Technorati href="http://www.technorProfile Thinking Nurse: December 2004

Thinking Nurse

This blog will reflect my interests in learning disabilities, nursing, nursing theory, philosophy and politics and my general interests in the arts and literature. (Nursing is an art as well as a science!) Philosophy and nursing have been intrinsically linked since the days of Socrates, his mother was a midwife, and taught him everything he knew!

Wednesday, December 29, 2004

Tsunami Action

The horrifying effects of the Tsunami that devastated coastlines across Asia have been felt, in these days of international travel, by every nation in the world. The full death toll is yet to be counted, but there is little doubt that it will climb much higher than even the astronomical figures being quoted today.

The Tsunami is being followed by another tidal wave, of human solidarity with the victims of this disaster - Western tourists are praising the Thai people who gave them shelter and food in the immediate aftermath, despite the many doubtless losses of their own that they had to deal with, and there is money pouring from the pockets of millions of ordinary people across the globe into the collection jars of charities that provide emergency relief in disaster. Even these funds will be inadequate to deal with the full effects of the earthquake.

The huge wave of sympathy, solidarity and charitable giving shows the human priorities of the vast majority of ordinary people.

There is one sad fact though - the amount contributed by the British and American governments towards aid for this disaster will be a tiny fraction of the amount they are spending on weapons and war in Iraq, showing the twisted priorities of those who hold power.

Thinking Nurse looks forward to the day when Emergency Disaster Relief is an unquestionable obligation on states, and when governments have to go out rattling tins in the street to raise money for their wars...

Thursday, December 23, 2004

Christmas and New Year Shifts

Thought I would dedicate this post to all those nurses and nursing staff working shifts over the Christmas and New Year period, and to the poor individuals who find themselves assigned with the thankless task of trying to cover those gaps in the off-duty, making fruitless phone call after fruitless phone call.

This is a time of year where nursing really counts - academics have always found nursing very hard to define, because nursing can often really be an interstitial role - nurses fill all the gaps left by every other healthcare profession, and never more so than at Christmas.

You would imagine that Christmas, and a christmas staffing crisis, would be fairly predictable, and therefore avoidable in the modern go-ahead super-managed NHS. Instead all too often, we find ourselves struggling to find an agency with available staff, and asking the dedicated few to take on even longer shifts in understaffed care environments, as all around the sickness list grows longer.

Good luck everybody, and enjoy the festive season!

Here's to Peace and Health in 2005

Tuesday, December 21, 2004

Thinking Nurse - Future Plans For This Site

Thinking Nurse has had a remarkable impact in the few days it has been in existence, with a high number of 'hits', and the ignition of a few quite fierce discussions.

I think the success is down to the need for a site that promotes critical thinking and alternative views of nursing, it's theories, philosophies and it's politics.

There may be a short break over the Christmas period, when I come back, I intend to continue posting with more provocative and contraversial articles.

I intend to continue posting around the need for a theory of Nursing As Human Solidarity - and developing my ideas on this topic.

On top of this, expect more discussion on radical and influential nurses from history - continuing the series that began with my attempt to make sense of the twisted history of Margaret Sanger.
One nurse that might well be featured will be Molly Murphy, who was born in Leyland in Lancashire, and became directly involved in the politics and action of the Russian Revolution and the Spanish Civil War. Other nurses will also feature - if you have one who you think deserves to be featured, post here and tell me why.

There will be more on the politics of disability, particularly learning disabilities, and I intend to look at, and criticise some of the philosophies such as 'normalisation' or social role valorisation (Wolfensberger, Race etc) and other theories that have influenced nursing practice in this field.

Further to this I am planning a few articles on the issues facing the NHS, foundation hospitals, PFI, 'Agenda For Change' - how we were sold a pup etc etc.

Plus this site is open to feedback and to reader's opinions - if you have anything to add, please feel free to comment, criticise, disagree. In the heat of discussion and debate, the best ideas are forged.

