Propuesta de metodología de compensación

Societies are made up of interconnected groups; this is reflected in the wider society within any country, community or organisation (Porter, 1998). Hospitals reflect this societal structure, without which the health service treatment and care could not be delivered. The work of Durkheim (1858 – 1917), an early sociologist, focused on the roles of social groups, for example the family, and how they contributed to the maintenance of social structure and social laws (Porter, 1998). Health care professions frequently work within small social groups in the secondary care setting; these consist of a range of professionals working in a given ward or clinical area.

174 Each individual member of this group is assigned to a professional group: nurses, medics, radiologists, and other therapists; in some cases this also includes members of social care professions. Participants’ accounts included evidence of this particularly between nurses and doctors (Lee, Nicky and Jo), and with other professionals, as demonstrated in the accounts of Chris, Jordan, Charlie and Ross.

Weber (1864-1920) identified social groups by stratification rather than by class as understood by Karl Marx (1818-83). Weber’s interpretation of social groups through stratification perhaps reflects some of the influences on the nurse’s place within the social context of their professional practice (Porter, 1998). Nurses fall within the final group within Weber’s theory; these are referred to as ‘parties’. Parties have a shared goal which is reflected in the party agenda which results in social status. Nurses achieve this partly through the specialist knowledge and skills they achieve through a programme of education. Equally, medical doctors have achieved social status which appears to hold greater power than other professionals involved in healthcare (Dierckx de Casterle, et al., 2010). It is, however, evident that with new nursing roles, nurses show willingness to challenge doctors’ decisions regarding individual patient’s treatment and care, as seen in participant accounts. For example, when caring for people at the end of life, Jo and Charlie both explained that they challenged doctors’ decisions about aggressive curative treatments (although they were not always successful in changing the treatment plan).

The structural purpose of societies is viewed by Parsons (1937) as having two distinct components, those which are functional and those which are instrumental.

175 Functional actions are those which serve to maintain equilibrium and ensure that the society meets its goals within the wider society, for example meeting the organisation’s targets and the functions are those set out in the organisation’s policy documents (Porter, 1998). Instrumental functions are those which are an end in themselves, such as those of providing comfort to a patient, treating individuals with compassion. Compassion can be seen in participant accounts and appears to be as important to these participants as functional aspects of their work, demonstrated by Charlie when balancing the benefits and burdens of transferring a patient to a non- specialist ward (see Chapter 9).

10.2d Power

Gender also influences the place of nurses within the context of secondary care; nursing, both historically and currently, is a profession dominated by women. Davis (1995) suggests that men can be influenced by female cultural codes and women by male cultural codes, each code valuing different characteristics; masculine social codes value autonomy, power over the world and self esteem, feminine social codes value altruism, group orientation and connectedness (Davis, 1995).

However, this is not the only power differential within the context of secondary care, as demonstrated in Johnson’s (1997) theory of social judgment whereby the patient remains disempowered by the context and social structures within secondary care. Internationally, policy initiatives and the World Health Organisation (Coulter et al., 2008) indicate that power should be transferred to the patient through patient- centred care and the promotion of autonomous decision making. However, the

176 patient’s ‘extraordinary vulnerability’ (as described by Sellman, 2011) through the nature of their condition, the unfamiliar environment and the power health care professionals hold through specialist knowledge, continues to perpetuate the patient’s lack of power, whether actual or perceived. Within participant accounts it has been possible to see how nurses try to promote patient autonomy, for example Chris, when planning a patient’s discharge (see Chapter 5) and Jordan when working with patients who have been recommended surgery to amputate a limb (see Chapter 5). However, as Charlie prepared to transfer a patient to another ward the patient had no influence in the decision to transfer, demonstrating a lack of power. Charlie did empathise with the patient’s situation and strove to minimise the negative impact the move might have had, using the power held as a nurse to influence patient experiences (see Chapter 9).

Historically the nurse was portrayed as the doctor’s assistant who followed ‘his’ directions in caring for the sick (Pugh, 1944). Nursing has been associated with the provision of intimate personal care or ‘dirty work’ and this has resulted in nurses’ position within the multi-professional team as those who do the unspeakable tasks, which other health professionals may see as beneath them Lawler (1991). Interestingly, none of the nurse participants discussed issues associated with ‘dirty work’, although it is implicit in their accounts that this is part of their role. This reflects Lawler’s (1991) research, which showed that some nurses believe that being able to support patients with these intimate and sometimes embarrassing aspects of care is a privileged position appreciated by those to whom they deliver this care but that nurses rarely discussed this type of work and, when they did, it was with other nurses.

177 It is reported that the doctor makes the final decision, particularly in relation to patient treatment (Dierckx de Casterle, 2010) but the doctor may choose to take account of the contribution made by others. When choosing to prescribe treatment to be delivered by others (often a nurse) who do not necessarily agree with the decision, this can result in moral distress for the provider of the treatment (Oberle and Hughes, 2001).

It could be concluded, therefore, that doctors have some authority over nurses, although this is not articulated in a nurse’s contract of employment. The nurse’s line manager is often a higher ranking nurse manager (for example: Blackpool Teaching Hospitals NHS Foundation Trust; 2014; Papworth Hospital foundation Trust, 2014). This demonstrates the doctor’s position of power within this context and the limitations under which the nurse may have to work when trying to abide by The Code (NMC, 2008). The Code (NMC, 2008) clearly states that the nurse has a duty to challenge doctors’ orders when there are concerns that these are not appropriate. Examples of this are seen in the accounts of both Charlie and Jo when discussing the care of patients at the end of life (see Chapter 5).