal contradictions, professional nursing actions are characterized by processes of alienation, corporal [leiblich] proximity, and horizons of uncertainties that require a negative didactic. This didactic, based on theoretical assumptions of education, aims to dissolve static categorical thinking through reflective thinking processes and initiates the potential for vivid experiences and constellational thinking. A structural grid developed for nursing education provided a set of criteria for her didactic with which she proposes a concept of education [Bildung] specifically modified for the profession. Comparable to the broad education [Bildungsbegriff] in didactics in general, this concept could become the pedagogical standard for academic didactics and for the development of curricula in schools. This chapter will explore both the concept’s theoretical foundation and its potential for pragmatic action. With the contribution by historian Susanne Kreutzer in chapter 10, the book takes another shift. Kreutzer contends that in current discussions in nursing studies, historical aspects play at most a marginal role. At the same time, (implicit) ideas on the development of their own profession have been substantially influencing the self-understanding of contemporary healthcare professionals. One of the common assumptions is an understanding that modernization processes in nursing have a positive connotation, that they are part of a history of progress. Certain developments and structures are deemed “normal” and are turned into standards of societal progress; deviations from the norm and resistance against reform processes can be presented as backwardness. For that reason, the alarming effects of modernization processes in nursing are systematically concealed. Kreutzer analyzes the rationalization of nursing through the example of Protestant deaconess motherhouses in West Germany and the US at a time when hospital care was increasingly becoming more specialized, scientific, economical, and technical. In the last chapter of this collection, Pawel Krol undertakes a theoretical examination of the issues that the Canadian province of Quebec’s euthanasia legislation, Medical Aid in Dying (MAID), raise for end-of-life nursing. MAID may seem to be a straightforward medical intervention to provide relief to people

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experiencing unbearable suffering at the end of life. However, as implemented in Quebec, the practice is to be governed by a purely normative deontology patterned on laws in Europe, where the contexts and practice of medicine and nursing are vastly different. Given the particularly instrumentalized healthcare environment in Quebec, breaches of professional conduct are liable to occur. In Quebec and in most of North America, healthcare systems have been compelled to adopt unprecedented measures of austerity, bureaucratization, technocratization, and commodification. These oppressive systems, as Nietzsche foresaw over a century ago, have given rise to the reification of the human body and spirit as a locus for domination and experimentation inspired by the cult of progress and governed by hegemonic narratives of pure logic and of control, both physical and mental.

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Habermas, J. (2001). The postnational constellation: Political essays (M. Pensky, Trans.). Cambridge: The MIT Press. Hall, S. (2011). The neo-liberal revolution. Cultural Studies, 25(6), 728. Hampe, M. (2009). Wissenschaft und Kritik. Einige historische Beobachtungen. In R. Jeaggi & T.Wesche (Eds.), Was ist Kritik? (pp.353–370). Frankfurt a.M.: Suhrkamp. Harvey, D. (2007). A brief history of neoliberalism. New York, NY: Oxford University Press. Holmes, D. & O’Byrne, P. (2012). Resisting the Violence of Stratification: Imperialism, War Machines and the Evidence-based Movement. In A. Broom & J. Adams (Eds), Evidence Based Healthcare in Context: Critical Social Science Perspectives (pp. 43–58). Aldershot: Ashgate. Horkheimer, M. (1974). Notizen 1950–1969 und Dämmerung. Frankfurt a.M.: Fischer. Horkheimer, M. (1974). Zur Kritik der instrumentellen Vernunft. Frankfurt a.M.: Fischer. (Original work published as Eclipse of Reason, 1947, New York, Oxford University Press) Horkheimer, M. (1985). Verantwortung und Studium. In M. Horkheimer, Gesammelte Schriften (Vol. 8). Frankfurt a.M.: Fischer. (Original work published 1954) Horkheimer, M. (1988). Materialismus und Moral. In M. Horkheimer, Gesammelte Schriften (Vol. 3). Frankfurt a.M.: Fischer. (Original work published 1933) Horkheimer, M. (1988). Zum Problem der Wahrheit. In M. Horkheimer, Gesammelte Schriften (Vol. 3). Frankfurt a.M.: Fischer. (Original work published 1935) Horkheimer, M. (1988). Der neueste Angriff auf die Metaphysik. In M. Horkheimer, Gesammelte Schriften (Vo. 4). Frankfurt a.M.: Fischer. (Original work published 1937) Horkheimer, M. (1988). Traditionelle und kritische Theorie. In M. Horkheimer, Gesammelte Schriften (Vol. 4). Frankfurt a.M.: Fischer. (Original work published 1937) Horkheimer, M., & Adorno, T. W. (1972). Dialectic of enlightenment. New York: Seabury Press. Jaeggi, R., & Wesche, T. (Eds.). (2009). Was ist Kritik? [What is Critique?]. Frankfurt a.M.: Suhrkamp. Jessop, B. (1995). The regulation approach, governance and post-Fordism: Alternative perspectives on economic and political change? Economy and Society, 24(3), 307–333. doi:10.1080/03085149500000013. Landwehr, A. (2012). Die Kunst, sich nicht allzu sicher zu sein. Möglichkeiten kritischer Geschichtsschreibung. Werkstatt Geschichte, 21(2), 7–14. Lemke, T. (2001). ‘The birth of bio-politics’: Michel Foucault’s lecture at the College de France on neo-liberal governmentality. Economy and Society, 30(2), 207. Lemke, T. (2007). An indigestible meal? Foucault, governmentality and state theory. Distinktion, 8 (2), 43–64. http://dx.doi.org/10.1080/1600910X.2007.9672946. Lorey, I. (2015). The government of the precarious: An introduction. In I. Lorey (Ed.), State of insecurity: Government of the precarious. London: Verso. Marin, A. (2010). The LHIN spin: Investigation into the Hamilton Niagara Haldimand Brant Local Health Integration Network’s use of community engagement in its decisionmaking processes. Retrieved from Ottawa: https://www.ombudsman.on.ca/Files/site media/Documents/Investigations/SORT Investigations/The-LHIN-Spin-EN.pdf. Meehan, E. (2003). From government to governance, civic participation and ‘new politics’: The context of potential opportunities for the better representation of women. Occa-

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sional papers. Center of Advancement of Women in Politics, School of Politics and International Studies. Belfast: Queen’s University. Mirowski, P. (2015). Postface: Defining neoliberalism. In P. Mirowski & D. Plehwe (Eds.), The road from Mont-PHlerin. The making of the neoliberal thought collective (pp. 417–457). Cambridge: Harvard University Press. Ontario Health Coalition. (2015a). Code red: Ontario’s hospital cuts crisis. Retrieved from http://www.ontariohealthcoalition.ca/wp-content/uploads/Code-Red-Report-on-Hos pital-Cuts-final-for-print1.pdf. Ontario Health Coalition. (2015b). Niagara health system under threat: A study of published documents for the Ontario Health Coalition. Retrieved from http://www.ontar iohealthcoalition.ca/wp-content/uploads/Niagara-Health-System-Lister-report-final. pdf. Ontario Health Coaltion. (2016). Ontario health coalition summary and analysis of Minister of Health’s white paper on health care reform. Retrieved from http://www.ontar iohealthcoalition.ca/index.php/ontario-health-coalition-summary-analysis-of-minis ter-of-healths-white-paper-on-health-care-reform/. Peck, J. (2010). Construction of Neoliberal Reason. New York: Oxford University Press. Ptak, R. (2015). Neoliberalism in Germany : Revisiting the ordoliberal foundations of the social market economy. In P. Mirowski & D. Plehwe (Eds.), The Road from MontPHlerin. The making of the neoliberal thought collective (pp. 98–139). Cambridge: Harvard University Press. RanciHre, J. (2013). Does democracy mean something? (S. Corcoram, Trans.). In J. RanciHre (Ed.), Dissensus: On politics and aesthetics. London: Bloomsbury. Rankin, J. M., & Campbell, M. L. (2006). Managing to Nurse. Inside Canada’s Health Care Reform. Rhodes, R. A. W. (1996). The new governance: Governing without government. Political Studies, 44, 667. Rose, N. (2005). Powers of freedom: Reframing political thought. Cambridge: Cambridge University Press. Scott, J. W. (2007). History-writing as critique. In K. Jenkins, S. Morgan, & A. Munslow (Eds.), Manifestos for history (pp. 19–39). Abingdon, Oxon: Routledge. Stedman Jones, D. (2012). Masters of the universe: Hayek, Friedman, and the birth of neoliberal politics. Princeton & Oxford: Princeton University Press. Walters, W. (2004). Some crtitical notes on “governance.” Studies in Political Economy, 73, 26–47.

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Chapter One: Neoliberal Demolition of the NHS: Challenges of Caring in a Corporate Culture

Introduction The National Health Service (NHS) celebrated its 65th birthday in 2013. While politicians cut celebratory ribbons and theoretical cake, they were also busy cutting the lifelines that make the service viable. Ceaseless scare stories; never-ending costly reorganizations; rampant commercialization and privatization; and the deliberate loading of unsustainable debt onto hospital balance sheets: these acts are killing the NHS. (Mendoza, 2015, p. 28)

This chapter explores the challenges of upholding the caring values of nursing within an increasingly corporatized health economy. The discussion of ideas around nursing research, education, and practice in a neoliberal climate has its origin in a narrative review conducted by the authors, exploring how core conditions of caring professions might be better embedded in clinical practice and education (Flynn & Mercer, 2013). Values and behaviours expected of health and social-care staff are enshrined in the UK’s NHS Constitution (Department of Health [DoH], 2012a). In UK health services, social care is that which is provided to the elderly, people living with long-term health conditions, and those needing rehabilitative care who are living in their own homes and who meet the criteria to qualify for the allocation of a personal social care budget from the state. These budgets can only be used for the purchase of essential support in everyday activities such as getting up and going to bed, washing, dressing, or making simple meals. The majority of the social-care workforce is unqualified, typically earning the minimum wage and employed by private “care provider” companies. Irrespective of the place of employment, the working practices of both qualified nurses and social-care staff are bound by caring and compassionate values, which are accorded a central place as quality markers in current UK health and welfare reforms. The Francis Report (DoH, 2013a) and the UK Care Quality Commission (CQC, 2011), though, highlight concerns about systemic care

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“failings” and declining compassion. Since publication of these reports, much of the professional nursing research and commentary has focused on understanding care and compassion within the existing framework of healthcare. However, there is little discussion about how neoliberalism itself may be the root of any “compassion failure” in nursing. The findings of our review of national and international research evidence and professional discourse suggest that the professional curriculum, role modelling, and work environment exert an impact on caring values and behaviours, but no studies were found which directly explored relations between healthcare policy, organizational structures and professional behaviours. Most reported research concerned medical, nursing, or patient and service-user experiences of care and compassion. From this literature, the authors identified social and cultural factors influencing health and social care, and critical discussion in this chapter focuses on exploring how core values can be embedded, and maintained, in an atmosphere of tension between the ideals of socialized healthcare and the forces of marketization in the context of a changing political and economic landscape. Values and behaviours expected of UK nurses and health and social-care professionals are embodied in the NHS Constitution (DoH, 2012a), where compassion, empathy, dignity, and respect are increasingly viewed as core elements of quality services within current UK policy (Coventry, 2006; DoH, 2006; DoH, 2010; DoH, 2011; Gallagher, 2004; Hoy, Wagner & Hall, 2007). It has also been suggested that declining care standards and negative patient experiences mean there is a need for nurses to re-establish kindness, caring, and compassion as fundamental professional values (Bradshaw, 2011; Peate, 2012; Straughair, 2012a; Straughair, 2012b). Caring has always been the central tenet of nursing, and in the UK health service the concept of nursing care and compassion is currently at the forefront of professional and political debate. The publication of the Francis Report (DoH, 2013a), Keogh Report (DoH, 2013b) and articulation of nursing’s “6Cs” (caring, compassion, competence, communication, courage, and commitment) by the Office of the Chief Nurse (DoH, 2012b), have reemphasized the centrality of compassionate care in nursing practice. As a result, much nursing enquiry and debate focuses on defining, understanding, teaching, and practicing compassionate care (Derbyshire & McKenna, 2013; Hayter, 2013; Horsburg & Ross, 2013; Maben, 2014; McCaffrey & McConnell, 2015; Paley, 2014). However, concepts which are central to the notion of compassionate services are not easily defined, and the professional literature reveals a body of health and social-care discourse and research findings centred on identifying how these key values are understood and operationalized by both care providers and the public. It has been suggested that social dignity is fundamental to humanity itself

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(Bramley & Matiti, 2014; Crawford, Brown, Kvangarsnes, & Gilbert, 2014; Jacobson, 2007), and that good nursing and healthcare practice is about much more than the sum of knowledge regarding disease and its treatment (RCP, 2005). Hopkins, Loeb and Fick (2009) posited that responsiveness of health and social-care professionals to non-medical expectations is what imbues healthcare experiences with the essential values that shape a compassionate service. In this context, Mercer (2015), in an illness narrative, challenged the conventional distinction between service provider and service user, inviting an exploration of the capillary power relations (Foucault, 1977) that permeate institutional healthcare interests.

Understanding Care and Compassion in an “Evidence Based” Health Service The notion of compassion in healthcare has been described as an abstract concept with both individual affective attributes and a social dimension (Alma & Smalling, 2006; Gallagher, 2004; Griffin-Heslin, 2008). It has also been argued that compassion is more than a singular characteristic and is more properly conceptualized as the product of relationships, cultures, and healthcare environments (Baillie, 2009; Spandler & Stickley, 2011). In the case of nursing, this “environment” consists of nursing research, education, and practice, all of which serve to construct the discourse around what constitutes care and compassion. Within nursing, a dominant narrative that permeates all aspects of nursing and healthcare policy is that of “evidence-based practice” (EBP), which itself holds a contentious position within the profession. There has been considerable debate about what constitutes appropriate evidence for nursing practice, how legitimacy is conferred on different sources of nursing knowledge, and what influence the prevailing political climate exerts on nursing research, education, and practice (Holmes, Perron, & O’Byrne, 2006; Murray, Holmes, & Rail, 2008; Murray, Holmes, Perron, & Rail, 2007; Porter & O’Halloran, 2009; Rolfe, 2005; Rolfe & Gardner, 2006; Rolfe, Segrott, & Jordan, 2008). It has been argued that the drive toward EBP in nursing has compromised care (Murray et al., 2007), and been suggested that nurse policy makers, educators, and practitioners may be guilty of uncritical “bandwagon jumping” in pursuit of an evidence base for nursing (Holmes et al., 2006). In this context, it is easy to see the potential for tensions to arise between individual nurses seeking to deliver compassionate care and wider professional and healthcare cultures (Jacobson, 2009). Modern health professionals are required to have a range of medico-technical

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competencies alongside caring attributes (Goethals, Gastmans, & de Casterle, 2010), and it may be the case that these fundamental values are being directly challenged by current economic and political influences on care provision (Faith, 2012).While the UK health and social-care environment is focused on the provision of evidence-based services (DoH, 2010), it could be argued that the drive to EBP is actually enacted at the cost of compassion in care. It may be the case that the socialization of nurses into the “real world” of service delivery creates a dissonance between their inherent values and the environment in which they work (Baillie, Ford, Gallagher, & Wainright, 2009; Curtis, Horton, & Smith, 2012; Jacobsen & Sorlie, 2010; Maben, Latter, & Clark, 2006; McSherry, Pearce, Grimwood, & McSherry, 2012; Wear & Zarconi, 2008). Georges (2011) boldly asserted that the “euphemism” of evidence-based healthcare is masking a depersonalization of core nursing values, resulting in a deficit of compassion. Professional nursing research has attempted to explore the meaning of these core values to those involved in both the delivery and receipt of healthcare, and to measure how these values impact on care behaviours and experiences (Baillie, 2009; Baillie & Gallagher, 2011; Baillie et al, 2009; Burhans & Alligood, 2010; Chadwick, 2012; Faithful & Hunt, 2005; Goodchild, Skinner, & Parkin, 2005; Heijkenskjold, Ekstedt, & Lindwall, 2010; Hoy et al., 2007; Matiti, Cotrel-Gibbons, & Teasdale, 2007; Matiti & Trorey, 2008; Santen & Hemphill, 2011; Walsh & Kowanko, 2002; Woogara, 2005; Woolhead et al., 2006). While there is some consistency in the way patients, service-users, and care professionals conceptualize “core caring values,” it is debatable whether appropriate and reliable measures of compassionate care exist (Pedersen, 2008; Whitehead & Wheeler, 2008; Yu & Kirk, 2008). In a climate of evidence-based health services, outcome measures assume considerable significance, and in the UK there is now a politically driven movement toward NHS Trusts and health professional groups demonstrating the mechanisms by which they ensure compassion, empathy, dignity, and respect in service delivery. With a neoliberal philosophy driving the marketization of an “evidence-based” UK NHS, these metrics will almost inevitably be used to determine future funding and resource allocation to care providers. It could be argued that, in the absence of any meaningful outcome measures for core caring values, one way of ensuring compassionate services is through the recruitment and training of health and social-care professionals who embrace these values as those which define their professional identity. Some research has suggested that individuals with appropriate values can be identified and recruited to professional education and training (Lumb & Vail, 2004; Lumsden, Bore, Millar, Jack, & Powis, 2005; Sellman, 2011).Yet, the socialization of health and social-care practitioners is also known to be influenced by experience, culture, and role modelling, and a considerable body of medical and

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nursing research suggests that professional programs do not prepare health and social-care students to be compassionate practitioners. Studies have shown that training programs themselves have an effect on core values, which can be both positive and negative (Cordingley, Hyde, Peters, Vernon, & Bundy, 2007; Cunico, Sartori, Marogoli, & Meneghini, 2012; Goldie, Schwartz, McConnachie, & Morrison, 2003; Johnston , Cupples, McGlade, & Steele, 2011; McKenna et al., 2011; Murphy, Jones, Edwards, James, & Mayer, 2009; Nunes, Williams, Bidyadhar, & Stevenson, 2011; Quince, Parker, Wood, & Benson, 2011; O’Neill, Owen, McArdle, & Duffy, 2006; O’Sullivan & Toohey, 2008; Ward, Cody, Schaal, & Hojat, 2012). There is also debate about whether or not core values can be taught, and it has been suggested that positive role modelling and innovative approaches to professional education are needed to ensure a caring and compassionate workforce (Alligood, 2010; Burhans & Warmington, 2010; Derbyshire & McKenna, 2013; McLean, 2012; MacLeod & McPherson, 2007; Smajdor, Stockl, & Salter, 2012; Wear & Zarconi, 2007). In this context, it is important that commissioners and providers of health professional education have an understanding of the means by which core professional nursing values and behaviours can be embedded and sustained within educational programmes that utilize practice placements as part of clinical learning experiences (Mercer, Kenworthy, & Pierce-Hays, 2016, in press). The discussion which follows in the rest of this chapter has its origins in a commissioned review of the national and international evidence base, which was designed to identify discrete themes in published research literature to facilitate understanding of individual, social, or organizational factors that have been found to influence the caring values and behaviours of health and social-care professionals. While recognizing the limitations of the research method and evidence as a politically legitimate source of professional knowledge, we nonetheless applied the methodological procedures of a narrative review to the project. This review method facilitates a structured and rigorous search of library databases and reference lists, and through the application of inclusion and exclusion criteria enables reviewers to identify research reports and other literature which will help address the review question. Key findings and concepts can then be extracted from papers eligible for inclusion in the review, and made subject to thematic analysis, synthesis, and interpretation. While both systematic and narrative review methods primarily seek to interpret research findings, we hold the position that legitimate nursing knowledge encompasses expert experiential knowledge, thought, and opinion, alongside those ideas which are amenable to testing in some way. We, therefore, deliberately included professional discursive papers as evidence to inform our review and our thinking. The review encompassed the international literature for all years from

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2001–2012, as this time frame acknowledged the first publication of the UK Essence of Care (DoH, 2001) benchmarks, and allowed the inclusion of any publications or research reported in response to media interest on the topic of care and compassion. Due to the time constraints of the project it was not feasible to translate any discursive papers or research reported in a language other than English. Studies were deemed eligible for inclusion if published between January 2001 and July 2012 (inclusive), were written in English, related to caring values and behaviours as defined in the NHS Constitution, and were either reporting a research study or were a professional discussion paper. Narrative synthesis of 177 research reports and discursive papers indicated that while individual and socio-cultural factors could be associated with key values and behaviours, there was little evidence to identify influential organizational or ideological factors. It is acknowledged that while this review study focused exclusively on the application of research findings to the UK NHS system of care delivery, international data is not without relevance to the issues; indeed, regardless of the organizational provision of healthcare, the concerns and questions hint at a bigger global problem.

Critical Narrative Review of Findings It is interesting to note that research has tended to focus on individuals and their experiences, with little direct attention to the impact of organizational factors on the values and behaviours of those who work within institutions. In the current climate of care delivery and service reform, this may be a worthwhile avenue for further enquiry. It is perhaps not surprising that the bulk of the research, both nationally and internationally, has focused on the medical and nursing professions and the experiences of those who use healthcare services. However, in a health and social-care system that depends on multi-disciplinary teamwork, the lack of research from social work and the allied health professions may be a concern. Key themes from the analysis of included papers are outlined below, and the review findings do suggest that there may be some utility in rationalizing curricula so that they are more congruent with dominant socio-cultural values and the wider expectations of health and social care. The evidence was derived from a wide range of disciplines including nursing, medicine, dentistry, and dietetics. Respondents/participants in these studies were students, qualified staff, carers, and service users, though in many of the articles the recipient of care is referred to as a “patient.” In part, this reflects the clinical context of the research(er) but, importantly, it also signals the importance of language in constructing accounts and identities, rather than merely describing events (Burr, 2003). In this sense, the data/findings can be under-

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stood as part of a set of discourses that “talk” about human qualities, interactions, and experiences. When these are enacted as discursive practices, they texture the cultural repertoires of healthcare “truth” (Smith, 2007; Springer & Clinton, 2015). Like research, language can never be a neutral category. It is ideologically situated and transmits personal, professional, and political values (Fairclough, 2001; Potter & Wetherell, 1987). Empirical evidence reviewed for this study was diverse in terms of both professional knowledge(s) and methodological orientation. In general terms, though, the issues that constructed the review question and project aims had resonance for healthcare providers, patients, and service-users in other advanced industrial societies (Wear & Zarconi, 2008; Woolhead et al., 2006). It is this social, political, and economic context that frames the narrative analysis of scholarly papers included in our review. Three emergent themes, elaborated below, focused on: power and (dis)empowerment; language, self, and systems; and context and culture.

Power and (dis)empowerment Power is a central concept in understanding the findings of health research accessed in the study, yet it is not a concept that received a good deal of critical attention in the individual papers. Not untypically, “empowerment” is lauded as a strategic panacea for a perceived decline in levels of empathy, compassion, or dignity ; yet institutional social structures that perpetuate inequalities and discrimination such as sexism or racism remain unseen or unchallenged. Most of the healthcare staff who took part in the included studies, to varying degrees, shared common cultural capital. They trained in a university setting, received prestigious qualifications, and are ambassadors of powerful discourses and knowledge(s), which define human difference and diagnose human sickness. In contrast, the descriptor of “patient” was emblematic of cultural disenfranchisement and discrimination. In healthcare settings where poor standards of care generated concerns it is, sadly, unsurprising that residents were the elderly, mentally ill, and dying. Vulnerable individuals with diminished social worth represent fiscal expenditure rather than economic value, and are often the casualties of wider social mechanisms of exclusion and marginality. This theoretical perspective is captured in a poignant extract of data from a study by Woolhead and colleagues (2006, p. 368) which explored dignity and communication in social-care settings for the elderly : One [caregiver] came in with a list to check who had to go to the toilet. People don’t have to go to the toilet by list. They have to go when they need to. Someone asked her to

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take them. She looked at the list and said, “it’s not your turn.” That’s not treating someone with dignity.

The older person here is reduced to a “task.” Routinized management, coupled with the denial of rights and decency, transform the human being into a (dis)attended object. This account is remarkably similar to denigratory practices that Goffman (1961) referred to as degradation ceremonies and mortification of self in the moral career of the mental patient.

Language, self, and systems Ideas about the concept and construct of the “self” were central to the analysis of reviewed papers and form an intellectual backdrop to discrete findings that are reported here. It is through micro-level interactional episodes that identity is transacted and that individual worth is developed or damaged. Again, the complexity of language is a feature of talk about “dignity,” “empathy,” and “compassion.” All of the included studies noted the semantic difficulties in defining these concepts in a way that makes them amenable to measurement that is meaningful. This point is well made by Pederson (2008), who draws attention to the large number of quantitative research instruments that have been deployed to quantify empathy in medical practice, and the distance that this kind of science places between the subject and the “natural setting” of clinical encounters. Qualitative designs have been less widely used when their philosophical orientation is premised upon understanding the social actor in relation to her/his social world (Cameron, 2001). Of the work reviewed it was qualitative projects, particularly phenomenological and ethnographic studies, which offered the most illuminating insights into the “lived experience” and “cultural construction” of healthcare practice. Jacobson (2009) employed a grounded theory approach to develop a “taxonomy of dignity,” and found that violations of dignity, as the negative behaviours of healthcare staff, were characterized by specific forms of organizational relations: unequal power dynamics, rule-structured regimes, and hierarchical structures. These themes are echoed in narrative interviews from nurse and patient respondents (Walsh & Kowanko, 2002), where talk about dignity, or the abnegation of dignity, shows a considerable degree of convergence. That practitioners can easily identify violations of privacy and respect in their everyday actions, and yet refuse to surrender core values in trying circumstances (Jakobsen & Sorlie, 2010), suggests systemic factors beyond individual indifference play a significant part in the problem of declining standards of care. Indeed, examples cited as evidence of poor practice are infringements of the

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basic foundation of healthcare ethics and professional codes of practice. Such include failure to screen the bed area when washing patients; embarrassment caused by the exposure of wearing hospital gowns in public space; the use of pet names as a form of address; the discussion of confidential information during ward rounds at the bedside; and the use of patients in medical teaching sessions without their consent. Other studies (Burhans & Alligood, 2010; Heijkenskjold et al., 2010; Hoy et al., 2007) illustrate clearly that nurses and healthcare staff can easily articulate the core tenets of compassionate care. Without adopting an apologist stance for neglecting a duty to care, one has to take account of those impediments that are invoked to explain, or excuse, the compromise of professional principles.

Context and culture Recurrent themes in data from the qualitative studies drew attention to political and economic structures that organize and resource health and social-care services. Here, the accounts of professionals conveyed a disempowering discourse of frustration and disillusionment. One phrase used by several respondents to describe their experiences was “assembly-line” care. This powerful metaphor captures the endless, repetitive, and alienating drudgery of the factory-floor worker, a mechanistic division of labour where the individual is a factotum, the appendage of an industrial process over which there is no control and with which there is no engagement other than a cash-nexus relationship. In this context, people spoke about feeling remote from management teams; they were not being listened to and their complaints were ignored; they were forced to undertake routines that prioritized efficiency over care; and they were faced with a challenging mix of patients with assorted conditions and different care needs (Woogara, 2005). For Jakobsen and Sorlie (2010), these experiences and expressions cannot be understood outside of theorizing about contemporary society, where the care setting represents one sub-system of a neoliberal, market-driven, global economy in which workers have a “colonized” status. Spandler and Stickley (2011), in a critical review offer an alternative solution to environments that generate “compassion fatigue” and “burn-out.” In their analysis, compassion is neither “individual attribute,” “quick fix,” nor “technological solution.” Rather, a quality or philosophy should underpin all interventions, innovations, policies, and practices through investment in “healing cultures” and collaboration with service users (Baillie et al., 2009; Spandler & Stickley, 2011). The issues discussed above indicate why rigidly quantitative studies, though the predominant approach in this field, encounter methodological dilemmas

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and generate inconclusive data in attempting to assign numeric values to human emotions. Of the included studies that adopted a traditionally scientific model, most focused on “empathy” as a measurable trait in practitioners and students of healthcare and medical practice. Some findings, though, are of note in relation to the aims of this project. Maben et al. (2006) suggest that newly qualified nurses exit programs with appropriate values and ideals, but that the implementation of these is “sabotaged” by organizational and professional factors that manifest in bureaucratic work conflict and adherence to “covert rules.” This is similar to the idea of a hidden curriculum exerting powerful influences on the occupational socialization of medical students. Johnston et al. (2011), in a cross-sectional survey, noted a progressive decline in the “professionalism scores” of medical students on a five-year program of study. More worryingly, their anonymous free-text responses listed examples of bullying, racism, sexism, and lack of respect in discriminatory cultures that prized “teaching by humiliation.” Exploring ethical challenges faced by trainee medics, Cordingley et al. (2007) identified similar issues and suggested remedial strategies. Quantitative investigation that has addressed empathy and compassion as individual attributes and teachable skills has produced largely inconclusive findings (Cunico et al., 2012; Goodchild et al., 2005; Quince et al., 2011; Wear & Zarconi, 2008). McKenna and colleagues (2011), in a study of Australian midwives, noted that empathy levels were poor in year one, but increased across the educational program as students had greater exposure to patients. Conversely, Nunes et al. (2011) found that empathy levels declined in students from five health disciplines during the first year of training. It is interesting to situate the rationale and aims of the various research studies in a critique of the changing cultural values and political ideologies that construct healthcare services. Academic research is, typically, a response to issues that have attracted national attention, and offer funding opportunities. In the UK context, debate about a failure of the caring services to provide quality care has been informed by professional, political, and media discourses. The research response, in large part, has been to compartmentalize concerns and focus on individual traits, with the assumption that these can be measured as a guide to the recruitment, training, and retention of a new generation of healthcare workers. Instead, it might be more useful to explore the conflict between the collectivist and social welfare ideals that are enshrined in the birth of the NHS (McKeown, Mercer, & Mason, 1998) and its guiding constitution (DoH, 2012a), and the acquisitive, competitive and entrepreneurial ideology that characterizes the modernist body-politic. Bradshaw (2009, p. 465) offers an apt synopsis:

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The current market driven approaches to healthcare involve redefining care as a pale imitation, even parody, of the traditional approach of the nurse as “my brother’s keeper.” Attempts to measure such parody can only measure artificial techniques and give rise to a McDonald’s-type of nursing care rather than heartfelt care.

Concluding Remarks In ending this chapter, it is timely to return to the words and ideas of Kerry-Anne Mendoza (2015) that introduced the debate, summarizing implications for nursing practice, education, and research of the global and ideological dominance of neoliberalism. Our review revealed that irrespective of the inherent intent of individual healthcare workers, social, cultural, and organizational factors had potential to exert a damaging influence on values and behaviours. Based on the results, it would appear there is a tension between core professional values and the organizations in which health and social-care professionals operate. In the wider context of UK national health and social care it may be that policy makers, professionals, and the public need to clarify how ideals, enshrined in the NHS Constitution (DoH, 2012a), can be retained in an increasingly corporate culture of care delivery, one proceeding with legislative stealth under the auspices of the Health and Social Care Act (2012) characterized by critics as the requiem mass of the NHS. Of the studies interrogated in our review, it was in the domain of social and political science that critical analysis of healthcare and ideology dominated. In contrast, recognition of a political economy of health was obfuscated in nursing literature, despite the centrality of this issue for the profession in terms of practice, education, and research. A lengthy history of investigation that clearly demonstrates a relationship between mortality/morbidity and social class/ power (Doyal & Pennell, 1979; Townsend & Davidson, 1992) has continued into the current climate of economic crisis and savage welfare cuts with ever greater veracity (Labont8 & Stuckler, 2015; Mendoza, 2015; Stuckler & Basu, 2013), where the message is both simple and stark: austerity kills. The nursing profession, conservative by nature, can no longer take refuge in a rhetoric of care that itself is hostage to the rhetoric of centre-right politics, where emancipatory goals, foundational to the creation of the NHS (Delamothe, 2008), are being sacrificed to entrepreneurial greed (Ali, 2015). Good clinical research is essential to the provision of quality care, but no more so than uncompromising critical inquiry into the apparatus of state machinery. This context is particularly significant for clinicians, educators, and academics as the National Health Service and university sector increasingly embrace corporate models of management (Callinicos, 2010; Clarke, 2004; Davis,

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Lister, & Wrigley, 2015; Davis & Tallis, 2013). The move of nurse and allied health professional training into higher education institutions [HEIs] was celebrated as recognition of professional skills and specific bodies of knowledge, liberating students from the parochial apprenticeship style learning of nursing schools attached to large teaching hospitals and where tuition fees and training costs of undertaking a nursing or other health professional studentship were underwritten by the NHS. This made them a markedly different student population from those electing to read for traditional academic degrees, where rising tuition fees generated widespread dissent and public protest. As part of a recent UK government spending review, these costs are to be passed on to the consumer, and “market-metrics” will likely overshadow workforce planning and health professional education, prioritizing capital over caring and profit over people. In simple terms, nurse education, like the rest of the NHS, will be put up for sale and auctioned off to the highest bidder (Davis et al., 2015). The progressive global marketization of higher education (Callinicos, 2010; Goodnight, Hingstam, & Green, 2015; Lorenz, 2012,) and the public sector, accompanied by brutal cuts in welfare spending, mean that core values such as care are compromised by, or in conflict with, a larger agenda of cost, where performance management and target-driven outcomes reconstruct the central relationship between carer and client. Increasingly, there is a drive for healthcare students to gain practical experience in the private or charitable sector, propping up services that ultimately compete for public sector monies. Any health curriculum needs to address, in a way that students can understand, the politics as well as the practice of healthcare, the distinction between an ideal of healthcare as a fundamental human right, regardless of the ability to pay, and an ideology of neoliberalism that understands market forces as the basis of personal and political freedom. For those who defend socialized healthcare, the future is uncertain, but for financial speculators it undoubtedly represents an opportunity for lucrative investment. It is in the territory of this debate, rather than an obsessive desire to measure and map individual traits and qualities, that the real struggle to retain “value led nursing practice” must be enacted, ever mindful that healthcare, and healthcare practice, are part of our political and social fabric.

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Chapter Two: Privileging Practices: Manifesto for “New Nursing Studies”

Introduction The title of this book could be read as suggesting that theory and research precede practice – that research and theory have implications for practice. In this chapter we challenge this formulation by privileging practice. Rather than theory and research informing practice, we argue that how we conceive of practices, that is, how we theorize practices such as those practices recognizable as nursing – has consequences for how and why we theorize nursing and what we expect nursing research to generate. While some may argue that all nursing theories are really theories of practice, we want to differentiate our argument in this chapter from that perspective. It is our contention that the practices constituting nursing have not been taken nearly seriously enough – and this is especially so in explicitly theoretical writings. This chapter is not about theory of and for nursing. Instead, we articulate an approach to nursing as a set of empirical practices that occur in organizational contexts. Practices inform, and are informed by, those organizational contexts. The approach we take here is that, by taking the study of practices seriously, we are able to think deliberately about the practices that constitute nursing, to theorize them in ways that can strengthen those practices and thus, are able to talk about practices on their own terms. By doing so, we endeavour to encourage good practices to travel outside of the very particular circumstances where we find them to make practice better in other locations. We begin with a brief example that is a description of nursing practice recently published in a local newspaper. The context behind the story is the recent rise in deaths associated with the drug fentanyl, which is a synthetic analgesic approximately 100 times more potent than morphine and 50 times more potent than heroin. Police and health authorities have tracked the increase in accessibility of this drug to illegal imports from Asia to Canada’s west coast. The nurse 1 Each of the authors contributed equally to the writing of this chapter.

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whose practice is described in this story works as a street nurse in Victoria, British Columbia, a mid-sized city on Canada’s west coast. [Sage] Thomas carries a kitbag with nursing supplies ranging from over-the-counter painkillers and antacids to clean syringes and crack-cocaine pipes, along with the opioid-antidote naloxone – the injectable lifesaver for overdoses of painkillers such as fentanyl. “My week was full and intriguing and wonderful,” Thomas said on a recent Friday evening in August, sounding anything but worn out. “Always an adventure. I love my job.” Some people might wonder how it can be rewarding to seek out unpredictable people affected by severe poverty, mental illness and addictions. “I really get to know people on a very human level and they are all incredible people,” she said. “One hundred percent have had a lot of trauma, but it totally blows me away to see the strength and resiliency they embody.” The majority of her clients are homeless, while others are at risk of being evicted. “It’s a matter of keeping an eye on them, learning the places they hang out, their favourite parks and getting to know the people who know them – in case they don’t show up.” “I’m in touch with people who historically have a very damaged relationship with health care and society, and I put the onus on health care and society [for that],” Thomas said. “And our team is about bundling relationships and trust. We work with folks with no expectation that they will quit [using drugs.] Wherever they’re at, we support them.” (Dedyna, 2015, emphasis added)

What’s going on here in this example of nursing practice? Sage Thomas is engaged in forms of nursing practice that are distinct from the location of the vast majority of nursing work in hospitals. She does not wear a white uniform. She does not monitor her patients with telemetry, nor do her patients seek her assistance by pressing a call bell. In fact, it seems that even that very basic relationship between nurse and patient is reversed in this example: rather than being drawn away from work with patients by a ringing bell from elsewhere on the nursing ward, this nurse spends her day tracking patients down, searching for them in familiar places, and, when they are not found there, drawing on the knowledge of other members of the street community to try to find them. What is the best way to think about this as an example of nursing practice? Many elements in the preceding example might be considered examples of practice. We could have pointed to her account of her week, that it was “full and intriguing and wonderful.” We could have pointed to her account about the way her team works by “bundling relationships and trust.” Instead, we have highlighted her method for finding patients: “It’s a matter of keeping an eye on them, learning the places they hang out, their favourite parks and getting to know the people who know them – in case they don’t show up.” Why is this section of the story the focus of a chapter that seeks to illustrate an approach to theorizing practice? The reason is both simple and complex: The statements attributed to the

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nurse in the newspaper article and reproduced in the preceding paragraph are accounts of a practice that are thoroughly interpenetrated by theories of work (“full and intriguing and wonderful” – a theory of work that stands in contrast to “drudgery” and therefore does the journalistic work necessary in the article to mark this nurse as heroic), and theories of psychology (“bundling relationships and trust” – this description of practice is so abstract that it effectively conceals any actions taken by the team). By contrast, the italicized section offers examples of actions engaged in by the nurse to accomplish her work in this unique practice setting. Upon first reading this account of nursing, we wondered where this individual learned to nurse in this way and in this place. It is unlikely that she was taught about finding patients in need of healthcare in parks and back alleys in any of her nursing courses. But she will have learned other things about caring for patients – and we read in this example an instance of a nurse adapting that learning to the particular circumstances she works in. There is something underway here that leads her to practice in this particular way in this particular place. It is our contention that it is possible to consider these actions as practices that are useful in this work setting and therefore to theorize the practice of nursing in this setting.

“New Nursing Studies” We are interested in outlining an approach to the study of nursing and its constitutive practices that privileges a dynamic rendering of nursing-in-process – a becoming-nursing. The use of this language, taken from the work of nurse philosopher John Drummond (2002, 2004), underlines an approach to “knowing nursing” that is at once philosophical and empirical. To figure nursing as an open event (Drummond, 2002) entails recognition that its enactments continuously emerge and are yet-to-emerge, that nursing practices are distinguished by contingency rather than determinacy. And yet, at the same time as we work to hold nursing open, as nurses and as researchers we are called to account for specific enactments of nursing, to offer empirically grounded analyses of “what is going on.” To attend to what is going on and at the same time, keep the event of nursing open, clearly requires a view of practice (and practitioners) more fulsome than one which suggests that nursing is (or should be) the rational application of a stock of knowledge to nursing situations (perhaps most familiar to nurses in the articulation of the “nursing process”). Against this static, scripted, and highly individualistic understanding, we draw on a more recursive understanding, taking nursing practice to be an unfolding activity situated in a collective social and material world (Palsson, 1994). We have placed “new nursing studies” in quotations to try to mark this

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approach to studying the dynamism of nursing practice, not necessarily to claim that what we are proposing here is entirely new. Indeed, as is indicated by examples of this sort of work we point to later in the chapter, some scholars have taken similar approaches to the study of nursing practice. Our effort here is to try to gather those approaches together under the name of “new nursing studies” to encourage the rise of an intellectual movement. Thinking nursing in this way is intended to keep the event of nursing open, recognizing its contingencies and differences, resisting the seduction of limits, and ensuring the work of thinking nursing has an open future (Drummond, 2002). Can “new nursing studies” develop knowledge to answer the critical questions how can we do what is best and how can we know if it is best? Current theories of nursing have tended to profess and claim territory, territory associated with particular knowledge (for example, knowledge derived from nursing theory or from evaluations of practice that generate “evidence” that, it is argued, drives nursing “interventions”) and locations (for example, hospitals, communities, homes, residential care settings) in an effort to form and bolster the profession as an outcome of research. This tendency to shift focus away from specific practices over to outcomes has been noted by scholars both inside nursing (see Wainwright, 2000) as well as outside the profession (see Mol, Moser, & Pols, 2010). Speaking specifically of practices of care, Mol, Moser, and Pols (2010) credited nursing theory with starting a scholarly conversation about care (p. 7). However, tracing the path taken up within conventional nursing studies, they noted, “analysts of nursing care, while exploring how (care) was organized as ‘women’s work,’ argued that, for all that, nursing needed to be understood as a real profession. Rather than a criticism, this was a claim – in pursuit of power” (p. 9). So, instead of engaging in a detailed criticism of how the practices of nurses were being interpreted to inform and advance the profession, it is our contention that a concern for examining practices has been set aside by nursing scholars. Our aim is to re-institute a concern for practice in a way that keeps the practices and their effects in our view and available for study on their own terms in order to provide tools for reflecting and improving on them. Awell-known example from nursing history of the distinction we seek to draw out here will illustrate our point. In the nursing literature of the late 1980s and throughout the 1990s, an emphasis on the concept of health promotion emerged in which a position was advanced, perhaps most notably by Nola Pender (1982), that there was a strong alignment between the goals of health promotion and those underlying the educational preparation of nurses. Pender’s position exemplified a claim in pursuit of power. Health promotion was, for Pender and many of her contemporaries, a unifying goal for nursing, and in this way, a powerful claim on territory that could be used to advance nursing’s pro-

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fessionalizing efforts. But while the explicit goal was for nursing to occupy and lead the practice of health promotion, associated practices were rarely the subject of research (Purkis, 1997), and subsequent theories of health promotion have been primarily prescriptive rather than descriptive (Whitehead, 2011). In 2009, Wilhelmsson and Lindberg interviewed district nurses working across a range of jurisdictions in Sweden. They sought a purposeful sample of nurses who had experience in what nurses self-identified as “health promotion work” (p. 157). Despite this self-identification as a prerequisite for participation in the research project, these nurses described “indistinctness” as a key barrier in their efforts to prioritize health promotion in their everyday practice. One nurse was reported as stating: I’d like to know exactly what the [district nurse’s] job description is; that’s something we’ve always wondered about and don’t think it’s clear. How many functions are we supposed to be able to do? We take care of all of the patients. You can look in any book you like from the National Board of Health and Welfare, there’s no description of our functions. A more detailed description is needed (p. 161, emphasis added).

It is curious to us that a practice, introduced into nursing almost 40 years ago, a practice that some argue is synonymous with nursing, continues to be experienced by these practicing nurses as something they are deeply unclear about. They wonder, when asked by researchers about their health promotion work, if what they do in the name of health promotion is accountable on those terms. The interviewee recorded here seems confident that she and her colleagues “take care of all of the patients.” Yet she is not sure whether the care they provide would be accepted as legitimate by those who ask them to incorporate health promotion into their practice. It is important to note here that the lack of clarity about what health promotion practice is does not stop these nurses from practicing. In its preoccupation with the professionalizing agenda for nursing, attention to practices was set aside as though they were not important. As a result, health promotion remains overdetermined and under-theorized and completely unavailable to these nurses to provide an account of their work with the people they care for. In advancing “new nursing studies,” we wish to return our gaze to the practices of nursing that have always been there, available for study, for debate and for interpretation. “New nursing studies” seeks to create and protect a space where the practices that nurses enact in all their diverse locales can be put into words in order to “help to make the specificities of (nursing) practices travel” (Mol, Moser, & Pols, 2010, p. 10). This articulation of the specificities of practices is not prescriptive but suggestive (Pols, 2015); practices are talked about, shared and examined for their use and effectiveness in other circumstances and in other care locations.

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What is it that is done by nurses, and how may their local dealings with particular problems be of use elsewhere? What, for instance, can Sage Thomas’s practice learn from other practices – or what can her practice inspire for others? If we think about her practice context, we could imagine that a practice concerned with clean syringes and harm reduction rather than care aimed at curing addiction can learn from, or inspire care for, people with chronic diseases, or suggest good ways to manage practices of reaching out to patients rather than always expecting patients to come to the nurse. Many of the intricacies in nursing practices are these local responses to specific problems. But what is learned in one place tends not to travel to other practices. For example, in her study of the uses and effects of telecare technologies for people with chronic diseases, one of us (JP) learned that “reaching out” to care for symptoms is not an uncomplicated good (Pols, 2015, p. 83). As in Thomas’s practice, some people may value “being connected,” and welcome professional surveillance of potential harms, but there are situations where increased control by professionals does not give people opportunities to develop their own practical knowledge (p. 87). So, while research on effects of telecare devices is piling up, we are still largely in the dark about how nurses put these devices to use, what problems they encounter in doing so, how they work around these problems, and in what terms they evaluate the results and the reshaping of their care practices. It is this type of knowledge we attempt to make transportable in “new nursing studies,” even though it may not be possible to grasp it in statistical generalizations or predictions on probabilities. Our interest is in articulating and creating new sensitivities that are relevant for care practices, and that may create practical and moral suggestions for practices in other locales and under different circumstances. We argue for an approach to the study of nursing as myriad practices that cannot assume fixed identities or fixed intentions, but rather takes up nursing as comprised of practices influenced and shaped by the forces within which they are enacted, day-by-day, moment-by-moment. Why? Because nursing, practice, and care are all complex and contested activities – we cannot take any of them for granted. Contested practices such as these, left unexamined and unspoken, risk being “squeezed” (Mol, Moser, & Pols, 2010, p. 11) into a straightjacket of methods that cannot articulate care practices on their own terms. As we advance this work, we work within the challenges posed by a portrayal of nursing as innumerable “instances.” These instances are each unique in their expression on one side, as well as being shaped by the organizing limits of language on the other side. These limits can be imposed with care and sensitivity to “tame” all that uniqueness in order to show how practices in one setting might well learn from or inspire practices within quite different settings. Our aim will be not to point to such alignments as obvious instances of where nursing might

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claim territory, but rather to figure nursing as an open event by noticing such patterns, asking questions about what characterizes such patterns and whether they might be theorized as nursing. It is in this way that we seek to undermine and challenge the long-held view that practices emerge unproblematically from abstract theory. “New nursing studies” looks to practice first and foremost in order to theorize nursing.

Nursing: A Polyvalent Profession As noted above, commonalities among specific enactments of nursing certainly do exist. But these may be at a high level of abstraction (i. e., nurses “care for all the patients”), suggesting that any specific nursing practice gathers together a range of elements, including its material practices, to constitute itself as something we then call nursing. We take the notion of care practice as a loose concept to direct analysts towards actual situations and events where people, together with their artifacts and ways of understanding the world, aim for improving or stabilizing the situation of the people or things cared for. Care practices have a normative orientation towards some kind of good that needs to be specified by such empirical analysis. Nurses evaluate their actions and adapt them if they judge necessary. They tinker, as it is called in care studies (Mol, Moser, & Pols, 2010) or are concerned about their practices (Latour, 2004; Puig de la Bellacasa, 2011). Care practices is also a loose notion because it is possible to trace elements to different places with which they have relations. As noted previously, the sociality of practices is given from the outset; to be in a practice means to actively and knowledgeably engage an environment constituted in and by persons, relations, materialities, and discourses (Palsson, 1994). The work of care is dispersed in this collective of people and things (Winance, 2010). This understanding has the practical effect of decentering the nurse, the patient, or even the nurse-patient dyad, shifting attention to the relational networks that comprise everyday life. Struhkamp (2005) described this well in her analysis of what is involved in caring about patients’ autonomy through something as apparently straightforward as food choices. On one level, patients are offered menus through which they make selections. But for this to work, one must also consider the organization of meals in institutional settings – the trays, the food trolleys, the kitchen staff, the unit routines, the convenience of preparing certain food items – a whole set of material practices that make a choice possible. Some decisions depend on capacity, but “things” help make eating well more possible or easier. Decisions by themselves, like individualistic models of practice, are not enough. The privileging of this understanding of practice in studies of nursing is not

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unknown, but it is not a dominant way of proceeding within the academy. Instead, nursing history has been characterized by struggles to define nursing, or to propose one unifying and correct theory for nursing, struggles through which we would argue that scholars have failed to attend to or take care of the multiplicity of ways the event of nursing continuously emerges. We see in this widespread desire to curtail diversities associated with multiple practices a related tendency, which is to treat nursing as a matter of fact. This problem we will explore by drawing again on the work of John Drummond (2002, 2004), and extending his insights through the use of Bruno Latour’s (2004, 2005) differentiation of matters of fact from matters of concern. We begin with Drummond’s conceptualization of polyvalence as it relates to nursing. Across many of his essays, Drummond’s concern was the same: he was against dogmatic images of thought in nursing and wanted to draw us to the practices of nurses as a matter of concern. In an essay exploring the place of the humanities in nursing, Drummond (2004) reflected on theories of the avantgarde, late nineteenth- and early twentieth-century artists and writers concerned with what they saw as an increasing techno-rationalism in society and the displacement of the arts and humanities from the social world. To be clear, Drummond did not argue that avant-garde theory is a theory for nursing, but rather used the concerns of these authors to think through the conditions – political, economic, and cultural – through which the avant-garde emerged. Drummond then linked these to the problem of what appears to be an increasingly disembedded rationality constituting the limits of nursing today. And there is plenty of evidence for Drummond’s concern. For example, Rudge (2013) recently analyzed nurses’ enrolment in “quality improvement projects” such as the “Productive Ward,” where good care is tied to reducing “wasted time” and sold to nurses as “releasing time to care.” What interests Rudge is how nurses have been drawn into this preoccupation with productivity, (cost)effectiveness and efficiency, and more specifically, to accept and work hard for what has come to count as productivity in healthcare settings, a concept lifted from the manufacturing sector. Notable is the ease with which economic discourses and industrial processes are incorporated into care practices, valued by nurses as a means to recapture consistency and reliability in an increasingly turbulent work environment, albeit without the sources of this turbulence – austerity measures and changing workforce characteristics – either named or addressed. But, as Rudge observed, the appearance of a smooth running system is all important: “the ward sails like a swan (all surface beauty and serenity) while the tools (those ugly legs) work frantically under the water” (p. 208; see also Rudge, 2011). In this, nursing is an object to be manipulated like any other – limited, determinant and bound tightly to a narrow conception of “good” practice.

