The power in the nurse-patient relationship: integrative review

An integrative literature review was performed by searching seven of the main electronic health databases order to describe and analyse the production of knowledge about the power in nursing care relationships to hospitalised patients. According to the established criteria, 10 articles were selected from the year 2000 to September 2015. The analysis of these data evidenced that the scientific knowledge and the hospital routines and norms are instruments of exercise of power that end up violating the identity of the person who is transformed into a patient. However, the studies revealed that nursing professionals do not always perceive themselves as exercising power over patients, arguing that they act according to the needs diagnosed care, prescribing interventions, not always agreed with the patients, but resolutive. In short, nursing professionals need to reflect on their work processes to perceive themselves as care professionals and to guarantee the space for autonomy.

The power in the nurse-patient relationship: integrative review http://dx.doi.org/ 10.1590/1983-80422018264274 The care received by the health care system user is generally seen as the result of several small gestures of partial attention that are completed explicitly or implicitly from the interaction between the various caregivers. This process, which compose health care 1 , generates a fabric of acts, procedures, flows, routines, and knowledge that, at the same time, complement and compete with each other. Therefore, to understand the relationships that permeate nursing care among professionals and individuals under their care, it is necessary to observe the scenario in which this relationship is established. In the hospital environment, whether public or private, attention involves the work of several professionals. In these places, the patient is exposed to a situation in which he is hospitalized in an completely foreign environment for him, outside his family life, where he finds routines, norms and procedures aimed at controlling and determining his actions 2 .
This strangeness caused by the hospital environment, coupled with the need for assistance from health professionals, due to a certain momentary condition of fragility, turns the hospital into a dependency relations space. Moreover, the technical-scientific knowledge used in health care surpasses the subjectivity of the subject, and can establish some exercise in this relation of professional power over the body of the being under care 3 .
At this juncture, the nursing team stands out for being composed of professionals who maintain direct and constant contact with the patient throughout the hospitalization, considering the patient´s level of dependence. Therefore, it is understood that this team is more likely to establish power relations during attention to the person under their care 4,5 .
Collière 6 affirms that there can be no life without power, because human existence is the incessant mobilization of forces in constant reaction that are maximize and obstruct to maintain and sustain it. Such a statement corroborates Foucault's idea that a society without power relations can only be an abstraction 7 , because power permeates social life. With this assumption, one can ponder about the power relations in the care practices environment and how they manifest themselves in this scenario.
Understanding the relation of power as something that immanently permeates life in society, and understanding the increasing complexity of the relationship between nursing professionals and inpatients 4 , is admitting that caring is the way to act on the power to exist. Caring mobilizes, uses and develops this power whenever it maximizes it; or, on the contrary, reduces it, contracts it or immobilizes it every time the assistance restricts the capacity of the human being to exert his existence. This leads to the need to better understand the power in care relationships between these professionals and inpatients 6 .
In view of the above, an integrative review of the literature was carried out in national and international publications. The purpose of the survey was to reveal the production of knowledge about the power in care relationships between these professionals and inpatients. The review intends to contribute to the nurses' reflection on their care practice, because it is in the health care that the interrelationship takes place and it is at that moment that beliefs, decency and wishes must be respected, in the name of the ethical principle of the subject autonomy, for human and respectful assistance.

