CHAPTER 13. Power and politics in the practice of nursing
Annette Huntington and Jean Gilmour
• understand the nature of power and politics
• have an awareness of different theoretical conceptions of power
• understand the way in which nurses possess power individually and collectively
• understand the advocacy role and how it relates to power, and
• appreciate the complexities of whistleblowing and its consequences.
NURSING AND POLITICS
Nursing is a political activity. Politics, in the broadest sense of the word, is part of all nurses’ lives, especially in the large institutions within which many of us work. It is therefore important that we think about power and politics. At the very least, we need to understand that the health sector is a highly politicised environment at both micro and macro levels, and that the health sector is not an apolitical or neutral site. As nurses, we have considerable power in this highly political arena.
Health is fundamental to life, and nurses are intimately involved in caring for the sick and supporting the healthy, either directly or indirectly, wherever they are working. Nurses are in a privileged position in that millions of people every day put their trust in nurses and assume that nurses will always work on the public’s behalf. When you become a nurse, you accept the obligations and expectations that go with being in that highly responsible and highly respected (particularly by the general public) role. When you become registered, you also accept all that registration carries with it in terms of commitment to a code of ethics, at the centre of which is the safety and wellbeing of those for whom you care. Key to this is using the power that you have wisely, and being aware of the moral and ethical obligations you have because of this position of trust.
Every nurse has a degree of power. Even as a newly registered nurse you immediately have power over patients/clients, who are nearly always in a less powerful position due to your knowledge of both health and illness, and the healthcare system. Knowledge is power, and just the ability to impart or withhold information puts you in a privileged position in relation to the people and/or communities with whom you work. Henderson’s (2003) research in Western Australia exploring the power imbalance between nurses and patients clearly highlighted this, as the nurses in the study showed a reluctance to share any meaningful power with the patients. As the author says: ‘This imbalance of power was most evident in information-giving and during nurse–patient interactions, where nurses used their power to maintain control’ (Henderson 2003:504).
In addition to an individual nurse’s power in the patient/client relationship, nurses as a collective also have considerable potential power. In many countries, nurses are the largest occupational group in the healthcare sector. In New Zealand, nurses comprise 50% of the health and disability workforce (Health Workforce Advisory Committee 2003) and, in Australia, nearly 60% (Commonwealth of Australia 2002). Many of the reforms and restructuring that have taken place in Western health systems in recent years are focused on controlling and managing this considerable workforce—often due to the perceived cost of providing nurses’ services in the health sector. However, these same numbers give nurses power—power that can be used to influence the health system and improve it for both nurses and the public. As Holmes and Gastaldo (2002:563) state: ‘Nurses also form a critical group that challenges the status quo and works for a more equitable society’. To be active in such a way, nurses require an understanding of power and its effects, and the way that they can use their power to enhance the health and wellbeing of people.
Power is often considered a negative and oppressive attribute. However, new definitions of the nature of power by philosophers such as Michel Foucault, who will be discussed in this chapter, incorporate the notion of power as constructive and constitutive, as well as having the potential to be destructive and oppressive. These new definitions also provide nurses with a new way of considering power, a way that means we can view nurses as being powerless in certain situations but very powerful in other circumstances. This frees us from the idea that we are inherently powerless and/or victims, simply through being nurses. This rethinking and reshaping of nurses’ positioning can be particularly valuable in the current climate of global nurse shortages and shrinking health sector resources, which can result in a highly stressful environment in which nurses can feel they have little power to influence or change practices or structures.
In this chapter, we explore the concept of power and its multiple meanings and understandings. We then go on to discuss nurses’ political power, followed by a discussion of power in practice, including issues of advocacy and whistleblowing.
Power is a concept that has many meanings and definitions, and different perceptions of power will influence both people’s actions and the outcomes of these actions. Simple definitions consider power to involve something one person has over another (Poggi 2001), and the potential to be influential—that is, make your ideas known to others and gain their support (Sullivan 2004).
Dye and Harrison (2005) offer a more complex definition of influence, suggesting that it is a form of power where particular effects are produced through a system of reward and punishment. They argue that power is based on access to intertwined resources such as wealth, education, political influence and economics. Resources are not evenly distributed through society, and those with ‘power’ control resources through rewards or the threat of deprivation of resources. An example related to nursing is when managers or clinical leaders control nurses’ workload and conditions through processes such as rostering. The management role can be enacted in a range of ways, from an autocratic top-down directive with no space for personal preferences, to a participatory style of management where the nurses in a ward manage their own roster and the allocation of patient care. Ultimately, however, the manager or clinical leader has the ability to choose how they will organise work and shift allocations, and therefore has the power in this situation.
