Nurses, Clients and Power

[Anxious Patient]

There's a discussion going on at a bioethics blog dealing with patient modesty. The discussion went a little offcourse with an interesting subtopic called "Nurses, Clients and Power". I wonder if you agree if the types of power listed are used by nurses when dealing with patients.

The Powers:

1. Overt Power --Nurses "openly giving orders or making decisions without consulting patients." There was often a shared assumption between patient and nurse that the nurse will be in control. "Thus we can see that overt power is not simply a matter of making people do things against their will. In many cases, patients interpreted nurses' open power as legitimate, and willingly went along with it."

2. Persuasion -- Nurses "cajoling patients to do things that they originally did not want to do. This often involved negotiation. The "nurses' position within the organization of health care gives them a pegged position in the negotiating process."

3. Controlling the Agenda -- This was the most common method nurses used. In this case "the exercise of power is very subtle and comes in the form of manipulation." The nurse appeared to give the patient a choice by asking questions, but the questions were constructed in such a way that, "in reality, patients have little choice but to go along with" the agenda.

4. Terms of Endearment -- This was the most subtle form of power nurses used -- based upon "displays of affection." In other words, treating the patients similar to the way a parent would treat a child.

The study is not a definitive example of how power works within health care -- but as just one example of how power can be studied within the hospital culture.

The source material:

Chapter 8 "Nurses, Clients and Power" by Martin Johnson, in the book Sociology as Applied to Nursing & Health Care by Mary Birchenall et. al.

A. Hewison (1995) "Nurses power in interactions with patients" in the Journal of Advanced Nursing 21: 75-82. The nurses studied were working with the elderly.

The discussion was here:

blog topic: Patient Modesty and Caregivers

http://bioethicsdiscussion.blogspot.com/2009/03/patient-modesty-volume-12.html#c6253700032823945852

poster's entire comment:

http://bioethicsdiscussion.blogspot.com/2009/03/patient-modesty-volume-12.html#comments

[Cul2]

"This is where the medical profession goes wrong, who fault is it that you have 7 patients certainly not the patients fault and I suggest you take that up with your employer" Gepdar

We can approach this two basic ways. We're either all in this together, patients and

caregivers, or we'll fight it out. If nurses are being worked to death in certain hospitals, B

no medical professionals who care have an obligation to help the situation. Join them on the

picket line. Write letters to administration complaining about the nurse work load. Certainly,

nurses like all professionals need to fight for themselves. But, for example, if there were 40 children in your child's kindergarden class with one teachers -- would you advocate for you child and help the teacher to improve the system? I would hope so. Healthcare affects us all, patients and caregivers alike. We need to work together to make it better. Patients -- fill out those survey forms, write letters, give credit where it's due and provide constructive criticism.

It's not us vs. them. It's us, all of us, vs. those in the system who create situations where nurses can't do what they should be doing as well as they can.

[tbrd450]

I'm not quite sure I'm following the main theme of this particular thread, but do I understand that here it is regarding the manipulation of the power imbalance in regard to patient modesty? Convincing a patient, through these power techniques, to allow the cross-gender cath, for example? Or, just power in general -- convincing him/her to get out of bed and walk because he/she just needs to walk a little?

In any case, I happen to think that yes, of course, a degree of this goes on all the time. And, another aspect of this is the patient participation. Many patients (particularly young patients) are particularly suspetible to power ploys, techniques and manipulations.

This is one area where patient advocates would really make a huge difference. A lot of power ploys would never even be attempted knowing an advocate is close at hand.

It is sort like when detectives abandon manipulative interrogations upon learning the suspect's attorney just arrived at the station house.

[anonymurse]

There's a discussion going on at a bioethics blog dealing with patient modesty. The discussion went a little offcourse with an interesting subtopic called "Nurses, Clients and Power". I wonder if you agree if the types of power listed are used by nurses when dealing with patients.

"To a man with only a hammer, every problem looks like a nail." Ya need to take a chill pill, power player.

I've had every power play in the book thrown at me by patients, every game, every dog pack dominance stratagem, every armchair psych theory. Machts nichts. When it's out of their system, it's a done deal. Over. We start from scratch. And every patient I see is new to me, an individual.

I suggest you do likewise for those who provide care for you, first, because it best reflects reality and potentiates a synergistic partnership in healing, second because it must suck out loud to be stuck viewing the world like that, day in and day out.