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It is with a view of this sort of practice context that Drummond (2004) made what he described as “four modest observations,” questions or issues that he suggested nursing will need to return to again and again. Nursing continually returns to these issues not because, or not simply because, they are irresolvable, but because somehow thinking through these observations is essential to scholarship; we return to these questions “with a force of purpose” (p. 528), needing to revisit these concerns each time, in a different way. Drummond’s observation most relevant to this discussion is that “nursing is a polyvalent profession” (p. 528). Polyvalence refers to the combining power of elements, and for Drummond, nursing is polyvalent insofar as its enactments “stretch across a continuum where the discourse practice at one end of the continuum may bear little epistemic relation or resemblance to the discourse practice at the other end” (p. 529). The Swedish nurses asked to account for their practices of health promotion represent an example of such polyvalence. In most contexts, having the quality of polyvalence is understood as a strength, a capacity to gather together a range of elements to constitute something novel. The same could be said for nursing, with the notion of polyvalence recognizing that any specific instance of practice is new, gathering together a range of elements to constitute itself – nursing, so figured, retains an open future. However, against this useful notion of polyvalence, we have years of effort by managers, administrators, and educators to form the nurse and the practice itself in a uniform way to meet the demands of the day (Ceci, Purkis & Wynn, forthcoming) and, as noted earlier, a near total disregard on the part of researchers to treat practices seriously and to develop research strategies that centre practice. As is aptly demonstrated by Rudge’s (2013) analysis, Drummond’s (2004) attention to the concern expressed by avant-garde writers as to how to proceed in an uncertain world, one where nurses’ practices have become increasingly instrumental and rationalized, is not misplaced. As he frequently observed, failing to recognize the nature of the practice lends itself to closure in thought, rather than to the (necessary) struggle to get things right. Closure is also the effect of efforts to treat nursing as a “matter of fact.” These efforts are ongoing and forceful, taking up a great deal of nursing energy, and yet have mostly been in vain because, we argue, nursing is not actually a matter of fact; nursing is a “matter of concern.” What is the distinction? Here we draw on Latour (2004) to extend and consolidate Drummond’s reflections on polyvalence. Most simply, matters of fact are objects that have been disconnected from the web of associations and relations that enable their existence. In Latour’s (2004, 2005) account, the first thing to understand is that the world is not actually made up of matters of fact. Matters of fact come, so to speak, after the fact. And though they represent much work on the part of human beings (or more accurately, on

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the part of assemblages of human and non-human actors), they are also, suggested Latour, “a poor proxy of experience and of experimentation … a confusing bundle of polemics, of epistemology, of modernist politics” (2004, p. 245). Latimer’s (1998) work on the complex translational processes of nursing assessment, which is often treated as if it were a relatively straightforward and objective procedure, provides a good example of this. Latimer suggested that most often assessment is treated primarily as an episodic, cognitive activity ; patients’ needs are given and nurses simply read the signs, the “facts.” Instead she found that assessment practices are continuous, situated, and skilled, with patients’ needs organizing and organized by the context, as well as requiring a context in which they can be viewed, all bearing little resemblance to the fivestep nursing process that most students are taught, and through which nursing itself and patients’ needs emerge as tight, contained matters of fact. The idea that there are objects “out there,” in this case, patient needs that are simply waiting to be discovered, reflects an attitude of modernity where the human subject is set over and above the world, retaining for him or herself the principles of agency, action, and will and assuming for all other entities a mere background status. It is this attitude or centring of the human subject that enables a division, creating an “out there” which we then come to “know” through our particular knowledge practices. Matters of fact thus emerge apparently naturally from our knowledge practices, but significantly, they tell us more about how we can know than about what is there. As Pyyhtinen and Tamminen (2011) observed, if we only try to explain action and events with reference to an intentionality and will located in the human mind, we will not be able to explain very much. We end up muddling the question “What is there?, with the question, How do we know it?” (Latour, 2004, p. 244). It is not, then, that matters of fact are simply made up or that they are not real, but rather that they represent a partial and polemical understanding of experience; reality is not exhausted by matters of fact (Latour, 2004, p. 232). As he wrote, it is not that we should dispense with matters of fact, but rather, he suggested, we need to treat them more carefully by making sure that the diversity of agencies is “not prematurely closed by one hegemonic version of one kind of matter of fact claiming to be what is present in experience” (2005, p. 118). In Latour’s (2004) analysis, matters of fact are objects whereas matters of concern are things. This distinction is both crucial and liberating for thinking nursing. An object, a word that is derived from the Latin, meaning “to throw,” is only ever a partial rendering of a matter of concern. Things or matters of concern, on the other hand, may be understood as gatherings, the meaning of the word “thing” being rooted in Old English, Norse, and Icelandic languages and referring to a meeting, council, or assembly. For Latour, the difference is clear : “things that gather cannot be thrown at you like an object” (2004, p. 232).

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Though it is a problem of modernity that objects have become how we deal with things, with matters of concern the relation remains fluid: objects or matters of fact may become things again, and matters of concern may become objects. And, of course, things that are things may be recognized as things again; this way of returning objects to the practices from which they come and in which they figure is our hope for nursing. Although not from nursing, one startling visual example from Latour (2004) may help to clarify this point. In 2003, at the point of lift off and through its long journey, the space shuttle Columbia existed as a matter of fact. When it disintegrated at the point of its re-entry into the earth’s atmosphere, it suddenly and tragically became a matter of concern. It was reconnected to the web of associations that made it possible, violently returned back into the structural conditions of its own production, and it became necessary to examine the assemblages that had made its existence possible (Latour, 2005, p. 175). We were, as Latour observed, “offered a unique window into the number of things that have to participate in the gathering of an object” (p. 235). Efforts to turn nursing into a matter of fact, an object, have become so commonplace we hardly ever remark upon them anymore. John Drummond was one who did not let these go but continually brought our attention to the emergence of these objects, the mechanisms of their effect and the implications for nursing as a matter of concern (2001). Quality of care, for example, a matter of concern in which facts, values, politics, actions, people, and institutional routines gather of necessity, is increasingly read primarily as an object with programs of quality improvement, and outcome specifications becoming the sites of production of something called quality of care. The silencing of the event of quality of care, its emergence as “real” only to the extent that we might efficiently track and measure it, loosens its status as a desirable ideal, something that we might tensively strive for and experience in innumerable ways. And it is not that quality of care as a matter of fact, an object, is not real or significant, but that it is a partial and political conflation of the numbers of participants that are gathered in the thing – quality of care – to make it exist. We see this in our own work, in the response to the gathering of what it is to care for a family member with dementia. For all sorts of reasons, family caregivers, and their health and ability to keep going, are a matter of concern to governments and health systems. Yet from all the beliefs, values, institutions, routines, actors, and material worlds that of necessity gather here, the question of what we can do is too often answered by the production of a new object, in this case, a tool to measure caregiver burden that is capable only of affirming a specific and limited understanding. In this object, caring for a family member with dementia is a burden, one that may be assessed and measured and alleviated with episodic interventions or applications of care. Yet, at the same time, while it

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seems obvious that tools that measure care burden are a “poor rendering of what is given in the experience” (Latour, 2005, p. 244), these objects stand as seemingly transparent carriers of the experience, now defined by inputs and outputs disconnected from how they have been made (Purkis & Ceci, 2015). Our task is not to simply debunk these objects, to demonstrate their inadequacies, but rather to gather, to show, as Latour suggested, “how many participants are gathered in a thing to make it exist and to maintain its existence” (2004, p. 246, emphasis in original). Our critical task is to reconnect care burden, quality of care, health promotion, the nursing process and the like back to their webs of associations, to allow things to become things again by relating them to the practices in which they are assembled. As Latour (2005) argued, this is the important ethical, scientific, and political point: when we shift our attention to the worlds of matters of concern we challenge the indifference to reality that accompanies treating the world, treating nursing, as a matter of fact.

Articulating “Good” Nursing Practices “New nursing studies” focuses then on descriptions arising out of close observations of nurses as they engage in their practice and compares such practices across contexts in an effort to articulate the values and concerns of nurses. In raising the notion of “values” here, we want to distinguish our approach in the “new nursing studies” from that of principle-based ethics, commonly used in medical ethics, and the normative stance taken in care ethics literature (e. g. Tronto, 1993). We do not seek to apply a normative definition of “care,” for instance, and show how instances of practice either measure up or fall short. To do so “positions care practices in the world of facts, to which ethics and morality are added from the outside” (Pols, 2015, p. 82). Rather, we advance an approach here that Pols (2015) has described as an “empirical ethics of care” (p. 82) that articulates the forms of the good that participants cherish or attempt to bring into being, to gather, in their practices. An example will illustrate our direction. Recall the description of nursing practice described at the beginning of this chapter. Nurse Sage Thomas’s practice was described as “keeping an eye on [her patients], learning the places they hang out, their favourite parks and getting to know the people who know them – in case they don’t show up.” This description clearly shows that Sage Thomas is not in need of external guidelines, regulations, or normative frameworks, but that her practice has a fine-grained normativity to make her care practice “good.” Now, let’s look at an example of nursing practice described by Davina Allen (2015) in her recent book. In this example, Allen describes the work of nurse Maureen who works on a surgical unit as a ward coordinator.

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Maureen has just completed processing a newly admitted patient and inserts the various assessment tools, care plans and record forms into the patient’s file. She places the medication chart prominently on the nurses’ station and affixes to it a note requesting that the doctor prescribe night sedation which, she has established, the patient usually takes to help her sleep. Maureen removes a sheet of paper from her pocket, unfolds it and scrutinizes the content. It is a list of all patients on the unit; for each a complex set of symbols denotes the current status of their care. Some of these inscriptions are in blue, some in red. The latter is information Maureen has added, having attended the ward round earlier. It is her practice to colour code her entries so she can identify readily new developments to be passed on to the person responsible. Several issues now have been attended to: the junior doctor has prescribed medication for the patients going home tomorrow; the discharge letters for the community nursing service are prepared and the receptionist has been instructed to arrange out-patient appointments. Maureen ticks off these items on her sheet and glances at the clock. There is just enough time to telephone the social worker to check the progress of Mr. White’s home care arrangements before she must leave for the morning meeting to discuss the bed state. All today’s discharges are going ahead, but she knows the elective admissions are likely to remain on hold as there are patients in the Emergency Unit who require beds. She hopes she will not have to take patients for whom another service is responsible, as the work of organizing care for “outliers” is more difficult, but she accepts that this obligation is sometimes necessary. (Allen, 2015, p. 2)

It would seem that these two descriptions of nursing practice could not be more different from one another : one describes care in the community, the other on a busy, modern surgical ward; one describes the nurse as being in search of people who may require her assistance, the other describes the actions required by a particular nurse whose job it is to get patients in, and then out of hospital again, as quickly and as efficiently as possible. Yet rather than being distracted by the differences between these examples of practice, we could instead examine these practices in a more symmetrical (Latour, 1987) way. While the practices are different, both descriptions of practice point to the matters of concern that organize the work of these nurses. For nurse Sage, her gaze is characterized by a wide-scale view of the community. Her patients could be anywhere, though she knows that there are particular places in the community where they tend to “hang out.” If they are not found there at times of the day that Sage has come to know as their typical pattern, she fans out her concerns to other members of the community to ascertain if those she is worried about – for instance, those she suspects might be active drug users – have been seen recently and if so, where. If she is to intervene before the deadly effects of fentanyl take their course, she needs to be constantly vigilant as to the whereabouts of these individuals. Sage’s concern appears to be the protection of her patients from the often unanticipated effects of a drug that is mistaken for other drugs of much lower potency. She cannot know if those

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patients actually have fentanyl nor where they might go to take the drug. And so she practices a form of protective vigilance while wandering the streets and parks, meeting people known to her and likely being introduced to people new to the street community. Nurse Maureen’s gaze encompasses the entire surgical unit. At the beginning of the shift, she has recorded specific bits of information about each of the admitted patients on her piece of paper. Having made rounds with other ward personnel earlier in the shift, she has added her own observations or notes about specific actions that will be required of her or others on the team over the course of the day in order to keep patients moving towards discharge. Maureen, too, practices a form of vigilance. Her worries are those that impede patients’ progress towards discharge. Maureen’s vigilance is directed towards ensuring other members of the team do their work so that all the required pieces of the puzzle are in place when a patient is ready for discharge: prescriptions and letters for the community nursing service are ready, care requirements for each discharged patient have been prepared, and out-patient appointments have been made. Everything is ready for the eventuality that the patient is deemed ready for discharge. Maureen’s gaze remains above the details of everyday care for the patients on her ward. Indeed, she orients her gaze beyond the present moment and into the near future when patients currently awaiting admission from the emergency ward will require processing, in a manner we assume would be similar to the processing she has just completed. She wonders whether or not patients who will need to be admitted to her ward are surgical patients. And even here, she does not express concern about what sort of illness the patient is experiencing but rather what different sorts of arrangements might be required by those patients she calls “outliers” in order to organize them towards discharge. What can such different forms of practice tell us about nursing? How can what is gathered in these instances recognizable as nursing tell us something about the specificities of care practices? And how can those specificities inform each other? Responding to these questions, we recognize the possibility of valuing nurse Sage’s practice over nurse Maureen’s practice. Sage’s practice seems somehow closer to patients, less bureaucratic, more humane perhaps. But to make such judgments is to remain in matters of fact (e. g. proximity to patients, professional attire, tools used to engage in practice) rather than where matters of concern are privileged. How might “new nursing” take up these very different descriptions of practice and enable us to articulate “good” practice in ways that allow those descriptions to travel to other practice settings and possibly inform “good” practice there?

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Aesthetics and Nursing Practices In order to perform “good” (another loose concept that needs empirical substantiation) nursing studies we need tools and vocabulary that allow us to empirically discover and theoretically discuss more varied types of goodness than “principles” only. With the social sciences leaving normativity either to medical ethics to suggest rules and guidelines, or to translate it into measurements and outcome evidence, there are not many tools to articulate the intricacies of nursing practices. What different types of values and goods are important for nursing? How do these motivate people and practices? What vision of the world do they accompany? How do values organize people by creating particular kinds of generalities, or where do they make differences? When can it be good to look out for people, or even bring them crack-cocaine pipes, and when is care best shaped as having the overview? We suggest a rehabilitation and reinvention of the notion of “aesthetic values” for this work. Pols (2013) argued that aesthetic values in daily life and care are best understood as social values, referring to “what we appreciate and value in a fundamental way” or to what emerges as good in our social practices of valuing (p. 187). Aesthetics provides a vocabulary to talk about values that are not universal, but are also not completely idiosyncratic. “New nursing studies” aims to study these forms of morality, or matters of value or concern, by attending to the everyday practices through which these values emerge. In the eighteenth century and before, aesthetics described values that not only related to art, but also to daily life. Later however, the use of the term aesthetics was limited to descriptions of private matters of taste, to individual matters of virtue and the good life, or for theorizing the fine arts – thus the meaning of aesthetics became quite limited. However, restricting aesthetics to private matters of taste or private idiosyncrasies ignores the social and cultural practices in which such valuing emerges. Clearly relating aesthetics only to the arts is of limited use to nursing practice; however, we suggest that studying how nurses and others engage in the social activity of valuing is critical. What are the values that emerge in care practices, and how are they influenced by situations, technologies, and research practices? What values lead to what kinds of care practices? What values do nurses care for? These questions need empirical specifications and theoretical reflections. We conclude by returning to our critical questions: how can we do what is best? And how can we know if it is best? The answer is that there will never be a final answer, nor a statistical certainty. Nurses will have to keep tinkering, evaluating their actions in ever differing situations where they seek to care. These nursing practices can be cared for in turn by research that is sensitive to what is of value within these practices, hence creating new sensitivities that help

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reflect both on connections to other practices, and to see where improvements could be made. This is the aesthetic task we suggest for “new nursing studies.”

References Allen, D. (2015). The invisible work of nurses: Hospitals, organisation and healthcare. Abingdon, Oxon: Routledge. Dedyna, K. (2015, September 8). Street nurse says her job is “always an adventure.” Retrieved from http://www.timescolonist.com. Drummond, J. (2001). Petits differends: A reflection on aspects of Lyotard’s philosophy for quality of care. Nursing Philosophy, 2, 224–233. Drummond, J. (2002). Freedom to roam: A Deleuzian overture for the concept of care in nursing. Nursing Philosophy, 3, 222–233. Drummond, J. (2004). Nursing and the avant-garde. International Journal of Nursing Studies, 41, 525–533. Latimer, J. (1998). Organizing context: Nurses’ assessments of older people in an acute medical unit. Nursing Inquiry, 5, 43–57. Latour, B. (2005). Reassembling the social: An introduction to actor-network-theory. New York, NY: Oxford University Press. Latour, B. (2004). Why has critique run out of steam? From matters of fact to matters of concern. Critical Inquiry, 30, 225–248. Mol, A., Moser, I., & Pols, J. (2010). Care: Putting practice into theory. In A. Mol, I. Moser, & J. Pols (Eds.), Care in practice: On tinkering in clinics, homes and farms (pp. 7–25). Bielefeld: Transcript. Palsson, G. (1994). Enskilment at sea. Man (New Series), 29, 901–927. Pender, N. (1982). Health promotion in nursing practice. Norwalk, CT: Appleton-CenturyCrofts. Pols, J. (2015). Towards an empirical ethics in care: Relations with technologies in health care. Medicine, Health Care and Philosophy, 18, 81–90. Puig de la Bellacasa, M. (2011). Matters of care in technoscience: Assembling neglected things. Social Studies of Science, 41, 85–106. Purkis, M. E. (1997). The “social determinants” of practice? A critical analysis of the discourse of health promotion. Canadian Journal of Nursing Research, 29(1), 47–62. Purkis, M. E., & Ceci, C. (2015). Problematizing care burden research. Ageing & Society, 35, 1410–1428. Pyyhtinen, O., & Tamminen, S. (2011). We have never been only human: Foucault and Latour on the question of the anthropos. Anthropological Theory, 11, 135–152. Rudge, T. (2013). Desiring productivity : Nary a wasted moment, never a missed step! Nursing Philosophy, 14, 201–211. Rudge, T. (2011). The ‘well-run’ system and its antimonies. Nursing Philosophy, 12, 167–176. Struhkamp, R. (2005). Patient autonomy : A view from the kitchen. Medicine, Health Care and Philosophy 8, 105–114.

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Tronto, J. (1993). Moral boundaries: A political argument for an ethic of care. New York, NY: Routledge. Wainwright, P. (2000). Towards an aesthetics of nursing. Journal of Advanced Nursing, 32, 750–756. Whitehead, D. (2011). Health promotion in nursing: A Derridean discourse analysis. Health Promotion International, 26(1), 117–127. Wilhelmsson, S., & Lindberg, M. (2009). Health promotion: Facilitators and barriers perceived by district nurses. International Journal of Nursing Practice, 15(3), 156–163.

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Chapter Three: Care: Existential Assets and Nonpartisan Justice. On Several Ethical Aporiae of Care Professions (Translation by Thomas Foth)

Introduction The main focus of this chapter is the ethical self-image of caring professions, in particular, the nursing profession. Principle-based ethics of nursing or medicine (such as respect for autonomy, beneficence/non-maleficence, and justice) play an important role in solving clinical problems. However, when questions that involve more than clinical aspects of practice are concerned, principle-based ethics must make way for meta-ethical considerations. The main concern is how to define a particular overarching ethics specifically for caring professions that is able to consistently justify aspects like the emotional attention that nurses are to provide to others [Zuwendung]. Meta-ethical justifications, or universal principles, encompass a diversity of perspectives. We will develop a theoretical approach that is able to grasp these perspectives by using historical and theoretical approaches informed by sociological and psychological theories. One of our main assumptions for this endeavor is that both the moral orientation of a person as well as that of institutions, which guarantees the functioning of a given society, undergoes continuous change. For a sociologist, this fact is related to the classical question of stasis and dynamism. Their dialectical relationship becomes apparent if one wants to make an assumption about continuous change, for in order to be able to measure change there must be a component that is still part of this change and yet removed from it. This component is permanent, or substantial, and necessary for change to be measured (cf. Adorno, 1995). Furthermore, this dialectical relationship also demonstrates the significance of an anthropological argument to which we will turn later. If we look back on societal developments of approximately the last 150 years we can characterize their consequences for nursing as profound transformations in professional self-conception, in the attitudes that inform nursing actions, in the way nursing care services are delivered, and in the institutions in which

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healthcare takes place. Healthcare professions thus respond to the transformation of the societal context. These changes affect mainly the roles that society ascribes to these professions. We emphasize professional roles because they are constituted out of the definition and perception of care. They are morally coded and guarantee the direction professionals (or professions) should take and the societal expectations of them in the care system. Any social change effects a change in moral codes that in turn influences the definition of care. In this context the contradictory and tension-laden relationship between stasis and dynamism is of particular interest. Since the 1960s and 70s, significant changes in the socio-moral basis of life have taken place. These changes, characteristic primarily of Western industrialized countries, have been described as a shift in values, with a growing importance given to claims of self-determination, equality, and justice in a climate of increasing permissiveness that has been accompanied by a loss of attachment to traditional values (Inglehart, 1977). A consistent trend, associated with economic change, consists of individualizing one’s range of options amid a pluralizing of lifestyles and preferences (Beck, 1992). This change also has repercussions on the ethical self-image of the profession, and the question emerges, can a core of nursing care actions be assumed despite the change in societal values? In other words, to what extent is it possible to relate to an invariantly important quasi-anthropological fundamental fact of human life in the sense of a basic human experience, which would be highly significant for an ethical basic understanding ? (Joas, 2000).1 What is meant here is that, despite enormous improvements in living conditions, at some point in their lives humans unavoidably find themselves in a critical situation with a need for acute or chronic care. Situations of care are characterized by non-symmetrical relationships with a typical imbalance of power, in contrast to average normal daily life and its typically symmetrical conditions of interaction. These contexts raise the ethically relevant question of whose moral perspectives, influences, and dispositions are the basis for not only the perception of the need for care, but also how the caregiver personally experiences the obligation to provide care as a moral requirement. Professionally employed caregivers are bound, by the tenets of their profession, to provide care. At the same time, led by their personal value systems and through their choice of profession, these professionals are also intrinsically drawn to taking on such roles. We therefore assume that the (morally-coded) perception of an obligation to provide care is supported emotionally and meets the deeply anchored motivational resources of the professional care provider’s personality and emo1 For a critical analysis on questions of philosophical anthropology see Horkheimer (1935). He contested the assumption that there is a uniform definition of human, because human fate has been extraordinarily varied up to now.

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tional life.2 In care situations, the expectation of reciprocity that occurs in everyday life is suspended for a one-sided, pure, unconditionally personal involvement with the expectation of only a symbolic thanks at most, if at all. We will discuss later this non-reciprocal structure of relationships, understood as a social foundation of care, using L8vinas’ concept of ethics. We will now briefly focus on the socio-historical changes of moral consciousness and its impact on the self-image of caring professions. As is commonly known, social modernization processes have led to the splitting of the moral orientation of good and just that was formerly perceived as unified, and in doing so society has been divided into two gender-specific spheres of social life. Historical research on ethics has demonstrated that the institutional differentiation of bourgeois society has led to the good life being considered as exclusively restricted to the private sphere of the household, with its intimate familiarity and its expectations and obligations. Only in the liberal conception of the public sphere, which is strictly segregated from the private sphere of the household, are human subjects recognized as autonomous persons and general imperatives regarding common justice respected and followed regardless of the person. In contrast, the private sphere of the family functions as the space where fundamental conditions of human life are attended to, meaning that the vital and emotional needs of individuals are fulfilled. It is in the private sphere of the family where ascribed gender specific reproductive work is performed. The most important aspect of this structural differentiation is that individual emotional needs cannot be fulfilled by generalizing the needs of a universal autonomous subject. This structural difference leads to a social environment that is thus characterized by asymmetrical commitments and empathy for the distinctiveness of a concrete Other. In this social form, moral-emotional values such as love, compassion, empathy, and solidarity, all of which have been historically represented as feminine characteristics, prove to be important for the functioning of society. Only by recognizing these emotionally charged values can a guarantee be provided that morally relevant conflicts, which require decisions that have an impact on the lives of others, can be adequately judged if one takes into consideration an individual’s biographical peculiarities, as the social philosopher Benhabib (1995) emphasized. Furthermore, the gender-specific distribution of emotionally laden moral values correlates to the distribution of socially necessary work – in other words, a gendered division of labour. The question that emerges is how these moral orientations, that from very early on in the history of our societies have become part of a socially secured and legally protected private sphere, can effectively be used as a moral orientation for professions that act outside of the private sphere but are organized around the 2 Joas (2000) refers here to a core of human experience.

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ideas of care and help. The emotional correlates of these moral orientations must be transformed into personal dispositions and ultimately, on a cognitive dimension, be institutionalized as moral obligations. Internalization of these values usually takes place through habituation, which is part of an individual’s primary socialization, and transcends into a tertiary professional socialization. It thus follows that the aim of socialization into care professions is determined by the fact that the affective “trigger conditions” of caring behaviour must be morally coded. Once this is achieved, socialization becomes independent of those emotionally intensive attitudes, preferences, and values that characterize intimate familial situations. Certainly, the ability to respond professionally to the need for care requires the highly personal participation of an individual if only to comply with the imperative that the need has to be recognized in the first place. Generally speaking, this form of professionalism only emerges if the professional simultaneously feels completely and intrinsically motivated by morally normed triggers. These motivational foundations are constituted to a large extent by the professional’s moral attitudes, values, and personal traits. This is why professional actors are able to perceive the vulnerability of those in need of care and become personally affected by their neediness of care. Several questions thus arise: what is the motivational basis of caring interventions, to what extent has this motivational basis been influenced and changed through societal transformation and the social-moral transformations that go with it, and finally, to what extent will institutional changes make the ambivalent character of this motivational basis more apparent? Engaging with certain aspects discussed by Michel Foucault, we will explore the contradictory institutionalized instrumentalization of care within the context of relationships of power.

An Ethics of Care Preliminary conceptual outlines The basic concept of an ethics of care, which is in no way limited to the professional connotation of caring, is multilayered and diverse. Important components of this concept are: human dependency on others as conditio humana (cf. esp. Conradi, 2001), reliability (Käppeli, 2004), appreciation and awareness (Conradi, 2001), responsibility on different levels of social action implying opportunities to shape politics (Tronto, 1993). A basic anthropological assumption of care states that humans can only acquire those skills or competencies necessary for autonomous action and the ability to articulate one’s own needs if they have experienced personal affection and attention themselves (Conradi, 2010, p. 98). Therefore, the concept of care must not be understood merely as

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clinical nursing practice. Even differentiating care from the concept of cure does not really advance our understanding. This is because care is a practice directly linked to the reproductive functions of human life worlds, transcending individual horizons to the political. And political action opens up potential for individuals to build communities enabled through care as a conditio sine qua non (Tronto, 1993; Watters & Johnson, 2008). The consequences of these formational tasks of community building [Gestaltungsaufgaben],which can reach even to the level of international politics (Conradi, 2010; Held, 2005) must reflect ethical thinking in all their facets. Despite the fact that an ethics of care leads to political consequences, meaning that it provides an ethical foundation of actions in the forming of a community [Gestaltungskonsequenzen], the core concern of such an ethics is about the fundamental anthropological condition that persons in need of care are wishing to maintain their personal autonomy [Lebenspraxis] as far as possible. However, it would be a misunderstanding if an ethics of care is conceptualized as the programmatic counterpart to an ethics of rights and obligations of morally accountable individuals (Pauer-Studer, 2006, p. 353). An ethics of care and its corresponding key concepts (such as human dependency, responsibility, reliability, mindfulness, mutual appreciation, living in relationships), is similar to the concerns and basic ideas of an ethics of human prosperity [Gedeihen], wellbeing, and success [Gelingen]. These aspects are associated with individual rights, entitlement to social goods, and the removal of “conditions of serious suffering” (Siep, 2004, esp. pp. 19–56, quotation p. 43; cf. also Remmers & Kohlen, 2010), an ethics of preservation and protection of those conditions of human life that cannot be disregarded. It includes not only the biological conditions that safeguard life, but also those social conditions that foster cooperation, a basic necessity of human life (Dabrock, 2003). The need and the ability to cooperate transcend the mere natural reproduction of life and must be considered as a basic condition for the higher development of human capacities and their organization in life forms that are unburdened of both immediate existential forces [Daseinszwängen] and the uncertainties of external powers of nature [Naturmächte]. Freedom gained in this way does not annul the fundamental dependency of humans on social community, which is based on the need for cooperation. Under these (anthropological) conditions, an ethics of care can also be understood as a relational ethics (Leist, 2005) because of the irrefutable need for support and care. This rough outline of an ethics of care should not be equated with an ethics for caring professions, or professional ethics. The specific relevance of an ethics of care is that it establishes specific perspectives of perception and judgment that are based on the continuous vulnerability and neediness of human beings, from which follows a particular responsibility to provide care, protection, and ad-

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vocacy. In contrast, a universalistic ethics, which deals with rationale issues of legitimate rights, uses neutralized perspectives of perception and judgment that are immunized against practical and concrete interactional relationships. Meanwhile, clinical studies highlight the extent to which the perception of problems and the definition of personal responsibilities are determined by the specific relationships to the affected person and therefore this dimension must be reflected. For instance, due to their close proximity to patients, nurses often consider what an affected person worries about, wants, or would even reject – a very different approach compared to that of doctors (Kohlen, 2009). Therefore, one should consider the extent to which principle-based ethics fall short analytically due to idealized assumptions. Above all, they cannot provide access to what the affected person subjectively considers relevant (i. e., What is important? What is authentic? What makes sense?) This dimension can only be grasped through a person’s subjective and biographic narrative (cf. Kohlen, 2009). In what follows, we will continue our discussion in more depth on the conceptual foundations of an ethics of care. Initially, we will ignore what could be called care policy concepts that provide a critique of society and power (Tronto, 1993). These concepts have been developed especially in the Anglo-American context. However, we will take them up again in our discussion of Foucault.

Contact and interaction: Aspects of medical anthropology We defined care as a particular human practice that was closely associated with biological as well as social reproduction. A more precise meaning requires close attention to the concept of care and to the response to the question of the social, psychological – and what we will deal with more specifically– the corporal [leiblich] constitution of human beings. The term corporality [Leiblichkeit] is more than an idealistic Cartesian abstraction, in the sense of the body as object. With respect to the concept of care, it means more the specific qualitative characteristics of corporality that require special attention, such as the quality of touch with its physical associations – the recurring, cyclical processes of needs, but also those inevitable external and internal perceptible traces of ageing, and eventually, the unavoidable, irrevocable extinguishment of death. Hence, the question is about the relevant relationships of humans with themselves and with the nature of their external and internal living environment. Medical-anthropologist Victor von Weizsäcker (1987a),3 realized that medi3 Victor von Weizsäcker (1886–1957), neurologist and doctor of psychosomatic medicine, was greatly influenced by the consolidation of scientific and humanistic perspectives on patients

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cine, reduced to a natural science based on experiments and aiming to provide merely a diagnosis, was devastatingly limited. He tried to “introduce the subject” in medicine by attempting to involve patients and their biographies as subjects, with the intent to establish how they experienced illness and loss during an inevitable “metamorphosis of life.” By introducing the concept of the subject into medicine, he developed an “interpretive term of the pathological,” thus opening up queries into the meaning of an illness for the person, of the “biographical meaning” of suffering (Weizsäcker, 1987b, p. 366). Patricia Benner (1994), too, argued from a nursing standpoint that subjects not only suffer from a disease, but also from the life changes associated with it, which she often described as a serious biographical, partly tragic rift, leading equally to an epistemological extension of the concept of illness (Remmers, 2014). The concept of medical anthropology also transforms the understanding of therapy, which, to a certain extent, means being released from the fetters of a “forced role of impact obligation [Bewirken-Müssens]” (Jacobi, 1996, p. 146) opening medicine towards a broader understanding of care. Thus, even therapeutic aims change; they are seen as enabling, as supporting of remaining or hidden potential (maieutics), but also as a reorganization of the biographical situation of the patient (restitutio ad integrum). Faced with increasing chronic, degenerative, incurable diseases, a biographical orientation should become more important for treatment methods, which also take into account the characteristic courses of diseases (Corbin & Strauss, 1988). Weizsäcker’s concept of medical anthropology is highly significant for an ethics of care due to its epistemological and action-theoretical premises, because it requires an altered form of doctor-patient relationship – a care relationship that renders access to and addresses the “biographical meaning” of a sustained illness. The notion of “contact” [Umgang] is thus Weizsäcker’s central concept (Weizsäcker, 1987a, p. 261). However, diagnostically as well as therapeutically, effective human contact can only be obtained under the conditions of an altered relationship to nature. This relationship to nature seems new, but from a scientifically historical perspective, it is more a buried understanding of nature. The concept of contact has both a practical as well as an epistemic meaning, implying first and foremost an understanding of nature that can be traced back to Goethe, according to whom nature’s laws can only be accessed through, so to speak, clinging attitudes of epistemic awareness [anschmiegende Erkenntnishaltung].

at the Ludolf von Krehls clinic in Heidelberg. He is considered one of the founders of medical anthropology and psychosomatic medicine in Germany.

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Excursus: Alternatives of human experiences In his Bildungsroman Wilhelm Meister, Goethe had critical reservations about the emerging industrial society of his time and its signal of fundamental change in human relationships and in relationships with nature. In these changes, Goethe perceived a transformation in the concept of knowledge and in the way knowledge was constructed. He did not think that nature could be accessed by distancing the cognitive subject from it, pursuing the ideal of an impassive objectivity as in the classic experimental situation. Rather, he argued that it was important to recognize the vitality of both external and internal nature and to view the cognitive subject as a part of nature. Nature, in turn, thus becomes a more challenging and vitalistic “companion” for this subject. In this context, Weizsäcker’s later emphasis on contact proves to be essential. However, Goethe’s conceptualization possesses a certain ambiguity in so far as it relates to the concept of “life circumstances” [Lebensverhältnisse]. Life circumstances refers both to the biological substrate of human life and also to the relation of a concrete living being, as an individual, to its encompassing social life world [Lebenswelt]. This is why Goethe’s concept of human life circumstances is not aimed at comprehending life as an absolutely objectifiable correlation of facts that are faced from a distance. Goethe’s epistemic stance touches upon certain natural-philosophical assumptions. In his view, human experience is a quasi-organic process that cannot be reduced to an individually isolated experience, nor to the subject’s neuropsychological performance. An organic process is understood as a mutual structure that develops between subject and object. In essence, Goethe uses a physiognomic approach to explain how human experience is formed and how it is characterized as a mimetic relationship. Here is where we encounter the dependence of human experience on what we call contact, which is contact with the surrounding material and the social world. Contact means a personal connection to both tools, instruments, and natural forces, which can be turned into allies [Bundesgenossen]. In contrast to a rigid Cartesian dichotomy [res cogitans vs. res extensa], the realm of contact is distinguished by mobility and versatility, enabling us to see only that which is based on our original familiarity with the nature of things. Treating nature as a part of contact means that it can be objectified only in a limited way and can only partially be subsumed under general laws. As Theodor Litt argued, objectifying nature “would sacrifice contact for bloodless abstractions” (Litt, 1959, p. 84). This diagnostic approach is not unfamiliar to those in a caring relationship with others; however, in most cases, they are not aware of its natural philosophical and epistemic justification.

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Existential dependence on Others: Morality as protective coat for human vulnerability Existential crisis situations are decisive in character [Entscheidungscharacter]. Not only do they stimulate questions about possible causes such as triggering illnesses, personal consequences, and associated suffering, they also raise issues regarding the existential horizons of people’s biographical self-image, formative attitudes and values, and how they lived their lives. Above all is the struggle to remain one’s self [Selbstseinkönnens] even in such a burdening situation that forces a reorientation of life. It seems that in these situations an existential ethics, or more precisely, a maieutic ethics of re-appropriation [Wiederaneignung], would best suit the circumstances (Grewe, 1990). Re-appropriation is closely related to the principle of “adopted understanding” [aneignendes Verstehen], which implies a particular structure of communication enabling the affected person to develop a hermeneutical understanding of self by “distancing oneself from the immediacy of one’s situation” [Abstandnahme von der eigenen Unmittelbarkeit]. This, in turn, enables the person to dissolve self-deception and to change his or her attitudes (Grewe, 1990, p. 264; Remmers, 2000, p. 173). Kierkegaard (1843, pp. 839f.), an exponent of maieutic ethics, stated that the “personality of an individual is not created by itself, but it has been chosen by itself.” Therefore, obligations are an expression of absolute dependency of an individual and for its absolute freedom. Thus, absolute dependency and absolute freedom have to be seen in their common identity. In this respect, Kierkegaard noticed, that in cases where one individual chose itself ethically, this individual has chosen itself in its concretion. “This means a decision [has been taken] without arbitrariness, which is often associated with abstractness as the opposite of concreteness.” Transitions of this type of hermeneutic understanding of self into psychotherapeutic methods may occur at any time. Moreover, the practical horizon of an existential choice is characterized less by questions of justice than by questions of a good life and therefore has a certain proximity to the Aristotelian ethics of virtue. Currently, influenced mainly by existing biotechnological cultures, ethical questions regarding a good and right life are more frequently being raised in the context of an “anthropological commonality” (Habermas, 2003) and a quasiinstitutionalized morality in cultural ways of life. Therefore, the anthropological facts of illness, existential distress caused by subjective phenomena of suffering such as fear, pain, and stress, make us conscious of human life taking place under irreversible conditions of physical and social dependencies. Because, in a world shared in common, what are our moral convictions and certainties other than “constructive responses” to mutual dependencies – a “porous protective covering” against the equally unpredictable nature of the vulnerable corporality and

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personality of human existence? (Habermas, 2003; cit. 2001, pp. 62f.). It is our mutual dependency that explains our vulnerability overall. It should be recalled that, in a biological sense, human beings are born “‘unfinished’ and remain dependent on the help, care and recognition from their social environment over their entire lives” (Habermas, 2003; cit. 2001, p. 64). Biographical processes of individuality are only possible within an intact network of “reciprocal relationships of recognition.” An ethics of solidarity and respect for the Other in his or her vulnerability integrates this anthropological fact and constitutes, as it were, a minimum of civilization for human life. This corresponds to an ability for empathy, a quasi “resonating comprehension for the vulnerability of organic life within the sphere of inherent corporal sensation [Sphäre eigenleiblichen Spürens]” (Habermas, 2003; cit. 2001, p. 83). Hence, it is claimed that ethically strong premises, if observed in practical reality, are a rather volatile motivational resource within a social culture of mutual consideration and respect. However, is it possible to detect certain motivational resources “resonating” pleasantly, completely separated from a deeply sunken, quasi-primal sphere during basic human encounters? Here we turn to Emmanuel L8vinas, who has answered this question in several profound ways.

Two Opposing Perspectives of Care Fundamental ethical experience and motivation: Emmanuel Lévinas A deontological ethics of justice is based on universalistic principles of justification. The problem with these ethics is that the motivational basis for right actions remains unaccounted for. This is different from an ethics that focuses on existential questions of a good life. In these ethics, intrinsically motivated decisions of one’s way of life and how to conduct a good life play a particular role, as the example from Kierkegaard demonstrated. This is comparable to the motivation behind ethically demanding actions in the context of caring relations that are associated with very specific moral attitudes, values, and personal characteristics. Situations of professional caring relations imply that the professional who underwent a formal education continuously demonstrates the willingness to value the vulnerability of the Other and accepts the fact that he or she will be personally affected by the need for care of this Other. Motivationally relevant attitudes of care are therefore linked to a certain moral sensitivity and to the ability to perceive the particularities of the individual in need of care. To concentrate ethically on a situation with an individual, who, for example, expresses an urgent need or is suffering, is not fully compatible with moral claims raised in modern ethical theories, like, for example, the universal obli-

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gation for equal treatment of all human beings. This fact poses a serious problem particularly in professional care scenarios because they must proceed on the assumption that there is an irrevocable difference between human beings – a circumstance that is expressed in the imperative of individualization [Individualisierungsgebot]. In contrast, modern ethical theories insist on excluding or separating that which is non-identical or different, due to their universalistic claims for equal treatment. The interests and concerns of a concrete Other in his or her particularity and uniqueness are the focus of postmodern ethics, which has a special emphasis on personal, asymmetrical relationships of responsibility.4 This particular perspective corresponds to the fact that a postmodern ethics keeps a critical distance from an “activist understanding of the world” that characterizes modernity with its universal “obligation to act” (White, 1991, p. 35). A postmodern ethics proposes instead to “slow-down activity” in the tradition of the Heideggerian philosophy’s idea of releasement [Gelassenheit], which enables the provision of due attention to the uniqueness and sophistication of the Other. One of the exponents of a postmodern ethics, oriented toward the nonidentical Other, is unquestionably Emmanuel L8vinas (esp. 2005, pp. 85ff), who has, surprisingly, not yet been recognized in the foundational discourse for an ethics of care. In his widely diversified work, L8vinas also aims at explaining the moral foundations per se of asymmetrical interpersonal relationships, particularly caring relationships. One of the special interests of L8vinas concerns the ultimately affectively based motivational resources for personal supportive and caring behaviour. According to him, the crucial condition for the Other to be able to address me as a being in the first place is that the Other expresses himself or herself in such a way that he or she exposes his or her vulnerability to me (L8vinas, 2005, p. 93). This occurs through a “speaking without words” (L8vinas, 2005, p. 96). Something is “spoken out” in the visible, and something is only looming, something whose entire meaning cannot be revealed completely through language (cf. Wenzler, 2005, p. xvi). In contrast to the assumption of a discourse ethics, that structures of communicative understanding can be installed through the creation of symmetrical relationships and commitment (Habermas, 1994), L8vinas’ starting point is the assumption that ethical relationships cannot be characterized as anything other than asymmetrical and must therefore be understood as relations of unilateral responsibility. Since this relationship lacks the usually presumed demand of mutual obligation, the two partners do not have reciprocal entitlement for respect as autonomous persons. The anthropological justification for an ethics that is based on relationships of 4 Cf. Also Honneth & Rössler (2008). Unfortunately, this collection of articles does not deal with the ethical aspects of (professional) caring relationships.

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radical unilateral responsibility can be characterized in its extreme as “exposedto-prosecution” (L8vinas, 2005, p. 95; my translation). Strongly influenced by religion and featuring cabbalistic, mystic, neo-platonic, and Christian motifs, L8vinas’ (1987) ethics can only be understood if one realizes two critical impacts of its justification: on the one hand, at the level of ontology, a critique of modern, action-oriented, universalistic moral imperatives, and, on the other hand, a criticism of ontology as such in that L8vinas (1987, p. 289) reverses the relationship between ontology and ethics. The difference to ontology is that L8vinas – distinguishing himself clearly from Heidegger as a “guardian of silence” [Hüter des Schweigens] – grants the “inner world,” the perception, the feeling of an Other in interpersonal encounters a “predominant existential position” (Honneth, 1994, p. 213) before all for other areas of being. “Preexisting the disclosure of being in general taken as basis of knowledge and as meaning of being is the relation with the existent that expresses himself; preexisting the plane of onlotogy is the plane of ethics” (L8vinas 1991, p. 201). The reason L8vinas rejects ontological claims in favor of an ethics of existence, which is an ethics of the inscrutability of an Other, results from his critical insight that ontologies are characterized through identifying reasoning. However, for L8vinas, the human being (the human counterpart) as the being of an Other can only be done justice by respecting and supporting the Other’s indelible difference and non-identity. “Western philosophy has most often been an ontology – a reduction of the Other to the same by the interposition of a middle and neutral term that ensures the comprehension of being. This primacy of the same was Socrates‘s teaching: to receive nothing of the Other but what is in me, as though from all eternity I was in possession of what comes to me from the outside – to receive nothing or to be free” (L8vinas, 1987, p. 43). Closely related to the impulses of “rescuing the non-identical” as postulated by Th. W. Adorno in his Negative Dialectics (1973), L8vinas distinguishes himself from the ontological compulsion of thinking in identical reasoning. Instead, he wants to unravel, through quasi-phenomenological means, the core of ethical experience and conduct. L8vinas reveals such a core in the sensory perception of the “face” of the other person, convinced that no one can spontaneously escape the absolutely fundamental impressions of mimicking the expressions of an Other ; this is the phenomenological dimension. The moral content in this elementary experience that can be accessed on this dimension exists in the encounter with another human and the mere fact of seeing the Other [ansichtig] addresses an infinite, though unintentional, responsibility. Thus, the impression of inescapable responsibility is anchored in the experience of incommensurability : the expression of a face and its language that no

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one can escape through silence (L8vinas, 1987, pp. 288f.).5 To speak of the incommensurability of an Other as a person is based on three assumptions: (1) the Other is considered a unique individual; (2) due to this uniqueness, the individual is considered irreplaceable; (3) the subjectivity attributed to an individual is founded not in activity but in a vulnerability that is incalculable, indisposable (L8vinas, 2005, p. 97). These are the reasons why, for L8vinas, an endless moral responsibility towards others in need exists that verges on moral constraint. An individual is violable solely because of his or her uniqueness and irreplaceability ; a sensually rooted openness and “nakedness” is the reason for vulnerability (L8vinas, 2005, p. 93). Inevitably, a moral relationship is inherent in every existential encounter, which, due to incommensurability, has an asymmetrical character of responsibility where not only the egocentrism of interest-driven actions ricochet, but caregivers’ claims to individual autonomy fail as well. L8vinas’ existential ethics proves to be fruitful for the philosophical foundation of an ethics of care, because it unravels the motivational resources to assume responsibility for an Other in non-reciprocal relationships as deeply rooted in affects. However, this approach appears exaggerated when a quasitranscendental analysis of an existential encounter is confused with the empirical conditions of institutionalized care relationships. It is exactly on this dimension that this approach overstretches its normative claim. At the same time, this criticism should not be understood as an argument to reject L8vinas’ claim, which to a certain extent is attributed to the “extremism” of a radical phenomenological reduction to existential facts. Necessary and more important is to focus on specific forms of mediation [Mediatisierung]. Sociological and psychological studies inform us that a breakdown of motivational drive (which is never in a pure form) is programmed in the experience of unavoidable limits of caring actions as well as in psycho-emotional competencies. (Remmers, Holtgräwe & Pinkert, 2009). From the perspective of an existential ethics, these limits are in no way merely the result of the institutional framing of a power-exerting system of human alienation (Menzies, 1960). The limits of an unprotected commitment toward a person results from the fact that caring relationships can ultimately be instrumentalized. Indicative of instrumentalization in the German context are numerous side effects of a diaconal, strongly ecclesiastical, hierarchical nursing care. This appropriation of care through power [Vermachtung] can only be understood from an exterior perspective. An existential analysis from an insider perspective of fundamental ethical relationships can generate neither substantial 5 This statement requires a historical, sociological, socio-psychological differentiation given political atrocities, above all, the fact of extermination camps.

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sociological nor psychological insights into the processes of instrumentalization. This is another reason why conceptual foundations of care cannot be reduced to ethical assumptions but must be critically supported through political theoretical considerations (Conradi, 2001; Tronto, 1993). To what extent these caring relationships, aimed at satisfying existential needs, can be institutionalized as a kind of personal service and thereby be regulated judicially, is a general problem regarding the legislation of individualized care systems. Statutory regulation guarantees the enforceable part of care service obligation. However, it cannot guarantee the driving factors (sense, motivation) that are required to deliver care because these are deeply rooted in the personality.

Caring pastoral power as a phenomenon complementary to scientific disciplinary power: Michel Foucault As we have seen, L8vinas’ ethics can only be understood adequately when one main theoretical condition is made clear – the critical relation to modern science, whose goal it is to achieve control and power over humanity and the world. This critical perspective on the history of science was radically sharpened by L8vinas’ contemporary, Michel Foucault. What answer does Foucault provide to the question of how a person’s claim for his or her uniqueness, for the possibility to become one-self [Selbstseinkönnens], for recognition, or for his or her biographically incommensurable life plan to be respected? Categorically, one would expect that Foucault, based on the results of his investigations in the history of sciences, would have sceptically rejected L8vinas’ strongly accentuated ethical conceptualization of a boundless devotion to the Other. Foucault would likely have raised the suspicion that the ethical claim of an altruistic surrender for the sake of an Other actually conceals the caring pastoral power that merged with the disciplinary power of modern scientific discourses (Foucault, 1994). What is to be made of this perplexing assumption? As is well known, Foucault, by deconstructing the epistemic system of modern humanities, demonstrated that the idea of humans as working and speaking beings under other living beings is a construction, an invention of the scientific discourses. With this “epistemological configuration” (1995a, p. 418) a development with far-reaching consequences is initiated, consisting of the fact that everything that could not be subsumed under, and was not identical with, general abstract, norm-setting knowledge about the human has been excluded. This tendency eventually leads to the omission of Aristotle’s assumption, according to which no general knowledge about the individual can be constituted. Foucault’s Archeology of Knowledge (1969) and the modern subjectivity emerging from this knowledge leads to the assumption that the individual is

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reduced to a kind of parallelogram of forces and freedom-annihilating structures of power and discourses. On the level of micro structures, these discreet forces materialize in political-social practices of normalization, that is, in the form of clinical internment, punishment, and banishment. The result is the distressing perspective that any spontaneous emotional and physical behaviour of expression is subject to heteronormative schematic patterns of thought, perception, and action. The formative character of this biopower, strongly established at the beginning of the nineteenth century, is that social procedures of discipline and control in connection with institutionalized discursive strategies discreetly permeate the microstructures of social life. In contrast to this totalizing scientific perspective, Foucault asked, not only in his later works but even at the beginning of the 1970s, the unexpected question about the possibilities of an expressivity that is undistorted by civilization and a corporality of the individual that is not reified by science. A self-referential, free subjectivity can be achieved through creative activities and presents a contradictory relationship with the Christian pastoral of moral self-relations and to those Christian hermeneutics of self that are ultimately based on altruism in the care for the Other (Foucault, 1994). In contrast, to develop an ethics of existence Foucault drew on ancient ideals. Following these, a new elaboration of the Greek techne as artistry is suggested, which enables one’s own life to be considered an object of aesthetic formation of self (Foucault, 1994). However, these assumptions imply seemingly irresolvable contradictions to L8vinas’ ethics. Initially, a positive conjunction to L8vinas results from the fact that Foucault’s ethics of existence systematically excludes the idea of reciprocity. Contrary to L8vinas, Foucault, though, systematically denies the ethically significant reciprocity of perspectives. He does so because it would tacitly create the preconditions for the establishment of a Christian pastoral power from which arises concern for the Other ; these, in turn, are the conditions for such medical, educational, psychological, or educational discourses and practices of normalization that are anchored in the obligation to confess (Foucault, 1995b). In another respect, incompatibility with L8vinas is obvious: Foucault’s ethics of existence coincides insofar with a “virtuoso’s ethics” as it assumes subjective freedom as the horizon of possibility for an aesthetic “true” way to exist (Heidegger, 1927; Remmers, 2000, p. 78). The case is different when Foucault attempts to keep questions regarding a good life clear from the requirement of being based in abstractly universal reasoning or justification. In this respect, there is a certain degree of consistence with L8vinas that is dismissed in the same instant, however, because Foucault’s ethics is based on rules of wisdom, on which a moderately aesthetic as well as an autonomous life-practice can be oriented. Due to their ability to autonomously create their lives, individuals have at their

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disposal leading points that enable them to decide what knowledge they consider decisive for their practice. If we are not mistaken, Foucault’s ethics of existence opens up a perspective on creating one’s life that enables it to undermine both humanities’ truth discourses about the individual and technologies of domination generated by tacit micro-physics of power, thereby neutralizing their coercive force. Meanwhile, expectations appear to be somewhat sociologically uninformed, and what is more concerning, is that this approach does not distinguish enough between the educational normative elements of an ethics of existence and those normative guarantees of the conditions under which an existential choice can be made freely and on one’s own responsibility between beneficial, thus livable, and nonconducive plans of action. In this respect, the question emerges whether Foucault’s ethics of existence eventually implies a radical-liberal “decisionism” (of values) (Kögler, 1990). Despite these, from our perspective, not insignificant problems, one should not overlook the productive aspects of an interpretive analytics of ethical-aesthetic practices of subjectivization. This way, Foucault uses, for example, ancient testimonies of classical self-care as backdrop for the way he utilizes a vitalistic life-philosophical version of a self-experience corporality [Leib] in association with philosophers like Bergson, Dilthey, and Simmel. Therefore, the intention is to restore “life” as a transcendental-logical core concept in philosophy, a position that in Foucault’s other studies was occupied by “power” as a “transcendental-historicist core concept of history as critique of reason” (Habermas, 1987; cit. 1985, p. 298 and p. 335). Apart from similar considerations in Foucault’s early lectures at the CollHge de France, particularly in his later work, he concentrates on two existential dimensions of individual self-assertion: an ethical dimension of the subject’s self-experience and, associated with that, an aesthetic dimension of self-improvement related to corporal existence. In both dimensions, Foucault safeguards an irretrievable notion, to which we would critically object, of a classical-antique form of life that he also uses as a reference for the individual’s dignity (Foucault, 1990). And it is this dignity that individuals are deprived of through the scientific “pastoral” concern for the Other, as Foucault is continuously pointing out. The reason why Foucault explicitly talks about the “insidiousness” of humanities’ discursive strategies is that the scientification of life is structurally based on the corporal “obligation to confess.”6 In contrast, he believed that he could find in the language of a corporality, 6 This conclusion corresponds to a frequently quoted observation of Kant’s in the preface to the second edition of The Critique of Pure Reason (B XIII). There, Kant refers to reason as a quasiinquisitorial function, provided that reason forces nature to give answers to questions of reason.

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which is not tormented by these coercions, symbols for an integral life-form. In the humanities’ rational discourse about the individual, not only does that meaningful form of life vanish, but an individual’s rights to freedom as well. Whether the latter implies that the ethical discourse of justice, in which universal principles of justifications are asserted, must also be rejected because their abstract universality cannot do justice to the incommensurability of individual life forms but are rather part of a disciplinary power, will be addressed from a different perspective in what follows.

