Trends That Will Affect Doctoral Education
Questions Begged About the Nature of Education
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 simple 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 well-being, 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 lies 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 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 aware 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 Of Education In Nursing
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 reflective 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 we are also faced with fuzzy worlds and complex, rapidly changing situations: acquired immune deficiency syndrome/human immunodeficiency virus, elder care, suicide, are but a few examples.
However we deliver our nursing doctorates in the future, one thing is certain: we will not be able to depend exclusively on old formulae for solving new problems. While the traditional starting principles and skills of inquiry may form the bases of such programs, the capacity to respond to new situations with new modes of inquiry will be a vital ingredient.
And many of the issues we must resolve will not be amenable to single worldviews, uni-disciplinary perspectives, or even uni-national modes of inquiry. Beyond the premise of complexity, there are indeed other trends that may be of importance. These might in general fall under the following headings:
- Modernity
- Consequent changes in healthcare systems
- Globalization
- The professional response
Modernity
The Modern condition
In North America the influential work of Charles Taylor (1991) drew attention to the crisis of what he termed the ethics of authenticity—the negative impact of the modern condition upon the way we live.
He spoke of the three malaises: increasing individualism where, while there is individual choice and freedom, there is also the demise of a stable order and a communitarian consciousness; the impact of instrumental reasoning and ways in which science and technology are in one sense liberating and empowering, but in another sense disempowering and increasingly creating designed environments that place limits on our freedom of choice; and the increasing lack of confidence and engagement in the modern politics as, individualized and isolated, people become ‘enclosed in their own hearts’.
As was the case for the old religions with their claim to establishing a sacred order in society, so too has the new age of science and technology failed to create a modern utopia.
We do of course have the advantages of modern science and technology, and nowhere is this more evident than in the field of healthcare. But as we have entered a new millennium, the risks incurred by failure to control advances in science and technology threaten our very existence on the planet (Beck, 1992, 1997).
The Postmodern Turn
One consequence of what became known as the postmodern turn, particularly as it progressed towards the final decades of the last century, was its increasingly critical stance in relation to the given order of things. The works of Jean Francois Lyotard (1984) and Michel Foucault (1970) were significant drivers in this postmodern approach. In essence, the perspective is represented by a skeptical critique of any perspective whose discourse seeks to explain the world, what Lyotard described as ‘incredulity towards metanarratives’.
The postmodern legacy of skepticism —in essence a questioning and critical attitude—was a significant influence upon late twentieth century thinking in all walks of life, including nursing (Watson, 1999). However, this critical stance contained its own inbuilt demise. Postmodernism also required a skeptical attitude to any claims it might itself make in respect of a response to the limits and excesses of modernity.
The movement offered only a critical response, but no solution to the failures it identified; such claims would in turn be subject to the circularity of postmodern criticism, in that any constructive way forward emerging from a postmodern discourse would itself be subject to critical deconstruction. It was therefore for others to propose new ways forward.
These new ways have been contained within movements variously termed late modernity or new modernity (Beck, 1999, 2000; Giddens, 1999, 2001; Giddens and Hutton, 2000). The basic tenets of such positions run as follows: in a new world characterized by burgeoning change, increased risks, and an increasingly global consciousness, the solutions and formulae of the past no longer hold.
As new technologies of modernity emerge and advance at an increasing rate, the discourse has moved from one of hailing in an unconditional way how we are moving towards a new utopia, to a recognition that the technologies of the past and those now emerging present major threats to our very existence. We realize, perhaps too late, that the biggest challenges of the future will include how we contain the risks we have ourselves manufactured.
We are, in effect, entering a new world that demands of us new-thinking responses. This is of profound importance in respect to how we will prepare the most capable among us to confront the challenges of the future. Here too there comes a realization that while doctoral education for nurses in the future may find some historical firm ground from which to push forward, the greater demand will be that of preparing our thinkers of the future for responding to new and changing situations with new and different modes of inquiry.
Changes in Healthcare Systems
The advances of modernity impact with particular effect on our healthcare systems. Advances in science and technology are nowhere more dramatic than in the field of healthcare. There are the impacts of the harmful or threatening effects of modernity—ranging from the malaises identified by Taylor (1991) to the more concrete impact of pollution (from chemicals, emissions and radiation), through the demands on resources imposed by increased longevity, to ‘new’ healthcare problems ranging from AIDS to obesity.