Method
This is a descriptive research in the form of literature integrative review, a research method that allows to identify the knowledge state of a given subject and the gaps that need to be filled with new studies based on the synthesis of multiple published researches. This process leads to more general conclusions about the particular area of knowledge 8,9 .
To guide the development of the review, the following guiding question was formulated: "what has been written in the articles published since the turn of the 21st century on the power that permeates the relationships of nursing care to inpatients?" From this point of view, the descriptors "enfermagem", "poder (psicologia)", "pacientes internados" and "ética" were chosen according to the Health Science Descriptors (DeCS) and the terms "nursing", "power (psychology)", "inpatients" and "ethics", according to Medical Subject Headings (MeSH).
The search for studies has taken place in the following electronic databases: Latin American and Caribbean Literature in Health Sciences (Lilacs), US National Library of Medicine (PubMed) / International Literature in Health Sciences (Medline), Scientific Electronic Library Online (SciELO), Nursing Database (BDENF), Scopus and Cumulative Index to Nursing and Allied Health Literature (Cinahl).
They occurred in the third quarter of 2015. In Lilacs, SciELO and BDENF databases, the following associative strategies were used: "nursing and power (psychology)", "nursing and inpatients", "nursing and ethics", in the "all indexes" fields. The following strategies were used in the Medline / PubMed, Scopus and Cinahl databases: "nursing and power (psychology)"; "Nursing and inpatients", "nursing and ethics". The use of the Boolean operator "and" stands out in both, because its application avoided the recovery of studies whose subject touched other areas of knowledge.
The titles of the publications obtained were read, eliminating those that did not cover the proposed theme, resulting in 171 papers. Then, they were excluded from reading the abstracts, which reduced the sample to 145 articles. In cases where title and summary were not sufficiently enlightening (120), the document was read in its entirety. Most of them referred to the study of power (112), which led to the application of the following inclusion criteria: directly addressing the study of power in the nurse-patient relationship, responding to the guiding question; be fully available online; and have been published in Portuguese, English or Spanish since 2000z.
In the case of studies with participants, we chose those whose informants were patients who were in follow-up, in any mode of care. Furthermore, based on the idea that this study aims to investigate aspects pertinent to the relationship between nurse and patient, we also included research whose sample comprised the participation of both of them. Editorials, biographies, letters to the reader and similar publications were excluded. The articles distribution and the elimination process can be seen in Table 1.
As shown in Table 1, after applying the inclusion and exclusion criteria, 10 papers composed the sample of this review, which were electronically filed for analysis and are presented in Chart 1 according to authorship, year of publication and title. The selected articles were submitted to the analysis from the application of the instrument for external and internal document criticism, usually used in the studies carried out by the Study Group D. Isabel Macintyre, but that in this revision was adapted to ensure the identification and registration of all relevant information 20 .
The external analysis addressed the following variables: database, year of publication, language, origin, periodical and authors qualification. The intern was focused on aspects related to the knowledge of power and its action in the relations established between professional and patient, considering the following variables: the object of study, the methodological approach (including the subject / sample categories, data collection techniques, data analysis techniques and theoretical references) and conclusions.
The information obtained was organized into tables and analyzed in a descriptive way. In order to identify the theme nuclei, the content of the study's conclusions was considered, which, after analysis, allowed to establish three categories: 1) environment as an amplifier of the power relations; 2) technical's and scientism as promoters of asymmetric relations; and 3) patient as being passive and submissive.

Results
The first variable analyzed was the year of publication, and it was verified that most of the articles were published between 2002 and 2008. The predominant language was Portuguese. Although it was included among the inclusion criteria, no articles were found in Spanish that met the research objective. Most of the papers selected come from Brazil, and the remaining studies were divided between publications from other countries. No other work was found, probably due to the search criteria used and / or characteristics of the consulted databases.
Analyzing the linkage to academic programs, it is verified that half of the journals are linked to some national postgraduate program. It is noteworthy that more than half of the articles were published in national scientific journals and a small portion in international journals. From this data, it was possible to verify the classification of publications in the Qualis Periódicos, considering the evaluation area "nursing" and the 2014 version, finding that a very significant portion fit the strata A1 and A2. However, it should be noted that some of the studies had a "not evaluated" Qualis, which means that these journals have only international evaluation. This information is detailed and presented in Table 2. Another aspect analyzed was the authors qualification. For this, the number of researchers was counted in the 10 selected studies, totaling 22, and after exclusion of the repetitions, 21 authors remained. By consulting the metadata available in the articles and also the authors' CVs, it was possible to identify the professional qualifications of all: 62% are doctors; 24% are masters; and 14% are among specialists and graduates, mostly in the "nursing" category.
As to the internal criticism of the articles, in relation to the objects of study, it was possible to verify that 70% of them considered power directly or discussed the asymmetry between professional and patient relationship, and 30% directly addressed the relationship between professional and patient and their participation in the decision-making process in the health care context. Regarding the methodological approach, it is important to note that all the studies were classified as qualitative studies. In addition, it was found that, in relation to the study subjects, half of the articles had both nurse and patient participants. In contrast, only a small portion of the studies included only patients as participants. Regarding the techniques used to collect information, it is noteworthy that most of the articles used some type of interview and some of them associated this technique with others, such as participant observation and drawings made by the informants.
Regarding the analysis of data collected, it showed that not all the articles outlined the technique used. Nevertheless, it was possible to identify that the content analysis was the most used and presented one or more modalities. Table 3 presents the methodological characterization of the studies according to the variables studied. Regarding the theoretical references, the concepts from different areas were used. Regarding the references, 11 were identified: 36% from theories or philosophy of nursing; 36% related to classics of philosophy; 18% coming from sociology; and 9% related to administrative theory. Still on this issue, 19 concepts were used in the discussion of the phenomenon of power in the total publications analyzed:47% worked on concepts of power, relations of power or forces and violence; 21% analyzed the experience of the relation with the other and with the world; 21% conceptualized care; and 11% presented ethical principles such as autonomy and heteronomy.
Still regarding the internal criticism of the studies selected, we proceeded to the analysis of the main conclusions in the documents, which allowed identify their findings about the power in the relations of nursing care. In order to analyze these data, all the conclusions identified (n=45) were listed and comprehensively read in search of similarities and approximations to create statements with the ideas raised. No conclusion was ignored.
Said process showed that 29% of conclusions conveyed the idea that power is directly linked to decision making and to the restriction of the patient's autonomy in the care provided by nursing. Another 11% bring the idea that the relation of power is manifested when the technical and scientific knowledge of the professional surpasses the autonomy of the person cared, and refers to the power of the institutions to which the patient is subjected which would end up negating their knowledge and reducing it to the submissive object.
It showed that 42% of conclusions dealt with actions and factors inherent to the relations of power and care:7% of conclusions consider that the relations between knowledge/power and trust/ power are intrinsic to care relations; 4% indicate that the environment of the care relation enhances the work of power; and 31% showed the need for deeper discussions on power in nursing practices and their consequences for professional practice.
However, it is important to mention that the rest of the conclusions analyzed (18%) emphasizes the role of the nursing professional as a transforming agent of the work of power, being responsible for expanding the autonomy of the patients and encouraging them to self-care and participation in the recovery process.

