Editorial: Nursing Informatics and Nursing Culture. Is there a fit?

By June Kaminski RN MSN PhD Student

Citation: Kaminski, J. (October, 2005). Editorial: Nursing Informatics and Nursing Culture. Is there a fit? Online Journal of Nursing Informatics (OJNI), 9, (3) [Online]. Available at http://ojni.org/9_3/june.htm


            A first step in promoting both informatics theory and practice entails an analysis of the historical and contemporary evolution of nursing culture, with a lens focused on how nursing informatics can become part of the evident culture. It is important to nursing informatics adoption to view nursing as a cultural phenomenon, as a system in which nurses act in relation to each other and with others outside of the cultural milieu. Culture is a deep core structure within any group of people that is expressed through the members' knowledge, beliefs, values, convictions, morals and laws (Suominen, Kovasin,  & Ketola, 1997). To reach this deep inner core, one must examine gender, power and rituals inherent in the nursing profession.  “Culture finds expression in learned, shared, and inherited values, in the beliefs, norms and life practices of a certain group, guiding their processes of thinking, decision-making and action. Past events and the anticipation of future are both reflected in culture” (Suominen et al, 1997, p, 186). Seen as both an art and a science, nursing presents a rich and complex culture that has been constructed, deconstructed and reconstructed over time. The art or aesthetic side of nursing culture can be witnessed in the actions, bearing, conduct, attitudes, narrative and interactions of the nurse in relation to others” (Cronin & Rawlings-Anderson, 2004, p. 29).

Beals et al (1977) identified five major components of any cultural system within society:

            Nursing culture is made up of its history, traditions, rituals, myths, routines and stories and underpinning assumptions and values (Hill, Lomas & MacGregor, 2003). “Culture comprises a series of cultural schema or collective knowledge structures, which are socially constructed and rely on negotiation, consensus and agreement for their sustenance. They are communicated and maintained through the socialization process and in everyday interaction, through ceremonies, rituals, myths, and symbols.” (Brooks & Brown, 2002, p. 344). Culture acts to maintain the internal cohesivon of a group, and serves as a defence against external threat, and the anxieties which emerge from both real and perceived intrusion from others outside of the culture (Chapman, 2002).

            Culture can be viewed as both dynamic and structural. “Dynamic in the sense that culture emerges in the complex interactions of human behaviour, and structural in the sense that such interactions produce particular patterns (or structures) which, in turn, influence the interactions themselves.” (Chapman, 2002, p. 14).

            Since nursing is a heavily female-dominated profession even now, in the twenty-first century, the culture of nursing demands an analysis that takes stereotypical conceptions, myths, and models into account, since these strongly influence the way the culture of nursing evolves and takes shape (Suominen et al, 1997). “Visible and invisible power is closely related to the practice of everyday nursing. Power can be seen either as a relation or a capacity.” (p. 188).  Traditionally, nurses as a group, have been considered subservient to physicians and administration and were regarded as handmaidens and assistants. (Boulos & Rajacich, 2003). Even though nursing is the largest professional group within the health care profession, nursing still remains relatively powerless.

            Although nursing is habitually aligned with medicine, the two cultures have strikingly different beginnings and continued power sanctions and imbalances. Foucault provided a fascinating description of the evolution of medical culture in his published work, Birth of the Clinic. “The years preceding and immediately following the (sic French) Revolution saw the birth of two great myths with opposing themes and polarities: the myth of a nationalized medical profession, organized like the clergy, and invested, at the level of man's bodily health, with powers similar to those exercised by the clergy over men's souls; and the myth of a total disappearance of disease in an untroubled/dispassionate society restored to its original state of health (Foucault. 1975, p 31-32).

            Amazingly, medicine rose from obscurity and quackery to become the most noble and sanctioned profession in society. Patients somehow accepted this pedestral view of the physician and responded with unchallenged trust and dependence on the family doctor. Historically, virtually all physicians were male, well-educated and socialized to believe and behave as if they were the elite, the right hand of God, if you will, who became an instrument of healing through the administration of medicines and the cutting of the flesh through surgery. “According to the myths of modernity, doctors were wise. They could see past distractions into the truth of things. We could tell them our problems and their wisdom would lead us to a better life. The relationship between a good life and good health blurred, and the doctors became the carriers of cultural wisdom” (Shawver, 1998, p.1).

            Credited as the “mother” of nursing culture, Florence Nightingale attempted to distinguish nursing from medicine by focusing on the environment and health as the concern of nursing. However, the goals of nursing became allied with those of medicine, in part because of medicine's more powerful and well-established position. Thus, despite itself, nursing became focused on illness. Nursing adopted the language of medicine and nursing complemented and perpetuated medical work. (Cronin & Rawlings-Anderson, 2004). Nursing was grounded in the domain of women where care and comfort became the dominant ethic. Since women are seen as more intuitive and affective, less scientific and rational, the image of nursing is often still conveyed as mothering and nurturing. “For decades, nursing culture conjured up only the image of the caring, yet controlling female, dependent on the physician and the paternalistic management structure of a health care system” (Hill, Lomas & MacGregor, 2003). Early nursing culture was centralized on caring for the sick (Holland, 1993) reflecting a supportive role for the stronger, more powerful medical culture, perpetuated by the male/female role since doctors were men, and nurses were women.

            Since the nineteenth century, the nursing profession and its epistemological foundation have emerged from a patriarchial philosophy. The viewpoint traditionally adopted by nursing was based on positivism, behaviourism and the scientific method. (Boulos & Rajacich, 2003). Foucault (1980) recommended that power must be investigated from the microlevel of society to reveal how mechanisms of power have been able to function. Unless power relations are traced down to their actual physical functioning at the microlevel, such as the bedside or hospital ward, they escape analysis and continue to operate with “unquestioned autonomy, maintaining the illusion that power is only applied by those at the top of the nursing hierarchy, such as professional nursing associations and health care administrators, to those at the bottom in clinical practice.” (Riley & Manias, 2002, p. 318).