Outlook: Responsibility and Justice Up to this point, we have attempted to highlight the characteristic ethically charged relationship of care relations. Already the empirical description of care relationships (in nursing, medicine, and social work) implies a structural asymmetry regarding the reason for establishing such a relationship and its preconditions like capacities, competencies, etc. However, one could also speak of an ethical asymmetry, in respect to the fact that the person in need of care normatively takes precedence, requesting the respect of his or her mental state, desires, and interests as well as the subordination of the caregiver’s interests in most, if not all, areas of his or her personal life. This description certainly is an elementarized, normatively sharpened description of care relationships. A similar description can be found in L8vinas’ ethics presented as a commitment without reservation of a person to the demands of another person, transferring the affective-motivational foundations into normative obligations of a practice of care. This certainly introduces ethical aporiae. On the one hand, we attest that the way L8vinas develops his normative horizon of orientation leads to a kind of blindness toward the forces responsible for the structures that dominate the field of institutionalized care, thwarting its primary impulses. It seems to us that L8vinas’ framework of justification for his existential ethics is too narrowly conceptualized. This is the reason why L8vinas’ ethics appears relatively vulnerable to being instrumentalized by, as Foucault demonstrates, for example, “normalization strategies” of professional care institutions in the name of a “pastoral” form of care. By genealogically decoding social disciplinary powers and their forms of knowledge and discourses, Foucault exposes instrumentalization as structurally implemented in the form of a “pastoral” of care, encoded as an ethos of aid. On the other hand, the question (not dealt with here) is to what extent Foucault’s detailed counter-concept of an aesthetic ethics of existence, greatly inspired by Nietzsche, can claim sufficient plausibility. L8vinas’ and Foucault’s conceptualizations and studies can be made fruitful if combined together because they provide fundamental aspects of both an ethi-

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cally founded mandate and a critical perspective on science and institutions of care professions, thereby implementing relationships of responsibility. The ethical self-image of care professions must also include the fact that these relationships of responsibility are developed in the sense of a political mandate, which needs to be brought to the fore. For this purpose, in our opinion, both perspectives should not be abandoned because of their limitations, but they need to be supplemented. The potential of L8vinas’ ethics is found in its sensitization towards alterity (the non-identical). The potential of Foucault’s scientific philosophy is found in its sensitization towards a microphysics of power concealed in institutional practice. Due to its totalizing perspective, however, no analytically substantial statements can be made under which conditions discourses of justice, leading to political activities in order to arrive at equitable conditions of work and provision, can emerge. Contradicting L8vinas, institutionally as well as politically oriented discourses of justice stipulate distance, without regard to the distinctiveness of a specific person. In contrast to Foucault, these discourses do not solely encompass acting participants able to self-confidently articulate their interests (above all professional caregivers), but also include, in the form of an advocatory discourse, the non-articulated interests of persons in need of care and protection, who may be completely deprived of any possibilities of selfrepresentation. Certainly, just solutions for intersubjective conflicts of interest can only be found if they are kept clear of emotional values of personal sympathies because they would violate the moral entitlement for equal, mutual respect (Remmers, 2000). However, moral entitlements cannot be fully met from the imperative of non-discrimination only, but rather, they require an existential compassion with the unique destiny of the Other and his or her burdens and suffering. Even if one assumes that everyone can potentially be affected by these burdens and suffering, and that they must be understood as collective ethical aims for mutual support, individuals and their special needs can still be fulfilled solely by unilateral, non-reciprocal attention and care. In this asymmetrical relationship of responsibility, the emotional ties of a shared ethics of care converge with the moral substance of a universal ethics, which means with that principally claimed respect for one’s decidedly incommensurable human dignity. However, on the basis of respect, an obligation of care and beneficence is limited to those cases in which persons find themselves in situations of comprehensive need. In other cases, unilateral relationships of care are prohibited, because from a patriarchal point of view they violate the principle of autonomy as a condition of justice by perpetuating dependency as well through unilateral emotional ties. Even if unilateral, completely indifferent care must be given its place in the phenomena of morality, this is always associated with an irresolvable relationship of tension with the domain of morality (Honneth, 1994). To a cer-

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tain extent, two separate sources of our moral orientation come into effect in the perspectives of equal treatment and care. Thereby, the practical conveyance of the good and the obligatory can be made dependent upon a functional evaluation of an entire human life (Leist, 2005). Basically, it must emanate from a variation of vital commodities and their evaluative components in the entire course of life (Remmers, 2006). On the level of normative substantiations, nevertheless, the relation between an ethics of care and an ethics of justice cannot be identified in any other way than aporetic – being aware that aporiae simultaneously imply relationships of tension.

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Chapter Four: Nursing and Critique: Elements for a Theory in Nursing (Translation by Thomas Foth)

Introduction A scientific examination of the phenomenon of caring is an achievement of the last one hundred years since it was only in the twentieth century that the academization of nursing as a discipline took place. This institutionalization led to the establishment of a theoretical discourse and a “scientific community” that first evolved in the US and later in Europe and other continents. These developments resulted in the implementation of the discipline as an integral part of the canon of scientific disciplines. However, until today no broad consensus exists about what a conclusive definition of nursing science might be. So far, the goals of emancipation and political maturity [Mündigkeit] have not been taken up in nursing theories, surprising because nursing practice takes place in the context of asymmetrical power relations, structures of domination, and conflicts of interests. In nursing, understood as a field of action, the interaction with human life has become increasingly problematic through scientification particularly of the natural sciences, technological processes, and processes of economization. This development actually makes a fundamental, theoretically based and critical perspective in nursing necessary. However, overall a kind of “theory fatigue” exists, with theorists tending toward developing situational and clinical-based theories that aim at problem solving specific clinical questions (a kind of dispositional knowledge). They are less interested in orienting nursing towards a critical perspective, and when this function is missing in nursing theories and is coupled with the lack of a strong theoretical base in general, a paradoxical situation results, because it is precisely a lack of theory that inhibits successful practice. But what is successful and reasoned practice? The expectations are high that a normative profound and critical nursing theory could provide theoretical and ethical justifications for nursing practice. The following chapter argues for the need for a justified and explicated

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specific form of critique, which does not provide a kind of external measurement for nursing practice nor does it aim to re-establish internal values of an ideal nursing practice. Instead, this kind of critique is understood here as an immanent critique (in the form of an ideological critique), whose norms are already immanent in nursing practice, although in a deficient and distorted manner. We are basing our critical theory of the science of nursing on that of critical theory from the Frankfurt School, particularly the most recent, and the critical theory of corporality [Leib]. These philosophical-theoretical approaches enable both a critique of the economization of care and the conceptualization of a “normative and profound” definition of nursing action.

Care and the Core of Nursing Nursing action can be conceptualized as a form of social action. The particularity of nursing action results from situations in which care is provided, that is, nursing action or care is performed in a specific institutionally regulated context and is realized on a corporal-bodily dimension with human beings in existentially important situations (Höhmann, 2006). By using the terms “corporality” [Leib] and “body” [Körper], we introduce two different perspectives, not two different objects (we will come back to this point later in the chapter). The term body encompasses the external perspective or the perspective of the body as an object, which can be analyzed by science. The German term Leib cannot be translated into English but it is a much older term than that of Körper and emphasizes the experience of one’s lived life [Lebensvollzug], self-awareness and that which is perceptible. In the eighteenth century the concept of corporality [Leib] had been suppressed by scientific discourse, but recently the term has undergone a renaissance primarily through phenomenological approaches. Different scholars in medicine and nursing sciences refer to this dimension in their work (see, for example, Benner & Wrubel, 1989; Friesacher, 2008; Fuchs, 2010, 2015; Kollak & Kim, 2006; Nerheim, 2001; Remmers, 2000). Nurses normally become active in situations in which others have experienced restrictions, at least temporarily, in their autonomy to act for themselves. These restrictions are due to illness, disability, crisis situations, old age, and processes of dying. Care situations are therefore characterized by asymmetrical and non-reciprocal relationships and an uneven distribution of power and autonomy. The asymmetry is double-sided, being on the one hand between nurses and the persons they care for (patients, residents of long-term care facilities, or nursing homes), and on the other hand, between nurses and the “system,” that is, the organizational, legal, and economic structures in which they work. Nurses

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thus have a double mandate that is characterized by a certain tension: first, they have a responsibility toward the recipient of care, and, secondly, toward society, more specifically, towards the healthcare system. Actions (and non-actions) in carrying out these responsibilities need to be specifically legitimized and justified. Professional nursing action must include the competence to justify an action scientifically, to decide what to do, and to carry out that decision. Hence, nurses by their actions connect with persons’ life horizons, their habits, and their personal values. Nursing interactions possess a deep moral content, the normative foundation of responsible nursing action (Friesacher, 2008; Remmers, 2000). The core of nursing or what makes nursing caring [das Pflegerische] (Wettreck, 2001, p. 260) is realized as a form of care, concern, and support in a work alliance with the receivers of care, which connects with contexts of both their life world and their existential situation. Approaching the other from the perspective of both body and corporality and, when combined with a caring and compassionate therapeutic and advocating attitude and action, constitutes a discrete response to a confrontation with suffering, illness, dying, grief, or death. Connecting to the experiences of being ill, which is a corporal experience (as opposed to having a disease), enables nursing to go beyond the narrow boundaries of a perspective based on medical sciences and natural sciences (Friesacher, 2015, 2016; Wettreck, 2001). Transformed in this way, nursing stands for its own therapeutic value. Thus, it is not the question what kind of tasks nurses could take over from physicians. Instead one needs to ask, what is the actual contribution nurses can deliver in a manner different from any other healthcare professional? … A compensatory understanding of advanced and specialized nursing should be replaced by a model based on an advanced nursing practice. This advanced practice would mean an advancement of nursing fields of action. Thus, the model of an advanced nursing practice would be constituted from a perspective, which is original to nursing, of the connectedness to the life-world, the closeness to the patient and the safeguarding of continuity in the provision of healthcare (Gaidys, 2013, p. 297, emphasis in original).

Thereby, nurses rely on scientific knowledge that cannot simply be applied uncritically to practice. The generalized rules of knowledge (theories, models, guidelines) must be combined and intertwined with an understanding of the individual case (a double logic of action). The combination of reconstruction (understanding) and subsumption (explanation) is the particularity of a practical science, which differentiates it from theoretical and so-called applied sciences (Bishop & Scudder, 1995; Friesacher, 2008; Hülsken-Giesler, 2008; Oevermann, 1996; Remmers, 2000).

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Preliminary Considerations for Theoretical Foundations for Action and a Theory Program in Nursing Science Historically, the natural sciences have been perceived as the foundation of nursing science. In an increasingly technologized and rationalized world, science tends “to withdraw from critical, evaluative considerations that it itself asks for in regard to traditional knowledge” (Nerheim, 2001, p. 10). Therefore, science itself has become problematic. The plea for a profound critical perspective dies away, or rather any critique is reduced to only methodological problematizing in the sense of Popper’s falsificationism. This form of critique relates only to problems within science itself, and forecloses any form of external critique (see also Böhme, 1998). To sharpen the argument further, one could argue that the constitutive elements of every science – the stimulation of critical thinking and the cultivation of doubt – are pushed to the margins by the science, technology, and medicine complex (STM) and are sacrificed for market economic interests (Hagner, 2012). Accordingly, the humanities and with them the hermeneutically oriented sciences are increasingly perceived as a luxury in the academic enterprise: they are considered incapable of producing any useful results and with their sceptical habitus, impede the “profit-oriented circulation of knowledge as a commodity” (Hagner, 2012, p. 14). The systematic development of the discipline of nursing with the evolution of its own specific theoretical inventory has at least partly been woefully neglected. This has led to essential problems with regard to the identity of nursing science and its place in the canon of other disciplines (Remmers, 2014). The challenge for a basic theory of nursing science is to elaborate the essential core of nursing to provide the foundation for a disciplinary identity. Previous preliminary considerations emanate from the insight that the core of nursing lies at the intersection of knowledge derived from the natural sciences and the humanities and that nursing as a discipline manifests a cross-sectional character because it merges different forms of knowledge and different reality constructions and methodological approaches. Therefore, the decisive point is not to insist on a simple “either-or solution” and declare the natural-scientific methodology obsolete, but, on the contrary, it is to develop a critique that is based on understanding and opposes the illegitimate use of a “singletrack communication.” This critique will focus on natural science’s own concern to acknowledge the extent to which it is interconnected with hermeneutics to achieve legitimacy or meaning (Nerheim 2001, p. 11).

Habermas’ (1995) considerations about theory development in sociology are also crucial for nursing science, which is understood as an action science (see also the fundamental debates in Nicoll, 1997 and Remmers, 2000) with its double

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logic of action. It is also necessary to recognize “meaning” as a basic concept for developing a theoretical perspective in nursing science, for once it is accepted as essential, communication (verbal and non-verbal) becomes a constitutive element of the field. Closely related to this theoretical perspective are differentiations between action, behaviour, and observation versus understanding of meaning. Kim (1997, p. 166) asked if the primary aim of nursing science is “understanding” or “control.” Indeed, actions need to be observed in such a way that one can understand the meaning behind them, but a rule-guided behaviour, which we call action, can only be understood through interpretation. Modern action theories start from the assumption that actions are modes of behaviour “that can be described through propositionally substantial intentions … And we identify a substantial intention by understanding its propositional content and its psychological mode. Therefore, actions are considered primarily as objects of understanding, but not objects of a natural scientific explanation” (Detel, 2007, p. 15, emphasis in original; see also Browne, 2000; Friesacher, 2008; Kim, 1997). Actions are characterized in multiple dimensions; they are associated with external observations of movements, and, at the same time, they are experienced by those who are acting and who perceive actions related to intentions, goals, and normative justifications as aspects of their self-interpretation. Human action comprises, on one side of the spectrum, explicitly rationalized and planned decisions between different alternatives of action, and, on the other side, more or less automated, routine activity and intuitively improvised actions. Thus, skills (knowing how) and theoretical assumptions (knowing that) merge (see, for example, Benner 2012; Friesacher, 2010, 2008, 229ff; Neuweg, 1999; Polanyi, 1985). In an action and practice discipline it makes sense to conceptualize nursing theory from an action theoretical perspective (Dean, 1995; Friesacher, 2008; Kim & Kollak, 2006; Mosque-Diaz et. al., 2014; Princeton, 2015; Remmers, 2000). First, it must be decided whether nursing action is oriented primarily toward communicative action or toward instrumental-rational action, which in the modern world is the dominant form of action and which has often been critiqued in the literature (Friesacher, 2008; Habermas, 1981; Remmers, 1998; Weber, 2005). Instrumental rationality is characterized by success-oriented acting based on a means-end relation and is measured by how successfully a target has been achieved. An action is considered instrumental if it follows technical rules, if it is considered strategic, and if it is analyzed under the aspect of rational choice. Both sub-forms of the instrumental-rational type of action coordinate actions through egocentric calculations of success. We find instrumental-rational acting, in the form of a systematically planned, target-oriented performance, represented in nursing in the nursing process, but also in types of nursing organization like functional nursing, clinical pathways, and in

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some cases, management approaches. The problem of this kind of nursing lies in the technological approach to nursing actions and its orientation to the cybernetic model, implying that what makes us human may be reconstructed and transformed through the language of technology (Friesacher, 2011; Habermann & Uys, 2006; Hörl & Hagner, 2008; Hülsken-Giesler, 2008). The idea that nursing should be controlled entirely by a nursing process, expressed in a mathematical-physical theoretical formula, has proven to be a vehicle for the economization of care (Friesacher, 2008, 2011). In regard to the nursing process Buus and Traynor (2006) concluded that the promotion of the nursing process developed in two important contexts: one was the influence of medical discourse as seen in the move from the “Yale” process to the “Catholic” process. The second was a predominant belief in scientific and human progress. This evolutionary approach was applied as a way of understanding the uptake of scientific and technological innovations within nursing … In the specific context of managerialism, this approach could make explicit the contribution of nursing care to health outcomes and, it is hoped, safeguard the profession in a time of financial stringency and insecurity (p. 44).

The type of action called communicative action is a form of action in which the aims of the participants are negotiated through a shared definition of the situation in which an interaction takes place. The coordination of the plan on how to act is achieved through processes of understanding and not through egocentric calculations of success (Habermas, 1981). This type of action is much more appropriate for caring actions because nursing work is mostly performed through relational acting, in interactions and as actions in relationships (Friesacher, 2008; Kim & Holter, 1995; Nerheim, 2001; Remmers, 2000). Both types of actions described so far (instrumental-rational and communicative) are explicitly rational types of action. However, actions in nursing are not always rational and consciously performed. This kind of cognitive conception should be broadened by adding a corporal-bodily [leib-köperlich] and creative-situational dimension to human action. Much of nursing action can only be roughly planned and the consequences of actions are often not foreseen. Nurses act under conditions of insecurity and imponderability. For these situations, knowledge gained through experience – the implicit and tacit knowledge of intuition and corporal-bodily understanding, as described in phenomenological approaches of corporality [leibphänomenologisch] (Benner, 2012; Böhme, 2003, 2008; Uzarewicz & Moers, 2012; Waldenfels, 2000) – are central elements for situatively subjectified and creative acting. These types of action are not explicitly rational but are rather emotionally motivated. Thus, emotion and reason do not necessarily exclude each other categorically if rationality is not reduced to technical and instrumental aspects and if a cognitive

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dimension is included in regard to emotions. Reductive determinations of concepts are rather counterproductive and cannot do justice to the complexity of acting (Böhle, 1999; Friesacher, 2010; Hastedt, 2005; see also Ryle, 1949).

Theory Development in Nursing The onset of a theoretical discourse in nursing science can be dated to the 1950s in the US (Alligood, 2014; Kim & Kollak, 2006; Reed & Crawford Shearer, 2011). However, both the cultural context and the conceptualization of science differ crucially between the US and Europe. Whereas the enlightenment as critique is a fundamental characteristic of European intellectual culture, American society is characterized by a latent conservative tendency that becomes obvious in mainstream sociology’s central concept of “integration.” Its all-encompassing faith in science assumes a nearly unlimited belief in the feasibility and manipulation of nature and society, and theory obtains the status of a tool. In this type of pragmatic orientation, an instrumental-rational principle guides action and the scientific ideal is an empirical-analytical orientation to social sciences. This conceptualization of science has considerably influenced the development of a coherent theoretical perspective in nursing science (Remmers, 1997). The strong worldwide acceptance of the concept of evidence-based nursing (EBN) promotes “practice- and problem-oriented research” rather than an engagement with theory development (Meyer, 2013, p. 36). Thus, Fawcett (2000) has insistently warned of the decline of nursing science, as only a few studies involve theoretical approaches to the discipline and many others often rely on theories derived from other disciplines. Furthermore, the insistence on the clinical in general leads to simplifying theories and to making them manageable in order to integrate them into existing practice. The result is the strengthening of the status quo. If a critical interest (see below) is missing, nursing can only assume a compliant function in the healthcare system without challenging or changing existing conditions.

Nursing theories: Critical analysis and theory-guided transformation of reality Theories and emancipatory interest of reason: First conceptions for a critical theory of nursing Nursing theory is critical if it follows an “emancipatory” interest (Browne, 2000; Friesacher, 2008, 2011, 2015; Nerheim, 2001; Princeton, 2015; Ray, 1999; Remmers, 2000). According to Habermas (1971), three knowledge-constitutive

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interests can be demarcated in the sciences. First, in an empirical-analytical conceptualization of science, a technical interest expands technical control and aims to provide prognoses and explanations. This approach leads eventually to the plundering of natural resources and to power and domination of humans over humans. Second, the practical interest of the hermeneutic sciences is constituted in the medium of language and provides interpretations and understanding of meaning of the socially constructed world. It enables orienting actions within the frame of an inherited self-understanding, to set out different interpretations and to find a shared definition for a situation. However, both these knowledge-constitutive interests fall short because only with emancipatory interest, which is constituted in the medium of domination and enables analyses that free “the consciousness from the dependence of reified forces,” is the way open to being able to speak for oneself. Emancipatory interest can only be realized through (self-) reflection. Only when understanding and change merge is the subject able to free itself from external relationships of dependence. Emancipatory interest is partly derived from the practical interest of understanding and is enlarged by critical reflection. The critique of existing conditions aims to achieve reasoned conditions. Habermas saw language as a medium of understanding and as an interactive form of communication between humans that is free from coercion. The starting point for critical theory must be the pre-scientific sphere of everyday practice and it must be able to rationally reconstruct this practice. Habermas’ further explorations in the form of a theory of communicative action (1981, 1981a) and his discourse ethics (1983, 1991) have also been well-received by nursing science (Browne, 2000; Friesacher, 2008, 2011a, 2015; Hülsken-Giesler, 2008; Kim & Holter, 1995; Mosqueda- Diaz, 2014; Nerheim, 2001; Princeton, 2015; Ray, 1999; Remmers, 2000). Kim and Holter (1995), as well as Nerheim (2001), initially took up Habermas’ epistemological differentiation of interests within science. Using an emancipatory understanding of science and with it a larger concept of nursing action provides the opportunity to resolve alienation and to reveal social processes that seem to be historically given and that appear as eternal and unchangeable necessary conditions of life. The methodological foundation for such a critique constitutes self-reflection, which frees subjects from their external conditions of dependence (Nerheim, 2001). Using Habermas’ theory of communicative action, Kim and Holter (1995) and Nerheim (2001) demonstrated how a dimension of action can be explicated in nursing where the relationship between nurses and patients is guided by communicative rationality. Linguistic understanding as the mechanism to coordinate actions thus comes into focus. Through the concept of communicative rationality, it is possible to think of action and communication simultaneously. Thus, Habermas makes clear that an internal connection exists between a sociology that aims to understand meaning and the problem of ra-

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tionality, because communicative action always requires a rational interpretation, at least at the beginning. Kim and Holter (1995) concluded that the “applicability of critical theory and the theory of communicative action to nursing is evident when we view nursing practice as involving collaboration and mutuality between the nurse and client, which helps to empower clients and enhance their lot within the health care system” (p. 218). The orientation toward understanding overcomes the single-track structure of communication and opens the way for a real double-track communication. As fruitful as Habermas’ theory is for the development of theory in nursing, internal problems of justification exist (Friesacher, 2008). First is the problem of conceptualizing the development of society as rationalized and its division into a two-level social theory (system and life-world), with the consequence that the system has an overwhelming influence on the life-world. Second, a too-rigid typology of action (instrumental-rational versus communicative action) largely excludes creative-situative actions, neglects the corporal-bodily dimension, and is based on a single-sided, positivistic conceptualization of nature. Third, the emphasis on the normative foundation of a formal and theoretical pragmatic and speech version of the paradigm of communication is too far away from the individual’s world of moral experiences. Humans experience the disruption of their moral expectations not as violations of rules of speech but as a violation of identity claims that are acquired through intersubjective recognition. Hence, it is obvious that Habermas’ communication paradigm must be expanded. Critical theory of nursing: An advanced approach Particularly adequate approaches for a normatively rich critical conceptualization of nursing appear in the Frankfurt School and its recent concepts of critical anthropology and phenomenological approaches of corporality [Leibphänomenologie]. Critical-normative theories to orient a philosophical caring framework Following Habermas’ foundational ideas, nursing science can be conceptualized as an enterprise aiming for emancipation and political maturity, one that provides justification and orientation, explanations and processes of understanding, and options and strategies for action in situations in which humans depend on professional care. To depend on other humans, or being in need of care, is a fundamental aspect of human life. However, even in extreme situations of needing care, autonomy and equality are not necessarily abandoned but are often sustained, although in modified form and with different degrees of freedom. If these desires are ignored, social pathologies result. These pathologies are not caused by the violation of speech regulations and failed processes of un-

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derstanding, as Habermas conceptualized them on a rather cognitive-rational dimension. Social pathologies – which for nursing could be inappropriate, patronizing, neglectful, or humiliating care – appear as the lack of recognition of the other or as “forgetfulness of recognition” that leads to the reification of the other, to “perceive [the other] like an insensate object” (Honneth, 2015, pp. 61 and 68; see also Friesacher, 2008, 2011a and b, 2015). An individual’s actual lived experiences become the starting point for critique and the “enabling conditions for self-realisation” constitute the measuring stick “on which social pathologies are measured” (Honneth, 2000, p. 58). The three dimensional social-philosophical justice and social theory that Axel Honneth (2003, 2003a, 2003b, 2005, 2010, 2015) developed (also through a fruitful dispute with Nancy Fraser) can be adopted for nursing and nursing science. Human beings are in need of more or less intensive emotional attention in the form of care, that is, care that is directed toward their natural needs and affects and recognizes their corporality (see also Benner & Wrubel, 1989), enabling the development of self-confidence and providing for physical integrity. This is particularly true in complex and burdensome situations where caring attention is a fundamental norm (Friesacher, 2008, 2016; Gahlings, 2014). Maltreatment and violence of any type demonstrate that care has been disregarded. Still, the context-bound perspective of care needs to be complemented or corrected through a universal position in respect of the rights of the other. This principle of equality before the law “takes precedence” over the principle of need. An ethics of care holds the danger of a more than latent paternalism and often constitutes an excessive demand. “A moral theory of ‘care’ can turn out to be a mindset that merely defines as ‘morally good’ what is best for one’s equals and such a position is not different from the attitude morally good is what suits me” (Benhabib, 1995, p. 205, emphasis in original). The esteem for another person is the foundation of the self-esteem of an individual and enables or enhances social integrity. The practice of care, as concern about and for other humans in their vulnerability and their need for help and protection, is bound to the idea of the person of rights (Mohr, 2009). This conception includes institutionalizing the reciprocal recognition of humans, including those who are no longer able to recognize others, such as persons with dementia, or those in a waking comatose state, or even infants who are not yet able to recognize anyone. “Not this or that moral, but the idea of the right for reciprocal recognition of personality and therewith of spheres of manifestation of self-determinate freedom is a proper starting point for the justification of human rights” (Mohr, 2009, pp. 75–76). A violation of recognition cannot claim recognition for itself. Therefore, recognition proves to be “the guiding target for caring interactions in professional nursing … [to safeguard] the personal integrity of the patient” (Höhmann, 2006, pp. 23–25; see also Baranzke, 2015; Friesacher, 2008).

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Besides the two dimensions of care and esteem, Honneth conceptualized social esteem as a third form of recognition, in which self-esteem is realized through a shared consensus about values, a form of recognized solidarity. The social value of a person is threatened through debasement and stigmatization with the consequence that dignity is violated. The struggle over the uncritical use of inappropriate nursing diagnoses as set out by NANDA (North American Nursing Diagnosis Association) shows clearly, according to Powers (1995) and Zanotti & Chiffi (2015), that the fight for recognition is political and shaped by power interest. Social esteem is necessary to develop and sustain self-esteem and is therefore as closely related to human dignity as are care and autonomy. However, the concept of recognition has also been viewed suspiciously as an ideology and its critical potential has been questioned as the result of a culture that is through and through compliant. In such a context, social recognition deteriorates to become merely a symbolic act with the aim to conform conduct within the system. The goal is thus not the subjects’ empowerment but, on the contrary, their subjugation and obedience (Allen, 2014; Honneth, 2010). Concepts such as “informed consent” only apparently strengthen patients’ autonomy in an economized healthcare market. Autonomy within the institution transforms into a formalized protection and a voluntary takeover of risks on the part of patients/users. The idea of autonomy is reduced to an unambiguous choice of options guided by pragmatic requirements of the system. Informed consent is linked to experts, who, through the information they provide, activate a “manipulated future.” Consent thus resembles a “blind buying decision” (Gehring, 2002, p. 28). A non-ideological act of recognition goes beyond the purely symbolic and is manifested in material fulfillment. In healthcare organizations (e. g., hospitals, long-term care facilities, homecare) this form of recognition would lead to real changes in institutional arrangements and processes that would make the needs of those needing care the starting point for action. However, recognition in this way is rather questionable in an economized healthcare system (Hartzband and Groopman, 2011; Maio, 2014). But what is so wrong with capitalism and a healthcare system oriented and organized to the market economy? A functionalist critique would target the phenomena of crisis in a market economy and the dysfunctions that would result from these crises, but there can also be a moral and an ethical critique of capitalism (Jaeggi, 2013; Rosa, 2012). The moral variant focuses on the unjust structure of society, whereas the ethical perspective uses the notion of an alienated life under capitalism as the starting point for its critique (Maurer, 2015). It is this latter form of critique that Rahel Jaeggli makes the focus of her theoretical critique of life forms (Jaeggi, 2005, 2009, 2009a. 2014). Jaeggli understands life forms as social practices and develops evaluation criteria “that are

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oriented to the normative conditions for the success of these practices” (Jaeggi, 2014, p. 14). Being able to conduct a non-alienated life means having the ability to make your own decisions. “Being not alienated designates a particular way of living one’s own life and a particular way of establishing or maintaining a relation between oneself and the contexts in which one is living and that determine oneself” (Jaeggi, 2005, pp. 50–51). Capitalism shapes a relation to the world and to the self in a specific way ; it shapes a specific life form. Because the economic sphere is not an ethics-neutral zone, these specific life forms can thus be evaluated. However, the critique must be able to relate the dimension of the functional, the moral, and the ethical to each other (Jaeggi, 2013). Yet, how would we be able to measure this critique? A critical theory of life forms needs a normative criterion that enables us to acknowledge when a life form gets into a crisis; without this criterion problem solving is not possible. Immanent critique focuses on the norms that constitute reality and their inner inconsistencies. Consequently, it is different from the perspective of an external constructive critique that targets the discrepancy between external criteria (e. g., basic human needs and characteristics of a good life) and existing practices. It is also different from an internal constructive critique, which focuses on the inconsistencies between inner ideals (e. g., the expectations of optimal and high quality care) and lived practices. An immanent transformative critique takes crises and dialectical contradictions in the interior of constellations as its point of departure (Jaeggi, 2014). In this way it is possible to formulate the (Marxist) critique of capitalism as an immanent critique. Norms like freedom and equality that are the foundation of the capitalist labour market and are part of the self-conception of modern societies are suspended through existing social practices in just these societies. This kind of critique enables the establishing of a systematic relationship between the two aspects of formal equality and social (also health-related) inequality (Jaeggi, 2014). The crises of capitalist life forms have the potential to reveal the conflict of these social formations. This critique is transformative because it is not about restoring valid norms or ideals but about converting a crisis-laden situation (here the economized care practice) into a new practice. To this end, immanent critique depends on analysis and theory. How else would it be possible to decipher alienation and reification? Besides Jaeggi’s theory of life forms, the critical theory of proportions of time and acceleration is another variant, or rather modification, of normative oriented critical theory coming out of the Frankfurt School (Rosa, 2005, 2009, 2012). Modernization is characterized by material, social, and intellectual conditions being “set in motion” ever faster. Social acceleration, or the acceleration of life tempos, is the central characteristic of modernity ; it includes a form of technical acceleration (e. g., of communication) where humans are re-

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quired to perform more tasks in shorter periods of time. These changes in the structures of time lead to alienation and the inability to respond to these accelerated changes, which is particularly evident in nursing. Self-relations and relations to the world are primarily corporal, emotional, and existential experiences, and these are at risk of being lost under a regime of permanent time compression. Technological acceleration transforms primarily our relationships to other humans but it also changes our relation to space and to the things around us. These changes thus follow the same logic; “they become semi-fluid, that is to say transitory, quickly transformable and contingent” (Rosa, 2005, p. 170). The interconnection of clinical data (e. g., score systems for the classification of severity of diseases) with managerial operating figures for the steering of processes in nursing and medicine transform not only therapeutic decisions, but also social relationships and interactions (Friesacher, 2015a; Maio, 2014; Manzei, 2009; Sandelowski, 2000). Using a variant of immanent critique enables a critique of working conditions, communication, and conditions of recognition that take up the tradition of normative approaches that have come out of the Frankfurt School. The critiques of life forms and of acceleration broaden these approaches because they enable a critical focus on social practices against the backdrop of dynamic processes. Corporal body [Leibkörper]: An original nursing perspective The direct work of nursing is to a great extent an activity on and with the body – the corporality [Leib] of the other. What is in normal life an intimate, private, and personal act becomes public. Against this backdrop, the activity of washing someone can be described “as a sensitive clash of ethical claims” (Krainer & Raitinger, 2008, p. 162; Pols, 2013). Personal body care as part of the social practice of care can only succeed if effective norms are demonstrated through a professional ethics and an ethical attitude of “good practice.” “Therefore, the ethos of a practice defines the conditions under which a given practice can be considered a good practice of its kind” (Jaeggi, 2014, p. 174). Nursing, as a practice of care that includes being concerned and responsible for someone, thus constitutes a field with diverse demands and contradictions, challenges and requests that requires, besides a technical-instrumental competence, a competence of social, ethical, and moral action. Involvement in situations of dependency in nursing care is often experienced as burdensome for the dependent person but is an experience of self. This can be described as an experience of corporality [Leiberfahrungen] because it concerns human nature. But what actually is nature? So far, nature has only been defined by natural sciences, which provides an empirical-analytical approach to the object nature. The preoccupation with nature was and still is primarily its appropriation through

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explanation of laws of nature, or its imitation through such things as artificial ventilation in ICUs, for example, to the point of where nature is exploited, resources are wasted, and nature is technically reproduced. According to Böhme (2003), “corporality is the nature that we are ourselves” (p. 63). It is essential that this innate nature or corporality is established as a key concept in nursing science alongside the concept of the body. The concept of corporality makes it possible to criticize alienation, the distancing and instrumentalization of human beings. Within a critical theory of corporality, it becomes possible to determine what is objectively given (the body) and at the same time to capture the perspective of self-experience [Leib]. Hence, two perspectives are assumed. The perspective of the body suggests a distanced approach. In this naturalistic attitude I perceive myself and the others as a thing – it is about something. The body appears merely as a controllable, professionally manageable body-thing that I possess. In contrast, the sensually tangible and sensible corporality is a medium of subjective experience. This personalist stance is a form of “being-in-the-world” that is characterized by intersubjective relationships to others and participation in a particular life form (Benner & Wrubel, 1989; Böhme, 2003; Uzarewicz & Uzarewicz, 2005; Waldenfels, 2000; Wettreck, 2001). The concept of the corporal body [Leibkörper] expresses these dual perspectives and the privileging of the personalist over the naturalistic attitude (Friesacher, 2008). The technologization of corporality fundamentally challenges the self-rapport and the naturalness of the human being by enabling the threshold to move between the artificial and the natural. Thus, the corporal form of existence [Leibsein als Existenzform] is apparently jeopardized. A critical phenomenology of corporality [Leibphänomenologie] evolves from the tension between these two approaches and ways of interpretation (corporality and body). A philosophy of corporality becomes, in this understanding, a critical theory (Böhme, 2003). Corporal bodily mediated interactions enable access to the other and signify a distinct nursing specific perspective on phenomena like ageing, illness, dying, and death (Uzarewicz & Moers, 2012; Weidert, 2007; Wettreck, 2001). Thus, corporality [Leiblichkeit] has the potential for me to accept what has befallen me. To accept the vulnerability, limitation, and mortality and, at the same time, to be mature in the sense of being able to push back the experts’ objectification and authority of interpretation, is a challenge for nursing science and nursing practice.

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Conclusion Critical theories provide foundations for justification and frames of reference for change. At the moment, critical thinking and extensive theoretical discourses have given way to a rather pragmatic science solely interested in usefulness, usability, and quick problem solving. Research programs are necessary that are able to highlight the controversies, paradoxes, and inconsistencies of the economization and technologization of healthcare and nursing. On the macro level a socio-critical position could become a central perspective in nursing, creating an association of ideas and values along with social, philosophical, and cultural coherence (Kirkevold, 2002). This kind of perspective could also help in examining the political, juridical, and administrative framework of nursing. At the meso level, realizing reasoned conditions in the institutions of our healthcare system depends on whether or not it is possible to demonstrate that the moment of “breaking free” is a paradox. The “pathology of the institution” is part of the opaqueness of which our world is made. According to Jaeggli (2009a), it follows that “a good institution must not be constituted in such a way that it hides the conditions of having been made as the result of human practice, that is to say, it is the result of the acceptance of collective institutionalization. A good institution is one in which individuals can realize their interests and with which they can identify. Those institutions exerting external coercion are characterized by rigidity ; resistance and that which does not conform to institutional processes can no longer enter the institution’s field of vision” (pp. 542–543). At the micro level, nursing action is the core of nursing (Friesacher, 2008, 2015, 2016). A theoretically based conception of action needs to be realized that is able not only to reconstruct the visible aspects of nursing practice but also those aspects that can only partly be verbalized through an (implicit) nursing theory (Friesacher, 2008; Nerheim, 2001; Remmers, 2000).

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Chapter Five: The Limits of a Theory of Recognition: Toward a Nursing Ethics of Vulnerability

At mid-afternoon on September 19, 2008, Brian Sinclair, a 45-year-old man of Aboriginal descent wheeled into the emergency room (ER) of the Health Sciences Centre in Winnipeg. He interacted with a triage aide, showed his family physician’s letter, then parked his wheelchair in what would be his final resting place. The video footage from security cameras shows Mr. Sinclair moving around the waiting room with intermittent moments of rest, and medical staff walking by him in a nearly empty waiting room but no one whatsoever inquiring if he needed assistance. Twenty-four hours after his arrival, housekeeping was called to attend to a bodily fluid discharge in the waiting room – Brian Sinclair’s vomit. From 4:37 pm on September 20th to the time of the first attempt at resuscitation at 00:51 am the following day, he does not move an inch, his head slumped forward in what is now known to be the position he died in. During his entire stay in the ER, Brian Sinclair was invisible to the medical staff, even after he vomited in the waiting room. He spent what is more than likely eight hours dead in his wheelchair before anybody attempted any resuscitation maneuvers on him. Vulnerable and with no advocate, he was considered a “frequent flyer,” drug user, and a homeless First Nations man, and he died while attempting to get help for what he knew was a serious medical condition. Between his arrival and the certification of his death, Brian Sinclair had neither been triaged nor had a nurse seen him in the 34 hours he spent in the ER, although 150 other patients had been processed through the department. A visitor eventually made the staff aware that Brian Sinclair’s neck was blue. Rigor mortis had already set in, with the coroner estimating that he had died hours prior to the first attempt at resuscitation. According to the coroner’s report, this death was preventable (Preston, 2014). The inquest into his death, published in 2014, makes clear that his visit to the ER was only the last station in a life lived under unlivable conditions. In 2004, Sinclair had had a bilateral lower leg amputation secondary to frostbite, suffered after he had been evicted from his apartment in the winter. During his hospital admission Mr. Sinclair was assessed by a multitude of medical professionals who

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considered him incompetent to manage his medical care on his own due to their perceptions of his cognitive impairment, non-compliance, and aggression. Some of Sinclair’s aggressive outbursts were undoubtedly related to his speech impairment, making it difficult for him to be understood; when he was eventually fitted with a “Chattervox” (a voice amplifier), it was easier for him to communicate. But only rarely during the inquest did medical personnel speak of his desire to help others, his fierce independence, his lasting friendships, and his ability at saving money. Following the rehabilitation period after his amputations, he attended a clinic specializing in reintegrating clients into the community. Nevertheless, he was soon deemed an inappropriate client and was discharged from the program with no other alternate care. At the same time, Sinclair was receiving home care for his indwelling Foley catheter, in place due to his hypotonic bladder. The nurse in charge of his care noted multiple times “the client’s noncompliance by being over a week late” (Preston, 2014, p. 30), not knowing that Sinclair had been admitted to hospital many times for bladder infections. His nurse at home care services put an “indefinite” hold on his catheter changes, a hold that was only reassessed after his death, because the system was not “designed for tracking down noncompliant clients” (Preston, 2014, p. 31). On September 17th, the nurses therefore had not flushed Mr. Sinclair’s catheter, leaving him with draining pus and abdominal pain. On the morning of September 19th, he saw a family physician who sent him to the ER on his own. His previous encounters with the ER staff and all of the assumptions that had been made about him contributed to an invisibility that was only deepened with the absence of an advocate and the loss of his complete medical chart in the department (Preston, 2014). How was it possible that the nurses did not see this man – that for them he did not exist? As critical theorist Axel Honneth would answer, the nurses failed to recognize, or they misrecognized, Brian Sinclair. Central to Honneth’s concept of recognition is the notion that for every human, cognitive attitudes are primarily grounded in affective relations: involvement, concern, interrelatedness, and modes of care. Humans can only survive in relationships of involvement and care with other humans – it is the basis of being human – and through these relationships the Other is recognized as a human being. In Sinclair’s case, because the nurses failed to be emotionally involved with him, they therefore could not recognize him. In Honneth’s approach then, “humans” are a given; they exist. If we fail to recognize another human being, it is because we have lost sight of our connection with him or her and perceive them as objects. A complete forgetfulness of recognition Honneth called “reification” (Honneth, 2008). But where Honneth understands reification as a set of practices that deny or lose sight of the primacy

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of recognition as a social practice, we will argue that this approach is not sufficient to understand the nurses’ actions in Mr. Sinclair’s case. We will demonstrate that Honneth is trapped in a paradox, because even if, as he contends, recognition is extended to all humans, a theoretical pre-condition still exists that excludes a large proportion of people who fall outside the boundaries of being recognizable – those who are unrecognizable. There will always be a remainder or a region of the unrecognizable; even if the parameters of granting recognition are expanded, this region is preserved and extended accordingly. And, we contend that recognition is based on power that differentiates, which explicitly and implicitly produces forms of inequality, and which will always be reactivated in the process of extending recognition. Recognition, understood through Honneth, cannot avoid mechanisms of inclusion and exclusion. In contrast, we will argue that we need to interrogate the concept of human itself. Survival depends foremost on whether or not patients are considered human subjects, which is of utmost importance for contemporary nursing, because a patient not perceived as a subject is either invisible or considered less than human and therefore, in the extreme, having a life not worth living. Nurses not only play a crucial role in constructing patients’ identities (through, for example, their observations and nursing reports) but are also sometimes directly involved in the murder of certain “abjects” (Foth, 2013a; Kristeva, 1982). We will highlight that Brian Sinclair’s death in the ER was only the final stage of a process of exclusion that started years prior to his death. These forms of inequality, we will claim, need to be addressed by nurses, and nurses must actively support democratic struggles around these questions. It is not possible to discuss all the implications of Honneth’s ethics of recognition within the limits of this chapter. However, we want to focus on the author’s assumption that intersubjective recognition is part of the ontogenesis of human beings. We will challenge the idea that a critical theory of nursing action means solely trying to extend recognition to include all “the people.” Instead, we will emphasize that a critical approach needs to challenge and change the relation between who is recognizable and who is not recognizable. Following this idea allows us to demonstrate how equality is understood in current societies and enables us to constantly negotiate what is meant and who is named by the people. In the following section, we will briefly critique some of the concepts in Honneth’s theory of recognition. Subsequently, using theorists like Foucault, Butler, Althusser, and others, we will describe how the “field of appearance” is structured by norms that determine who is visible and who cannot be seen. The final section will develop some ideas about how movements like Idle-No-More

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are effective ways for resisting the regulation of the field of appearance and how nurses should support these struggles.

Honneth’s Concept of Recognition and Reification The following summary of some of the main concepts cannot do justice to Honneth’s sophisticated theory and ethics of recognition. We point the reader to Friesacher’s contribution in this book for a more detailed and profound presentation of his approach (see also Friesacher, 2008). Central to Honneth’s social critique is an analysis of relations of recognition in contemporary societies. He called multiple forms of disrespect and humiliation social pathologies (Honneth, 1995), and the concept of alienation or reification that he developed in reference to Lukasc and that he defined as a complete forgetfulness of recognition, is a key concept of his social critique (Honneth, 2008). Honneth (1995) differentiated among three kinds of interpersonal recognition: first, emotional attention in the form of love and care; second, cognitive esteem in the form of accordance of rights; and third, social esteem as a sign of solidarity. The principle of love and care is dominant in the sphere of close relationships. Desires for love, emotional affection, and bodily proximity are fundamental for the development of self-confidence. The violation of this primary recognition in the form of abuse and assault threatens the physical integrity of the body. In the second, the sphere of legal relationships, justice is realized through the principle of equality. Recognition is shown to every subject in the form of cognitive respect and is based on the moral accountability of the Other. This aspect is important for the development of self-respect. Violation of this form of recognition, as, for example, in restricting the autonomy of residents in nursing homes and violating their privacy, threatens social integrity (Friesacher, 2008). The third sphere of recognition concerns social esteem. With this form of recognition – Honneth called it solidarity – a practical self-relation is realized as part of a shared consensus of values. The recognition of the social value of a person is threatened through debasement and stigmatization with the consequence that his or her dignity is violated. Seen from Honneth’s perspective, Brian Sinclair was not recognized on the dimension of love and care, the system granted him no rights, and nurses obviously did not show any solidarity with him. But these dimensions cannot explain how nurses literally did not see him, that only the surveillance cameras did. Brian Sinclair was not just misrecognized, but rather he was invisible and had no chance to appear – even after he vomited the nurses did not see him. From our critical perspective, the norms that regulate the field of appearance

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need critical analysis; Sinclair was more than reified, or objectified, by the nurses – he simply did not exist for them. Some of Honneth’s philosophical considerations are based on Hegel’s conceptualization of recognition (Honneth, 2010). In a chapter entitled “Self-consciousness” in his book Phenomenology of Spirit, Hegel demonstrated that a subject gains consciousness about itself only under the condition that it enters into a relationship of recognition with another subject (Hegel, 1807/1986). For Hegel this was the transcendent fact and a precondition of all human sociality. Only at the moment that the subject realizes that it is bound to its human counterpart is it able to control its desires because it depends on other human beings. The transformation from the natural to the spiritual/intellectual being, or the transformation from the human animal to the rational subject, is at the core of Hegel’s description. The life-and-death struggle that he described later in this chapter is a kind of procedural articulation of the implications that this basic spirituality/intellectuality possesses for humans (Honneth, 2010). Honneth combined Hegel’s philosophical assumptions with Mead’s social psychology and empirical findings from neuroscience, developmental psychology, and socialization research. Thus, Honneth demonstrated that in ontogenesis – that is, in a chronologically understood process – recognition must precede cognition (Honneth, 1995). This is to say that the individual’s learning process functions in such a way that a small child first of all identifies with her figures of attachment and must have emotionally recognized them before she can arrive at a knowledge of objective reality by means of other perspectives. Our epistemic relation to the world must be preceded by a stance of care, existential involvement, or recognition. According to this perspective, a child could not advance if he or she had not already developed a feeling of emotional attachment to a psychological parent, “for it is only by way of this antecedent identification that a child is able to be moved, motivated, and swept along by the presence of a concrete second person in such a way as to comprehend this person’s changes of attitude in an interested way” (Honneth, 2008, p. 42). Honneth argued that an autistic child is structurally prevented from emotionally identifying with a concrete second person, and due to this “emotional blindness,” remains entrapped within its own perspective on the world. Autistic children do not see, or rather they do not feel, that facial expressions, bodily movements, and communicative gestures give expression to attitudes. They are blind to the expressive mental content of such phenomena, or rather to their meaning (Honneth, 2008, p. 58). These forms of corporeal expressions, which can be described as anthropological universals independent of different cultural influences, are also an important part of interactions between adults. Reification is the abandonment of the originally given affirmative stance because it results in the elements of our

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surroundings being experienced as mere objective entities, as objects that are present-at-hand. Reification “signifies a habit of thought, a habitually ossified perspective, which, when taken up by the subject, leads not only to the loss of the capacity for empathetic engagement, but also to the world’s loss of its qualitative disclosed character” (Honneth, 2008, p. 39). Over and against a relationship of involvement and care, reifying attitudes are those that deny or deflect from this primary mode of engagement and support detached and distanced modes of observation and instrumentalization. We see several problems with linking Honneth’s definition of reification and recognition to nursing actions. For example, Honneth’s definition of reification as attitudes and relations that are distanced and detached is too narrow for a critical perspective of nursing action. While Honneth claims that reification occurs because people can merely observe others, we argue that modes of involvement and care exist that lose sight of others, but yet still qualify as modes of engagement. In many nursing contexts, nurses do more than merely observe their patients; they care for them but nevertheless violate them. I can “care” for someone to the point that she loses all independence. And in extreme cases, as Foth demonstrated for nurses under the Nazi regime in Germany, or for nurses working with different kinds of shock treatments in Canada, nurses can be emotionally engaged with their patients but still kill them (Foth, 2012, 2013a, 2013b, 2013c). If we consider involvement as neither good nor bad in itself but neutral with respect to normative claims, we then must acknowledge that even violence can be considered a kind of involvement, and that extreme aggression is an equally primordial, social, and human mode of engagement with others. Another critique of recognition is that Honneth understood love as a primary relationship that is constituted by strong emotional attachment among a small number of people. For Hegel, love represents the first stage of reciprocal recognition because, in it, “subjects mutually confirm each other with regard to the concrete nature of their needs and thereby recognize each other as needy creatures” (Honneth, 1995, p. 95). In the reciprocal experience of emotional involvement, both subjects know themselves to be united in their neediness, in their dependence on each other. But Judith Butler contended that we are beings “who have to struggle with both love and aggression in our flawed and commendable efforts to care for other human beings” (Butler, 2008, p. 101). If we do not define involvement as something that has a particular moral value before it is expressed in action then we have to acknowledge that we are struggling with ethical demands that can be answered by different affective responses (and any of these possible responses can be defined as morally good). Because we cannot determine the moral valence of these affective responses from the onset, we cannot search for the benevolent core of nursing or return to what Honneth called “genuine practice” (Honneth, 2008, p. 38).

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According to Butler this tension in social bonds between the capacity for destruction and a kind of goodness produces the ambivalent structure of the psyche, which in turn forms individual and group ethical attitudes and actions (Butler, 2005). It is also at the core of L8vinas’ considerations of responsibility (Butler, 2012; Foth, 2013c), where responsibility emerges as a consequence of being subject to the unwilled address of the other (L8vinas, 1981). He called this pre-ontological condition of being persecution, and it is persecution that eventually creates responsibility for the other (L8vinas, 1981). However, our most important critique concerning Honneth’s concept of recognition is his basic assumption that all human subjects should be recognized equally, an assumption that is based on the idea that all human subjects are, in principle, equally recognizable. In the following section, we will challenge this assumption and demonstrate the theoretical difficulties that come with this approach.

