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ENFERMEIRAS SUBMISSAS SAO ETICAS? REFLETIN DO SOBRE ANOREXIA DE PODER1

ARE S U B M I SS IVE N U RSES ETH ICAL 7 : REFLECT I N G O N POWER ANOREXIA

G ES ETICA LA S U M I S ION DE LAS E N FERMERAS7 REFLEXI ONAN DO SOBRE LA ANOREXIA DE PODER

Valeria Lerch Lunard i2 El izabeth Peter3

Denise Gastald04

RESUMO: Acred itamos que a n09ao de anorexia de poder, que defin imos como a fa lta de desejo de exercer poder, e centra l para a reflexao de questoes eticas em enfermagem . Questionando 0 pressuposto de que enfermeiras sao powerless (nao tern poder) , argumentamos que as enfermeiras podem e exercem poder e que suas a90es e omissoes tem conseqOencias nao apenas para elas mesmas, mas tambem para quem elas cuidam . Propomos a etica femin ista como uma perspectiva tanto para entender quanto para superar a anorexia de poder das enfermeiras. I ntelectuais femin istas destacam 0 impacto psicologico da opressao e que percep90es estereotipadas sobre a mu lher sao socia lmente constru fdas, portanto podem ser mudadas. Propomos que as enfermeiras, uti l izando esta orienta9ao teorica, devem explorar as impl ica90es da central idade da n09ao de cu idado para as maneiras como nos concebemos rela90es de poder em saude. Talvez, a desconstru9ao do conceito de cuidado focal izando em como as enfermeiras exercem poder, possa ajudar-nos a reconceptual izar enfermagem e promover novas agendas para a saude e os cuidados em saude. PALAVRAS-CHAVE: enfermagem, etica , cu idado, poder, governabi l idade, etica femin ista

ABSTRACT:We bel ieve that the notion of power anorexia , which we define as a lack of desire to exercise power, is centra l to reflections about nurs ing eth ical concerns. Questioning the assumption that nurses are powerless , we argue that nurses can and do exercise power and that their actions and inactions have consequences not only for themselves, but also for those for whom they care . We propose that a femin ist eth ics perspective be used both to understand and to overcome nurses' power anorexia . Femin ist th inkers remind us not on ly of oppression's psychological impact, but that stereotypical views about women are socia l ly constructed and , therefore , can be changed . N u rses using this framework should explore the impl ications of a central ized notion of caring to the way we conceive of power relations in health care. Perhaps deconstructing caring by focusing on how nurses exercise power could help us to re-conceptual ize nurs ing and promote new agendas for health and health care. KEYWORDS: nursing , eth ics, caring , power, governmental ity, femin ist eth ics

RESUMEN: Creemos que la nocion de anorexia de poder, que defin imos aqu f como una falta de deseo de ejercer poder, es una idea central para la reflexion sobre cuestiones eticas en enfermeria. AI plantear la premisa de que las enfermeras son powerless (no tienen poder), a rgumentamos que las enfermeras pueden y ejercen poder, y que sus acciones u omisiones tienen consecuencias no s610 para el ias mismas, sino tambien para aquel los a los que cu idan. Proponemos usar una perspectiva de la etica feminista para comprender y para superar esta anorexia de poder de las enfermeras. Las intelectuales femin istas destacan no solo e l impacto pSicologico de la opresion, sino tambien q ue las imagenes estereotipadas sobre las mujeres son construcciones sociales y, por tanto , se pueden cambiar. Proponemos que las enfermeras, uti l izando esta orientacion teorica , exploren las impl icaciones de la centra l idad de la noci6n de cu idado en la forma en que conciben las relaciones de poder en salud . Tal vez, la desconstruccion del concepto de cu idado a l focal izarse en como las enfermeras ejercen el poder, pueda ayudarnos a reconceptualizar la enfermerfa y a promover una nueva plan ificacion para la salud y los cuidados en salud . PALAB RAS-CLAV E : enfermer ia , etica, cuidado , poder, gobernabi l idad , etica femin ista

Recebido em 1 4/04/2002 Aprovado em 26/06/2002

1 A prel im inary version of this paper was pub l ished in Spanish in the Conference Proceed i ngs of the IV I nternational Nursing Diagnostic Symposiu m , May 9-1 0 , 2002 , A Coruna , Spain (CD format) .