            A recurrent pattern that emerges in oppressed groups is the displaced oppression of weaker individuals or groups. A chain of power imbalance and oppression can be identified, in that nurses had power of their own – power over their dependent and ill patients. They also had power as gatekeepers into the profession since most new members of the group were indoctrinated into the fold through clinical mentoring relationships with older, more experienced nurses. Wolf (1988) noticed that two issues situated nurses and their work. One was the underlying notion of doing good and avoiding harm; the second was that the transfer of cultural knowledge was mainly transmitted by word of mouth and demonstration. The phenomenon of “eating our young” was clearly visible within the context of nursing practice which perpetuated issues of dominance, patriarchy, hierarchy, and oppression in the everyday work-world of the nurse. These dynamics reigned strong within the larger heavily structured and conservative institutional environment. “There was an exclusionary healthcare culture that was not only the result of nursing practices but also broader institutional and government policies that shape and constrain nursing practice.” (Blackford, 2003, p. 242).

            Within the past thirty to forty years, the culture of nursing has experienced a refreshing yet dissettling transformation, especially in academic circles. In the 1970s and 1980s, nursing began to consider itself as distinct from medicine and professionalism was seen as one way of establishing this distinction. (Cronin & Rawlings-Anderson, 2004). Nursing as a culture began to experience a major paradigm shift and is still struggling to consistently demonstrate this shift, especially in the practice arena. To become accepted as true professionals, nursing began to establish roles as scholar, theorist, scientist, and artist: to articulate their unique body of knowledge, and to exhibit their ability to be  active and powerful in their roles as client advocate, health promoter and teacher.

            And yet, nursing still struggles to shed the image of dependency on the medical profession. Through the everyday process of cultural reproduction, nurses maintain and perpetuate the conditions of their domination. This limits the ability of nurses to exercise autonomy and self-determination to control what counts as knowledge in their field, or to demonstrate knowledge about professional nursing practice and to use that knowledge in appropriate ways for health care.

            The role of the nurse has intensified and diversified with the widespread integration of communication technology and information science into health care agencies. The nurse's role in the delivery of patient care is intensified by redefinition, refinement, and modification of the practice of nursing (Hannah, Ball & Edwards, 1996). The professional nurse is now expected to function well within a technologically advanced healthcare environment, carry out higher-level, complex activities, and are held responsible and accountable for the systematic planning of holistic and humanistic nursing care for clients and their families. This is expected to occur within a system plagued by a nursing shortage, heavy workloads and long shiftwork hours, tight budgets, modest wages for work rendered, and an increasingly ill hospital population. They are expected to keep abreast of technological implementation within their work environment with little time for professional development activities or inservice attendance. Technology does not function in a vacuum but within a social matrix, interacting with individuals in an organization: if nurses are to integrate technology into their culture, many factors and forces must be addressed (Richards, 2001).

            As Editor-in-Charge of the Virtual Nursing Practice and Culture, I encourage nurse researchers and writers to consider how informatics can fit comfortably and perhaps, seamlessly into the culture of nursing – and to write about it! We are always open to articles and papers that describe how informatics is represented in our professional culture, and in my case, and how nurses express their culture in the virtual environment.

References

Beals, R.L., Hoijer, H. & Beals, A.R. (1977). An introduction to anthropology. New York: MacMillan.

Blackford, J. I. (2003). Cultural frameworks of nursing practice: Exposing an exclusionary healthcare culture. Nursing Inquiry, 10 (4), December, 236 – 244.

Boulos, P. & Rajacich, D. (2003). Critical theory as a philosophical base for nursing science. Guidance and Counseling, 19 (1), Fall, 37 – 44.

Brooks, I. & Brown, R. (2002). The role of ritualistic ceremonial in removing barriers between subcultures in the National Health Service. Journal of Advanced Nursing, 38 (4), May, 341 – 352.

Chapman, L. (2002). A cultural revolution? Primary Health Care, 12 (7), 14 – 15.

Cronin, P. & Rawlings-Anderson, K. (2004). Knowledge for contemporary nursing practice. Toronto: Mosby.

Foucault, M. (1975). The birth of the clinic: an Archeology of medical perception. (A. M. Sheridan Smith, trans.) New York: Vintage Books.

Hannah, K.J., Ball, M.J., & Edwards, M.J. (1994). Introduction to nursing informatics. New York: Springer-Verlag.

Hill, Y., Lomas, L., MacGregor, J. (2003). Managers, researchers, teachers and dabblers: Enabling a research culture in nursing departments in higher education institutions. Journal of Further and Higher Education, 27 (3), August, 317 – 331.

Holland, C.K. (1993). An ethnographic study of nursing culture as an exploration for determining the existence of a system of ritual. Journal of Advanced Nursing, 18(9), 1461 – 1470.

Richards, J. A. (2001). Nursing in a digital age. Nursing Economic$, 19 (1), Jan/Feb, 6 – 12.

Riley, R. & Manias, E. (2002). Foucault could have been an operating room nurse. Journal of Advanced Nursing, 39 (4). August, 316 – 324.

Shawver, L. (1998). Notes on reading the Birth of the Clinic. Retrieved 07/15/05 from the World Wide Web: http://www.california.com/~rathbone/foucbc.htm

Suominen, T., Kovasin, M. & Ketola, O. (1997). Nursing culture – some viewpoints. Journal of Advanced Nursing, 25 (1). January, 186 – 191.

Wolf, Z.R. (1988). Nurse's work: The sacred and the profane. Philadelphia: University of Pennsylvania Press.