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THE CIRCUMSTANCES AND IMPACT OF POWERLESSNESS IN
PSYCHIATRIC NURSING
by
Janice Cathcart
B.S.N., The University o f British Columbia, 1989

THESIS SUBMITTED IN PARTIAL FULFILLMENT OF THE REQUIREMENTS
FOR THE DEGREE OF
MASTER OF EDUCATION
in
COUNSELLING

Janice Cathcart, 1998
THE UNIVERSITY OF NORTHERN BRITISH COLUMBIA
April 1998

1 ^ 1

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0-612-62468-4

CanadS

APPROVAL
Name:

Janice Cathcart

Degree:

Master of Education

Thesis Title:

THE CIRCUMSTANCES AND IMPACT OF
POWERLESSNESS IN PSYCHIATRIC NURSING

Exainining Committee:
Chair: AlexMichalos
Professor and Program Chair, Political Science
University o f Northern British Columbia

Supervisor: Colleen Haney
Assistant Professor, Education
University of Northern British Columbia

(J/ y
Beverly üepert
Assistant Professor, Nursing
U n iv e r^ of Northern British Columbia

(„ k

l/A

Marika Ainley
/
Professor and Program Chair, Women's Studies
umyersity ot
i
Uniyysity
of Northern British
Columbia
C

2

£

Ronald Lehr
Assistant Professor, Education
University ofNortheplfSritish Columbia

External Examiner: Glen Schmidt
Assistant Professor, Social Work
University of Northern British Columbia

Date Approved:

^

S

11

Abstract
Nurses comprise the largest professional group in healthcare; yet, they do not
possess a degree o f power compatible with their numbers. Nursing, being a
predominantly female profession, suffers many o f the same oppressive forces imposed on
women in a patriarchal society. In addition, nurses suffer the oppression inherent in the
hierarchical healthcare structure. A sense o f powerlessness may compromise nurses'
competency, and this is o f particular importance in the mental health field where nurses'
ability to advocate for patients can significantly impact the care given. The aim o f this
study was to explore the situations in which acute care psychiatric nurses feel most
powerless, and the impact this has on them, both personally and professionally. A
qualitative research design was used, and data were collected through four focus groups
with four to five nurses in each group. Three groups were conducted in lower mainland
hospitals, and one group took place in an interior British Columbia hospital. Four
common situations in which psychiatric nurses feel powerless, emerged from the data.
These include (a) those related to medicine's dominance and control; (b) when nurses feel
they are in a no-win situation; (c) when there is a lack o f communication and support; and
(d) when there are system problems. The personal and professional impact o f feeling
powerless is explored. Implications for both nursing and counselling are discussed.

Ill

TABLE OF CONTENTS
Page
A bstract......................................................................................................................................ii
Table of Contents...................................................................................................................... iii
A cknow ledgem ents................................................................................................................. v
CHAPTER ONE: INTRODUCTION...................................................................................I
Background to the p ro b lem .................................................................................................... 2
Research purpose...................................................................................................................... 4
Research questions....................................................................................................... . . . 5
Research design.........................................................................................................................5
CHAPTER TWO: LITERATURE R E V IE W ..................................................................... 7
Traditional model o f p o w e r.................................................................................................... 7
New understandings o f p o w e r ............................................................................................... 7
O ppression................................................................................................................................11
Power in health c a re .......................................................................................
Hierarchy..................................................................................................................... 16
Medicine and the western medical model.................................................................18
Nursing and power..................................................................................................... 20
Patient advo cacy.....................................................................................................................23
Psychiatric nursing.................................................................................................................. 24
Research in n u rs in g ............................................................................................................... 26
Perceptions o f power and powerlessness in general n u rsin g ............................... 27
Circiunstances o f empowerment and powerlessness in general nursing............. 29
Experiences o f power and powerlessness in psychiatric n u rs in g ........................33
Sum m ary.....................................................................................................................35
Research purpose.....................................................................................................................35
Research questions.................................................................................................................. 36
CHAPTER THREE: METHODOLOGY........................................................................... 37
Research design....................................................................................................................... 37
Feminist fram ework...................................................................................................37
Focus groups................................................................................................................39
Interview q u e stio n s......................................................................................40
Researcher's assu m p tio n s..................................................................................................... 41
Leader and c o -le a d e r.............................................................................................................41
Participants............................................................................................................................... 41
Demographics............................................................................................................. 42
Procedure..................................................................................................................................42
Ethical considerations................................................................................................ 43
Data A naly sis..........................................................................................................................44
Stage O ne.....................................................................................................................46

