‘What nursing’s all about’: the caring ideal and ambivalence to ‘profession’ in nursing’s occupational discourse

Abstract

This thesis examines the occupational discourse(s) of a group of nurses working on a single medical unit in a Scottish NHS hospital, in light of debates concerning the contemporary function and focus of nursing. There are a number of (seemingly conflictual) impulses concerning how the work of nurses might be conceptualized and the study here aims to demonstrate how nurses’ discursive practices seek to negotiate these varying demands and expectations. Principally, the research comments on the relationship between ‘care’ and ‘profession’ which, as the thesis establishes, are mutable concepts whose discursive elaboration can be variously realized. Recent efforts to establish nursing as an independent profession have identified ‘care’ as the theoretical basis of professional knowledge, with the recent move to degree-level study seemingly providing the academic credentials to support this. Some have argued however that a professional, academic outlook is antithetical to authentic caring, while others, still, have made the case that the centrality of relational care to the actual work that nurses undertake is questionable. These debates are inherently complicated by the fact that the terms ‘care’ and ‘profession’ have been theorized and interpreted in numerous different ways and are indeterminately related to one-another. The significance of ‘person-centred care’ (PCC) is examined in the thesis as one concept in which both discourses of profession, and care, might be articulated. The research eschews any attempt to concretely define ‘profession’ or ‘care’ and focuses on the discursive construction of these concepts; that is to say, on how such terms are appealed to in making certain claims. Conducting loosely-structured, qualitative interviews with nurses from each of the occupational bands represented on the ward, I aimed to find out how they conceived of their occupational role and the ways in which they sought to legitimate these perspectives. A critical realist ontology informs how nurses’ discursive constructions are understood and analysed, which means that the intelligibility of nurses’ responses is comprehended in the way that they correspond to extra-discursive contexts. In this regard, empirical data is analysed in terms of how it relates to the real-world contexts in which it is produced, and discussion seeks to elucidate the plausible reasons for nurses’ particular discursive practices. The findings are considered in relation to the practical service contexts of nursing, and of healthcare more generally, as well as in relation to extant discourses through which nursing work has been understood. The results of the empirical study indicate that nurses, on the whole, are ambivalent about claiming professional status as this would appear to contradict the notion that caring is internally motivated and reflects a sincerely felt concern for patients. Many nurses expressed that a personal predilection to caring was necessary to fulfil the demanding nursing role, and several seemed to see their job as a natural extension of their private (caring) selves. Thus the findings problematize the notion that ‘care’ represents the theoretical basis for nursing’s professional practice, however nurses did accede to the importance of professionalism in their conduct, though this was recognized as arising from a personal regard for the welfare of patients. Because interviewees perceived the capacity to care as resulting from a natural predisposition to do so, they were largely dismissive of educative attempts to inculcate caring behaviours. In spite of pressures on services, nurses’ sought to maintain the primacy of interpersonal relationships with patients and were derisory about working practices which reduced the prospects for this kind of relational engagement. The thesis concludes that nurses’ commitment to a particular caring ideal allows them to retain valued sources of prestige and offers a means of validation for work whose ‘professional’ rewards remain obscure. Nonetheless, it is suggested that nursing’s singular relationship with the concept of care may detract from the wider realization of care as an institutional endeavour. Regarding the study of professions, the thesis makes the case that it is more productive to concentrate on ‘profession’ as a rhetorical device which may be employed to achieve various ends, and not always simply in making claims to professional status, which may not, in every case, be desirable.