necessary to produce rational clarity, but to dissolve those barriers which prevent people from living in accordance with their genuine will. Put in another way, its aim is to help people not only to be transparent to themselves but also to cease being mere objects in the world, passive victims dominated by forces external to them.
TABLE 1.1 Barriers to Rational Change (Fay 1987)
| Tradition | – a pre‐reflective state reflected in the assumptions and habitual practices that people hold about the way things should be. |
| Authority and power | – the way normal relationships are constructed and maintained through authority’s use of power. |
| Embodiment | – the way people have been socialised to think, feel, and respond to the world in a normative and pre‐reflective way. |
The influence of these barriers lies thick within any experience. They are evident in patterns of talk that are deeply embodied to serve the status quo (Kopp 2000). It is obvious that to bring about desirable change, these barriers need to be understood, and practitioners are skilful and empowered to overcome them. Thus reflection is concerned with un‐concealing these barriers. Greene (1988, p. 58) writes:
Concealment does not simply mean hiding; it means dissembling, presenting something as other than it is. To ‘unconceal’ is to create clearings, spaces in the midst of things where decisions can be made. It is to break through the masked and the falsified, to reach toward what is also half‐hidden or concealed. When a woman, when any human being, tries to tell the truth and act on it, there is no predicting what will happen. The ‘not yet’ is always to a degree concealed. When one chooses to act on one’s freedom, there are no guarantees.
Tradition
Tradition is reflected in the way practice gets done. It is handed down, perhaps shifting slightly to prevailing ideas and directives. It constitutes ‘normal practice’ and, as such, is largely taken for granted. When tradition is dissected, it can be viewed as the assumptions and attitudes that govern everyday practice. Bohm (1996, p. 69) writes:
Normally, we don’t see that our assumptions are affecting the nature of our observations. But the assumptions affect the way we see things, the way we experience them, and consequently the things we want to do. In a way we are looking through our assumptions; the assumptions could be said to be an observer in a sense.
Practice is contextual set within particular organisational settings. Dawson (2015, p. 25) notes that ‘context refers to the grand societal narratives, those clusters of beliefs and cultural norms that give shape and meaning to the human cultures within which we live’.
Responding in more desirable ways to a situation is likely to disrupt normal practice and require a shift in cultural norms and assumptions and, as such, may be resisted by those who have an investment in maintaining normal practice and its status quo. You might say, ‘I believe in treating patients with dignity and compassion’ and believe your practice reflects that. However, on reflection you may acknowledge that your responses lack these qualities leading to uncaring behaviours what Jameton (1992) and Corey and Goren (1998) have labelled the ‘dark side of nursing’. So next morning you may set out to remedy this in your own practice and get criticised by other staff for getting too involved with your patients. The pressure is immediately put on you to conform to normal practice. You feel the creative tension and the difficulty in resolving it.
Authority and Power
One aspect of tradition is the way authority works through power. Power is embodied through socialisation processes and reinforced through everyday patterns of relating. Hence it is normal and largely unchallenged. Subordinates get told what to do. Play the game, do as you are told, keep your head down to avoid sanction, and then one day you too will gain authority with power over others.
Force is the negative aspect of power used to ensure people conform to certain ways of behaviour endemic within transactional organisations such as the NHS whereby people are subordinate to authority transmitted down through its hierarchy where power is invested in positional roles. Positional power is laced with a coercive threat of sanction if resisted (French and Raven 1968) that can constrain the practitioner from taking desirable action. This works at every level of the organisation. Hence those who exert power at one level have power exerted on them from a higher level.
Power is also invested in professional roles – so for example, doctors often perceive themselves as superior to nurses, coining the expression nurses are the ‘doctor’s handmaiden’.
It can be argued that nursing, as a largely female workforce, has been oppressed by patriarchal attitudes that have rendered it docile and politically passive and thus limits its ability to fulfil its therapeutic potential. If so, then realising desirable practice would require an overthrow of oppressive political and cultural systems. The link between oppression and patriarchy is obvious, considering the way nursing has been viewed as women’s work, and the suppression of women’s voices in ‘knowing their place’ within the patriarchal order of things. Images of ‘behind the screens’ where women conceal their work, themselves, and their significance (Lawler 1991) and images of emotional labour being no more than women’s natural work, therefore unskilled and unvalued within the heroic stance of medicine (James 1989), are powerful signs of this oppression.
No easy task. Those in authority have vested interests to maintain the status quo, to keep people in their place rather than in the place they need to be in tune with realising their vision. Hence being in place becomes a contested arena. As Mayeroff (1971, p. 68) notes:
I am in‐place because of the way I relate to others. And place must be continually renewed and reaffirmed; it is not assured once and for all, for it is our response to the need of others to grow which gives us place.
Fear is a powerful deterrent for being different. It suppresses practitioners from voicing their opinions and asserting autonomy. Yet how comfortable are people in their illusions of truth? Is it better to conform than rock the boat? Is it better to sacrifice the ideal for a quiet life and patronage of more powerful others? Better to keep your head down than have it shot off above the parapet for daring to speak up?
Nurses are taught to ‘know their place’ within the order of things. It is natural for dominant professions such as medicine to reinforce subordinate behaviour in other healthcare professions, such as nursing (Oakley 1984). In other words, doctors are always motivated to maintain the status quo and resist rivalry for power. Nurses rationalise their compliance with medical domination because of the need to be valued. Chapman (1983) suggested that doctors reinforce nurses’ subordination through humiliation techniques that become a normative pattern of relating. Hence it becomes difficult for nurses to claim autonomy to move into the right place to practice desirably, kept in place by both managers and doctors. It is also the same with students and teachers. Even in Universities, teachers traditionally set the agenda and control the classroom. Students learn to be ‘good’ otherwise sanctions will ensue. Of course, some students like practitioners rebel against stifling authority. They are labelled ‘trouble makers’. They often quit rather than lead unsatisfactory lives.
Embodiment
Practitioners are socialised into a culture determined by tradition and authority. This becomes their normal framework for viewing practice. It is what it is whether you like it or not. For an easy life the practitioner conforms to ‘fit‐in’ to be recognised as a ‘good team player’. Because normal ways are embodied they are not normally scrutinised for their appropriateness. Hence we tend to go about practice in the same old way with minor tweaks here