15

IV

Interrater re lia b ility ......................................................................................48
Stage T w o .................................................................................................................. 48
CHAPTER FOUR: RESU LTS..............................................................................................49
Situations o f powerlessness...................................................................................................49
Medicine's dominance and control........................................................................... 50
Feeling unheard..............................................................................................51
Feeling undermined and b e little d ...............................................................53
Feeling forced to participate in care............................................................ 55
Feeling inhibited from providing the best c a re .......................................... 56
No-win position............................................................................
Patient needs vs. physician n e e d s ...............................................................58
Patient needs vs. system n e e d s ....................................................................62
System issu e s ............................................................................................................. 64
Inadequate resources......................................................................................65
Values driving health c a r e ........................................................................... 68
Lack o f communication and s u p p o rt...................................................................... 73
Trust and resp ect........................................................................................... 74
Teamwork and consistency o f c a r e ............................................................ 76
Isolation............................................................................................
Sum m ary.................................................................................................................................. 81
CHAPTER FIVE: DISCUSSION.........................................................................................83
Review o f situational categories o f pow erlessness............................................................ 83
What inhibited the nurses from acting more powerfully?..................................................86
The impact o f pow erlessness................................................................................................ 91
Nursing practice and collegial relationships............................................................ 91
Personal lif e ................................................................................................................94
Needed changes........................................................................................................................95
Limitations............................................................................................................................... 99
Implications and recommendations for n u rs in g ............................................................... 100
Implications and recommendations for counselling.......................................................... 102
Conclusions.............................................................................................................................104
REFERENCES..................................................................................................................... 107
APPENDICES
A. Key interview questions................................................................................................. 114
B. Personal assumptions...................................................................................................... 115
C. Demographic d e ta ils ...................................................................................................... 116
D. Informed consent form ....................................................................................................117
E. Demographic information qu estio n n aire.................................................................... 118

57

78

Acknowledgments

I would first like to thank my participants for your courage and willingness to
share your experiences so openly, and for committing your time in an already stretched
work schedule. This research simply could not have proceeded without you.
I would also like to thank the hospitals, and specifically the nursing managers
who supported my research by facilitating recruitment o f participants, providing me with
a space to conduct my focus groups and a multitude o f other small details which made a
significant impact on the success o f my data collection.
The support and guidance o f my committee members was invaluable, keeping me
on track and committed, particularly at those times when this endeavor threatened to be
an ordeal. Special thanks to Dr. Colleen Haney for your patience and continued support
throughout the various phases o f this study. I am also very grateful to Bev, Marika and
Ron for your ideas, suggestions, and guidance.
My family and ftiends - well, what can I say. Thank you! Thank you! Thank
you! Your unending support has sustained me in so many ways. Thanks for never losing
faith in me.

CHAPTER ONE
Introduction

In spite o f feminist advances, Canada's dominant culture remains patriarchal. The
structure o f the healthcare system mirrors that o f society, with a well sanctioned hierarchy
reinforcing gender-based power differentials (Hugman, 1991). The dominant force
positioned at the top o f the hierarchy is the medical model, a philosophy o f healthcare that
tends to objectify and pathologize the human experience, incorporating power differences
between helper and patient as integral to the cure (Hall, 1996; Liburd & Rothblum, 1995).
The dictates o f this philosophy attribute physicians, who are predominantly male and the
most powerful professional group in healthcare, a tremendous amount o f responsibility for
meeting the health needs o f society. Adherence to the medical model has traditionally been
perpetuated through the education o f healthcare professionals; however, society has come to
embrace this ideology with a great deal o f tenacity. Though the public may, at times,
question this dominant approach to healthcare, there is a continued widespread expectation
that physicians be omniscient and capable o f miracles. In the face o f such expectations,
physicians do, at times, experience a sense o f powerlessness, or inability to know and effect
change.
Although the word powerlessness may seem to suggest a complete lack o f power, it is
used in this study to suggest a sense o f impotence or "inability to accomplish an effect"
(Funk & Wagnalls, 1989, p. 1058), with an accompanying lack o f authority. In order to
minimize their sense o f powerlessness, doctors have traditionally dominated those groups
lower in the hierarchy, most notably nursing (Dykema, 1985). Power plays over nurses are
manifested in the devaluation o f nursing care, and in the disrespect o f nursing decisions and
viewpoints. Medicine, being the dominant group, has had the privelege o f establishing its
ideas as the righi ones. "One o f the basic elements o f power is that those who have positions
o f power are able to manufacture ideas" (Kirby & McKenna, 1989, p.23). Nurses, who are