2 Professor, Nu rs ing Department, Funda<;:ao U niversidade Federa l do Rio Grande (FURG) , Brazi l . Scholarship of CNPq-Brazi l .

3 Assistant Professor, Faculty of N u rsing and Centre of B ioethics, U niversity of Toronto, Canada. 4 Assistant Professor, Facu lty of N u rsing and Centre for I nternational Health , U n ivers ity of Toronto , Canada .

Rev. Bras . Enferm . , B ras i l ia , v . 55, n . 2 , p . 1 83-1 88 , mar./abr. 2002 1 83

Enfermeiras submissas . . .

During the past 20 years, many authors ( M U RPHY, 1 983, ROBERTS 1 983, YARL l NG ; MCELMU RRY, 1 986, LOYOLA, 1 987 ,COLL IERE , 1 989, GASTALDO; M EYER, 1 989, CONDOM, 1 992, GERMANO, 1 993, JAMETON, 1 993, LUNARDI , 1 993, LUNARDI F ILHO, 1 995, WOLF, 1 996, L 1PP, 1 998, BOWDEN , 2000, HAM RIC , 2000 , PETER, 2000a, SOARES, 2000, TUCK; HARRIS; BAL l KO, 2000, HOLMES; GASTALDO, 2002) have described nurses' powerlessness or, at least, perceived powerlessness . Erlen , Frost ( 1 99 1 , p. 397) , for example, most emphatica l ly stated that nurses "perceive themse lves to be powerless to effect eth ical decisions involving patient care . "

I n th is paper, we question the assu mption that nurses are powerless . Instead we argue that nurses can and do exercise power and that their actions and inactions have consequences not only for them, but also for those for whom they care . In formu lating our arguments , we recognize that there are leg itimate constraints to nurses' agency5 and that, as for a l l persons , nurses' autonomy is situated in their practice contexts (SH E RW I N , 1 998) . Nevertheless, we mainta in that nurses do not recognize , or perhaps they underesti mate , the i r power i n ways that render them unnecessarily powerless . When nurses frequently deny themselves the power to res ist others in the ir professional l ives , they might be denying their patients the best care possible. Therefore, reflecting on how nurses exercise power and nurses' apparent lack of appetite for power, that is, power anorexia is crucia l to genera l cons iderations of eth ical concerns in nursing .

NURSES EXERCISING POWER

I n contrast to the prevai l ing notion that nurses are powerless , Holmes, Gastaldo (2002) maintained that nurses exercise power in d ifferent ways and that they are a powerfu l group who govern individuals , g roups, and populations, and create pol icies and knowledge . Power is u nderstood in this paper as a relational exercise, "a productive web which goes through all the socia l body more than a negative instance function ing to repress" (FOUCAU LT, 1 990a , p . 8 ) . For example, Mckeever ( 1 996) and Stewart (2000) emphasized that Canad ian nurses are important agents who fu rther advances in home care and health promotion . As health care professionals who are in d i rect communication with care recipients both individually and collectively, nurses are a group of experts that can represent ind iv iduals , institut ions, and the state. In fact, "nursing research provides knowledge about the popu lation and helps to decide priorit ies in fu nd ing" (HOLMES , GASTALDO, 2002, p. 1 0 ) . N u rses are "an

important group that helps the state to govern at a distance" (HOLMES, GASTALDO, 2002, p . 1 7), according to Foucault's concept of governmentality6 (FOUCAULT, 1 990b). Through power relations, this professional group, l ike others, promotes and restores health , gathers and d isseminates knowledge, and also constructs people 's subjectivities and ways of l ife . Yet in spite of being the largest health professional group with in the Western world 's health care systems, nurses are frequently perceived as invisib le . Holmes, Gastaldo (2002) underscored nurses' feel ings of being unimportant and victims of the institutions and organizations they helped to construct, support, and administer. Arguably, they may be experiencing an ambivalence associated with participati ng in thei r own oppression . Or, perhaps, many nurses are not aware that they exercise power in numerous ways and that they have the potentia l to exercise power in unaccustomed ways . I ndeed , "they se ldom reflect a bout the ir own ways of exercis ing power or rarely perceive health care as pol itical care" (HOLMES; GASTALDO, 2002, p. 1 8) .

