A Time to Heal:
Creating Healthy Conditions for Service
By Peter Block
...continued
Nursing, more than almost any other profession, defines the meaning of
service. The nurse is the front line, what we might call the touch
labor, of the U.S. health care system. The job represents the heart and
soul of authentic health care.
Why, then, is there a shortage of nurses and why do so
many nurses find the job so stressful? The crisis is not about the work
itself, but how to create more fulfillment in the work. The problem is
not primarily lack of skill or motivation, but the context in which the
work is done.The agenda for health care reform
does not focus on those delivering the service; it’s mostly reduced to a
problem of cost and restructuring how the system is managed. Reform has
become an issue more of politics and economic interests.
Those providing the care—physicians and
nurses—occupy only a small part of the conversation. This is tragic for
a nation that outspends any other country on health care and ranks
barely in the top 10 in effectiveness.
If we want to create a system where
nursing can fulfill its purpose of being a calling for service and
healing, we need to focus attention on the conditions within which
nurses work. Two of these are: a) the capacity of nurses to set limits
and boundaries for themselves and b) the quality of relationships
between nurses and physicians.
Each of these conditions has an
impact on patient safety and the quality of care in our health care
institutions. Changing these conditions means that nurses need to first
care for themselves to sustain personal strength. Second, they need to
become active in reforming the critical relationship between nurses and
physicians.
Setting boundaries as an act of
self-care
At the center of sustaining our
sense of purpose and personal power is our capacity to maintain
boundaries. Boundaries give us a sense of empowerment, the belief that
our life and work are ours to choose. The essence of personal
empowerment is the capacity to say no. If we cannot say no, our yes
means little. Many in health care have surrendered their capacity for
refusal.
You might ask, how can you say no
with so much suffering surrounding you, and shrinking resources to deal
with it? The choice is to reframe what “no” means. It does not have to
be the end of a conversation. An authentic no, one that comes from
caring about quality of care and the people providing it, needs to be
viewed as the beginning of a conversation, rather than the end.
Refusal is an expression of personal
power, about each person having the right to define the nature of the
work and how it is done. Refusal is not a form of protest or a
negotiating stance. It is a commitment to something larger—knowing that,
at times, what is being demanded of us is not serving care.
The argument against refusal is two-fold.
First, in a highly patriarchal system, refusal is considered disloyalty.
Refusal in the context of nursing can be an act of commitment. Justified
refusal only gets corrupted as disloyalty when the institution cares
more about control than serving its employees or its customers. So to
say no, in service of a larger intention, carries a cost. It means the
loss of favor in the eyes of those who manage. This is always the price
of empowerment.
Saying no also bridles against our sense
of duty and obligation to give the best care we can. We become willing
to sacrifice our own lives, our own health, our own optimism and energy
for life, and we burn out in the name of generosity. This idea of heroic
sacrifice as the measure of service is something we have swallowed. It
is our collusion with the patriarchy that demands dominance and leaves
caregivers at the bottom of the institution, carrying the weight of what
is unwilling to be dealt with at the top.
Patriarchy is the belief that those at
the top own those beneath them and, whenever change is required, it is
the people at the bottom who must change and pay the price for that
change. Selling the need for sacrifice and greater productivity at the
bottom, among direct-service people, is a defense against real reform.
Nurses need to see clearly how buying
this notion of sacrifice and giving beyond their limits undermine the
profession and create unhealthy working conditions. This begins with
believing that they have a right to say no. This, then, can begin a
conversation about creating a different set of relationships with
physicians.
Renegotiating the nurse-physician relationship
Patient safety and well-being are the
outcomes of a positive relationship among nurse, physician, family and
patient. It is a relationship issue. In a wealthy nation like ours,
mistakes in health care are usually caused by humans and not technology,
inadequate tools or techniques.
If inadequate patient safety and care are
problems associated with a human health care system, one of the weakest
links in that system is the nurse-physician relationship, a holdover
from a time when we believed that the only health care individual who
counts is the physician. The dominance exercised by the physician and
the sacrifice required of the nurse are what need renegotiation.
The challenge is to move the
nurse-physician interaction from one of parent-child to one of
partnership—to get rid of the notion that, in all cases, the physician
knows and the nurse does not. And it must be done in the name of patient
safety, creating a climate where physician and nurse can fulfill the
purpose and work they care so much about.
The shift from parenting to partnership
is difficult, for it is hard to change an ingrained relationship
pattern. The physician is reluctant to surrender power, and the nurse is
reluctant to give up the payoffs of being the oppressed party. Luckily,
the whole system and working environment are under such pressure that
many physicians and nurses are open to reconsidering their relationship.
If we can assume there is a desire to
move toward partnership, what does this entail? First, we need to
realize that this shift in relationship cannot be legislated, mandated
or driven from the top. Partnership is not created by newly defined
roles and protocols, but chosen through a shift in conversation between
nurse and physician.
The new conversation begins with a
statement of intention to move toward partnership. The first step,
mentioned earlier, is the willingness of the nurse to say no. The final
authority remains with the physician—no one questions this—but if we
view no as the beginning of a conversation, then each member of a
partnership has the right to express doubts and reservations about
treatment.
A second element of partnership is the
ability of both sides to express wants and make demands of each other.
Expressing a want does not mean you get what you ask for, but it does
mean you stand as an equal in the relationship. If nurses are unwilling
to express their own wants and points of view, for whatever reason, they
will forever remain subservient.
The third element of partnership is
willingness to make promises to each other. There has to be time and
space for nurse and physician to answer the simple question, “What is
the promise you are willing to make to each other?’’ A promise is an
expression of commitment to an alternative future. Using the language of
promise recognizes the sacred nature of the work and the primacy of this
relationship.
Valuing the importance of
relationship
Health care is probably the most
regulated of all business sectors. We labor under the belief that more
watching, more legislation, more regulation will create better health
care, despite mountains of experience that more controls in the
workplace reduce quality rather than improve it.
What does not enter
the public debate about health care is the primacy of relationship at
the care delivery level. The importance of relationship consistently
takes a back seat to the discussion of costs, technology and who is in
control. The marginalization of relationship and the human dimensions of
care may be the greatest obstacle to
creating conditions of work where nurses can find fulfillment in the
path of service they have chosen.
Peter Block, a resident of
Cincinnati, Ohio, is a consultant and author of several best-selling
books. The most widely known are Flawless Consulting: A Guide to
Getting Your Expertise Used (1st edition 1980); Stewardship:
Choosing Service Over Self-Interest (1993) and The Empowered
Manager: Positive Political Skills at Work (1987).
Reproduced with permission from
Reflections on Nursing Leadership, Fourth Qtr. 2004, published by
the Honor Society of Nursing, Sigma Theta Tau International.
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