It is true that the discoveries of new and more effective antibiotics and antiseptics throughout the twentieth century saved hundreds of millions of lives. However, as we move into the twenty-first century these same substances create new ‘superbugs’ that may even threaten humanity.
Also impacting upon our healthcare systems are the rapid increases in information and technology. There is the possibility of knowing more and better, and of technology allowing us to do more than we perhaps ever dreamed of.
But even here, there is a sense in which modernity turns back upon us. In the quest for quality, we aspire to health services that provide safe and effective services based upon the modern-day mantra of evidence-based medicine (EBM) and its fellow travelers (evidence-based practice, evidence-based nursing, evidence-based healthcare ).
But such is the speed and volume of information production and technology advancement that the capacity to ascertain the quality of the product, disseminate it and effectively incorporate it into clinical practice is almost insurmountable (Baker, 1998).
The sum of these trends can be viewed in terms of a net increase in demand—for more and better services—set against a constant increase in scarcity of resources. In the developing nations the scarcity of resources is absolute and more often than not life threatening. However, even in the developed nations this has become a crucial issue. Despite the fact that over 90% of healthcare provision is concentrated in the richest nations, the demand continues to outstrip the resources.
It is within this real-world scenario that nursing must find its place and meet its commitment to best purpose. We need to know how we will cope with changing patterns of health and healthcare delivery. We need to establish what evidence is needed for our best practice, and how this is best disseminated and implemented.
Furthermore, we must also establish how nursing will respond to the ethical dilemmas that are already appearing in the developed and developing world, as demand outstrips supply. Importantly, we must also recognize that these complex and multidimensional concerns cannot be addressed exclusively from a nursing perspective. We speak a lot today of multidisciplinary care and teamwork.
In promoting such an orientation, we recognize the importance of shared education and training. But behind and underpinning these orientations is a need to recognize the importance of multidisciplinary approaches to research and the need to incorporate such an orientation and the particular attitudes and competencies required within doctoral preparation.
Globalization
Of particular importance in the thrust of modernity is the phenomenon that has become known as globalization. The term is the subject of much use and indeed abuse, meaning different things to different people. In general, it contains somewhere within it a closing down of space and differences as a consequence of developments in new technologies, particularly those involving high technology communication and rapid-transit travel.
Not only is the entire globe aware of and contributing to is the exchange of global information, but it is also possible to physically traverse the globe in less than a day. By the end of the 1990s there was a lauding of economic globalization (with the institution of the World Trade Organization (WTO) and the creed of free trade), and the major powers were adopting a global consciousness within which they viewed themselves as the caretakers. of the new global stage. However, contained within this trend are the threats emerging from our failure to recognize the risks involved. This was powerfully expressed by Capra, when he stated:
As this new century unfolds, it becomes increasingly apparent that the neoliberal ‘Washington Consensus’ and the policies and economic rules set forth by the Group of Seven and their financial institutions—the World Bank, the IMF and the WTO—are consistently misguided.
Analyzes by scholars and community leaders…show that the ‘new economy’ is producing a multitude of interconnected harmful consequences—rising social inequality and social exclusion, a breakdown of democracy, more rapid and extensive deterioration of the natural environment, and increasing poverty and alienation .
The new global capitalism has also created a global criminal economy that profoundly affects national and international economies and politics; it has threatened and destroyed local communities around the world; and with the pursuit of an ill-conceived biotechnology it has invaded the sanctity of life by attempting to turn diversity into monoculture, ecology into engineering and life itself into a commodity.
It is perhaps unsurprising that Beck (2002) also links such developments to the emergence of global terror, and in turn the way in which this not only brings threats to communities from without, but also a new consciousness of fear and confinement within.
Causes of Failures
It may be the case that to some extent those such as Giddens, Beck and Capra are excessive and unreasonable in their claims. And there is certainly a case for introducing balance, by recognizing the great successes science, technology and international relations have sometimes brought in the previous century. Notwithstanding this, we must also recognize that the global threats we now face do to some extent emerge from a range of failures, including:
- The inability to anticipate or take adequate action to avert the negative effects of modern developments such as fossil fuel and nuclear energy usage.