Lunard i F i lho ( 1 995) identified nurses' experiences of feeling impotent, unimportant, unrecognized , devalued , and blamed for bad outcomes and mistakes. He also establ ished that nurses perceive themselves as being responsible not only for organizing the work environment, maintaining working conditions, and ensuring the professional fu lfi l lment of other health professiona ls , but a lso for accompl ishing everyday ca re g i v i n g a ct i v i t i e s t h ro u g h t h e i m p l eme ntat i o n , management , a n d contro l of these d i fferent activities . Accord ing to a perspective from DEJOU RS ( 1 997) , Lunard i F i l ho (2000, p . 1 4) affi rmed that "the organ ization of work i s noth ing else but the expression of the w i l l of those who organize it . When others accompl ish their work accord ing to those who have organized it, they are enacting the power that comes from these organizing activities . Thus, when nurses occupy organizational , coord ination , and management roles, they are exercis ing power in ways that these roles make possible"7 . These roles are circumscribed and lead into particular modes of power relations due to their structure and the particu larities of a g iven setting .

When Lunard i F i lho (2000) also observed nurses' work in hospita ls , he concluded that nurses are (a) the ones who hold a lmost all the information of the hospita l , (b) the organ izers of the care environment, (c) the keepers of institutional norms and routi nes, and (d) the organizers of caregiving . Accord ing to h im , "Such capacities seemingly give the nurse the necessary and sufficient capacity to act as the global caregiving admin istrator with in h is/her area of influence in the m icro space where he/she practices and develops such activities" (p. 1 97) . However, as Lunard i Fi lho

5 Liashenko ( 1 994, p . 1 7) definesd agency as "the capacity to in itiate meaningfu l action . " and as "a mix of motivation and physical action d i rected toward some end." Peter (2002 , p. 2) modified Liashenko's defin it ion to specify moral agency, which Peter (2002 , p .2) defineds as "a mix of motivation and physical action d i rected toward some moral end". Using femin ist eth ics to define the meaning of moral , Peter (2000b, p . 1 1 0 ) suggestsed that "the development and ma intenance of relationships; care; justice; and freedom from exploitation and oppression" are the core values of a feminist eth ic in nurs ing.

6 Govern mental ity, accord ing to Foucau lt ( 1 990b) , describes the meeting point between the power technologies exercised by others and those exercised by the self. Dean ( 1 999) definesd government as the "conduct of conduct" (p. 1 0) , emphasizing that "the term governmentality seeks to d istingu ish the particular mental ities , arts and regimes of government and admin istration that have emerged since 'early modern' Europe, whi le the term government is used as a more genera l term for any calculated d irection of human conduct" (p.2) .

7 Author's free translation from the orig inal Portuguese.

1 84 Rev. Bras. Enferm. , Bras i l ia , v. 55, n. 2, p. 1 83-1 88, mar.labr. 2002

(2000) argued , some elements can interfere in the fu lfi lment of these act iv i t i es , such as the way in wh i ch hea lth professionals understand the i r own work, particu larly nurses and physicians, and both the qua l itative and quantitative precariousness of human and materia l resources avai lable in the work setting , especia l ly i n less affluent countries l ike Brazi l .

These critica l perspectives about nurses' perceived powerlessness inform the d iscussion that fol lows . We wi l l explore some relations between ethics and pol itics to search for potential explanations of the cu rrent power anorexia orientation that is pervasive in nurs ing .

POWER ANOREXIA AND ETHICAL CONCERNS

The Canad ian and Brazi l ian nursing codes of ethics serve as our point of departure to analyze the re lationship between ethics and power relations. The stated values with in the Canad ian N u rses Association Code of Eth ics for Registered Nurses ( 1 997) continua l ly reinforce the nurse's responsib i l ity to advocate for the interests , health and care cond itions, pol icies, and environments that protect cl ients from unethical care . Beyond d i rect cl ient care , it is the nurse's responsib i l ity to "advocate for work environments in which nurses are treated with respect" (p . 22) S imi larly, in Brazi l , the Code of Ethics for Professional Nurses (Codigo de Etica dos Profissionais de Enfermagem , CONSELHO FEDERAL DE ENFERMAGEM, 1 993) asserts in i ts preamble that the code is cl ient-centred . Moreover, it assumes that nursing professionals are al l ied with cl ients , fight ing for safe , qua l ity care that is accessible to the entire population .

