Response
Susan Tregoning
School of Nursing and Midwifery, University of South Australia, SA
PP: 54
Article Text
The conditions for best practice are inexorably linked to responsible and professionally competent nurses. How this competence is maintained and developed has been the topic of scholarly discussion for three decades. Kay Roberts's article Mandatory continuing professional education: trends and issues Vol 5(4) adds value to the debate. Firstly, by providing a well-researched overview of the ethico-legal, economic and socio-political implications of mandatory continuing professional education (MCPE) which she locates well within the context of Australian health care, while making some poignant crosscultural comparisons. Her second major contribution advances debate on the implications of MCPE for work environments, nurse-regulatory authorities and education providers. However, it is Roberts's concluding remark about advancing 'life-long learning' as an alternative to MCPE that invites further discussion.
It may be appropriate at this stage to define what, in the new paradigm, is meant by life-long learning and why it is important to the links between the health industry and higher education. Life-long learning refers to the development of human potential through a continuously supportive process which stimulates and empowers individuals to acquire and apply all the knowledge and understanding they will require throughout their lifetime (Mitschke-Collande 1996). This definition implies that individuals will make learning a worthwhile and continuous activity and embrace it with confidence and enjoyment. It also emphasises the pervasive nature of life-long learning as a way of life rather than an educational concept as MCPE implies. If universities exist in the next millennium with education-based nursing within them and, if universities continue to foster the development of life-long learning skills as foundational to their mission, then MCPE will become redundant. The change of thinking that will accompany life-long learning will be the challenge and potential for higher education and the health industry as thinking shifts toward putting the focus on learning, and the nurses responsibility to define it and invest in it as a means of realising his or her own potential.
Access to life-long learning and its validation will also be thematic in the twenty-first century. At present, many health care decisions are based principally on values and resources. Consequently, decisions are often grounded in opinion rather than evidence derived from research. However, the new millenium nurse who is equipped with life-long learning skills will be a health care decision maker who will need to practice evidence-based decision making. Every decision will have to be based on a systematic appraisal of the best evidence available. In other words, doing things 'better, cheaper and right' will be replaced by doing 'the right things right'. As higher education and the health industry develop partnerships to support life-long learning processes, stakeholders will be evaluating competence in different ways. Roberts's alternative view is a reminder that nurses of the future may be judged less by the facts that they know, but more by the questions that they pose.
Susan Merritt
Senior Lecturer, Faculty of Nursing
Royal Melbourne Institute of Technology (RMIT)
Merri Paech's article Sex or gender? A feminist debate for nurses Vol 5(4) poses some exciting questions which require solutions. The following comments are designed to add another dimension to this debate.
The convention of assigning roles to individuals based on gender impacts on praxis. Gender, age and social class influence medical practitioners' diagnoses and treatment. Individuals' interpretation of their symptoms also differ according to their gender. Secondly, although the health care system is dominated numerically by women, men occupy most senior positions and make the majority of the decisions which affect health care. It is interesting to ponder how the current health care system would appear if women assumed more leadership roles-probably very little. However, if individuals, who espouse so-called 'woman-centred values' occupied these positions it may be a different matter.
As Paech points out, Foucault argued that discourses including medicine, sociology, psychology and criminology developed in response to a perceived need for an increase in surveillance of the population. The body of the patient became the subject of the 'medical gaze'. Medicine has played a significant role in defining and regulating normal and abnormal behaviour. It 'sold' the public the notion that biology explains a range of human problems from sexual deviance to school failure. In Western society, socially-constructed 'male-centred' discourses have medicalised child birth so successfully that the majority of women accept and indeed request a number of surveillance techniques and other interventions during birth. Why this is so has not been satisfactorily explained but it is possible that so-called 'male norms' structure women's consciousness of themselves.
Both nursing and midwifery are informed by notions of what constituted appropriate 'feminine' characteristics and behaviours of the nineteenth century. In contrast to their medical colleagues, many nurse academics have evaluated the importance of 'feminine' values or behaviours such as empathy or altruism for 'good' practice. However, until recently, both nursing and modern midwifery were aberrations of a positivistic medical science grounded in 'male' attitudes, values and beliefs. This may explain, in part, the consistent attempts of nurse academics to develop theories using the nursing process, diagnoses and models based on hierarchical and dualistic thought processes. At the same time, many have tried to make 'woman-centered' values such as caring, nurturance, empathy and empowerment central to theory development. It is no wonder that many practitioners are confused and find it difficult to relate theory to practice.
Feminists such as Sawicki (1991) use Foucaultian ideas to describe sites of opposition and resistance. Sawicki proposes that discourses are prone to conflict and debate and that women have opportunities to challenge them. She criticises feminists who neglect to analyse differences between women or the range of their experiences. For example, some women welcome medical intervention in childbirth while others reject it. Sawicki (1991) suggests that 'power' provides individuals with opportunities to create new possibilities for thought and action without necessarily resorting to grand theory. Power is not necessarily repressive but may be exercised in productive ways. Foucault argues that individuals are the 'vehicles' of power not its points of application and that resistance is most effective when it is directed at the techniques employed in its production. To effect change, both nurses and midwives must firstly clarify the conditions and the tactics used to develop praxis concerned with the truth about women's bodies. Secondly, the creation of innovative every day strategies will effect the most profound change. The incorporation of ideals such as autonomy, diversity, selfdetermination and plurality into praxis may be a first step.
Carol Thorogood
Coordinator Midwifery Program
School of Nursing
Curtin University of Technology
References
Gray J (1997) Evidence-Based Health Care. Churchill Livingstone, New York.
Mitschke-Collande V (1996) Core competences and learning careers of the future employee. Conference paper at 'The Joy of Learning Conference', Switzerland.
SawickiJ (1991) Disciplining Foucault: feminism power and the body. Routledge, New York.
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