The Configuration of Nurse-Patient Relationships: A Critical View
May, Carl R. BScEcon, PhD, Purkis, Mary Ellen Rn, PhD, Scholarly Inquiry for Nursing Practice
This paper sets out the grounds on which a reconfiguration of the ideas currently employed to conceptualize nurse-patient relationships might be founded. It is apparent that much of the rhetoric on which education for nursing practice is founded is difficult to relate to the realities of everyday nursing work. We explore the production of the nurse-patient relationship, in theory and practice as a therapeutic relationship. The paper moves beyond outlining yet again disparities between theory and practice. We argue that a more productive direction for research and analysis aims at understanding conditions that support sustained conduct characteristic of nursing practice in everyday work settings. We demonstrate some of the central conflicts operating between the professionalizing aims of nurses and the establishment of equitable positions for doing the work of nursing.
A recurrent complaint from patients and practitioners alike has been the extent to which modern health care systems objectify and industrialize the experience of being ill (Anderson, Blue, Holbrook, & Ng, 1993; Thome, 1993). Advances in technology have led to practice conditions in which care is seen to be increasingly dehumanized; and a key problem for nurses-in both theory and practice- has been how to remedy this problem (Adam, 1987; Benner, 1991; Lowenberg, 1994). Increasingly, the relationship between nurse and patient has come to be seen as an intrinsically therapeutic device through which remedies to the technological practice context can be delivered (Gadow, 1985; MacMahon & Pearson, 1991; Morse, 1991; Morse, Miles, Clark, & Doberneck, 1994).
Lowenberg (1994) has formulated a challenging critique of the literature on nursepatient relationships in which she argues for an expanded debate on the nature and status of difference in studies of these relations. For instance, Lowenberg suggests that differences among practitioners may have as much to do with the nature of the work nurses do (outpatient services versus operating room services) as they do with the social class and ethnic background of the practitioner (p. 181). In this way, Lowenberg introduces doubt about the efficacy of education for nurses, built around particular ideologically driven models for nursing practice.
In this paper we question the very production of the nurse-patient relationship as therapeutic and the effects of such a conceptualization on the practices of nurses. We undertake this critical inquiry by exploring some of the ways in which ideas about relationships between nurses and patients are currently constituted and how they might be reconfigured to meet the problems posed by the profound disparities between theoretical aspiration and pragmatic achievement when nurses and patients encounter one another in practice settings.
We present our argument in two stages: First, we explore contemporary, critical accounts of how ideas about the nurse-patient relationship emphasize the way in which the patient is specified as a recipient of nursing practices. Therapeutic practices are said to reveal in a holistic and authentic way a set of psychosocial signs and symptoms requiring resolution and disposal within the domain of experience constituted through the presence of nurse and patient together. We highlight existing nursing theories, which do not attend to the constitution of experiences. In this way, we problematize the idea of "authenticity".
Second, we examine the processes and practices through which the work of nursing (understood here as the constitution of domains of experience) represents forms of nursing knowledge. We argue that these forms of knowledge must be understood to include the positioning of participants in workplace interactions. Ideas about what it means to be a nurse and to do nursing work involve, for both the nurse and the patient, the productive work of establishing a sense of location. Negotiating mutual positions within interactions represents a necessary condition enabling the work of nursing, and being nursed, to proceed. …