- The failure to control the impact of scientific and technological advances in increasingly complex situations that result in increasing risks to health and well-being, within and across national boundaries.
- The introduction of economic models that, while having the appearance of sophistication, were in reality based upon values of profit and vested interest that served to widen inequalities, increase global poverty and create new health risks.
- The failure to accompany global development with a global ethic that reflects values of global justice and communal concerns.
- The resulting backlash of a destabilized global politics , which includes a new threat of global terrorism.
We have already noted how modernity and its risks, in and of themselves, require such new orientations. But now we find that the changes taking place, the information explosion and its rapid transmission, the impact of technology, the emerging risks, and the responses demanded are increasingly global.
They confront not only national governments, industry and commerce, societies and the global community of the future but also the academic community of scholars and researchers. Significantly, knowledge is no longer localized and bound to particular contexts. It is shared and transmitted globally; not only influencing others in other settings but also being adapted by them and reflected back upon their origins.
In their seminal work on how thought (as a source) emerges, Deleuze and Guattari (1987) spoke of nomadic thought (now often spoken of as nomadic theory). According to this, a theory has an origin, a distance traversed, a set of conditions for acceptance or rejection, and finally a transformed (incorporated) idea occupying a new position in a new time and place.
The difference now, in the global era, is the extent to which an element of reflexivity and non-linearity enters upon this process. Now, the transformed thinking (or theory) is turned back on its origins, where it is in turn transformed.
Edward Said (2000) spoke of this as traveling theory, influencing and being influenced. Thus, something as fundamental as gender and equality may transfer from the USA to an Eastern country and be interpreted in that location. Such interpretation is now reflected back upon northern England, impacting not only upon the Anglo-Saxon population but also the large Muslim community in that location.
We see in such processes the extent to which academic study has now also truly reached global dimensions. The non-linear ways in which knowledge is constructed are no less relevant to nursing than to other areas of academic endeavour . Indeed, it might be argued that in a world facing the global threats referred to by Capra (2002) nursing can be a vital force in infusing a caring and compassionate dimension in a world increasingly threatened by the politics of power and the ethics of utility.
This is witnessed, for example, in the International Council of Nurses (1999) courageous stand in decrying the trend of developed countries attempting to remedy their own nursing shortages by recruiting from areas of great need in the developing countries. Significantly, the Global Advisory Group on Nursing and Midwifery (established by the World Health Assembly in the early 1990s) has emerged as a recognition of the vital role nurses can play on the world stage (World Health Assembly, 1996, 2001).
When we now speak of a community of scholars, and more specifically a community of nursing scholars, we increasingly must see this as a global community where collaborative working and sharing crossing national boundaries and cultures may become the norm. It might be argued that what we have here is an imperative for revolutionary changes in nursing doctoral education that encompasses this global dimension .
The Professional Response
Thus far we have recognized the importance of a firm disciplinary foundation from which nursing must move forward. And we have also recognized that one aspect of this is accepting that nursing is by contextual and relational definition. That is, nursing in the past, in the present, and in the future has and will continue to be a social construction influenced by trends within the wider world in which nursing takes place.
We have considered some of these trends in the previous sections: increasing complexity; modernity and its risks; the emergence of health and healthcare patterns in the modern age; and the increasing global nature of these trends.
However, it is important to avoid a deterministic outlook that sees nursing as being exclusively reactive in its response to such trends. There is a sense in which nursing must also be proactive in determining how the profession will not only respond to such influences but also how it will shape itself to serve more effectively in the future.
It is important to recognize that the changes now taking place beg questions in respect of the shape our profession will take in the future. Insofar as nursing sees itself as a profession, it is important to reflect briefly upon how this is perceived. A consideration of the etymological roots of the terms is of help. There are two root terms of importance here, both of Latin origin.
The Latin word profession refers to a public declaration and it is the root word of the term ‘profess’ or ‘I profess’. The Latin word vocatio refers to a calling or calling out. Originally, it related to a calling from God to perform some duty or take up some position. Thus we have the first great or high profession: that of divinity or the church. To a call from God, some publicly professed their response to enter into this service.
Carr-Saunders (1955), in what is widely considered the most famous position on the nature of a profession, added two other great professions that also emerged in antiquity: law and medicine. In respect of these three (church, medicine and law), they consisted of learned men, recognized as being possessed of knowledge and skill in a special area of work, and charged with and devoted to the service of others.
