Doctoral Education in Nursing

International Perspectives

Shake Ketefian, Hugh McKenna, Shake Ketefian, Hugh McKenna

• Publisher: Routledge
• Year: 2005
• ISBN:
  9781134365500
• Edition: 1
• Topic: Medicine
• Subtopic: Health Care Delivery

An international team of contributors examine best practice in doctoral education, covering key topics including:

• what doctoral study in nursing involves
• the roles of the student, the supervisor, the awarding institution
• the doctoral process
• quality monitoring
• funding for doctoral education and research
• models of international exchange
• postdoctoral study.

This book is an indispensable source of reference for doctoral students and their mentors, wherever they are pursuing their research.

Chapter 1
The substance of doctoral education

Oliver Slevin and Somchit Hanucharurnkul

This first chapter is primarily concerned with the content of doctoral education in nursing now and in the future. In addressing this, it is necessary to consider the context within which such education takes place and the wider emerging trends that may influence future directions. We have identified three issues: the content of doctoral programmes; the context within which they develop; and nursing as the field of study in such programmes. The links and interrelationships between these will influence the structure and processes as well as the content of future doctoral preparation.

The problem with taking account of context is not only that it is by definition complex, but also that it is a constantly changing milieu. When faced with burgeoning change we are immediately drawn with urgency towards consideration of the future challenges and how we will respond to these. This can emerge as a sense of drivenness in respect of arriving at solutions. However, in such circumstances there is a risk that the fundamental nature of the phenomena under consideration and how they came to be may be overlooked. It is vitally important that the ground from which we move forward is not only fully understood but that the movement into the future takes full account of our past and the issues confronting us in the present. There are essentially two scenarios that may unfold, although it may be more appropriate to see these as extreme ends of a continuum. One road (and perhaps that most travelled) is to continue in a piecemeal fashion. The other represents an opportunity now given to us to reflect upon a more meaningful way forward.

In this chapter we will demonstrate that even on an international level there is a degree of commonality between doctoral programmes. However, there is also a great degree of variance and this is the case not only between nations but also between higher education institutions within nations. In the past, this has been a matter of some concern. However, as the pace of change increases, and as we attempt to change our doctoral programmes to maintain their relevance in a changing world, there is a greater risk of doctorates losing even that limited amount of international currency they presently enjoy. Here we cannot hope to present anything approximating to a master plan for the development of doctoral programmes in the new millennium, but perhaps we can outline the issues and in so doing contribute to that reflective dialogue.

In attempting to ensure that order emerges from the edge of chaos, there is perhaps at least one ‘constant’ to which we can hold. The foundational premise among all of the above considerations is that of nursing. Whatever we determine to be the purpose of doctorates and the nature and content of doctoral education, they are first and foremost about nursing. That is, we are concerned with the highest source of learning that will inform our practice. We have alluded already to the issue of historicity, how the past informs the present and how we must endeavour to bring the best of what we have learned into the future. We have long recognized the importance of establishing a sound body of theory that informs (and is informed by) our practice, in terms of what Dickoff and James (1968) termed ‘situation producing theory’ and Argyris and Schön (1974) later referred to as theory-of-action that would be enacted in ‘theory-in-use’. Similarly, while we are well acquainted with the dangers of mindlessly following tradition in our practice, we nevertheless value the wisdom that has emerged through experience, as reflected by Benner and her colleagues (Benner, 1984; Benner et al, 1999). Such groundings must be adapted to future circumstances and supplemented by new knowledge. The nursing paradigm or worldview, in the sense originally posited by Kuhn (1970), is a dynamic and changing perspective, and much more so in a rapidly changing world. The current and future cohorts of doctoral nurses will be those most charged with meeting this challenge in the future. They are the creators, innovators, keepers and purveyors of the paradigm. It is therefore of vital importance that those so charged are adequately prepared for the task. This is the matter we must address here and throughout this book.