Monday, December 20, 2004

Nursing - The Humane Interface (More on Raskin and Rogers)

I have had some horrified feedback on my article on Raskin Vs Rogers (17 Dec 2004). Apparently , comparing the interface between a human and a computer and a patient and a nurse is evidence of my 'empirical science' mindset and my failure to recognise 'human science'.

I think the problem is partly that I did not express myself clearly enough in my previous post, and partly that some people are reading it through an ideological filter.

Anyway, I will write a little more about why I think Raskin's work is analogous to some of the tasks of nursing, in the hope that it will make my meaning a little clearer.

As I wrote previously, Raskin's big achievement was to open up computers to non-technical users - before he started using such things as icons and 'click and drag' using a computer was a difficult and laborious process. You needed to understand obscure technical language, and know all the possibilities of a machine with enormous functionality, far more than you were ever likely to use.

I feel that patients/clients of the health system are today faced with a similar problem - the healthcare machine uses obscure language, and has vast functionality, much more than any individual person is likely to use (he would be unfortunate indeed)!

The point of interface between the complex bureaucratic Gormenghast that is today's hospital or healthcare system and the patient is the nurse - it is a job of nurses to make this interface as 'user friendly' as possible - and as open to human beings of all levels of ability and intelligence as possible. This is where the 'human science' comes in - being able to relate to people in a human way, rather than merely a representative of the state, or the healthcare institution, and to spend the time neccessary to make the services that are due to people by right, actually accessible (and understandable) to them.

I am glad to be getting feedback on my posts, and astonished at the level of interest they have created only days after I started this weblog. I hope people will continue to read and comment on these posts, and that this site, in it's own small way, contributes to the discussion and debate surrounding modern nursing.

Friday, December 17, 2004

Jef Raskin Vs Martha Rogers

Jef Raskin is a leading designer and developer of Computers, instrumental in the conception of the Apple Macintosh, his key revolutionary concept being to make computers usable by everyone, rather than just by technophiles, by using pictures that you can point at rather than having to laboriously type in code.

In his spare time, Raskin uses his considerable intellect to commentate on a wide variety of subjects, but with a common theme of the defence of the scientific method, and it’s achievements, against ignorance and misinterpretation.

It is in this quest that he has ‘banged heads’ with the work of Martha Rogers, who was a nurse theorist, a PhD, and dean of Nursing at New York University. It is hardly surprising that Raskins theory base and that of Martha Rogers should clash, with Roger’s belief in human beings as ‘infinite energy fields’ being a direct challenge to conventional scientific thought!

Raskin has written a highly entertaining, and utterly ruthless destruction of Rogers’ ideas, which you can reach by clicking on the title of this post.
I think every potential nurse should read it, as it highlights the pitfalls that many Nursing Theorists fall into, and the dangers of much ‘New Age’ type thinking.

Opponents of Raskin have suggested that he is defending ‘empirical’ science, and has not recognised the existence of ‘human’ science, which is ironic given his record of enabling humans to interface with science based machinery!

The argument that there is ‘human science’ starts out easily enough; take the human face, it is possible to identify the scientific name of each muscle, and chart their positions and fields of movement. None of this work would tell you much about the meaning of a smile - the human meaning expressed through our faces.

It can be argued that there are different types of knowledge that work at different levels, the high level rules that attach to human meaning are different from the fundamental laws of physics.

However, what is crucially important is that these laws of meaning are confined to their own realm – within the human mind, and between one mind and another – it is not possible, and this is where Martha Rogers falls down, for events in the ‘higher’ realm of human meaning to defy the basic laws of physics.

The writing that your PC is delivering to you now conveys my meaning (or as much of it as I am capable of expressing), wherever you are in the world – but there are still physical processes going on which enable my meaning to get from my end of the wire to your end. These physical processes are measurable, and can be proved to be there.

Equally in nursing, we transmit information to our patients and clients, not just verbally, but through our tone of voice, and through body language, and we receive information in a similar way. This information is carried on photons of light, sound waves etc.