Slevin (2003a) has suggested that these elements or properties of a profession can be identified in terms of certain rights and obligations: delegated rights, that include autonomy, monopoly, and rewards; and accepted obligations, that include expertise, integrity, and service.
The extent to which nursing has achieved these professional attributes is one of ongoing debate. It is certainly recognized that nursing has aspired to such status. In this respect, it might be recognized that it has met its professional obligations: nursing might claim to have achieved a degree of expertise attained through higher education; it has certainly (at least in most developed countries) met a condition of integrity by vesting its moral obligations in sophisticated professional codes of conduct; and it might claim to meet the condition of ‘service’ insofar as care is delivered effectively and in accordance with defined standards.
However, on the issue of rights the situation is less clear. It is generally recognized that nurses do not have autonomy except in a few circumscribed situations. It would be hard to identify aspects of the diffuse range of nursing activities that could truly be seen as monopolistic, or exclusive to the work of qualified nurses.
Amongst all these professional attributes, that of autonomy is particularly important in determining professional status in the classical meaning of this term. It seems clear that no matter how far nursing may progress in other respects, the likelihood of achieving true autonomy within the context of how health services have been structured and delivered is remote.
This situation is powerfully recognized, eg by Walsh (2000), and others such as Johnson (1972), Parry and Parry (1979) and Hugman (1998) have described a lesser position for which alternative terms such as ‘mediated’, ‘agency’ ‘ or ‘bureau’ profession have been known.
The aspiration of achieving professional status (in the traditional sense) would in any case require of nursing that it accepts a particular form of advanced knowledge and particular orientations towards maintaining autonomy, demanding monopoly, adopting moral positions and interpreting the notion of ‘service’. In general, these are characteristically rational, logical, empirical, framed in problem-solving outlooks and typically assertive.
It would indeed be remiss of nursing, as a predominantly female profession, if we did not also acknowledge the feminist insights behind this discussion, as addressed by Savage (1987), Davies (1995), Slevin (1999) and Walsh (2000). There is a sense in which the clinical detachment and case orientation of the medical profession is part of a broader masculine orientation, and as such, alien to the compassionate ‘person- centeredness ‘ of the nursing project.
There may of course be other professional groups who can avoid attaching a premium to the caring dimension of their work. But for nursing, this is not an option. Caring is a fundamental issue for nursing, it amounts to our raison d’être. A professional profile that engenders dispassion rather than compassion, clinical coldness rather than human warmth, detachment rather than connection, cannot be an option.
In entering the professional discourse, nursing must itself have a clear sense of the direction it wishes to take—not in terms of its own self-interest but in terms of the interests of those nursing represents, its patients or clients. It is astonishing that this very question was asked almost 20 years ago by Salvage, and we have not yet succeeded in answering it. She stated:
Nurses should not go along with the assumption that gaining professional status for nurses would mean nothing but good for nurses and patients… Even if it could be proven that nursing did fulfill the criteria, nothing would change. We would still be as badly paid, and powerless, and patient care would not change. The question we should ask is not ‘Is nursing a profession?’ but ‘Should we want nursing to be a profession, and if so, what do we mean by it? What are we hoping to achieve, and is this the best way of going about it?’
The trends we have considered create urgency for now arriving at an answer to these questions. A more informed public has begun to question and indeed openly criticize the old monolithic notion of profession. The postmodern turn to which we referred earlier no doubt heralded this critical stance.
As the limits of science have become more transparent, as access to information has become more readily available, and particularly as the negative effects of modernity become apparent, there is an unwillingness to mindlessly accept professional monopoly of knowledge and total autonomy in respect of important decisions to individuals and communities.
The established professions are having to contemplate major shifts in their position within the modern world. Nursing can no longer turn to the old notions of what a profession is to inform how it will meet its responsibilities in the future. We are drawn back once again to Salvage’s (1985) question. Those who will lead in the first decades of this new millennium must seek alternative professional orientations that more appropriately respond to the challenges of a new world.
Old claims to autonomy and monopoly, and old forms of knowledge and knowledge construction will no longer hold. The demands of the new age point more towards involvement, empowerment and negotiation with those we serve, and the seeking of new ways to address new problems.