Michel Foucalt’s concept of governmentality suggests that modern types of government work through forms of moral regulation rather than coercion. Experts such as health professionals play an important role in this.
Tony Gilbert (2001) posits that reflective practice, like supervision, moves coercion out of the public realm and into the personal, moral realm. He suggests that reflective practice makes the individual complicit in their own coercion by operating a sort of surveillance on themselves, and by acting as public agents of coercion in oppressing society by virtue of their own ‘professional’ expertise. Reflective practice encourages the practitioner to take one’s eye off the ball, so to speak, so that all criticism is devoted to discussing the efficacy of different systems of reflection or of supervision.
Gilbert pointedly notes that:
The identification of individual nurses as autonomous practitioners brings with it a moral superiority which can become symbolized through accredited roles such as ‘clinical supervisor’ or ‘advanced nurse practitioner’….. In contrast critical reflection enables the development of self-determination and humanist values which are ethically superior….
In this sense it is the moral superiority of the professional which authorises them to define situations and to claim hegemony over the body.
What the government has explicitly done however is introduce market mechanisms into health care. This makes what care professionals do subject to the priorities of non-professionals (such as measuring audits and outcomes).
To maintain the effectiveness of surveillance people have to know it is there, and this is the purpose of clinical supervision and appraisal, an assertion qualified by Kitchener et. al. (2003) and of professionals being encouraged to develop their reflective practice. In this way, care professionals become agents for the secret agenda of governmentality at the same time as ‘developing’ their own practice.
Gilbert suggests there are two types of reflective practitioner: those who think that reflection can achieve ‘truth’, and those who feel they should take part but remain cautious. Nurses are told that they can discover ‘truth’ through the ability to reflect and understand their own private experiences.
What Gilbert calls “ethically self-managing individuals” is for him the new form of health care professional (which includes nurses). This serves to
regulate the intentions of autonomous individuals rather than the punishment of transgressions.
He points out that whilst nursing as a professions lauds its own emancipation from one of “habitual practice” to “autonomous practice” it is really the exchange of one form of control for another, far more subtle one.
Historically the ritual of the confession has been a primary means of ensuring this ‘self-regulation’. However modern society requires more devious forms of confession such as creative writing and reflective diaries – the latter being a staple of contemporary nurse education. The ‘end product’ (or more accurately the work-in-progress) of nurse education and of professional development is the nurse who is indeed an ‘autonomous practitioner’ but one who is “docile, useful and self-managing’.
In the process of the confession are two parts – the listener and the confessor. In reflection the individual adopts both roles – both elements in this process work according to ritual, according to expected rules of conduct (which involve such elements as history, tradition, inter-professional expectation etc.). In this way the penitent reveals the ‘truth’ about themselves and the confessor suggests recompense and improvement. Gilbert’s argument suggests that popular writers on reflective practice are naive to insist that “the effective practitioner knows, monitors and ensures their own effectiveness”.
Nurses experience a form of ethical tension when they reflect upon the dichotomy between private desire and public duty, which they tend to resolve through their affiliation to a community (nursing or health care), which implies the idea of self-sacrifice in fulfilling their obligation. This also forces the nurse to confront their own weaknesses and failings in the context of a collective (group) responsibility and to act upon these usually in an acceptable way. The expert nurse has an ‘inner supervisor’.
The confessional (the process of reflection) works to enable practitioners to recognize the limitations of their practice while the ethical grid sets out the norms and rules of autonomous practice.
Gilbert powerfully concludes to assert that ‘expert’ practitioners and educators use reflective practice to ‘empower’ others which assumes that the recipients of this expertise are in some way ‘damaged’ and so require repair.
This damaged subject requires remedial work through reflective practice and clinical supervision in order to achieve forms of subjectivity consistent with modern forms of rule.
To put the argument bluntly then: nurses are unavoidably agents of social control (as are all workers recognised by society as ‘expert’ in some way) – [in mental health care of course this is most blatant through the mental health nurses’ articulation of the Mental Health Act] - , and one of the ways in which this agency is achieved is through the false empowerment of reflection and the seeking of the ghost of the autonomous practitioner.
References:
Gilbert, T. (2001), Reflective practice and clinical supervision: meticulous rituals of the confessional, Journal of Advanced Nursing, 36 (2), pp. 199-205;
Kichener, M., Kirkpatrick., I. and Whipp, R. (2003), Supervising professional work under new public management: evidence from an