Martha Roger’s theories rely however on an energy field that cannot be measured, and for which there is no evidence, and as Raskin points out in such devastating fashion, she and her followers have constructed a whole system of humbug and pseudoscience to justify this.

Nurses must be very careful about their claims – there is nothing mystical about the healing power of human touch – it is an expression of emotional caring that is immensely beneficial to patients, a direct transfer of meaning between one person and another. There is no need to construct a pseudoscience about mystical energy fields to explain this phenomenon.

Nothing Raskin says contradicts the need for nurses to be sensitive to the human needs of their patients and clients, and in a way, Raskins attempts to make the interface between man and machine totally intuitive seems to echo Benner’s assertion that experienced nurses can develop an intuitive rapport with their patients.

Our understanding of the workings of the human mind is still far in it’s infancy. It is such a complex organism that much of our appreciation of it’s functioning is really at the level of astrology and alchemy rather than fully informed science. In such an atmosphere, the pseudoscientific assertions of people like Martha Rogers can all too easily gain credibility, unless we train ourselves in our abilities to spot humbug.

Wednesday, December 15, 2004

Mental Capacity Bill and The Rights of Vulnerable People

There has been a huge furore over the Mental Capacity bill over the last few days. Under pressure from reactionary organisations like SPUC, MP’s have got it into their minds that the bill has something to do with euthanasia, and whipped themselves into a massive moral panic.

There is a danger that this unfounded panic about euthanasia could mean the dilution of the best aspects of the bill, and distract from the most important debate about the bill – whether it genuinely protects the rights of vulnerable people.

The bill itself is tremendously important for people with learning disabilities and for the professionals who work with them. A clue about it’s philosophical direction was given when the decision was made to change the title ‘Mental Incapacity Bill’, the justification for the bill is that it emphasises the recognition of peoples capacities to make important decisions, rather than their incapacities.

The most positive aspects of the bill are:

· The assumption of capacity – this means that you cannot assume someone is not capable of making a decision just because they have a learning disability, or a mental illness.
· The grading of decisions – just because someone lacks capacity to make decisions about some things, does not mean they cannot make decisions about others. There must be proof that a person cannot make the decision if someone else is to make it for them.
· A requirement to assist a person to participate in making decisions – by providing them with accessible information, and giving them the time and support necessary to do this, for example.
· A recognition that people have a right to make decisions about themselves that others might regard as eccentric or unwise.

These provisions, if they were put fully into effect would enormously help learning disability professionals who are trying to enable people with learning disabilities to gain access to generic services. It would put a legal obligation on all professionals in these services to LISTEN TO THE VIEWS of people with learning disabilities themselves – something that all too often does not happen today.

Implemented properly, these clauses would be a challenge to the prejudices that exclude so many people from access to the social and health provision that other people take for granted.

But it is questionable whether the legislation would really make professionals change practices like using inaccessible jargon and language, rushing people, consulting carers rather than the person themselves, or unilaterally making rationing decisions that someone should not receive a particular care intervention because of assumptions and prejudices about the impact of a learning disability on their quality of life or contribution to society.

Even so it would certainly strengthen the arm of self-advocates and others who are trying, in accordance with the aims of ‘Valuing People’ (2001), to ensure that generic services deliver the services that people with learning disabilities need.

A number of organisations have pointed out weaknesses in the bill;
The ‘Making Decisions Alliance’ suggests that the role of advocates needs to be given much more legal force, otherwise the legislation will be “toothless”.

Big holes in the bill have been pointed out by the Mental Health charity MIND, specifically the lack of provision for those patients that fall into the ‘Bournewood Gap’, people who are incapable of giving or refusing consent, and who are detained without being sectioned under the Mental Health Act, and thus gaining the legal protections that this act insists on.