Give yourself a break. Walk the beach. Feed a pigeon. Take a kid to the playground. Take a deep breath and let yourself feel good about something. Allow yourself to experience every day as the new day it is. Helps me out, why wouldn't it work for you too?

[tbrd450]

It must be extremely difficult for a decent professional to hear/read about these types of potentialities. For professionals that work hard every day to ensure these types of issues never impact his or her care delivery, his or her patient, such considerations must seem demoralizing if not counter-intuitive. To imagine that people are employing such tactics, one has to imagine they are occuring someplace else -- someplace other than my world, my day, my job, my patients.

To a nurse that ensures all her/his patients are treated equally with the utmost respect and consideration on modesty issues, she/he has to try to imagine where are these nurses that are not doing this ??

To those decent, professional nurses and doctors their view of this is going to be slanted from their perspective, naturally. And, when the perspective is that of a decent, professional standard (their own standard) it becomes difficult to entertain that the opposite exists, or that it exists to a larger degree/extent/prevelance than suspected.

For them: Don't own it. It's not yours to own.

Studies have shown that, on average, when surveyed, police officers believe police abuse (power abuse) occurs far more infrequently than it is perceived to occur by the general, non-police public. Why? Two reasons. The first is that they interpret "abuse" on a different scale (from a different perspective) than the non-police general public. They, over time, come to desensitize to the violence they encounter as part of their job. For them, an extra punch or dropped knee doesn't really rise to the level of "abuse." Second, because most police officers do not abuse their power. So, for them, to sketch out an imaginary environment where this is going on, they have to imagine something opposite of what they encounter every day.

It is challenging for good, decent police officers to face the criticism of the general public when bad cops become nightly news regulars, or power abuse becomes the topic for roundtable discussions, or political policy change. Police public image is an ongoing challenge.

I happen to beieve that whenever, wherever, a power imbalance exists, some people will push the envelope further than it should be pushed. The Stanford prison experiment has shown that. And, depending on the context or platform, the impact of such power can be either extremely devasting (abused arresstees and inmates) to far less devastation (patient modesty inconsideration). But it is all the same process.

There will always be these people to some extent. It is likely that the general power tactics described here are employed in a lot of social interactions, between professionals serving people. Sometimes it is just ingrained in "efficient" operational protocol. For example, the male patient in room 334 needs a cath. The female nurse needs to get it done and move on. From her perspective, it is nothing for the patient to be embarrased or upset about since she has done this countless times before, and she intends to do it quickly and with little time for discomfort to set in. It is just another body part. From her perspective, it would just be great if the patient allows it (says nothing), she can get it done and get out. If, God forbid, he should request a male, or insist that the trainee assistant shadowing her that day not be present, well then the process grinds to a crawl - and, this day of all days!, she reasons. She has 10 other patients to see before noon!. The rationalization begins as she approaches the patient's room - Ok, I'll handle this in such a way that the patient isn't fully aware of his rights, she rationalizes. Hopefully, he doesn't realize that asking for male nurse would even ever be considered. I won't really ignore him (and his ignorance), but I'll just not leave the proverbial door open (so to speak) for dialogue on this. Ok, I'll just march in there and in a matter of fact way, pull the sheet back and just get to the procedure -- I won't leave room for discussion or complaint. Before he knows it, I will be done and out of there. If he is upset about it, he will have to just deal with it on his own. That is the rationalization sometimes.

It is not so much an evil attempt at intentionally humiliating a patient, or discounting his/her feelings, or ignoring his/her rights. It is just sometimes perceived as the easiest course of action in a busy day. Sometimes, it seems absolutely necessary. The system sets that stage, not necessarily the nefarious intentions of individual "bad" nurses and doctors.

[oryxandcake]

Once the patient enters the hospital and/or facility, a power imbalance is created. All of those power techniques are used at one point or another - it is embedded in the training of most health care professionals. Before, there was an attitude that the doctor was always right and you went along with what you were told to treat your health problem. Persons did not have information access like we do today. Now the attitude has shifted; our patients are considered customers who are more educated on health issues or atleast, are not as trusting that the health care professionals know everything.

With that, the uses of power (as mentioned above) are less accepted as they were before and are also, more blatant as methods used to obtain what the health care professional wants.

While, I too, do my best to work with the patient - we work in a hierarchical system which encourages a paternalism - almost always you have someone telling another what is best for them. This is ingrained in how we work.

One area of nursing that has fought this is in treating patients who have been sexually assaulted. The focus is on returning the power to the patient in attempt to avoid harming them anymore than they already have (emotionally, physically, spiritually).