predominantly female, can be conceptualized as an oppressed group that has integrated the
dominant group beliefs, in spite o f the incompatibility o f some o f these beliefs with the
nurturant, holistic nature o f nursing. Many of the collective behaviours o f nurses reflect
typical oppressed group behaviours (Ford & Walsh, 1994; Roberts, 1983).
Like those above them, nurses may try to gain a sense o f power through exerting
control over those below them in the system (Hewison, 1995; Huston & Marquis, 1988;
Kavanagh, 1991; Lanza, 1997a). For example, nurses may unnecessarily control the routine
and agenda o f care, limiting the choices available to patients. Ultimately, it is the healthcare
consumer who suffers at the bottom o f the hierarchy. This phenomenon is often most
profound in the mental health field, as many patients are particularly vulnerable to external
control when mentally ill. For this reason, the need for patient advocacy is extraordinarily
important within psychiatry. Perhaps, with a greater sense o f personal and collective
empowerment, psychiatric nurses will be more able to empower and advocate for mental
health consumers.
Change within a system can begin at any level. No one person or group o f persons
can exist without affecting others and being affected by others. A change at one level o f a
social system necessarily creates change within the entire system (Becvar & Becvar, 1996).
A shift in nursing attitudes and behaviours, therefore, has the potential for creating a cascade
o f changes throughout the healthcare system. An understanding o f nurses' experiences of
powerlessness within the workplace is essential if change is to be activated at the level of
nursing practice. This study explores the circumstances o f powerlessness for psychiatric
nurses, and the impact on them. The focus is on nurses working in acute care institutional
settings, as power relationships are often most integrated and oppressive in such settings
(Hugman, 1991; Yarling & McElmurry. 1986).
Background to the problem
My interest in this problem stems from personal experience working as a psychiatric
nurse. As a nurse, I often felt I lacked significant influence regarding patient care decisions;

the essence o f my role seemed to be to carry out actions dictated by others, often physicians.
As a result, I frequently found myself carrying out procedures to which I was personally
opposed. With horror, I would observe myself actively limiting patients' autonomy under the
guise o f beneficence. Any autonomous interventions I made seemed to be considered 'extras'
and were not given much validation. Without ftilly understanding how the dynamics o f the
healthcare hierarchy were affecting me, I found myself feeling increasingly hostile and
uneasy at work. I have come to understand this as my reaction to being oppressed by my
position in the healthcare system. When I began to acknowledge and react to this oppression,
I was confronted with tremendous resistance to change on behalf o f all members o f the
healthcare team, including nurses. As a result, 1 experienced a sense o f isolation and a lack
of collegial support, which added further to my dis-ease at work. Eventually, my distress
manifested physically, and I was forced to acknowledge the toll it was taking on me.
Ultimately, I left my job. Since this time, a number o f psychiatric nursing colleagues have
spoken to me about similar experiences o f feeling oppressed at work, and all described a
sense o f isolation.
I began to wonder what kept psychiatric nurses working under these conditions, and a
number o f questions emerged for me. Why do some nurses seem more comfortable in their
nursing role than others? Why is the subordinate position acceptable for some nurses? Why
do nurses experience a sense o f isolation when they challenge the oppressive structure in
which healthcare is delivered? Why was there such resistance to the changes 1 was
proposing? If change could make things better, why wouldn't people want it? Clearly, 1 have
my own ideas about what "better" is, and they do not seem to coincide with how some o f my
co-workers felt. I seemed to represent a significant threat for some reason. I observed
myself begin to separate from my identity as a nurse. For me, 'nurse' began to mean someone
who accepts a subservient role; someone who either does not think critically or finds it
acceptable to act incongruently with how one feels. How could I identify myself with such
an image?