These moral respons ib i l i t ies reflect a h istorical evolution that has seen nurs ing 's role change from that of a dependent servant to physicians and health institutions to the current one of patient advocateS . Yarl ing, Mcelmurry ( 1 986) described how nurses from American nursing schools during the n ineteenth century were taught to bel ieve that "absolute and unquestioning obed ience must be the foundation of the nurse's work" (p . 66) . By the end of World War I I , however, the changes that had taken place in nurs ing were reflected in the American Nurses Association's (ANA) Code for Nurses, which indicated nursing's increasing professional autonomy and the shift in accountabi l ity from the physician to the patient. Although profess iona l codes may have l ittle i mpact on practice, each new version registers a professional evolution . For example, the most recent ANA code, which was adopted in 200 1 , not only promotes patient advocacy, it also highl ights the d ut ies n u rses owe to themse lves , such as the i r responsib i l ity to preserve their own i ntegrity and safety.

Yarl ing , Mcelmurry ( 1 986) argued that whi le student nurses learn th is new ideology when they join the profession , they also qu ickly learn that these com mitments must be conta ined : " N u rses who open ly cha l lenge estab l ished authority structu res of powerfu l phYSicians i n a hospital bureaucracy most often put their jobs, their economic welfare,

LU NARDI , V. L . ; PETER, E . ; GASTALDO, D .

and the ir professional careers on the l ine , even if they are acti ng on behalf of the patient and have strong justification for doing so" (p . 70) . Therefore, Yarl ing & Mcelmurry asserted that nurses "are often not free to be moral" (p . 63) and "have no moral status" (p . 66) . Nevertheless, they also contended that nurses "are in some l im ited sense free , they are also in some l imited sense cu lpable, for the r isk attached to an action does not completely cancel the obl igation to perform the action . I f it d i d , nu rses wou ld have no mora l problems, but unfortunately they do" (p . 70) . We maintain that for nurses to be free , to be mora l , they must develop a strong sense of p rofe s s i o n a l a u t o n o m y a n d be a b l e to act on t h e i r responsib i l it ies t o the patient.

In acting on their respons ib i l it ies, nurses can face problems related to the organizational cond it ions in which they must provide care to patients . A number of Brazi l ian authors, for example, (M IRANDA 1 993, LUNARDI 1 994, 1 999, PEREIRA; NAKATAN I ; SOUZA 1 994, S IQUEIRA, 1 998, 200 1 , SOARES, 2000) emphasized the impact of a lack of human or materia l resources or of poor working cond itions on the mora l agency of nurses . I n contrast, research publ ished in E n g l i s h l a n g u a g e j o u rn a l s tended to be focused o n i nst itut iona l and p rofess iona l h ierarch ies that l im it t h e capacity o f nurses t o act, not on the lack of human and materia l resources . Th is is not to say, however, that Engl ish­speaking authors are unaware of l imited resources. Instead , these issues tended to be cast as resource al location/priority sett ing concerns as opposed to issues of moral agency. I n add ition , resources are l i ke ly not a s scarce in the health care systems they described , for example, American or Canadian.

In short , the constra in ts to mora l agency that Brazi l ian nurses experienced were frequently relative to the serious insuffic iency of hu man and materia l resources , although they cou ld a lso be of an interpersonal natu re , reflect ing confl icts and power d ifferences among hea lth professionals, health admin istration , and patients . But when the necessary materia l cond itions to provide nursing care are nonexistent, it may be more d ifficult for nurses to identify and problematize circumstances of a pol itical natu re where their responsib i l ity to advocate for patients is thwarted .