Ideally, you would hope that you would be able to educate your patients fully and maximize their choice - this can be difficult in the greatest of places to work. So what this post can teach us all is to recognize that we do use power, daily, in our care of patients. And evaluate what kind of effect that has on our patients vulnerability, health and well-being and also, reflect on how it effects us personally and professionally.

[piperknitsRN]

deleted for multiple posts; please excuse!

[piperknitsRN]

I wish to address the statement made by GEPDAR:

"Many nurses do not deal with life or death on a regular basis in a hospital and the ones who do are paid even more, so to pull that card out is not going to work with me."

I respectfully disagree with the above.

I believe that hospital nursing--and any indeed, any job setting in which a nurse and medical team performs their assigned duties--is by its very nature, concerned with "life and death." One careless mistake or oversight--regardless of inpatient, or outpatient status or level of acuity level--and you could cause irreparable damage or the death of the patient.

Also, I am not sure which nurses/specialties you are referring to in your comment regarding pay that is commensurate with acuity level of the patient, but in every hospital setting I've worked in, nurses are typically paid by years of experience, regardless of their specialty or its level of acuity as deemed by the hospital.

For example, critical care nurses--whose patients are generally considered of the highest acuity in an inpatient setting--make no more than any other nurse in the hospital.

(And, may I add, the perception that ICU's have the "highest level of acuity patients" does not hold true in all cases. I've seen patients just as sick on med-surg/tele floors as those in the ICU, and those nurse who "work on the floor" have much higher ratios, and a very level of high acuity patients to begin with.

These patients often decompensate suddenly and quickly due to their disease processes, and require just as much intervention as those in an ICU until they are stabilized or sent to a critical unit. It takes a lot of savvy, knowledge and experience to take on a full floor load and manage a decompensating patient in addition to the rest of the patients you are assigned.)

The reality is, almost all nurses in an inpatient setting are dealing with very high acuity level patients, regardless of whether or not these patients present to a critical care unit, ER, or any other area perceived to have the most "critical/unstable" patients; and no one gets paid more than another except in regards to years of experience.

[piperknitsRN]

deleted for duplicate post

[tbrd450]

Once the patient enters the hospital and/or facility, a power imbalance is created. All of those power techniques are used at one point or another - it is embedded in the training of most health care professionals. Before, there was an attitude that the doctor was always right and you went along with what you were told to treat your health problem. Persons did not have information access like we do today. Now the attitude has shifted; our patients are considered customers who are more educated on health issues or atleast, are not as trusting that the health care professionals know everything.

With that, the uses of power (as mentioned above) are less accepted as they were before and are also, more blatant as methods used to obtain what the health care professional wants.

While, I too, do my best to work with the patient - we work in a hierarchical system which encourages a paternalism - almost always you have someone telling another what is best for them. This is ingrained in how we work.

One area of nursing that has fought this is in treating patients who have been sexually assaulted. The focus is on returning the power to the patient in attempt to avoid harming them anymore than they already have (emotionally, physically, spiritually).

Ideally, you would hope that you would be able to educate your patients fully and maximize their choice - this can be difficult in the greatest of places to work. So what this post can teach us all is to recognize that we do use power, daily, in our care of patients. And evaluate what kind of effect that has on our patients vulnerability, health and well-being and also, reflect on how it effects us personally and professionally.

Absolutely. The power imbalance is understood. What is changing, as you explained, is that people are starting to question things. People have been educated to the point that they want to know why?

I agree as well on the one area that seems to counter this historical, natural imbalance momentum -- treating those who have been sexually assaulted. This is great in that it serves as a cutting edge, progressive standard by which others (nursing areas) have some basis on which to compare.

Unfortunately, it should be mentioned that such cutting edge, progressive treatment (treatment in which power is turned back over to the patient) serves primarly only half the population -- the female half. This is not necessarily due to any intentional effort to extend it to female victims only, but rather identifying as a victim is not in the male patient playbook. To do so, and receive the treatment they deserve, they must add insult to injury and man-up to the vulnerability of presenting as a victim in the first place. Therefore, any wholesale pardigmn shift across the nursing profession involving an equalization of power between nurse and patient will likely stand to positively impact males more so than females -- for they won't have to jump through hoops to receive the empowering treatment they deserve, the treatment all patients deserve.