The problem with recognition We argue that the field of appearance is highly regulated and does not allow everybody to appear. Being able to appear, or being visible, means to embody norms that make one recognizable in the first place, and it also means that these norms need to be reproduced or performed, thereby reproducing the field of appearance at the same time. Therefore, recognizability cannot be thought of as a natural quality of individual humans (Murray & Butler, 2007; Murray & Holmes, 2009). The idea of personhood is based on a normative ideal, which produces certain recognizable persons but makes it far more difficult to recognize others because they do not conform to that which is normatively understood as recognizable. As mentioned, Hegel concluded that recognition results in a transformation from the natural to the spiritual/intellectual being, or the transformation from the human animal to the rational subject (Hegel, 1986). Questions arise as to what exactly is it that separates the rational subject from the human animal, and would it even be possible to recognize a human if it were not separated from its animalistic existence? The fact that it is possible to ask which human can be recognized demonstrates that there exists a field of “the human that remains unrecognizable, according to dominant norms, but which is obviously recognizable within the epistemic field opened up by counterhegemonic forms of knowing” (Butler, 2015, p. 36). This highlights a fundamental contradiction in the concept of recognition. The moment one argues that the non-recognized group should be included, one implicitly introduces a criterion by which one can judge who can be recognized as human. Butler called this a “bind” (Butler, 2015, p. 36) of

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recognition; the criterion presumes there is a realm of the nonhuman because the human can only be differentiated against what is considered nonhuman. Norms of recognition constantly differentiate between people who will be recognized and those who will not – or, in other words, who is a subject and who is not. Foucault highlighted that this mechanism is decisive in societies of normalization. He believed that modern societies were based on a specific regulatory power that he called biopolitics, which is a form of power anxious to provide the means to sustain a population and allow it to prosper. This power governs through norms and processes of normalization rather than through the law, but it comes with what Foucault called state racism. Racism is a means to introduce a distinction between those who are allowed to live and those who must die. This rupture in the biological continuum of the human species enables differentiation between races, allows them to be hierarchically sorted, and qualifies some races as superior to others. Racism, in other words, introduces difference into populations. As Foucault noted, “this will allow power to treat that population as a mixture of races, or to be more accurate, to treat the species, to subdivide the species it controls, into the subspecies known, precisely, as races” (Foucault, 2003, p. 255). Regulatory power “not only acts upon a pre-existing subject but also shapes and forms that subject” (Butler, 2004, p. 41), and even disciplinary power has productive effects. Furthermore, “to become subject to a regulation is also to become subjectivated by it” (p. 41), or in other words, a subject is brought into being through the act of regulation. The precondition for someone to be culturally intelligible is to occupy a subject position and to come to terms with the norms that govern recognition. These norms have not been chosen by the individual but rather, the individual is the result of a cultural power that formed it. A social existence requires an unambiguous affinity to the norms of appearance because it is not possible to exist in a “socially meaningful sense” outside these established norms (Butler, 1986, p. 508). A subject, according to Butler, becomes a subject only by entering the normativity of language; the “rules precede and orchestrate the very formation of the subject” (Butler, 1997b, p. 135). In other words, the individual becomes a subject at the moment it accepts the norms that make it intelligible. Althusser’s idea of interpellation is another way of conceptualizing the fact that an individual can only occupy a subject position if it reacts to the call of a power. He perceived this call as a demand of an ideology to conform with this ideology. An ideology describes “systems of representation – composed of concepts, ideas, myths, and images” (Hall, 1991, p. 101); in short, it is another term for language or discourses. By defining ideologies as “systems of representation,” Althusser demonstrates that the human is itself a product of power

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and can only appear within specific systems of representation and meaning. His central claim is that ideology “acts” or “functions” in such a way that it “recruits” subjects among individuals (it recruits them all), or “transforms” individuals into subjects (it transforms them all) by that very precise operation which I have called interpellation or hailing, and which can be imagined along the lines of the most commonplace everyday police (or other) hailing: “Hey, you there.” Assuming that the theoretical scene I have imagined takes place in the street, the hailed individual will turn round. By this one-hundred-andeighty-degree physical conversion, he becomes a subject. Why? Because he has recognized that the hail was “really” addressed to him, that “it was really him who was hailed” (and not someone else). (Althusser, 2001, p. 118)

To become a subject means turning around to face the ideology and enter into the language of self-description – hence, “Here I am.” It is only by accepting the call, by acknowledging that it is me who is called by power, that I become a subject. But entering into language has its price because “the subject is differentiated against the ‘unspeakable’; the production of the ‘unspeakable’ is the pre-condition for the subject’s formation” (Butler, 1997a, p. 135). Along with Lacan, Butler argues that a “bar” exists within political life that marks the point from where the question of being able to speak is a condition of the subject’s survival. Butler calls this “foreclosure” because it is prior to speech and is a reiterated effect of a structure, meaning that the subject is performatively produced as a result of the “primary cut” (p. 138). Henceforward, “unintelligible” creatures emerge that dwell in uninhabitable zones (“abjects,” according to Kristeva) (Butler, 1997a). The action of foreclosure does not happen just once, but continues to happen, “and what is reinvoked by its continued action is precisely that primary scene in which the formation of the subject is tied to the circumscribed production of the domain of the speakable” (p. 139). This poses the problem that in order to explain foreclosure one must use grammar that constitutes this foreclosure. All these theoretical considerations highlight that, in contrast to Honneth’s assumptions that humans and recognition precede cognition – that they are ontological a priories – humans are actually produced by power. Recognition is only possible within historical schemas that establish domains of intelligibility for the human (Butler, 2009a) and for what is considered human life. A life must be knowable as a life, and in order to achieve intelligibility it has to conform to certain conceptions that define what life is. Thus, schemas of intelligibility condition and produce norms of recognizability. The paradox of the frame exists in that it never contained the scene it was meant to limn, because something is already outside, excluded by the frame, which makes the sense of that which remains inside possible. Every identity is relational within an unstable system of

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differences (Laclau, 1994, 2007; Laclau & Mouffe, 1985). For those who are excluded by the norms but who are expected to embody these norms at the same time, the struggle becomes an embodied one for recognizability. The healthcare system itself is organized, structured, and regulated as a field of appearance that determines who can be seen, recognized, allowed to speak, and be cared for. Sinclair’s case clearly indicates that if one is in need of the healthcare system one must be able to appear in some form. So, too, for another example, must those who become aware that they are HIV-positive, for under new prevention strategies like “STOP/Test-and-Treat,” they are expected to become responsible self-governing citizens or risk being criminalized or abandoned by the healthcare system. Few of those living at the margins of society – drug users, Aboriginal peoples and sex workers, etc., – are able to conform to these norms of responsibility, but the Test-and-Treat strategy makes it no longer necessary to examine or ameliorate the underlying social factors producing marginalized at-risk populations (Foth, O’Byrne, & Holmes, 2015). Those who do not or cannot comply with the demands of the healthcare system are but one version of a population deemed disposable.

What Makes for a Grievable Life? An Alternative Foundation Of Ethics As Brian Sinclair’s case demonstrates, being able to appear in the healthcare system is complicated because it is not only a question of how the body presents itself, but “how one even gets a place in the queue that might possibly lead” to treatment in the hospital (Butler, 2015, p. 41). Throughout the latter stages of his life, Sinclair struggled to appear; as an alcoholic Aboriginal man he conformed neither to racial norms nor to the norms of a compliant patient in the healthcare system, and he lived under unlivable conditions. But if we reject Honneth’s ethics of recognition, which we contend is based on the dichotomy of human versus nonhuman, what alternative do we have to develop another ethical foundation? In the following section we will briefly outline how an alternate ethics could be conceptualized that is not based on the idea of recognition as an ontological given of human beings, but rather uses the idea of the vulnerability and precariousness of life, and one that incorporates Honneth’s emphasis on the interconnectedness of beings. We propose using Butler’s “perspective of loss” as an alternative foundation of ethics (Butler, 2009b, p. 20). Different from an ethics based on recognition, in which a “we” is defined by a shared humanness, a perspective of loss speaks of a “we” because “all of us have some notion of what it is to have lost somebody”

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(Butler, 2009b, p. 20). Thus, “we” is constituted by our shared experience of loss. No longer do we need to recognize another human, but rather, the moment we experience the pain of losing somebody, “we” realize that our body is a social phenomenon constituted through the world of others. Loss, and the vulnerability that accompanies it, are important aspects of our living condition because we are socially constituted bodies attached to others. In Butler’s understanding, mourning means that we accept the loss of another and through it, will be transformed – that something larger than one’s own deliberate plan or project takes hold of oneself. Mourning is a sign that I have lost somebody who was part of what I am. In losing somebody, I lose something of me. In other words, mourning reveals something about us; it reveals that we are interconnected with others and that these ties constitute us. In losing an “other,” a “you,” one discovers that “‘I’ have gone missing as well” (Butler, 2009b, p. 22). Understood in this way, grief provides a sense of political community (see also Foth, 2009; Foth, 2013c). Living in this world means sharing it with others and if another dies, something that I myself need to live is lost. This basic condition of my embodied life binds me to the Other, another I never chose, and that not only shows that I cannot be perceived as autonomous, but it also makes me vulnerable to the actions of others. I cannot live autonomously in this world; I need those who surround me, even those who I do not know, because they are a part of the world in which I live. It is this “unwilled proximity” with others (Butler, 2006; L8vinas, 1996) that makes us vulnerable and life precarious because it implies that we can be exposed to violence, a violence that results from exploiting this precariousness of life. I become vulnerable because I can be neglected, or not allowed to appear, by the Other. Thus, a hierarchy of grief exists, meaning that some lives are not grieved; they cannot be mourned for. As Butler noted, to have a grievable life, “there would have had to have been a life, a life worth noting, a life worth valuing and preserving, a life that qualifies for recognition” (Butler, 2006, p. 34). Otherwise, “there is no life, or, rather, there is something living that is other than life … ‘there is a life that will never have been lived,’ sustained by no regard, no testimony, and ungrieved when lost” (Butler, 2009b, p. 15). Certain lives that are lost do not touch me; if I cannot grieve for somebody it is because I don’t consider that life a part of what I am and therefore fail to acknowledge its vulnerability. If I accept that I am vulnerable because I depend on others, then I cannot neglect or violate another, because I know that I would destroy what enables me to live. Violence begins at the level of discourse because those lives that are not considered lives at all cannot be humanized; they do not fit into the frame of the human. Dehumanization first occurs within discourses and then gives rise to physical violence “that in some sense delivers the message of dehumanization that is already at work in the culture” (Butler, 2006, p. 34). In 2015, for example,

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the CBC decided to temporarily shut down its comments section on stories about indigenous people, due to the “uncivil dialogues” and the openly racist comments on its website (Office of the GM and Editor in Chief, 2015). Nevertheless, the discourses themselves can effect violence through omission; they do not simply produce a treatment that is structured by this very discourse, but rather, dehumanization emerges at the limits of discursive life; a refusal of discourse produces dehumanization: there is “a limit to discourse that establishes the limits of human intelligibility” (Butler 2006, p. 35). The result is a death that is unremarkable – a death that vanishes. “Violence against those who are already not quite living, who are living in a state of suspension between life and death, leaves a mark that is no mark.” If a life “is not grievable, it is not quite a life; it does not qualify as a life and is not worth noting. It is already the unburied, if not the unburiable” (Butler, 2006, p. 36). We argue that it was this mechanism that was at work in the life of Brian Sinclair. His life was not valued nor considered worthy of preserving – even his medical file was lost. It took more than seven years before his case was investigated, and the inquest never addressed the racism that led to his death. A critique of violence must begin by questioning the representability of life itself, because such an interpretative scheme tacitly divides worthy from unworthy lives.

Implications of vulnerability for nursing ethics It is of paramount importance for nurses to comprehend that what we consider “ontological givens” are the result of specific operations of power. One aspect of this power is what we call state power, but the power that we try to understand here precedes and exceeds state power. These ontological givens comprise notions of the subject (or in Honneth, the human), culture, identity, and religion that seem to be self-evident within a historical, normative framework. These frameworks determine modes of intelligibility that are often supported and used by the state but “are themselves exercises of power even as they exceed the specific domain of state power” (Butler, 2009b, p. 149). They encourage reducing the complexity of populations to specific identity forms. A critical perspective in nursing must focus on the violence affected by these normative frameworks and must offer “an alternative account of normativity based less on ready judgment than on the sort of comparative evaluative conclusions that can be reached through the practice of critical understanding” (Butler, 2009b, p. 150). Critical understanding destabilizes and reworks normativity, which delivers the “unjust judgment that certain lives are worth saving and others worth killing” (p. 151). The perspective that we propose here for nursing requires a rethinking of the subject as a dynamic set of social relations.

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As such, if my constitution implicates the other in me, I am constituted with something foreign as part of myself, which is the source of my ethical connections. This kind of analysis is capable of “calling into question the framework that silences the question of who counts as a ‘who’ – in other words, the forcible action of the norm circumscribing a grievable life” (Butler 2009b, p. 163). Conceptualizing the body as bound up with others enables one to reconsider the body in the field of politics. The body “that exists in its exposure and proximity to others, to external forces, to all that might subjugate and subdue it, is vulnerable to injury ; injury is the exploitation of that vulnerability” (Butler 2006, p. 61). Nurses in particular must be aware of the two separate truths about the body : it is intimately tied to others, enabling the living of a life, and it allows for the possibility of subjugation and cruelty. Lost Aboriginal life is not grievable because it does not matter as life, and the fact that members of Aboriginal communities are at an increased risk for murder and violence is rarely recognized by the public. Brian Sinclair’s ungrievable life is just one among many. Many Canadian Aboriginal women, for example, are killed or disappear without leaving any mark. In 2014, an RCMP report concluded that the number of missing Aboriginal women, the vast majority of whom are presumed murdered, constituted 16 % of all murdered women in Canada (Government of Canada, 2014, p. 3), even though they make up only 3 % of the female population; more recently, the government acknowledged that this number is much higher than previously thought. Suicide attempts are also more frequent among Aboriginal women, with a rate 3.6 times higher than for all Canadian women. The refusal of the former Conservative government to conduct an inquiry into these deaths highlights the willingness to allow these women (and men) to just disappear without grieving their deaths. The deaths of these women, and of Brian Sinclair, were not due to human failure but rather to the fact that the communities and populations to which they belong have no way to appear in public; they are literally not seen. If we want to truly understand what makes for a livable, or grievable, life, we need to move beyond Honneth’s concept of recognition. The world we share is not restricted to humans, and thus human life can never be used as the crucial aspect to define what the human is. What we call human life presumes connections to other (nonhuman) forms of life. As Butler (2015) emphasized, the connection with nonhuman life is indispensable to what we call human life. In Hegelian terms: if the human cannot be the human without the inhuman, then the inhuman is not only essential to the human, but it is installed as the essence of the human. This is one reason that racists are so hopelessly dependent on their own hatred of those whose humanity they are finally powerless to deny. (Butler, 2015, p. 42)

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What is called human life must be negotiated based on the fact that we are “a living creature among creatures and in the midst of forms of living that exceed us” (Butler, 2015, p. 43). Therefore, a critical perspective must be based on the insight that other lives are the condition of who I am and I am only alive because I am connected to what is living – beyond the realm of the human. Humans can only live because they are part of a “biological network of life that exceeds the domain of the human animal” (Butler, 2015, p. 43). The destruction of the environment and infrastructure necessary to sustain life destroys the possibility of living a livable life. We argue therefore that nurses need not only to critically question the frames of normativity that regulate the field of appearance and that lead to injury and violence against those who are excluded, but also to fight for the protection of conditions necessary to live a livable life. A 2011 United Nations report, for example, demonstrated that the Attawapiskat First Nations were living in “dire” conditions (Mackrael, 2011), with no drinking water available and housing consisting of tents and sheds (Pentland & Wood, 2013). One in six First Nations’ reservations lives under a water warning that has been in place in most cases for many years (Pentland & Wood, 2013). Yet another example is the toxic soil on which many Aboriginals live. Butler rightly reminds us that contaminated soil undermines the survival of all humans because each life in a common world is connected to all others, and unlivable conditions for some undermine the possibility of my own life (Butler, 2015).

Resistance and Nursing The demand for the right to appear is not just theoretical but rather is a bodily demand for more livable lives. We take the Idle No More movement, one of the largest Indigenous mass movements in Canadian history, as a paradigmatic example of this demand. Initiated by those who had been abandoned by the political realm and excluded from economic processes, Aboriginal communities entered the field of appearance and claimed their right to be recognized. Through ongoing mass demonstrations they claimed that they were still here and that their condition was shared. Their bodies became a means to say that “we are not disposable,” and that we demand livable lives, to be recognized and valued (Butler, 2015, p. 25). We contend that this movement is not just an embodied way to challenge the relation between who is recognizable and who is unrecognizable; it is also about the question of how equality can be understood and carried out. Nurses, we believe, need to actively engage with and support these movements.

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Conclusion This chapter began with the example of Brian Sinclair, who died alone in an ER in 2008 with, literally, never having been seen. According to Honneth’s concept of recognition, nurses lost sight of the primacy of recognition as a social practice and “reified” Brian Sinclair. We argued that Honneth’s concept of recognition cannot escape the paradox that as soon as we speak about the “human,” something that is not human must be excluded – the notion of the human is already based on a normative frame. According to the considerations we developed here, a human can only be considered a human if it is produced according to norms that qualify it as human. The same is true for life as such. According to Butler, only a life that is grievable is a life that matters and the normative frames that determine who counts as human also determine what counts as a grievable life. Using the idea of grievable lives as a basis for an ethics in nursing enables us to question the way these normative frames work and the inequalities they produce, without resorting to an ontological notion of the human. Using the idea of vulnerability and precariousness of life incorporates Honneth’s emphasis on the interconnectedness of beings without being trapped in the paradox that even if recognition is extended to all humans, a theoretical pre-condition still exists that excludes a large proportion of people who fall outside the boundaries of being recognizable – those who are unrecognizable. Since normative frames generate specific, historically contingent ontologies of the subject, Brian Sinclair’s death raises the ethical question: When and how do violence and injury emerge? To answer this question means acknowledging that not only does a normative notion of the human exist, thereby creating a category of nonhuman whose members are forever excluded from being regarded as human, but also that this restrictive conception of the human permits violence and even murder against these excluded individuals. The recognition of what counts as a human is political and not based on a universal trait of the human. We assert that Honneth’s concept of recognition cannot comprehend this dimension. We wanted to demonstrate that the subject itself is the result of specific operations of power, that what we can recognize is already the result of a power that forces a particular identity on us. We therefore can only acknowledge what has been produced by this power, not something (the human) that is antecedent to power. Brian Sinclair’s death, and the ungrievable deaths of thousands of Aboriginal people, can only be understood when we begin to question the representability of life itself – meaning who can be seen – because this kind of an interpretative scheme divides those who can appear from those who cannot. A critical, political task of nursing must be to question the functioning of these interpretive schemes and to highlight how certain parts of a population are rendered invisible. Moral

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horror may be a sign of our humanity, but the humanity in question is divided into those whose lives touch us, and those whose lives, and deaths, remain invisible to us.

References Althusser, L. (2001). Ideology and ideological state apparatuses. Notes towards an investigation. Lenin and philosophy and other essays (pp. 85–126). New York, NY: Monthly Review Press. Butler, J. (1986). Variations on sex and gender : Beauvoir, Wittig, and Foucault. Praxis International, 5(4), 505–516. Butler, J. (1997a). Körper von Gewicht [Bodies that Matter]. Frankfurt a. M.: Suhrkamp. Butler, J. (1997b). The psychic life of power: Theories in subjection. Stanford: Stanford University Press. Butler, J. (2004). Gender regulations. In J. Butler (Ed.), Undoing gender (pp. 40–56). New York, NY: Routledge. Butler, J. (2005). Giving an account of oneself. New York, NY: Fordham University Press. Butler, J. (2006). Precarious life. In J. Butler (Ed.), Precarious life: The powers of mourning and violence (pp. 129–151). London: Verso. Butler, J. (2008). Taking another’s view: Ambivalent implications. In M. Jay (Ed.), Axel Honneth reification: A new look at an old idea (The Berkely Tanner Lectures, pp. 97–119). Oxford, New York: Oxford University Press. Butler, J. (2009a). Introduction. In J. Butler (Ed.), Frames of war : When is life grievable? London: Verso. Butler, J. (2009b). Precarious life, grievable life. In J. Butler, (Ed.), Frames of war : When is life grievable? (pp. 1–32). London: Verso. Butler, J. (2012). Parting ways: Jewishness and the critique of Zionism. New York, NY: Columbia University Press. Butler, J. (2015). Notes toward a performative theory of assembly. Cambridge, MA: Harvard University Press. Foth, T. (2009). Biopolitical spaces, vanished death, & the power of vulnerability in nursing. Aporia 1(4), 16–26. Foth, T. (2012). Nurses, medical records and the killing of sick persons before, during and after the Nazi regime in Germany. Nursing Inquiry, 20(2), 93-100. doi:10.1111/j.14401800.2012.00596.x. Foth, T. (2013a). Caring and killing: Nursing and psychiatric practice in Germany, 1931–1943. Göttingen: V& R. Foth, T. (2013b). Shock therapies as intensification of the war against madness in Hamburg, Germany : 1930–1945. Canadian Bulletin of Medical History, 30(2), 161–184. Foth, T. (2013c). Understanding ”caring” through biopolitics: The case of nurses under the Nazi regime. Nursing Philosophy, 14(4), 284–294. Foth, T., O’Byrne, P., & Holmes, D. (2015). Health prevention in the era of biosocieties: A critical analysis of the ‘Seek-and-treat’ paradigm in HIV/AIDS prevention. Nursing inquiry. doi:10.1111/nin.12114.

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Foucault, M. (2003). Society must be defended: Lectures at the CollHge de France 1975–1976. New York, NY: Picador. Friesacher, H. (2008). Theorie und Praxis pflegerischen Handelns. Begründung und Entwurf einer kritischen Theorie der Pflegewissenschaft (Vol. 2). Göttingen: V& R. Government of Canada. (2014). Missing and murdered Aboriginal women: A national operational overview. Government of Canada. Retrieved from http://publica tions.gc.ca/collections/collection_2014/grc-rcmp/PS64-115-2014-eng.pdf. Hall, S. (1991). Signification, representation, ideology : Althusser and the post-structuralist debates. In R. K. Avery & D. Eason (Eds.), Critical studies in mass communication (pp. 88–113). New York, NY: The Guilford Press. Hegel, G. W. F. (1807/1986). Selbstbewußtsein. Die Wahrheit der Gewißheit seiner selbst [Self-consciousness. The Truth of the certainty of one self]. In Hegel, Phänomenologie des Geistes [Phenomenology of spirit] (pp. 137–177). Frankfurt a. M.: Suhrkamp. Honneth, A. (1995). The struggle for recognition. The moral grammar of social conflicts (A. Joel, Trans.). Cambridge, MA: The MIT Press. Honneth, A. (2008). Reification and recognition. A new look at an old idea (J. Ganahl, Trans.). In M. Jay (Ed.), Axel Honneth reification: A new look at an old idea (pp. 17–96). Oxford: Oxford University Press. Honneth, A. (2010). Das Ich im Wir [The I in We]. Frankfurt a. M.: Suhrkamp. Idle No More. (n.d.). The Manifesto. Retrieved from http://www.idlenomore.ca/manifesto Kristeva, J. (1982). Powers of horror : An essay on abjection. New York, NY: Columbia University Press. Laclau, E. (1994). Why do empty signifiers matter to politics? In J. Weeks (Ed.), The lesser evil and the greater God (pp. 167–178). London: Rivers Oram Press. Laclau, E. (2007). On populist reason. London: Verso. Laclau, E., & Mouffe, C. (1985). Beyond the positivity of the social: Antagonisms and hegemony. In E. Laclau & C. Mouffe (Eds.), Hegemnoy and socialist strategy (pp. 93–148). London: Verso. L8vinas, E. (1981). Otherwise than being: Or beyond essence. Boston, MA: Kluwer. L8vinas, E. (1996). Peace and proximity. In A. T. Peperzak, S. Critchley, & R. Bernasconi (Eds.), Emmanuel L8vinas: Basic philosophical writings (pp. 161–169). Bloomington: Indiana University Press. Mackrael, K. (2011, December 20). UN official blasts ‘dire ’ conditions in Attawapiskat. The Globe and Mail. Retrieved from http://www.theglobeandmail.com/news/politics/unofficial-blasts-dire-conditions-in-attawapiskat/article4085452/. Murray, S. J., & Butler, J. (2007). Ethics at the scene of address: A conversation with Judith Butler. Symposium: Review of the Canadian Journal for Continental Philosophy, 11(2), 415–445. Murray, S. J., & Holmes, D. (2009). Introduction: Towards a critical bioethics. In S. J. Murray & D. Holmes (Eds.), Critical interventions in the ethics od healthcare: Challenging the principle of autonomy in bioethics (Vol. Medical Law and Ethics, pp. 1–11). Cornwall, Great Britain: Ashgate. Office of the GM and Editor in Chief. (2015). Uncivil dialogue: Commenting and stories about indigenous people. Retrieved from http://www.cbc.ca/newsblogs/community/ editorsblog/2015/11/uncivil-dialogue-commenting-and-stories-about-indigenouspeople.html.

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Pentland, R., & Wood, C. (2013). Drowning in neglect. If the government treated Attawapiskat like Afghanistan, Canada’s First Nations communities would have safe water. alternativesjournal.ca, 39(4), 39. Retrieved from http://www.alternativesjournal.ca/. Preston, T. J. (2014). In the provincial court of Manitoba: In the matter of the fatality inquiries act of Brian Lloyd Sinclair, deceased. Retrieved from Ottawa, Ontario: http:// www.manitobacourts.mb.ca/site/assets/files/1051/brian_sinclair_inquest_-_dec_14. pdf.

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Chapter Six: Professional Responsibility and Technologically Informed Decision Making: The Rise and Demise of the Compassionate Algorithm

Introduction This chapter situates professional responsibility as a potential site of meaning construction for nurses in the development of their professional identity. The line of argument is directed towards the interrogation of professional responsibility as it is understood by professionals working in particular clinical contexts – professionals who are engaged in the performance of person-centered practices that are driven by integrated and embodied knowledge (see, for example, Lapum et al., 2012). Specifically, our purpose in this chapter is to work towards the deconstruction of the dominant model of professional responsibility, which supports practitioners engaging with technological expertise (for example, the use of algorithms (Freshwater, 2014) and their cyborgic desires (what Haraway (1991) and Lapum et al. (2012) perceived as the hybridity of machine and human, including the use of electronic and mechanical devices to enhance human functioning and processes), while maintaining a commitment to provide compassionate and responsive care respectful of patients’ autonomy. The focus of this chapter is on the technologies that aid decision making, that is, Clinical Decision Support Systems (CDSSs). Accordingly, technological expertise is defined as the user’s ability in the management of such technologies. Technical expertise, which aids decision making, is sometimes perceived as contributing to efficiency, certainty, and rationalization through a logical stepby-step approach to the diagnosis, assessment, and management of a clinical problem. However, the literature on technical expertise is contradictory ; some of it suggests that the use of technology contributes to a higher number of errors and “unsafety” (Jerak-Zuiderent, 2012), while some argues that it prevents errors from occurring (Balla, Heneghan, Thompson, & Balla, 2012). The translation and implications of technological aids in decision making in relation to professional responsibility in nursing is as yet an under-explored area, as is the role of nursing in supporting data-driven decision making, and in this context, even what counts as data. As such, this chapter will seek to respond to a number

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of questions regarding the impact of technological expertise in relation to the diagnosis, assessment, and management of treatment, and how technological expertise based on algorithmic thinking can be integrated into compassionate and safe care that is respectful of patient autonomy. We will also explore the implications of the application of technological expertise in decision-making processes in the development and enactment of professional responsibility.

Background The premise of this chapter is focused on the discourse of professional responsibility as a site of meaning construction for nurses in the development of their professional identity. While this chapter will consider the evidence-based status of technology/technical expertise in its supportive role in nurses’ decision making, the focus will be as much on the discourses underpinning the concept of evidence and the definition of practice as decision making, as well as the dynamic function that discourses play in the construction of meaning. Meaning making is inherently a dynamic process facilitated through engagement with (or resistance to) dominant discourses – in this case, that of “professional responsibility.” Such an approach aligns with the overarching aim of this chapter to foster a critical and reflexive approach to generating models of nursing ethics – models that are derived from a plurality of understandings and a genuine acknowledgement that discourses themselves at any point in time represent only a partial view and reading of current practice. Explicitly adopting a questioning and critical stance is not just an academic consideration. Unquestioning acceptance of a dominant discourse around, for example, “professional responsibility,” without giving due consideration to other competing discourses, may lead to all kinds of problems for patients, practitioners, and indeed the profession of nursing itself (see, for example, Francis, 2013).

Defining the Concepts Before we interrogate the discourse of professional responsibility – how it has evolved and how it may be de/constructed in the future – we set out some key working definitions. In the context of this text, we use the term discourse to denote a formalized way of thinking that is manifested not only through language, but also through actions embodied, enacted, and performed through social practices (Butler, 1990; Freshwater, 2007). We also use the term discourse to refer to a set of rules and assumptions for organizing and interpreting the subject matter of an academic or practice discipline or field of study such as

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nursing (Freshwater, Cahill, & Essen, 2013). Discourse is an umbrella term used to cover a number of theoretical approaches and analytical constructs derived from linguistics, semiotics, social psychology, cultural studies, post-structuralism, and postmodernism. Freshwater (2007, p. 111) argued that the concept of discourse captures a variety of different approaches to understanding and goes “beyond language to apprehend organized meanings on a given theme.” Thus, for the purposes of this chapter, we define discourse as a detailed exploration of political, personal, media, or academic “talk” and “writing” about a subject. We agree that “it is designed to reveal how knowledges are organized, carried and reproduced in particular ways and through particular institutional practices” (Freshwater, 2008, p. 221; see also Freshwater, 2007; Maclure, 2003). In addition, we argue for a composite definition of discourse, which, in going beyond language, allows both linguistic and individual agencies to exist in parallel (Freshwater, 2007; Freshwater & Rolfe, 2004). In this chapter we are using the current dominant model of professional responsibility in nursing, which has emerged from practitioners engaging with technological expertise and its resulting cyborgic ontology (as described by Haraway (1991) who posited that we are all materially and ontologically cyborgs), while maintaining a commitment to provide compassionate and responsive care respectful of patients’ autonomy. Technological expertise we define as a range of technologies used to enhance clinical professional practice, specifically decision making, including active and passive systems. The general principle is that in technologically informed decision making, patient characteristics are matched to a computerized knowledge base to generate assessment and recommendations specific to each patient. At this point, however, we want to highlight that there is no definitional certainty of the sociological term profession (Evetts, 2006). As Freidson (1986) noted over three decades ago, there must be some shared, minimum understanding of a profession in order for it to be defined and recognized as such. The concept of professional identity is closely associated with that of professional responsibility. As Essen, Freshwater, and Cahill (2015) observed, identity is not static, and rather like the dynamic notion of professional responsibility, we often fail to recognize that the term “professional” is context dependent and changes over time – a point that is missed by many managerial and ideological agendas. The Francis Report (2013) examined the causes of the failings in care at the Mid Staffordshire NHS Foundation Trust between 2005–2009. Of the 290 recommendations that were made, “openness, transparency and candour,” including a statutory duty of candour, were signalled as fundamental standards for healthcare providers that would provide improved support for compassionate and committed caring and stronger healthcare leadership. This report, however, attempted to define and describe professionalism (or rather the absence of it)

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outside of the context of practice, the underlying considerations of occupational autonomy and control, and the professional ethics and moral values of integrity and trust. Nevertheless, the Francis Report must be understood within the ideological agendas of the state, where managerial and even intra-professional hierarchies cannot be denied or ignored.

The Evolution and Problematizing of the Discourse of Professional Responsibility Health professionals in general seem to practice with little awareness and indeed acknowledgement of the constructed and storied nature of the health field (Holloway & Freshwater, 2007) and of the construct of professional responsibility (Stronach, Corbin, McNamara, Stark, & Warne, 2002). We argue that critical engagement with the discourse of professional responsibility, its problematizing, can be realized through the practice of deconstruction. Any deconstruction of a discourse is, of course, reliant on an awareness of the processes that establish and maintain the discourses. For clarity, here we define deconstruction as the process of making the construction and development of a text explicit and subsequently, the posing of challenges to that construction (Freshwater & Rolfe, 2004). We argue that it is through this process of deconstruction that we arrive at sharper definitions and can contribute to the refinement of the discourse. Challenges to a discourse include interrogations of the way in which language is used in the text to define social systems. Language is not innocent; it does something, is active, and its actions have consequences (Widdowson, 2004). Such consequences have implications for the ways in which individual and professional identities are conceptualized within nursing practice. In other words, individuals and disciplines both invent and are invented by the discourses or stories around them. Understanding how a discourse has developed is, we suggest, a necessary precursor to deconstruction of that discourse. Hence, we take a minor detour here, focusing on the evolution of the discourse of professional responsibility in order to help us arrive at an understanding of how this discourse has secured its privileged position. We also present some challenges that are currently being mounted to the discourse of professional responsibility, a discourse that is predicated on practitioners engaging with technology and technologically aided decision making alongside maintaining the commitment to the provision of compassionate and responsive patient-centered care. Often informed by state and managerialist agendas, a professionally responsible practice is seen as one in

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which scientific data is increasingly being used to drive decision making in aspects of care that may previously have relied upon tacit knowledge and expert practice. Williams (2008, p. 535) has argued that “professions and academe have developed a symbiotic relationship, although which is ‘tenant’ and which ‘host’, and which derives benefit from which, is characteristically contested.” We assert that traditional academic conceptualizations of professionalism are simply social constructions, in that they are always in the process of becoming, are dynamic, contingent, partial, and unstable. Nevertheless, professions have attempted to define themselves, in part, at least by shared minimum understandings and expectations, many of which form the basis of codes of professional conduct that underpin professional curricula and training schema. Williams (2008, p. 534), drawing on the work of Stronach et al. (2002), suggested that “Professions exist, it would appear, in the ‘inside-out/outside-in’ negotiating space between the two competing agendas of the ‘ecologies of practice’ (linked to intra-professional hierarchies) and the ‘economies of performance’ (linked to state and managerial agendas).” Gannon (2010, p. 868), also referring to Stronach (2010), proposed that “Professional identities are worked in the gap between the increasing neoliberal pressures for accountability and audit, or ‘economies of performance’ and individual and collective ‘ecologies of practice,’” contending that the professional is framed as an implementer of policy (Stronach et al., 2002). It can be seen then that professional practices, and the regulation of professions, are highly political, and discourses around professional responsibility and identity must be understood in this context. Fisher and Freshwater (2014a, p. 14), referring to the practices of mental health professions, argued that “mental health and social functioning are significantly shaped by social and political issues,” including the exercise of power. Such issues pose interesting challenges to the identity of a profession and to the conceptualization of what it is to be a professional, a debate that has been welldiscussed by and about nurses for decades. Healthcare and healthcare policy, like higher education, are challenged and influenced by a range of changing socio-economic and environmental factors (Freshwater, 2014), and increasing pressure, most often neoliberal in origin, for greater and more transparent accountability, auditing, and metricization – the previously mentioned economies of performance (Freshwater, 2014; Stronach, 2010; Stronach et al., 2002). This overemphasis on audit and regulation is focused on the “being” (current state) of the profession, rather than its “becoming” (the appreciation of its movement and fluidity), as if professions and professional identity are static and unchanging, whereas what is captured and measured by the current state of auditing is actually only a snapshot of a moment in time.

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Against this epistemological backdrop, discourses of professional responsibility and specifically those that support practitioners in embracing technological expertise, have been and continue to be privileged. They have been viewed as the pinnacle of the delivery of effective nursing care, focused as they are on objectives of patient safety in the diagnosis and management of clinical problems (Balla et al., 2012; Garg et al., 2005; Locsin, 2005; Sherwood, 2013). However, there are other competing discourses and lines of evidence suggesting that technology may contribute to a higher number of errors (Jerak-Zuiderent, 2012) through creating new forms of “unsafety” because of its focus on removal of errors (for example, uncertainty about symptoms when they first present themselves). Ironically, these errors could actually contribute to another kind of knowledge, constituted through knowing, acting, and caring in nursing and indeed in any other therapeutic practice. Jerak-Zuiderent (2012, p. 747) made a compelling case that conventional patient safety measures might actually inhibit the situation of safety they are designed to promote. For example, technology (in this case the Clinical Decision Support Systems) may use its authority to override the evidence generated from the “lived experience of the clinical encounter”; a given protocol or norm demands that practitioners give up their ability to respond to the specific needs of the client/situation in the unfolding therapeutic clinical context. The author argued that new forms of unsafety can emerge when practitioners are urged to practice safety (adhere to protocols) under conditions of uncertainty – a situation that can lead to errors in clinical judgement. “If the protocol is taken as absolute, the actions it was designed to guide are themselves dangerous and potentially destructive, resulting in a form of certain unsafety by inhibiting local practices of uncertain safety” (Jerak-Zuiderent, 2012, p. 747–748, emphasis in original). The author’s concern about how practices of certain unsafety are promoted as a consequence of the privileging of “certainty” is linked to questions and assertions regarding the hierarchy of evidence and the development of discourses around ways of knowing in nursing (epistemological valuations); “evidencebased” knowing is ranked above knowing derived from “clinical judgment” or the “lived experience of the clinical encounter” (Jerak-Zuiderent, 2012, p. 747). This is of little surprise given that the hierarchy of evidence (Guyatt et al., 1995; National Health and Medical Research Council [NHMRC], 2009), also dubbed the “hierarchy of trustworthiness,” continues to inform the direction of healthcare provision. Sustained pressure is placed on providers to privilege evidence in their practice, evidence that is allocated worthiness according to the hierarchy. In the remaining sections of this chapter we consider the evidence base of technological expertise and Clinical Decision Support Systems (CDSSs) with reference to the paradigms of evidence-based practice and practice-based evi-

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dence. Our consideration of the evidence will be addressed through the following questions: How do nurses view the impact of technological expertise in relation to the diagnosis, assessment, and management of treatment? How do they attempt to integrate the use of technological expertise with other forms of knowledge, for example, professional, experiential and tacit knowledge? What are the implications of the application of technological expertise in decisionmaking processes for the development and enactment of professional responsibility?

Technology/Technological Expertise in Clinical Decision Making There are many and various technologies including nomograms, electronic patient records, early warning scoring systems for clinical event risk, patient information leaflets, and algorithms (step-by-step formula or sets of rules for solving a problem, typically composed of flow diagrams requiring the nurse to evaluate a patient’s condition by supplying “yes” or “no” answers to a series of questions, with each answer leading to one or another branch of the decision tree). However, as Luca, Kleinberg, and Mullainathan (2016) noted, algorithms require managers too. In this context it is not always clear, specifically in protocols and care pathways, what the role of nursing professionals is in supporting data-driven decision making. Following the definition from Dowding et al. (2009), a CDSS is “a computerbased form of decision tool, integrating information (ideally from high quality research studies) with the characteristics of individual patients, to provide advice to clinicians.” CDSSs have been designated “active” or “passive” (Dowding et al., 2009, p. 27) according to their functionality and the response required by the user. For example, computerized clinical reminders are an example of an active system and are usually integrated with an Electronic Patient Record (EPR) to present reminders to practitioners based on the evaluation of available patient data. Electronic information tools that provide practitioners with online access to resources such as research evidence or clinical practice guidelines are considered examples of a passive system (Dowding et al., 2009). These do not automatically provide support for clinical actions or interventions, thereby requiring more effort on the part of the practitioner. The concept and practice of clinical decision making have been variously defined in the literature, leading to a degree of conceptual inconsistency. A study conducted by Tiffen, Corbridge and Slimmer (2014) to develop a definition and framework for clinical decision making involved a literature review and a series of interactive panels. The final definition proposed by the authors incorporated the characteristics of practitioners and their situations as well as the dynamic

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nature of the process. “Clinical decision-making is a contextual, continuous, and evolving process, where data are gathered, interpreted, and evaluated in order to select an evidence-based choice of action” (Tiffen et al., p. 401).

Ways of knowing: Evidence-based practice, practice-based evidence, and practitioner paradigms As we consider the evidence around technological expertise in decision making, we return to Jerak-Zuiderent (2012), who highlighted the politics in the hierarchy of evidence, in that evidence-based knowing is ranked above other forms of evidence derived from direct clinical encounters with the patient. However, even if we draw evidence from the top of the pyramid, we nevertheless find that in the Tiffen et al. (2014) conceptual review, there was conflicting evidence about the effectiveness of technological expertise in the published reviews and whether or not it contributed to efficiency, certainty, rationalization of diagnosis, and management of clinical problems. Randell, Mitchell, Dowding, Cullum, and Thompson (2007) found that the impact on performance and patient outcomes of nurses’ technologically informed decision making was inconsistent. Interpretation of the findings of this review was limited by the methodological quality of the studies: there was a lack of detail in the reporting, meaning that it was difficult to determine whether the lack of success was connected to issues with the computer interface, work process, or organizational context. More research is warranted to determine the contextual factors that make this form of decision making successful. There are other equally important reasons for adopting methodological pluralism when researching the area of decision making. Jerak-Zuiderent’s (2012) concern with the privileging of certain forms of knowledge that leads to the silencing of others is not new. Debates regarding the dangers of epistemological hegemony have been conducted from within a range of disciplines and professions for many decades. For example, the evaluation and regulation of healthcare is heavily impacted by government privileging of the evidence-based practice (EPB) paradigm. According to this paradigm, in deciding whether or not a certain treatment or therapy works, and if so, for whom, raises questions of efficacy or the potential to bring about a desired effect. Questions on safety, feasibility, side effects, and dose must be prioritized to provide “robust evidence” in support of answers. As a result, caregivers delivering treatments in healthcare settings remain under continued pressure to produce evidence for their practice. In the UK, for example, National Institute of Clinical Excellence [NICE] Guidelines all adhere to the EBP paradigm and have played a huge part in guiding the direction in healthcare provision and policy.

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Hierarchy of evidence, also referred to as the hierarchy of trustworthiness, guides evidence-based research that tends to value large-scale surveys (e. g. randomized controlled trials (RCTs)) which may not have been conducted in real practice settings. In order to engage with EBP discourses impacting clinical practice we contend that it is necessary to interrogate the processes by which evidence is constructed. We believe that practice-based evidence (PBE) and practitioner-research paradigms, used as complementary to the EBP paradigm, should be considered options for practitioners and clinicians to evaluate their practice so as to enable them to address variations in care which more accurately reflect the setting in which therapy is delivered. The practice-based evidence paradigm promotes the collection of evidence derived from routine practice settings and measures what normally happens in them. PBE aims to demonstrate that procedures work and are effective in improving the quality of care in real-life practice settings. Broadly speaking, PBE challenges the capacity of EBP to provide a full and accurate picture of practice; aims to capture differences and idiosyncrasies in clinical practice with reference to the varying characteristics of individual therapists and clients; and focuses on variations in care rather than seeking to isolate the effects of a specific intervention (see Cahill, 2013; Cahill, Barkham, & Stiles, 2010, for full definitions and explanations). The practitioner-research paradigm is further differentiated; while practicebased research relies largely on quantitative measurement and evaluation, practitioner research goes one step further in incorporating the use of therapeutic skills as a research tool and it often becomes the main method. For example, McVey, Lees, and Nolan (2015) worked on “therapist reverie,” which draws on both intersubjective and development theories and necessitates the judicious use of therapeutic skills in the collection and analysis of data (see Lees & Freshwater, (2008) for more details on the application of the practitioner research paradigm). What makes this approach most important and relevant in the context of this chapter is how the “lived experience of the clinical encounter” is privileged in generating knowledge rather than viewed as something to be ironed out in favour of norms-based general knowledge. We now propose to address the different aspects of nurses’ negotiations with technological expertise using knowledge generated from a range of methodologies and sources. We believe it is essential to have methodological pluralism across the different epistemological paradigms outlined above if we are to do justice to the questions raised and to make bona fide recommendations for critiquing technologies, professional responsibility, and the contemporary understanding of nursing ethics. In considering the question of how nurses view the impact of technological expertise in relation to the diagnosis, assessment, and management of treatment,

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we draw on two main sources: 1) an auto-ethnographic account from a university academic with a professional background in adult nursing, who as a service user underwent treatment for breast cancer and whose personal experience of technologically informed nursing care so exposed the gap between theory and practice that it pushed the author to revisit the concept of evidencebased practice and nursing education (Freshwater, Cahill, Muncey, Chin, & Esterhuizen, 2016; Muncey, 2010); 2) a multi-site case study that explored nurses’ use of technologically informed decision making across a range of contexts (Dowding et al., 2009). In the auto-ethnographic account, the author came to the following conclusion: I suggest that nursing is actually no longer about caring for people but in supporting patients to take full responsibility for their own decisions, providing an outline of all the risks involved and application of a vast array of technology aimed precisely at distancing the personal element from treatment. (Freshwater et al., 2016)

This view is somewhat at odds with that subscribed to by Locsin (2005) who contended that technology is a vehicle for enhancing ethically informed high quality care in nurse-patient relationships. In the account of her experience of outpatient radiation treatment, the author wryly appraised how care was relegated to the margins in the wake of technology, with even that technology ultimately found defective. I met technicians and assistants in both the wards and departments but nurses seemed almost invisible and what I thought of as care non-existent … I was familiar with the world of surgery and outpatients and nursing care but radiotherapy was a completely different ball game. The most frightening, lonely, annihilating experience of my life started on August 9th. But there were moments of humour. Probably the funniest moment was when they played Coldplay’s record “Fix Me” in one of my radiotherapy sessions. I said, “I hope you can,” and they said, “hope we can what?” I said, “Fix me,” but they couldn’t see the irony of the title and despite the vast technological knowledge required to operate the linear accelerators we didn’t get music very often as most of them couldn’t work the CD player. (Freshwater et al., 2016; Freshwater et al., 2011)

To summarize, through auto-ethnography, the author used individual reality to critically reflect on and analyze the rhetoric of nursing education, a rhetoric that figures prominently in discourses of professional responsibility, revealing the dichotomy (and dissonance) between what is taught and what is practised in nursing care: Quite simply we need to adjust the rhetoric we espouse in education and that nurses ignore in practice, and quite simply reinvent ourselves as technological support assistants responsible for helping patients to manage the risks inherent in anything that might be done to them. Practice has changed beyond recognition, and education

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(including its supporting rhetorical devices) and the public needs to catch up. (Freshwater et al., 2011)

The second source of evidence we employ to address how nurses view technological expertise and practice is based on a multiple case site study (four sites) across a variety of clinical settings including 1) an anticoagulation management clinic; 2) a spinal assessment clinic; 3) a walk-in centre; and 4) a respiratory centre. The aim of this study was to determine how nurses used technologically informed CDSSs to support their decision making. In this study a key factor that influenced how nurses viewed the potential impact of the technologically informed CDSS was the degree to which the CDSS instructed nurses to take specific actions. In sites 1 and 3, the nurses frequently overrode the technology because, according to their perception, it did not cohere with their own judgement based on their specific clinical experience. Not only were the nurses uneasy about what seemed like an act of resistance, they also worried about the potential adverse impact of the technology on their interactions with their patients. Thus, the nurses’ expressed concern over the mismatch between the evidence generated from the technology and their own clinical judgement lends further empirical support for Jerak-Zuiderent’s challenge to knowledge hierarchies, and in practice highlights the development of “workarounds” in order to adapt the technology as a way of resolving dissonance. The author of the study raised the issue of ethics in a context where an increasing emphasis is placed on scientific data in decision making in healthcare settings. Reflecting on how nurses integrate the use of technological expertise with other forms of knowledge such as professional, experiential, and tacit knowledge, it would seem, at least in this study, that there is evidence that these knowledges are applied in parallel rather than being integrated, raising concerns regarding both patient safety and the quality of patient care. Is it possible then to integrate technological expertise based on algorithmic thinking into care that remains compassionate and safe, and in addition is respectful of professional autonomy? As Luca et al. (2016, p. 99) note, “algorithms are essential tools for planning, but they can easily lead decision makers astray.” Recognizing the limitations of algorithms assists in their management and encourages allowances to be made for the softer goals of an institution, which are often unspoken and difficult to measure. The authors (p. 99) go on to say that “all algorithms share two characteristics: They’re literal, meaning they’ll do exactly what you ask them to do. And they’re black boxes, meaning that they don’t explain why they offer particular recommendations.” In other words, algorithms are short-sighted, focusing on the data at hand. We do not doubt the value of algorithms, nor their power in identifying patterns too “subtle to be

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detected by human observation,” which are then used “to generate accurate insights and inform better decision making” (Luca et al., 2016, p. 101). Technologically supported decisions provide a disruption to the old order of things, and as Ilya Prigogine’s 1971 prize-winning work teaches, disorder can be the source of new order. The apparent order/disorder presented here in relation to the contradictory evidence that technological competence supports safe clinical decisions, which, in turn, supports compassionate and individualized care, represents an opportunity for disruption to the meta narrative of the profession, and to the notions of professional identity and professional responsibility (for a further detailed explanation of biographical disruption in the context of narrative research, see Holloway and Freshwater, 2008). Vexing for proponents of algorithmic thinking, and key to professional responsibility, is the question of who takes responsibility when decisions made through algorithms go wrong. Prigogine (1971) coined the term dissipative structures for these newly discovered systems to describe their contradictory nature. Dissipation implies loss, a process of energy gradually ebbing away, while structure implies embodied order. Prigogine argued that the dissipative activity of loss was necessary to create new order. Dissipation does not lead to the death of a system, but is part of the process by which the system lets go of its present form so that it can reorganize in a form better suited to the demands of its changed environment. In a dissipative structure anything that disturbs the system plays a crucial role in helping it organize into a new form of order. Whenever the environment offers new and different information, the system chooses whether to accept that provocation and respond. Dissipative structures demonstrate that disorder can be a source of new order and that growth appears from disequilibrium, not balance. Accordingly, we suggest it may be useful to think of technology as a new system forcing professionals to let go of an old system (tacit knowledge and other ways of knowing) and to encourage the view that an integration of both leads to new improved knowledge and practices. The things we fear most in organizations – disruptions, confusion, chaos – need not be interpreted as signs that we are about to be destroyed; instead, these conditions are necessary to awaken creativity. Professionals and disciplines have indeed been challenged by the march towards technology and CDSSs, with their potential to reduce the number of qualified practitioners required and to replace them with a battery of highly proficient teams in data centres. But perhaps these technologies can be viewed as an additional form of knowledge to supplement and enhance, rather than replace, existing knowledges, in such a way as to negotiate the tension between the desire for predictability and stability on the one hand, and the acknowledgement of certain uncertainty on the other. This tension, we believe,

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informs integration and application in the service not only of quality and safety, but also of humanized and ethically personalized care. Still, we have concerns regarding the ability to apply and integrate decisions informed by algorithmic approaches and their use as an additional form of evidence and knowledge in the context of professional care giving and practicebased evidence. How might nurses integrate the use of technological expertise with other forms of knowledge? Locsin’s theory of technological competency offers some insights into this critical relationship (for further detailed reading, see Locsin, 2005). We propose that there are at least two pre-requisites for integration to succeed, that of critical consciousness and curiosity, despite those who believe that clinical decision- support systems foster mindlessness rather than reflection, as well as a sociability of care, or aesthetic rationality, as defined by Bologh (2009) and further delineated in Fisher and Freshwater (2014b).

Situating Curiosity in the Context of Technologically Driven Interventions Our experiences of working with nurses in practice have led us to believe that their world is a foggy, chaotic place where complexity, uncertainty, powerlessness, and confusion prevail. After hearing their voices in both open and closed work settings (e. g. forensic care environments), the clinical world appears to be an unfathomable, complex field of play where permanent “white water” resides to create states of critical and reflexive inaction, stagnation, and perceived oppression (Freshwater et al., 2012). The notion that practice and personhood is “forever becoming” (Freshwater, 1998; Freshwater et al., 2016; Parse, 1998), is challenged, since through exploring daily practice, it is seemingly suppressed by institutionally created silence, where any attempt to confront given knowledge and established clinical practices is perceived as poisonous, unsafe, and open to recrimination. We suggest that critical consciousness may be harder to develop in the less politically polarized and more economically comfortable context of Western Europe. Practitioners in these contexts can be positioned as de facto agents of the state and the status quo, however reluctant they may be to accept this role and however much they may try as individuals to resist its insidious pressure. This is why we believe that critical thinking based on a model of curiosity, developed in Latin America and spread through the social and political consciousness of European practitioners, is fundamental to a truly integrated approach to decision making. Critical consciousness is important to apply in the utility and understanding

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of CDSSs, but necessitates that the practitioner has dynamic capabilities; an appreciation of the value and existence of dynamic disequilibrium; an awareness of the importance of discontinuous change as evidenced and experienced in the technological revolution, and a knowing that this will be a continual feature of healthcare practice in the future; an awareness of incremental change and continuous improvement; and an awareness of the impact of decisions and practices on others through critical consciousness and a sociability of care. Nursing is both a political and a social intervention that involves the actions of people and thus, reflecting on and understanding human intentions and motivations is essential to understanding its implementation and subsequent evaluation. In this sense nursing is part of an intervention chain. Social and political intervention is both a product of its context and produces context; in other words, interventions are open systems that feed back on themselves. A social intervention affects society writ large, whether through large-scale organizations such as health providers or corporate bodies, or through individuals, families, and communities. It is an interactive process and involves feedback and negotiation, based on pragmatism and circumscribed indeterminacy. Interventions are embedded in social systems and how they work is shaped by the context of interpersonal relationships, institutional culture, and even infrastructure and technology, and they are subject to continuous modification as they are implemented. CDSSs are not social systems; however, they can be described as part of a sociability of care. We have a collective capacity to question assumptions and to inquire into the nature and consequences of social power relations and interventions within seemingly competing systems and paradigms, such as between compassionate care and the CDSS paradigm. Contemporary corporate-level conceptualizations of care and caring do not recognize the ways in which nurses construct the complex and sophisticated knowledge needed to provide person-centred care. We assert that the prevailing culture of compliance to organizational truths and artifacts stifles the emerging rhetoric of innovation, erasing the need for curiosity and driving critical consciousness and a sociability of care underground. Actualizing curiosity through critical consciousness attracts significant ethical risk, as it has the power to shift one’s position from a private place of safety to one of public exposure. Once voiced, curiosity and learning have the potential to be consumed by the fire of a closed and seemingly oppressive system: the proliferation of oppressive rhetoric can act as a discursive fuel to support aversion. Thus, anxieties created by the tensions of integrating multiple knowledge sources, including technology, have the potential to be contained. Through a sociability of care, however, curiosity can be nurtured and given credence, via conversational action, to become a validated part of the journey of knowledge integration and practice transformation. Discursive practices, which

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open up rhetoric towards understanding and recognition, can therefore be construed as a constructive force.

