Political dimension of care: Power dynamics in health and its influence on the nurse work process

Abstract

The study aimed to analyze how the political dimension of care interfere in the work process of nurses and other professionals, in this path, identifying constitutive elements (capitals) of power relations in the field of health. The research used a qualitative approach, with data collection taking place in a city in the interior of Ceará, Brazil, in a Reference Hospital and in Basic Health Units, between February and December 2020, through a semi-structured interview and non-participant observation. Thirty-three professionals were interviewed (nurses, doctors, dentists and physiotherapists), were totalized 43 hours of observation. The findings were analyzed based on Pierre Bourdieu’s “Habitus Theory”. It was observed that power relations interfered in the practice of nurses and other professionals, such interferences were expressed in the form of silences, hesitations and constraints. Some capitals in the field were identified: knowledge, ways of communicating, posture, gender, experience, professional category, friendship relationships, configuring constituent elements of power relations in the health field, therefore, being able to contribute for asymmetries in the distribution of power between agents.

Keywords:
Nursing; Nursing Care; Health Services; Work; Politics

Resumo

O estudo objetivou analisar como a dimensão política do cuidado interfere no processo de trabalho do enfermeiro e demais profissionais, nesse percurso, identificando elementos (capitais) constitutivos das relações de poder no campo da saúde. A pesquisa utilizou abordagem qualitativa, com coleta realizada em uma cidade do Interior do Ceará, Brasil, em um Hospital de Referência e em Unidades Básicas de Saúde, entre fevereiro e dezembro de 2020, mediante entrevista semiestruturada e observação não participante. Foram ouvidos 33 profissionais (enfermeiros, médicos, odontólogos e fisioterapeutas), totalizando 43 horas de observação. Os achados foram analisados a partir da “Teoria do Habitus” de Pierre Bourdieu. Foi observado que as relações de poder interferiram na prática do enfermeiro e dos demais profissionais, tais interferências foram expressas na forma de silenciamentos, hesitações e constrangimentos. Foram identificados alguns capitais no campo: o conhecimento, as formas de se comunicar, a postura, o gênero, a experiência, a categoria profissional, as relações de amizade, configurando elementos constitutivos das relações de poder no campo da saúde, portanto, podendo contribuir para as assimetrias na distribuição do poder entre os agentes.

Palavras-chave:
Enfermagem; Cuidados de Enfermagem; Serviços de Saúde; Trabalho; Política

Introduction

Many agents ensure that care is provided in the health production process: professionals who provide direct care, managers, users, family members, caregivers, and others.

Several professions coexist in this setting, including nursing, which expresses its practice by offering autonomous and collaborative care to individuals of all ages, families, groups, and communities, whether sick or not, and in all environments, promoting health, preventing diseases, treating sick, disabled, or final-life people (ICN, 2002).

Nurses develop care and management activities inseparably in their work process, mediated by power relations, articulating philosophical, political, and technical knowledge in a different work process. They are the only professionals who coordinate the nursing work process since they are responsible for nursing assistants and technicians, and, at the same time, direct the health work process, as they manage the therapies established by the other team members and conduct care activities (Leal; Melo, 2018).

Nurses’ work specificity places clients at the center of attention, as they are directly responsible for the dialogue between professionals regarding the established therapies. Thus, considering that intense social interaction is inherent to the health work process (Oliveira et al., 2016), nurse centrality exposes these professionals to the different tensions in the arena where health institutions are established, and the health production process depends on the aligned interests of nurses, clients, the organization, and the other multidisciplinary team members.

Nursing care comprises an intentional process essential to life, which occurs in the meeting of humans who interact through attitudes that involve awareness, zeal, solidarity, and love, expressing know-how based on science, art, ethics, and aesthetics directed to the needs of the individual, the family, and the community (Vale; Pagliuca, 2011). The political dimension of care comprises power relations established from professional interactions inherent to the health work process. This web of power relations, in which one agent influences the path of another, which is irremediably produced between the agents of the care process, creates an invisible atmosphere that influences how nursing and health care are provided.

