Assuming practice amid the culture wars: a response to James P. Smith 28 years later

Smith (1978) claimed some 28 years ago that ‘Undoubtedly, both the quality of nursing care and the standing of the nursing profession will be enhanced by…institutions of higher education’ (p. 220). This was certainly debatable in 1978. I suggest, however, that it is no less debatable today. Smith goes on to add that the enhancement is only likely if ‘the products of the programmes continue to relate to the real world of health care and avoid the danger of becoming intellectually arrogant’ (p. 220). Just what is ‘the real world of health care’ and moreover what does ‘intellectually arrogant’ mean? Does being an intellectual, or developing an intellectual disposition, imply arrogance in nursing? Recently, in a fourth year advanced theory undergraduate class, my students began to bemoan their ill-preparation for the job of nursing. Moreover, they complained of the fragmentation and incoherence of their education and, as they often do, denounced as meaninglessly opaque and clinically irrelevant the theory that they had been forced to endure as part of their baccalaureate nursing programme. Although I agreed with them to some extent, I also accused them of assuming practice, which provoked a wonderful debate (one which I sincerely thank them for). Wonderful for me at any rate because I have long maintained, as Clarke (2003) put it that: ‘Nurse education at all levels needs to free itself from the straitjacket of quality assessments, curriculum equivalence…and get back to some of the doubts and uncertainties’ (p. 37). So what then did I mean by assuming practice? During the discussion, I asked my students if it was the responsibility of a proper nursing education to produce (a) practitioners who can think or (b) thinkers who can practice? Most of them agreed with the former, whereas believing that they were wrong, I countered with the latter. If the assumption of nursing education is a given practice, would this not suggest that the thinking that is largely done is about that given practice? Therefore, should such practice need to change, perhaps even radically, I argued that the practitioner thinking (predominately) about practice is far less likely to be critical, or even capable of being critical, of the greater context of the given practice. In effect, they would be much more likely to lack awareness of the greater socio-political context of any given method of practice. While nursing certainly is not an abstract and, hence, a purely intellectual discipline – and nor should it be – and the goal of a proper nursing education surely is practice – any form of practice is social (or even socio-political) in nature and thus has consequences well beyond an individual being cared for. Thus, to assume practice prior to the task of thinking about what it is, is to defeat the critical purpose of higher education. And yet, as Cook cogently notes, there is a ‘common tendency for nurse educationalists to incorporate uncritically into their practice important and problematic concepts’ (Cook 1999, p. 129). Cody (2002) even went so far as to claim that nursing education uncritically indulges itself in the rhetoric of critical thinking rather than serious thought. It is as though many nurse educationalists fail to realize that we are no longer in the either/or world, as Beck and Lau (2005) put it, of modernity. The ‘either/or’ principle ‘seems increasingly to be eclipsed or indeed replaced by the ‘both/and’ principle. Instead of there being either knowledge or not knowledge…there is instead both knowledge and not knowledge…’ (Beck & Lau 2005, p. 527). Whether we call the contemporary period of history ‘postmodernity’ or not, Beck and Lau favour second or reflexive modernity and, in my view, provide a rather compelling argument for it. There is a little doubt that knowledge, and of course any social practice that follows from it, is just not what it was even half a century ago. Yet, Thorne (2005) argues that ‘conceptualizing is a crucial activity but only…when it has the purpose of enhancing knowledge for practice’ (p. 107). Although this view of enhancement seems familiar, I would ask – knowledge of what? Practice, you say? Health care perhaps, even health itself, but indeed what or whose definition of it? The biomedical/bio-statistical, or what Garland-Thomson (2002) called the ideology of cure? The holistic, the bio-psycho-social-spiritual model, or what Paley (2002) as well as Barker and Reynolds (1995) have suggested, that in its extreme, may well constitute an ideology of caring? Education ineluctably takes place today amid The Culture Wars, where modernists, scientists and epistemologists have squared off against the postmodernists, social constructivists and relativists. That nursing is unavoidably caught in the middle of this often hostile internecine is without question. ‘(P)ostmodernism…and the ‘culture wars’ are at the centre of nursing studies…what is at stake is not only professional self-image and definition, but also conceptions of nursing practice and education’, according to Peters (2002, p. 49). That nursing education needs to address this deeply divisive issue is also without question. However, to do so uncritically, for the sake of an assumed practice is just plain bad (higher) education. Despite the polarization in educational theory, there does appear to be a certain agreement concerning what the general process of higher education ought to be, even among the fiercest adversaries. For example, Henry Giroux and Alan Bloom are theorists who could hardly be further apart on both the political spectrum and the Culture Wars debate. Giroux (2003) claims that ‘higher education is defined neither as a consumer-driven product nor as a form of training and career preparation but a mode of critical education’ (p. 476). Bloom's (1987) view is remarkably similar: namely, that ‘the university is not merely a training ground for a profession. Those who have such a goal go through…with blinders on, studying what the chosen discipline imposes on them…education requires that the student's whole life be radically changed by it’ (p. 370). Of course, we do have to respond to the ‘rapidly changing society’ which Smith identified in his 1978 JAN Editorial, as many others writing about nursing education since then have done (Bartels 2005). In fact, it has become somewhat of an assumed argument for higher education in nursing. However, while a ‘rapidly changing society’ does accurately characterize the one we practice in, it says nothing about whether or not such rapid change is good and, if so, good for whom. As Bertrand Russell once put it, ‘change is inevitable, progress is not’. Indeed, it seems as though the health establishment is just waking up to the distinct possibility that both the change and/or progress of the 20th century health industry, upon which current nursing practice is still largely based, are hardly an unmitigated good. Choi et al. (2005) ask What is really driving the global chronic disease epidemic? Why are demands on health care rising, putting growing pressure on health care expenditure? What has to happen to stem the rising tide of obesity and physical inactivity? With what is claimed to be human progress playing a part in the answer to them…in this and the 22nd centuries, the human race will be pushed towards a primary cause of death from ‘diseases of comfort’…due to technological advance’ (p. 1030). Perhaps, our response to a rapidly changing society ought to be less an assumed practice that just gets better with ‘more knowledge, more education, and more skills’ (Bartels 2005, p. 221), but rather a continuous critique of it. Moreover, perhaps the focus of a proper higher education in nursing is one that is given to the development of a (critical) thinker who can practice rather than a practitioner who can critically think (only about practice). As Watson and Thompson (2004) unabashedly contend, and I fear it might well be a valid claim, ‘we are not currently offering the majority of people who wish to be nurses a proper university education’ (p. 75). While I am convinced that nursing belongs in higher education, the greater question appears to be whether higher education belongs in nursing. The author thanks Clinton, Katherine, Bradley, Lisa, Julia, Michelle, Jessica, Roya, Stephen and Angela (McMaster-Conestoga Collaborative BScN Nursing Program Level 4, 2006) for their thoughtful engagement, as well as the Editor-in-Chief of JAN for her editorial assistance.

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