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In the Nursing Interest: Reading and Thinking Critically in the New Millennium
Nicholas G Procter
Associate Professor, School of Nursing and Midwifery, Division of Health Sciences, University of South Australia, City East Campus, North Terrace, Adelaide SA
Suzie Burford
Institute of Nursing and Education Research, National Kidney Foundation, Singapore
Alison Dixson
Department of Nursing and Midwifery, New Zealand
Article Text
Every day, when we switch on the television or open the daily newspaper, we are confronted with images and messages that require sifting, sorting, and critical interpretation to discover what they really mean. The facts do not necessarily speak for themselves.
Consider, for example, the recent political heat in Australia about refugees and asylum seekers. A shift in refugee law has meant that, in Australia, new legislation is now being applied to some refugees, most recently from countries such as Iran, Iraq and Afghanistan. These people have become 'temporary protection visa holders'.
As the Australian Government has repeatedly informed us, several hundred of these people arrived illegally on Australian shores, largely by boat and without documentation, in the last six months of 1999. On being apprehended, these people were placed in detention centres while all their available documents were processed; some have now been released into the Australian community with temporary protection visas. Those deemed to have arrived illegally are not entitled to permanent residence status; this will only be granted if, after three years, they are able to demonstrate that they are still refugees. Their visas give three-year temporary, rather than permanent, residence, under a policy that was introduced by the Federal Government to make Australia seem a less attractive destination for illegal immigrants. To this end, the Government of Australia has built in a number of disincentives to discourage unauthorized arrivals. For example, temporary protection visa holders are unable to sponsor their families to join them; they are not eligible for on-arrival accommodation, English language tuition, or material assistance under the Community Refugee Settlement Scheme. Hence, what seems to be the gift of temporary respite also carries a clear and unwelcoming message in the restrictions attached to these temporary visas. They are not as straightforwardly positive as they may seem.
Inherent in the process of securing the visas are a number of health-related concerns and issues that are significant to this group. Firstly, the decreed non-access to English language classes will eliminate opportunities for cultural networking and emotional support, and this may give rise to increased feelings, among refugees, of isolation, rejection and alienation. For those who do not speak English, trying to find emotional and social stability in a foreign land will be more difficult. Secondly, boredom, loneliness and a lack of meaningful purpose - already a problem for some members of this group - will increase, as social supports and interactions built around English language proficiency and material assistance with settlement are diminished.
By looking beyond the taken-for-granted issues associated with refugee and asylum seeking, a number of questions emerge which have significant, although complex, implications for health and helping professionals. What interface will these people have with health services, should they become ill, fall pregnant, or seek health checks? As nurses, we see such people at the very point of their distress and, at the very least, their conditions of stay in Australia will influence their help-seeking behaviours. Our consideration of these issues, in the context of delivery of appropriate care, calls for an effective and informed knowledge base.
It is only through careful examination and evaluation of what is being said and done by others - in this instance the Australian Government - that we can look beyond the taken-for-granted in our professional lives. Looking beyond the legislative conditions of illegal arrivals in Australia, for instance, is an example of how we can begin to evaluate what is said and done by others in order to improve our understanding of the world we live and work in. Ultimately perhaps, we can use the same critical and reflective processes to shape our attitudes and beliefs in professional practice when working with refugees.
The points being made here are equally applicable to the nursing profession itself. How do nurses move beyond taken-for-granted assumptions in their own practice? Self-understanding and self-reflection are not new in nursing, though it is only in recent times that these have been given full expression.
In the 1920s, a group of nurse leaders in New Zealand were trying to establish the first nursing degree, leading to registration, in their country. Not unexpectedly, this proposed change had both supporters and detractors. Entering the debate about this proposed shift in nursing education, a regional newspaper wrote that, compared with some other professions, the nursing profession was singularly inarticulate. Support or resistance was not expressed through an outpouring of letters to the paper as one might expect. Instead the debate was kept 'in house'. Nurses did not, at that time, engage in writing through a public medium. But in (wrongly) interpreting the nurses' silence, the paper concluded, 'We have heard of no profession of which so much is expected and which seems to expect so little of itself' (Otago Daily Times ,16 October 1922).
As we stand at the turn of a new century, entry to the nursing profession finally is by undergraduate degree in a large number of countries. Many more colleagues are involved in the pursuit of higher degrees than was the case even five years ago. One of the stated outcomes of degree programs is that graduates will contribute to their discipline by disseminating the products of their critical thinking and reflection through publication. Writing has not been the traditional channel for nurses to have their voices heard. Instead, there has been a reliance on the personal approach, on face-to face-encounters with colleagues, politicians, policy and decision-makers, and members of the public. Our oral voice has been stronger, perpetuating patterns of knowing from habit and custom, with little emphasis on the generation of knowledge through critical scholarly inquiry.
Increasing numbers of nurses are now presenting papers at national and international forums, engaging in consultancies and sponsored research, or contributing to policy documents related to their area of interest. All these activities involve critical examination of events and information in the wider world, as these issues impact upon health, illness and death.
One example of how the development of critical literacy skills can enhance nursing practice may be found in Singapore, where the government, through the Ministry of Health, has implemented Casemix and, more recently, Evidence Based Practice to support care delivery. A range of government-sponsored health promotion and prevention programs is aimed at reducing the incidence of diabetes and hypertension. Users of the health care service are often well informed, with Internet access to a variety of health information sites. These are examples of how the health care delivery system, although unique to Singapore, has adapted systems from North America, Europe and Australia to the local culture and needs.
However, in response to such structural improvements, users tend to have increasing expectations of health care delivery, including nursing care. So how do, or should, we as nurses, prepare for these challenges? We can no longer excuse ourselves by saying '… the doctor ordered it … I was just following orders …' The fact is that, for effective, quality health care delivery, the whole health profession needs a questioning, informed work-force, in order to meet the challenges and needs of the community we care for. Because nurses are the main source of health care workers, it is of paramount importance that they be both well informed and critically aware.
Certainly, early educational preparation is important in nursing, not only to equip the novice nurse for practice, but also to cultivate professional self-respect and pride. Whereas at one time the curriculum was primarily content based, now it should also prepare nurses to access and critically examine information, in order to determine its applicability to care. Through this preparation nurses learn skills in reflective practice and develop an ability to critically examine the literature, skills that will prepare them for life long learning in support of professional practice. These are evolving skills that require support and fostering, perhaps in the form of mentorship, whereby nurse leaders can incorporate critical reading skills and analysis within courses, alongside journal clubs and nursing research interest groups.
Perhaps the most difficult aspect of critical reflection, or looking beyond the taken-for-granted in all the information we take-in, is deciding what to pick up on. We know that careful and critical analysis of information in practice will help shape the way we strengthen our knowledge base, and ultimately, the standing of nursing in the community. Recognition of nurses' contributions to the discussion and delivery of health related issues and concerns (as influenced by events and issues in the wider world) spells the opportunity for a louder nursing voice on health issues in the public arena.
The challenges of modern health care systems, and the complexities of the population requiring care, mean that nurses must be united and supportive of each other and their needs. Critical reading is a fundamental activity for the professional nurse, in planning, predicting and evaluating nursing care. The nurturing effect of this is not only professional self-esteem and confidence, but also the community's acknowledgment of nurses' contribution, and their pivotal role in providing quality care and best outcomes for the wider society.
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