In this sense, power is the transformative capacity of social interactions linked to agents’ attempts to make others conform to their desires (Giddens, 2018). Power relations are regulated by autonomy and dependence, always with a two-way street; no matter how subordinate one of the agents in this relationship is, the relationship itself always grants them some degree of power over the other (Giddens, 2018; Bourdieu, 2011).

Pierre Bourdieu clarifies how agents in the field are mobilized based on power relations. He considers that this ability to influence other agents in the field results from symbolic power, corresponding to the power of building the reality that tends to establish an order. This power is invisible and achieves the same effects achieved by imposing physical or economic force (Bourdieu, 1989).

Bourdieu also brings some central concepts into his theory to explain these movements, such as habitus and capital. The first, habitus, comprises the principles that generate practices but are also principles of classification, vision, division, and tastes, from which all the dispositions to perform any action, whether individual or collective, originate, configuring the “unspoken rules” of practices in society (Bourdieu, 1996); the second, capitals, which the author considers as assets that can be accumulated to allow agents to exercise symbolic power. They can be material (economic), cultural (titles) or social (friendships or access to some groups) assets (Bourdieu, 2011).

Some studies have pointed out the fragile political empowerment of nursing professionals (Porto; Thofehrn, 2015), revealing the need to discuss power within this profession, which is relevant because it allows professionals to understand this barely apparent network, but may be limiting their performance as a critical, transformative and, therefore, political agent.

Reflecting on the political dimension of care may allow nurses to navigate this network better, breaking the alienation often inherent to the work process. It also supports reflecting on their place in health as critical and transformative practice agents.

This study aimed to analyze how the political dimension of care interferes with the work process of nurses and other professionals in this path, identifying elements (capitals) that underpin power relations in health.

Methods

The study was conducted in the PHC and Emergency Service settings of a Tertiary Hospital in a medium-sized municipality in the State of Ceará. We selected the emergency service as a setting because this sector accommodates the most significant number of professionals. This is a structuring characteristic for the research since the most significant number of professionals generates greater interactions, thus making it more likely to observe and understand the events that characterize power relations in this field.

In the PHC, the observation was conducted in 2 UBS in the municipal seat because they had more than one health team in the same UBS, one in a very vulnerable area and the other in a less vulnerable one. Choosing UBS with more than one team was due to the exact need of the first setting, as more teams produce more interactions between the agents. The option to research in areas of different vulnerabilities is justified by the consideration that the profile and care needs of clients can interfere with how professionals interact, thus identifying a wider range of interactions.

For information collection, the sample was selected by convenience and divided into two groups: nurses and non-nurses. The group of non-nurses was invited in the following sequence: in the hospital, (1) doctor, (2) physiotherapist, (3) doctor, (4) physiotherapist, (5) doctor, and (6) physiotherapist. In the PHC, (1) doctor, (2) dentist, (3) doctor, (4) dentist, (5) doctor, and (6) dentist, until the saturation point of responses was reached (Minayo, 2017). Participants were identified from a list provided by the service coordinators and invited through visits by the researcher to the fields. Professionals with more than two years of experience were included, and those who were away, either due to vacation or medical certificates, and those who were unavailable to participate in the study were excluded. There were no refusals, but some could not participate due to scheduling conflicts.

In the hospital context, 10 nurses, 3 doctors, and 3 physiotherapists were interviewed, totaling 16 professionals. In the PHC, 11 nurses, 3 doctors, and 3 dentists were interviewed, totaling 17 professionals. In total, 33 professionals participated. In the hospital and PHC, the three professional categories were chosen because they represent those who, at the undergraduate level, have the most intense contact during work. Other professional categories at the technical level were not included, as the education level would be a factor that could configure bias.

We adopted semi-structured interviews and non-participant observation. Due to health protocols resulting from the COVID-19 pandemic, the interviews were conducted in person or remotely via the Google Meet platform outside of working hours. They were held at the participants’ homes and, when held at the hospital or PHC Unit (UBS), in a private room after working hours. Only the audio of the interviews was recorded, and no images of the participants were captured.