MIND argue that the provisions of the bill do “not contain explicit safeguards to control the use of specified, serious treatment, such as second opinion clinical approval. They contain none of the processes that would monitor care and treatment during hospital admission or in the process of planning for discharge and/or provision of social care in the community. They would not ensure that the rights of patients did not go by default while treatment was being given.”

MIND call for the inclusion in the bill parts of the draft Mental Health Act that were removed – specifically

· notification of help available from mental health advocates
· special authorisation for ECT and serious non-emergency treatment before approval of the treatment plan
· expert, independent approval for the treatment plan
· the appointment of a Nominated Person, who would be consulted about treatment and discharge, and who could apply on the patient’s behalf to the Mental Health Tribunal
· mandatory annual reviews of the treatment plan, and
· access to the independent Mental Health Tribunal about failures by the hospital to comply with the safeguards or to be discharged if the continuing hospital admission was not lawful.

MIND have considered the problems facing people who lack capacity and are detained by the mental health system, organisations like the Greater London Action on Disability feel even more worried about the potential for abuse of vulnerable people, particularly by the people who may be appointed under the provisions of the bill to make decisions on their behalf.

GLAD argue: “as the Bill stands, the risk of exploitation by carers, families and professionals has not been adequately addressed. People who society would consider “vulnerable” are unlikely to be in a position to challenge (legally or otherwise) exploitation by the above mentioned groups of people. GLAD feels that the Bill is utterly naïve and not taking into consideration the full range of possibilities and situations that may arise. There is plenty of evidence from organisations of disabled people of widespread abuse – we believe the government would do well to take this into account and make conclusions having heard the full spectrum of information.”

The Coalition of Organisations of Disabled People are even more fearful of the effects of the bill. They argue
"the Mental Capacity Bill does very little to strengthen our right to choice and control over our lives, and in fact has the potential to further disempower and dehumanise us" It seems that the more directly representative and controlled by disabled people an organisation is, the more sceptical and even hostile to the bill the organisation will be. Nurses should take serious note of this opposition as it comes from the people most likely to be affected by the bill.

The bill seems to be a step forward, at least in establishing that there is a continuum between capacity and incapacity, and suggesting that people who may not have universal capacity should be enabled to make decisions where they do have capacity, and will have ramifications across the healthcare system but it does not resolve the many problems of exclusion, discrimination, exploitation and abuse suffered by many vulnerable people, particularly in the potential power over some disabled people it will give to appointed guardians – these problems are a reflection of the devalued position of these people in a disabling society.

Tuesday, December 14, 2004

Nursing Theory - Links That Make You Think

Here are a few links to some of the Nursing Theories and theorists that I have found most useful or interesting over my training. I intend to write more, with more information on each specific theory, and my own criticisms and thoughts about these theories (and others) over the next few weeks and months - so watch this space!

Paterson and Zderad’s Humanistic Nursing Theory:
Phil Barker’s ‘Tidal Model’ of recovery:
Boykin and Schoenhofer’s Theory of Nursing as Caring:
A site dedicated to Hildegard E. Peplau:
Madeleine Leininger’s Website:
Rosemary Rizzo Parse's Theory of Human Becoming:
Archives of the Nursing Philosophy List (well worth joining):

Here are a few good general nursing theory links pages:

When reading all these theories, remember Marx's maxim: "Philosophers have only interpreted the world, in various ways, the point however is to change it." (Theses on Feuerbach)

Monday, December 13, 2004

Disability Rights Commission Expose Health Inequalities

The Disability Rights Commission have unearthed yet more shocking statistics about the health of people with mental and physical disabilities in this country, for example they have found that:
People with learning disabilities are four times more likely to die as a result of a preventable condition.
People with diagnosed schizophrenia die on average nine years before the rest of the population.
Fewer than 20% of learning disabled women attend cervical screening.
People with learning disabilities are 58 times more likely to die before the age of 50.

Here is the URL of the DRC investigation, which is continuing, there are questionnaires for both people with disabilities and healthcare professionals, as well as excellent articles and compilations of evidence on the health outcomes of people with mental health problems or learning disabilities.

