This chapter is about the relationship between nurses and their patients and the power that holds it together. It also considers some of the wider issues of power as an aspect of professionalism. We considered professionalism in Chapter 4 and examine nursing professionalism in Chapter 9. In particular, we will examine how it is that nursing care, as currently conceived, can effectively ‘disempower’ patients, despite the official desire to increase their independence. The place of nurses in relation to other professionals is examined briefly; this is developed further in Chapter 9. We then look at the ways in which nurses and patients negotiate, and sometimes collude, in seeking to influence events. In particular, we examine the strategies that patients and their nurses may use to access power and achieve objectives. Sometimes these goals are less in tune with patient preferences than we would like to think. The chapter concludes with a discussion of particular views of power which, though not new, have perhaps been neglected in nursing literature.

Although we all probably imagine that we have an idea of what power means, a concrete definition is usually found wanting.

The great British philosopher, Bertrand Russell (Russell 1938) argued that it is ‘the production of intended effects’, which seems reasonable. If we want to achieve something and we can make it happen, then we must have had the ‘power’ to do so. Unfortunately, this view now seems rather oversimplified. Our actions and those of others may also have unintended effects that illustrate our ‘power’. For example, when nurses put on a uniform it may not be directly to create obedience in their patients, but it often has this type of effect, and of course the nurse’s power to influence the patient’s behaviour increases accordingly.

Both philosophers and sociologists have wrestled with clarifying the concept of power. One of the most widely respected of these, who is seen as both sociologist and philosopher, is Steven Lukes, 1974 and Lukes, 2005. His and other theories of power are examined at the end of this Chapter, but to give a flavour of the complexity, he describes power as ‘ineradicably value-dependent’ and ‘essentially contested’. By this, he means that Russell and others had failed to take into account the history and culture that people bring to the use and the understanding of power.

Many books address the question of the power of the nurse but it may be fair to say that this is often in the context of leadership and the simplistic Russell-type view prevails. Bryan Turner (1987) however, makes the important point that, in the context of work, nurses are for the most part instruments of the power of at least one other occupational group: the doctors. This builds upon the earlier, but still very relevant analysis by Eliot Freidson (1970), in which he argues that all occupations whose work is essentially ‘medical’ in character cannot fail to be subordinate in authority and responsibility to the medical profession. Turner goes on to illustrate how it is that what dentists are allowed to do is very tightly controlled by the medical profession. In this ‘control by limitation’, dentists, despite a 6-year training, are confined to work on the teeth, and may practise wider ‘surgery’ only under strict control. Turner shows how other occupations with claims to manage illness, such as the clergy and practitioners of alternative therapy are controlled largely by ‘exclusion’. The excluding profession maintains a register of legally licensed practitioners to which only the properly qualified are admitted. Turner argues that the strategy through which the medical profession controls nurses is by ‘subordination’. Taking an historical perspective he seems to mean that, partly by means of their status as educated men, doctors successfully convinced not only a willing public and government, but nurses themselves (less well-educated women), that medicine rightfully controls all medical work and that much of this that is mundane should be delegated to ‘inferior’ occupations while physicians and surgeons retain overall ‘responsibility’. If this analysis is correct, we must conclude that much of what nurses do will be, whether they realize it or not, in pursuit of medically desired objectives. This view casts doubt on the validity of much of the rhetoric on the nursing process which speaks of nurses and patients agreeing mutually acceptable goals for which the nurse will be accountable (Roper et al 1996).

Another dimension to the question of nurses’ power base is that they are also subordinated to another group: the professional health service managers, who increasingly have business-related objectives (Traynor 1999). Nurses have begun to sense an important constraint to the development of autonomy in the face of targets set by managers who, for the most part, are not nurses (seeChapter 4 and Chapter 9). Overall, the resultant picture is one where Conrad (1979) feels that nurses can best be described as ‘captive professionals’.

A good deal of the language of the last decade has been in terms of service user, client, or patient empowerment. Even the increasing use of the term ‘service users’ for health service consumers reflects this trend, despite little evidence that patients or clients actually prefer it. The term ‘service user’ generally refers to a person who makes use of the services of health and social care services delivered by professional and related support staff. The term ‘client’ became fashionable in the 1990s. In the case of legal or accounting services, it implied a more equal relationship between the professional and the purchaser of a service. In principle, if unsatisfied, the client can take their money elsewhere. In the private health sector, this could increasingly describe the situation accurately, even though the majority of patients are still paying via a once-removed bureaucracy, such as an insurance plan (rather than with cash). More recently, the words ‘service user’ have become popular (DoH 2005) to imply even greater autonomy of those who might use and benefit from health and social care services. A term more appropriate than ‘patient’ or even ‘client’ seemed to be a good idea, particularly in mental health and learning disability services, as it might remove some of the stigma from holding this status. How equal the professional–service user relationship actually is remains in some doubt, as I hope to show. This section examines the ways in which service users could, and sometimes do, exploit what power is available and how, perhaps more commonly, they comply with nursing and medical goals. I will make no effort, however, to modernize terms such as ‘client’, ‘patient’ or ‘inmate’ when they are used by researchers and theorists. I take the view that in general, the social definition of a word, such as service user, is determined by the use of the word by real people rather than by Government Policy.