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Rev. Latino-Am. Enfermagem vol.15 no.3 Ribeirão Preto June 2007
Nursing ethics and its relation with power and work organization
Valéria Lerch LunardiI;Wilson Danilo Lunardi FilhoI;Rosemary Silva da SilveiraII;Mara Regina Santos da SilvaI;Jacqueline Sallete Dei SvaldiIII;Michele Salum BulhosaIV
IRN, PhD in Nursing, Professor, e-mail: email@example.com, firstname.lastname@example.org, email@example.com
IIRN, Doctoral Student in Nursing, Professor, e-mail: firstname.lastname@example.org
IIIRN, M. Sc. in Nursing, Professor, e-mail: email@example.com
IVRN at the Municipal Health Secretary of Rio Grande, RS, Master Student, e-mail: firstname.lastname@example.org. Fundação Federal University of Rio Grande Department of Nursing
Difficulties faced in the nursing routine, mainly in hospitals, have been reported without the resulting ethical implications to workers and especially to clients, been sufficiently questioned. The work organization can be the main source of suffering to nursing workers, related to the exercise of power of different actors involved in the health institutions, which can potentially cause multiple problems and distress of ethical order. This study aims to make a critical reflection about some relations between the nursing work organization, power relations and its ethical dimension. Strategies for an ethical performance of nurses and other nursing professionals in the organization of work in the healthcare institutions point to the need of these professionals exercise power in an ethical way.
Descriptors: ethics, nursing; work; power (Psychology); professional autonomy
Due to its nature and characteristics, nursing work itself commonly involves coping with situations of suffering by clients, related to losses, disease, frustration and death, which can constitute a source of suffering for the workers who perform it. The situation of clients who need health professionals' knowledge, can commonly represent suffering, pain, among other feeling, strengthening the professionals' urgent commitment to respect the clients' rights and the permanent need to recognize their human condition. However, contradictorily, nursing work can be perceived as extremely pleasurable, when it can be realized, depending on the obtained results and, also, because it attends to nursing workers' needs of feeling useful and wanting to help(1). In this sense, it seems relevant to highlight that "feeling useful" and "wanting to help" can constitute a necessary but insufficient condition to work in health/nursing.
The organization of health/nursing work, on the other hand, considered as "in a way, the other person's will"(2), can be a greater source of suffering for nursing workers and is related to the exercise of power by the multiple actors involved in health institutions. Therefore, talking about power means talking about the exercise of power, about Power in a relational conception, whose existence depends on multiple resistance points(3). It is relevant to highlight that a power relation needs to be understood as an action not on the others, but as an action on the others' action, whether these are real or possible. Hence, a power relation aims neither for the other's destruction nor his/her annulment, as all relational possibilities would be closed off, but the other's survival as a subject of action is fundamental for the power relation to be sustained and maintained, allowing for answers, reactions, constructions(3).
A new economy of power relations requires the use of forms of resistance against the use of power forms. In a Foucaultian perspective, then, power relations can only occur between free subjects who are capable of resisting, of exercising opposite forces as, in the absence of this freedom, relations of domination instead of power would occur(3). Thus, talking about power necessarily requires talking about forms of resistance, as "power needs resistance as one of its fundamental operational conditions". It is through the articulation of resistance points that power spreads in the social sphere. However, it is through resistance that power is broken. Resistance is at the same time an element of the power's functioning and a source of perpetual disorder. In this sense, if work organization in a way corresponds to the other's will, submitting to the way work is organized can mean submitting to the other's power exercise, to the other's will, accepting, not resisting(3).
Hence, it is important to underline that the way nursing and health work is organized entails implications for the workers and for the clients who are attended and receive care, in terms of the suffering that could and needs to be avoided(4-6). In Brazil, difficulties nurses face in their daily work have been denounced, using different approaches. These are represented by low wages, Double employment with long work days, inappropriate work conditions, precarious material resources, insufficient human resources, disrespectful relations in the health and nursing team, among others, related to the organization of work(1,7-9), without focusing on or at least sufficiently studying the consequent moral suffering and ethical implications for the workers as well as for the clients.