Summary In summary, what are the implications of the application of technological expertise in decision-making processes for the development and enactment of professional responsibility? We believe that the current service delivery model, which underpins professional responsibility, is akin to a Newtonian approach to organizations – one that privileges planning, predictability, and manipulation and is based on an intense belief in cause and effect. A Newtonian image of an organization, in this case one of healthcare practices that has a substantial education and research base, is one in which responsibilities are turned into functions, people are organized into roles, and page after page of organizational charts depict the working of the machine that is defined by boundaries, lines of accountability, and by an increasingly large market share of the pie. A problematic organization is treated with machine consciousness: bad managers, poor leadership, or a dysfunctional team are analyzed instead of using a whole systems approach, or, by what others refer to as the quantum level, are analysed to the point of nihilism and irrelevance. Hans Peter Durr, former director of the Max Planck Institute, stated: “There is no language to describe what we are seeing at the quantum level. I can only say that it does not help to analyze things in more detail. The more specific the information, the less relevant it is” (Vincent, 2011, p. 85). Against this backdrop, education then becomes an ideal breeding ground for formulaic, robotic, disembodied, and algorithmic approaches to leadership that produce what we call “flat pack leadership”; it comes in a box, you make it yourself, but it all looks the same. Algorithms increasingly run human resource departments, which recruit and retain nursing staff and health practitioners. Metaphors for successful organizations are masculine: direction, ambition, and prediction. This is an important lens but not the only one, and, as with the formation of all dominant discourses, the lens soon begins to believe that it is the “mono-lens,” not merely one of them. In our view, this absence of plurality leads to identity constraints for professionals and indeed, an identity crisis, in turn impacting professional responsibility. A leader’s role is not to make sure that people know exactly what to do and when, it is rather to make sure that the organization knows itself. We argue this aspiration towards reflexive selfknowledge is hampered by certain strains of algorithmic thinking. The type of algorithmic thinking we caution against is a reflection of machine consciousness and small mindedness. Although we concede these algorithms offer clarity of

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direction, perhaps even align with strategy, they do not necessarily deliver certainty of outcome precisely because the resources being used to enact the algorithm are human, and humans are inherently unpredictable. In this context a good leader is seen as someone who can astutely manipulate (rather than respond to) resources. As a counterpoint to the above, what we argue is that agility, effectiveness, and flexibility come in the form of unconventional working practices. Such practices are both challenged by and mount a challenge to technology and tethered and untethered working practices, and as Haraway (1991) pointed out, are social practices, which require health professionals to step into the complicated and sought after space between technology and person-centred care. The “internet of things” is not about devices talking to each other (a nurse is not a device), but about embedded applications talking to each other. Does this mean that we need to start teaching coding as part of nursing education? It is clear that a culture that works both for the employee and the bottom line, but also for the end user, is demanded; in this sense it is a marrying of the universal and the particular. We argue against using a machine consciousness to understand a world that is not a machine. Algorithms and machine consciousness present a significant challenge to nursing leadership: machines are all the same, and algorithms produce similar outcomes every time, which is somewhat at odds with our construction of leadership viewed as it is from within a particular discourse and lens. In closing, we acknowledge that professional identity is beset by challenges. Increasingly, it is subject to public scrutiny in the form of research into its efficacy and effectiveness. But, as leaders, we must recognize that in dynamic practice, identity is not continuous, and that failing to recognize that the concept of professional is context dependant and historically contingent will stymie any movement towards genuinely inclusive leadership. We acknowledge the rise of the algorithm and indeed welcome the way in which it enhances nursing knowledge and practice. We also recognize that most nurses are propelled to simultaneously seek change and seek integration: this paradox is, after all, the nature of what it is to be human.

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Chapter Seven: Mimesis in Nursing Practice: The Hermeneutical Potential of the Body to Understand Patients’ Lived Experiences

Introduction The scientification of nursing and the gain in empirical knowledge that comes with it provide growing possibilities of interpretation for a broader understanding of health problems. Individual and situational experiences of sickness, however, can barely be accessed through evidence-based findings. Individual experiences cannot be completely generalized and must be evaluated anew in every case in order to access the meaning of the situation for the patient and to draw professional conclusions. The goal here is not to identify seemingly objective facts in the form of nursing diagnoses but to access the immediate experience of the other in order to take their interpretation of their own illness as a starting point for initiating support. This reference to the experience of care receivers legitimizes care work as professional work based on research results (Oevermann, 2002). This process of understanding can be described as a hermeneutic process that entails rational-cognitive and pre-rational elements (Phillips, 2007). The international nursing-scientific debate usually turns to Gadamer (1975) in order to base hermeneutic competence of care work on his notion that understanding is dialogical, historical, and hermeneutical (Fleming, Gaidys & Robb, 2003; Geanellos, 1997; Pascoe, 1996; Phillips, 2007; Spence, 2001; Truglio-Londrigan, 2002). To reduce hermeneutic casework to the verbal capabilities of humans overestimates the potential of verbal communication to adequately express lived experiences in situations relevant to care (Cameron, 2006, based on MerleauPonty, 1964; for a summary see Hülsken-Giesler, 2008). Language is based on general rules and as such is not well-suited to capture the unique aspects of individual experience (Adorno, 1973). With language comes the possibility of reflexive understanding of an experience (Habermas, 1971), that is to say, the possibility of an intersubjective communication about sense and meaning. In many relevant contexts of care (assessment, transfer, ward rounds, etc.) as well as

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in contexts of qualitative research, approaches that focus on the verbal take a special position (Binding & Tapp, 2008). However, if the understanding of the other is solely based on verbal expression throughout the care process, other relevant ways of perceiving, experiencing, and expressing are systematically ignored, simply because they are found in the corporal [Leib] layer of human beings. This neglects, for example, sensuous experiences such as the smell that caregivers experience when entering a patient’s room in the morning, the overall appearance of a bed, the feel of a tense body during mobilization, or the sound of a tired voice when care receivers had a sleepless night. Following the insights of corporal-oriented phenomenologies, such as theories of the felt body’s constitutive involvement in human experience (Schmitz, 2011), a phenomenology of the Alien (Waldenfels, 2011), or a phenomenology of Perception (MerleauPonty, 2013), experiences of this corporal form condense into a sensing of atmospheres. The felt body is constitutive of situational perception and decision making. In professional care these complex perceptions provide additional value or even correctives to rational-verbal statements, for example, in the case of a patient stating that he or she spent the night “not badly given the circumstances.” Corporal [Leib] perception represents a specific form of practical knowledge that experienced practitioners possess in the form of implicit knowledge (Polanyi, 1966), tacit-knowledge-in-action (Schön, 1983), embodied intelligence (Benner & Wrubel, 1989), intelligent hands (Sennett, 2009), or embodied skill (Benner & Wrubel, 1989). These pre-rational kinds of knowledge enter the situational perception and decision-making processes of those who have reached a certain degree of experience in their field. The concept of mimesis attaches to that line of argumentation and bases an understanding of the other in the corporal being of actors. Given the manifold usage of the notion of mimesis and in order to make it useful for the field of professional care, a look at the history of the concept, its varying meanings, and the resulting implications is necessary. In the following passages, we present a selected conception of mimesis in order to be able to detect mimetic movements in professional care. Tied to this conception is the discussion of social mimesis as a basic element of social acting, or rather, of social interaction. We will then analyze social mimesis regarding its potential for what will be called a hermeneutics of mimeses. In a last step, the concept of mimesis as proposed by Adorno and the subsequent thoughts on hermeneutics of mimeses will be examined regarding their value for professional nursing practice, bringing to the foreground the concept’s potential to interpret sensuous and bodily dimensions of human experience as well as its potential regarding the creation of social worlds.

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Meaning and Conceptual History of Mimesis The Greek term mimesis was originally translated as (re)presentation, expression, or imitation, or to (re)present, to express with the connotations of making something similar or of emulating (Gebauer & Wulf, 1996). Today it is mainly used in cultural-scientific disciplines (for a summary see Gebauer & Wulf, 1996). The wide variation in the term is, on the one hand, due to problems with translation and, on the other hand, mirrors its lively history. The usual interpretation of the term as imitation does not capture the full range of the original Greek meaning. The meaning of the term mimesis originates in a religious context, or, more precisely, in contexts of pre-Greek cultic dance. Mimeisthai primarily means to present through dance or to express through dance (Gebauer & Wulf, 1996), and in ritualized dances, gods and demons are represented. In this sense, mimesis is originally understood as a non-rational holy act that combines representation and expression, dance and gesture, rhythm, spoken word, and melody into one. Historically, usage of the term expands to imitations of appearance, expression, and actions of animals and humans. Mimesis thus means to sculpt oneself, based on the other, in voice and expression through speech, song, or dance (Gebauer & Wulf, 1996). Mimetic processes aim at coherence of imitator and imitated. It is, however, not judged by identity or sameness, but rather by accordance and similarity. This understanding opens up a space for creative presentation and a wider variety of expression. Mimesis thus extends the naive conception of sheer imitation by being characterized by emulation and creating something new in the process, thereby unlocking its creative power. Due especially to Plato’s critique in the 10th book of his Politeia, mimesis as a human capability has been historically discredited and the concept has been banned to the field of aesthetics (Gebauer & Wulf, 1996). The attempt to capture the nature of things to mimetically express was not sufficient for Plato, as such an attempt was bound to express not pure ideas but rather their reflection. Furthermore, the creative power of mimesis, Plato argued, came with the danger of young people being subjected to bad influences through wrong role models. Mimesis was thus seen as unethical and wild, because it did not question whether or not the imitated was also good. Mimesis educated the imitator in both a positive and negative sense and was therefore taken as a dangerous practice. It was put into theoretical quarantine by being placed solely within the field of aesthetics (Gebauer & Wulf. 1996). Aristotle then rehabilitated the concept, seeing it as a constitutive power in an independent aesthetic world of appearances. Unlike Plato, Aristotle saw the mimesis of ideal, non-real role models, for example, in poetry, as a chance for an ethical education. Even the mimesis of negative role models could have a positive

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educational effect through deterrence. This assessment, however, did not lead Aristotle to extend the usage of the concept to a wider field. Its theoretical quarantine has therefore been effective and the variety of mimetic conceptions developed have been used solely in aesthetics until a few years ago (Gebauer & Wulf, 1996). Next to this idea of “relations to the world” that would still justify a translation to “imitation” in the broader sense, Koller (1954) argued that the term mimesis also contained the opposite of all possible relations to the world: the relation to the self. Mimesis is here seen as a corporal expression of the inner state and as such is described as basic to human existence. Mimetic processes can thus not only refer to elements of the outer world, but also to inner states of mind in order to give form to what is thought or experienced and to embody these thoughts and express them with one’s whole being (Weidl8, 1969). This mimetic selfreference is attributed meaning through the diverse kinds of self-metamorphosis that are not adequately addressed within the paradigm of imitation. Additionally, the question of what is the mimetic object (Benjamin, 1986) is also highly significant. The question arises whether the mimetic movement is directed primarily at a natural phenomenon (Horkheimer & Adorno, 1972), an artifact (Genth, 2002), or a living other (Hülsken-Giesler, 2008). If the focus of the mimetic movement is a living other, lived experiences – in the sense of Patricia Benner’s “illness” (Benner & Wrubel, 1989) – can be shared. Gebauer andWulf (1996) summarized the historic reconstruction of the term mimesis by stating that the question “What is mimesis?” is misleading. The term is not homogeneously used. It can rather be seen as a highly complex construct that combines conditions of theoretical and practical attitudes towards the world, perception and action, cultural iconism and media of communication, and relations of the self and the other. Mimesis must, following this line of argumentation, be seen as a conditio humana that renders possible different ways of being human. A clear explanation of the term or even a definition of mimesis seems not plausible, since the artificiality, poignancy, and inflexibility of definitions in scientific thought do not lend themselves to mimetic processes that are tied to acts of execution, variations in time, and productive activities. Mimesis as a concept shows a resistance to theory building and skepticism towards pure theory that rejects any blending with human praxis (Gebauer & Wulf, 1996). The challenge in discussing the relevance of the term mimesis thus lies in the contradiction of needing to address verbally that which is closed to rational and language-based intrusion, yet highly important to lived experience. Every historic conception of mimesis has its own constellation, yet the central question always addresses the relation of a symbolically created world to a world that is seen as being basic, the role model, or meaningful: The actual world.

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Mimesis as a corrective to instrumental rationality Following the critical theory of Adorno (1997) and Horkheimer and Adorno (1973), the specific potential of the mimetic power lies in its power to serve as a corrective to the historically growing dominance of instrumental rationality. The mimetic power serves Adorno as a starting point to bridge difference without denying it. The difference between subject and object is seen as the cognitive-semantic appropriation of the object by a subject, which is described by Adorno as an usurping process. Mimesis roughly maintains the equality of object and subject. The mimetic process is dominated by the imitated object; the imitating subject is rather passive. Because the subject passively approaches the form of the living or non-living object, the sensuous and somatic moments are kept in the process, while purely cognitive processes tend to lose these aspects entirely. Mimesis therefore hands a central function in the interaction between self and world to the lived body. Mimesis in this conception is not seen as an opposite to a rational approach towards an object. The mimetic power is rather seen as a physiological primordial of the mind (Adorno, 1997). The basic meaning of mimesis was developed by Horkheimer and Adorno (1972) in Dialektitk der Aufklärung [Dialectic of enlightenment] as an underground history of rationality suppressing the mimetic concept. The central organ of mimesis is, according to Horkheimer and Adorno (1971), the lived body, the felt body [spürender Körper], as it is described in a corporal [Leib]-oriented phenomenology. The suppression of mimesis is performed through and within this central mimetic organ. Semantic recognition takes the place of the lived body imitating nature. This abstraction of the corporal nature of thinking (Gebauer & Wulf, 1996), the conversion of the mimetically gifted lived body to a functional body with a rational mind (Descartes), is accompanied by a defamation of subjectively experienced life. Against this background, Horkheimer and Adorno see mimesis as a corrective to identifying thought and semantic knowledge and to the reign of the abstract and reification (Gebauer & Wulf, 1996). They thus call for a communal recollection of nature within the subject (Horkheimer & Adorno, 1972). Mimesis in this sense facilitates access to the world through adjustment and enables subjects to experience objects, creations, and humans without intention, thereby granting them an enigmatic state (Gebauer & Wulf, 1996). A mimesis understood in this way is given referent power for the creation of social reality by enabling a reconciliation with nature (Gebauer & Wulf, 1996). In summary, Adorno’s subject-theoretical perspective sees mimesis as a general human quality that has socio-historically been suppressed and is in this interpretation subject to an epistemological-critical turn. Adorno sees aesthetic

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behaviour to have the potential to break the mimetic taboo and restore the lived body through balanced mimesis-ratio dialectics.

Social mimesis Mimesis can be seen as a human capacity to imitate, on the one hand, the contents of one’s own consciousness through bodily expression (self-reference) and, on the other hand, to again through bodily expression, imitate phenomena of the external world (world-reference). The terms imitation and expression should not be reduced to a sort of exact mirroring. Rather, they should be seen as pointing to a relation of model and modeler. Gebauer and Wulf (1996, 1998) attempt to broaden the conception of mimesis that has survived in the aesthetic field and restore its anthropological meaning. To them, the mimetic capability plays a central role in nearly all realms of human action, imagination, speech, and thought, and is thus a necessary condition of societal life. In a societal context, mimesis can therefore be seen as the capability to perceive and comprehend as well as to express and present human behaviour, human actions, and social situations (Gebauer & Wulf, 1998). This process entails underlying institutional and individual norms, without necessarily being in the foreground of rational awareness. Processes of social mimesis are performed with the help of sensuous perception, yet cannot be reduced to it, as they reach into the world of inner imagination. Mimesis thus presents a link between the inner and outer world (Gebauer & Wulf, 1998) and simultaneously overcomes the boundaries between them. The reference points of social mimesis therefore surpass the real social processes, situations, and expressions. One can talk of social mimesis, when mimetic behaviour is directed at real or imaginary, literarily or artistically created situations, actions, or behaviour (Gebauer & Wulf, 1994). Social mimesis takes a mediating form between inner and outer, between individual humans, between things and their mental images (Gebauer & Wulf, 1994). This character can be more precisely defined as a relation of worlds directed at each other. Social mimesis is generally marked by the assumption that there is no single world but at least two, where the second world relates to the first (Gebauer & Wulf, 1994). The first world – be it empirical or fiction – is assumed to exist. The second world exists in a form that can be sensuously perceived and felt through the lived body. Social mimesis creates a special relationship between these worlds that is expressed through gesture, expressive action, and sounds or similar corporal activity. These expressions thusly form an inter-worldly relation that represents the central aspect of social mimesis (Gebauer & Wulf, 1994). Social actions can be seen as based in mimesis if and when the physical body

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of the other serves as the reference point of social mimesis. The symbolically coded and normatively determined bodily movements are sensuously perceived by the interacting partner and internalized through imitation. Social action can therefore be characterized as mimetic if and when movements relate to other movements and can be seen as bodily performances that possess aspects of expression and presentation as well as present independent actions that can be understood on their own while being directed at outer actions or worlds (Gebauer & Wulf, 1998). Wulf (1990) points to a special connotation of using the term other : the term is to him an indicator of non-semantic experiences that cannot be prematurely canalized through interpretation of meaning and where non-sense or nonmeaning can be seen as a defining property. By trying to understand the other, enigmata are reduced to the known and thereby misjudged or even destroyed (Wulf, 1990). An encounter with the other, however, that is not aimed at reification, leads to accepting humans as having bodies that are not verbally accessible (Wulf, 1990). The starting point for encountering the other can in this case be seen as the realization of the other’s fundamental and undeniable strangeness and of the impossibility of understanding it. A mimetic approach builds a bridge to the other. The phenomenon of the other, their appearance, their voice, their actions can be imitated in imaginations and therefore can be part of the inner world. These abstract-theoretical processes are usually not immediately detectable in the field of professional nursing; however, they often indirectly appear in the form of metaphors. In a study regarding expertise in professional nursing, Böhle et al. (1999) noted that decision-making processes regarding the necessity and possibilities of nurses’ actions often take the form of mental images. “I remember certain situations. I see the people before my inner eye,” a nurse said. A rational and unambiguous interpretation of this statement is neither possible nor necessary. The ambiguity of the statement offers the experience of otherness, of the multilayered complexity of strangeness. Intensities of the other can be perceived without subjecting them to a bi-polar order that, for example, in the case of standardized diagnoses, seeks to reductively operationalize perceived phenomena to “applies” versus “does not apply.” Mimesis can thus provide a non-reifying access to the other that leaves the other in their otherness and multilayered complexity and therefore in their freedom (Gebauer & Wulf, 1996, 1998). Systematic structuring of phenomenon and experience, projectable order or objective insights, are hardly possible in this context. While approaches in the social sciences highlight the cognitive aspects of social interactions, taking social mimesis as a starting point leads to a focus on their corporal aspects. This focus emphasizes the relevance of the materiality of the body in social processes as well as the relevance of the lived body in the

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mediation between acting subject and the world. The mimetic unfolds in the corporal. The manifold interpretations of the world are mimetically communicated through the body and its movement and thus simultaneously become the model and the image of modeled mimetic movement. Physicalness and movement can therefore be seen as basic necessities of participating in others’ worlds and in forming societies with others. Following this understanding, the mimetic constitution of the social world precedes social behaviour that is based on cognitive understanding of social rules. While bodily actions follow a rule-based structure, this structure usually functions without cognitive involvement, and bodily actions mainly generate their own rules (Gebauer & Wulf, 1996, following Bourdieu, 1974; Elias, 2000; Foucault ,1975; Mauss, 1973). Following the line of argumentation described above, mimesis is identified as a human capability that allows understanding the other on a pre-rational and therefore pre-semantic level. The following will now present how mimetic movements take effect in social situations. Diseased persons in need of care will perform the first mimetic process alone, as they will express their own state of mind through self-referential mimetic movements with their lived body. Facial expression, gesture, tonicity, posture, movement, sounds, and other bodily expressions together mirror the inner state of a person, express this inner state through the lived body, and introduce it into the care situation in a way that the felt body can sense. A caregiver can sense this corporal expression and, in a second mimetic process, relate to the other’s lived body. In the mimetic process the other is perceived with all senses and then transferred to inner images, sounds, and worlds of touch, smell, and taste, thereby binding the lived experience to the ineluctable physicality of the situation. Such care situations are often characterized by mutual mimetic conditions. Because of the mimetic movements of one partner, the other feels compelled to mimetically relate to them as well. Both partners are influenced by these mimetic movements. A mimetic spiral ensues, in which the original social situation develops through the alternating mimetic movements of the involved partners (Gebauer & Wulf, 1994). Following Lavant, Schlör (1998) developed four characteristic traits of the “Mimetic Ego,” which can be seen as prerequisites for a mimetic access to the other in social situations and therefore also present a prerequisite for a theory of mimetic hermeneutics. The “Mimetic Ego” is sensitive and susceptible and therefore allows for precise observation and attention to detail in social situations. It is willing to be impressed by the other. The mimetic act is a corporal act and the lived body is both expressive and empathetic. The “Mimetic Ego” is open and without rigid borders of the self, making it a multilayered subject. It has the capacity to be open towards the other, so that the Ego and the other can enter into a relation that brings them closer together. This openness is specific to

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mimetic capability. The “Mimetic Ego” is willing to be fascinated and affected by the other and to change itself in the process. It must first abandon its own “Ego” in order to recognize the “Non-Ego,” that is to say, the other. It is only when its own and known categories are not applied to the new – the “Non-Ego” or the other – that new experiences can truly be made and the new that the “Non-Ego” holds can be rendered visible and experienced. The “Mimetic-Ego,” however, has to remain within itself to avoid the danger of getting lost in the other.

Mimetic Hermeneutics in the Context of Professional Nursing Practice Mimesis, as it is laid out here, can be discussed on many levels regarding its meaning for work and interaction processes in general, and especially regarding professional nursing. Mimetic processes can be analyzed regarding their socializing, ritualizing, and educative significance. They are realized in the social institutions of the family, schools, and businesses, and manifest themselves within the possibilities and boundaries of the respective structures found there (Gebauer & Wulf, 1994). Within a hospital, mimesis plays a major role in institutional socialization as well as in face-to-face communication with the diseased. When seeking to understand the other on a micro level of caring activities, the more or less identifying relation with the diseased is of major interest. Mimetic movements do not allow for the creation of an exact copy of the model, yet will lead to similarities and will establish a relationship that facilitates access to the perception that being sick is a lived experience (Benner & Wrubel, 1989). Mimetic processes open up possibilities of taking another’s perspective by means of the lived body, and allow at least briefly, an empathy with phenomena relevant to care such as pain or suffering in sickness, disability, or ageing from the perspective of the other’s body. These processes need to be distinguished from concepts of professional empathy discussed prominently in Nursing Science. Empathetic capability is described as a human capacity that allows a person to take another person’s place and include their feelings and moods, even if they are not verbalized. In the context of professional nursing, this capability is then differentiated between “natural” and “clinical” empathy (Alligood, 1992; Ehmann, 1971; Forsyth, 1980; Kramer & Schmalenburg, 1977; Morse, 1992; Reynolds & Presly, 1988; Zderad, 1969). While “natural” empathy is placed in the life-world and tied to empathetic processes of becoming one with the other, “clinical” empathy is based on distance and objectivism of the empathetic experience (Ehmann, 1971; Sutherland,

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1993,1995; Wheeler, 1988; Williams, 1990; Zderad, 1969). Objectivization is reached through a transfer of an experience of the lived body into a process of cognitive-intellectual understanding. The cognitive aspect of this process becomes the measuring stick of the objective analysis of knowledge about the patient that is gained through empathy, meaning that the cognitive aspects of empathy are seen as rendering this capability relevant to professional nursing. All other aspects, such as affective moments and sensuous experience of the lived body, are relegated to the private sphere. The original intention, namely to experience the state of the other, is reduced to a mere registration of the other’s state by means of known and usually cognitively legitimized categories. This conception of professional empathy is thus focused on overcoming subjective experiences of the lived body and necessarily leads to an impoverishment of mimetic and imaginative potentials. The immediate sensuous-empathetic experience of the strange in and through the own lived body is replaced by cognitive-rational access to the unknown, which is judged by its potential to be useful for “professional work.” The reductions that come with such a cognitive conception of empathy render all the more relevant the mimetic capability, for which strangeness, multilayered states, and ambiguity are constitutive factors. Using the approach of a mimetic hermeneutics avoids cognitive-semantic interpretation. The appearance of the other is kept as much as possible in order to overcome alienation and reification. The mimetic experience of the lived body is manifested in a form of knowledge that cannot and need not be objectified or verbalized, yet is formative of further action. Once one seeks to grasp the mimetic experience in cognitive-semantic terms, a reduction to known previous experiences is inevitable. Another essential difference lies in the fact that mimetic experience – unlike professional empathetic capabilities – cannot be eliminated from the social process, whether we are aware of this or not. Zderad (1969) states that empathetic behaviour in professional nursing is only necessary if a patient is not able or willing to communicate and an understanding of the patient’s experience is necessary for the care process. Empathetic behaviour is thus seen as goal-oriented, conscious, and purposeful professional competence that is used to gain immediate usable knowledge. Mimetic knowledge, on the other hand, is usually gained unconsciously and unintentionally. What needs to be taken into account, however, is the need in professional nursing – one that is based on mimetic experiences – for a corrective in the form of rational control. The danger of personal projections taking over mimetic experiences of professional nurses is too high. This corrective, however, should not stem primarily from cognitive reflections of the involved actors or from the instrumental logic of rule-based knowledge with relevance to care. Rather, one should turn to the sensuous communication of the lived body with the other. The

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look, meeting the other’s expression, can serve especially to judge the quality of mimetic experiences (Plessner, 1948; for a perspective from nursing science, see Jansen, 2006). This does not eliminate the possibility of an accompanying verbal exchange, but reminds us that this exchange must be seen as an incomplete act of understanding and cannot claim ultimate justification of a verbally communicated experience of suffering. Other dangers of a mimetically based access to the other have been discussed in the context of research on empathy under the heading “Burn Out,” which motivated the cognitive turn of discussion on empathy in professional environments. Unprotected empathetic processes can lead to nurses staying in a empathetic state in order to fill their own existential void. The “Mimetic-Ego” must stay within its own self in order to resist the dangers of reversal. One’s own self must be stable and prepared for the mimetic process (Schlör, 1998). The mimetic approach to the other initially manifests itself in the form of “mimetic sediments” (Genth, 2002). They affect further perceptions, receptivities, imagination, and actions, albeit to different and not foreseeable degrees. If mimetic sediments are mimetically passed on in forms of imagination, habits, and rituals, practical knowledge can be built that can inform future actions. Practical knowledge must not be seen as rule-based or analytical knowledge, but rather as a form of know-how that manifests itself in the lived body as embodied knowledge (Gebauer & Wulf, 1994). This form of knowledge cannot be sufficiently grasped by means of logic or semantics. Every interpretation of know-how ascribes to it a clearness and logic that it does not possess in the moment it informs an action and which it also does not need. Practical embodied knowledge is built in social situations over longer periods of time and can be seen as the result of previous experiences. As such it provides the basis for new mimetic experiences and manifests itself in the immediate situation as action-guiding performative expression. Mimetic knowledge is performative embodied knowledge – practical knowledge that through socialization becomes habit (Bourdieu, 1974), and that substantially helps to shape concrete care situations. This aspect still seems underexposed in Nursing Science, given its relevance to a vocation that is both directed at the lived body and performed mainly by the lived body. Mimetically relevant situations and social situations that form habits can be found in the context of inpatient hospital care such as in highly ritualized procedures in personal hygiene or ward rounds. Mimetically gained know-how is produced by constantly attending to these social processes. In these situations the mimetic movement is directed mainly at social interactions in the form of ritualized procedures and has a primarily socializing and disciplining character for the mimetic subject. The resulting embodied knowledge here mainly leads to the reproduction of an institutionally legitimized, normative, practical knowl-

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edge that manifests itself in presentations of facial gesture, posture, and movement according to an “adequate professional conduct.” In the mimetic movement, however, situationally directed at the bodily expression of the other, embodied knowledge can be built, which enables the mimetic subject to immediately react with his or her lived body to the expressed inner state of the other, based on previous habits. In a developing mimetic spiral between the caregiver and the care receiver, socially and institutionally licensed norms overlap with the immediate experience of sickness and its perception. The mimetic experience manifests itself in these situations as performative actions of the lived body. While the mimetic experience itself can count as immediate, its corporal expression is biographically, socially, and institutionally formed. The necessary relation of mimetically gained knowledge with the lived body and the accompanying problems with its translation into cognitive and verbalized knowledge usually lead to a situation where these forms of embodied knowledge are excluded in professional and scientific discussions. Only in recent times have discussions that are inspired by approaches within the sociology of knowledge tried to rehabilitate non-discursive forms of knowledge in Nursing Science, therefore allowing it to be developed further. The discussion on forms of knowledge relevant to care has become more dynamic (Benner, 2001; Benner & Wrubel, 1989; Carper, 1997; Chinn & Kramer, 1996; Hülsken-Giesler, 2008; Nerheim, 2001; Remmers, 2000). The special relevance of mimetic knowledge needs to be differentiated from other forms of non-discursive knowledge. Its potential to form the basis of forms of knowledge, however, still needs to be determined further. Discussions surrounding non-discursive practical forms of knowledge are diffuse. In the German-speaking community the following approaches play a role: implicit knowledge, notion [Ahnung], intuition, and experimental knowledge [Erfahrungswissen] (for a summary see Friesacher, 2008, Hülsken-Giesler, 2008). These concepts are discussed in their role in becoming an expert (Benner, 2001; Dreyfus & Dreyfus, 1986). The role of mimetic processes in this context cannot be determined. One can assume, however, that mimetic capabilities of humans have a substantial function in developing both long-term implicit and experiential knowledge as well as in activating intuitive knowledge in situations relevant to care. As a way of accessing the other through a lived body, mimetic experiences are antecedent to cognitive-intellectual processes of insight and must be distinguished from other non-discursive forms of knowledge (those relating to diagnosis or solving problems). Set in the lived body, these experiences form the basis for rational insight but are still inaccessible when trying to make it explicit.

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Deformations of Mimetic Capabilities The conditions of possibility regarding a mimetic hermeneutics lie, as shown, in the development of a “Mimetic-Ego” that manages to remain sensitive to the special in social contexts. Powerful tendencies in professional care are challenging this sensitivity : the importance of cost-reducing measures in care is weakening the mimetic motive of emphasizing the special as opposed to the general. The focus is shifting towards questions of efficient care in the framework of free markets and income-oriented, economic services. Professional nurses, as has been empirically shown (see, for example, Manzei, 2007) internalize economic logics of the market and thereby neglect the diversity and uniqueness of individual cases. Scientification of care is developing in a way that places experiential justification of action second to that gained through rational means until it is almost discredited. Evidence-based knowledge replaces experiential knowledge of the lived body, and empathy is reduced to its cognitive aspects. The dictate of rational thought gains gravitas, while the barely graspable experience of mimetic knowledge is neglected and undermines caregivers’ confidence in their mimetic abilities (Hülsken-Giesler, 2008). Furthermore, the immediate encounter of caregiver and care receiver is increasingly set in sociotechnical arrangements and is today embedded in complex networks of the computer-assisted healthcare system (Hülsken-Giesler, 2008). Professional nurses use technologies to plan and support their activities, to document care processes, and increasingly, to optimize communication. Also, technical artifacts are increasingly placed in the care receiver’s environment, on their body, or, in individual cases today but surely with a view to becoming mainstream, in their body, in order to measure vital signs, mobility, hydration, or other aspects relevant to care and communicate them to professional or informal caregivers who are sometimes far away. The loss of mimetic experiences in these cases is literally programmed. The time spent in contact with the patient – a contact of two lived bodies – is presumably reduced through these technologies. Studies have indicated, however, that internet-based contact might be improving the relationship of caregiver and care receiver (Wakefield et al., 2004), although any improvement was at the cost of losing human experience. Participants in these studies lamented the decreasing possibilities for caregivers to judge the immediate need for care by taking into account the context of the patients’ conditions of life and by relying on sensuous experience as a basis for their professional definition of the situation (Wakefield et al., 2004).

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Maintaining and Promoting Mimetic Capabilities in Care Finally, the question remains how mimetic capabilities of humans can be promoted and maintained in the context of care in order to develop a basis of nondiscursive knowledge. In German nurse education, the call to include the teaching of interpretative skills through the lived body is strong (Ertl-Schmuck & Fichtmüller, 2009; Greb, 2003). Böhle and Brater (1999) too remind us of the importance of systematically including such educational processes in vocational training. As a starting point, one needs to recognize the value of sensitive, situation-oriented, and situationally grounded perception, and the resulting experiential knowledge, as part of the self-conception of professional nursing. Related competencies must be seen as professional and not discounted as prerational or pre-professional. Mimetic processes are not tied to language or thought but can rather be found in the corporal, sensuous, and imaginary dimensions of being. These processes must be taken seriously in conceiving of an education in mimetic capabilities. In order to accommodate these considerations, a reversal of the usual relationship of sensuousness and rationality is warranted. Reifying thought that is tied to rationality is dominant in the newly developing fields of German nursing science, nursing pedagogy, and didactics, and carries with it processes of abstraction and rationalization under the cloak of modernization. Mimetic potential, however, calls for a kind of rationality that is based in sensuousness. A primary concern of nursing education should therefore be the rediscovery of the senses, of sensitivity, of aisthesis in the broader sense, for an aisthetic education aims to educate all senses and therefore promotes perceptive and sensitive capacities (Wulf, 1991). Matheis (1998) cautions educators not to actively promote mimetic processes through pedagogic interventions but to rather empower learners to determine their own sensuousness through aesthetic processes. The task of pedagogy is to provide room for autonomous and spontaneous stocktaking of oneself, while at the same time, present ways to cope with the contradictory and the undecidable (Stemmer, 2001). Next to addressing concrete methodical challenges, the primary task of nursing pedagogy is to avoid negative processes of education, including the suppression of mimetic processes that is common in regular schools (Vogel, 1998). If mimetic processes are subjected to semantic reflection, one needs to ensure that respective corporal experiences are expressed in a kind of language that is close to the context of experience and that allows the inclusion of sensuous perceptions and seemingly irrelevant information in the reflection. This result can be achieved primarily through narrations that provide access to the nursing routine via analogies and similarities that are situationally, personally, temporarily, and locally tied to the process.

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Conclusion The mimetic capacity of humans opens up the perspective of a non-reifying, corporal [Leib] access to the other in the context of professional care. While mimesis is generally seen as a pre-ethical capacity, it must in social contexts be understood to be at the core of an “ethical hermeneutics” (Schlör, 1998). A mimetically grounded experience withstands absolute definition and classification within a system; it is characterized by experiencing the other in their strangeness while leaving them indefinite. Social processes are substantially tied to the mimetic capacities of humans, which are in turn tied to the way of humans as having a body and also tied to the way of humans as being a lived body. Social mimesis, through this lived body, provides an access to the other that retains the enigma of the other by not reducing them to the known. This kind of access in its non-reifying nature stays relevant only as long as the mimetic experience is not immediately entered into cognitive contexts – as long as it is not, for example, verbalized, but is rather kept within the context of the lived body as a performative basis for further action. Rationalization is exerting strong pressure at the micro-level of professional care work, and, as a result, mimetic processes are being suppressed. Situations that promote successful mimetic experiences through the “lingering gaze” (Adorno, 1997) directed at the other are almost impossible to create in the institutional setting of modern healthcare systems. The necessary pause of activities that is characteristic of mimetic impulses are now – more than ever – seen as unbecoming in the context of institutional care. In the future, the task of professional nursing should be to emphasize mimetic experiences as being at the core of care work and to demand the necessary conditions for its execution.

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Schön, D. (1983). The reflective practitioner : How professionals think in action. London: Basic Books. Sennett, R. (2009). The Craftsman. New Haven, CT: Yale University Press. Spence, D. G. (2001). Hermeneutic notions illuminate cross-cultural nursing experiences. Journal of Advanced Nursing, 35, 624–30. Stemmer, R. (2001). Grenzkonflikte in der Pflege. Patientenorientierung zwischen Umsetzungs- und Legitimationsschwierigkeiten. Frankfurt a. M.: Mabuse. Sutherland, J. A. (1993). The nature and evolution of phenomenological empathy in nursing: A historical treatment. Archives of Psychiatric Nursing, 7(6), 369–376. Truglio-Londrigan, M. (2002). An analysis of wisdom: An experience in nursing practice. Journal of New York State Nurses Association, 33, 24. Vogel, R. M. (1998). Geleitwort. In R. Mattheis (Ed.), Bildungsästhetik und Selbstverständnis. Grundlegung einer Subjektkonstitution in der Dialektik von Mimesis und Ratio (pp. I–X). Wiesbaden: DUV. Wakefield, B., Holman, J., Ray, A., Morse, J., & Kienzle, M. (2004). Nurse and patient preferences for telehealth home care. Geriatric Times, 5(2), 27–30. Waldenfels, B. (2011). Phenomenology of the alien: Basic concepts. Evanston, IL: Northwestern University Press. Weidl8, W. (1969). Vom Sinn der Mimesis. Eranos-Jahrbuch, 31, 249–273. Wheeler, K. (1988). A nursing science approach to understanding empathy. Archives of Psychiatric Nursing, 2(2), 95–102. Williams, C. A. (1990). Biopsychosocial elements of empathy : A multidimensional model. Issues in Mental Health Nursing, 11, 155–174. Wulf, C. (1990). Ästhetische Wege zur Welt. Über das Verhältnis von Mimesis und Erziehung. In D. Lenzen (Ed.), Kunst und Pädagogik (pp. 156–170). Darmstadt: Wiss. Buchges. Wulf, C. (1991). Mimesis in der ästhetischen Bildung. Kunst + Unterricht, 151, 16–18. Zderad, L. T. (1969). Empathic nursing. Nursing Clinics of North America, 4(4), 655–662.

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Chapter Eight: The Reflective Practitioner as Critical Theorist

Introduction It is now 30 years since Donald Schön observed that “what aspiring practitioners most need to learn, professional schools seem least able to teach” (Schön, 1987, p. 8). He argued that the roots of the problem could be traced to “an underlying and largely unexamined epistemology of professional practice – a model of professional knowledge institutionally embedded in curriculum and arrangements for research and practice” (Schön, 1987, p. 8). Schön referred to this “positivist1 epistemology of practice” as technical rationality, which he described as practice based on external, formal knowledge and theory rather than the practitioner’s own experience and expertise. He argued that a technicalrational approach failed to address the real and pressing problems faced by practitioners on a day-to-day basis, resulting in what he called the “rigor or relevance dilemma.” In his well-known analogy, he contrasted the high hard ground of technical-rational practice where “manageable problems lend themselves to solution through the application of research-based theory and technique,” with the swampy lowland where “messy, confusing problems defy technical solution.” The dilemma which the practitioner faces is whether to 1 The term “positivism” or “positive philosophy” was coined by Auguste Comte in the 1830s to describe the accumulation of facts and the connections (laws) between them through the method of science. The original positivists of the nineteenth century believed that the aim of science was not the search for ultimate truth or first causes, which fall under the remit of theology, but “only to discover, by a well-combined use of reasoning and observation, the actual laws of phenomena – that is to say, their invariable relations of succession and likeness” (Comte, 1830/1988, p.2). Comte argued that positivism could be fruitfully applied to all human endeavours to explain the world, including the humanities and the social sciences. Schön used the term “positivism” in a much broader way to encompass a range of scientific or evidencebased approaches to practice which validate knowledge according to the methods used to acquire it (rigour) rather than its usefulness to practitioners (relevance). As we shall see later in the chapter, Habermas similarly uses the term positivism as a general cipher for all unreflective and unself-critical approaches to knowledge generation, stating “that we disavow reflection is positivism” Habermas, 1968/1987, p. vii).

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remain on the high hard ground that provides rigorous and evidence-based solutions to relatively trivial problems, or “descend to the swamp of important problems and nonrigorous inquiry” (p. 3). As Schön suggested, the “rigor or relevance” dilemma is an issue not only for the practitioner but for the educator of practitioners. He argued that the skills and knowledge necessary for professional practice cannot be acquired in the classroom through the technical-rational transmission of propositional knowledge from teacher to student, but rather that learning to be a practitioner involves an accumulation of informal, often tacit (implied but unspoken) experiential knowledge gleaned directly from practice itself in a process of what he termed reflective practice. A very different approach to education is therefore required in order to prepare the practitioner for the swampy lowlands of indeterminate everyday problems. As Schön suggested above, the challenge for educators is compounded by the fact that the technical-rational approach “is built into the very foundations of the modern research university” (p. 3). The positivist epistemology of technical rationality dictates that the most important knowledge for practice is formal propositional knowledge, which is produced by theorists and researchers, reproduced in textbooks, and handed down to practitioners through lectures and research papers. Technical rationality therefore privileges research-based theory over practice, and academics over practitioners. I will suggest in this chapter that, from the outset of the reflective practice movement, nurse educators and researchers have recognized that any challenges to the dominant technical-rational epistemology pose a substantive threat to their own hegemonic power, position, and practice. They have therefore sought, either tacitly or explicitly, to suppress the radical promise of reflective practice by presenting reflection as merely another technical-rational tool under their own control. I will argue that, if it is to present a serious and sustained challenge to the dominant technical-rational approach to nursing, the reflective practice movement must develop a sound epistemological framework, and I will offer certain elements of Jürgen Habermas’s critical theorist philosophy for consideration. Since Habermas’s work is outside the academic scope of many nurse theorists and scholars, I will spend some time outlining the background to his thought, and particularly to his attempt to build an anti-positivist alliance of like-minded philosophers (Habermas 1968/1987). I will conclude by exploring the parallels between Habermas’s attempts to develop a reflexive response to positivism and Schön’s call for an anti-positivist epistemology of practice to counter technical rationality.

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Towards a Reflective Paradigm for Nursing Nurse educators first began to engage with the challenges of a reflective curriculum in the early 1990s (see, for example, Atkins & Murphy, 1993; James & Clarke, 1994). At least some of these academics were already familiar with the work of Kolb, Boud, and other educationalists from the experiential learning movement, but it was only with the publication and popularization of Schön’s work that the possibilities of reflective practice (in contrast to reflective learning) began to emerge. Schön (1983) presented reflective practice, or what he also referred to as reflection-in-action, as a response to “situations of uncertainty, instability, uniqueness and value conflict” (p. 50) where the problems of everyday practice take us by surprise or result in what he called “puzzlement.” In such cases, the practitioner experiments in real time in the practice setting by reflecting on the presenting problem, formulating a hypothesis, testing it out and, if necessary, reformulating it until the situation is resolved. Reflection-inaction draws primarily on the informal experiential knowledge and heuristics of the practitioner rather than on formal, research-based propositional knowledge, and brings together learning and doing in a single, reflexive act. Although many of these early advocates recognized the radical implications of Schön’s vision for a reflective profession, they were also aware of the problems and difficulties involved in introducing reflective practice to a wider nursing audience. As Clarke, James, and Kelly (1994, p. 2) warned: Despite the considerable debate and discussion of reflection in nursing and in other professions, reflective practice remains a highly problematic concept. This presents nurse educators with particular challenges. We have the responsibility of helping others to understand a concept which we ourselves may have difficulty in grasping and of which there is no shared understanding in the profession. Also, in our attempts as professionals to define and describe reflection so as to make it understandable and accessible, all too easily we can narrow the focus, routinise the process and technologise the activity.

Despite this warning, most of the nurse academics who subsequently translated Schön’s philosophy into practice either misunderstood, misrepresented, or misapplied his central ideas. As a consequence, while it is not unusual to find models and frameworks of reflection being taught to undergraduate students, and although space is often made in the curriculum for students to reflect on their practice, curricula that confront the full implications of reflection-in-action are rarely, if ever, to be found in departments of nursing. It is important to emphasize that Schön was advocating far more than simply a technique for retrospectively thinking about practice. In fact, he hardly mentioned reflection-on-action in either of his seminal books. His aim was

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rather to offer a challenge to the dominant technical-rational epistemology and replace it with “an epistemology of practice which places technical problem solving within a broader context of reflective inquiry, shows how reflection-inaction may be rigorous in its own right, and links the art of practice in uncertainty and uniqueness to the scientist’s art of research” (Schön, 1983, p. 69). And of course, when Schön talked of an epistemology of practice, he was referring not only to a way of thinking about it, but of doing it. A reflective epistemology of the kind envisioned by Schön would privilege practitioner knowing-in-action over knowledge from empirical research and would therefore shift the site of knowledge production and dissemination from the university to the practice setting. This in turn would have a profound impact on the role and practice of educationalists and researchers. Thus, Schön’s challenge to teach “what aspiring practitioners most need to learn” requires nothing less than a paradigm shift, a new framework of concepts, assumptions, beliefs, values, and principles for practice and education more suited to the needs of practising nurses. For a paradigm shift to be successful, the new paradigm must first present a coherent and viable alternative to the dominant epistemology, and second, it must demonstrate that this new paradigm is better able to solve the problems of current concern to the discipline. Unfortunately, the advocates of reflective practice have largely failed on both counts. There is neither a unified and coherent philosophy of reflective theory, research, and practice in nursing, nor is there an extant body of work that seriously addresses the problems and concerns of nurse theorists, researchers, and practitioners as they go about their work in the swampy lowlands. Despite (or perhaps because of) promises that a new paradigm of reflective nursing practice would “empower nurses to become fully cognizant of their own knowledge and actions” (Street, 1991, p. 1), would enable nurses “to separate out the various influencing factors and come to a reasoned decision or course of action” (Clarke & Graham, 1996, p. 26), and would radically transform not only nursing practice, but also the person of the nurse (Johns & Freshwater, 1998), there is little evidence today that reflective practice has presented any real and substantive challenge to the dominant technicalrational positivist paradigm. Rather than offering a radical alternative to technical rationality, reflection has become merely another technique or method for meeting technical-rational goals (Rolfe, 2002). Whether this failure to engage seriously and fully with the implications of a reflective paradigm can be attributed solely to ignorance and misunderstanding on the part of nurse academics is questionable. More likely, at least some educationalists, theorists, and researchers have given reflective practice their serious attention and have been somewhat concerned by what it might imply for their own positions in the profession and the discipline of nursing. Paradigm

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shifts usually have profound and often deleterious consequences for those in positions of power and authority within the current dominant paradigm, and for that reason, incremental change is usually strongly resisted by those with most to lose. Thus, while many educationalists feel the need to pay lip service to the idea of reflective practice, few have sought to develop it in any serious way. As a consequence, the reflective practice movement in nursing has developed over the past 20 years in a somewhat ad hoc fashion with little or no agreement even about the meaning of the term “reflective practice.” Rather than building a substantive body of theory around Schön’s radical epistemology of reflectionin-action for the nursing profession, many academics appear (perhaps in some cases deliberately) to have oversimplified reflective practice to the point where it has become, as Clarke et al. predicted, narrow, routinized, and technologized. Despite citing Schön as a major influence and inspiration, most nurse academics and educationalists promote reflection and reflective practice as something we do after we have left the swampy lowlands of practice and are safely back on the high hard ground of academia. I have suggested that is partly an attempt to present reflection as a tool for learning about practice over which academics and researchers retain control rather than, as Schön intended, a way by which practitioners can organize and understand their own practice. For example, Bulman and Schutz (2008) and Taylor (2000) have each written foundational texts on reflective practice in nursing, and each dismissed reflection-inaction as flawed or as irrelevant to nursing. Jasper, in her book Beginning Reflective Practice, was more sympathetic to reflection-in-action, but appeared to misunderstand its full meaning and significance, describing it as “the way that people think and theorise about practice while they are doing it” (Jasper, 2003, p. 5). However, as Schön pointed out, this is not its defining feature; while it might sometimes be possible to think on-the-spot in the midst of practice, it is not a necessary prerequisite. To regard reflection-in-action as a form of reflection-on-action occurring in real time derives from “a lingering model of practical rationality” (Schön, 1983, p. 281) and somewhat misses the point. Reflection-in-action is a way of practising; reflection-on-action is a way of thinking and learning about practice. As such, and contrary to common usage in nursing, the term “reflective practice” should arguably be restricted to the former. We can see, however, why nurse academics might prefer the latter. Even those writers who appear to understand and appreciate the concept of reflection-in-action are generally reluctant to pursue its full implications for nursing practice and education. For example, Gillie Bolton discussed Schön’s concept of reflection-in-action approvingly, but then went on to define reflection as an

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In-depth review of events, either alone – say, in a journal – or with critical support with a supervisor or group. The reflector attempts to work out what happened, what they thought or felt about it, who was involved, when and where, what these others might have experienced and thought and felt about it from their own perspective. (Bolton, 2014, p. 7, my emphasis)

This definition is typical of the way in which reflection is usually defined in nursing and other practice disciplines, and appears almost deliberately to ignore Schön’s pragmatist epistemology of reflection as on-the-spot experimenting. In almost every case, reflection is presented by nurse academics as a learning strategy to be undertaken in the classroom rather than as a way of practising nursing. It is not surprising, therefore, that Gibbs’s reflective cycle, which is probably the framework most often used by nurses, is the work of an educationalist who is primarily interested in student learning rather than nursing practice. Thus, despite a great deal of support and enthusiasm expressed by the nursing community, Schön’s radical “new paradigm” of reflective practice and education has been largely misinterpreted or overlooked.

Habermas and the Anti-Positivist Alliance I have argued thus far that Schön’s radical anti-positivist epistemology of reflection-in action has been largely neglected by nurse academics, who have focussed instead on reflection-on-action as a tool or technique in an otherwise technical-rational curriculum. Thus, reflective practice remains under-theorized and the dominant paradigm of technical rational nursing has gone largely unchallenged. I now wish to examine the attempts by the critical theorist Jürgen Habermas to develop a sound and rigorous reflective response to positivism that could form the theoretical foundation for a reflective epistemology for nursing. Habermas was concerned throughout his life with developing a reflective (or, more correctly, a reflexive) alternative to counterbalance the positivist scientific paradigm. Indeed, he defined positivism explicitly as a “disavowal” of reflection (Habermas, 1968/1987, p. vii) and believed that it could only be countered by a fully self-reflective epistemology. His early work in particular attempted to pull together an anti-positivist reflexive alliance of pragmatism, hermeneutics, and critical social science, opening a way forward for nursing and nurse education to establish a viable and intellectually rigorous alternative to what Schön called the positivist paradigm of technical rationality. Since its inception in the 1930s, the Frankfurt School of critical theory has taken a strongly anti-positivist stance in the field of sociology (e. g. Horkheimer, 1937/2002; Marcuse, 1941/1998), but it was Habermas, a prominent member of the postwar “second generation” of the Frankfurt School who, for reasons we

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have touched upon above, launched a broader attack on positivism. Habermas joined the Institute for Social Research in Frankfurt in 1956 as an assistant to Theodor Adorno, and later worked for several years with Hans-Georg Gadamer in Heidelberg before returning to Frankfurt in 1965 to take up a Chair. In his early work, Knowledge and Human Interests (Habermas, 1968/1987), Habermas attempted to reclaim the discipline of philosophy in general, and epistemology in particular, from being subsumed into science, a process that he considered to have begun with the original project of positivism in the early part of the nineteenth century. Thus, “Positivism marks the end of the theory of knowledge. In its place emerges the philosophy of science” (p. 67). That is to say, under positivism, any inquiry into the nature and production of knowledge is only possible in the form of an inquiry into scientific methodology. While Habermas’s reclamation project was not directed specifically towards education, we can see the consequences of this turn to positivism for the twenty-first-century university in general, and for the academic discipline of nursing in particular. Under positivism: transcendental inquiry into the conditions of possible knowledge can be meaningfully pursued only in the form of methodological inquiry into the rules for the construction and corroboration of scientific theories … The replacement of epistemology by the philosophy of science is visible in that the knowing subject is no longer the system of reference … Once epistemology has been flattened out to methodology, it loses sight of the constitution of the objects of possible experience. (Habermas 1968/1987, pp. 67–68)

Arguably, the epistemology of nursing practice has been similarly “flattened out” to the extent that all practice interventions are evaluated in terms of research evidence, and evidence is judged according to the methodology by which it was produced, with the positivist experimental method at the top of the hierarchy. As Habermas pointed out, this turn to positivist science removes both the knowing subject and the objects of experience from the process of knowledge-making, thereby evicting experiential and reflective knowledge from the technical-rational “hierarchy of evidence” and, by extension, from the classroom. Habermas’s primary concern was that positivism promotes the “illusion of objectivism” (p. 69); it has no mechanism through which self-reflection on its own limitations is possible. Thus objectivism deludes the sciences with the image of a self-subsistent world of facts structured in a lawlike manner ; it thus conceals the a priori constitution of these facts. It can no longer be effectively overcome from without, from the position of a repurified epistemology, but only by a methodology that transcends its own boundaries. The beginnings of this sort of self-reflection of the sciences can be found in the works of

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Charles Sanders Peirce and Wilhelm Dilthey. (Habermas 1968/1987, p. 69, his emphasis)

The entire epistemological project of philosophy is therefore susceptible to scientism, the view that “the meaning of knowledge is defined by what the sciences do” (p. 67). As Habermas pointed out, positivism can only effectively be challenged from the inside, and he therefore undertook “a historically oriented attempt to re-construct the prehistory of modern positivism … to recover the forgotten experience of [self-] reflection” (p. vii). His aim was to examine some of the reflexive philosophical traditions that positivism “so lastingly repressed” (p. 69) in order to construct a viable alternative and thus to rescue philosophy from itself. He began with Marx, whom he considered to have initiated a “science of man” as a logical extension of positivism. However, he came to the conclusion that this was a dead end at best and a recapitulation to a pre-critical scientific materialism at worst. As we have seen, Habermas located the strongest and most effective resistance to early positivism in the work of Peirce and Dilthey. Peirce, who is generally acknowledged to be the founder of the philosophical school of pragmatism, was considered by Habermas to be the first philosopher of science from the era of positivism to challenge its objectivism through critical reflection. For Peirce, scientific knowledge is not validated through strict and rigid adherence to method, but through consensus within a community of investigators. Preempting later philosophers and social theorists such as Feyerabend, Kuhn, and Wittgenstein, Peirce wrote “Science is to mean for us a mode of life.” He continued: If I am asked to what the wonderful success of modern science is due, I shall suggest that to gain the secret of that, it is necessary to consider science as living, and therefore not as knowledge already acquired but as the concrete life of the men who are working to find out the truth. (Peirce, 1895/1958, p. 54)

For Peirce, scientific inquiry is not objective and it is not transcendental; rather, it is based on the intersubjective agreement of the community of scientists. Furthermore, science cannot lay claim to fundamental or foundational propositions, nor to immediate and undistorted empirical knowledge. All knowing is mediated by prior knowledge in what Peirce called a chain of reasoning with no distinct beginning or end. If Peirce’s pragmatism attempted to undermine the project of positivism from within the natural sciences, then Dilthey attacked it from the then recently established tradition of the human or cultural sciences. If, as Peirce claimed, the natural sciences proceed on the basis of mutual understanding and agreement, then the focus of the human sciences is to understand this process of human understanding. As Habermas (1968/1987) concluded, “The difference between

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the natural and the cultural [human] sciences must therefore be reduced to the orientation of the knowing subject, to its attitude with regard to objects” (p. 141). In particular, the natural sciences are concerned with the construction and study of “laws” from which, as Dilthey pointed out, the knowing subject (“man”) excludes himself in the quest for objectivity, a process which Habermas referred to as “alienating distanciation” [Verfremdung]. In contrast, the subject matter of the human sciences is “man” himself, in which “the experiencing subject is given free access to reality” such that “reality seems to open itself up to experience from within” (p. 143). In the natural sciences, the constraints of having to examine the world through the construction of objective hypotheses and scientific laws restricts our cognitive activities merely to explanation [Erklären], whereas the human sciences permit a deeper, subjective, situated understanding [Verstehen]. Furthermore, this understanding is necessarily hermeneutic in the sense that it is only possible through what Habermas described as “experiential reconstruction such that we revert to the process in which meaning is generated.” He continued: “Every experience of any cognitive significance is poetic, if poesis means the creation of meaning: that is the productive process in which the mind objectivates itself” (p. 147, his emphasis). The production of knowledge is therefore intimately linked to the empathic understanding of self and others. Furthermore, knowledge is not “out there” in the world, fully formed and waiting to be revealed or discovered but is, at least in part, constructed or created. Habermas’s project during the 1960s and 1970s was thus to develop “a new critical philosophy of science” (p. 308) to challenge the dominant positivist paradigm of the human and social sciences. As we have seen, he drew on early critics of positivism from the hermeneutic and pragmatist traditions and attempted to incorporate them into his model of knowledge-constitutive interests. Thus, Peirce’s pragmatist critique of the empirical-analytic sciences incorporates a technically exploitable cognitive interest and Dilthey’s interpretive hermeneutic incorporates a practically effective cognitive interest (Habermas, 1968/1987, p. 191). However, both Peirce and Dilthey “were each in his way still so much under the spell of positivism, that in the end they do not quite escape from objectivism and cannot comprehend as such the foundations of the knowledge-constitutive interests towards which their thought moves” (Habermas, 1968/1987, p. 69). This caveat on the ability of pragmatism and hermeneutics fully to confront the unreflective (and therefore unself-critical) nature of positivism left the door open for Habermas to position critical social science as fulfilling the third and most important cognitive interest of emancipatory reflection as a response to the “false consciousness” of a positivist approach to the natural sciences. Habermas regarded Freud’s psychoanalytic theory as the best and most complete example

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of emancipatory reflection since it not only offered a deep-rooted “critique of meaning,” but “at the same time could credibly claim legitimation as a scientific procedure in a rigorous sense” (p. 214). It is not difficult to see how this opposition between the technical-rational objective sciences and the reflective-empathic humanities plays out in academic nursing. However, just as Habermas claimed that Peirce and Dilthey ultimately could not shake themselves loose from the spell of positivism, so the reflective movement in nursing has failed to detach itself from technical rationality.