When nurses accept working in precarious conditions where they cannot do what they have learned to bel ieve and value , they are denying themselves the opportunity to br ing respect to themselves and their profeSSion and possibly also fa i l ing to bring respect to their patients . What impact does this situation have on nurse-patient relationships? Do patients know that their care is not adequate? Do they know they are being d isrespected? Are the nurses aware of the relation between their self-den ia l and the denia l of patients' r ights? Final ly, who benefits from such a current arrangement of power relations? Worthley ( 1 997) described how professionals deny that they wield power or at least underestimate the power they exercise . In do ing so, professionals, such as nurses , can avoid responsib i l ity and can as Rubin ( 1 996) described ,

8 "Advocacy is one of the fundamental values of professional nursing" (HAM R I C , 2000, p. 1 03) , having been d iscussed in the l iteratu re since 1 980 (beg inn ing with GAD OW, 1 980) . As a moral concept, it requ i res an active movement to support patients in their rights and possib le choices. I t has been described by a l l recent codes as a core responsib i l ity (HAMRIC , 2000) .

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"delegate up" (p. 1 83), a process whereby nurses can avoid ethical decision making by i nvoking physicians' authority as the basis for their decision making . As Germano, Brito , Teodosio ( 1 998, p . 376) expla ined , " it is not enough to understand reality and to have the tools of know-how to assure that our project for nurs ing and health wi l l occu r. To make it happen, it is necessary to want, to have the polit ical wi l l , the intentional ity, and the perception of duty. "

By d e m a n d i n g better work i n g o rg a n i zat i ona l cond itions, nurses ind i rectly advocate for patients. Nurses can also more d i rectly advocate for patients by expl icitly demanding that nurses' values, as wel l as thei r professional and eth ical responsibi l ities, be upheld . However, nurses must be convinced that their actions are fundamental to patient care, and they must develop a sense of professional identity and pride . Advocacy cou ld be easier if nu rses had more of the sense of confidence that stems from professional self­worth .

Unfortunately, when nu rses do not i ntentional ly exercise power towards a given professional/ethical agenda, they, to some extent, participate in their own oppression and are moral ly cu lpable for accepti ng the status quo . Nurses need to consider what responsib i l it ies are real istical ly theirs . It i s a Nurses commonly ta l k among themselves aboutin nursing to ta lk inequa l it ies , but rare ly take their concerns outside of nursing . The chal lenge resides in taking action and speaking out. enacting such a theoretCan nurses use their knowledge to change socia l relations and values when they benefit in d istinct degrees from the current arrangement of power relations?9 As Jameton ( 1 993) suggested , nurses can choose d i ffe re nt poss i b i l i t ies beyo n d res i g n i n g , screaming, saying a prayer, o r doing noth ing , depending on the situation . They can "talk with the physician in an attempt to reach a compromise on handl ing these situations; submit an incident report; d iscuss the problem with the medical head of the un it; d iscuss the problem with the head nurse or a higher level nursing supervisor; d iscuss the problem with the med ical head of the un it ; . . . pose the issue to the hospital 's committee ; ca l l the newspapers ; jo in an activist publ ic or professional organization" (JAM ETON , 1 993, p. 544-545) .

Like ly, nurses can use many other possib i l it ies to attempt to make the changes they bel ieve they must. I n any case, nurses should understand how and why they exercise power in some situ ations to be ab le to transfe r such knowledge to other ci rcumstances . N u rses shou ld feel comfortable with their own appetite for power, implement their power strategies, and after feel satisfied or "fu l l " because they did what they believed was necessary. Sti l l , nurses must a lso reflect upon thei r own want or need to exercise power: Motives of personal van ity and professional agenda may inevitably get intertwined on some occasions . Although the exercise of power involves mu lt iple situations of oppression and dominance, a reflexive process that gu ides the search for eth ical standards in care can involve scrutinizing the d ifferent agendas being addressed in each situation . This reflexive process could be informed by the values inherent in

a femin ist eth ics approach .

F E M I N I S T B I O E T H I C S : U N D E RSTAN D I N G AN D OVERCOMING N U RSES' POWER ANOREXIA

Femin ist b ioeth ics is a perspective that offers a means to both understand and overcome nurses' power anorexia . Feminist bioethics, un l ike mainstream approaches to bioeth ics , focuses d i rectly upon power and strives to overcome unjustified power d ifferences . Sherwin contended that, "questions about dominance and oppression are essential d imensions of feminist ethical analysis" (SHERWIN , 1 996, p . 52). Femin ist bioethics unearths issues of dominance and privi lege in the "i nterpretation and responses to i l lness a n d oth e r h e a l t h - re l ated m atters as we l l as in o u r interpretations of the ideal of autonomy" (SHERWI N , 2000 , p. 76) . As such , femin ist b ioeth ics resists reproducing the inequ ities that can go unexamined in other mainstream approaches.