Hence, we present this reflection, aimed at making explicit relations among the organization of nursing work, especially in the hospital sphere, the power relations present there and their ethical dimension. Initially, we appoint evidence of feelings of moral suffering in nursing workers, associated with the way nursing work is being organized and implemented in different spaces, and the consequent situations of disrespect that are experienced, whether by the workers themselves as subjects, or by the clients they attend, due to the disrespect for their rights. Thus, the moral dimension of nursing practice is addressed, associated with the possibility of power exercise by its workers, in order to cope with the multiple moral problems experienced in daily work.
RELATING WORK ORGANIZATION, POWER AND ETHICS IN NURSING
In examining the creation of pleasure and suffering in nursing work, as a contribution to its organization, the expression of feelings of pleasure was observed, associated with demonstrations of the valuation of nursing work, as well as with professional life in a harmonious work environment, based on mutual respect, understanding and a cordial relationship. Feelings of suffering, on the other hand, were associated with anger in the face of assessments of their work, without considering the conditions it is realized in; with the permanent search of better work conditions; with the need to comply with what they acknowledge to be administrative incoherencies, with respect to routines, standards and punishments; to impotence, guilt and fear, in view of the impossibility to carry out what they believe to be correct and of manifesting movements of explicit resistance, considering the risk of punishment; to anguish and concern about using broke equipment and apparatus; to the lack of respect by physicians, exacerbated in emergency situations, leading to a climate of restlessness and fright, among others(1).
In the attempt to get to know how patients' rights are being respected at a hospital institution, feelings of guilt were evidenced in the nurses, due to care actions that were not realized. In the face of the inappropriate work conditions faced in daily work, these professionals' defense of the institution seemed to be more evident than clarifications to the clients. In short, we could verify that the nurses denied the patients' right to information, out of fear of retaliations and punishments by the heads and administration (9).
The "culture of silence" in nursing work, on the other hand, was denounced as creating an apparent harmony and a politically correct environment, favoring the workers' daily contact with error and negligence, with feelings of fear and impotence when acknowledging the need for denouncements. "Superficial and current negligence", including patients' exposure to risks, associated with the administration of wrong medication doses because of unreadable handwriting on the prescription; and/or wrong medication concentrations sent by the pharmacy, among others, which denote lack of respect for the client as well as for nursing, which seems to choose a role of "protecting" the institution and other professionals, without defending its own rights(8).
Feelings of suffering and guilt derive from their perception of connivance because they do not offer the basic and essential care to a death considered as dignified. In view of patients' pain manifestations, the fear of the physician's possible reaction to the questioning of his medication prescription contributes to nursing workers' retracting and giving up any intervention and movement of reaction and resistance, a feeling that seems to be overcome in situations of risk for the patient's life(8).
These situations(1,8-9) show evidence not only of suffering, but of moral suffering by nursing team professionals, caused by disrespect of and even denial of their condition of subjects, due to the need to deny and omit their values, beliefs and knowledge, as well as by the potential disrespect and denial of the clients attended by these teams and their rights as citizens. Thus, it can also be confirmed that health care practice is a moral activity, as the way professionals perform their role entails moral implications(10) for the multiple subjects involved, mainly due to the different relations of forces, of power, of multiple social, cultural, language, knowledge inequalities present there, among others.
Hence, when nursing professionals accept to work in precarious conditions, in organizational conditions in which they cannot perform what they have learned to believe and value and/or do not perform what they can and should, they are denying themselves the opportunity of guaranteeing respect for themselves and their profession and, mainly, failing to guarantee the necessary respect and care for their patients. Thus, it can be questioned: what impact does this situation exert on the professional nurse-patient relation? Do patients know that their care is not adequate? Do they know that they are being disrespected? Are the professionals aware of the relation between the way nursing and health work is organized and their participation or not in this organization, the denial of themselves, of their condition as subjects and, mainly, the denial of patients' rights? Finally, who benefits from these power relations? How have these professionals been taking care of their clients?
The look at daily nursing work can represent an extremely rich source of problems and questions, coping with which requires the permanent construction of partnerships between professionals with a stronger presence in the academy and those predominantly working in health institutions, in an attempt to search and construct strategies that favor the achievement and overcoming of answers. This look commonly seems to focus on nursing work, whether in its organizational or ethical dimension, without sufficiently expressing the possible relations present between the way nursing work has been organized in the health context, the power relations present there and the ethical dimension of this work: What are the ethical implications of nursing work organization? Do nursing and nurses clearly understand that the way their work is being organized entails moral and ethical implications, that is, that their professional practice entails permanent ethical implications? Do the nursing team and nurses understand that their exercise or non-exercise of power can entail ethical implications for themselves as well as for the clients they deliver care to?
