Editorial
Caring and politics: An uneasy combination for nurses?
Meredith Bucknell
Department of Community and Mental Health Nursing,
Faculty of Nursing, Royal Melbourne Institute of Technology, Melbourne VIC
PP: 002 - 004
Article Text
Caring is becoming increasingly politicised. As a psychiatric nurse, an educator and a researcher, I am engaged in political processes. Yet there are aspects of being a political person that create conflict for me in all those roles. I am referring to politics in its broad and narrow sense; I include the administration of events, power relations, activities aimed at achieving influence, and party politics in my use of the word. I have reflected on the centrality of caring in nursing in an attempt to integrate political activity into a personal conception of nursing as a powerful activity.
Acts of caring and caring as a motivation are both integral to the professional practice of nursing. In order to engage in caring/or someone, or caring about a situation, to achieve health goals, I need to be political, to exercise power. All nurses engage in power relations, whether they wish to or not. The therapeutic relationship between nurse and client is a delicate balancing act of negotiated power relations. With highly dependent clients, our expertise and their caring requirements give us power, yet we are also dependent on their consent to continue the caring transaction. In psychiatric nursing, a therapeutic contract may only be achieved after an extended period of bargaining takes place. This interchange may focus on mutual agreement of what health goals are, establishing boundaries and expectations, and modifying behaviours in response to the other's preferences. Either the nurse or the client has the power to withdraw from the relationship. Admittedly, those psychiatric clients who are being compulsorily treated do not have the option of withdrawing from the treatment situation, but there is still impact in their withdrawal from the relationship. Effective nursing occurs when a collaborative relationship exists, and nurses generally aim for this, but at times we resort to manipulation to achieve this end. We reward, bribe, praise, charm and humour our clients to gain their co-operation. Occasionally we plead, flatter, threaten or punish them to achieve the same ends. Of course we prefer to rationally and respectfully offer our services, and work with the client to achieve their goals, but to claim that nursing is always so empowering of clients is to deny not only our expert knowledge (we do, at times, know better than clients what their health problems are, and what is most likely to be effective in resolving them) but also the power inherent in the caring role. The psychiatric nurse cannot truly be in a power neutral relationship with a client. If the health status of clients deteriorates so as to put them at risk, the nurse's duty of care necessitates taking action, possibly even against a client's expressed wishes. Caring in this context means exerting power over the client. Further, the advocacy role of the nurse only becomes necessary because of the erosion of the client's power, whether due to health status, or the client's location within society. The nurturing role most commonly occurs in the context of doing for others what they are unable to do for themselves, that is, when they lack personal power/autonomy.
There are power relations in the organisations and health care settings in which we work. Tensions exist in caring for clients, within limitations imposed by resources, both organisational and personal. Government policies and budgetary constraints impact on nursing care. Reluctant as most nurses are to exert their collective power in industrial action, when they are no longer able to care effectively, to maintain quality care, their power is used to safeguard client care standards. Nursing care is threatened unless nurses assert the power of that care. In order to do this, nurses become more political. Nurses are analysing the political processes behind health policy development and implementation. They can identify the dominant groups and the key stakeholders in the health arena, and develop strategies to enhance their capacity to influence events. Nurses are entering into the decision making arena, and speak with an authoritative voice. Alliance with consumers is one avenue used by nurses for collaboratively working towards shared health goals. Nursing leaders are achieving representation in national and international forums. Yet I feel that nurses' voices are often not heard, and their contribution to health care not valued proportionately to their presence.
The disempowerment of nurses can be attributed to many factors; the status of nursing as a predominantly female occupation, historical influences of religion on nursing identity, the incompatibility of nurturing and power broking, the diversity in nursing practice that makes it hard to speak with a single voice, the development of nursing knowledge from experiences of caring rather than 'science'. I would argue that all these factors are at the same time the source of nursing's strength. Women's ways of knowing and being in the world are increasingly being valued as a means to achieve a more co-operative, inclusive, and sustainable world ecology. The moral ideal of nursing that survives from the vocational era of nursing is crucial to the caring imperative in nursing. To act as advocates for psychiatric clients, to challenge the injustices within the health care system, nurses need to burn with moral indignation.
