Power, Collaboration, and Culture in Healthcare

Social Construction of Medical and Nursing Knowledge

  • Social construction: Issues like disease, health, and well-being are based on perceptions influenced by culture, society, experience, and individual personality.
  • Knowledge is not neutral: Even validated knowledge is influenced by medical/nursing culture, practices & organizations.
  • Medical knowledge: A particular way of thinking influenced by medical culture, practices, and associated organizations.
  • Nursing knowledge: Influenced by nursing culture, practices, and associated entities.
  • Knowledge as ways of thinking: Schools of thought influenced by class, culture, environment, etcetera, rather than viewing knowledges as neutral and objective.
  • Knowledge can be seen as affected by power, the dominance of professions, and the influence on society.
  • Social Construction of Reality: Peter Berger and Thomas Luckman book if interested in exploring this further
  • Treatment imperative: The principle that underpins the practice of biomedicine.
  • Biomedicine: Sees the body as a machine and aims to fix a broken part.
  • Antibiotics: Saves millions of lives, but are sometimes prescribed for viruses, leading to superbugs.
  • Medical interventions: These treatments are powerful, effective, and proven because they are the products of science.
  • Germ theory of disease (1870): Many diseases are caused by infections and microorganisms.
  • Vaccines:
    • Rabies vaccine (1882).
    • Anthrax vaccine (1881).
    • Polio vaccine (1955).
  • Medical Technology:
    • CAT scans (1975).
    • First test tube baby (1978).
    • Smallpox eradicated (1980).
    • Dolly the sheep, first clone (1996).
    • First vaccine to target the cause of cancer (2006).
  • Medicine's influence: It has power, authority, and social control.

Power in Biomedicine

  • Power: The ability to structure the possible field of action of others.
  • Foucault's Power Knowledge: These dimensions of human life are interdependent. That is one does not exist without the other.
  • Power as a relationship: It's dynamic and shifts (balance of power).
  • Biomedical dominance: Illnesses and diseases are solely about the biology of individuals.
  • Social determinants: Factors outside individual control that impact health.
  • Sociological perspective: Biomedical dominance and medicine as a site of power relations.
  • Medicine's Power: They determine the way people live their lives.
  • Medical Power Extends Across Time and Space:
    • Past (medical history).
    • Present (current conditions).
    • Future (DNA tests predicting risk of disease).
  • Total Surveillance: Medical discourse determines the past and the future.
  • Pregnancy/Birth Example: Medical advice given at all stages.
  • Resource Allocation: More money is spent on treating diseases instead of promoting health.

Nursing Knowledge

  • Florence Nightingale: Her nineteenth century writings were all about high moral tones and about women's roles in the care of the sick
  • Nursing services in Australia developed in the late nineteenth century, and services were mainly provided by charity organizations providing a combination of care for the sick as well as welfare.
  • Nurses at this time were expected to be Christian and to focus on hygiene and morals.
  • Hospitals: Established since mid nineteenth century primarily by charities and churches.
  • Lucy Osborne: Nightingale trained nurses in 1868, there was no formal training for nurses in hospitals
  • Informal training: Not always supported by hospital management, except for training on hygiene, order, and discipline.
  • Doctors: Didn't see the need for nurses to learn except for menial work (cooking, serving meals, washing linen, and hygiene).
  • Change was really slow: Senior nurses struggled to have control over nursing as they became locked in power struggles between doctors and hospital management.
  • Professional nursing: Nurses needed to work together for it to develop.
  • Victorian Trained Nurses Association (1902): The first Australian nursing organization, with a register for nurses and the first nursing journal (United Nurses Association or UNA).
  • Membership: Nurses had to pass exams to practice in relevant states.
  • Occupational closure: Strategy of increasing nurses' knowledge base through education, identifying nurses' scope of practice, development of career pathways, and improvements in pay and work conditions which were all strategies to recognizing nursing professionalism.
  • Doctors in nursing organizations: Doctors blocked nurses' desire for pay rises and better working conditions.
  • Medical bias: Doctors were also editors for the nurses' journals, so they had the power to accept or reject nursing journal content.
  • Queensland (1912): First state to establish a nursing registration board.
  • Nursing registration: It Was seen as the responsibility of hospitals.
  • Medical practitioners: Medical practitioners only achieved full state run registration boards in 1936 after the establishment of their journal, the Australian Medical Journal, later called MJA, in 1857.
  • Medicine controlled nursing: It Placed limits on the practices of nurses and midwives.
  • Biomedical model: Nurses worked within hospitals, and working outside of hospital was not considered.
  • Public health movement: Health care expanded to home visits and school nurses (around 1902).
  • Primary health care setting: A very different culture of nursing compared to real nursing which was seen as within hospitals.