U n d erstan d i n g women 's experiences of be ing members of an oppressed group is the starting point to a feminist approach , a long with the commitment to overcome this oppression ( L iASCH E N KO, 1 993, p .72) . A femin ist bioethics approach pol iticizes ethical concerns by attempting to understa nd l ived p rob lems and confl i cts and th e i r expression within power relations. Therefore, "only when we understand the ways in which oppression can infect the background or basel ine cond it ions under which choices are to be made wi l l we be able to mod ify those conditions and work toward the possibi l ity of greater autonomy by promoting non-oppressive a lternatives" (S H E RWIN , 2000 , p . 80) . To understand how oppression affects the basel ine cond itions of nurses' eth ical practice, it is necessary to be aware of how oppress ion i s i nte rna l ized . Sherwin (2000 , p . 79 ) described how interna l ized feel ings of being incapable and or not important compromise self-esteem and "how such d im in ished expectations read i ly become translated into d imin ished capacities . " . S im i larly, Bartky ( 1 990 ) observed the psychological impact of oppression . She stated that, "psychological oppression is such that the oppressor and oppressed a l ike come to doubt that the oppressed have the capacity to do the sorts of th ings that only persons can do , to be what persons , i n the fu l lest sense of the term , can be" (BARTKY, 1 990, p. 29) . In add ition , the social stereotype of the passive and vu lnerable woman may lead some women , such as female nurses, to feel self-conscious or un ladyl ike when they make known to others the power they are capable of exercis i n g . An appreciat ion of the interna l ization of oppression and stereotyping helps us understand why nurses have power anorexia in certa in situations, but not in others .

A l th o u g h acknowl e d g i n g oppress ion a n d its psychological and social impacts on nurses is important, more action is requ i red . Beyond consciousness-rais ing, col lective efforts to make change are necessary, much in the way that Yarl ing, Mcelmurry ( 1 986) advocated that nurses deve lop a spec i a l eth ic focu sed u pon socia l reform .

9 I n the Brazi l ian case, usual ly nurses not only suffer suffer from the lack of a lack of avai lab le resources avai lable to them with which to provide care ; , these same cond itions a lso make them ind ispensable to the everyday functioning of their work places. and tTheir competence is acknowledged , for instance, by their problem solving capacity (LUNARDI F ILHO, 1 995).

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Specifical ly, they suggested that hospita ls be reformed so that nurses acqu i re sufficient power with in them to create a balance of power between physicians , admin istrators , and themselves . They also mainta ined that , as members of a caring profession , nurses at al l ranks have been too concerned with the personal and have not been adeq uately pol iticized . Femin ist healthcare eth ics offers a reform eth ic that wou ld address the need to make structural/systemic changes to policies, institutions, and hierarchical relations among nurses, physicians, managers and others . It a lso can act as a much needed pol iticizing agent.

FINAL REMARKS

Perhaps highl ighting the eth ical impl ications of power anorexia is an effective way of u rg ing nurses to be more responsible for a greater understanding of the ways in wh ich they are a l ready powerfu l and exercise power. But, it cou ld also be a sub-product of the mental ity of anorexia that reasons that nurses can only accept deal ing with power if they see that it benefits others rather than themselves. I n other words, nurses may make the change to del iberately exercising power only if they can continue to perceive themselves as self­sacrificing .

As we have seen i n this paper, femin ist th inkers remind us of the psychological impact of oppression , that stereotypical views about women are socia l ly constructed , and that, therefore , they can be changed . We bel ieve that nurses using this framework should go beyond exploring the impl ications of how the notion of caring is central to the ways in which we exercise power. Perhaps de-constructing caring by focusing upon how nurses exercise power cou ld help us to re-conceptual ize nurs ing and promote new agendas for health and health care . These days anorexia is treatab le .

ACKNOWLEDGEMENT

To the Brazi l ian Research Agency, CNPq, for funding Valeria's post-doctoral stud ies at the Facu lty of Nurs ing , University of Toronto.

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