Discussion
Most of the articles analyzed was published by media highly rated in Qualis, so it is possible to assume that they are high quality publications. This probably relates to the titration of the authors, who are mainly masters and doctors, that is, researchers who are familiar with the scientific context and commitment to the results of their studies and theoretical reflections 21 . It also showed that most of the research was published in the first decade of the XXI century, being worth mentioning that among the publications of this period are predominantly Brazilian studies, which indicates the interest of the nursing professionals of the country in discussing power in this type of relation. This finding may come from the association of this issue with the integrated care and humanization of health services, for which the Brazilian nursing has dedicated many thoughts since they are ideas on which Sistema Único de Saúde (the Brazilian Unified Health System) is built 22 .
The linking between half of the journals to national postgraduate programs reaffirms the idea that a good part of the advances in scientific research is taking place in this global perspective: all articles are indexed on international basis ensuring that researchers from other countries have access to the scientific production of Brazilian nursing. In addition, it should be noted that these journals could influence professional practice since they provide research and disseminate essential evidence to promote significant changes in nursing care. Thus, the publication of these articles cooperates to increase the acknowledgement of the nursing activity as a social practice with direct impact on the quality of life and health of the patients 23 .
The analysis of the objects of study of the articles selected shows that in the Brazilian and international context there are similarities in the way of understanding the topic -most of the researches 10-15 addressed the multiple relations of power in the professional health work among several participants, in addition to their symbolic and concrete effects involving or not patients in the hospital setting.
However, few have turned directly to the topic of caring in the nurse-patient relation demonstrating that this is also a relation of power due to the professional's domain of knowledge/authority over the patient's fragility/subjection [16][17][18][19] .This can be related to the fact that for some authors 13,16 it is impossible to have a human group in which power does not exist and is not experienced daily.
Regarding the methodological approach, the fact that all articles have a qualitative design is pertinent, since this clipping allows understanding the power in nursing care relations. What makes this method effective is its ability to bring to the contextual and interpretive reality of science what was once only subjective 24 .Thus, it is important to mention that qualitative research presents an idealistic, subjective and interpretive view of reality, and allows us to understand relations in meeting/ interaction situations when words, gestures, and various other symbolic aspects blend and allow unique interpretation 25 .
Most of the studies comprising the sample [14][15][16]18 presented both patients and nurses as subjects, suggesting the need to understand the context in which power is inserted consubstantiating the association between both. The interrelation between nurse and patient is a dynamic process in the form of manifest and non-manifest, verbal and nonverbal behaviors, feelings, psychological and/or physical reactions, and it creates a complex network to which these studies have devoted their attention 26 .
However, the few studies 10,11,15 performed with patients alone revealed some flaws in the investigation. Such research could deepen the analysis of the relation of power between them and nurses, since the perspective of nurses needs to be analyzed and verified in order to support procedures and techniques respecting their ethical and moral values and principles 27 .It is important to consider that, although numerically significant, the number of nurses in general is unquestionably lower than the number of people in need of their services, and it is possible that they will become patients under certain circumstances but the opposite is less likely.
Given the complexity involved in the subject, the most used technique to collect information was the interview, since it allows the researcher to know the reality of the other by the communication and interpretation of speeches and gestures 28 . The interview associates to the choice of content analysis as the predominant method for examining information. We believe this fact may be linked to the ability of the method to grasp the core of the message communicated, the expression of meanings and senses, sometimes veiled, that must be interpreted. This method considers cognitive, affective, evaluative, and ideological aspects which give meaning to the discourse and condition its reproduction and mediate the theoretical view of the researcher regarding the object of study 29 .
Considering this methodological characteristic of the sample, the most used theoretical references were analyzed. Most of the studies showed classic references of the philosophy from which the concepts of power, relations of power, strength, and violence were discussed. However, it worth mentioning that all of them take into account the dynamics of the relation examined here, an aspect understood as the main characteristic of care which in turn was conceptualized by nursing references to justify the use of the expression "nursing care relation" used in the present study 16,17 .
Despite the different references, the correlation between the concepts showed significant contribution to broaden the conceptions about the subject. In addition, the purpose of the theoretical thinking is to follow and expand the scientific activities in order to guide the understanding of the situations studied, since its purpose is not to formulate indisputable truths, but to observe reality and, if possible, understand it 30 .
Considering the information collected by the articles studied and their connection with the respective theoretical and philosophical notions, the conclusions of each article were considered the product of this interaction. Thus, the detailed analysis of each of them allowed establish the three categories discussed below.