Non-participant observation occurred in the morning and afternoon shifts. At the hospital, each observation lasted an average of 2 hours, totaling 19 hours. At the UBS, observations lasted an average of 2h30min, totaling 23 hours. An observation roadmap and a field diary facilitated this stage of data collection. The roadmap contained the following guidelines: 1. Characteristics of professional interactions; 2. Power relations established/critical moments/conflicts; 3. Perceived capitals.

The interviews lasted between 56 minutes and 2 hours and 15 minutes and were conducted from February 22 to December 7, 2020. The same researcher performed the collection and transcription to minimize the loss of information and enhance the interpretation of the meanings of the empirical material gathered. The interviews were transcribed, categorized, and analyzed using Pierre Bourdieu’s “Habitus Theory” as a theoretical-methodological reference (Bourdieu, 2011). Codes identified the statements throughout the text: ENF-APS, APS nurses; ENF-H, hospital nurses; MED-APS, APS doctors; MED-H, hospital doctors; FIS-H, hospital physiotherapists; ODO-APS, APS dentists.

The informed consent form was emailed in advance to participants who completed the interview remotely, and data was collected only after their consent was recorded in the interview or by e-mail. The local Research Ethics Committee approved the study.

Results and discussion

In the hospital context, ages ranged from 29 to 47 years (average 33), with 7 women and 9 men. Service seniority ranged from 2 to 7 years, with an average of 5 years. Time since graduation ranged from 5 to 20 years (average 9), and only four graduated from private institutions. All reported experiences in another hospital besides the hospital that served as the setting for the study. All have Consolidation of Labor Laws (CLT) employment relationships.

In PHC, ages ranged from 28 to 59 years (average of 39), with 12 women and 5 men. PHC service seniority ranged from 2 to 22 years (average 7 years). Time since graduation ranged from 3 to 37 years (average of 12 years). Regarding the employment relationship, only 1 was statutory, 2 were linked to the Mais Médicos Program, and 15 were linked to temporary contracts. Situations that reveal the interference of power relations in health practices were perceived in the field and are expressed in the statements.

Not the category (doctors) but the professional […] complicates things. The patient needs interventions and the professional is procrastinating. Knowing that the patient needs care, knowing that the professional is there to provide that care and this does not happen, causes indignation, exhaustion, a feeling of injustice, and revolt. However, you do not have the autonomy to come and give a voice of command […] (ENF-H-1).

They accept our opinion. If there is a severe patient, we question it, and they comply, but some are hard to deal with. Sometimes, the patient dies, and they (low-complexity doctors) do not want to transfer, thinking that the red-level doctor will be upset. The doctors seem afraid to transfer to the red-level (high-complexity) (ENF-H-2).

I am tired. I try not to spend so much energy if it does not get complicated. Unless it is a (cardiorespiratory) arrest or something more severe. I am trying to relax (ENF-H-6).

I do not have issues with doctors. Not me. I have been through a situation where I saw the mistake and confronted the doctor. He was a nephrologist. I see nurses who see the wrong things and do not speak up (ENF-H-4).

I perform my activities independently, but I am afraid because the political issue of the nursing relationship still prevails. I still have a commissioned position; it is a very fragile relationship. Another fear and concern I have is management. We know that managers can make demands (ENF-APS-3).

[…] I am very shy. I used to stay quiet. Then, sometimes, I see (misconduct) and cannot speak up. When I did speak up, it was much later. I did not speak up, trying to avoid conflict; I know it is not right, but I tried to avoid conflict with management, the patient, and my peer (ENF-APS-4).

[…] I am afraid people will think I do not want to work when I complain. For example, I have suffered much with this, staying from 12 pm until 6 pm at the clinic, and the next day, I did not dare to complain to my manager for fear that she would say, ‘Oh my God, it has only been an hour since the workday, and you are tired. You do not want to work.’ I have always been afraid of this. […] I fear doing this, of being labeled as not wanting to help or work (ENF- APS -11).

I have seen things go wrong. A doctor wearing a procedure glove put his finger in the incision with just the procedure glove on. I saw it and was shocked. I could not do anything. Afterward, I tortured myself because I did not question that doctor. I was with a doctor, who later told me about it, and neither of us questioned the surgeon (ENF-H-9).