Theories of Professions and Gender

  • Trait Theory: Professions have core characteristics, including a body of knowledge acquired over time from extensive and prolonged training and education that is based on science
  • Core characteristics: Mastery of techniques, self regulation, autonomy, social status, and prestige.
  • Power: Professions employ power to create and control their market of professional services by surrounding their knowledge and mystique to promote their self serving social status and prestige.
    • Medical profession: Carved out a niche in the market where they have gained authority over their work from the state.
  • Goal: To show how medical dominance was created to have occupational autonomy and control over practice and to limit other occupational groups and either exclude or subordinate them.
  • Gender: A social construct based on the values perceptions of the society we live in. That is in this context, what society thinks men and women's roles should be.
  • Traditional stereotypes: Promotion of women in science, the promotion of women in politics, and the interest to increase the number of women in positions of power.
  • Medicine excluded women: Based on stereotypes of women being more suited to caring rather than science, however, things have changed now

Nursing's History and Power Dynamics

  • Hospital-centric nursing: Hospital training based on what the hospital needed.
  • Matrons' Power: Hospital matrons managed to establish their power over nursing organizations and nurses registration boards, although members of the medical profession often held the balance of power
  • Hierarchy and Class Divisions: Most early leaders in nursing were lady nurses (from the middle class).
  • Nurse Organizations: Were reluctant to be involved in industrial actions as they were often dominated by matrons and the medical profession.
  • Matrons' Alignment: They aligned with hospital medicine and the powerful position of the medical profession.
  • Trade-off: Nurses were reluctant to push for better training and better working conditions, as they didn't want to rock the boat.

Nursing Regulations

  • Nursing and Midwifery Board of Australia (NMBA): Regulates nursing and midwifery in Australia to protect the public.
  • NMBA's Role: Develops standards, codes, and guidelines for professional and safe practice.
  • NMBA Functions: Set by the health practitioner regulation national law.

Registered Nurse Standards for Practice

  • Standards one, two, and three relate to each other as well as to each dimension of practice in standards four, five, six, and seven.
  • Standard 1: Thinks critically and analyzes nursing practice. Engage in reflection to develop their practice.
    • Registered nurses respect all culture and experiences, which includes responding to the role of family and community that underpin the health of Aboriginal and Torres Strait Islander peoples and people of other cultures.
    • Comply with regulations and using ethical frameworks when making decisions.
  • Standard 2: Engages in therapeutic and professional relationships.
    • Build mutual trust and respect, collaborative manner, and in partnership.
    • Recognizes that people are experts in the experience of their life.
    • Advocating for people as needed.
    • Effective communication and respectful of a person's dignity, culture, values, beliefs, and rights.
  • Standard 3: Maintains the capacity for practice.
    • Registered nurses to ensure they are safe and have the capacity for practice. This includes ongoing self management and responding when there are concerns about other health professionals' capacity for practice.
  • Standard 4: Comprehensively conducts assessments.
    • Accurately conduct assessments in their practice and to be able to communicate these outcomes to others.
    • Ensure that these are conducted in a holistic and culturally appropriate manner and to work in partnership with others.
  • Standard 5: Develops a plan for nursing practice.
    • This standard is also about working in partnership with others to be able to develop plans as well as to communicate well with others and using the best information available to develop patient plans.
  • Standard 6: Provide safe, appropriate, and responsive quality nursing.
    • Registered nurses must provide quality, safe care that are responsive to the needs of the people that they are caring for.
    • Ensuring that nurses work within their scope of practice, so they are not a danger to the public and works within the relevant legislation, standards, guidelines, regulations, etcetera.
  • Standard 7: Evaluates outcomes to inform nursing practice.
    • The registered nurse taking responsibility for their practice, evaluating their actions, and revising their practices as needed.