Michel Foucault (1980), a French philosopher, has another viewpoint on power. He suggests that power is exercised rather than possessed, is productive rather than mainly repressive, and furthermore emerges from below. This means that people traditionally constructed as powerless and oppressed can be seen as actually having agency—defined as the capacity to act and exert power, and therefore affecting the way it is enacted. Power circulates, rather than being localised ‘never in anybody’s hands, never appropriated as a commodity or piece of wealth’ (Foucault 1980:98). People are simultaneously affected by power relationships and participate in those relationships.
Foucault’s definition highlights the flow of power in everyday practices and relationships, and the inherent potential for the exercise of power as a productive force in social relationships. He also differentiates power relations from relations of force or violence where there is no choice and where possibilities are curtailed. The significant factor for nurses in this representation of power is that power relationships involve the possibility of resistance—the person over whom power is exercised has the capacity to react and respond in a range of ways (Foucault 1983).
Feminist writers also focus on power, as it is a central concept in any discussion of agency and/or oppression. Many feminist scholars engage with postmodern thought that considers power, in a similar way to the work of Foucault, as being a discursively constructed relationship, rather than an oppressive force requiring a victim (Peter et al 2004). As Shildrick states:
… what becomes possible is to speak of power, not perhaps in the sense of monolithic structures, but as a field of forces held together in shifting but temporally analysable contestable configurations (Shildrick 1997:115).
While many feminist scholars consider concepts from the work of Foucault and postmodernism to be useful for feminist thinking related to power (Lupton, 2003 and Weedon, 1997), others critique the lack of acknowledgment of the gender dimensions in such constructions of power—gender obviously being a central tenant of feminist thinking around power (Huntington & Gilmour 2001).
POLITICS AND POWER
Politics permeates all aspects of life. Mason et al (2007:4) define politics as ‘the process of influencing the allocation of scarce resources’. As to who is influential, Lasswell (1958) describes them as those who get the most of what there is to get. If success in politics is judged by control over resources, nurses historically have been unsuccessful in the political arena when judged by such factors as pay parity with equivalent professional groups or satisfactory working environments. Sullivan (2004) argues that historical factors still impact on nurses’ degree of influence in contemporary healthcare, with values such as personal discipline, a focus on service and obedience being seen by some as fundamental characteristics of nurses.
While many nurses have effectively engaged in politics at all levels, these values, along with the issues around the gendered culture of nursing (discussed in Ch 12), have limited the full realisation of nurses’ and nursing’s potential for political action, influence and advocacy. Takase et al (2001) also argue that nurses have been historically disadvantaged by their close relationship with medical colleagues. This has positioned the practice of nursing as subservient to the practice of medicine, and impacts negatively on nurses’ perception of themselves. This perception can inhibit nurses from seeing the power that their increasing professionalisation confers.
Politics at state and national level is often thought of as only involving government. Governments are critical bodies for regulating behaviour in that ‘government lays down the “rules of the game” in conflict and competition between individuals, organizations, and institutions within society’ (Dye & Harrison 2005:198). But politics, seen as the exercise of power in the form of influence, is also part of everyday life. Engaging in political action—learning to be more influential in relation to matters that count—is therefore a possibility for all nurses. Sullivan (2004) suggests that influence exists through relationships and is more significant than authority. It is gained through position or respect for knowledge and skills. She also suggests that influence is earned through effort and that the skills of influence can be learnt, the most crucial factor being the personal decision to become influential.
Nurses tend to think that because they are good people doing a good job they should be valued and fairly rewarded and, if that does not happen, they blame themselves or the profession (Sullivan 2004). However, nurses may in fact be unrewarded due to not effectively engaging in the underlying political game—engagement, which requires adherence to a particular set of rules that they may not even know exists. Critically, we as nurses must therefore recognise the existence and reality of politics, the legitimacy and necessity of being involved in politics, and learn skills to gain greater influence if personal and professional goals are to be achieved. Sullivan (2004) identifies some possible workplace strategies for developing influence, including:
• reciprocity with other workers (i.e. exchanging favours)
• having a good understanding of the informal information that circulates within the organisation
• avoiding confrontation
• compromising when necessary to achieve a more important goal
• accepting responsibility for individual actions, both positive and negative, and
• finding a mentor.