Power relations can hinder nursing practices, and this is evidenced in the expressions of “fear”, “apprehension”, and “I could not do anything”. Studies have discussed the interference of power relations between professionals in PHC, especially between doctors and nurses, and point out that how power relations occur strongly influence the quality and ability of professionals to provide care (Oliveira; Moretti-Pires; Parente, 2011; Villa et al., 2015), focusing on knowledge as the main constitutive element of power relations in this setting (Silva et al., 2019). However, they do not expand the analysis to other factors that may interfere with these relations.

A review identified the types of violence suffered by the nursing team in the hospital context. Moral harassment between doctors and nurses was one of the most recurrent, expressing an asymmetrical power relationship between the two categories in which nurses find themselves in unfavorable situations (Pedro et al., 2017). Still, a study with obstetric nurses in Mexico in the hospital environment showed that dysfunctional power relations between doctors and nurses could adversely interfere with care provision (Rangel-Flores; Martinez-Villa; Jiménez-Arroyo, 2022).

The fact that they remain silent and feel restricted may be related to the desire to avoid conflict. In addition, such attitudes may arise from the fear of not having better arguments because they believe that the other person knows more, and they perceive themselves as having limited resources for the dispute, which could embarrass them. Thus, possibly one of the reasons why nurses and other professionals avoid entering into conflicts would be shame, this self-destructive emotion that arises when the dominated begin to observe themselves through the eyes of the dominant; that is, when they are forced to experience their ways of thinking, feeling, and behaving as degraded and degrading (Wacquant, 2006).

Such situations occur through symbolic power, which makes the other keep quiet to avoid conflict. This fact makes nurses fear conflicts with doctors because the latter may have a better argument due to their supposedly greater knowledge, which may embarrass the questioning professionals. Doctors in the less complex locations avoid transferring the user to the more complex one because doctors with more knowledge about critical care may have better arguments to justify the patients remaining where they are.

Thus, when faced with conflict, some nurses avoid it by remaining silent, believing they do not have the capital to win the battle. In this way, nurses may fail to promote changes or behaviors that would benefit themselves or the patients under their care. This behavior is possibly related to the tendency to perceive the “greats” as if they were even greater (Bourdieu, 2008, p. 196), adding to this the tendency of subjects to become accomplices in processes that tend to carry out the probable, which is more accepted in the field (Bourdieu, 2011), which would discourage many professionals from assuming more combative positions in the face of conflicts.

The statements of other professionals also allow us to recognize that, like nurses, they have already experienced situations in which the manifestation of agents’ symbolic power hindered their professional practice.

It is incredible how silent and mute we are regarding these things. I even feel like I am being complicit. I feel so anxious, just like the day we saw the guy being negligent and incompetent, and we got stuck. I do not know what causes this, honestly (MED-H-3).

Because we are so used to the power relationship, the stereotype that the doctor is the world’s owner, we do not want to argue with him because we are afraid of doctors. This makes our profession decline because we fear him (the doctor), and this cannot happen. This happens for historical reasons. Until recently, there was only him. Our professions are new. Today, he shares power with many people; when you share power, you fear losing power and status (FIS-H-2).

It has already happened to a doctor. I saw him when there was a young patient with pancreatitis, and he only intubated her because the nurse begged him to intubate her. She begged him, look at that! Another doctor came and asked what happened and why they did not send her to the ICU, and we waited, but he was right. I even said, do you think this patient needs intubation? He said yes, and she was going to die! I think we end up keeping quiet because of this coldness and ignorance. […] Some people are afraid of what he will say. I think it comes down to misinformation, thinking that he (the doctor) is the one who says what should be done, thinking that he has the final answer, and fear of what he will say (FIS-H-3).

This happened about 15 days ago. I had a patient I was already seeing who had DM (diabetes mellitus), but my colleague still asked for more tests. So I called the ACS (Community Health Worker) and said he could have acted more appropriately because I would not go to my peer’s office and say that. I do not have any contact with her. She is closed off. I do not think she would be welcome (MED-APS-1).

It is a somewhat embarrassing situation, which even goes against professional ethics. Once, a patient had a very severe infection, and a peer prescribed an antibiotic that would not work. So, I called the patient and spoke to him, but at no time did I want to be more than my peer (ODO-APS-3).