The environment as an amplifier of power relations
In one of the studies part of this review, the participants referred to the place where attention is given as environment of intense pain, distress, loneliness and abandonment 31 , exposing the patient's feelings of vulnerability during hospitalization. Insertion in this context favors this fragility, since the individual finds himself living with unknown people oblivious to their daily routine, and is obliged to wear clothes that are not their, follow different schedules, and carry out activities that they would not normally do. All this together with illness, pain, fears, procedures, and the anxiety for the diagnosis contribute to the loss of identity and the perception of restriction of freedom experienced by the patient 32 .
The presence of these factors directly influences the patient's ability to understand situations and discern between imposition and proposition, reflecting incisively in their decision-making process. The combination of all these hospitalization aspects interferes with the autonomy of the patient during the health-disease process, which relegates power to the health care providers 33 .
In addition to these factors which can be characterized as subjective, we found another study 12 supporting the idea that the hospital structure -represented by the standards and routines adopted -and its ranking regulated by the exercise of biopower by health professionals restrict the exercise of the patient's autonomy. This hierarchical, inflexible and limited structure was established in the second half of the nineteenth century, when hospitals became environments ruled by technical-scientific and rational standards 34 .
Currently, factors such as the development of technology in health and the increasing improvement of technical-scientific knowledge have favored the hierarchy and contributed to the paternalism of health professionals. In this context, care is often limited to the application of technical and almost mechanical procedures that do not take into account the autonomy of the patient and open precedents for nurses to exercise power over the hospitalized individual 35 .