Fundamental issues

Nursing

Nursing and its mission must be the foundation of our future development of doctoral education. However, it is a characteristic of the foundationalist epistemology that a body of knowledge depends for its endurance upon the strength of its foundational premises. On this basis, the survival of our project depends on a strong and enduring conceptualization of the nature of nursing itself. Should this be unsound, the total edifice of nursing knowledge and practice that we construct through nursing scholarship (including doctoral and postdoctoral study) is unstable and in danger of collapse. We must, after all, know what doctoral education is intended to improve or advance. It is beyond the remit of this chapter to enter upon a lengthy discourse on the nature of nursing. This is a matter that has been addressed elsewhere. Within modern times, it is many years since Henderson’s (1966) celebrated definition of nursing laid the groundwork of nursing as a service of helping those in need when they were unable to meet such needs themselves. Since then, many have made their contributions. Watson’s (1990) seminal notion of ‘informed moral passion’, identifying the vital importance of the integrity and interrelationships between best available knowledge and skills, ethical deportment and a commitment to concern and care for the other, admirably conveys the essential nature of nursing work. On a different level Slevin (1999) has spoken of ‘nursing as a relationship that involves caring for others in a health context’, bringing together the four metaparadigmatic elements of person (others), health, environment (context) and nursing (caring), previously identified by Fawcett (1984, 2000).

It might well be argued that this is going over old ground, that indeed there is no longer controversy or issues to resolve in this area. This might be true if nursing is considered to be synonymous with (or accurately reflected by) the voluminous academic nursing literature on the nature of nursing. However, if it is recognized that nursing is also in the nature of a social contract, whereby ‘society’ expects nursing to provide care of a particular form and nursing is in turn recognized and accepted to the extent that it meets this commission, all may not be well. For example, even in the closing weeks of 2003, in the United Kingdom (UK) there emerged two damning reports (Magnet, 2003; Sergeant, 2003). Both claim that nurses are failing their patients within the UK National Health Service (NHS), and that they all too often exhibit uncaring attitudes and fail to provide even the most fundamental aspects of physical and psychological care. Our doctoral education, and its content, will be of little value if it does not contribute to us seeing how nursing is and what it could become. Criticisms such as these typically argue that the preparation of nurses has become too academic, that the movement of nursing into higher education is the root cause of the failure to provide adequate preparation for practice. Nurses, so the argument runs, become more concerned with status, more involved in administrative tasks and specialized technical work, and less prepared to undertake what might be considered menial ‘bed and body’ work. Such arguments might extend to question the relevance of higher degrees in nursing, and the relevance of doctorates in particular.

Nature of a doctorate

It is helpful at this stage to briefly consider the idea of a doctorate. The term ‘doctor’ derives originally from the Latin docere meaning to show or to teach. Such teachings would be based primarily on the doctrina, the body of teachings. The ‘doctor’ or ‘scholar’ (derived from the Latin scholasticus or learned, and the Ancient Greek skholastikos or studious) was recognized as the producer and conveyor of such knowledge. Thus, the qualification of ‘Doctor’ (initially in theology and later in other professions) emerged from the Middle Ages as the highest degree of a university—the doctorate (with its most universal title being Doctor of Philosophy or PhD). Significantly, in later centuries, and particularly during the era of scientific positivism, there emerged the idea of science as a pure calling, concerned with the quest for truth and knowledge and not its practical and ethical implications. Postdoctoral scientists, active in research, tended to distance themselves from the social consequences of their work and even within the universities viewed teaching as a lesser activity to be tolerated if not indeed avoided. It is only in recent decades that the link between scholarship and teaching again emerged as an important concern.

There can of course be no rational argument against the education of nurses for a complex and often life-saving undertaking at an appropriate and advanced level. There may, however, be a recognition that such education could go astray, that there is indeed a possibility of failing to see the wood for the trees. It therefore becomes imperative that nursing as a profession develops a relevant body of knowledge and skills, that these are enhanced to meet changing needs, and that there is leadership for a way forward that is firmly grounded in knowledge and wisdom. It is the need for this grounding, and this wisdom, that is in fact the raison d’ ê tre for doctorates in nursing. The content of doctoral programmes, in terms not only of what this learning is but also how it is to be achieved, is therefore of vital importance.

Context

We have considered nursing as being a social contract between ‘society’ and the profession. This is a sense in which we must respond to the needs of those we would care for. These needs are complex and demanding when they are expressed in the wants of public opinion. The demands placed upon nursing are at once imposed by governments and their political agendas for health, yet in a sense transcend party politics and time. There are calls (as in the papers by Magnet (2003) and Sergeant (2003)) for nursing to be not only a stabilizing and humanizing constant in an increasingly complex and alienating healthcare world, but also a challenge to modernize in the face of rapid change and technological advancement.

