Launch of the Centre for Critical Research in Nursing and Midwifery: What is critical research in nursing and midwifery?
Professor Michael Traynor, co-funder of the centre
Talk given on 8th December 2015
Getting approval for this research centre was an unexpectedly long and sometimes frustrating process. But it had the advantage of getting us to examine and re-examine what gave coherence, or potential coherence, to the research that we were doing and planned to do in the future. The challenge, as anyone who has tried to establish a similar centre, or write a narrative for the REF knows, is the need to start from where you are. Do you risk excluding half the work that is done because you want a coherent focus, or do you chance an indistinct identity because you want to include every successful project that colleagues are working on? At around draft number 8 of the proposal for this centre and struggling with Aims, Missions and themes, the penny finally dropped that what genuinely integrated the work that we were doing was not so much to do with its substantive topics but an overall approach. And critical was the word that finally stuck to define it.
So I want to say a very few words about what we mean by critical research (I’m certainly not the first person to do this) and a little about its genealogy in nursing and midwifery research and give a couple of examples from work we are doing. Sue and Helen will talk separately later.
Most research to some extent challenges the taken for granted. That is what makes it research, but research that has gone under the name of critical does this in a relatively programmatic way. Critical research refuses to accept that a research question can ever be a purely technical question. How can we be more productive? Does this drug for depression work better than current drugs, or than a talking-cure? How can we increase resilience among our workers or our students? A question is asked from the interests and perspective of a particular group and in a particular context. And sometimes the interests of one group may be furthered at the expense of others, however benign the overall project might appear like, perhaps the current interest in resilience in the health service. Or perhaps those who bring questions for research are themselves caught up in a policy predicament not of their own making, obliged to seek answers in research when the course of action needed is already clear but the implementation is thwarted. If you read research on resilience done by nurses in various health systems around the world you can read that it is often based on a pessimism about being able to influence those things that are requiring nurses to ‘be resilient’ in the first place.
So critical research sets out to make clear, to illuminate, taken-for-granted assumptions and talks about power and influence and how that is achieved and maintained. And because people don’t always act in their own best interests—critical research can be transformative when it brings this to light because people can start to see that things are how they are for particular reasons.
So what sort of precedents are there for critical research in nursing and midwifery? I think there are very few – but there are some. Jane Robinson’s work comes to mind first. She founded the Nursing Policy Studies Centre at the University of Warwick in the 1980s, funded by what is now the Kings Fund. Jane along with her centre is all but invisible on Google. She teamed up with medical sociologist Phil Strong to write about the impact of general management on the clinical trades in the NHS of the mid 1980s, after the Griffiths reforms. She always put issues in nursing into a social, political and policy context and her conclusions were sometimes unwelcome. For example with Phil Strong she developed the ‘black hole theory of nursing’, the image rather fancifully taken from astronomical theory about which I imagine Jane new very little. Like those super-dense stars, she concluded that nursing remained virtually invisible to policy makers and the most strenuous efforts of the profession’s leaders failed to escape it’s intense gravity. Nursing, she argued, was always caught up in the side effects of health policy aimed chiefly at medicine, often at bringing medicine under the control of governments and managers. She drew attention to the divided interests within nursing that kept its potential power at bay: the division between managers and educators and ward nurses for example. She acknowledged that gender, class and race all contributed to the profession’s lack of power and influence.
There have been other policy centres in nursing since her day, at the London School of Hygiene and Tropical Medicine and at Kings, London but while these centres have done valuable work, their remit was never explicitly critical. There have been individuals producing powerfully critical and insightful work for nursing but they don’t have the prominence that they deserve. I’m thinking of Hannah Cook who has written for decades about violence in nursing and bullying, working now on a teaching only contract at Manchester University. Then there is Joanna Latimer, working in sociology in Cardiff, arguing recently that biomedical and managerialist forces combine to draw nurses – in Emergency departments in her example – to police the patients and divide the deserving of treatment from those who are required to wait longer or to leave. When many nurses draw a sense of identity and worth from thinking themselves patient advocates, her conclusions, based on her and her doctoral students ethnographic work, are shocking and unpalatable to some.
