In this paper, we make explicit the changing configurations of power relations that currently characterize the Brazilian Emergency Care System (SAMU) team in Belo Horizonte, Brazil. The SAMU is a recent innovation in Brazilian healthcare service delivery. A qualitative case study methodology was used to explore SAMU’s current organizational arrangements, specifically the power relations that have developed and that demonstrate internal team struggles over space and defense of particular occupational interests. The argument advanced in this paper is that these professionals (...) are developing their work in conditions of exposure, that is, they are always being observed by someone, and that such observational exposure provides the conditions whereby everyday emergency care practices are enacted such that practice is shaped by, as well as shapes, particular, yet recognizable power relationships. Data were collected through the observation of the SAMU’s work processes and through semi‐structured interviews. Research materials were analyzed using discourse analysis. In the emergency care process of work, visibility is actually embedded in the disciplinary context and can thus be analyzed as a technique applied to produce disciplined individuals through the simple mechanisms elaborated by Foucault such as hierarchical surveillance, normalizing judgment, and the examination. (shrink)

Foucault's preoccupation with the visual, specifically his positing of a sort of ‘positive unconscious of vision’, offers an entry point for examining data generated through a field study of home‐care case management practice. In Foucault's work, our attention is directed not so much to what is seen but to what can be seen and to the effects of practices of knowledge and power in constituting these particular realities. Knowledge emerges as a matter of what it is possible for knowers, for (...) nurses, to see and to say, as well as the conditions that constitute these specific possibilities for seeing and saying in a given context. Given the significance of practices of seeing in case management – seeing clients, seeing situations – examining how possibilities for understanding are constituted through ways of seeing helps us to ‘see’ the limits of currently possible practice. In the case examined in this paper, these limits constitute a gap between what a client may actually need and what it is possible, in the context of current practice, to provide. To change practice it seems important, if only as a first step, to recognize the constraints of thought in what we see. (shrink)

This paper is concerned with events that were the subject of an inquest into the deaths of 12 children who died while undergoing or shortly after having undergone cardiac surgery at the Winnipeg Health Sciences Centre, Manitoba, Canada, during 1994. A notable finding of the Sinclair Inquest was that nurses involved with the pediatric cardiac surgery program were concerned about the competence of the surgeon and made sustained efforts throughout 1994 to have these concerns addressed. That the nurses’ concerns were (...) not taken seriously is the central problem of this paper. Essentially, the position articulated is that gendered and gendering discourses constituted a form of power that structured the field of nurses’ possible actions. These discourses constituted a resource to make nurses knowable, to produce them as certain forms of the person, and were therefore part of what governed nurses everyday conduct. Though neither simply good nor bad in themselves, in this case, these discourses had constraining effects on how nurses were able to conduct themselves. (shrink)

The paper contrasts understandings of knowledge grounded in Enlightenment norms with the departures from those norms taken by some strands of feminism and hermeneutics, as well as the contributions made by the writing of Michel Foucault. A reading of Foucault's writings on knowledge, power and the discursive constitution of self and world is offered as a potentially useful frame within which to raise questions about nursing, nurses and knowledge.

In 2008, the Minister of Health for Iceland issued a new regulation intended to govern assessment practices related to placement in nursing homes. One of the aims of the regulation was to ensure that those with the most severe need would have priority. This would be achieved, in part, by requiring older people to exhaust all available community‐based service options before an assessment for placement would even take place. The new regulation was received with some hostility and criticism on the (...) part of older people and their relatives, who described the changed expectations as ‘abandonment’ by the authorities. We present our analysis of these changes by examining how older people and families are reconfigured through the new policy and argue that this ‘new’ practice of de‐institutionalization is underpinned by a shifting epistemic and normative context that is working to create a new identity and a different way of life in advanced age in Iceland. The analysis has implications for other nations as well, as much policy related to older people is broadly informed by this idea that ‘home is best’, that is, the idea that more care simply needs to happen outside of institutional settings. (shrink)

An increase in the number of older people with dementia is currently a trend around the world. In low and middle countries, effective public health services are not yet well‐developed, and family care‐givers may be overwhelmed by the requirements of care. This paper has two purposes: to share findings from an ethnographic study about family dementia care practices in Brazil and to draw attention to the significance of the materiality of care practices in the family context. The study was conducted (...) in Belo Horizonte, Brazil. We describe the care trajectory of one family and, analysing data using the insights of Actor Network Theory, show the significance of objects in a networked relation of care. In particular, we show how incontinence products such as adult diapers assume different positions in the network, acting as either mediator or intermediary of care in relation to other elements of the network composed of family members and their living situation, the person with dementia herself, the doctor, and Brazilian health policies. Although the diaper is often seen as an ordinary object for care providers, its participation in a care network shapes relations, activating conflict, financial constraint, and disciplining the body of the person with dementia. (shrink)