The statements reveal that nurses and other professionals are influenced by the power relations established in the work process, highlighting how the political dimension of the care process influences health work.

The findings reveal power asymmetries and how they can limit the potency of health interventions since they limit teamwork, which is troubling because health work is guided by the interrelationship between professionals, where teamwork promotes better performance (Daneliu et al., 2019; Reeves et al., 2017).

Collaboration presupposes the desire to contribute to collective work. To do so, it is necessary to reduce competition and the adverse repercussions of power relations between professionals, which compromise the quality of care for users, families, and the community (Peduzzi; Agreli, 2018) since they limit interprofessionality, as this presupposes collective work in the reciprocal relationship between technical interventions and the interactions of the multiple agents involved, which requires, on the one hand, coordinating the actions of different professionals, and on the other, a complementarity between instrumental action and communicative action (Peduzzi et al., 2020).

Although many participants averted conflict, we identified situations where nurses showed themselves as reality transformation agents, breaking with the inanition imposed by symbolic power and exercising power in the field. However, they recognize that power influences them more than they exercise it.

Knowing how to receive power and exercise power in a middle ground. Most of the time, I can influence professionals. It depends on the professionals we are dealing with (ENF-H-3).

There are times when we cannot influence. Sometimes, during triage, I would see a hyposaturated patient and would take him to resuscitation. The doctor would say that he was fine and to take him to the office. It was frustrating. However, some days you win, and some days you lose. I feel more submissive, but I also have the power to give orders, have my space, and do what I think. I feel more influenced (ENF-H-4).

There have been times when my perception helped change behavior, but other times it has not. I have been able to influence less often than more often. When I see something wrong, I usually speak up. I see myself influencing more than being influenced (ENF-H-5).

I cannot always influence. I realize that I have gained this power with younger people. I do not know if it is due to inexperience. It is because they study more, and we can persuade them. I do not know whether it is because of how they speak or because they are closer to my age. The older ones are more resistant. However, I will give my opinion, although I will not persuade. Argument and evidence are decisive (ENF-H-7).

My friendship makes the work easier. It is easier for a doctor to understand that the patient is serious when I say so than other peers. Even so, I struggle. I think about the vision of some peers, my 20 years of experience, 7 years here, that counts for something. Most of the time, I can influence (ENF-H-6).

I can influence a lot, but not every time. What is decisive is what I showed. I took the lead on my last shift because the doctor was not up to speed. I gained his trust. I think there is a gender issue. We often see no problem between female doctors and male nurses, but there is still difficulty between male doctors and female nurses (ENF-H-8).

I notice power relations in the service. I see myself being influenced more than exercising power (ENF-H-10).

I see myself being influenced more by the power of others (ENF-APS -4).

I am more influenced (ENF-APS -9).

Some elements were identified as influencing/qualifying these power relations; that is, elements such as age, friendship, gender, knowledge, and way of speaking were identified as enabling greater exercise of power. These elements, which allow the exercise of more or less (symbolic) power, are called capitals by Bourdieu (2006).

Friendship relations have been referred to as facilitators of workplace interactions. This event involves an exchange of gifts, which is the only means of establishing lasting relationships of reciprocity, domination, and feelings of obligation (Bourdieu, 2011). Given this, it seems coherent to induce the construction of friendship relationships between professionals, allowing for more functional performances in the workplace.

The effect of forms of communication and their potential to exercise power may be related to the fact that discourses are signs intended to be understood and signs of wealth and authority to be evaluated, appreciated, and obeyed. Language rarely functions as a pure communication tool (Bourdieu, 2008), always expressing more than what is intended to be said.

Gender issues were also observed. Female professionals seem to have more difficulty in developing their activities or are more influenced by symbolic power, ratifying the androcentric vision, thus continually legitimized by the very practices it determines: because their dispositions result from the incorporation of the unfavorable prejudice against the feminine, instituted in the order of things, women can only continually confirm such prejudice (Bourdieu, 2012). Gender relations in health have been the subject of studies, showing that they interfere in care, with nursing very often being in a disadvantaged situation in these relations (Rangel-Flores; Martinez-Villa; Jiménez-Arroyo, 2022). Although nurses can exercise power, making moves to break practices and power relations in the field, most perceive themselves as being influenced by the power of others rather than exercising it.