At this point I want to forestall a possible thought that this kind of work is simply negative. The answer is that there is a strong difference between critique and complaint. I believe that we don’t solve problems by minimising them. It is only when we understand the full policy and political influences on a problem that we can see it for what it is and understand the areas where activity needs to take place to address it, sometimes far from the site of the apparent problem. Nurses are experts at complaint but critique involves analysis of causes and the seeking—even if only in concept to start with—of alternatives.
There is of course critical work in many disciplines, despite what commentators like Terry Eagleton see as the university’s general abdication of its critical role. There is critical management studies, and within that field healthcare researchers ask what an overriding concern with efficiency in health services might mean for the practice of traditional professions such as medicine and nursing. There is critical legal studies, for example at Birkbeck, which explores how economic power relations influence legal practices and consciousness. And of course there are other research centres in this university whose work combines a focus on urgent topics with a critique of accepted policy in the area, the work done by migration researchers is just one of many possible examples.
There is room for critique in most research. In fact there is an urgent need to take this perspective. We have recently had the privilege to be asked to evaluate a number of major workforce initiatives in north east London, in the health service. I’m thinking in particular of the launch of the Super-Hub for community-based integrated education for nurses and the introduction across diverse organisations in Islington of the Care Certificate, the basic qualification demanded of health care support workers, that was recommended in the Cavendish report (the government did not agree to recommendations for a regulated support workforce). I think it is fair to say that the bodies charged with making these initiatives happen successfully had their work made much more difficult by policy imperatives characterised by contradiction and unnecessary restructuring within an overall climate of severe financial cutbacks and the difficult decisions that spring from this. We think it is important to spell these out lest it be thought that partial success and difficulties in these projects are a result of personal failure on the part of local bodies. We might even note that the passing down to these local bodies of responsibility without overall control or adequate funding, and increasing fragmentation is a particular approach of neoliberal governments.
Another area where we have made an impact in using our insights into the context in which nurses, even in senior roles, work is research into the role of senior nurses who sit on clinical commissioning groups. These groups now plan and procure most health services in England. Well, so far they do.
These nurses are expected to bring a nursing view to all aspects of CCG business. The role is at a senior level and requires experience of strategic commissioning. However we know very little about how nurses function in these roles. Helen Allan, drawing on work by Berg on ‘new public management’ argues that nurses on CCGs work hard at aligning the interests of biomedicine and managerialism. She argues that the way this nursing role is being implemented might paradoxically offer further evidence of the devaluing of nursing rather than the emergence of a strong professional nursing voice at this level.
So, what we are doing today is just marking the founding of this Centre. The challenge will be what we do now, balancing the demands of any research group in a competitive funding climate, with a desire to influence the preparation of students in nursing and midwifery, to be involved in our local health economy—where a lot of our research contract funding comes from—and to do work that is consistent with the ideas I have just set out. Having a commitment to explore the critical aspect of any research we do, in my view is a real help in providing coherence and depth to our research, more helpful I think than any attempt to focus on a single substantive topic.
We are also pleased and proud that among our colleagues whose main and vital responsibility is to provide high quality teaching for large numbers of undergraduate student nurses and midwives, a great many are taking bold steps in research. We have a group who some call ‘the fourteen’ who are preparing or just have registered for research degrees taking questions from their practice as educators to explore in depth. We have other colleagues who are releasing major textbooks and edited books on specialist subjects like Pharmacology Case Studies for Nurse Prescribers. I don’t know how they find the time for this. They are also needlessly modest. We have others who have made the most of small start-up grants the School has awarded them to develop important research projects with external and sometimes international partners, and get great publications and develop real expertise.
We also have two great research fellows, and administrator (0.2) and a supportive head of department.
So to finish, I’d like to ask: Why is this centre important? Because nursing as a professional community is under enormous pressure in the NHS and, I have to say, is often uncritical and uninformed about the origins of the pressures it faces and about the solutions that are proposed. Nursing needs a critical voice alongside the other voices and we plan, through our work—we have three books coming out in the next year or so, aimed at students, educators and the workforce—to be part of that voice.
The critical theorists of the Frankfurt School, the Institute of Social Research, founded in the 1920s, set out to do research and develop theory oriented toward critiquing and changing society as a whole. Our aim is to make it possible for nurses, midwives, managers and those involved in their education to understand, to put it simply, how we got to where we are and to imagine something different to the status quo. We believe this is the first step to bringing about change, bringing about a health service and education system that is fair to those who use them—patients and students—and also those who work in them.