The Nursing Process As a Strategy for a (De-)Professionalization in Nursing a Critical Analysis of the Transformation of Nursing in Germany in the 1970S and 1980S
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The Nursing Process as a Strategy for a (De-)Professionalization in Nursing A Critical Analysis of the Transformation of Nursing in Germany in the 1970s and 1980s Jette Lange Thesis submitted to the University of Ottawa in partial Fulfillment of the requirements for the PhD degree in Nursing Sciences. School of Nursing Faculty of Health Sciences University of Ottawa © Jette Lange, Ottawa, Canada, 2020 Abstract In this study, I analyze a discourse that emerged during the 1970s and 1980s in German nursing. At that time, the German healthcare system underwent dramatic changes and economic reorganization, which can be understood as the emergence of the neoliberal rationale in Germany. The argument of cost explosion was used to restructure hospitals into enterprises that were to operate based on the logic of the market. At the same time, the nursing process was introduced into German nursing. The nursing process is a cybernetic, problem-solving cycle containing distinct steps of assessing the patient, planning nursing goals, executing and documenting nursing interventions, and evaluating performance. German nurses valued the nursing process as a central component of the professionalization of the nursing vocation. However, in neoliberalism, professions are seen as obstacles to free competition in marketized areas, and thus strategies such as accounting mechanisms were implemented to decrease their power. Using the historical approach of the history of the present, the perspective of governmentality and insights from critical accounting, this study analyzes the impact of the nursing process on the German nursing vocation. The nursing process needs to be understood as an accounting tool and hence, as a component of neoliberal strategies to make formerly intangible fields of work like nursing service calculable. As an accounting tool, the nursing process does not represent reality in a neutral manner but affects the areas to which it is applied in a constitutive way. As this study shows, the implementation of the nursing process led to reconstituting the nursing vocation into a calculable entity. And while German nurses valued the potential that the call for increased accountability and transparency in nursing care held for their ii professionalization, the findings suggest that a newly constituted accountable nursing vocation can instead be considered as de-professionalizing. iii Content Abstract ........................................................................................................................................... ii Abbreviations ................................................................................................................................ vii Acknowledgements ........................................................................................................................ ix Chapter 1 Introduction ............................................................................................................... 1 1.1 Research Objectives ......................................................................................................... 9 1.2 Research Questions .......................................................................................................... 9 1.3 Organization and Structure............................................................................................... 9 Chapter 2 Background ............................................................................................................. 12 2.1 Societal Transformations in Germany “After the Boom” .............................................. 13 2.2 The Transformation of the Healthcare System .............................................................. 17 Chapter 3 Studies on Developments in German Nursing and on the Nursing Process ........... 21 3.1 Historiography ................................................................................................................ 22 3.2 Critiques on the Nursing Process ................................................................................... 33 Chapter 4 Methodological Considerations .............................................................................. 41 4.1 The History of the Present .............................................................................................. 41 4.2 Historical Discourse Analysis ........................................................................................ 49 4.3 Data Collection and Data Analysis ................................................................................ 52 Chapter 5 Theoretical Framework ........................................................................................... 62 5.1 Biopower and the Development of Expertise in Healthcare .......................................... 63 iv 5.2 Governmentality and the Issue of Professionalism ........................................................ 70 5.2.1 The Neoliberal Rationale and Professions .............................................................. 72 5.2.2 De-professionalization or the Concept of New Professionalism ............................ 83 5.3 Critical Accounting and its Application in Healthcare .................................................. 89 5.4 Summary ........................................................................................................................ 94 Chapter 6 The Nursing Process and Its Way into German Nursing ........................................ 95 6.1 Introductory Explanation................................................................................................ 95 6.2 The Nursing Process....................................................................................................... 98 6.3 The WHO’s Role in the Implementation of the Nursing Process ................................ 104 6.3.1 The WHO’s Construction of Health as an Economic Product ............................. 107 6.3.2 The Nursing Process as an Instrument to Transform Healthcare Services ........... 111 6.4 The German Debate over the Medium-Term Program of the WHO ........................... 121 Chapter 7 The Benefit of the Nursing Process to the Economization of Healthcare ............ 131 7.1 Reorganization of Nursing Care in the Hospital .......................................................... 136 7.1.1 Patients’ Needs as Foundation for the Reorganization of Healthcare Services .... 137 7.1.2 Focusing on Health ............................................................................................... 145 7.1.3 Economizing Subjects in Hospital Care ............................................................... 148 7.2 Making Nursing Service Traceable .............................................................................. 153 7.2.1 Transparency ......................................................................................................... 154 7.2.2 Control .................................................................................................................. 164 v 7.2.3 Quality................................................................................................................... 168 7.3 Digitalization ................................................................................................................ 171 7.4 Accountable Nursing – A Summary ............................................................................ 176 Chapter 8 The Impact of the Nursing Process on the Concept of Professionalism in Nursing ... ............................................................................................................................... 178 8.1 Autonomy Via a Distinct Scope of Practice................................................................. 182 8.1.1 Stepping Away from the Medical Profession: The Focus on Health and Basic ........ Nursing Care ......................................................................................................... 183 8.1.2 Influencing the Patient: The Focus on Cybernetic Holism ................................... 190 8.1.3 Becoming Autonomous: The Focus on Rationality and Accountability .............. 195 8.1.4 Establishing Nursing Research: The Focus on Cost-Containment ....................... 203 8.2 Professionalization or De-professionalization – A Summary ...................................... 208 8.2.1 Implementation of Mechanisms of Mistrust ......................................................... 209 8.2.2 The Decline of Monopolized Knowledge ............................................................. 211 8.2.3 Subordination Under Economic Premises ............................................................ 213 Chapter 9 Conclusion ............................................................................................................ 217 9.1 Summary ...................................................................................................................... 218 9.2 Limitations ................................................................................................................... 224 9.3 Relevance and Implication ........................................................................................... 226 Bibliography ............................................................................................................................... 228 vi Abbreviations AEDL Aktivitäten und existentielle Erfahrungen des Lebens [Activities and Existential Experiences of Life] AKV Agnes-Karll-Verband [Agnes-Karll-Association] BMG Bundesministerium