Friday, December 10, 2004

The Twisted History of Margaret Sanger - Woman, Rebel, Nurse, Oppressor

Margaret Sanger could have been everything I think a nurse should be.
She made a stand for birth control at the beginning of the last Century, and campaigned for the liberation of working class women, making direct links between their social and sexual oppression, and their health.

In the early part of the century, Sanger was inspired by revolutionary thinkers and activists like Emma Goldman, people who challenged the huge gulf between the classes that was opening up in the USA, and across the world.

Sanger was persecuted for her beliefs, and was no stranger to the law, which was used against her and her campaigns, particularly her brilliant publication 'Woman Rebel'.

Even so, the ideas about birth control that she advocated were enthusiastically taken up by the women themselves, creating an irresistable movement that considerably improved the lives and health of countless ordinary women.

Of course today, the multinational drug companies have realised that they can exploit women's need for contraception, in a big way.

Unfortunately for those who would wish to honour the first part of Sanger's life, in later years her enthusiasm for contraception led her away from liberation campaigns, and into the arms of reactionary eugenicists. Instead of campaigning for contraception as a method for working class women to take control of their bodies and their lives, Sanger campaigned for contraception as a method of preventing the existence of the 'feeble minded' - she helped turn birth control into a weapon for the oppression of people with Learning Disabilities (Intellectual Impairment).

I feel that there are many other issues affecting the health of oppressed groups that need to be taken up by nurses and campaigned on, with the same fighting spirit displayed by Margaret Sanger in her early career, before she succumbed to eugenics.

One example is the health of people with Learning Disabilities, the very people that Margaret Sanger felt had no right to existence, in her later chilling vision of 'a race of thoroughbreds'.

In the UK people with these disabilities have largely escaped the oppression of the large asylums and institutions to find their rightful place in the community (though there are important exceptions to this process), however this escape has actually been accompanied by a fall in their life expectancy, and an increased failure to meet the health needs of this socially oppressed group. Both mainstream 'generic' services and specialist learning disability services have reflected society's continued repression of this group, and colluded in denying them access to the healthcare that they need.

However pressure from the disability movement, particularly groups like 'People First' and 'Values into Action' as well as some health professionals is beginning to get some results in the UK. The inequalities in health experienced by people with Learning Disabilities has been highlighted in the government white paper 'Valuing People' (2001), but it remains to be seen whether these words will be turned into action.

Learning Disability Nurses, and other people who live and work with people with learning disabilities are beginning the process of getting every person with a learning disability a 'Health Action Plan' - but we need to make sure that this is more than just a piece of paper, but a challenge to those services that still exclude people with learning disabilities to think about how they can deliver the rights of this section of the population.

Here is a good link to an article that looks at the allegations of racism that surround Margaret Sanger (not without justification):
More on this to come...

Thursday, December 09, 2004

NHS Backing for the British Olympic Bid

This is part of a message I received this morning from Trust HQ

"We been sent a huge stack of car stickers supporting the bid for the Olympics. The NHS is supporting the bid because it is hoped the Olympics will encourage more people to live a healthier lifestyle."

My impression of the olympics is that it encourages more people to sit in front of their TV set, and that the money spent on the olympic bid, stadia, accomodation, transport systems and nice presents for IOC members might result in better health outcomes if it were spent on the NHS itself.

I do not therefore feel that this is an appropriate use of NHS resources!

Clicking on the title of this blog will take you to a poll on whether NHS resources should be used to back the olympic bid, so far it is a decisive NO!

A Charter For Human Caring In Nursing

Here is a charter for human caring in nursing that I have adapted from something I originally posted on the 'Nursing As Caring' discussion forum, run by Savina Schoenhofer.

Like Savina, I see caring as being a central aspect of nursing, but feel that her theory neglects the political and social life of both patient and nurse, concentrating too closely on an abstract 'nursing moment' that has been wrenched out of any material context.