Code of Conduct for Nurses

  • Codes set out the legal requirements of the professional behaviors expected for all nurses regardless of workplace settings.
  • Minimum standards nationally and is a document available to the public.
  • Practicing safely, effectively, and collaboratively relates most to person centered practice and the provision of culturally safe practice and respectful relationships.
  • Principle 3: Cultural safe practice and respectful relationships.
  • The value here is nurses engage with people as individuals in a culturally safe and respectful way; foster open, honest, and compassionate professional relationships; and adhere to their obligations about privacy and confidentiality.
  • Nurses must provide care that is holistic, free of bias and racism, and provide culturally safe and respectful care.
  • Aboriginal and Torres Strait Islander peoples: Nurses must understand and acknowledge historic factors that have impacted First Nations people.
  • Culturally safe and respectful practice involves the nurse having self awareness of their own culture, values, attitudes, assumptions, and beliefs, and recognizing how this influences their interactions with others.
  • Only the person and/or family can determine whether care is culturally safe and respectful.
  • Future nurses: You need to be familiar with the code of conduct and practice in accordance to it.

ICN Code of Ethics for Nurses

  • The code of ethics for nurses is a statement of the ethical values, responsibilities, and professional accountabilities of nurses and nursing students that defines and guides ethical nursing practice within the different roles nurses assume.
  • Element 1: Nursing and patients.
    • Provide nursing care to all who need it, to provide people focused, culturally appropriate care that respects human rights and is sensitive to the values, customs, and beliefs of people without prejudice or unjust discrimination, ensuring to obtain informed consent at all times and remembering that people have the right to refuse care and treatments.
    • Effective communication.
  • Element 2: Nurses and practice.
    • Engage in continuous professional development to provide safe care to the public and to promote patient safety.
    • Maintain their fitness to practice so patient care is not compromised.
    • Nurses also need to value their own dignity, well-being, and health.
  • Element 3: Nurses and the profession.
    • Working in collaboration with others to promote positive outcomes for patients, participate and promote favorable socioeconomic and working conditions for nurses.
    • Providing care and working well with others regardless of race, nationality, ethnicity, or language.
    • Engage in ethical behaviors and develop strategies to deal with moral distress during crises such as the pandemics and conflicts.
  • Element 4: Nurses and global health.
    • Value health care as a human right, affirming the right to universal access to health care for all.
    • Contributing to sound health policy development.
    • Understanding the significance of social determinants of health.
    • Collaborating with others to uphold principles of social justice.

Cultural Safety in Healthcare

  • Cultural Safety and Healthcare for Indigenous Australians Monitoring Framework: It collates available data to assess how well we are achieving cultural safety in the health care system for First Nations Australians.
  • Culturally Respectful Health Care Services: Cultural respect achieved when the health system is a safe environment for First Nations Australians and cultural differences are respected.
  • Patient Experiences of Health Care: First Nations population need positive experiences accessing health care where they feel their cultural identity is valued, respected, and empowered in their decision making with the inclusion of loved ones.
  • Access to Health Care Services: Barriers due to affordability, cultural safety, distance traveled, especially in remote areas, and previous experiences of racism when accessing care.