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The Foucauldian concept of power incorporates the ability to influence the behaviour of another (Cooper, 1994: 437; Foucault, 1982: 221. Expert power has been defined in nursing as ‘the ability to influence others through the possession of knowledge or skills that are useful to others’ {Kubsch, 1996 #485: 198). It is how this influence, or ‘neutral’ power is exercised within the interaction that determines whether it is liberatory or oppressive (Cooper, 1994: 435). Benner (1984: 209), in her seminal book From Novice to Expert, described how skilled and experienced nurses can empower their clients via expert power through the nurse-client relationship, but only, she stressed, when these relationships are based on ‘mutual respect and genuine caring’. Such relationships are crucial to pastoral power and influence how nurses guide the behaviour of clients. A therapeutic relationship of mutual trust, respect and equality where clients are equal participants in the process facilitates the empowerment of clients including those in underprivileged groups (Kuokkanen and Leino-Kilpi, 2000: 237).

The empowerment approach in health care has become prominent following the Declaration of Alma-Ata in 1978 (Falk-Rafael, 2001: 1). This declaration, from an international conference on primary health care, heralded the view of health as a social justice issue – health was acknowledged as a fundamental right for all, and all had a right and duty to be involved with planning and implementing their health care (Aston, Meagher-Stewart et al., 2009: 24; Falk-Rafael, 2001: 1; World Health

Organisation, 1978). Encouraging populations to take control over their own health is a feature of governmentality and the productive aspects of power. Empowerment became identified with health promotion, defined in the Ottawa Charter as the ‘process of enabling people to increase control over, and to improve their health’; a key feature of a new public health movement (World Health Organisation, 1986). Across the health disciplines empowerment has become associated with enabling

people ‘to gain some measure of power in their own lives’, although how this occurs differs according to the discipline focus and setting (Falk-Rafael, 2001: 2).

Chandler’s (1992: 65) definition of empower; ‘to enable to act’, reflects a nursing position which draws on the possibilities for empowerment. Zerwekh’s (1992b: 102) definition of empowerment describes a nurse approach whereby parents are enabled ‘to develop personal capacity and authority to take charge of everyday family life’. This focus melds well with the humanistic caring approach which views caring as helping the client grow towards their potential. Guiding clients in this way is a feature of pastoral power. Empowerment is described as essential to nurse practice when working with families (Aston, Meagher-Stewart et al., 2006; Cawley and McNamara, 2011; Houston and Cowley, 2002; Mitcheson and Cowley, 2003; Rao, 2012).

In line with a collaborative approach, empowerment is viewed as client-centred and is underpinned by the development of a trusting relationship. Negotiating health goals with the client, being a resource of knowledge, building client skills and capacity, and using a strengths-based approach have all been described as features of empowering practice (Falk-Rafael, 2001). They are also features of pastoral power in that they focus on guiding the client towards appropriate behaviours. The use of empowerment in nursing has been focused at the level of the individual rather than at a more radical level of population (social) change. This is due in part to the fact that power in the nursing context has remained largely unexplored.

Much of the nursing literature that examines empowerment fails to address the relationship between empowerment and power (Gilbert, 1995: 865). While readily accepting a positive concept of empowerment in their practice, nurses have expressed discomfort with the idea of power (Rafael, 1996: 3). Nurses engage much more readily with the ‘intuitively attractive’ concept of empowerment, which is closely linked to their conceptualisation of ‘care’ (Ryles, 1999: 600). Where power is considered within the nursing literature, it has been defined as ‘control, influence, or domination’ (Chandler, 1992: 65), and thus is conceptualised in direct opposition to care (Manojlovich, 2007: 2; Rafael, 1996). The interpretation of power as ‘coercion and domination’ (Kuokkanen and Leino-Kilpi, 2000: 236) also conflicts with nurses’ beliefs

around empathic and therapeutic caring. The tension between adverse perceptions of power and humanist perceptions of care suggest the reason for nurses’ discomfort and reluctance to engage with power.

Researchers contend that examining empowerment in nursing practice through a critical lens will reveal underlying dynamics of power (Bradbury-Jones et al., 2008: 258; Gilbert, 1995; Perron et al., 2005). Powers (2003) for example, critiques strategies of empowerment in nursing and argues that empowerment is used as a coercive strategy under the guise of choices offered to clients. The choices presented, however, tend to be limited to what the health professional believes are safe options, while alternative choices outside the dominant paradigm are not offered. Because they are undertaken for the ‘good of the patient’ such strategies may be seen as ‘benign coercion’ with little critique of the exercise of power. However, the essence of power is not so much about who has it or what it is, but how it is exercised (Kuokkanen and Leino-Kilpi, 2000: 237); in this case, how it is applied in nurse-mother interactions.

Attempts to empower clients may prove difficult for nurses as the existing unequal power relationship can operate to constrain fundamental requirements of

empowerment such as open communication (Delmar, 2012; Kuokkanen and Leino- Kilpi, 2000: 238). For example, language can be used to exercise the nurses’ power over, and control of their clients. Hewison (1995: 78-80) described several ways this can occur in interactions with clients in a nursing home: overt practice such as ordering a client to undertake an activity; persuasion such as amicably deterring a client from an undesirable behaviour; controlling the agenda which Hewison describes as using routine communications about what was expected to happen; and using terms of endearment which engendered a mother-child encounter.

Humanistic ideas and approaches to the conceptualisation of care in nursing pre- suppose that the nurse-client relationship is collaborative and enabling. A collaborative rather than expert approach is favoured as it fits with CFH nurses’ conceptualisations of care. This approach centres on communication and client involvement in their own health care, which is constructed as empowerment. These ideals and approaches can

obscure strategies of persuasion or ‘benign coercion’ that are inherent in nurse-client conversations and the presentation of health care information and options. These strategies are central to the exercise of pastoral power.

CONTESTED CONSTRUCTIONS OF CARING, KNOWLEDGE AND