"It has been argued that there is a paradigm shift toward 'caring' in nursing. The idea that human beings are caring by virtue of their humanity goes right back to pre-Christian thinkers like Cicero - so as a 'paradigm shift' it is a very slow one! It is perhaps really a rediscovery of ideas that were neglected when it looked as if biomedical technologies and techniques had all the answers.It has been shown that every human being seeks inter-relatedness from birth, I think our caring stems from what Peplau called this 'need for connectedness'.

I feel that there are many reasons why nurses do not achieve genuine human caring in their daily practice.

There are so many other things that get prioritised over human caring. Tired nurses in understaffed care environments driven with economic pressures from health bureaucracies, operating in a world full of racial, class, cultural, religious, and gender prejudices can find it incredibly difficult just to BE, one human being with another.

If we are to enable nurses to deliver genuine human caring and human comfort to their patients, then we need to:

1,. Set objectives for nurses that are realistic - I.e. achievable by humans in a human way.

2. Look at all the local and global factors that are obstacles to the delivery of such caring: Are there enough staff for nurses to spend more than a cursory amount of time with their patients? Are adequate resources present, or are staff spending all their time trying to chase basic equipment? Are efforts being made to enable communication between people of different cultures and backgrounds, to overcome all the prejudices that exist in society?

3. Establish an environment where caring is nurtured, rather than having to be fought for by a few brave individuals - what are the priorities of the care environment - targets, profit or human caring?

4. Truly promote human caring in nurse training.

5. Ultimately the care environment cannot be an island, it is directly affected by the values and attitudes of wider society. Societies that prioritise wealth and power and that are uncaring for their weaker or less lucky members are going to be less conducive to human caring in their health professionals - the attitude can become one of just patching people up rather than of truly human healing. Therefore it is neccessary to question these values and attitudes of society that lead to negative health outcomes in so many of it's citizens, and which denigrate the human in all of us.

The Need For Social Consciousness In Nursing Theory

Here is a piece I wrote, originally as a post to the student nurses' discussion board on the International Council of Nurses website: it received no replies!

"I have been studying some nursing theories, and feel that many, if not all, lack awareness of social and political issues.
I do not disagree with studying closely the relationship between nurse and patient, but I feel that many such approaches rip the patient out of the social and political world and view him instead as an isolated individual.

Many major health factors facing people today are social and political - the domination of the globe by huge multinationals, which are affecting the way we spend our time, what we eat, how we interact with each other. The results are overwork, stress, obesity, violence etc etc, all the 'ills' of modern society.

The effects on the ex-colonial countries of exploitation by the multinationals is more devastating still, with a third of the world's population living on less than a dollar a day.

We cannot ignore the major deleterious effect that war has on the physical and mental health of all those it affects, or that behind every war there are economic motives.

Nurses need to look at society itself, and the way it discriminates against those who are different. People with physical disabilities, mental illness, with learning disabilities, or who are simply 'neurodiverse' find themselves excluded and discriminated against.

The position of nurses themselves in society also needs to be considered. All too often nurses are low paid and overworked, in a society that values stockbrokers and arms manufacturers above healthcare workers.

Perhaps because nursing theories have trapped themselves inside the hospital, nurses have seemed nervous about commenting on these major political issues (with several important exceptions!).

I am searching for a 'theory of nursing as human solidarity', which treats human beings as social and political, as well as personal, enabling nurses to look at approaching the social and political causes of much ill health, rather than always struggling to cope 'firefighting' the symptoms. Such a theory could be informed by the social model of disability - but reflect more specifically the potential of nurses to intervene as socially conscious health activists."

Wednesday, December 08, 2004

Prayer in Nursing

I post quite a bit to the ICN discussion boards, here is the most contraversial discussion by far:
in it I question some of the unstated generally accepted attitudes that prayer is always beneficial to patients, taking a stance for atheism, and a humanistic approach to evidence based practice in nursing. I may have gone a little bit too far in some posts!

Cost of the War in Iraq
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