Critical Theory and the Turn to Hermeneutics As we have seen, Habermas’s attempted alliance of critical theory with late nineteenth-century pragmatism and hermeneutics ultimately failed in its promise to refute positivism. However, in On the Logic of the Social Sciences (Habermas, 1967/1988), written at around the same time as Knowledge and Human Interests, Habermas extended his argument to contemporary writers, most notably Hans Georg Gadamer, with whom Habermas had previously worked, and who had recently published the second edition of Truth and Method. As before, Habermas’s project was to bring social science and hermeneutics “under one roof,” albeit within the house of critical theory. This attempt to assimilate hermeneutics within the rubric of the social sciences provoked a number of responses, most notably from Gadamer himself, which triggered a series of debates and cross-fertilizations between the two traditions (see Ricoeur, 1981/2008, p. 335 for a brief chronological account of the Gadamer-Habermas debate). Gadamer (1967/1976) responded almost immediately to Habermas’s critique of Truth and Method, in particular to his claim that hermeneutics lacks the selfreflective critical awareness required to avoid “systematic distortion.” The dispute rested largely on whether Gadamer’s concept of prior judgment or “prejudice” as a necessary component of understanding could fully negate the distorting influences introduced by ideological pressures; that is to say, whether it is possible through hermeneutic reflection “to distinguish the true prejudices, by which we understand, from the false ones, by which we misunderstand” (Gadamer, 1960, pp. 298–9, his emphasis). For Habermas, as we have seen, only critical social science offered a comprehensive theory of society that allowed for the kind of emancipatory reflection necessary to see through ideological distortion. Gadamer, in contrast, argued that such a transcendent reflective stance is simply not possible. He took Habermas’s paradigm example of psychoanalysis and attempted to demonstrate that the emancipatory self-reflection that is so necessary in the psychoanalytic

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relationship breaks down in the everyday social world. That is to say, the psychoanalyst is able to facilitate an emancipatory awareness in her or his patient that results in self-understanding and liberation from ideological constraints, only because of the “game” they are engaged in. However : what happens when [the psychoanalyst] uses the same kind of reflection in a situation in which he is not the doctor but a partner in a game? Then he will fall out of his social role! A game partner who is always “seeing through” his game partner, who does not take seriously what they are standing for, is a spoil sport whom one shuns. (Gadamer, 1967/1976, p. 41)

For Gadamer, then, Habermas’s claim that critical social science occupies a privileged transcendent position from which it is possible to see through the ideological distortions encountered in everyday life, is applicable only in particular bounded settings such as the consulting room. In most situations there is no such elevated position, and understanding can only be reached through messy “prejudiced” discourse. “This is something that hermeneutical reflection teaches us: that social community, with all its tensions and disruptions, ever and ever again leads back to a common area of social understanding through which it exists” (Gadamer 1967/1976, p. 42, his emphasis). To be sure, there is still the question of how we are to distinguish between “blind” prejudice which stands in the way of understanding, and “justified” prejudice which enhances it. We have seen that, for Habermas, we transcend ideological distortion by understanding the social processes which produce it. For Gadamer, however, there is no transcendental position from which to distinguish between true and false prejudices; rather, we continually test out our presuppositions through dialogue and “hermeneutical conversation.” He explained: Conversation is a process of coming to an understanding. Thus it belongs to every true conversation that each person opens himself to the other, truly accepts his point of view as valid and transposes himself into the other to such an extent that he understands not the particular individual but what he says. What is to be grasped is the substantive rightness of his opinion, so that we can be at one with each other on the subject. (Gadamer 1960, p. 385)

Testing and refining our prejudices is therefore an ongoing process, an authentic striving towards truth through a “fusion of horizons.” Although Gadamer made the point that the process of coming to an understanding is predominantly verbal, he suggested that it is possible to conduct a hermeneutical conversation with a text as well as with another person. He added that “This is not to say, of course, that the hermeneutic situation in regard to texts is exactly the same as that between two people in conversation,” since “one partner in the hermeneutical conversation, the text, speaks only through the other partner, the in-

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terpreter” (p. 387). Nevertheless, the very act of interpreting the meaning of the text in order to converse with it is itself an act of understanding. Paul Ricoeur, an existential phenomenologist who turned to hermeneutics in the 1960s, approached the process of coming to an understanding from the opposite direction. Whereas Gadamer suggested that texts could be understood as a special case of verbal communication, Ricoeur argued that discourse is a form of action, and action can be considered and analyzed as a text. Thus, “an action leaves a ‘trace,’ it makes its ‘mark’ when it contributes to the emergence of [patterns over time], which become documents of human action” (Ricoeur, 1971/2008, p. 149). This approach to hermeneutics, which draws on Schleiermacher’s much earlier work on textual exegesis, allowed Ricoeur to apply concepts from literary criticism such as narrative and metaphor to social and philosophical critique. Ricoeur responded to the Habermas-Gadamer debate with an attempt to unite hermeneutics and critical theory in a “critical hermeneutics” (Ricoeur, 1981/2008, p. 287). Unlike Habermas, however, who sought to subsume hermeneutics under the rubric of critical social science, Ricoeur attempted a reconciliation between the two. Thus: My aim is not to fuse the hermeneutics of tradition and the critique of ideology in a super-system that would encompass both. As I said at the outset, each speaks from a different place. Nonetheless, each may be asked to recognize the other, not as a position that is foreign and purely hostile, but as one that raises in its own way a legitimate claim. (Ricoeur, 1981/2008, p. 287)

The key question in this proposed recognition and reconciliation was, as before, whether hermeneutic philosophy is able to account for the demands of a critique of ideology. We have seen that Gadamer answered this question by denying that a “strong” transcendent critique is possible. Ricoeur took a somewhat different approach by identifying and deconstructing the “deceptive antimonies” in the work of Gadamer and Habermas. Thus, Gadamer’s concepts of prejudice, human science, misunderstanding, and ontological dialogue are compared respectively to Habermas’s concepts of interest, critical social science, ideology, and communication. While each of these antimonies appears to widen the gulf between hermeneutics and critical theory, Ricoeur, through a somewhat labyrinthine argument, reduced them to what he called “the dialectic of the recollection of tradition [hermeneutics] and the anticipation of freedom [critical theory]” (p. 299). When put in these terms, he claimed, the antimony is clearly false, adding that “We have encountered these false antimonies elsewhere: as if it were necessary to choose between reminiscence and hope!” (p. 299). For Ricoeur, then, the work of Habermas and Gadamer together constituted a “critical her-

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meneutic” to counter the ideology of the “scientific technological apparatus” of the modern state (p. 297). When applied to nursing, this critical hermeneutic raises some challenging epistemological issues. To what extent can reflective practitioners justify their practice with a claim that they have a grasp of its substantive rightness, that they have fused their horizons or that they have performed a textual analysis of their practice intervention? In other words, to what extent can critical theory and hermeneutics offer anything substantive to underpin Schön’s pragmatist project of reflective practice?

Reflective Practice as a Theory of Communicative Action We have already seen that Habermas was sympathetic towards pragmatist philosophy, particularly the work of Peirce, and described his own position variously as “transcendental pragmatism” (Habermas, 1973/1987, p. 374), “a universal pragmatic” (p. 354) and later, as Kantian pragmatism. On the one hand, Habermas’s project of emancipatory reflection demanded a Kantian, transcendental stance from which to critique positivist science. On the other hand, this a priori transcendental knowledge base must itself be open to self-reflective (reflexive) critique in a way that Kantian philosophy would not readily allow. Habermas’s initial solution was to present his theory of knowledge-constitutive interests as a “nexus between action and theoretical knowledge” (Habermas, 1973/1987, p. 370) in which experiential and practical knowledge from the lifeworld of the social actor or practitioner is given priority over theoretical knowledge. In Postscript to Knowledge and Human Interests, Habermas framed this opposition as “The practice of life versus the practice of research” (Habermas, 1973/1987, p. 369), in which “life-praxis” makes a claim for objectivity based on the acquisition and, most importantly, the sharing of action-related experience. Habermas’s transcendental pragmatism thus not only has a great deal in common with the work of phenomenologists and hermeneuticists such as Husserl, Heidegger, and Gadamer, but also overlaps significantly with the pragmatism of John Dewey and Schön himself. In particular, Habermas’s dialectic of research versus life resonates strongly with Schön’s “rigor or relevance” dilemma, with his distinction between the high hard ground of technical-rational theory and the swampy lowland of practice, and with the problematic for nursing of the theory-practice gap. In his later work, Habermas largely abandoned his concern with epistemological solutions to the problem of life-praxis, arguing from the distinctly pragmatist position that the merits of critical theory can best be assessed according to what it achieves rather than on methodological grounds. In The

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Theory of Communicative Action, Habermas (1981/1984) outlined a typology of action framed in ontological rather than epistemological terms (p. 87), in which action2 is categorized as either communicative or purposive-rational, with purposive-rational action further divided into strategic and instrumental actions (Baynes 2016, see Table 1). Communicative action (consent-oriented)

Purposive-rational action (success-oriented)

Strategic actions

Instrumental actions

Attempt to reach an agreement or mutual understanding (not to influence others) through a co-operative process of interpretation

Influence others for the purpose of achieving some end

Goal-oriented interventions in the physical world

Requires an interpretive or Verstehen approach

Follows theories of rational choice

Follows technical rules

Actions can only be understood by relating them to the actor’s own pre-theoretical knowledge as a member of the lifeworld

Success is appraised by efficiency

Success is appraised by efficiency

Table 1: A typology of action (after Baynes, 2016)

Although it represents a greatly simplified summary of Habermas’s theory, this typology mirrors Schön’s distinction between technical-rational and reflective actions and practices, and is therefore a potentially useful theoretical framework through which to understand, expand, and develop a paradigm of reflective practice for nursing. What Habermas refers to as purposive-rational actions are aimed at achieving a personal goal, that is to say, a goal that has taken on personal significance for the social actor or practitioner, and can be achieved either strategically by attempting to influence others or instrumentally by directly intervening in the physical world. To take a health-related example, the nursing goal of reducing smoking behaviour might be achieved either by influencing politicians to increase taxes on tobacco (strategic action), or directly through health education interventions with smokers (instrumental action). These are what Schön called technical-rational approaches; they are usually based on best evidence from empirical research studies and their success will be judged by measuring the reduction in smoking behaviour. Communicative action is based on a different set of epistemological and ontological assumptions. Habermas defined the concept of communicative ac2 Habermas’s definition of action includes speech acts as well as other “symbolic expressions,” but not those bodily movements which are only concomitant on other intentional actions.

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tion as “the interaction of at least two subjects capable of speech and action who establish interpersonal relations (whether by verbal or extra-verbal means). The actors seek to reach an understanding about the action situation and their plans of action in order to coordinate their actions by way of agreement” (Habermas, 1981/1984, p. 86, my emphasis). We can see that the purpose of communicative action (or what in this context we might call a reflective intervention) is not for the practitioner to impose her or his own goals for smoking cessation, but to reach a mutual agreement through a process of working together to understand the issue in relation to the lifeworld of the social actors (the patient/client and the healthcare practitioner) and the social system in which they find themselves. There are no predetermined instrumental outcomes to be met and the success or otherwise of the intervention can only be judged from the inside by the participants coming to a mutual understanding of the situation and a mutual agreement on what counts as success. In this case, a successful intervention may or may not involve the patient/client giving up smoking. Habermas’s theory of communicative action provides an account of reflective practice (reflection-in-action) not merely as a hermeneutic process of coming to an understanding, but as a “life praxis” which includes action as well as agreement. Thus, Schön described reflection-in-action as a reflective conversation with the situation in which practitioners “[shape] the situation, but in conversation with it, so that [their] own models and appreciations are also shaped by the situation … [They understand] the situation by trying to change it, and [consider] the resulting changes not as a defect of experimental method but as the essence of its success” (Schön 1983, pp. 150–151). Not only does the reflective practitioner shape the situation as a way of understanding it, she or he is also shaped by it. As in the case of Gadamer’s hermeneutical conversation, an agreement is reached between practitioners and clients based on a mutual understanding about the significance, function, benefits, and disadvantages of smoking as it impacts their lifeworld. That decision might not have been the one originally envisioned and planned by the nurse, who might have had her or his own preconceptions of what constitutes a successful smoking cessation intervention challenged and altered as a result of the encounter. More importantly, however, in addition to and as part of this coming to an understanding, an intervention has occurred; the practice of research and the practice of life are, to some extent, reconciled. I have illustrated this reflexive approach to nursing with a fairly simple health education example. However, with a little imagination it can be applied to any clinical situation for which there is no single, straightforward, universally accepted intervention, such as carrying out an intimate or invasive nursing procedure, reassuring a worried patient, or comforting a bereaved relative. In fact, it can be applied to most of the day-to-day non-technical encounters between

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individual nurses and patients in most clinical settings. Furthermore, Habermas claimed that these reflective conversations could only be understood in relation to the practitioner’s own pre-theoretical (that is, experiential) knowledge. Thus, the validity or “truth” of a reflective intervention must be ascertained through participation in the situation; that is to say, a judgment on whether the outcome is successful cannot be made by an outside observer or researcher. Any thirdperson, so-called objective attempt at understanding a complex social or (in this case) clinical encounter will necessarily miss (at least some of) the point. In other words, the application of the positivist criteria for validity such as objective detachment and the rigorous application of method will, in the case of non-technical clinical interventions, result in a less valid understanding than Habermas’s criteria for communicative action.

Conclusion I began this chapter with Donald Schön’s observation that “what aspiring practitioners most need to learn, professional schools seem least able to teach,” which he attributed to the fact that the positivist epistemology, which promotes theory over practice and theorists over practitioners, has gone largely unrecognized and unchallenged. Schön’s solution to the problem, his challenge to technical rationality, was to present reflective practice as an alternative epistemology that privileges practitioner knowledge, theory, and research over that produced by academics. Thirty years on, however, we are no closer to a reflective paradigm for nursing than we were when Schön wrote his seminal texts in the 1980s. Thus, while most nurses are familiar with the idea of reflecting on their practice, and while models and frameworks for reflection-on-action are taught in pre- and post-registration nursing courses, Schön’s radical epistemology of reflection-in-action remains under-theorized and largely unpractised. My aim in this chapter has been to explore Habermas’s critical theory as a possible framework through which to understand, develop, and defend a reflexive epistemology for nursing practice and education. I have traced the development of Habermas’s opposition to technical rationality from his early attempts to forge an anti-positivist alliance between critical sociology, pragmatism, and hermeneutics through to the “life praxis” approach of his theory of communicative action. I have tried to demonstrate the strong similarities between communicative action and reflective practice, and to reconcile Habermas’s critical hermeneutics with Schön’s particular take on American pragmatism, in the hope that nurse academics and practitioners might adopt critical theory as a useful and productive theoretical foundation for the development of a reflexive epistemology for nursing.

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As I suggested, this task is complicated by the fact that a new paradigm based on Schön’s epistemology of reflection-in-action would necessarily shift the locus of power in the academic discipline and the profession of nursing from academics to practitioners and patients, and from the classroom to the clinic. Given that the reflective practice agenda is currently controlled predominantly by academics, it is perhaps unreasonable to expect them to behave in ways that challenge their own self interests. Ironically, the critical self-examination necessary for this undertaking can perhaps only be achieved through the emancipatory reflective stance advocated by Habermas. Nevertheless, my hope is that practitioners, academics, researchers, and patients might work together to develop a “life praxis” approach to nursing more suited to the realities of practice in the swampy lowlands.

References Atkins, S., & Murphy, K. (1993). Reflection: A review of the literature. Journal of Advanced Nursing, 18, 1188–1192. Baynes, K. (2016). Habermas. London: Routledge. Bolton, G. (2014). Reflective practice: Writing and professional development (4th ed.). Los Angeles, CA: Sage. Bulman, C., & Schutz, S. (2008). Reflective practice in nursing (4th ed.). Oxford: Blackwell. Clarke, B., James, C., & Kelly, J. (1994, May). Reflective practice: Broadening the scope. Paper presented to the First International Nursing Times Open Learning Conference, Nottingham, UK. Clarke, D. J., & Graham, M. (1996). Reflective practice: The use of reflective diaries by experienced registered nurses. Nursing Review, 15(1), 26–29. Comte, A. (1988) Introduction to positive philosophy. (F. Ferr8, Trans). Indianapolis, IN: Hackett Publishing Company. (Original work published 1830). Gadamer, H.-G. (1960). Truth and method. London: Sheed & Ward. Gadamer, H.-G. (1967). On the scope and function of hermeneutical reflection. In D. E. Linge (Ed and Trans), Philosophical hermeneutics (pp. 18–43). Berkeley, CA.: University of California Press. Habermas, J. (1981). The theory of communicative action: Volume 1: Reason and the rationalization of society. London: Heinemann. Habermas, J. (1987) Knowledge and human interests. (J.J. Shapiro, Trans.). Cambridge: Polity Press. (Original work published 1968) Habermas, J. (1987). Postscript to knowledge and human interests. In J. Habermas, Knowledge and human interests (J. J. Shapiro, Trans., pp. 351–86). Cambridge: Polity Press. (Original work published 1973) Habermas, J. (1988). On the logic of the social sciences. (S.W. Nicholsen & J.A. Stark, Trans). Cambridge: Polity Press. (Original work published 1967)

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Horkheimer, M. (2002). Tradition and critical theory. In M. Horkheimer, Critical Theory : Selected Essays (M. J. O’Connell, Trans., pp. 188–243). New York, NY: Continuum. (Original work published 1937) James, C. R., & Clarke, B. A. (1994). Reflective practice in nursing: Issues and implications for nurse education. Nurse Education Today, 14, 82–90. Jasper, M. (2003). Beginning reflective practice. Cheltenham: Nelson Thornes. Johns, C., & Freshwater, D. (1998). Transforming nursing through reflective practice. Oxford: Blackwell Science. Marcuse, H. (1998). Some social implications of modern technology. In D. Kellner (Ed.), Technology, war and fascism (pp. 39–66). London: Routledge. (Original work published 1941) Peirce, C. S. (1958). Scientific method. In A.W. Burkes (Ed.), Collected papers of Charles Sanders Peirce, Volumes VII and VIII: Science and philosophy and reviews, correspondence and bibliography. Cambridge, MA.: Harvard University Press. (Original work published1895) Ricoeur, P. (1971). The model of the text: Meaningful action considered as a text. In P. Ricouer, From text to action (K. Blamey & J. B. Thompson, Trans., pp. 140–63). London: Continuum. Ricoeur, P. (1981). Hermeneutics and the critique of ideology. In P. Ricouer, From text to action (K. Blamey & J. B. Thompson, Trans., pp. 263–99). London: Continuum. Rolfe, G. (2002). Reflective practice: where now? Nurse Education in Practice, 2, 21–9. Schön, D.A. (1983). The reflective practitioner. London: Temple Smith. Schön, D.A. (1987). Educating the reflective practitioner. San Francisco, CA: Jossey-Bass. Street, A. (1991). From image to action: Reflection in nursing practice. Geelong: Deakin University Press. Taylor, B. (2000). Reflective practice: A guide for nurses and midwives. Buckingham: Open University Press.

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Chapter Nine: A Nursing Didactics Model based on a Constellational and Critical Identity Perspective

Introduction In their introduction, the editors state that this comprehensive collection looks at nursing practice, theory, research, and nursing history from various critical theoretical perspectives. A brief explanation of my critical perspective developed in this chapter will help the reader to follow the shift from a focus on critical nursing sciences toward nursing education, since my didactic model is hardly self-explanatory. A critical identity perspective objects to a mode of thinking that uses familiar identities as labels and refers to an open attitude towards facts in nursing that we believe familiar, or phenomena whose scientific definition has already been fixed. A contemplative process of engaging with a phenomenon is to show that it is not, in fact, sufficiently described by its familiar term, that it is only to a greater or lesser degree that thing because the terminology identifies it as such. An effective criticism of such identities is provided by multiple, varying perspectives that gradually dissolve the preconceived union of object and term, as they show the object in a new light, finally putting an end to its reified identification. This multi-perspectivity only becomes truly constellational through a productive form of observation that not only views the matter at hand in a different light, but specifically, in the light of terminological reference points, also (metaphysically) functions as regulative ideas enabling a process of education beyond academic operationalization: “The terms accumulating around the matter to be identified potentially define its core and achieve, in thinking, what thought itself necessarily expelled from itself” (Adorno, 2003, GS 6, p. 164, my translation). In a critical reference to the societal system of exchange and power, this language-critical standpoint in the sense of Adorno’s negative dialectics oscillates, meaning that it is hardly possible to keep your feet firmly on the ground as you shift perspectives. Suspending terminology and judgment, and specifying matter at the micro-level in order to grasp its alienness, is the constellational attempt to create a negative didactics of nursing, which necessarily

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remains negative because it subjects to criticism even the conditions under which a rational subject is capable of undertaking criticism. As more and more aspects of life are subjected to scientific analysis by measurable data, criticism and affirmation are increasingly indistinguishable. This insight into the dialectics of the enlightenment [Dialektik der Aufklärung] also confronts nursing didactics with the classic imponderables of developing any pedagogical theory. We are, for example, unable to say how learners, who as apprentices are paid for their labor1 and are therefore dependent on their apprenticeship, achieve maturity (i. e. are capable of independent judgment) through that same system, yet we cling to this regulative idea. I will address such problems of power and legitimacy in the development of nursing didactics more closely in the first part. In terms of content, the construction of a didactic model for nursing is indebted primarily to two disciplines: in regard to its theoretical foundations the model is grounded in education, and in regard to the internal logic and dynamics of its subject it is based on nursing science. The mediation between the two through the definite negation of the metaparadigm of nursing is introduced in part 2 as a frame of reference for reflecting on nursing didactics. The dialectical categories thus generated for both academic didactics and for nursing didactics (for so-called epochal key problems [epochaltypische Probleme]) with their potential applications in an exemplary, case-oriented curriculum development will be discussed in part 3.

Pedagogical Aporiae: The Dialectics of Enlightenment Through the increasing scientification of all areas of life, criticism and affirmation are increasingly indistinguishable, which is precisely why Herwig Blankertz argued that scientific knowledge must become a subject for teaching in all types of schools. Inspired by Blankertz’s approach of the structural matrix [Strukturgitter],2 I am trying to provide a response, in the form of an academic didactic, to the challenge of the enlightenment’s dialectical pedagogical aporiae through a constellational and critical identity model. Because the enlightenment 1 In the German system of nursing apprenticeship, nursing students are employees of a hospital and are therefore paid by the hospital in which they undertake their training. It is only in recent years that nursing students can simultaneously complete an undergraduate academic program – but that does not change the fact that they are still employed by a hospital. 2 Structural matrices are created “when fundamental facts, that is,‘structures’ of a field are related to educational intent through the means of the academic discipline concerned with that field and are thus constituted as curricular content.” (Blankertz, 1975, p. 179) According to Blankertz, guiding pedagogical and political intentions are questioned through the medium of field-specific facts to arrive at regulative criteria (Greb, 2003, pp. 134–147).

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as an educational project was so successful in subjecting mythical fears to rational control, its dialectic created aporiae that became an existential threat to education, since the modern pedagogical self-understanding is inherited from the enlightenment’s master plan of humanization: It shares its vision that an understanding of the preconditions of their own view on themselves and the world can enable humans to place their relationship with themselves and the world on a rational footing. All depends on humans themselves – and therefore ultimately on their education (Schäfer, 2004, p. 9, my translation).

The idea of the self-organized, autonomous working and learning subject has thus become a clich8 in German vocational education, a de facto unquestioned presupposition of a didactic concepts and qualifications framework. Reinforced through the introduction of evidence-based approaches in nursing and in other disciplines, the orientation points for pedagogical reflection and responsibility have become independently verified knowledge and practical self-determination. Similarly, a critique of science considers itself to be on the safe side as long as it points to the social intermediation of its concepts, and that scientists engage in self-reflection and identify their societal standpoint in their research. All of these beliefs must be distrusted since the publication of the Dialectic of Enlightenment [Dialektik der Aufklärung] (Horkheimer & Adorno, 1944) – since German fascism assumed the right to define life unworthy of living and delivered it to industrial killing processes.3 Therefore a nursing didactic has to consider that, at any time, its rational foundation may turn out to be irrational, that the autonomous rational subject turns out to be non-existent and that the entire project of a scientific enlightenment reveals itself to be a perfidious selfdestructive process with a built-in mechanism of delusion. Nonetheless, no alternative exists to the enlightenment. Even early critical theory remained indebted to its goals – though in a sense of enlightening the enlightenment – as is demonstrated by such provocative terms as totality, primacy of the object, or non-identity that also underlie the structural matrix of nursing didactics (Greb, 2003). However, referring to Auschwitz in academic debates rarely ends well. It leads to averted eyes and embarrassed silences. The impression of the improper [Ungebührlichen] is justified inasmuch as these historical events go beyond anything that is normally a subject of educational academic discourse. Auschwitz is always disproportionate. However, in Adorno’s theory, Auschwitz stands for what science claimed to be its very aim: 3 Referring to Adorno’s categorical imperative that Auschwitz must not be repeated, Alfred Schäfer summarized the pedagogical consequences: “There is no place outside this event from which it is possible to speak reasonably about the event. Adorno does not view Auschwitz as a road accident on humanity’s path toward increasing humanization, but as an expression of the destructive tendencies inherent in that very humanization itself.” (2004, p. 28)

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Since the beginning the enlightenment, as an all encompassing progression of thought, has always pursued the goal to relieve humans from fear and to install them as masters. Yet the fully enlightened earth radiates triumphal disaster. The programme of the enlightenment was the demystification of the world. It sought to dissolve myths and replace imagination with knowledge. (Adorno & Horkheimer, 1988, p. 9, my translation)

Today we look on the many facets of enlightened barbarism like famines and food waste, wage dumping, wars and refugees, but also neglect in nursing homes, low-budget airlines, competency frameworks, and text-messaging culture. The term itself makes us suffer for the inability to express creatural [kreatürlich] pain. Language locks out our suffering. To protest against this and to give voice to concrete experiences of suffering in scientific theories is a concern that early critical theory shares with nursing science. Admittedly, contaminated theories provoke fear of contact, which is why both are preferably kept in quarantine.4 It is this shared intention that allowed me to find answers for the most challenging questions of the transformational process in nursing didactics: how can the core of nursing, or what makes nursing particular compared to other healthcare professions, and its actual reality be detected at all in spite of its context of delusion, and how can they be grasped in a nursing science without forcing lived experience into abstract terminology? After all, in Adorno’s Negative Dialectic, the key purpose of rational theories is to lend voice to the experience of suffering. Like no other epistemological theory, it acknowledges the role of corporality [Leib] in the epistemological act, making corporality the cipher of non-identity. I cannot go deeply into Adorno’s reception of Hegel’s idealistic dialectic and the historical materialism of Marx here (cf. Greb, 2003, pp. 16–134), but I will briefly address two quotes on the Hegelian concept of sublation [Aufhebung] and Marx’s mediation [Vermittlung] of economic contradictions in consciousness. What actually happens to reality when we appropriate it? This Hegelian mental exercise is still an amazingly didactic thought experiment, in so far as we cannot let go the question about the relation between cognizance of reality (the structure of life) and cognizance of knowledge (logic): By thinking an object, I turn it into a thought and deprive it of the sensory ; I turn it into something that is centrally and immediately mine: only in thought am I with me, and only this mental grasp allows penetrating the object that no longer opposes me, from which I took that own quality which it had against me for itself. As Adam said to Eve, you are flesh of my flesh and bone of my bone, so the spirit says, this is spirit of my spirit, and all alienness vanishes. All perception is generalization and this is part of thought: generalizing something means thinking it. (Hegel, 1970, p. 47, my translation) 4 For an examples, see Jochen Temsch (1994), as quoted in Greb (2003), pp. 220–227.

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Cognizance [Erkenntnis] is an act of desensualization and abstraction, but Hegel’s description retains a palpably corporal [leibhafte] quality : penetrating the object strikes us as an almost painfully mental intrusion. How it eradicates distances and how it comprehends by incorporating that what is disturbing of the unknown – flesh of my flesh and bone of my bone. The cannibal charm of identifying thought becomes evident here, hinting at the gestus for the domination of abstract scientific thought with its enraged striving for total control against which Adorno’s critique of ideology was directed. From this encounter both parties emerge mutilated: the enlightened, but desensualized person and his scientifically evident object. For Marx, on the other hand, we can only make an assumption about an object of cognizance “when, through practical or theoretical activities, it has turned into an object for us” (Marx & Engels, 1958, 3, 39). He localizes the processes of mediation between subject and object in the social labor of a capitalist system of domination: The ideas of the ruling class are in every epoch the ruling ideas, that is, the class, which is the ruling material force of society, is at the same time its ruling intellectual force. The class that has the means of material production at its disposal has control at the same time over the means of mental production, so that thereby, generally speaking, the ideas of those who lack the means of mental production are subject to it. (Marx & Engels, p. 46, my translation)

Marx criticizes Hegel’s attempt to encompass the reality of historical events in the tripartite mode of thesis, antithesis, and synthesis5 : contradictions cannot be resolved through thought, but only in the course of a proletarian revolution. For vocation-educational processes and their didactics this constitutive contradiction between the social character of production and the capitalist appropriation of the products is essential (Greb, 2009). Adorno built on both positions to develop a negative dialectic. In contrast to Hegel’s approach, Adorno’s dialectic remains negative because he criticizes the (premature) reconciliatory synthesis. Thesis and antithesis, subject and object, language and reference remain in living contradiction. In contrast to Marx, social domination is not exclusively perceived as economic relations between classes, but its internalization in the new context of Freudian psychoanalysis. The internal mediation between the two extremes of individual and society now characterizes the contradiction, explaining that the working class failed to be5 In describing his concept of synthesis, Hegel states that thesis and antithesis are not merely limited in their validity, but sublated [aufgehoben]. This word has a triple meaning: It can be read in the sense of tollere, to remove, of conservare, to preserve, or as elevare, to raise. In this sense, mediation means the juncture of extremes (individuality and generality) through their shared middle (particularity) through the intermediary of a Third.

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come a revolutionary subject because of its identification with the aggressor. Thus, Adorno’s dialectic is negative because it does not have an interest in possession [Verfügungsinteresse] and distances itself from scientific tendencies to overpower their objects. Its most positive element is the definite negation. Students must learn this method in order to work with the categories of the structural matrix (part 3). In a process of internal and external reflection, we seek differences in identities and identities in difference. The object of critique, though, will still be sublated [aufgehoben] in the terminology, but in the sense of conservation [conservare] in a new gestalt, which makes sublation more closely resemble a transformative process as in the example of the metaparadigm of nursing (part 2). I encountered this critical position in educational theory during my own graduate studies with Heinz Joachim Heydorn. In his writings he understood that there is a fundamental contradiction between education [Bildung] and domination [Herrschaft] that cannot be separated from the concept of political maturity [Mündigkeit] and the history of Western identity. A systematic historical reconstruction from Greek antiquity to the mid-twentieth century demonstrates this contradiction. With the institutionalization of education, a fundamental conflict on the part of the state apparently emerged because education was aimed only at increasing rationality (enlightenment) in order to satisfy the particular interests of production and administration. The stateoperated education system thus produced an enlightened rationality that aimed “at the universal achievement of humanity through itself,” thereby contributing to overcoming this fundamental conflict. Heydorn’s alarm that the technological development of the means of production has advanced far beyond practical control does not really surprise us from a present-day perspective. After all, we experience daily the truth of his conclusion that “the capacities of understanding and action that humans acquire in an educative process are anchored in our biological history and the comparatively inadequate historical emancipatory movement of the present day remain unreachable to each other” (Heydorn, 1980, pp. 58, 122). Since we cannot gain access to the world independent of a description, let alone develop a didactic model, the question in the process of developing such a model must be its reference: What do our sensations, perceptions, thought and speech patterns relate to when we speak of nursing? The specific nature of nursing itself must enter the discussion and when the concepts of experience and the primacy of the object from the abovementioned criticism of Hegel become important: Humans no longer come to themselves through the understanding of the objects they engage with. The object must retain its independence, its incomprehensibility ; this,

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however, only appears imaginable if humans also come to grips with the limits of their comprehension and their own subjectivity in engaging with these objects … In the face of all (necessary) efforts towards comprehension, the object retains its primacy. (Schäfer, 2004, pp.87, 93, my translation)

Specific Negation: The Metaparadigm of Nursing Didactics for specific subjects or areas of expertise can only legitimize their existence alongside general didactic models by being grounded in the specific logic inherent to their field. An example of this kind of logic in the field of nursing science was Jacqueline Fawcett’s 1996 “Pflegemodelle im Überblick,” a work that found international interest. It aimed to define the scope of nursing science and its boundaries with other disciplines. The paradigmatic framework it outlined was defined by four concepts existing in an abstract interrelation: person, health, environment and nursing (p. 17f.). It offered nursing science the opportunity to lay claim to an independent status and gave its didactics the hope of developing a foundation for its curriculum. Thus, the metaparadigm represented the broadest possible consensus among nursing scientists and offered itself as the structural basis of a didactic model for the field. During a graduate course, the students and I reorganized this model in a process of definite negation in order to mediate between the dimensions of nursing science and educational theory. On the basis of the structural matrix approach formulated for vocational and professional curriculum development by Herwig Blankertz, we transferred the paradigmatic framework into a matrix. The students practiced definite negation by analyzing Fawcett’s study, first following up the real contradictions inherent in the interdependencies of the key concepts, then trying to frame an objection through a critique of imposed identity. They thus took Fawcett at her word, developing the yardsticks of their criticism from the claims of the theory itself. It became clear, for example, that the concept of “environment” broadly encompasses society in its “environs within which nursing takes place” (Fawcett, 1996, p. 18), but lacks an understanding of concrete processes of mediation. How social, cultural, and economic conditions are reflected in nursing relationships or professional organizations and can be experienced as individual problems or contradictions remain unclear, to the extent that these questions are raised at all. In our class, we therefore began looking for more apposite ways of framing nursing practice in its societal context by more clearly defining the material content of the four key concepts (Greb, 1997). Ultimately, a new form of the metaparadigm emerged, characterized by an open, dynamic understanding of nursing as a constellation in a context of societal contradictions whose inter-

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mediation in the nursing profession was little understood as yet. The course of this terminological transformation formed the framework for our first nursing didactics matrix (Figure 1). The tautological component of “nursing,” previously defined as “activities that are undertaken by nurses on the patient in the patient’s interest as well as the aims and results of these activities” (Fawcett, 1996, p. 18), was now sublated [aufgehoben] into the totality of the matrix. As our only access to nursing as a phenomenon is in its mediated form, we reconstructed Fawcett’s paradigm and its elements from the totalitarian perspective of a system of health policy and economics. This was an innovation in nursing didactics, where epistemological, social and corporal [leiblich] processes of mediation have gone unthematized. The totality of society as a system being subjected to criticism as it was developed by early critical theory is therefore identified in the top bar of the matrix.

Figure 1: Structural Matrix developed from a critique of the Metaparadigm of Nursing (Greb), translated version

The constellation we developed experimentally using this matrix opened up a qualitatively new perspective on the specific dynamic of nursing and its particular logic as a social practice through language, as Adorno predicted.6 The 6 Where this constellation primarily occurs as language and becomes representation, it does not

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three perspectives (individual, interaction, institution) can also be read empirically as the entry ports of societal contradictions, and, conceptually, as the sociological forms of reflection in tertiary level didactics. They correspond with the material content that consists of the experience of disease, professional care, and the healthcare system, that form the factual levels.

Individual (PI) and Experience of Disease (L1) “Nursing is concerned with the principles and laws that are significant for the life process, the well-being and optimal functioning of healthy and non-healthy persons” (Fawcett, 1996, p. 18.). I replace this link between person and health in a nursing perspective with the sociological term of “individual” because a negative dialectic requires viewing even a single person in social categories and from the abstract principle of exchange (totality).7 These corporeal interpretations (PI) are to give a voice and the power of objection to corporality [Leib].8 In German, we speak of the corporal [Leib] to mean the felt body with its own quality for mind and psyche that is solely the own experience of the person in it, unmediated through others or through diagnostic technology. The more familiar term in nursing is body [Körper], a word used since the eighteenth century to refer to an outside perception, which we use to refer to didactic analyses of medical research, therapy, diagnostics, or in nursing interventions. A perspective that allows for a unified view of corporality and body is provided in Bernhard Waldenfels’ term somatic [Somatik]. The duality of this term would correspond to a duality of corporality itself, since it does not distinguish two substances, but two perspectives. One is a personal view in which the corpus features as a medium (e. g. as a mover when in motion) and a naturalist view that sees it as a mere body-object, allowing us to view ourselves and others as a something that “undergoes certain processes or exists in certain states. I myself define its terms. It provides their objectivity through the relation in which it places them around the object at their centre. Thus, it serves the intention of the term to define the meant object in its entirety. (Adorno, 2003, GS 6, p. 164) 7 ‘Exchange’ here means the imposition of the universal, the expression of the totality of the social system as a form of social integration. Its most salient features are “the sale and purchase on cash terms, the binary buyer-seller structure, the fleeting and impersonal nature of exchange relationships, and finally, the individualisation and rationalisation of the act of exchanging itself.” (Kerber & Schmieder, 1991, p. 604) 8 The corporal individual experience of care recipients is key to the experience of disease, the experience of caregiving through nursing, and the relevance of the offers the healthcare system provides. Using the nursing didactics matrix, I reflect on case-related nursing issues, relationship dynamics, and social and logical contradictions at the intersections with factual levels.

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and others are characterized from a perspective of a distanced observer. This observation is not tied to a vital process, but to a Naturtechnik (a social technology to engage with the natural world)” (cf. Greb, 2003, pp. 62f., 196–200; 2007, p. 153f.; Waldenfels, 2000, p. 248f.). It is up for debate to what extent this duality of corporality can illustrate what the dialectic of the enlightenment calls the melding of technological rationality and dominance: where a naturalist perspective dominates, the corporal nature falls silent and is threatened with the loss of its inherent value and meaning. In view of this danger, I must agree with Böhme (2003) in his questioning of whether nature is still viewed as a basic determinant of the human condition, or whether a vigorous defense of “corporal nature” [Leib qua Natur] is needed in defense of human dignity. Central to the nursing profession, his question of corporality [Leib] as the place where human dignity is undermined, injured, and degraded is all the more pressing with the advent of transplant medicine opening up limitless possibilities for manipulating human nature. With this, Böhme states, humanity is advancing on a broad front towards the transformation of the human being into an artefact (2003, pp. 75f., 152; Greb, 2007). Adorno and Horkheimer (1988) adopt Weber’s term of disenchantment [Entzauberung] to describe this: Enlightened individuals develop a scientifically molded perspective on external and internal nature, identifying with a view that ultimately aims at domination and exploitation – an identification with the aggressor. This is also evident when nursing professionals use the word “resources.” Illich (1975) provides the term “medicalization” in his critique of dominance structures in scientific medicine: Medical progress, vitally important though it is, ultimately comes at the price of accepting the definitory power of medical science as a technological rationale of dominance even in the nursing profession. This corporal perspective of the individual corresponds to the factual level Experience of Disease (L1), replacing Fawcett’s expansive normative concept of health as the “status ranging from complete well-being to incurable illness” (Fawcett, 1996, p. 18). By focusing normatively on the optimal functioning of healthy as well as non-healthy persons, it becomes political in its support of a currently fashionable attitude of forced optimism that veils the consequences of cuts to health budgets. The health paradigm shows a broader tendency to exclude social and psychological suffering, disease, disability, and death. It stands for medicalization, early screening, apportioning of blame (risk factors), and greater financial burdens shifted on the ill, who are conveniently relabeled as “empowered consumers.”

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Interaction (PII) and Professional Care (L2) “Nursing is concerned with the activities and processes through which positive changes to health can be effected” (Fawcett 1996, p. 18). We transform this ideological idea of a “union of person and nursing” to a humanitarian moral perspective of nursing interaction. This emphasizes a collective view of the nursing profession and the co-productive nature of outcomes. In practical terms, nursing is usually a face-to-face or body-to-body relationship, but nurses adopt a professional role in it, that is, they act from a collective understanding of nursing, bound by a theoretical understanding and ethos that we must consider in our didactic reflection. Regarding the expectation that nursing be a humanitarian act, we again refer to the categorical imperative that Adorno places above all educational action.9 This reference appears anachronistic to most students. Too far removed from nursing didactics, they find. Yet in Germany, the moral quality of an irreducible pedagogical value system derives from precisely this reference. In it, the educational concept of critical theory (Adorno, Heydorn) preserves the intersection of Kantian morality and corporeality. Unlike Kant’s purely rational imperative, this is forced on us physically in an actual power relationship. It requires mimetic identification with the victims’ suffering. By contrast, the morality of pure reason remains a mere idea. Only their intersection, the insight into barbarity and the animal revulsion that is created by knowledge of the other’s pain, creates the impulse that generates action. It is only from barbarity that we derive the determination of moral action, just as all humanization makes inhumanity concrete. It is from this realization that Adorno stresses the importance of a corporal element as a necessary completion of Kantian morality.10 In the established relation of person and nursing, this relational perspective (PII) corresponds with the second factual level (L2) of Professional Care. Ursula Rabe-Kleberg (1996) has studied nursing care as a form of professional action. Through didactic transformation, the new term encompasses traditionally established and professional forms of care in their societal context within the professional context of nursing: 9 Hitler forced a new categorical imperative on humanity in its state of unfreedom: to form thought and action in such a way that Auschwitz not be repeated and nothing like it occur again. This imperative resists its justification as much as the Kantian one its givenness. To treat it discursively would be sacrilegous: In it, we may physically experience the element of the additional in morality. Physically, because it exposes individuals to the experience of abhorrence of the unbearable pain become practical, even as individuality begins to disappear as a form of mental reflection. 10 Nursing didactics finds easier access to this hypothesis through neurological research on the phenomenon of mirror neurons.

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Personal services are characterized by uncertainty at several levels. Given that this type of labor is standardized only to a small degree, that it requires a high degree of additional qualification to be held in reserve, and that it calls for the perpetual generation of new competences, it can only adequately be carried out as professional labor. … However, professional action can take place in a space outside of society. It is bound by various references and structures: Socially, it is grouped with the activity of aiding and, as a paid profession, subject to the question of extraneous control. (Rabe-Kleberg, 1996, p. 296f.)

At the second level, nursing is to be analyzed across the entirety of its spectrum, including the historical dimensions and its traditional motivators (charity, neighborly love) and traditional forms of monastic and secular care. The term professional care also refers to the actual capacities of aiding, carrying actual content of lived nursing experience in its inherent reference to the outside and to others: supporting, fostering, protecting, and, as atmospheric qualities, warmth, attentiveness, attention. In this aesthetic understanding, the term professional care not only refers to the mental and sensual qualities of a critical identity perspective, it also points to its dialectical undercurrent – the tension of an asymmetric relationship between the recipient’s need and the caregiver, and the merciful concealment of the harsh, unacceptable realities of a healthcare system operated on budgets and increasingly subject to economic competition. That makes it ideological in itself (Greb, 2006).

Institution (PIII) and Healthcare System (L3) Aside from the personal “environment” as a determiner of experiencing disease, we differentiate the concept of environment as the institutional context of professional care, on the one hand at the factual level (L3), but on the other, through the perspective of economics and health policy adopted by the health system as a societal institution. Institutions such as the healthcare system function as a nexus between society and the individual. Critical theory views them as obstacles to reflection through their reifying tendencies. The healthcare system regulates the legal framework, and is responsible for economic necessities and the political mainstream beliefs that produce the economic and policy calculations through which the professional actions of nurses are effected, guided, and limited. Students and trainee nurses are mainly encouraged to act as devils’ advocates, studying the strategies of politicians, lawyers, insurance providers and hospital administrators, which they seek to counter from the other two perspectives. Yet the institutional perspective also represents society’s interest in the health and labor capacity of its members and its expectations of the healthcare professions to maintain or restore it. From this point of view, we

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are interested in care provision research, the measurable data that allow individual states of health, sickness, disability, and age to be captured, the respective need for intervention and treatment to be quantified, and healthcare to be made manageable across a given population. Universal rules govern what is desirable and appropriate, what needs can be met, and ultimately, who is counted as ill enough to deserve financial support and who is considered healthy enough to take care of him- or herself. Based on the requirements the structural framework of Figure 1 imposes on a metaparadigm of nursing to form it into a new shape, I spent several years reviewing nursing literature, journals, patient reports, and other sources with students to identify nursing-specific educational content. From about 2000 onwards, they were used to formulate dialectical categories of reflection and epochal key questions for tertiary-level didactics and curriculum development. The form of a structural matrix assisted in this endeavor because its cross-hairs point our thinking to the relations and interconnections of its contents, recalling the complexity of the issue. In their totality, the pairings of categories represent a nursing-specific understanding of education. They are suitable to provide the theoretical foundation of a didactics of nursing science and nursing education as much as for vocational curriculum development. In the latter sense, the heuristic matrix may be understood as a dialectic modification of Herwig Blankertz’s curricular structural matrix approach.

Negative Didactics: Categories of Reflection Hegel’s assertion in the preface to his Phenomenology of Spirit (1986), that the familiar is unknown precisely because it is familiar, was validated when we deployed the speculative categories of our set of criteria. Theories, situations, and phenomena of nursing that the students assumed they were familiar with took on a different dynamic in dialectical reflection11 because their material content became a physical objection at the factual levels of experience of disease (L1), professional care (L2), and healthcare system (L3), and the inherent societal contradictions showed different facets from a perspective of corporeality, humanitarian morality, or economics and policy. German university-based training for vocational school teachers has been focusing on curriculum development in close cooperation with the hospital 11 The manner of dialectic testing, interpretation, and critique that must be used in university aims at a careful, patient engagement with its object. Adorno emphasized the importance of a passive “lingering gaze” (2003, GS 6, 38) that gives voice to the object. Only in this contemplative mode can thought enter the issue at hand, arriving at preliminary terminological determinations and limitations that come close to its own sense and momentum.

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based and owned nursing schools since 1996. Groups of teachers are expected to develop educational fields [Lernfelder] that become partial curricula for complexes of related professional actions such as caring for patients with chronic diseases, on the basis of an overall frame provided by the Ministry of Education [Rahmenplan]. Didactic reflections in each of these fields refer to seven specified levels: societal processes and problems, scientific foundations, business processes, work procedures, operations, professional experiences, and the reflective capacity of the learning group. The complex situations underlying each field are accessed in these seven dimensions through examples. Examples in nursing didactics are only authentic, unredacted, and uncut materials: appropriate narratives of care recipients, relatives, caregivers or trainees, newspaper articles, journals, self-help literature, documentaries, films, paintings, sculptures, and other items relating to nursing. The field is first opened up and interpreted through an example in order to develop a theoretical foundation specific to nursing with the aid of concepts and models of general didactics.12 This procedure is part of the curriculum for vocational teacher training. Categories of reflection for tertiary-level didactics were specified for this type of field-specific work (Figure 2), that is, the material content of an example was reflected on at the factual levels (L1–3) from three nursing-related perspectives (P I–III) to determine the educational content of a professional action plan. I will now briefly introduce these categories.

Reflecting the Experience of Disease (L1) Case-related factual knowledge at the first level is not limited to an understanding of medical and public health studies, but must keep the individual experience of the other and his or her crisis in view. Category 1.I The experience of suffering and alienation of corporality [Leib] (L1/PI) Reflecting on the subjective experience of disease from an individual perspective (PI), we proceed on the basis of a number of assumptions: psychoanalytically, the assumption that the self is concealed, and societally and culturally, that specific cultural, gendered, biographical processes of alienation exist that mediate corporal [leibliche] existence as a corpus. The students practice filtering 12 Examples of such field-related examples for reflection are given in Greb (2009); Greb and Fuhlendorf (2013); and Greb and Hoops (2008). In my classes, I use the theory of exemplary teaching by Wolfgang Klafki (1964).