Other studies also identify power and subordination relations in nursing, including situations of harassment, but they also point to changes, with resistance movements being identified regarding the hierarchical social structures established in health services (Rangel-Flores; Martinez-Villa; Jiménez-Arroyo, 2022). Our findings also identified these changes since, although many participants demonstrated an aversion to conflict, we identified situations where nurses showed themselves as reality transformation agents, escaping the stereotype of a submissive professional predominant in the social imagination.

Considering these events, the idea of care’s political dimension and the work of a politicized professional gains meaning from them. This professional would recognize these power relations and make efforts to move through this dimension and its tensions, causing resistance or disruptive movements, which could produce better results in providing care to clients or in working conditions.

Statements evidence how practice results from the gap between habitus (mental dispositions) and the power relations established in the field (Bourdieu, 2006). Thus, practice originates from what can be done given the power relations established in the field. Thus, the more professionals know and know how to move in the political dimension of care, the more their habitus can be converted into practice.

Given the above, we can affirm that nurses can also exercise power, even under pressure, due to the symbolic power of other team members. These nurses use different artifices to exercise power and mobilize agents in the field: friendships, communication, discursive strategies, and arguments.

Few studies discuss the influence of power relations between professionals in health work since most of the studies that address power in this field have discussed the power relation between professionals and institutions (Lemos; Cardoso Júnior; Alvaréz, 2014; Silva; Mininel; Silva, 2022) or between professionals and clients (Caminha et al., 2021; Sieger; Them, 2012).

The studies found that although they discuss power relations, there is a lack of in-depth analysis of the elements that interfere with them and more detail on the repercussions of these often dysfunctional relations. In our study, we advance by exploring some of these elements and the effects of these relations, which are often represented by limitations in professional practice, such as, for example, silencing, evasions, avoidances, and consents, which are the result of coercion imposed by symbolic power. Another contribution of the study is the proposed thematic category political dimension of care, which could provide incentives for investigations into the several aspects that comprise this dimension, especially the factors involved in establishing power relations.

Most of these studies focused on Hannah Arendt and Michel Foucault as a theoretical framework. Unlike ours, which grounded its analysis on Pierre Bourdieu’s “Habitus Theory”, we could not find any studies that were similar in terms of the theoretical approach used to discuss power relations between health professionals.

The time allocated for field observations is highlighted as a study limitation. Given the complex topic, more observation time is required, which is limited due to the restrictions imposed by the COVID-19 pandemic. It is also important to consider that, compared to face-to-face interviews, remote interviews limit the perception of non-verbal communication. This aspect must be considered for qualitative research.

The lack of other stakeholders’ voices, such as community health workers, nursing technicians, other professional categories, and even clients who share the health production spaces with nurses, prevents consideration of all the nuances involved in exercising and distributing power in health.

Final considerations

The political dimension of care consists of the power relations established by agents in the field. Based on the findings, we perceived how these power relations interfere with professional practice, as they can hinder and shape their practices. The elements that interfere in power relations in health, called capitals, were identified as knowledge, gender, friendship bonds, and ways of communicating, showing that they can influence the formation of power relations.

The analysis of the political dimension of care dialogues closely with other concepts, such as teamwork and interprofessional work. Further studies are needed to clarify the constituent elements of this care dimension and to what extent the interface occurs with other concepts used to analyze the work process in health.

Nurses need to recognize the political dimension of care, know how to identify the capitals that feed it, and, from there, initiate movements to acquire capital to exercise symbolic power in practice settings, leading transformations to improve health services, client care, or that benefit them as a category.

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Edited by

• Editors:
  José Miguel Olivar
  Luziana Silva

Publication Dates

• Publication in this collection
  27 June 2025
• Date of issue
  2025

History

• Received
  25 Jan 2023
• Reviewed
  25 Mar 2024
• Reviewed
  21 June 2024
• Accepted
  25 Nov 2024