In this paper, we explore the concept of bearing witness in nursing practice. We examine the description of bearing witness in the nursing literature, particularly that offered by William Cody who suggests that bearing witness results in the limited moral obligation of “true presence.” We then turn to Lorraine Code's work on testimony, drawing parallels between the concepts of testimony and bearing witness. Code suggests that receiving testimony results in a responsibility to respond, and that this is an ethico‐political obligation. (...) We discuss these ideas in relation to a Canadian exemplar of witnessing the Truth and Reconciliation Commission of Canada's work to understand and address the historical injustices done to Indigenous peoples in Canada. Here, we focus on the Commission's definition of witnessing and highlight the experience of Shelagh Rogers who served as an honorary witness. As an outcome of our analysis, we suggest that bearing witness in nursing practice is most usefully conceptualized as both a moral and a political obligation. Implications for nursing practice are suggested, including first, the need to critically examine our own understandings of power and privilege in order to authentically bear witness and avoid being complicit in injustice, and second, the concomitant responsibility to take action to challenge injustice once we have borne witness to it. (shrink)

To address the growing costs associated with chronic illness care, many countries, both developed and developing, identify increased patient self‐management or self‐care as a focus of healthcare reform. Health coaching, an implementation strategy to support the shift to self‐management, encourages patients to make lifestyle changes to improve the management of chronic illness. This practice differs from traditional models of health education because of the interactional dynamics between nurse and patient, and an orientation to care that ostensibly centres and empowers patients. (...) The theoretical underpinnings of coaching reflect these differences, however in its application, the practices arranged around health coaching for chronic illness self‐management reveal the social regulation and professional management of everyday life. This becomes especially problematic in contexts defined by economic constraint and government withdrawal from activities related to the ‘care’ of citizens. In this paper, we trace the development of health coaching as part of nursing practice and consider the implications of this practice as an emerging element of chronic illness self‐management. Our purpose is to highlight health coaching as an approach intended to support patients with chronic illness and at the same time, problematize the tensions contained in (and by) this practice. (shrink)

Developments in professional practice can be related to ongoing changes in relations of power among professionals, which often lead to changes in the boundaries of practices. The differing contexts of practices also influence these changing relations among health professionals. Legislation governing professional practice also differs from country to country. In Brazil, over the past 12 years, in a climate of deep disagreement, a new law to regulate medical practice has been discussed. It was sanctioned, or made into law, but with (...) some notable changes, in July 2013. Of interest to us in this paper are the ways the proposed legislation, by setting out the boundaries and scope of medical practice, ‘interfered’ in the practices of other health professions, undermining many ‘independent’ practices that have developed over time. However, even taking into account the multiple routes through which practices are established and developed, the role of legislation that seems able to contradict and deny the historical realities of multiple, intersecting practices should be critically interrogated. In this paper, we use the theoretical resources of poststructuralist thinking to explore gaps, ambiguities, and power relations implicit in the discourses that constituted this law. We argue that although the new law can be understood as a social and political device that will interfere in the organization of other health professions’ practices, such legislation is only part of what constitutes change in a consolidated professional practice. And while it is important to understand the effects of such legislation, healthcare practices are also realized or ‘made real’ through ongoing relations of knowledge and power, including, as we will see in this case, activities of resistance. The problem, then, is to understand the practical arrangements, including legislation, traditions and routines, values and knowledge that come to shape the practices of nursing in a particular context. (shrink)

The analysis undertaken in this paper explores the significance of a central finding from a recent field study of home care case management practice: a notable feature of case management work is the preparation of an orderly, ordered space where care may be offered. However, out of their encounters with an almost endless variety of situations, out of people's diverse narratives of need, case managers seem able to pick out only limited range of recognized needs to which to respond and (...) demonstrate a series of responses themselves equally limited. Though this observation suggests a kind of efficiency that is currently highly valued within healthcare systems, it also underlines the system's inability to engage difference and variability in a meaningful way. This inability or limitation in effectively engaging difference is conceptualized here as, in some sense, a problem, and the nature of this problem is explored through the rhetorical process of problem setting. The central question becomes how might we develop and deploy an orderly and coherent system of care without essentializing people's experiences, without treating these experiences reductively, without, in a Foucaultian frame of reference, allowing what can be understood as similarity or resemblance among clients and situations to be folded back into sameness? As we encounter complexity, variability and difference in practice, how should we treat it? (shrink)