The idea of playing workplace politics may not initially resonate with the cherished nursing ideal of teamwork, but having influence and developing assertive and satisfying interdisciplinary relationships are essential factors in nurses being active in ensuring the provision of high-quality nursing care.
NURSES’ POLITICAL POWER
All people have political power as individuals, but nurses also have great potential as a collective body to exercise their power. Australian and New Zealand nurses are increasingly well educated at graduate level and have a growing evidence-based body of knowledge to support nursing practice. Nurses also work in wide-ranging roles in healthcare, spanning clinical, management, research, teaching and health policy domains that provide multiple opportunities to exert influence.
A key element of realising collective power is having formal ways to organise collectives of people for a common cause that is well articulated and appeals to broad segments of the population. In nursing, the protection, support and influence derived from the power of the collective is realised through professional organisations. This is shown clearly in situations such as collective salary bargaining or guaranteed nurse–patient ratios, such as those negotiated in Victoria, which have had a major impact on the working environment for nurses. Neither of these would be possible to negotiate at an individual level. There are many professional bodies that primarily serve to advance the interests of the nursing workforce. As nurses, you have the opportunity to be involved and shape the political activity of these organisations through contribution as a member or at governance level.
One of the most important choices you will make as a registered nurse, therefore, is the decision to join your professional body. The particular structures and focus of nursing organisations varies considerably, but their two broad areas of interest are industrial or employment concerns and what are loosely called ‘professional issues’. Some organisations have two arms and encompass both these aspects, while others will focus specifically on one area. The choice of which organisation to join is up to you, but should be given careful thought, considering what each organisation’s role is, the focus and achievements of each organisation, and what they can provide. An excellent overview of Australian and New Zealand organisations is provided at: www.nurses.info/organizations_australia_newzealand.htm.
While nurses are often considered an homogenous group, it is important to accept that nurses are enormously diverse. As a result, while the overall goal of nursing may be shared by everyone in the profession, individual nurses will not always share worldviews at either the macro or micro level. Therefore, using the power nurses have means being highly skilled at working not only with diverse population groups, but also with diverse nurses and nursing groups. Nurses have widely differing philosophical and political positions, and one strategy for managing this diversity is through the focus that professional organisations can bring. This means that individual difference can be accepted, but organisational power can focus on collective professional issues.
An example of nurses successfully using their collective political power to advance practice through the legislative process is the gaining of prescribing authority. Australian and New Zealand nurses have advocated for changes in legislation and governmental processes to enable nurses (usually advanced practitioners) to prescribe in their scope of practice. In New Zealand, extending prescribing rights to nurse practitioners has been contentious, with some members of the medical profession, such as general practitioners, concerned with potential competition for funding (Mackay 2003). After a drawn out and contested political process, the Medicines (Designated Prescribers: Nurse Practitioners) Regulations 2005 now provide a framework for nurse practitioner prescribing.
Jones’ (2004) description of the approach taken by the Royal College of Nursing (RCN) in the United Kingdom notes that the implementation of nurse prescribing required ‘political machination, the need to construct an effective case, and deft manoeuvring within the corridors of power’ (Jones 2004:266). Initial elements of the strategy to increase political influence included focusing on a clear objective, taking advantage of an existing opportunity (which in the United Kingdom was the review of community nursing), developing alliances with the British Medical Association and pharmacists, and ensuring a unified professional position by managing internal concerns raised by groups such as practice nurses.
Table 13.1 lists some ways of developing influence through knowledge, communication skills and action.
|Nursing knowledge base|
Evidence-based clinical practice knowledge
Patient and family knowledge/agendas/issues
Policy/legislation knowledge at government, discipline and organisational levels
Articulate and assertive verbal communication
Clear and appropriate written communication meeting academic/media/political/popular conventions, depending on context
Respond in a timely and coherent manner
Document using appropriate channels
Take opportunities to be involved in shaping policy through submissions and committee work
Use information technology competently for communication and information retrieval
Relationship of knowledge with power
Power as a circulating force
The capacity for resistance
Differentiation of power relations and force relations
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