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out qualitative expressions of this alienation in the statements of the case (example) and, conversely, notice how this alienation is transcended and the corpus rendered sense-able through the experience of suffering. It must be recalled that every (specific) message of individual suffering is subjected to another process of alienating abstraction in its translation to the (general) medium of language. Care recipients often use medical terminology to be understood in a clinical context. The epochal problem in this context is the capacity for introspection. Classes can reflect on the discrepancy between the expectations of life and its quality that may require continual adjustment under the influence of chronic disease. The rise in allergies and metabolic diseases means a growing number of students and trainees are themselves affected, an aspect that needs to be considered from an interactional perspective (Greb, 2003, p. 148–175). Category 1.II Mimesis and projection (L1/PII) From the perspective of nursing interaction (PII), the students reflect on proximity and distance with regard to both their own and others’ experience of disease because vicarious experience is always filtered through one’s own corporal experience and vice versa. Hermeneutically, we are especially interested in the connection between lack of distance and alienation in nursing relationships. Alienation in humans, according to Adorno, “is proved precisely through the omission of distance. It is only while they do not perpetually encroach on each other in giving and taking, debating and enacting, command and function that there remains room enough for the fine web of threads that connects them and in whose externality the internal is crystallised” (2003, GS 4, p. 45, my translation). Despite all effort to come close to the other in the process of understanding, it seems essential to maintain an inter-space in being. This serves as an unaffected space of self-reassurance where care recipients and caregivers may allow alienness and position themselves in the constellation of their relationship. This is especially necessary when, for example, in caring for people with chronic diseases, such relationships endure and develop greater depth. From a psychoanalytic perspective, it is important for the educational process to sensitize students for the transfer of emotions, pain, and fear. From an anthropological perspective, we are touching on the layer of mimesis as a fundamental precondition for any kind of access to the other. That means we are proceeding from the assumption that certain human constants and characteristics such as mimetic behaviour [Anähnelung] at the pre-conscious level open non-conscious avenues for understanding, but, in physical proximity to severe disease, disability, physical or mental deterioration, may also throw up psychosomatic defenses that create projections of loss of control or fears of destruction (Greb, 2003, pp. 55–65, 121–128, 196–199). Therefore, the manner in

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which nurses can or allow themselves to be touched by the suffering of others depends as strongly on their perception of self which is, in turn, determined by the alienation of the corpus, as it does on their self-understanding as members of the health system and their stance on the medicalization of everyday culture. To address this epochal key problem, we refer to the theory of recognition developed by Axel Honneth (2003).

Category 1.III Individuality and standardization (L1/PIII) Adopting a perspective of economics and policy is particularly challenging to students because it is very impersonal, and questions of care provision management largely exclude the individual experience of disease. Nonetheless, it is vital for teachers as well as future nurses to practice adopting this “cold,” economic view on quantifiable aspects of nursing. It is from this perspective that they may understand the limitations placed on their actions by the dominant healthcare policy : By what standards are states of health and age made controllable, treatable disease and disability calculable, and the provision of healthcare for the population plannable? The institutional response to individual experiences of suffering is through definitions, guidelines, and laws. A definite negation makes it clear that, in spite of all legitimate criticism of the system, care cannot be offered to individuals without medical and administrative standards. How such de-individualized standards can ensure the best possible care and coordination of individual caregiving is made transparent in, for example, the case of nursing standards for chronic diseases. An epochal problem for nursing in this context is the concept of customer sovereignty, especially in home care. In the classroom, this can be illustrated by the tension between diagnosis (closely supervised by the insurance providers) and the nursing options offered (Greb, 2003, pp. 201–218). Understanding the definitory power of the bureaucratic view is the central educational goal of this reflection. This calculating gaze does not remain external to the person (another case of identification with the aggressor). Rather, affected individuals understand chronic disease in normative terms of health and illness which, depending on the diagnosis (e. g., of diabetes or cyclothymia) affects their own experience of disease and ultimately impacts their self-image and sense of self-worth. Here, we return to our criticism of the metaparadigm (Fawcett, 1996): Where health is determined in the sense of the World Health Organization definition as complete physical, psychological, and social wellbeing, any deviation from this norm is defined as suboptimal life. Where health is the measure of what life should be like, a diagnosed disease becomes a disturbance of normal existence that should be treated and optimized by medical

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intervention or, better yet, prevented through early screening (Greb, 2012; Böhme, 2003, pp. 242f.).

Figure 2: Structural Matrix Nursing TUlrike Greb, translated version

Criteria and Epochal Key Problems Reflecting professional care (L2) At the second level, students develop their hermeneutical competence in the dimension of active nursing interventions. Professionalism in the process of nursing, which represents core academic and methodological competence, is called on in individual cases (See Figure 1). Category 2.I Relationship and method (L2/PI) Once more, the students adopt the corporal perspective of people in care to see their professional interactions through the eyes of the other side. What do nursing options in prevention, cure, and rehabilitation feel like to those at the receiving end? In general, what emerges are expectations of personal attention that are responded to with methodical, professional interventions. To charac-

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terize impositions of business practice on the faÅade of private interaction, the frequently used neologism relational work [Beziehungsarbeit] needs to be critiqued with regard to its ideological content. The mutual dependence of empathy and intervention in nursing can surface, for example, in caring for the chronically ill, through the fact that recognition of a professional specialization underlies all nursing intervention, but the quality of this professional knowledge only becomes evident during the intervention. Trainees especially are familiar with the fragile tension between lay and professional competence and quickly understand the epochal problem of asymmetry. Expert knowledge can sometimes block empathetic understanding, destroying what it aims to foster through its constant reference to theory (Greb, 2003, pp. 176–200). Category 2.II Self-determination and outside determination (PII) Here, a self-referential reflection on nursing from the humanitarian and moral perspective of the profession is used to clarify nursing’s self-understanding in multi-professional cooperation. This kind of reflection engages questions of professional socialization and roles as well as tolerance for ambiguity in situations where those roles conflict. The definition of a profession is historically determined by different interest groups and thus remains negotiable as different status groups deploy their definitory power. Thus, professions not only form a basis of social inequality, they also serve its reproduction. When status groups fight their power struggles on the backs of patients instead of using their respective expert knowledge to compete for the best solution, the results can be tragic. Here, the epochal key problem of reference to intersubjectivity comes into play – to adopt the perspective of other professions, it is first of all necessary to step away from one’s own. The theme of teamwork and competition aims to study how self-determination in the nursing profession is constituted in the face of external determination and how professional nursing positions itself within the network of health professions and in cooperation with lay care (family members). To address issues of social recognition we once again refer to Honneth’s theory, because in a situation where professional boundaries are under constant negotiation, all parties find their identities perpetually threatened. Accordingly, understanding the inconstancy of status in the competition of the various professions is a vital educational goal. Category 2.III Tradition and emancipation (PIII) Nursing in Germany is having a particularly difficult time with its own emancipation because institutionally, it is bound up with the history, status, and policy of the nursing profession. Having been systematically organized under

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the National Socialist government, the heritage of that era forms an important skein in the tradition of nursing professionalization. It is important in reflecting on this aspect to raise awareness of this legacy because emancipatory movements always become such in contrast to the traditions that went before them. To interpret the present and to assess innovation in nursing practice and education, the stance we take towards our tradition is key. To adequately understand this, we need a thorough knowledge of the institutions, practices, and procedures we aim to replace. In vocational training, this reflection can take place across all aspects of training. In the academic field, the focus lies on the epochal key problem of professionalization, that is, especially on the capacity to deal responsibly with uncertainty and with problems whose causes lie outside one’s area of responsibility (Greb, 2003, pp. 219–273; Rabe-Kleberg, 1996).

Reflecting on the Healthcare System (L3) At the third factual level, orientational and contextual knowledge from outside the realm of nursing science is needed to reflect preconditions of and limitations imposed on nursing from the vantage point of policy, law, and economics. An understanding of the structures, institutions, and funding of healthcare provision is necessary. Category 3.I Individual and organization (PI) Here, we study the concrete mutual interrelation between person and environment. “Nursing is concerned with patterns of human action in interrelation with the environment both under normal circumstances and in critical situations” (Fawcett, 1996, 18). The relationship care recipients and their families have with the healthcare system is ambivalent. On the one hand, they are needy, expecting a high-quality, individually tailored health solution to match their requirements. Yet they also face it as citizens, sharing political responsibility for the system and the financial burden of funding it. They are unwilling to accept that what the system offers tends not to be tailored to their individual needs and seems to be unrelated in scope to the cost imposed on the recipient. Yet it is only possible to provide individual service profiles when the administrative system treats the individual as a generalizable entity. Affected individuals face an opaque bureaucracy and must fight for every service or funding. That is why the epochal key problem can be defined as intransparency. Care providers must serve as guides, which is why engagement with the bureaucracy of the profession is a key element of their training; the respective field reflects the tension between individual needs and administrative structures (Greb & Fuhlendorf, 2013).

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Category 3.II Humanization and social technology Reflecting on the healthcare system from a humanitarian and moral perspective, we discuss the concrete influence and impact of the nursing ethos at the institutional level. How do nurses contribute their voices to the debate in the institutions of the healthcare system, and what is their impact? What is the stance of nursing management towards the marketized nature of care providers and the monetization of human relationships? Where does quality management become efficiency bullying? The professional goal of an increased say in designing the terms of their workplace and influencing the institutional conditions of nursing appears to call for a professional nursing management, which is itself an instrument of social technology.13 Nursing threatens to become enmeshed more deeply in this paradigm as it becomes more academically structured. In learning, the respective facets of the epochal key problem of nursing management can be explored in concrete terms, for example, the challenges of case management for chronic diseases, which allow insights into the problematic relationship between the politicization and the increasingly academic nature of nursing. Societal contradictions become evident where nursing management concepts turn out to work only once they become established parts of a purely economically defined healthcare system that they had originally set out to humanize (Greb, 2003, p. 112–117). Category 3.III Market liberalism and social justice The students adopt the political and business managerial perspective of a largely privatized healthcare system to explore the contradictions inherent in the system through reference to their own thought processes. According to its goals and societal function, the healthcare system is supposed to ensure social justice in care provision, but in the attempt, it becomes caught up in a contradiction with the very conditions it operates under. Decentralized, liberalized markets require at least a degree of profitability to survive. This conflict between social responsibility and the limits of the economically feasible in an industrial society is fundamentally irresolvable. Insurance holders have a right to medical and nursing services funded communally by society to the extent that these serve the maintenance of their health, the prevention or early detection of disease, or its treatment. The principle of insuring the individual against social risk still appears to be the guiding principle of social policy. However, the standards by which such services are meted out to the individual as sufficient, adequate, and 13 Social technology concepts seek functionalist solutions to social problems. They follow a scientistic and technological rationality and tend to be the outcome of practice-focused, often specifically commissioned sociological research.

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economically feasible remain unclear. In the grey area between basic services and excessive treatment, ethical standards regularly compete with economic ones. Different cultural expectations also come into play here. These uncertainties allow for a caring social policy, but they equally allow for injustice and the vagaries of unbridled competition (Greb, 2003, pp. 274–313).

References Adorno, Th. W., & Horkheimer, M. (1988). Dialektik der Aufklärung. Philosophische Fragmente. Frankfurt a. M.: Fischer. Adorno, Th. W. (2003). Gesammelte Schriften. GS 4: Minima Moralia; GS 6: Negative Dialektik. In R. Tiedemann (Ed.). Frankfurt a. M.: Suhrkamp. Blankertz, H. (1975). Theorien und Modelle der Didaktik (9th ed.). Weinheim München: Juventa. Böhme, G. (2003). Leibsein als Aufgabe. Zug/Schweiz: Die Graue Edition. Fawcett, J. (1996). Pflegemodelle im Überblick (I. Erckenbrecht, Trans.). Bern: Huber. (Originally published as Analysis and Evaluation of Conceptual Models of Nursing, 1989, Philadelphia, PA: Davis) Greb, U. (1997). Das Metaparadigma der Krankenpflege. Dr. med. Mabuse, 22(109), 60–64; (110), 62–65. Greb, U. (2003). Identitätskritik und Lehrerbildung. Ein hochschuldidaktisches Konzept für die Fachdidaktik Pflege. Frankfurt a. M.: Mabuse. Greb, U. (2006). “Helfen.” Eine Chiffre für pflegerisches Handeln im Diskurs der Negativen Dialektik. Pflege & Gesellschaft, Zeitschrift für Pflegewissenschaft, 1(6) 12–16. Weinheim: Juventa. Greb, U. (2009). Der Bildungsbegriff in einführenden Schriften zur Didaktik der Berufsund Wirtschaftspädagogik. bwp@, 16. Retrieved from http://www.bwpat.de/content/ ausgabe/16/greb/. Greb, U. (2010). Die pflegedidaktische Kategorialanalyse. In R. Ertl-Schmuck & F. Fichtmüller (Eds.), Theorien und Modelle der Pflegedidaktik. Eine Einführung (pp. 124–165). Weinheim, München: Juventa. Greb, U. (2012). Gesundheit und Krankheit. In I. Beck & H. Greving (Eds.), Lebenslage und Lebensbewältigung (pp. 272–276). Stuttgart: Kohlhammer. Greb, U., & Fuhlendorf, A. (2013). Hochschuldidaktik – ein Exempel: “MS” oder vom Leben auf einer Eisscholle. In R. Ertl-Schmuck & U. Greb (Eds.), Pflegedidaktische Handlungsfelder (pp. 90–123).Weinheim, Basel: Beltz Juventa. Hegel, G. W. F. (1986). Phänomenolgie des Geistes [Phenomenology of Spirit]. Frankfurt a. M.: Suhrkamp. Hegel, G. W. F. (1970). Grundlinien der Philosophie des Rechts. Werke in 20 Bd., (1832–1845) Vol 7. Frankfurt a. M.: Suhrkamp. Honneth, A. (2003). Kampf um Anerkennung. Zur moralischen Grammatik sozialer Konflikte. Frankfurt a. M.: Suhrkamp. Illich, I. (1975). Die Enteignung der Gesundheit – Medical Nemesis. Reinbek bei Hamburg: Rowohlt.

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Kerber, H., & Schmieder, A. (Eds.) (1991). Handbuch Soziologie. Zur Theorie und Praxis sozialer Beziehungen. Reinbek bei Hamburg: Rowohlt. Marx, K., & Engels, F. (1958). Marx Engels Werke (MEW) (Vol. 3). Berlin/DDR: Dietz. Rabe-Kleberg, U. (1996). Professionalität und Geschlechterverhältnis. Oder : Was ist “semi” an traditionellen Frauenberufen. In A. Combe & W. Helsper (Eds.), Pädagogische Professionalität (pp. 276–302). Frankfurt a. M.: Suhrkamp. Schäfer, A. (2004). Theodor W. Adorno. Ein pädagogisches Portrait. Weinheim, Basel, Berlin: Beltz/UTB. Tiedermann, R. (Ed). (2003). Theodor W. Adorno: Gesammelte Schriften. Frankfurt a. M.: Suhrkamp. Waldenfels, B. (2000). Das leibliche Selbst: Vorlesungen zur Phänomenologie des Leibes. Frankfurt a. M.: Suhrkamp.

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Chapter Ten: Rationalization of Nursing in West Germany and the United States, 1945–1970

In current discussions in nursing studies, historical aspects play at most a marginal role. At the same time, (implicit) ideas on the development of their own profession have been substantially influencing the self-understanding of contemporary healthcare professionals. One of the common assumptions is an understanding of the modernization processes in nursing as having a positive connotation, as part of a history of progress. Certain developments and structures are deemed “normal” and turned into a standard of progress in society ; deviations from the norm and resistance against reform processes can be presented as backwardness. For that reason, the alarming effects of modernization processes in nursing are systematically concealed. The history of nursing in the US set the standards in this regard and has been serving internationally as the reference model. By the nineteenth century, the idea of basing nurse training on rational, goal-oriented, organized, and scientific standards fell on fertile ground, and nursing had become a respectable occupation for unmarried women. In 1907, Columbia University in New York set up the first professorship in nursing (Christy, 1969). From 1910 onwards and increasingly after World War II, basic nursing training was gradually transferred to academia. In 1960, 84 % of nurses still completed their training at nursing schools run by hospitals but by 1980 this figure had fallen to 19 % (Lynaugh & Brush, 1996, p. 13). In comparison West Germany lagged far behind, since Christian sisterhoods shaped the field of nursing care until far into the second half of the twentieth century. For the entire period between 1945 and 1970, nursing training remained within the realm of the hospital, and additional training for nurses was offered only by non-academic institutions (mainly run by the sisterhoods). Thus, when compared to the US, West Germany can be regarded as a developing country with regards to nursing education. In the following I critically examine the concept of progress, based on the U.S. model that is used as the standard, to analyze the history of nursing as a process of rationalization of the profession. Rationalization is the process in which

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thinking and acting become increasingly subject to predictability and reason. Max Weber described the central transformational processes of Western societies such as increasing bureaucracy, standardization, and legalization of daily activities of life as Western rationalization. According to Weber, the principle of universally valid laws that are bureaucratically executed would formally allow for societal equality, but it would entail decreasing the importance of individual cases and restricting personal space for decision making (Münch, 2002, pp. 155–185). On the level of social action the model of Western rationalization would privilege a goal-oriented and rational action, targeting specific goals and carefully calculating the use of means – such as labour, time, or money – to reach the goal in the most effective way possible (Weber, 1922, pp. 404–414, and 1985, pp. 11–13). According to Tilla Siegel this approach to action has become the generally accepted mode of thinking in the twentieth century (Siegel, 2003). Experts in the humanities were granted the power to define the criteria of efficiency, in the same way that knowledge that could be rationally and scientifically justified was deemed superior to knowledge derived from experience (Raphael, 1996, 1998; Szöllösi-Janze, 2004). From this perspective, processes of professionalization are a significant part of processes of rationalization. The following article analyzes the rationalization of nursing through the example of Protestant deaconess motherhouses in West Germany and the US. I focus on this specific nursing organization that had its roots in the nineteenth century in Germany but was subsequently exported to many other countries, including the US, where it adapted to different cultural contexts. Due to these processes of adaptation the deaconesses are a magnificent lens for an international comparison of concepts and practices of nursing. The presentation at hand focuses on the time after 1945 and hence contemplates the evolved system of the “motherhouse diaconia” at a time when hospital care was increasingly becoming more specialized, scientific, economical, and technical. Two Lutheran deaconess motherhouses are the examples used for this analysis. The first is the Henriettenstiftung in Hanover, Germany, which was founded in 1859/60 and which evolved into the largest deaconess motherhouse in the region of Lower Saxony. The deaconesses worked in numerous hospitals and community welfare centres all over Lower Saxony and Schleswig Holstein. The second example is the American deaconess motherhouse in Philadelphia that was founded in 1884, following the German model. The motherhouse in Philadelphia developed into the largest institution for deaconesses following the German tradition in the US. It was focused mainly on hospital nursing care and continued to train its members as nurses after 1945. The following remarks on the Henriettenstiftung are partially based on interviews with deaconesses and partially on an analysis of the extensive archives of the motherhouse. Many documents written by the nurses, especially in cor-

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respondence with the motherhouse, have been preserved and provide excellent insights into the nursing routines of the sisters. Information on the organization of the Henriettenstiftung and on the deaconesses’ work areas has also survived so that I can also reconstruct the framework of nursing and the internal decisionmaking processes within the organization during the reformation of healthcare. The collection on the deaconess motherhouse in Philadelphia is housed in the Evangelical Lutheran Church of America, whose archives provide details on the enormous problems that the German model of the deaconess motherhouse faced when trying to establish itself in the US. These files also contain the strategies the deaconesses used to hold their ground in a rather unfriendly environment. The motherhouse in Philadelphia had the Lankenau (formerly German) Hospital as its one main area of service for which the first deaconesses had been recruited from Germany in the 1880s (Schweikardt, 2008). Since the Lankenau Hospital served as the training hospital for the deaconesses, it is of special interest here. The extensive files of the nursing school are located in the archives of the Barbara Bates Center for the Study of the History of Nursing at the University of Pennsylvania, and they provide a good understanding of the concept and reform of nursing training. In addition, the Lankenau Hospital has its own hospital archive that contains mainly the minutes of the committees of the hospital, including the nursing committee. These documents include information on the development of the hospital and the set-up and reform of nursing.

Deaconess Motherhouses in Germany: A Success Story The deaconess motherhouses founded in Germany in the nineteenth century saw themselves as communities of faith and service. Their members were unmarried women who regarded their work as a “labour of love” rooted in Christian faith, rather than as a means of earning a livelihood. The nurses received training and the security of unlimited provision for retirement if they in return were willing to dedicate their lives completely to service in the community and to work with people who were unwell and poor. In the nineteenth century, deaconess motherhouses were some of the few institutions that provided women with a thorough professional training and a “career” for life. They offered a highly regarded way of life and work outside of marriage (Schmidt, 1998, pp. 110–113). The motherhouse was at the centre of the community. The principal theologian and the Mother Superior, who also resided in the motherhouse, understood their role as “parents” of the sisters. In the nineteenth century, belonging to such a surrogate family was a crucial prerequisite to guaranteeing respectability for young unmarried women who lived and worked away from their original family. The sisterhoods were close communities of sisters sharing both

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their work and personal lives, but they also demanded a high degree of conformity from their members. Being a sister meant accepting the values and behavioural codes of the motherhouse institution. The discretionary power the motherhouses had over the life of each sister was enormous. For instance, they could transfer sisters at short notice to a new workplace and could prohibit them from working on their own for their own financial security. Although the benefits of the motherhouse were certainly attractive for the nineteenth century, members had little independence (Köser, 2006; Schmidt, 1998). The deaconess motherhouses represented a specific understanding of nursing that was based on caring for the body and the soul as one entity. In addition to the nursing activities in the stricter sense, the sisters also performed pastoral tasks. Thus, the deaconesses’ work was situated between the tasks of physicians and pastors. This life and work model of the deaconesses shaped the history of nursing in Germany until far into the second half of the twentieth century. There had been new formations of so-called free communities of nurses founded at the end of the nineteenth century, which offered their members more independence. Nonetheless, the position of the motherhouses was untouched for a long period of time and not even the anti-church politics of the National Socialists were able to change it. National Socialism made it difficult for Protestant – as well as Catholic – motherhouse organizations to recruit new members, in particular because the denominational institutions were suspected of promoting an “unworthy” life due to their belief in Christian love. Yet, as an organization, the motherhouses remained intact. Immediately after the Second World War, the deaconess motherhouses experienced a real boom of new recruits. During the hard times of the postwar years they offered women an attractive training and benefits package, which was particularly welcomed by many young female refugees who came to the Western occupation zones from the former Eastern territories of the German Reich. The motherhouses offered them not only financial stability but also a new social home (Kreutzer, 2014, pp. 60–66). The high regard for denominational nursing increased during the post-Second World War period because, in contrast to “free,” independent nurses, the Christian nurses were not suspected of having been actively involved in the National Socialist politics of genocide. A Christian ethos was therefore regarded as a guarantee of a “good” caring type of nursing. Even public hospitals were very interested in delegating nursing care to Christian nurses because such a move had a positive effect on the reputation of the hospital. Furthermore, the West German welfare state granted denominational institutions a privileged position. Independent welfare organizations had received public funds and support from the state after World War I (Kaiser, 2008, p. 60). The subsidiarity principle – the policy of giving preference to independent welfare organizations over public welfare bodies – had its roots in the Weimar

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welfare state (1918–1933) and was finally and fully recognized in the Federal Republic of Germany. It rewarded hospitals that had a specifically charitable approach to welfare (Schmuhl, 2010, p. 162). The result was not only that the economic pressure of competition was reduced but also that specific diaconal profiles of the hospitals were rewarded. Due to the low-cost work the deaconesses performed, the Henriettenstiftung could generate financial profits up until the 1960s. In this context, the deaconesses succeeded in preserving their traditions from the nineteenth century until well into the post-Second World War period. This became particularly apparent in the training of the next generation. From the beginning of the twentieth century, and initially in Prussia, training in the area of nursing was subject to some initial regulations (Schweikardt, 2008). Yet, the motherhouses managed to restrict that influence to a large extent. Until the middle of the 1960s, the legal guidelines provided only a rough framework such as prerequisites, duration of the training, and the number of hours of theoretical instruction. The Nursing Act of 1938, which regulated the training requirements, required only 200 hours of theory, spread out over one-and-a-half years. By 1957 the training time had increased to three years but the proportion of theory was still quite small – now 450 hours (Kreutzer, 2005, pp. 231 and 246). Students spent the majority of their training doing practical work on the wards. They learned the necessary skills from the older nurses and simultaneously absorbed their work ethic. The nurse trainer at the Henriettenstiftung, who was in charge of the deaconess students, explained in 1954 that the proper pastoral attitude was “not only taught through services and sermons or in the courses and other classes … but from the first day onwards through the entire atmosphere of the house, the exchanges between the sisters and the role model the older sisters represent” (Koch, Sister Martha, On the basic principles, June 28, 1954). The high value placed on practical training is apparent even in the structure of the curriculum. The students were sent to the wards from their very first day at the school. They had some individual lessons with physicians (“doctor hours”) that took place during the lunch break or in the evening when everybody involved was tired. The main part of the theoretical training took place as one block towards the end of the program. There were no legal regulations for the practical training, which was the main portion of the program, and the Henriettenstiftung was able to design the curriculum for nursing training largely as it saw fit. All roles that were crucial for the training of the next generation – the teaching staff and especially the ward nurses who supervised the practical training – were filled by deaconesses. Students who completed their training at the beginning of the 1950s at the Henriettenstiftung were firmly integrated into the community of deaconesses on site. This applied even to students who did not

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want to become deaconesses, but only chose to complete their nursing training in a Protestant institution (Kreutzer, 2014, pp. 157–165).

Rationalization of Nursing in West Germany during the “long 1960s” Only from the end of the 1950s did the Christian understanding of nursing start to come under pressure in West Germany, when West German society as a whole underwent fundamental changes (Frese, Paulus & Teppe, 2003; Herbert, 2002; Schildt, 2007, pp. 30–53). The original and guiding principle of the celibate “labour of love” rapidly lost its support. The ideal of self-sacrifice was increasingly at odds with the emerging consumer society. Hardly any woman was willing to dedicate her entire life to altruistically serving her neighbour, and the influx of new applicants dried up almost completely. As a result of the growing wealth of West German society, the healthcare sector expanded significantly (Krukemeyer, 1988, p. 85, pp. 98–99). However, there was a serious threat that the new hospitals could be jeopardized by the increasing shortage of nurses. If the hospitals wanted to attract new nurses and keep them in the profession, they had to adapt the working conditions to the life plans of the new generation of women. This changed the essence of the traditional Christian understanding of nursing. During the 1960s, nursing was changed into a female profession regulated by labour laws and wage contracts with fixed working hours and wage categories (Kreutzer, 2005, pp. 164–229). Even Christian hospitals had to follow the new zeitgeist if they wanted to attract and retain nursing staff. Particularly significant were the reductions in weekly working hours that had been implemented in 1956/57. These reductions were the starting point for comprehensive rationalization measures in nursing because working time developed into a precious possession that had to be treated efficiently. The manager of the Annastift hospital in Hanover, where deaconesses from the Henriettenstiftung worked, explained in 1957 in the journal Die Evangelische Krankenpflege (Protestant Nursing), that the introduction of shorter working hours was a clear sign “that the internal production reserves of the people working at the hospital had to be fully exhausted” (Arnstorf, 1957, p. 53). This factor fundamentally changed the understanding of nursing care. The nurse was transformed from a servant of God into an economic factor of production. By extracting nursing from its religious interpretation and moving it into the context of industrial production, the profession was opened up to the logic of economic cost-benefit calculations. During the 1960s the work routines of nursing on the ward was newly

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structured with the following time-economic efficiency criteria. Accordingly, “unnecessary runs and idle times” were to be avoided in nursing by completing “minor tasks” during idle times rather than in the evening (Weber, Principal Pastor and Mother Superior Florschütz, Relief measures for the nursing staff at the hospital of the Henriettenstiftung, December 22, 1965). A centralized courier service was to do the transporting in the hospital and a wireless search system was to relieve the sisters from the “eternal searching” (Henriettenstiftung Hospital, Committee Meetings, 1954–1975, Minutes, November 19, 1965). Working times were thus not only reduced but also became denser. One of the most consequential rationalization measures was the implementation of functional care, or a distribution of the work by role. A new profession was introduced – the nursing assistant – who was mainly responsible for basic care tasks. With this measure the continuity of care for the patients was drastically reduced. Patients who previously had had one main caregiver now had to deal with numerous nurses who were each responsible only for certain activities and left the ward when their shift ended. The fluctuation of nursing staff rapidly increased, the exchange of information became a growing problem, and the proportion of administrative and documenting tasks became significantly bigger (Kreutzer, 2008). Furthermore, a biomedical understanding of medicine based on scientific concepts also found its way into the Christian hospitals of West Germany in the 1960s (Kreutzer, 2014, pp. 93–101). The new physicians were not really interested in working with religious deaconesses and demanded to work with nurses who matched the professional standards of the modern hospitals equipped with new technology. The Nursing Act of 1965 reflected this development. The theoretical part of nursing training was increased significantly to 1,200 hours in total. In addition, the Henriettenstiftung now organized the theoretical training in parallel with the practical work. Thus, learning theory became a regular component of the curriculum. The practical training was also more strictly regulated. A card system was introduced to structure the order of learning: each card stated what tasks the students had to learn in which semester (Kreutzer, 2014, pp. 165–168). The new control measures document the increasing mistrust of traditional practices, which were based on the experiences the nurses had gained in their everyday work on the wards. In addition, they illustrate the fact that the Henriettenstiftung was slowly departing from its traditional understanding of education and training, which had centred around establishing ethical conduct in the everyday work and life practices of the nurses, rather than on learning standardized skills that could be tested. When a more scientific understanding of disease took hold, the nursing staff began to focus more on caring for the body. The tasks that fell under care of the

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soul were transferred entirely to the pastors’ area of competence and it was the pastors who now provided spiritual care in the hospitals. This meant a separation of physical and spiritual care – two areas that had been inextricably linked until then. In contrast to deaconesses, the hospital chaplains had not been integrated into the everyday practice on the ward. In addition, hospital chaplains looked after numerous patients. During the 1970s in the deaconess motherhouse of the Henriettenstiftung they had to care for more than 120 patients, while also performing other tasks such as holding services and fulfilling roles in the training and advanced education facilities (Helbig, Principal Pastor, Report on the work of the Henriettenstiftung, December 4, 1974; Schomerus, Pastor, Work report, n. d. [1977/78]). As a general rule, there would not have been much time for the individual patient. Furthermore, as Göckenjan and Dreßke have shown, the help of hospital chaplains was regarded more as a psychosocial rather than a religious service (Göckenjan & Dreßke, 2005, p. 246). The care for the soul that had previously been practiced by the deaconesses had now lost its established position within patient care – both in the daily care of the patients and also in the self-understanding and organizational logic of the scientifically oriented hospitals.

Deaconesses in the US: How the Model Failed Whereas in Germany the motherhouse principle of the nineteenth century became the dominant organizational form of nursing, institutions for deaconesses in the US were rather unsuccessful (Nelson, 2003, pp. 134–142). The first attempt at establishing a Protestant motherhouse in Pittsburgh towards the end of the 1840s failed due to a lack of apprentices (Doyle, 1929; Köser, 2006, p. 118). Only at the end of the 1880s was there a successful yet modest wave of new institutions for deaconesses (Weiser, 1960, p. 168; Zerull, 2010). One of them was the Philadelphia Motherhouse of Deaconesses, which, despite being the largest deaconess motherhouse in the US, had only 109 nurses in 1946 – approximately onefifth of the membership of the Henriettenstiftung (United Lutheran Church in America, Minutes, Fifteenth Biennial Convention, 5–12 October 1946, p. 545). Considering the low numbers, it is not surprising that a discussion of the reasons behind the difficulties in recruiting new members is found throughout the history of U.S. deaconess motherhouses. The relatively independent status of women in American society, compared to Germany, was seen as the main reason why the idea of becoming a deaconess had so little appeal for women. In the US, women grew so accustomed to earning their living that occupational work without salary became an impossibility. Moreover, the greater number of male over female settlers in late nineteenth-century America meant that women had

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better chances for marriage in the New World. With a wider range of personal and professional opportunities, employers were in the position of needing to come up with attractive offers to interest women in working as nurses. It only makes sense that, in this context, the deaconess motherhouse with its concept of organized unpaid posts for women had only a slim chance of success (Nelson, 2003, p. 142). While the German model of the deaconess did not succeed in the US, the notion of the Christian “labour of love” nonetheless influenced the everyday experience at American hospitals. Yet, it looked different and occupied a different space. This difference becomes clear in the example of the Lankenau Hospital, the training hospital of the deaconesses. The Lankenau Hospital was a so-called community or voluntary hospital – a type of hospital that had emerged in the nineteenth century and was supported mainly through fundraising (Lynaugh, 1989). Voluntary hospitals had distinguished themselves by the large proportion of volunteers who worked here. At the Lankenau Hospital local prominent people served in an honorary manner on the hospital board and a large number of voluntary helpers – mainly women – decisively contributed to maintaining the nursing care. They organized charity events and fundraisers for the equipment of the hospital, for example, for sheets, X-ray machines, air conditioners and lab equipment, and they helped both with the administration and on the wards. In 1960 the Lankenau Hospital had 667 voluntary helpers throughout the year who in total contributed 80,000 working hours (“Community relations”, 1961, p. 14). The contributions of honorary workers had not only a practical but also a farreaching symbolic significance: in the U.S. model of capitalism, volunteer work that had its roots in a Christian/humanitarian philosophy was essential, as Rosemary Stevens has argued. It promised (and is still promising) that not only business interests were becoming important but also a social feeling of community and a respective solidarity as an alternative to “socialism” that was depicted as a danger (Stevens, 1999, pp. 6–7). In the time period that I investigate here at the Lankenau Hospital, the deaconesses constituted merely a minority of the nursing staff. Nonetheless, they were significant as role models as they visibly represented the ideal of Christian “labour of love” through their uniform. Furthermore, the self-representation of the hospital deaconesses played a central role for the entire period under investigation. The hospital repeatedly invoked the first seven deaconesses who had come to Philadelphia from Germany in the 1880s and had founded a tradition of personal devotion to the patients, which had become integral to the general climate of the hospital and was presented as the “spirit of Lankenau” (Hosford, R. F., The Spirit of Lankenau, 1953). The hospital liked to present itself as a cutting edge institution of technical and medical modernity – yet a reference to the deaconesses was a welcomed way

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to provide the hospital simultaneously with a “human face” (The Lankenau Hospital School of Nursing, around 1956). However, with the transfer to the US, not only the status and significance of the deaconesses was altered, but also the understanding of nursing was fundamentally changed.

Rationalization of Protestant Nursing Care in the US In contrast to Germany, the American deaconesses were exposed much earlier to massive pressure for rationalization. The fact that the development of the American health insurance system did not start until the 1940s had far-reaching consequences for the history of Protestant nursing (Stevens, 1999, p. 259). Only hospitals that offered the best possible patient care were able to survive the competition when it came to attracting the few affluent, paying patients. American hospitals at that time were also mostly interested in professionally qualified nurses. At the beginning of the twentieth century, the so-called standardization movement, heavily promoted by the American College of Surgeons as well as secular organizations, made sure that the standards of “good” nursing care were based on a biomedical understanding of nursing (Mann Wall, 2005, pp. 167–171). Because they were so few in number, the American deaconess motherhouses were not in a position to counter this development. Even the Catholic sisterhoods, which were much bigger than the deaconess institutions, followed the general trend for standardization at the beginning of the twentieth century (Kaufmann, 1995, p. 168–192; Mann Wall, 2005, pp. 175–185). If the deaconess motherhouses wanted to train a workforce that was in demand and if they wanted to offer an appealing training program to the young women, they had to adapt to these new requirements. While the costs of the standardization process were a subject of controversy at the beginning of the twentieth century, during the 1920s the criticism gave way to broad approval. For instance, the head nurse of the Lankenau Hospital, deaconess Marie Koeneke, followed the contemporary trend and published Nursing Procedures in 1927 that established standardized working processes for nursing such as bathing, bed making, catheterizing of patients, measuring pulse and temperature, and distributing drugs (Koeneke, 1927). The extent to which the American deaconesses departed from the original German concept becomes particularly apparent in the following example of nursing training. By the beginning of the twentieth century, the school of the Lankenau Hospital regarded professional qualification very highly, relative to the Henriettenstiftung (Burroughs, Sister Louise, A short history of the Lankenau Hospital School of Nursing, April 22, 1974). Thus, in 1909 for instance, Ida F.

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Giles, a leading member of the professionalization movement, became the fulltime teaching nurse. Even the future deaconesses received their training by a secular nurse – a constellation that even in the 1950s would have been unthinkable in the Henriettenstiftung. This high regard for theoretical training in the US also determined the further development of the Lankenau School of Nursing. The first curriculum from Philadelphia that has been preserved is from 1925/26 and it contains a preparatory course with 300 hours of theory to prepare the students for their practical work. This curriculum also included an introduction to psychology (Lankenau Hospital Training School for Nurses, Curriculum, 1925–1926). In West Germany, in contrast, psychology was not introduced into the training and examination regulation before 1966 (Ausbildungs- und Prüfungsordnung für Krankenschwestern, Krankenpfleger und Kinderkrankenschwestern [Training and examination regulations for nurses and paediatric nurses], 1966). Thus, in the US there were obviously early efforts to make personal dealings with the patients more scientific. At the beginning of the 1950s the theoretical part of the training comprised a total of 900 hours (Lankenau Hospital Training School for Nurses, Curriculum, 1950–51). In 1962, the school had 13 teaching nurses who all held an academic degree, 5 of whom were deaconesses. The school also employed its own librarian (State Board of Nursing Education and Licensure, Annual report of School of Nursing, May 31, 1962).The willingness of the Lankenau Hospital to align its nursing training with the scientific standards of the time was further supported by the accreditation process of the nursing schools. As in Germany at the beginning of the twentieth century, nursing training in the US became subject to federal regulation, which, however, was much stricter than in Germany. From the beginning of the twentieth century, the State Board of Examiners for Registration of Nurses set the requirements for the training curricula and the general training and working conditions for nursing students. In the 1920s in Pennsylvania, the State Board consisted of leading proponents of the concept of nursing as a profession based on science, rather than as a skill acquired by experience (West, 1939, pp. 120–141). The State Board not only gradually increased requirements for the theoretical and practical training, it also began to regulate the living conditions in the nurses’ dormitories, for example, the minimum size of the accommodation (Pennsylvania State Board of Nurse Examiners, Handbook for schools of nursing in the Commonwealth of Pennsylvania, 1952; Commonwealth of Pennsylvania, Mary A. Rothrock, Department of Public Instruction to Mr. Hosford, Administrator of Lankenau Hospital, July 5, 1955). Those schools that did not pass the investigation by the State Board lost their federal approval, after which they found it very difficult to attract further trainees. Particularly effective for the implementation of new training standards were comparisons between the nursing schools, that is, the rankings the schools received from the State Board to ensure

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greater transparency of the performance of the various institutions. This ranking system did much to promote competition between the schools (Nursing Committee of the Board of Trustees, Minutes of the nursing committee of the board of trustees, June 11, 1951). After 1945 the accreditation process of the National League for Nursing – the association of leading teachers in nursing schools and colleges – was added, which, from the 1950s onwards, became the quality label. The fact that the Lankenau Hospital participated in the very first accreditation process of the National League in 1951/52 illustrates that the hospital did not wait for external pressure before it decided to take part. Rather, it wanted to be one of the first institutions to differentiate itself from its competitors with the new quality seal of the National League (Lankenau Hospital, Minutes of the nursing committee of the board of trustees, July 9, 1951; National League for Nursing, Accrediting your school of nursing, 1956). The National League for Nursing consistently increased the requirements for the theoretical training of both the students and the teachers and thus massively interfered with the training practice of the nursing schools. While the State Board followed the logic of minimum standards and mainly controlled the standardized framework, such as the number of working hours, the breakdown of the lessons within the curriculum, and the size of the rooms for students, the National League targeted a meticulous regulation of the nursing training and organizational structure of the nursing schools to promote “excellence” in nursing training (National League for Nursing, Towards excellence in nursing education, 1964). For this reason the nursing schools suspected that the policies of the National League were designed to force nursing training out of the hospitals and into the realm of higher education. Indeed, small nursing schools in particular struggled to survive from the middle of the 1950s onwards due to – in their opinion – the excessive demands of the National League (Lankenau Hospital, Minutes of the nursing committee of the board of trustees, March 17, 1958). Under the pressure of the accreditation process, the nursing school of the Lankenau Hospital became an increasingly bureaucratic organization that tried to fulfill the requirements of the National League with a new committee structure. The accreditation measures were repeated every six years in a fixed order. First, the school had to provide a self-evaluation of its entire work and evaluate in detail the strengths and weaknesses of the status quo. After this, representatives of the National League visited the school, preparing a report of their view on its performance status and need for reforms. Subsequently a consultant committee of the National League decided on the accreditation. The whole process ended with a report and a list of recommendations to the school to further improve its work (National League for Nursing, Policies and procedures of accreditation for diploma programs in nursing, 1969).

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This accreditation process supported the logic of continuous need for reform. If the National League wanted to prove its right to exist and not have the accreditation process appear as merely a bureaucratic imposition, the process had to end with criticism and suggestions for improvement whose implementation had to be checked with new controlling measures. The school responded to the demand of continuous improvement with establishing a highly complex system of success criteria. A significant part of the work of the numerous school committees seems to have been to define ever-new working goals and to check whether the targets were reached. To that extent they used an ongoing evaluation and self-evaluation process that included the teachers but also the students and the committees themselves (Minutes of the curriculum committees, 1963–72). These optimization practices resulted in an incredibly large portfolio of files that has been preserved from the nursing school in Philadelphia. By contrast, the Henriettenstiftung left hardly any documents, since its teaching nurses could teach until the 1960s as they saw fit based on their own experience. In the US it was seen as a matter of fact that only scientifically based standardized training and working procedures allowed for “good” nursing care. By contrast in the Henriettenstiftung of the 1950s, this view would have been met with strong rejection – not because the nurses were so “backward” but because they prioritized another type of knowledge with their concept of knowledge through experience and ethical education. This comparison demonstrates that the idea of “good” nursing and its implementation in reality varies strongly, both historically and culturally. In addition to representatives of professional organizations in the US becoming active in the State Board and the National League for Nursing, the state itself became increasingly active in the professionalization and academization process. The U.S. economy was strengthened after World War II. In this time of new affluence the university system and the entire healthcare system was expanded. The proportion of people with health insurance increased from approximately a quarter of the population in 1945 to about 70 % in 1960 (Stevens, 1999, p. 259). Socially disadvantaged groups had better access to healthcare when, in 1965, the social security programs Medicare and Medicaid were introduced. Along with this development the demand for nursing staff increased and at the same time there was a demand to improve the quality of nursing care. From 1964 onwards, there were federal funds specifically for the establishment of nursing care programs, and students in nursing could also receive student loans (Lynaugh, 2008, pp. 13–28). For colleges and universities it thus paid well to set up degrees in nursing care. At the same time, many hospitals began to recalculate the costs of their nursing schools. Under the pressure of the accreditation process many schools had become expensive affairs that were no longer sustainable in the eyes of the

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healthcare providers. During the 1960s, many hospitals closed their schools. This development further supported the trend towards a more academic approach (Mann Wall, 2011, pp. 13–15). At the Lankenau Hospital, the continuance of the nursing school was not seriously put up for renegotiation during the time period under investigation – possibly due to the lasting tradition of the deaconesses. In the context of the general trend towards academization, the Lankenau Nursing School found it increasingly difficult to attract new students from the middle of the 1960s onwards. As a result, it began to conduct some of its training in cooperation with nearby colleges, to increase the attractiveness of the training program (Lankenau Hospital, Minutes of the nursing committee of the board of trustees, September 8, 1969). It was not until 1992 that the Lankenau Hospital closed down the school completely, at a time when less than 10 % of future nurses opted to attend a nursing school linked to a hospital (“Lankenau nursing school closes when freshman class graduates,” February 1, 1990, Main Line Times).

Conclusion The very successful model of the deaconess motherhouse within the German context could only partially be transferred to the American context. The reason for this was not only that the life model of the deaconess found very little support in the US. The specific understanding of nursing as a unified caring for body and soul could not be maintained in the US at the beginning of the twentieth century where the biomedical understanding of disease dominated. Hence, the criteria against which “good” nursing were measured already differed vastly in the early twentieth century between the US and Germany. In the history of nursing the verdict on the country-specific traditions of nursing seems to have been relatively obvious until now: While the US is regarded as an internationally accepted model of the professionalization of nursing due to the scientific understanding of nursing, West Germany, with its strong Christian traditions, appears as a late-comer. German scholars in nursing studies often repeat that nursing in that country is still in a process of “catching up with modernization” (Schaeffer, 2003, p. 227), an assumption that is based on this idea. Indeed, until far into the 1950s the Henriettenstiftung – just like other motherhouses – successfully stuck to the traditional Christian concept of a “labour of love” and to the high value of ethical education and knowledge through experience. Only in the second half of the 1950s, when the celibate life model of the Sisters began to be phased out in West Germany, was it willing to engage in reforms and value a theoretical education more highly.

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By the beginning of the twentieth century in the US, a subject-oriented nursing training that was guided by scientific standards was regarded as much more substantial. This understanding applied even to the nursing school in Philadelphia, which was run by deaconesses. After 1945 the deaconess motherhouse there shared the essential idea that more science and standardization in nursing would in the end also result in better nursing care. Hence, the deaconesses from there were noticeably eager to follow the new scientific trends. The costs of the rationalization process can be shown through the example of the West German deaconesses because the restructuring of the profession was completed in a comparatively short time frame. When the concept of performing a “labour of love” faded out, nursing was reorganized within a few years, following time-economic efficiency criteria. The result was not only an intensification of work but also a de-legitimization of work that did not seem to have an immediate functional purpose. The implementation of functional care also significantly reduced the contact between nurses and patients. Written documentation replaced the previously constant presence of oral communication. The proportion of people engaged in administration also noticeably increased. When theoretical training gained in significance, a new area of conflict emerged that is described today by the term “double logic of action” [doppelte Handlungslogik]: How can we link a theoretical, scientifically based knowledge of rules that claims universal validity with a hermeneutic approach of understanding that understands the particularity of each patient and the importance of subjectively experienced diseases? This inherent contradiction of professional action in service professions involving people is particularly precarious in nursing: due to the strong connection to the patient’s body that needs deciphering, nurses must draw on implicit, non-rational, and unexplainable forms of knowledge. With the revaluation of scientific rationality as the universal measure of healthcare, it was precisely the experience-based knowledge, intuitive insights, and observations by nurses that could not be objectified, which were then degraded to non-scientific and hence meaningless claims (Kreutzer, 2013). The comparison of the West German and American deaconess motherhouses furthermore reveals that professionalization did not automatically lead to an increased autonomy of the members of groups that became more professional. Thus the policy-motivated accreditation process in the US significantly restricted the freedom in the everyday training practice. In contrast, the deaconesses of the Henriettenstiftung were able to maintain more independence and insisted on keeping their own traditions for a much longer period of time. They felt the changes of the 1960s even more drastically when the biomedical notion of disease also became dominant in the Christian hospitals in West

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Germany and when the deaconesses slowly became a minority in their own organization.

Acknowledgements This article is based on a project funded by the German Research Foundation on the topic “Rationalization of Nursing Care in West Germany and the United States: A Comparative History of the Exchanges of Ideas and Practices, 1945 to 1975.”

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Schaeffer, D. (2003). Professionalisierung der Pflege. In A. Büssing, & J. Glaser (Eds.), Dienstleistungsqualität und Qualität des Arbeitslebens im Krankenhaus (pp. 227–243). Göttingen: Hogrefe. Schildt, A. (2007). Die Sozialgeschichte der Bundesrepublik Deutschland bis 1989/90. München: Oldenbourg. Schmidt, J. (1998). Beruf Schwester. Mutterhausdiakonie im 19. Jahrhundert. Frankfurt a. M.: Campus. Schmuhl, H.-W. (2010). Der Neubeginn sozialer Staatlichkeit nach 1945. In J.-C. Kaiser & R. Scheepers (Eds.), Dienerinnen des Herrn. Beiträge zur weiblichen Diakonie im 19. und 20. Jahrhundert (pp. 148–163). Leipzig: Evangelische Verlagsanstalt. Schomerus, Pastor. [1977/78]. Work report, n.d. (S-9–3–2). Archives of the Henriettenstiftung. Schweikardt, C. (2008). Die Entwicklung der Krankenpflege zur staatlich anerkannten Tätigkeit im 19. und frühen 20. Jahrhundert. Das Zusammenwirken von Modernisierungsbestrebungen, ärztlicher Dominanz, konfessioneller Selbstbehauptung und Vorgaben preußischer Regierungspolitik. München: Martin Meidenbauer. Schweikardt, C. (2010). The introduction of deaconess nurses at the German Hospital of the city of Philadelphia in the 1880s. Nursing History Review, 18, 29–50. Siegel, T. (2003). Denkmuster der Rationalisierung. Ein soziologischer Blick auf Selbstverständlichkeiten. In S. Geideck & W.-A. Liebert (Eds.), Sinnformeln. Linguistische und soziologische Analysen von Leitbildern, Metaphern und anderen kollektiven Orientierungsmustern (pp. 17–36). Berlin: de Gruyter. State Board of Nursing Education and Licensure, Department of Public Instruction. Annual Report of School of Nursing for the Year Ending May 31, 1962. (MC 98, Series III, Box 14, Folder 61). Bates Center Archives. Steppe, H. (Ed.) (2001). Krankenpflege im Nationalsozialismus. Frankfurt a. M.: Mabuse. Stevens, R. (1999). In sickness and in wealth: American hospitals in the twentieth century. Baltimore, MA: Johns Hopkins. Szöllösi-Janze, M. (2004). Wissensgesellschaft in Deutschland. Überlegungen zur Neubestimmung der deutschen Zeitgeschichte über Verwissenschaftlichungsprozesse. Geschichte und Gesellschaft, 30, 277–313. United Lutheran Church in America. (1946, October 5–12). Minutes of the Fifteenth Biennial Convention, Cleveland, Ohio, 545. (ELCA 2/1, Box 5). Archives of the Evangelical Lutheran Church in America, Elk Grove Village, IL. Weber, M. (1922). Gesammelte Aufsätze zur Wissenschaftslehre. Tübingen: Mohr. Weber, M. (1985). Wirtschaft und Gesellschaft. Grundriss der Verstehenden Soziologie (5th ed., Rev.). Tübingen: Mohr. Weber, Principal Pastor & Mother Superior Florschütz. (1965, Dexember 12). Relief measures for the nursing staff at the hospital of the Henriettenstiftung. (S-11-2-2). Archives of the Henriettenstiftung. Weiser, F. (1960). Serving love: Chapters in the early history of the diaconate in American Lutheranism. The United Lutheran Church in America. West, R. (1939). History of nursing in Pennsylvania. Philadelphia, PA: University of Pennsylvania. Zerull, L. (2010). Nursing out of the parish: A history of the Baltimore Lutheran deaconesses 1893–1911. Charlottesville, VA: University of Virginia.

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Chapter Eleven: Nietzsche and the Right to Die: A Critical Dialectic of Access to Euthanasia or Medical Aid in Dying

Introduction Morality for doctors. Sick people are parasites on society. It is indecent to keep living in a certain state. There should be profound social contempt for the practice of vegetating in cowardly dependence on doctors and practitioners after the meaning of life, the right to life, is gone. Doctors, for their part, would be the agents of this contempt – not offering prescriptions, but instead a daily dose of disgust at their patients … To create a new sense of responsibility for doctors in all cases where the highest interests of life, of ascending life, demand that degenerate life be ruthlessly pushed down and thrown aside … Dying proudly when it is no longer feasible to live proudly. (Nietzsche, 1983) Morality for doctors. … Death chosen freely, death at the right time, carried out with lucidity and cheerfulness, surrounded by children and witnesses: this makes it possible to have a real leave-taking where the leave-taker is still there, and a real assessment of everything that has been achieved or willed, a summation of life – all in contrast to the pathetic and horrible comedy that Christianity stages around the hour of death. (Nietzsche, 1983)

In this chapter, I undertake a theoretical examination of the issues that the province of Quebec’s euthanasia legislation, Medical Aid in Dying (MAID), raise for end-of-life nursing. I employ a critical dialectic approach that involves iteration and the synthesis of a thesis based on studies of legal euthanasia, and an antithesis constructed from Nietzschean concepts and positions. Medical aid in dying may seem to be a straightforward medical intervention to provide relief to people experiencing unbearable suffering at the end of life. However, as implemented in Quebec, the practice is to be governed by a purely normative deontology patterned on laws in Europe, where the contexts and practice of medicine and nursing are vastly different. Given the particularly instrumentalized healthcare environment in Quebec, breaches of professional conduct are liable to occur. In Quebec and in most of North America, healthcare

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systems have been compelled to adopt unprecedented measures of austerity, bureaucratization, technocratization, and commodification (Betts, 2005; Krol & Lavoie, 2014). These oppressive systems, as Nietzsche foresaw (1971) over a century ago, have given rise to the reification of the human body and spirit as a locus for domination and experimentation inspired by the cult of progress and governed by hegemonic narratives of pure logic and of control both physical and mental. As Nietzsche wrote: Hubris today characterizes our whole attitude towards nature, our rape of nature with the help of machines and the completely unscrupulous inventiveness of technicians and engineers; hubris characterizes our attitude to God, or rather to some alleged spider of purpose and ethics lurking behind the great spider’s web of causality … hubris characterizes our attitude towards ourselves – for we experiment on ourselves in a way we would never allow on animals, we merrily vivisect our souls out of curiosity : that is how much we care about the “salvation” of the soul! Afterwards we heal ourselves: being ill is instructive, we do not doubt, more instructive than being well […]. (Nietzsche, 1979)

Employing a critical dialectical method, I suggest that our sanitary systems comprising an oppressive organization (i. e., some of the settings in which euthanasia is to be performed) and reifying actors (some of the professionals who may carry it out) will overwhelm the practice of MAID. In other words, it will succumb to the pressures of austerity and instrumentality brought to bear by modern narratives of the sanitary systems, provoking breaches of deontology – and thus of practice – with potentially disastrous results for the end-of-life experience. The following discussion begins with a brief outline of the dialectical method, a digest of current euthanasia practice in jurisdictions where it has been legalized, and a summary of Quebec’s recent legislation on the matter. I then utilize the Nietzschean concepts of “alterity,” “ipseity,” “will to power” and the “ethic of life” to develop a critical dialectic regarding issues likely to arise in the practice of MAID in Quebec.