I began to notice that psychiatric nurses seem to play an integral role in perpetuating
their own oppression. For example, the choice to work twelve hour shifts, as opposed to 8
hour shifts, leaves psychiatric nurses in a very disempowered position regarding patient care
decisions. How can one truly make an impact if one is absent from work more often than one
is present? With twelve hour shift scheduling, nurses are essentially on the ward for only two
days out o f a week. I recall returning to work each week, after night shifts and days off,
feeling very out o f touch with what was happening with my so-called "primary patients,"
those patients whose care 1 was supposed to be directing. I really had very little impact on
major patient care decisions. I also noticed that many nurses are very reluctant to challenge
physicians' decisions, in spite o f acknowledging their disagreement with them. Although
nurses are educated to believe that patient advocacy is central to the nursing role, very few
nurses take advocacy beyond voicing the patient's concerns.
1 began to wonder how things could be different if each health care discipline was
valued equally. If the unique expertise of each professional group was understood and
valued, then medicine would not sit in such a dominant position, and the experience o f being
a nurse could potentially be very different.
Research Purpose
Drawing from Freire's (1987) model which suggests that both insight and action are
necessary for the liberation from oppression, this study contributes to the first phase, that o f
insight, for psychiatric nursing. "By beginning with the experience and research needs o f
those who have been silenced, the process o f knowledge production is transformed and the
ideological power base is challenged" (Kirby & McKenna, 1989, p. 28). Nurses tend to
internalize their workplace frustrations (Attridge & Callahan, 1987) which feeds into a
further sense o f isolation and powerlessness. I intend to add to the growing body o f literature
that aims to expose the forces impacting the psychiatric nursing experience. The purpose o f
this study is to explore the circumstances in which hospital psychiatric nurses' most often feel
powerless, and the impact this has on them, both personally mid professionally. Tiuough

this, I hope to increase the visibility o f psychiatric nursing work and its undervalued position
in the healthcare hierarchy. An understanding o f the psychiatric nursing experience can
facilitate the development o f new structures and strategies with which to minimize
powerlessness. As well, increased discourse among psychiatric nurses may result, leading to
greater unity within the profession. Kirby and McKenna (1989) emphasize the importance o f
this kind o f research for subordinate groups: "Without reflection on our actions and
experience, we will continue to re-invent the wheel, and will remain divided and powerless"
(p. 168). This study may also increase awareness o f the power relationships between
psychiatric nurses and other groups within the healthcare system. A shift in these
relationships may ultimately advance the empowerment o f mental health patients.
Research questions
The research questions driving this study are:
1. What are the situations in which acute care psychiatric nurses feel powerless?
2. How does feeling powerless affect the personal and professional experiences o f
psychiatric nurses?
Research design
In order to access the complexity o f psychiatric nurses' experiences, while taking into
account the variation between nurses, a qualitative research design was used. A feminist
theoretical framework guided the research, in terms o f viewing all experiences as contextdriven. and recognizing multiple realities, rather than striving for generalizations (Kirby &
McKenna, 1989: Reinharz, 1992). Data were collected through focus groups. Focus groups
combine elements o f both individual interviews and participant observation in groups,
providing kinds o f data that cannot be accessed easily through only one o f the other two
methods (Morgan, 1988). That is, the interaction among members in the group stimulates
discussion and the development o f ideas. Thus, more information can be obtained than in
individual interviews alone. "The participants' interaction among themselves replaces their
interaction with the interviewer, leading to a greater emphasis on participants' point o f view"

(Morgan, 1988, p. 18). As well, the group format allows the researcher to observe the
interaction among group members, noting areas o f contention and agreement. The group
interaction also allows for more spontaneous responses than the individual interview. The
focus group data were analyzed for situations o f powerlessness and themes within these
situations. As well, the personal and professional impact o f powerlessness on psychiatric
nurses was examined.