The relations present between the organizational environment of work and nurses' ethical action are increasingly emphasized: "Nursing is a noble profession, but also frequently a terrible job. (...) Lack of time, support, resources, respect are mentioned again and again (...) In many nurses' daily life, there is the constant conflict between what nursing could be at its best - the ideal - and what it actually is afterwards - reality. For many nurses, that tension is intolerable" (11).
The frustration and disappointment many nurses experience, independently of their source, frequently are not perceived in their moral dimension: "There is no way of being an ethical nurse in environments where other powerful actors block what nurses acknowledge as their moral obligations", as "ethical problems in health care are inseparable from the social and organizational environment they emerge in"(11). Many authors have acknowledged that the organization and environment of nursing work influence ethical practice more than values and ethical concerns.
Moral problems can be conceptualized as "a situation in which a problem or dilemma is experienced between one's own values and standards and those of other people: a situation that one perceives as being incorrect or that should not occur"(12). These problems reveal to be more evident when nursing professionals appoint feelings of "lack of power" with respect to the patients' well-being.
Resistance, however, as a manifestation of the nurses' power exercise, does not seem to be a stimulated practice yet, neither in teaching nor in care, despite the possible ethical implications and moral problems deriving from the lack of counter-power actions in the power relations we are permanently immersed in. However, "there are moments in life when the question of knowing whether one can think differently from what is thought, and perceive differently from what is seen, is essential to keep on looking or reflecting"(13).
Thus, conflicts can occur when differences in the way a certain situation is perceived cannot be adequately communicated, understood and solved, which can cause moral suffering. Nurses and other professionals from the nursing team can present moral suffering when they are able to make a moral judgment of what they are experiencing and know what action would be morally necessary, but their decision making is constrained, whether by the institutional structure or other workers(14), "associated with feelings of anger, frustration and lack of power"(15).
These conflicts can determine a situation of ethical dilemma on how to make a decision/perform an action(16). Thus, moral suffering provokes a moral dilemma. In a moral dilemma, the professional acknowledges that different, but important values are in conflict in making a decision; however, choosing one option means excluding another, which also provokes moral suffering.
Possible ethical implications associated with the nurses' submission and their apparent difficulty to exercise power in the multiple relations of forces they insert themselves or are inserted in, in the health institutions they work at, have been focused on. Besides the questioning of this apparent "lack of power", there is the argument that nurses underestimate or do not acknowledge their power exercise. On the other hand, when nurses and other nursing professionals, in their professional exercise, refuse to resist against other people's action, they may also be refusing the best possible care for their patients (17), as "power is a critical variable in determining what will be acknowledged as an ethical problem and how public a debate and a solution will become"(11).
Thus, professionals like nurses can avoid responsibilities and "can delegate": a process through which they can avoid making ethical decisions, invoking the authority of physicians (and others representing power at the institutions) as a base for their decision making(18).
By demanding better organizational work conditions, nurses indirectly advocate for the patients, explicitly claiming that their values, as well as their ethical and professional responsibilities, be supported. The advocacy could be made easier if nurses had a greater sense of confidence, which results from their professional self-value.
Unfortunately, when nurses intentionally do not exercise power towards a given professional/ethical agenda, to a certain extent, they participate in their own oppression and are morally guilty for accepting this status quo. Nurses and other nursing professionals need to consider what responsibilities realistically are theirs. These professionals commonly talk among themselves and inside the profession about inequalities, but rarely take their concerns beyond nursing, despite the multiple different possibilities besides resigning, yelling, praying or not doing anything, depending on the situation (14).
Thus, we consider that strategies for ethical actions by nurses and other nursing team professionals, in work organization at health institutions, point towards the need for these professionals to exercise power, in their relation with themselves, with their desires, aspirations, as well as in their relation with others, clients, health professionals, institution managers, among others.
Hence, one of the ways to identify evidences of these professionals' power exercise in the institutional and organizational spaces they are active in, is through the analysis of the movements of resistance they have been constructing in their daily work. However, from an ethical perspective, it is not enough just to exercise resistance against the exercise of power, but this resistance, as well as other actions, needs to be morally founded for its exercise.
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Recebido em: 5.5.2006
Aprovado em: 13.9.2006