[middleager]

A big thank you to the moderators of this thread the opportunity to discuss this subject with professionals from the nursing community and the patient population are rare, especially at this level. After reading this thread there is one thing that seems to be clear, while there are outliers on both sides, nurses that seem to feel their job, their schedule, their their their is what is best for the paitent, they know best, and then there are the patients that think nurses are inheriently evil uncaring and could make the time to accomodate them if the only wanted to. The first fail to realize the the patient experience is more than physical, the second fail to understand they just CAN'T give every patient everything including time every time. Then there are the rest of us, who want to work together, who what to co-operate with each other. If I had a nurse tell me, You need to have a foley catheter I can do it but if you would rather have a male I can get one, but you may have to wait awhile for one to be available........that nurse would have my respect, my trust, and my apprecication. I would probably ask for the male, but the approach would greatly increase the odds I would not only accept her, but do so in a manner that made me appreciate, not resent her. While personally I have a lot of anxiety about medical situations that require exposure infront of females, I think I have much more problem due to the fact that so often I am not given the choice even when its a possiblity. I absolutely do feel there is a double standard in how a males modesty is treated, I have experienced it first hand. But I catagorically refuse to join the ranks that feel nurses are evil, or uncaring, or controlling. What I have found is in the vast majority of the cases, when I have asked, I have recieved accomodation in a compassionate way. So my wish is that patients ask, don't go in with your fists up first, and when you ask realize nurses run a tight schedule under pressure and if you expect accomodation expect that you may have to wait. And nurses, understand that the 6'1" 175lbs man who holds a position where I direct 175 employees, is completely freaked when I am on your turf. I may not show it, but I am. What may be a routine foley to you is humiliating to me. This is about as foriegn to me as it gets. Odds are i am to nervous or perhaps even intimidated to even know what is or isn't reasonable to ask. If you ask me if it matters, if I would feel more comfortable with same gender it could make all the difference in the world and set not only the tone of the event but our relationship. I can see you as someone who didn't care enough to ask or someone who cared enough to ask about me and my comfort, not just my physical condiction...You may be perfectly comfortable but your fully dressed on your home turf, another day at the office, I am not. I can say 90% of the medical personell I have met have been compassionate, great people, when I asked I was generally accomodated, but none, not one asked....please ask, don't assume we are OK with it just because we are going along with it. Thanks for the forum, and nurses thanks for all you do, the vast majority of us know your not the enemy.

[tbrd450]

Middleager,

As a middle ager myself, let me quote the great Arthur Fonzerli -- "Correctomundo!" Ahh..

I agree completely with you on just about every point you made. As a male who is also tuned in to the double standard working against males on the modesty issues, it truly is about having the same consideration as our sisters. Nothing more, just equal consideration and understanding on modesty -- for it impacts us more than most people realize, more than even we often realize. It is not silly. It is not trivial. We are not different than our sisters, in general, when it comes to that stuff. However, there is a major socialization underway to convince us we are -- to convince boys and men it doesn't matter because of the maleness.

Of course most nurses are not evil. In fact, the mere fact that a person chooses such a career is often a very good indicator, all other things equal, that he/she is caring, considerate and motivated by altruistic ideals to some extent.

The power imbalance (the topic of this thread) is necessary in the interest of the overall primary goal -- patient health. Consequently, trust is necessary.

The power imbalance as it pertains to patient modesty consideration is particularly raw with sensitivities -- some of which tie directly to the values of the individual professional as they compare to those of the patient. The gender issue is separate.

[middleager]

It has been sometime since there has been any activity on this thread. I hope it isn't dead. While I understand the purpose of this site is not intended to provide a platform for non-nursing people I do feel the exchange benefits not only the patient but the provider. I personally have gained alot of insight from this site and in paticular this thread. I understand now how nurses get baraged with patients who want accomodation and want it now. I know as a result of this thread the next time I ask for accomodation for my paticular level of modesty I will be sure to include that I understand it may take some time to achieve, and let them know I do not expect them to be at my beckon call. I understand they are busy and I guess I need to let them know I realize that. Often I feel it is the medical system, not the nurses that cause many of these issues. The result is the people in the street, the nurses and the patients end up with a conflict that is created by someone in an office removed from the interaction. A simple example, patients hate those stupid gowns, it is embarassing, it makes us self concious, and often there is no real need for it when a patient is mobile...yet that is standard issue when there are alternatives. Yet, who do we take it out on, either outright or subconciously, the nurses, when it inhibits communication due to the patient being uncomfortable or intimidated who deals with it, the patient and the nurses...yet who chooses the one size fits all gowns due to cost...the administrators...I hope this thread gets new life, it is very valuable