The nurse at the bedside faces the demands of the moment, within that culture and that setting, constrained by the policy of the wider institution and even by the wider conditions of national policy. However, increasingly, influences from the even wider global milieu press in upon this situation. Where this ‘bedside’ is in a developing country, the scarcity imposed by multinational pharmaceutical strategies, international trade restrictions and global harm factors are very real threats to the wellbeing and even survival of the person being nursed. In the developed countries, the ‘patient’ and/or the ‘nurse’ at this bedside— whether it be in New York, London or Paris—are now likely to have emerged from another culture, so that the actual delivery of care is now almost always transcultural in its delivery.

All these influences point up the third linking factor we propose, that of context. Insofar as nursing will be influenced by context (and possibly act as an influencing force within its context), the nature and content of doctoral education will similarly be influenced (and possibly equally influential). In a multicultural and global world the construction of knowledge and practice can no longer be unidimensional and bounded exclusively to a particular culture and its values. In the remainder of this chapter, we consider the impact of context and the implications of this for the content of doctoral programmes in nursing.

Trends that will affect doctoral education

Questions begged

What is good about doctoral education? What is bad about doctoral education? How will doctoral preparation evolve in the future? These questions are amenable to comparatively straightforward answers. Yet these are questions that have been posed before, certainly over some decades in the previous century, with little emerging in the way of clarity. Despite such ongoing dialogue, there has been no significant shift in the nature of doctoral education over these decades. Aware as we are that the world has changed significantly, especially in the two decades spanning the new millennium, it is reasonable to assume that the challenges faced by those who have undertaken doctoral preparation will also have changed dramatically. If this is the case, then serious questions must indeed be asked about the apparent lack of development in how such individuals are prepared. This is no less the case in respect of nursing, where what nurses do has a direct impact on the health and wellbeing, and indeed survival, of those they serve.

The questions now begged must therefore be: What is so different about this time? Why should our inquiries lead to anything more than maintenance of the status quo now? Part of the answer to these questions resides in the awareness that the world is rapidly changing, and our responses must change as well. It is many years since Alvin Toffler (1970) introduced the idea that the world is changing at such a rapid rate that we experience a sense of lack of control, a feeling of alienation, an awareness of our vulnerability—a phenomenon he described as future shock. More than a decade after Toffler had written, Naisbitt (1984) in his almost equally famous statement mapped out with extraordinary clarity the trends starting to emerge—including the movement from an industrial to an information age and the shift from national to world economies.

However, what may be different now is how change not only advances with increasing rapidity, but the way in which the consequences of such change are now starting to turn in upon us. We are confronted with the limitations of science in terms of its erstwhile apparent promise of a new utopia. Even those at the forefront of our sciences recognize the illusion of order in the face of chaos, and the limitations of science beyond certain points (Horgan, 1996; Barrow, 1998). But of even greater concern is the fact that while the advances in scientific knowledge have brought great advantages, we are now becoming conscious of the great damage and high risks of the often unanticipated negative impacts of these advances on local and global levels (Beck, 1999; Giddens, 1999).

Complexity

What, then, are the trends that are of particular concern to doctoral preparation in general and nursing doctoral preparation in particular? To a large extent these are made more complex by the fact that the trends are interrelated. In a sense, this is perhaps the fundamental and underlying change, often referred to in the scientific literature as complexity theory (Waldrop, 1992). The real world is complex, fuzzy and unpredictable. In the sense originally posited by David Bohm (1980), meaning is enfolded in the wholeness of what he termed the implicate order. In our attempts at unfoldment, at deriving meaning, we are at once faced with the danger of fragmentation—the illusion that the fragments we see through particular worldviews or lenses are in fact the real world. The project is further compromised by the fact that what is enfolded is dynamic and forever changing. This therefore becomes an issue of not so much what we think, but how we think. Old formulae no longer work, and there is a need to be more reflexive in seeking new ways to solve new problems that often have no precedents. It is increasingly the case that no single lens (or discipline) can satisfactorily address problems that are so enfolded and multidimensional.

This fact has implications for new physics and economics, as illustrated by Waldrop (1992), and it is no less important in nursing. Here also we ar...