Dialectics, Critical Theory, and Emancipation A critical theoretical approach in the social sciences entails examining the structural conditions of human existence in order to produce knowledge to help free the oppressed and improve their conditions of life (Chinn & Kramer, 2014; Denzin & Lincoln, 2011, p. 102, p. 55; Schwandt, 2007). Lincoln et al. recommend using the dialectical method in applying critical theory. From Krol and Lavoie’s (2015) Marxist dialectical perspective, this method involves constructing two opposing arguments – a thesis and an antithesis – about a topic (in

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this case aspects of euthanasia) and employing a deconstructionist critical approach to analyze the opposition between them and elicit a synthesis that would produce emancipatory substance and movement – that is, praxis (in this case, for nursing theory and practice). I begin by developing my thesis based on a deconstructionist reading of legal and empirical studies on the practice of euthanasia in jurisdictions where it is lawful, and by an examination of Quebec legal documents. My antithesis draws on selected Nietzschean positions, concepts, writings, and aphorisms to formulate a radical, critical argument that stands in sharp contrast to the practice of MAID that has been advanced in Quebec. The epistemic foundations of the deconstructionist approach used here lie in post-structuralism (Malpas & Wake, 2006). Deconstruction of empirical studies or legal documents involves bringing to light the meanings, structures, syntax, language, and actors behind the text, the instrumental rhetoric, and narratives about euthanasia. Texts are thus subjected to continual examination (dissection, criticism, evaluation) to reveal hidden meanings and agendas, dissect preconceptions, explore modern biases, and expose the influence of particular values by successively highlighting points of conflict and even sparking crises and controversies. Conflicts of this sort fuel the dialectic between the thesis of what is to all appearances an instrumental practice and the Nietzschean antithesis of an ethic of life; authentic choice at the end of life based on the concepts of ipseity, alterity, and the will to power. The dialectic is, furthermore, grounded in a critical ontic perspective from which the world is conceived as the interplay of forces of domination and power (Lincoln et al., 2011). This perspective, according to which historic phenomena are interpreted in terms of a struggle for strength, organization, and domination, is thus in keeping with the central Nietzschean concept of the will to power. In the interests of internal consistency and rigour, the critical dialectic is also founded on an epistemic approach strongly inspired by values of social justice, emancipation, (Lincoln et al., 2011) and Nietzsche’s ethic of life. The discussion here is not an empirical, “objective” enterprise that has been stripped of political values or a political stance. On the contrary, the purpose of my synthesis, the crux of this critical-theory approach, is to expose and challenge the organization, language, and actors that hold in their hands the power to dominate and oppress the ill, the dying. In addition, my political engagement entails constructing and proposing clear methods to keep people at the end of life from being subjugated to a single hegemonic “reality,” to a deontological sanitized biomedical prerogative subverting the practice of assisted death in Quebec.

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The Practice of Euthanasia This section summarizes the empirical nursing literature on issues and processes involved in euthanasia practice in jurisdictions where it has been legalized over the past few decades. The review will serve to provide the argument of the thesis for a critical dialectic regarding the introduction of MAID in Quebec. Published studies on euthanasia in some of the countries where it is legal practice (Netherlands, Belgium, and the state of Oregon in the US) have found that fewer than half the official requests for the procedure by pre-terminal patients living with extreme suffering are actually granted. Most are rejected by medical authority (Pasman, Willems & Onwuteaka-Philipsen, 2013, p. 313), who prefer providing additional, often futile – though purportedly palliative – treatment or who categorically refuse to perform euthanasia on religious or moral grounds. In a smaller number of cases, patients who apply do not follow through with the process. In almost every case though, the medical decision, which is fundamentally deontological in nature, weighs “heavily” on the attending physician, usually a general practitioner (Georges, The, OnwuteakaPhilipsen, & van der Wal, 2008, p. 151). Refusals often stir negative emotions in physicians, including guilt and withdrawal, and may even lead to anti-professional authoritarian and avoidance behaviour (Dees, Vernooij-Dassen, Dekkers, Elwyn, Vissers, & Weel, 2013, p. 32). Among nurses providing end-of-life care, many of whom favour euthanasia, refusals also have negative effects, ranging from a sense of professional impotence to self-deprecation (de Bal, de Casterl8, de Deer, & Gastmans, 2006, p. 593). Once euthanasia has been prescribed for a patient who has necessarily met all the requirements in accordance with the ethical standards in a given jurisdiction, a process gets underway, gathers momentum, and culminates rather quickly in ending the suffering of the patient as well as of the family ; sometimes the healthcare professionals involved too find relief (Norwood, Kimsma, & Battin, 2009, p. 477). A number of studies document the steps that the interventions must follow. They outline a complex, dynamic, relational process comprising a specific sequence of overlapping stages (de Casterl8, Denier, de Bal, & Gastmans, 2010; Dees, et al., 2013; Denier, de Casterl8, & Gastmans, 2010). Some research suggests that the process must, as far as possible, be procedurally oriented and fact based (Denier et al, 2010; van Bruchem-van de Scheur et al., 2008). It must consequently comply – that is, submit completely – with the deontological prerogatives per se. The purportedly “right” actions must thus be taken at the “right” time with the “right” people in the light of what is deemed “right” in the strict meaning of the law – as determined, of course, by the medical authority concerned. While a general process guiding euthanasia can be mapped out, the

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studies indicate the existence of fine procedural and deontological distinctions stemming mainly from political and socio-cultural variations between jurisdictions. Euthanasia processes thus vary by country or state. For example, in the Netherlands, general practitioners regularly make home visits and follow up scrupulously by telephone with patients at the end of life (Norwood et al., 2009, p. 475). As noted, the process depends fundamentally on the patient, nurse, and physician engaging in an open dialogue and deliberating jointly (Norwood et al., 2009; van Bruchem-van de Scheur et al., 2008) on how to organize care in the period before euthanasia (Denier et al., 2010). By the same token, the process necessitates creating and maintaining an organized dynamic, a momentum, to ensure continuity of care and fulfilment of the outcome (Norwood et al., 2009). This momentum should most especially and as far as possible channel decisionmaking towards ending the individual’s suffering with dignity (de Bal et al., 2006, p. 597). It also entails reaching an agreement that generally should favour and respect the autonomy of the person concerned in deciding the time and place for the euthanasia (de Bal et al., 2006). However, it is often unfortunately the case that the process is impeded at various levels of modern sanitary systems by an exacting and opaque bureaucracy and by the paternalistic attitudes of physicians opposed to the practice (de Bal et al., 2006, p. 595). Furthermore, Pasman et al. (2013) show that patients may abandon their request if they feel they are imposing a further burden on already overworked nurses. The issues and problems encountered in Europe – the subjection of euthanasia to a medical authority, the instrumental deontology, bureaucratic impediments, geographic and political variation, the need for process and momentum – raise fears that the practice of MAID in Quebec will be affected in a similar and possibly even worse fashion. This, then, is the argument of my thesis regarding euthanasia as it is practised internationally. I shall now turn to a discussion of the elements of the Nietzschean argument that form my antithesis and then proceed to the dialectic proper.

Nietzschean concepts The will to power [Anything which] is a living and not a dying body… will have to be an incarnate will to power, it will strive to grow, spread, seize, become predominant – not from any morality or immorality but because it is living and because life simply is will to power…

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“Exploration”… belongs to the essence of what lives, as a basic organic function; it is a consequence of the will to power, which is after all the will to life. (Nietzsche, 1987)

Nietzsche’s notion of will, Heidegger (1954) explained, refers to the volition to control and command, and especially, insofar as it is possible, to freely express the choice to strive towards strength and structure in accordance with a sorted – yet moving – hierarchy of values; hence, the fundamentally ethical nature of will. It stems from a perception of a lack or a void and stimulates a constant struggle towards power, which (like health) can never be fully attained. Power is the expression of the accumulation of strength, structure, and authority. Thus, for Nietzsche, the will to power, as an ontic process, constitutes the very essence of that which animates the world. Everywhere, in every space, there are only these power relations, relations of will to power (Montebello, 2001). More particularly, the will to power gives impetus to the direction of force, resulting in the perpetual movement that allows structure to endure and animates life.

Ipseity Influenced by biological theorists of his day, such as Wilhem Roux and Rudolf Virchow, Nietzsche developed the notion of an ethic of life animated by the will to power (Montebello, 2001) and modulated by, among other things, ipseity and alterity, key concepts in his complex thinking (Stiegler, 2001). Nietzsche was truly inspired by Willam Roux’s thesis on biological ipseity : The smallest organisms go very far in their assimilation of the new – the unknown – to their own: no one is more resistant to the diversity of external powers than the protoplasm, and on the other hand, no one is more sensible to alterations from the outside and the alterity as a whole, than the complex organism fighting to preserve its own identity and become itself. (Stiegler, 2001, p. 37, my translation)

Ipseity is the property that defines the very nature of things, the essence that colours their uniqueness and distinguishes them from other things (Lalande, 2007). Ipseity refers to that which is naturally and biologically specific to living organisms and makes their cohesion and cell survival possible. For Nietzsche, ipseity constitutes an immanent force that stimulates structures to endure and thus promotes the survival, growth, and fulfilment of a unified self (Stiegler, 2001). The self is conceived as a cellular “we” animated by the will to power, by the forces of ipseity and alterity actuated by an ethic of life. Viewed in terms of the will to power, ipseity constitutes an emancipatory, structuring, creative process; it fosters a constellation of forces of growth and fulfils a basic function in the realization of life’s potential. However, it is also a force that animates recognition and screening, the rejection of and struggle against everything that

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is other, principally, though not solely, the force of alterity and its potentially harmful processes. Alterity Alterity, the property that refers to everything that is other to the self, is the opposite of, and, at the same time, a necessary complement to ipseity. Viewed in relation to the will to power, alterity is also an immanent force of aggression emerging from both within and without the self and essential to mobilizing and maintaining the structure of, and struggle for, life (Stiegler, 2001). As an aggressive force emanating from the not-self, alterity stimulates and provokes life to constantly (re)build. As a potentially fatal force emanating from within, or “permanent suicide,” in Nietzsche’s view, the function of alterity is to seek by all means possible to change the physiological structure of life in order to destroy it. Indeed, “here it is important to defy all the cowardice of prejudice and to establish, above all, the real, that is, the physiological, appreciation of so-called natural death – which is in the end also ‘unnatural,’ a kind of suicide” (Nietzsche, 1983, p. 36). Thus, as Stiegler points out, the process by which alterity is recognized – namely, ipseity – protects life from the unknown, from danger, disintegration, and death. However, life’s mechanisms for evolution and resistance are limited by nature; alterity cannot be perpetually kept at bay. Like ipseity it plays a role in regulating the evolution and adaptation of living beings. The ethic of life For Nietzsche, as Stiegler (2001) put it, the ethic of life is animated by the will to a natural life, structured by the will to power and modulated, though not solely, by forces of alterity and ipseity. It is a basic premise of Nietzsche’s philosophy that the ethic of life is a natural conation, and given the assumption that life is not an exclusively human function, he espouses an anti-anthropocentric orientation. Nietzsche thus condemns modern man’s delusional worship of progress and celebrates the return of natural man. Furthermore, from the ontic perspective of the will to power, that which contributes to power, contributes to life. As an ethical volition, Nietzsche’s ethic of life fosters the structuring and natural fulfilment of the organisms it animates. For Nietzsche (1989), the ethic of life thus signifies expressing one’s conation to realize and surpass oneself by employing the natural possibilities offered by the present while aspiring to a future in continual becoming. Given the uncertainty of life’s duration and integrity, the active quest for structure and power is a constant of existence. Thus, life perpetually creates itself; it simply cannot remain a static phenomenon. This creative function, this “wasteful and indif-

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ferent magnificence” (Nietzsche, 1971b), drives the continuous transformation of life. It may consequently surpass alterity and generate a sense of power and freedom that in turn support its structured growth (Reginster, 2006). In this Nietzschean ethic, life is worth living freely and creatively.

Dialectic about Medical Aid in Dying In 2009 a select committee of Quebec’s National Assembly was formed to consider the thorny deontological and legal issues that would arise out of the eventual legalization of euthanasia. After numerous consultations over the following two years, it published a report in 2012 entitled Dying with Dignity, which made recommendations on “end-of-life care” and “medical aid in dying.” A bill on end-of-life care was consequently introduced with the stated aim of meeting the Quebec public’s demands to “democratize,” as it were, the quality of, and access to, palliative care and euthanasia. The main purpose was to improve the quality of existence at the end of life through the relief of suffering, palliative sedation, and (in an eminently politically correct formulation), medical aid in dying. Bill 2 came into force in December 2015 with the establishment of a special committee to oversee its implementation and to monitor outcomes and possible infringements. The oppressive organization The analysis of the studies presented above suggests conducting a critical dialectic on two levels: those of the oppressive organization (the sanitary systems) and the reifying actor (the medical authority). Major ER overcrowding as a daily reality, rising costs for medication, aging of the population, deinstitutionalization of primary care services, nursing shortages, low investments in infrastructure and sanitary systems management, retrieval or home care services : all these are ingredients of a major crisis which could cause the implosion of the system and put in danger accessibility. (Jett8, 2008, p.1, my translation) The New Idol. Somewhere there are still peoples and herds, but not with us, my brothers: here there are states. A state? What is that? Well! open now your ears to me, for now will I say to you my word concerning the death of peoples. State is the name of the coldest of all cold monsters. Coldly lies it also; and this lie creeps from its mouth: “I, the state, am the people.” It is a lie! Creators were they who created peoples, and hung a faith and a love over them: thus they served life. Destroyers are they who lay traps for many, and call it the state: they hang a sword and a hundred cravings over them. (Nietzsche, 1985)

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Quebec’s sanitary system has deteriorated sharply over the years (Jett8, 2008). The once-celebrated, socially prosperous legacy of the Canadian welfare state has undergone change after change since the mid-1970s. It has suffered from deinstitutionalization, commodification of services, and the damaging depletion of resources. It has been subjected to discourses of austerity, neo-liberalism, “excellence,” “best practices,” and more recently, to an interfering biomedical despotism that has ramified through the provincial government to the detriment of accessibility and quality of care. Studies in Quebec and North America as a whole reveal a situation in which the instrumentalization of sanitary systems goes hand in hand with an hierarchical autocracy. Medical authorities’ hegemonic domination is thus sustained by narratives of efficiency, technocracy, bureaucracy, and productivity aimed at achieving standardization and systematic efficacy of mainly curative interventions (Beagan & Ells, 2009; Jett8, 2008; Krol & Lavoie, 2014; Whiteside, 2011). Studies also illustrate the manifest neoliberalism of the Quebec sanitary system: it is directive – even oppressive – and poorly accessible; numerous services have been chopped to a bare minimum and strict rules limit access. This post-welfare regime reflects concretely how far the state has retreated from its commitments to health care and allowed the mercantilist delusions of the private-sector narrative to shape deregulation (Jett8, 2008). The situation is overwhelming, and we face the spectre of end-oflife care and especially of MAID mirroring these shortcomings. It is therefore little short of utopian to imagine it possible to implement the process and momentum that, according to European studies, are necessary for the proper administration of euthanasia (de Bal et al., 2006, p. 597; Norwood et al., 2009). MAID is thus all too likely to be subjected to instrumentalization by distant, intractable organizations. European studies reveal some of the recurrent organizational and bureaucratic impediments to the process and momentum required to make euthanasia a reality in Quebec. These impediments have the perverse effect of prolonging neglect and human suffering (De Bal et al., 2006). Most disgracefully, the actual operation of medical aid in dying in Quebec is bound, as in Europe, to hegemonic narratives of biomedical governance. Implementation will necessarily involve a bureaucratic organization of authoritarian, distant, complex, and impenetrable control, an organization of a type that, studies show, prolongs suffering and may even cause physical injuries (Abadia & Oviedo, 2009; Pannowitz, Glass, & Davies, 2009). The outlook for patients who request MAID in Quebec is thus grim, especially in light of the fact that the Quebec sanitary system already has trouble providing a minimum of fragmented, mainly curative services that are generally hard to access – if not simply nonexistent (Jett8, 2008). Furthermore, empirical studies show that nurses and physicians in some palliative care settings are highly reluctant to perform euthanasia (de Bal et al.,

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2006), even though patients in these facilities for “slow death” may be given ambiguously lethal treatments that verge on passive euthanasia. That said, the structural conditions cited – inaccessibility, bureaucracy, austerity, biomedical governance – are liable to create a situation in which MAID is forced to become a taboo “itinerant” practice conducted in inappropriate conditions far from the cheery pretentions of home care (Ganz & Musgrave, 2006; Thulesius, Scott, Helyesson, & Lynoe, 2013). Notwithstanding all the impediments and failings found to prevail in the oppressive organization of health care, the important thing, Nietzsche reminds us, is that people can still fulfil their potential for selfrealization in a death they have freely chosen – thus sanctifying the forces of alterity – as they carry out their last wishes. The reifying actors Morality for doctors. … Death chosen freely, death at the right time, carried out with lucidity and cheerfulness, surrounded by children and witnesses: this makes it possible to have a real leave-taking where the leave-taker is still there, and a real assessment of everything that has been achieved or willed, a summation of life – all in contrast to the pathetic and horrible comedy that Christianity stages around the hour of death. (Nietzsche, 1983) Over the last forty years, however, the death and dying discourse has changed. Paternalism is increasingly difficult to defend when treating competent patients and has eventually become a dysphemism, indicating an emergent taboo of questioning autonomy. (Thulesius et al, 2013, p. 12)

Quebec’s Bill 2 lays out how the practice of MAID is to be organized and identifies the conditions that must be met and the medical treatments that may be prescribed for a person at the end of life. The legislation defines a person at end of life as one suffering from an incurable condition and experiencing advanced, irreversible decline of his or her physical (or mental) capacities. Exercising their competencies in compliance with their professional deontology, attending physicians must make a diagnosis that their patient is indeed experiencing “constant and unbearable physical or psychological suffering which cannot be relieved in a manner the patient deems tolerable” (Gouvernement du Qu8bec, 2016). The provision of MAID consequently depends per se on a judgement exerted by medical authority ; that is, prescribed by healthcare actors who are bound to their normative deontology of being unbiased and somehow stoic. However, the empirical literature shows clearly that such decisions are anything but free of bias. Despite anything deontology in the various jurisdictions might suggest, a majority of physicians are reluctant to perform euthanasia because of their personal values or religious (principally Catholic) asceticism (Inghelbrecht,

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Bilsen, Mortier, & Deliens, 2009; Jylhankangas, Smets, Cohen, Utrianen, & Deliens, 2014; Sercu, Pype, Christiaens, Derese, & Deveugele, 2011). Moreover, many attending physicians become paternalistic and authoritarian when dealing with and refusing a request for euthanasia (Dees et al., 2012; Thulesis et al., 2013). The prospect of authorizing death apparently upsets certain core values; it leads physicians to entrench themselves in their role, their position of power and domination, and to condemn – and delegitimize – these requests. From a Nietzschean perspective, such a transgressional inconsequential deontology resembles nothing more than an insidious quest for biopower and domination over life and over the natural, vital forces of ipseity and alterity ; a quest, indeed, for the biomedical and metaphysical subjugation of human life on the part of actors, who by all means possible, intend to maintain their authority and power over subjection of life and death. The person at the end of life is effectually stripped of his or her autonomy and freedom and is subjected body and soul to reifying actors making virtually totalitarian decisions on the basis of “legislated” scientific standards, positions, and treatment options. These reifying actors, furthermore, exert their power in the name of arbitrary values metaphysically founded in Christianity. To Nietzsche, these values are among the most reprehensible, indeed contemptible, that can exist. From the perspective of his ethic of life: Morality for doctors. Sick people are parasites on society. It is indecent to keep living in a certain state. There should be profound social contempt for the practice of vegetating in cowardly dependence on doctors and practitioners after the meaning of life, the right to life, is gone. Doctors, for their part, would be the agents of this contempt – not offering prescriptions, but instead a daily dose of disgust at their patients … To create a new sense of responsibility for doctors in all cases where the highest interests of life […]. Dying proudly when it is no longer feasible to live proudly. (Nietzsche, 1983)

Nietzsche, who had been an army orderly, maintained that people who express a wish to end their distress should be allowed to carry out their free and final choice and be done with their suffering. Careful reading of the empirical studies on assisted-death practice in other jurisdictions suggests that the diagnostic and ethical criteria set out in Quebec’s Bill 2 are almost solely modelled on European legislation. While there are differences regarding diagnoses, a person requesting euthanasia must, as in some European countries, have a collaborative relationship with a physician. The request for assisted dying must be repeated over the course of several conversations with the doctor. Dialogue during these encounters should focus on informed consent regarding prognoses, palliative treatments, and the possible procedure for ending life. Quebec’s healthcare systems, however, are dominated by an ultraconservative medical hierarchy that provides little room for dialogue.

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Time, money, and resources are in short supply, and certain actors in this oppressive organization paternalistically impose decisions. If a trusting, authentic, close relationship between attending physicians and patients is as necessary as the international studies clearly indicate, it is hard to imagine a truly relational process for MAID developing in Quebec. The “comedy that… has [been] made of the hour of death,” as Nietzsche (1983) put it, is totally arbitrary, if not perverse, from the perspective of his ethic of life. Human life is ceaselessly interpreted through the effort to fulfil and surpass oneself, whether one seeks life or (ultimately) death. From this standpoint, it is essential we respect the free choice expressed by individuals suffering in body and soul. They should not have their existence and distress subjected to reifying actors, especially ones who exert arbitrary power based on ascetic metaphysical values and motivations that may upset, even prevail over, their commitment to a normative deontology. In the final analysis, Nietzsche’s ethic of life demands that the natural values and forces of life be respected, so that people may fulfil the possibilities for life or for death that the present offers them.

Synthesis, Conclusion and Recommendations My preceding discussion has offered a theoretical critique of the practice of euthanasia as a “biomedical, yet instrumental” treatment delivered in accordance with standards laid out by pure normative deontology. I described the sanitary systems and human issues involved and the consequences for the practice documented in empirical studies. I then undertook a dialectical speculation on issues raised by the more recent introduction of MAID in the dehumanized Quebec context. The preliminary conclusions are disheartening. I therefore suggest that MAID should be read in a radically different, a decidedly non-normative manner, and that the text on euthanasia should be rewritten; discussion should start from the premise that the right to die at the end of life is not a problem to be resolved by normative deontology but rather lived as a privilege, a natural phenomenon animated by the never-ending interplay of forces of alterity, ipseity, and the ethic of life. I presented two arguments in relation to the oppressive organization and the reifying actors: the instrumental thesis and an antithesis grounded in the Nietzschean ethic of life. From the standpoint of my critical, emancipatory position, I conclude that people suffering at the end of life should be able to exercise much greater freedom to make their own decisions. More particularly, I suggest that people suffering at the end of life be given due respect when they express their last wishes and final decision about their body, their spirit, and their existence, provided their decisions are autonomous, informed, and con-

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sidered. In accordance to Nietzsche’s position on the “live” end of life, I argue that euthanasia should not be thought of as an easy “way out” for everyone suffering at the end of life, nor should it be “democratized” without appropriate supervision. My serious concern – and the reason for this dialectic – is that MAID is likely to be practised in oppressive healthcare organizations and subject to arbitrary biomedical despotism. In these circumstances, the prospective experience for anyone requesting aid in dying is liable to be grim indeed. In light of the various issues one may encounter in MAID, I therefore maintain that consideration of Nietzsche’s ethic of life will allow us to avoid conceiving end-of-life care from a strictly deontological perspective, but, in accordance with the Nietzschean argument, I approach it from the standpoint of immanent, natural (biological and physiological) life. The ethic of life allows us to reconnect with our inevitable frailty and fate as human beings. However, it also encourages us to give the ultimate expression to our self-determination and our freedom to live our life to the utmost and to die with dignity.

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Norwood, F., Kimsma, G., & Battin, M. P. (2009). Vulnerability and the ‘slippery slope’ at the end-of-life: A qualitative study of euthanasia, general practice and home death in The Netherlands. Family Practice, 26(6), 472–480. Pannowitz, H. K., Glass, N., & Davis, K. (2009). Resisting gender-bias: Insights from Western Australian middle-level women nurses. Contemporary Nurse: A Journal for the Australian Nursing Profession, 33(2), 103–119. Pasman, H. R. W., Willems, D. L., & Onwuteaka-Philipsen, B. D. (2013). What happens after a request for euthanasia is refused? Qualitative interviews with patients, relatives and physicians. Patient Education & Counseling, 92(3), 313–318. Reginster, B. (2006). The affirmation of life: Nietzsche on overcoming nihilism. Cambridge, MA: Harvard University Press. Schwandt, T. (2007). The Sage dictionary of qualitative inquiry (3th ed.). Los-Angeles, CA: Sage Publications. Sercu, M., Pype, P., Christiaens, T., Grypdonck, M., Derese, A., & Deveugele, M. (2012). Are general practitioners prepared to end life on request in a country where euthanasia is legalised? Journal of Medical Ethics, 38(5), 274–280. Stiegler, B. (2001). Nietzsche et la biologie. Paris: PUF. Thulesius, H. O., Scott, H., Helgesson, G., & Lyne, N. (2013). De-tabooing dying control: A grounded theory study. BMC Palliative Care, 12(1), 13–20. van Bruchem-van de Scheur, G. G., van der Arend, A. J. G., Abu-Saad, H. H., Spreeuwenberg, C., van Wijmen, F. C. B., & ter Meulen, R. H. J. (2008). The role of nurses in euthanasia and physician-assisted suicide in The Netherlands. Journal of Medical Ethics, 34(4), 254–258. Whiteside, H. (2011). Unhealthy policy : The political economy of Canadian public-private partnership hospitals. Health Sociology Review, 20(3), 258–268.

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Contributors

Katrin Antweiler, MA, is currently a member of the Humboldt Graduate School in Berlin and working on a PhD project that deals with the correlation of Holocaust memory and human rights in a global context. Her research interests include cultural history and memory, Holocaust studies and politics of remembrance, as well as the ethics of human rights. [email protected] Jane Cahill, MA Hons, PhD, is currently a senior research fellow at the School of Healthcare at the University of Leeds. She publishes widely in the field of mental health with a special focus on the therapeutic alliance, evidence-based practice and practice-based evidence approaches, self-management of chronic conditions, workforce mental health issues, employment support, and mental health and organizational leadership styles. [email protected] Christine Ceci, PhD, RN is an associate professor in the Faculty of Nursing, University of Alberta. Her program of research includes empirical and theoretical work concerned with the organization of care practices for frail older people, currently with a focus on the situations of families in which one member has dementia. She is a co-editor of Perspectives on Care at Home for Older People and Philosophy of Nursing: 5 Questions. [email protected] Maria Flynn PhD, MSc, BSc, RGN, is a Senior Lecturer in the School of Health Sciences at the University of Liverpool, UK, with substantial knowledge, skills, and experience in nursing and applied health research. Her critical scholarship is located at the interface of the academy and care delivery, underpinned by encouraging nurses to question the concept and utility of “evidence-based practice,” and to address professional issues from a pluralistic knowledge base. [email protected] Thomas Foth, RN, MEd, PhD, is Assistant Professor in the School of Nursing at the University of Ottawa. His fields of interest include history of nursing, critical

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Contributors

analysis of nursing practice, nursing theories and epistemology, ethics, nursing care provided to marginalized populations, power relationships between healthcare professionals and patients, and finally, gender issues in nursing. [email protected] Dawn Freshwater, PhD, is the Acting Vice–Chancellor at the University of Western Australia. Dr. Freshwater maintains a strong track record in developing and interrogating methodological approaches underpinning research that translate into improved practice in mental health care. She has also developed creative and imaginative approaches to inclusivity and to understanding how large organizations use social systems as defence mechanisms as proxy for managing uncertainty and anxiety. [email protected] Heiner Friesacher, RN, MEd, Dr. phil., is a freelance lecturer at different German universities and educational institutions. He is co-editor of the journal intensive, member of the scientific board for the Bremer care congress [Pflegekongress] and an expert on “Patient’s well-being as an ethical yardstick for the hospital” for the German Ethics Board. Research and work interests include theoretical foundations of nursing actions, nursing ethics, professionalization, and quality development. [email protected] Ulrike Greb, M.A., Prof. Dr. phil., is Professor of Education at the University of Hamburg, Germany, with a focus on didactics for professional education of occupations in healthcare and nursing care. She has studied philosophy, education, and psychoanalysis. Her research focuses primarily on theories about academic education and development of curricula, and theoretical foundations of professional teaching and sustainability. She is co-editor of the Pflegedidaktisches Handbuch [Manual for nursing didactics] and she is a member of the German Society of Nursing Science. [email protected] Dave Holmes, RN, PhD, is Professor and University Research Chair in Forensic Nursing at the University of Ottawa. To date, Professor Holmes conducts his research program on risk management in the fields of Public Health and Forensic Nursing. Most of his work, comments, essays, analyses and research are based on the poststructuralist works of Deleuze & Guattari and Michel Foucault. He has held appointments as Honorary Visiting Professor in Australia, the United States and the United Kingdom. [email protected] Manfred Hülsken-Giesler, RN, Prof. Dr. phil., is a Professor of Community Nursing at the University of Vallendar, Germany and Vice-dean of the Faculty of Nursing Science there. His research interests include the theoretical foundations

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of professional nursing, especially the relevance of new technologies for nursing practice and corresponding consequences for the development of professional nursing in the future. He is a board member of the German Society of Nursing Science. [email protected] Susanne Kreutzer, Prof. Dr. phil., is Professor of Ethics, Philosophy of Science and History at Münster University of Applied Sciences, School of Health, Germany, and is as well Adjunct Professor at the School of Nursing, University of Ottawa. Her research interests include nursing history, transnational history, and biographical research. She has published on the history of religious and secular nursing in the twentieth century in Germany, the United States, and Sweden. [email protected] Pawel Krol, PhD, is assistant professor of Nursing at the University of Laval in Quebec City. His main topic of study is on the practice of nursing, especially a critical focus on psychiatric and end of life nursing within the complex context of modern society and health systems. He uses philosophical, phenomenological, and historical epistemology inspired by continental tradition and Frankfurt critical theory. [email protected] Kim Lauzier, RN, BScN, MScN (student) is at the University of Ottawa. Her 15year career in nursing sparked her interest in the treatment of vulnerable populations, and the injustices and repercussions of healthcare transformations. Her research interests are centered on the critical history of nursing. She is currently working as a staff nurse at The Ottawa Hospital as well as a part-time instructor with the University of Ottawa. [email protected] Dave Mercer, PhD, is a Lecturer in the School of Health Sciences at the University of Liverpool, UK, with an academic background in sociology and criminology. His research and scholarship, framed by critical analysis, focuses on forensic mental health practice. He is committed to a nursing philosophy that values diversity, encourages inclusion, and prioritizes anti-oppressive and anti-discriminatory working environments. [email protected] Jeannette Pols, PhD, is Socrates professor in the “Social Theory, Humanism and Materialities” at the Department of Anthropology, program “Health, Care and the Body,” at the University of Amsterdam. The chair is an initiative of the Socrates foundation to support reflection on humanism and ethical consequences of the sciences. She is also Associate Professor and Principal investigator in the section of Medical Ethics, department of General Practice of the Academic Medical Centre in Amsterdam. [email protected]

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Contributors

Mary Ellen Purkis, PhD, is a Professor in the School of Nursing at the University of Victoria. She completed doctoral studies at Edinburgh University. She has a long-term interest in theories of knowledge and theories of practice and the relationships between knowledge and practice within the context of contemporary discourses of nursing. [email protected] Hartmut Remmers, Prof. Dr. phil., is Professor and Director of the Department of Nursing Science in the Faculty of Human Sciences at the University of Osnabrück, Germany. Research interests include oncological nursing, palliative care, technologies in environments of the elderly and in nursing homes, and critical philosophical and sociological perspectives in ethics. He is editor of the scientific book series “Nursing Science and Nursing Education” in which this collection is published. He is a scientific consultant for different ministries, universities, and foundations. [email protected] Gary Rolfe, RN, PhD, is Emeritus Professor of Nursing in the College of Human and Health Science at Swansea University, Wales. His research interests include reflective practice, practice development, and action research. He has published 10 books and over 100 journal articles and book chapters on philosophical aspects of practice, research methodologies, practice development, and education. He holds a visiting Chair at Canterbury Christ Church University, Kent, and until his retirement was Professor of Innovation and Development with ABMU Health Board. [email protected]

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Index of Names

Adorno, Theodor 13, 25, 29, 69, 80, 151seq., 154seq., 165, 175, 187, 189–192, 194–197, 199, 201 Althusser, Louis 115, 120seq. Aristoteles 10, 77, 82, 153seq.

Gadamer, Hans-Georg 151, 175, 178–181, 183 Gibbs, Graham 174 Goethe, Johann Wolfgang von 75seq. Goffman, Erving 40

Bacon, Francis 10–12 Bayle, Pierre 10 Benner, Patricia 75, 92, 95seq., 100, 104, 152, 154, 159, 162 Blankertz, Herwig 188, 193, 199 Bolton, Gillie 173seq. Bourdieu, Pierre 19, 158, 161 Bulman, Chris 173 Butler, Judith 25, 115, 118–127, 132

Habermas, Jürgen 19, 25seq., 29, 77–79, 84, 94–100, 151, 169seq., 174–185 Hegel, Georg Wilhelm Friedrich 117–119, 190–192, 199 Heidegger, Martin 80, 83, 181, 234 Heydorn, Heinz Joachim 192, 197 Honneth, Axel 25, 27seq., 79seq., 86, 100seq., 114–119, 121seq., 124seq., 127, 202, 204 Horkheimer, Max 12–14, 70, 154seq., 174, 189seq., 196 Husserl, Edmund 181

Cartesian 74, 76 Castel, Robert 19 Comte, Auguste 169 Descartes, Ren8 11, 155 Dewey, John 181 Dilthey, Wilhelm 84, 176–178 Drummond, John 53seq., 58seq., 61 Fawcett, Jacqueline 97, 193–197, 202, 205 Feyerabend, Paul Karl 176 Foucault, Michel 17, 25seq., 35, 72, 74, 82–86, 115, 120, 158, 246 Francis Report 26, 33seq., 133seq. Frankfurt School 27, 92, 99, 102seq., 174 Fraser, Nancy 100 Freud, Sigmund 177

Jaeggli, Rahel 101, 105 Jasper, Melanie 173 Kant, Immanuel 11, 84, 181, 197 Kierkegaard, Søren 77seq. Koselleck, Reinhart 11 Kuhn, Thomas S. 176 Latour, Bruno 57–63 Lemke, Thomas 18, 20 L8vinas, Emmanuel 26seq., 71, 78–83, 85seq., 119, 123 Marcuse, Herbert

174

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Index of Names

176, 190seq.

Nietzsche, Friedrich 30, 85, 229–231, 233–236, 238–241 Peirce, Charles Sanders Pender, Nola 54 Plato 153 Popper, Karl 94

176–178, 181

Rabe-Kleberg, Ursula 197seq., 205 Ricoeur, Paul 178, 180 Rolfe, Gary 28seq., 35, 133seq., 172, 248 Rudge, Trudy 58seq.

Schön, Donald 29, 152, 169–174, 181–185 Schutz, Sue 173 Socrates 80, 247 Taylor, Beverley 173 Thatcher, Margaret 18 Vico, Giambattista

11

Waldenfels, Bernhard 96, 104, 152, 195seq. Weber, Max 13, 95, 196, 210, 215 Weizsäcker, Victor von 74–76 Wittgenstein, Ludwig 176

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Index of Subjects

academization 91, 221seq. action 10, 12seq., 24, 27, 29, 40, 53, 57, 60seq., 63–65, 70, 72seq., 75, 78, 80seq., 83seq., 91–99, 101, 103, 105, 115, 118seq., 121, 123, 125, 132, 134, 136–138, 141, 144, 152–154, 156–158, 160–163, 165, 172, 174, 180–183, 192, 197seq., 200, 202, 205, 210, 223, 232, 248 – communicative action 95seq., 98seq., 181–184 – instrumental action 182 – purposive-rational action 182 – strategic action 182 aesthetic 65seq., 83–85, 143, 153–156, 164, 198 aisthesis 164 algorithm 131seq., 137, 141–143, 145seq. alterity 86, 230seq., 234–236, 238–240 authority 20, 104, 136, 173, 232–234, 236, 238seq. autonomy 13, 19, 26, 28, 57, 69, 71–73, 79, 81, 83, 86, 92, 99, 101, 116, 123, 131–134, 141, 164, 189, 223, 233, 238–240 Best Practice 16, 22seq., 237 biographic narrative 74 biopolitics 120 biopower 83, 239 bourgeois 12seq., 71 bureaucracy 17, 42, 64, 202, 205, 210, 220seq., 233, 237seq. burn-out 41, 161 capital

18seq., 39, 44

capitalism 12seq., 101seq., 191, 217 care 15seq., 22–29, 33–44, 53–58, 61–65, 69–76, 78seq., 81–87, 91–93, 96, 99–103, 114, 116–118, 131–137, 139–144, 146, 151seq., 158–165, 195, 197–207, 209seq., 212, 214–218, 221–224, 230, 232seq., 236–238, 241, 245–248 – care caring values 37 – care provider 26, 33seq., 36, 70, 205seq. – compassionate care 34–37, 41, 144 – core caring values 36, 43 – core of nursing care 70 – functional care 215, 223 – social care 25seq., 33–39, 41, 43 Cartesian 74, 76 Chicago School 17 Christianity 10, 15, 80, 83, 209, 211seq., 214seq., 217, 222seq., 229, 238seq. chronic disease 56, 200–202, 206 clinical decision support systems 131, 136seq., 141, 144 communicative rationality 98 compassion 26, 34–36, 38–42, 71, 86 consciousness 12seq., 71, 98, 117, 143–146, 156, 177, 190 control 23, 29seq., 41, 56, 82seq., 95, 98, 117, 120, 134, 160, 170, 173, 189, 191seq., 198, 201, 215, 230, 234, 237 corporality 27, 29, 74, 77seq., 83seq., 92seq., 96, 99seq., 103seq., 152, 154–158, 162, 164seq., 190seq., 194–197, 200seq., 203

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– corporal-oriented phenomenologies 152 critical thinking 9, 14, 94, 105, 143 cure 73, 203 curriculum 34, 42, 44, 169, 171, 174, 188, 193, 199seq., 213, 215, 219–221 deaconess 29, 210–219, 222–224 death 51, 74, 93, 104, 113–115, 117, 124seq., 127seq., 142, 196, 229, 231, 235seq., 238–240 decision-making 9, 16–18, 21seq., 28, 131–135, 137seq., 141–143, 145, 152, 157, 210seq., 233 – informed decision-making 131, 133, 138, 140 dehumanization 123seq. dementia 61, 100, 245 democracy 15seq., 19–21, 115 dialectical 69, 102, 188, 198seq., 230, 240 – dialectical method 230 – negative dialectics 80, 187 didactic model 187seq., 192seq. dignity 34, 36, 39seq., 84, 86, 101, 116, 196, 233, 236, 241 discourse 16, 24, 34seq., 39, 41seq., 57–59, 79, 82–86, 91seq., 96–98, 105, 120, 123seq., 132–136, 139seq., 145seq., 179seq., 189, 237seq., 248 discrimination 39, 86 dissipative structures 142 diversity 60, 69, 163, 234, 247 double logic of action 93, 95, 223 economization 16seq., 19, 24, 27, 91seq., 96, 105 effectiveness 21, 55, 58, 138, 146 efficiency 21–24, 28, 41, 58, 131, 138, 206, 210, 215, 223, 237 empathy 34, 36, 39seq., 42, 71, 78, 159–161, 163, 204 empirical 13seq., 16, 26, 28, 39, 51, 53, 57, 62, 65, 81, 85, 97seq., 103, 117, 141, 151, 156, 163, 172, 176seq., 182, 195, 231seq., 237–240, 245 empowerment 39, 101

Enlightenment 11–13, 97, 155, 188–190, 192, 196 epistemic 59, 75seq., 82, 117, 119, 231 epistemology 28, 60, 169seq., 172–175, 184seq., 246seq. ethics 25seq., 28, 41seq., 62, 65, 69–71, 73seq., 77–87, 91, 98, 101–103, 113, 115seq., 118seq., 122, 124seq., 127, 132, 134, 139, 141, 144, 153, 165, 207, 215, 221seq., 230, 232, 234seq., 239, 245–248 – ethics of care 62, 72–75, 79, 81, 86seq., 100 Europe 12seq., 15, 30, 91, 97, 143, 229, 233, 237 euthanasia 29, 229–233, 236–241 evidence 9, 16, 34seq., 37–40, 54, 58, 65, 132, 136–139, 141–143, 172, 175, 182, 245 – evidence-based 22, 26, 28, 35seq., 97, 132, 136, 138seq., 151, 163, 169seq., 189 – evidence-based practice 35seq., 136, 138–140, 245 – practice based evidence 139 exclusion 28, 37, 39, 115 experiential learning movement 171 falsificationism

94

gender 71, 246 generalization 56, 71, 190 government 15seq., 20–22, 44, 61, 125, 138, 205, 237 guideline 16, 21, 62, 65, 93, 137seq., 202, 213 habitus 94 healthcare 15–18, 22seq., 25seq., 29seq., 34–36, 38–44, 52seq., 58, 70, 93, 99, 101, 105, 133, 135seq., 138, 141, 144seq., 183, 190, 198seq., 202, 205, 209, 211, 214, 221–223, 229, 232, 237seq., 241, 245–247 – healthcare policy 34seq., 135, 202 – healthcare system 15seq., 20–23, 25, 27, 30, 61, 93, 97, 101, 105, 122, 163, 165,

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Index of Subjects

195, 198seq., 202, 205seq., 221, 230, 239, 247 health promotion 54seq., 59, 62 hermeneutic 77, 83, 94, 98, 151seq., 158–160, 163, 165, 174, 177–181, 183seq., 223 – critical hermeneutic 180seq., 184 homo oeconomicus 18seq. humanities 15, 58, 82, 84seq., 94, 169, 178, 210 – cultural sciences 176 – human science 176seq., 180, 248 – social science 9, 15, 65, 97, 157, 169, 177seq., 230 – critical social science 174, 177–180 – sociology 12, 94, 97seq., 162, 174, 184, 247 human rights 44, 100, 245 ideology 12, 27, 38seq., 42–44, 92, 101, 120seq., 133seq., 178–181, 191, 197seq., 204 illness 28, 35, 64, 75, 77, 92seq., 104, 151, 154, 196, 202 incommensurability 80seq., 85 individual 13seq., 18–20, 28, 35–44, 53, 63, 65, 71–73, 76–78, 81–86, 93, 99seq., 105, 117, 119–121, 127, 133–135, 137, 139seq., 143seq., 151, 156, 163, 179, 184, 191, 193, 195–203, 205seq., 210, 213, 216, 233, 240 inequality 15, 28, 102, 115, 204 informed consent 101, 239 instrumentalization 72, 81seq., 85, 104, 118, 237 interaction 27, 39, 70, 74, 91, 93, 96, 100, 103seq., 117, 141, 152, 155, 157, 159, 161, 183, 195, 197, 201, 203seq. interpellation 120seq. invisible 113–116, 127seq., 140 ipseity 230seq., 234seq., 239seq. justice 11, 15, 21, 23, 26, 69–71, 77seq., 80, 85–87, 97, 100, 116, 139, 206, 231 Kaizen

22seq.

Keogh Report 34 knowledge 10–12, 16, 28, 35, 37, 44, 52–54, 56, 60, 76, 80, 82, 84seq., 91, 93seq., 96–98, 117, 133, 136–145, 151seq., 155, 160–164, 169–172, 175–178, 181, 184, 188–190, 197, 200, 204seq., 210, 221–223, 230, 245, 248 – embodied knowledge 131, 161seq. – experiential knowledge 37, 162–164, 170seq. – formal knowledge 19, 78, 99, 102, 169–171 – implicit knowledge 152, 162 – knowledge production 172, 175, 177 – nursing knowledge 26, 35, 37, 146 – practical knowledge 56, 152, 161seq., 181 – tacit knowledge 84, 96, 135, 137, 141seq., 152, 170 – theoretical knowledge 181 – transcendental knowledge 181 labour of love 211, 214, 217, 222seq. language 38–40, 53, 56, 60, 79seq., 84, 96, 98, 120seq., 132–134, 145, 151, 154, 164, 187, 190seq., 194, 201, 231 LEAN 22seq. Local Health Integrative Networks 21 management 20seq., 24, 28, 41, 43seq., 96, 131seq., 136–139, 141, 202, 206, 236, 245seq. – manager 21seq., 59, 137, 145, 214 – managerialism 96 – routinized management 40 market-driven 41 marketization 25, 34, 36, 44 Marxist 102, 230 medical anthropology 74seq. medieval 9seq. mental illness 52 mimesis 28, 76, 151–165, 197, 201 – social mimesis 152, 156seq., 165 modernity 60seq., 79, 102, 217 moral entitlements 86

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254

Index of Subjects

morality 12–15, 18seq., 27, 40, 56, 62, 65, 69–72, 77–81, 83, 86seq., 93, 99–103, 116, 118, 127, 134, 197, 199, 204, 206, 229, 232seq., 238seq. motherhouse 29, 210–213, 216–218, 222seq. mutual agreement 183 mutuality 99 NANDA 101 National League for Nursing 220seq. natural sciences 10, 27, 91, 93seq., 103, 176seq. negation 188, 192seq., 202 neoliberalism 14–20, 23, 25seq., 33seq., 36, 41, 43seq., 135, 237 new governance 17, 20–23 new nursing studies 26, 51, 53–57, 62, 65seq. New Public Management 20 Newtonian 145 NHS 33seq., 36, 38, 42–44, 133 normalization 83, 85, 120 normative 10, 18seq., 27, 30, 57, 62, 81, 84seq., 87, 91–93, 95, 99, 102seq., 118seq., 124, 127, 161, 196, 202, 229, 238, 240 normativity 62, 65, 120, 124, 126 nursing 9, 15–17, 22–30, 33–38, 43seq., 51–65, 69, 75, 81, 85, 91–101, 103–105, 113, 115seq., 118, 124, 126seq., 131–133, 136seq., 139seq., 144–146, 151, 157, 159–162, 164seq., 170–175, 178, 181–185, 187–190, 192–206, 209–224, 229, 231seq., 236, 245–248 – core of nursing 92–94, 105, 118, 190 – nurse educator 28, 170seq. – nurse theorist 170, 172 – nursing action 27, 29, 69, 92seq., 95seq., 98, 105, 115, 118, 246 – nursing diagnosis 101 – nursing didactics 187–190, 194seq., 197, 199seq., 246 – nursing-in-process 53 – nursing practice 9, 24seq., 27seq., 34seq., 43seq., 51–54, 56seq., 62seq.,

65, 73, 91–93, 99, 104seq., 134, 151seq., 159, 172–175, 184, 187, 193, 205, 246seq. – nursing process 9, 53, 60, 62, 95seq. objectivism 10, 22seq., 28, 60, 76, 117seq., 136, 151, 157, 159seq., 175–178, 181, 184, 195, 231 ontology 80, 133 Ordoliberalism 17 organizational 26, 34, 37seq., 40, 42seq., 51, 92, 138, 144seq., 216, 220, 237, 245 paradigm 99, 136, 138seq., 144, 154, 172–174, 177seq., 182, 194, 196, 206 – paradigm shift 172–174, 185 pastoral power 82–85, 212seq. paternalism 100, 233, 238–240 pathological 75 patriarchal 86 phenomenology 40, 80seq., 92, 96, 99, 104, 117, 152, 155, 199, 247 poesis 177 policy makers 35, 43 positivism 29, 169seq., 174–178, 184 post-structuralism 231 poverty 52 power 10, 12–14, 18, 20seq., 23–25, 27seq., 39seq., 43, 54, 59, 70, 72–74, 81–86, 91seq., 98, 101, 115, 120seq., 124, 127, 135, 141, 144, 153, 155, 170, 173, 185, 187seq., 195–197, 202, 204, 210, 212, 230seq., 233–236, 239seq., 246 – capillary power 35 pragmatism 144, 174, 176–178, 181, 184 – transcendental pragmatism 181 prejudice 178–180, 235 privatization 16, 33, 206 productivity 58, 237 profession 15seq., 25seq., 29, 33, 35, 38, 43, 54, 57, 59, 69–73, 86, 96, 132seq., 135, 138, 142, 171–173, 185, 190, 194, 196–198, 204seq., 209, 214seq., 219, 223 – professional behaviour 34 – professionalism 42, 72, 133, 135, 203 profit 16, 44, 94, 213 psychoanalysis 177–179, 191, 246

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255

Index of Subjects

quality of care

61seq., 139, 237

racism 39, 42, 120, 124 rationality 9, 17seq., 58, 95seq., 99, 143, 155, 164, 173, 192, 196, 206, 223 – technical rationality 28seq., 169seq., 172, 174, 178, 184 – techno-rationalism 58 rationalization 28seq., 59, 94seq., 99, 131, 138, 164seq., 209seq., 214seq., 218, 223seq. reality 13, 24, 60, 62, 78, 94, 97, 102, 117, 140, 155, 177, 190seq., 221, 231, 236seq. recognition 27seq., 43seq., 53, 78, 82, 99–101, 103, 113–123, 125, 127, 140, 145, 155, 180, 202, 204, 234 reflection 10, 14, 28, 59, 65, 98, 143, 145, 153, 160, 164, 169–176, 178seq., 189, 192, 195, 197–200, 202, 204seq., 247 – emancipatory reflection 177seq., 181 – hermeneutic reflection 178seq. – reflection-in-action 28seq., 170–174, 181–185, 248 – reflection-on-action 171, 173seq., 184 – reflective cycle 174 – reflective learning 171 – reflective nursing practice 172 – reflective paradigm 171seq., 184 – reflective theory 172 reification 13, 30, 100, 102, 114, 116–118, 155, 157, 160, 230 reproduction of life 73 reproductive work 71 resistance 14, 17, 19, 22, 29, 105, 126, 132, 141, 154, 176, 209, 235 rigor 113, 169seq., 181 role 10, 13seq., 18, 25seq., 29, 69seq., 75, 78, 115, 131seq., 137, 142seq., 145, 153seq., 156, 159, 162, 172, 179, 190, 197, 204, 209, 211, 213, 215–217, 235, 239 – role modelling 34, 36seq. scientism

176

self 13, 18seq., 25, 29, 39seq., 55, 70, 77, 82–84, 86, 92, 95, 98, 100, 102–104, 116seq., 121seq., 124, 145, 154–156, 158, 161, 174–179, 181, 185, 187, 189, 200–202, 204, 209, 214, 216seq., 220seq., 232, 234seq., 238, 241, 245 – self-conception 69, 102, 164 – self-esteem 100seq. – self-image 24, 26, 69–71, 77, 86, 202 sexism 39, 42 solidarity 71, 78, 101, 116, 217 somatik 195 stasis and dynamism 69seq. subjectivization 84 Sweden 55, 247 techne 83 – technocratization 30, 230 – technological expertise 28, 131–133, 136–139, 141, 143, 145 – technological innovation 10, 96 – technologization 94, 104seq., 173 telecare 56 theology 14, 169 theoria 11, 13 think tanks 15 UK 15, 26, 33seq., 36, 38, 42–44, 138, 245, 247 – UK Care Quality Commission 26, 33 – UK Essence of Care 38 violence 13, 40, 99–101, 116, 118, 123–127 vulnerability 16, 24, 39, 72seq., 77–79, 81, 85, 100, 104, 113, 122–125, 127, 247 welfare 14, 16–18, 20, 26, 33, 42–44, 55, 210, 212seq., 237 work environment 23, 34, 58 workforce 16, 26, 33, 37, 44, 58, 218, 245 World Health Organization 202

Open-Access-Publikation im Sinne der CC-Lizenz BY-NC-ND

Open-Access-Publikation im Sinne der CC-Lizenz BY-NC-ND