CHAPTER TWO
Literature Review
Issues o f power and oppression pervade the psychiatric nursing profession. As a
result, an understanding o f these concepts is necessary in order to understand the experience
o f the psychiatric nurse. The literature offers a variety o f perspectives on both concepts. A
number o f these perspectives are presented here. Applications o f these concepts to the
healthcare system, specifically the hierarchical structure and the nature o f relationships
between physicians, nurses, and healthcare consumers, are included. Specific emphasis is on
the mental health care system and the unique demands it places on these relationships.
Traditional model o f power.
Power plays an integral role in the human experience; yet the nature o f this role
eludes universal understanding. Traditionally, one paradigm o f power has dominated in
western societies. It involves the influence and control o f others, necessitating an imbalance
o f power in one's relationships (Dahl, 1957; Erlen & Frost, 1991; Yoder & Kahn. 1992). In
this model, power is viewed in terms o f dichotomies; that is. one is either 'powerful.'
'independent' and 'active.' or 'powerless,' 'dependent' and 'passive' (Surrey, 1991). Action
directed toward particular outcomes or goals is considered a requisite part o f power (Seeman.
1959), and it has been suggested that this action necessarily involves some degree o f conflict
(Hugman, 1991). As well, a detached intellectualism is considered essential for the
successful attainment and maintenance o f power, while emotionality is considered weak
(Hugman, 1991; Surrey, 1991). Although this conception o f power continues to dominate
the western mindset, alternate models are emerging in reaction to the limited and exclusive
nature o f this model.
New understandings o f power.
More current thought challenges the idea o f power as an absolute state that manifests
in certain actions. Rather, empowerment, or the attainment o f power is a very individual

; process, under constant revision and negotiation. It is a personally defined phenomenon; a
sense o f power is attained differently by different people. Feminist theorists have suggested
that the traditional view o f power reflects only the western male perspective, neglecting the
; experience o f other groups (Gilligan, 1982; Miller, 1991; Surrey, 1991). Thus, many
critiques o f the traditional model emphasize its exclusivity and its obvious neglect o f the
characteristically female experience (Gilligan, 1982; Miller, 1991; Surrey. 1991).
Gilligan (1982) discusses the differences between masculine and feminine approaches
, to empowerment in terms o f gender-related developmental issues. She suggests that boys
tend toward and are encouraged to make an early emotional disconnection in order to move
toward independence and self-sufficiency, whereas girls tend to have a greater focus on
relationships and on maintaining interdependencies. These different orientations are not
valued equally in western culture, where maturity and adulthood tend to be defined in terms
o f separation and individuation (Gilligan, 1982; Surrey, 1991). A focus on relationships, in
turn, is devalued. Surrey (1991) criticizes society for de-emphasizing the importance o f
ongoing interpersonal connection, and for not offering enough support to the development of
interpersonal skills. She claims that as a result o f this, women's "relational pathway o f
development is obscured; its potential remains unacknowledged and undeveloped" (Surrey,
1991, p. 169), and she suggests that this undermines women's efforts to develop and maintain
adult forms o f connection in which mutual strengths can be experienced. Gilligan (1982)
asserts that woman's role has traditionally been to nurture ongoing relational attachment
throughout the life span, "while the developmental litany intones the celebration o f
separation, autonomy, individuation and natural rights" (p. 191).
Surrey (1991) suggests the need to shift away from the perception o f feminine
characteristics as lacking in power. Rather, "one o f women's particular sources o f strength
(is) the power to empower others, that is. to participate in interaction in such a way that one
simultaneously enhances the power o f the other and one's own power" (p. 164). This process
is what has traditionally been called nurturing, and Miller (1991) has suggested that because