Technicality, scientism and asymmetric relations
In the field of health, there is a growing concern among professionals to improve their technical and scientific knowledge. This situation increases their responsibilities regarding the level and quality of care provided 36 .However, these care practices and also care giving are influenced by the hegemonic biomedical model which still presides over relations in health and vocational training institutions 37,38 .
This model feeds the function of these professionals who are expected to promote healing and restore health 37 from the Cartesian distinction between mind and body, the understanding of the body as a machine endowed with parts and minimized social, behavioral and psychological aspects linked to the health-disease process 39 . This scenario changes nursing actions into practice guided by and for the disease, not considering the experience of the person in need of care. Such an environment increasingly distances the nurse from the patient, leading them to focus on a type of care guided only by technology 37 .
A study 10 integrating this review shows that the use of standardized techniques and stereotyped attitudes prioritize the routine and comfort of the team to the detriment of the patient's well-being. Another study 15 shows that many health professionals claim that knowledge legitimates them to offer technology to their patients, which over-valuates the technique in relation to the human nature of care 40 .These circumstances confirm the idea that the practice of power in actions aimed at human care is based on the technical-scientific paradigm which currently prevails in the health area 16 .
Another study 13 selected emphasizes that nurses face the challenge of caring for the life that is in their hands in a confident and safe way reaffirming the commitment and technical and scientific competence of this professional with his patient. However, it must be considered that this idea favors the asymmetrical relation in which the scientific knowledge of one overlaps with the sensorial, existential knowledge and the need for care of the other, restricting the autonomy of those receiving the treatment.
Scientific knowledge is essential for the practice of professional care, and therefore is inseparable both from practice and from what regulates it (standards, routines, codes of ethics). However, this perspective brings the discourse taken as truth and described as the relation between knowledge and power, through which the latter exercises its domain 13 .This idea is in line with the research analysis 15 which understands loss of autonomy as also associated with the need for technology consumption that could be replaced by simpler care if it is accepted that the patient knows their body and has the right to decide about it. This would restore the space for the exercise of freedom and autonomy.
The considerations of the study mentioned find support in another work 14 which points to the coexistence between institutional regulatory norms -professional regiment and of health institutionsand legislation of protection to the patient, both results of games of power and knowledge consisting of disciplinary imposition mechanisms through which the power relations between professionals and patients materialize.

The passive and submissive patient
One of the articles 11 of the sample discussed the idea that as they are holders of specific knowledge, many health professionals develop a stereotyped conception according to which the patient would be very ignorant. For this reason, they are considered unable to understand what happens to their body, being relegated to the category of an object submissive of professional care. Another study agrees with this idea when defining the patient as an object whose voice is not heard 31 .
This is also the context regarding the authority to which the patient is the subordinate 11 , a situation that is considered inherent to the production of a disciplined individual and evidences the loss of the patient's autonomy regarding their body 18 . Consequently, the present study also reaffirms the heteronomy in the relations established in health services 15 .
The loss of physical autonomy also conditions the patient to lose space in the decision-making process related to their health. Some studies 11,17 helped identify the omission/regulation of care information or procedures, as well as the nonrequest of informed consent. These aspects can contribute substantially to the inequality of power between health professionals and patients.
In line with this concept of imbalance of power is another study 19 emphasizing that nursing professionals are generally not open to sharing their knowledge and decision-making power with patients, showing a considerable domination over what patients can and cannot do. It is not difficult to argue that this can come from the need to be respected in the relation with the patient. Although many of them are resignifying these behaviors, some studies 17,19 show that this professional often ends up restricting the autonomy of these individuals, even though this does not always occur in a conscious way. Either way, the process can result in paternalism, which will affect the nurses' personal conduct and increase the power coming from their profession.

Final considerations
The present study showed that the theme "power in nursing care relations" arouses the interest of current researchers in the area, since publications have been found since the beginning of the 21st century, especially in the first decade. Research in international and indexed journals has shown that the Brazilian discourse on the subject is brought to the international scientific community. From the methodological point of view, the articles included in this review presented internal coherence in terms of object, objectives, research design, techniques, and production of information. In addition, they adopted techniques of analysis of information based on theoretical frameworks consistent with the nature of the objects investigated allowing considering the results achieved as acceptable.
The analysis of the 10 articles selected showed that scientific knowledge is an instrument of power exercise, as well as hospital standards and routines that violate the patient's identity if blindly followed. The hospital as an environment of care ends up becoming an exercise space for power, since it imposes procedures and technological equipment unknown to the person who is subject to them. The patient accepts this behavior because they believe The power in the nurse-patient relationship: integrative review http://dx.doi.org/10.1590/1983-80422018264274 that it will make them healthy again, even if bringing suffering to them and violating their body or going against their will.
On the other hand, studies have shown that nursing professionals do not always realize that they exercise power over patients, because they believe that they act according to the diagnosed care needs for which they prescribe interventions that sometimes are not agreed. When questioned, these professionals give superficial explanations and persuasive arguments to get over with the plan, occasionally threatening or intimidating poorly collaborative patients in the certainty that they are doing their best for them. Therefore, we concluded that nurses need to think on the health work and understand they are responsible for care, knowledge holders and capable of empowering patients. It is necessary that they are able to understand and criticize daily their way of establishing power relations with the patient, taking into account the autonomy of the person they care for, observing the ethical principles and the right to decide about themselves. In this perspective, the best strategy for creating horizontal relations of power according to what was observed is to establish clear dialogues explaining procedures as accurately as possible, and respecting decisions even when they are different from those that professionals believe are the best.