The nurturing, parent surrogate role, the concern with bodily comforts, touching our clients, are the privileges of nursing. We are able to access our clients through all the dimensions of their experience. The sensitivity and responsiveness necessary for us to do this does seem incompatible with asserting our demands in the political arena. If concern for others is at the basis of nursing, and activating natural caring instincts is the vehicle for becoming engrossed in the experience of our clients, then it is understandably difficult for us to engage simultaneously in a fight against those powerful structures/groups that control nursing care settings. The exponential advance of knowledge necessitates specialisation in nursing to such a degree that nurses become locked into their own domain of expert practice, unaware of and disconnected from nursing in other settings, or with different client groups. But the advantage that derives from this is the universality and pervasiveness of nursing in life. We are involved with people at all stages of life, at all points on the health/illness continuum, we share those quintessential moments of existence; birth, death, pain, trauma, crisis and the struggle for reintegration following injury or suffering. And we do this while retaining a vision of health, growth, and actualisation which communicates hope to those for whom we care. Nurses are learning to adapt the language of science to the experience of caring. The tools of rational inquiry, the impetus of technology, the theory from other disciplines, are being incorporated into nursing knowledge and reinterpreted through nursing research. Gradually we are developing certainty and confidence in the healing power of nursing, measured by others' standards, and increasingly, by our own.
I believe we can be more political, and more caring. We can retain the uniqueness of nursing experience and knowledge, and have a greater influence on health outcomes. We can do this without losing our identity or denying our role as nurturers. Nursing has within it's value system everything needed for it's continuing evolution as a political force. All that is needed is that we consciously apply the values of nursing practice to promoting the development of nursing. Just as we value individual differences and respect the individual choices of our clients, so do we embrace/tolerate the diversity within nursing. Just as we form collaborative and growth enhancing relationships with clients, so do we relate to our colleagues with an appreciation for their varying needs for support and autonomy, creating opportunities for them to reach their potential. This means allowing that somenurses, like some clients, will not always share our goals, will not want to move at the same pace, will not want to be spoken for, nor be able to speak in a language that we understand. The power of caring that we have used to affirm our clients will be used to affirm each other. Knowing that as individuals we cannot be equally powerful, or expert, or talented, we will express our admiration and support for those nurses who are exceptional leaders, thinkers, practitioners, teachers or researchers. Similarly, we will nurture other nurses who are in relatively powerless positions; students, enrolled nurses, nurses from minority cultures, those with family responsibilities, and older nurses. Such a celebration of diversity in nursing frees us from the tyranny of individual responsibility/onus/ burden. We can extend the trust that we have in other nurses to share the responsibility for client care, to trusting other nurses to share all the work of nursing as a discipline. Some will be administrators and policy makers, some will be healers, some will be writers, philosophers, visionaries, some will be technicians, some will be teachers, some will be entrepreneurs, but all will be valued as nurses.
With the transfer of nursing education to the tertiary sector complete, the power of nursing is accelerated. Inclusion in nursing curricula of the study of power and politics is giving graduates an appreciation of means of accessing power, and awareness of the impact of power differentials on health. Exposure to a variety of research methodologies enables nurses to use appropriate tools to expose inequalities and articulate the power of nurses as carers. Academics and practitioners are collaborating in joint research projects, and establishing nursing practice centres, narrowing the theory-practice gap that has bedevilled nursing as a profession and a discipline. The more nursing's voice is heard, the more nursing knowledge is developed, the easier it is for nurses to value themselves, and communicate that esteem to others. We need not abandon our stance as nurturers, conciliators, and altruists in order to do battle with other powerful groups, our approach need not be violent. When we speak from a collective position, confident in our knowledge, secure in our caring role in health care, utilising the diversity within nursing, then we can be heard, then we can make a difference in the world.
Perhaps we could contribute personally to this process by borrowing from popular culture. Make a random act of affirmation to one of your nursing colleagues who is contributing to the work of nursing. By these acts of individual generosity, our power as nurses will continue to grow.
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