it has occurred primarily in women's domain, it has been undervalued and misunderstood.
Gilligan (1982) asserts that women fulfill the necessary roles o f "nurturer, caretaker, and
helpmate, the weaver o f those networks of relationships on which she in turn relies. But
while women have thus taken care o f men, men have, in their theories o f psychological
development, as in their economic arrangements, tended to assume or devalue that care" (p.
17).
Surrey (1991) offers a conception o f power that is more inclusive than the traditional
model, and "might be termed a power with' or 'power together' or 'power emerging from
interaction' model" (p. 165). Such a framework "overrides the active/passive dichotomy by
suggesting that all participants in the relationship interact in ways that build connection and
enhance everyone's personal power" (Surrey, 1991, p. 165). Surrey prefers the term
"empowerment" to "power," as she believes it lacks the connotation o f power over. Yoder
and Kahn (1992) agree, suggesting that personal empowerment embraces a "power to"
approach, as opposed to a "power over" approach. They define empowerment similarly to
Bandura (1989) who describes it as a sense o f personal control over one's thoughts, feelings
and behaviours, rather than control over others. Surrey (1991) defines "psychological
empowerment" as "the motivation, freedom, and capacity to act purposefully, with the
mobilization o f the energies, resources, strengths, or powers o f each person through a mutual,
relational process" (p. 164). She suggests that a potent source o f power exists in the fostering
o f relationships. In this relational model, one person is not in control; rather, "each is
enlarged and feels empowered, energized, and more real" (Surrey, 1991, p. 168).
Although gender appears to account for many o f the variances in expression o f power,
it is too simplistic to cite gender alone as the source o f power differences, Sagrestano (1992)
suggests that status and organizational power play a more significant role than gender in
one's approach to power attainment. However, because "gender is inextricably linked to
power and status" (Sagrestano, 1992, p. 439), separating the influences is difficult. Those
with greater power and status tend to use the power over approach more, regardless o f their

10

] gender (Sagrestano, 1992). Because men tend to have more power and higher status in
I society, this approach belongs predominantly to men. "When power is considered, people
I with power choose strategies typically associated with men and those without power choose
i strategies typically associated with women" (Sagrestano, 1992, p. 445).
I

In spite o f the increasing recognition o f human diversity, particularly o f women's
unique sources of strength, western culture continues to embrace the individualistic, 'power
over' approach as the superior model o f power. The patriarchal healthcare system
exemplifies this ideology, with its hierarchical structure dictating differing degrees o f power
for different occupational groups. Physicians, who are predominantly male, tend to value
independence, intellect, decisiveness, and control, all o f which are consistent with the
traditional, detached and dominating approach to power (Hugman, 1991; Roberts, 1983;
Will, 1995). Hugman (1991) asserts that "medicine's status as a profession is based

i predominantly on its claims to be regarded as a set o f practices derived from rigorously tested

I knowledge about and skills in treating disease and illness" (p. 17). The opposite qualities that
I often characterize the predominantly female profession o f nursing, such as warmth,
i nurturance, and sensitivity, in turn, are devalued (Roberts. 1983). In order to maintain its
i

I status, medicine, operating from within the traditional paradigm o f power, must necessarily
I undermine less objective approaches, such as the more intuitive and personal nurturance
i provided by nurses.
Not only is the individualistic, 'power over' model exclusive, but it can actually
disable women if they perceive their 'powerful' action to be disempowering o f others, or
i

leading away from connection (Surrey, 1991). This conflict has led to the perpetuation o f
male dominance in many relationships, as women will often choose to focus on the needs of
the other person allowing the other to feel powerful (Surrey, 1991). When viewed in terms o f
the dichotomies ("powerful-powerless;" "active-passive") that accompany the traditional
model o f power then, "women's behavior often looks 'passive' or 'inactive' or 'depressed'"
(Surrey, 1991, p. 165).

11

Oppression
Various theorists (Dykema, 1985; Freire,1987; Podgorecki, 1993; Roberts, 1983) link
such power dynamics to the phenomenon o f oppression. Freire (1987) describes oppression
in terms o f the dehumanization of people. Podgorecki (1993) concurs, explaining oppression
as "an external or internal man-made [sic] limitation o f the available options o f human
behavior o f an individual or a group" (p.6). Similarly, McLaren and Lankshear (1994) state
"oppression has been experienced as a constraint to living more fully, more humanly:
constraint bom o f social contingencies o f power; o f discursive regulation through interested
and contrived social practices carried out so as to privilege some at the expense o f others" ( p.
1). Although this definition hints that oppression involves the benefit o f one group at the
expense o f another, McLaren and Lankshear argue that oppression does not necessarily
involve a specific oppressor group; rather, it can result from more subtle oppressive social
forces. Young (1992) agrees that oppression is more complex than simple domination o f one
group over another. She suggests that rather than being the result o f evil perpetrated by a
single ruling power, oppression often involves "the everyday practices o f a well-intentioned
liberal society" (Young, 1992, pp. 175-176) Oppression is systematically reproduced in all
areas o f our lives; it permeates major economic, political, and cultural institutions (Young,
1992). It involves the "unconscious assumptions and reactions o f well-meaning people in
ordinary interactions, media and cultural stereotypes, and structural features o f bureaucratic
hierarchy and market mechanisms, the normal ongoing processes o f every day life" (Young,
1992, p. 177). For example, oppression is so integrated into the nursing role that nurses
willingly take orders from physicians without even questioning the use o f language that
clearly requires a dominant and a submissive party.
Because oppression is integral to so many o f our social structures, its existence is
often unacknowledged or minimized. Podgorecki (1993) differentiates between totalitarian
and post-totalitarian systems in order to create a framework with which to understand the
more subtle forms o f oppression occurring in modem societies:

12

The totalitarian system is understood as a social system dominated by a
homogeneous ideology imposed on society by a mono-party (one-party) and its
oppressive apparatus. A post-totalitarian system emerges when the dominance
o f a monoparty has formally ceased, but while its deeply entrenched bureaucratic
structure remains in place and the values, mores, and basic mechanisms generated
under the totalitarian system still predominate (p. 15).
Thus, oppression may originate within a totalitarian system, but it does not end with the
downfall o f such a regime. Over time, "social control enters into the psyche o f an individual"
(Podgorecki, 1993, p. 8), and it becomes internalized as normal. This insidious, internalized
oppression "can be more powerful than all the spectacularly oppressive or covert and
seductive institutions that constantly impose social conformity" (Podgorecki. 1993. p. 18).
Once internalized, oppression is self-perpetuating. Those who are oppressed often begin to
behave as oppressors o f those perceived to be less powerful (Freire, 1987).
Dominant groups have the privilege o f establishing their norms and values as the 'best
ones' in society; as a result, the characteristics o f subordinate groups are devalued
(Freire, 1987; Kirby & McKenna, 1989). The belief system o f the dominant groups
eventually becomes internalized by those in subordinate groups, leading to a rejection o f self
and the erosion o f self-esteem (Freire, 1987; Roberts, 1983). This self-depreciation derives
from the internalization o f the negative opinions that oppressors hold o f them (Freire, 1987).
The subordinate groups' rejection o f self manifests in their acceptance o f the belief that to be
like the dominant groups is to be superior and powerful (Freire, 1987; Roberts, 1983). This
adopted belief system is dangerous, as the members o f an oppressed group will never truly be
'like' those in the dominant group, and it simply adds to the rejection o f self (Roberts. 1983).
Roberts posits that if those in the oppressed group are "unable to avoid the presence o f their
devalued characteristics...self-hatred and a resultant low self-esteem develop, which
perpetuate the cycle o f domination and subordination" (Roberts, 1983, p. 23).

13

Because oppression is an imposed inhibition on the human experience, the struggle
against oppressive forces will always exist, either consciously or unconsciously (Freire,
1987). "No one can accept complete impotence short o f death. If he [sic] cannot assert
himself [sic] overtly, he [sic] will do it covertly" (May, 1972, p.94). Poor self-esteem and a
fear o f ftirther oppression often inhibits the oppressed person from directing aggression
directly at the offending forces (Freire, 1987; Roberts, 1983). Roberts writes,
.. .fear o f aggression against the dominant group originally develops as a result o f
the realization that the subordinate groups could be destroyed if they were to
attempt revolt. This tear is the basis o f submission to authority. A secondary tear
develops as the process o f oppression continues, that is. the tear o f change itself
and o f alteration o f the status quo, no matter how oppressive (p. 23).
Caught in this duality o f desiring freedom yet tearing it, oppressed people will often exhibit
passive-aggressive behaviour and misdirected aggression toward one's own group members
(Freire, 1987; Roberts, 1983). This intergroup conflict weakens the unity o f the oppressed
group, adding to the perpetuation o f powerlessness.
Nursing, being a predominantly female profession, suffers many o f the same
oppressive forces imposed on women in a patriarchal society. In addition, nurses suffer the
oppression inherent in the hierarchical healthcare structure by virtue o f being under' the
powerful medical profession (Ford & Walsh. 1994). Like other oppressed groups, nurses
have tended to internalize the dominant group beliefs, that is those o f medicine, as superior.
This is apparent in nurses' struggle to gain increased credibility through attempts to establish
medical-like scientific' theory based on the principles o f objectivity. Keddy (1996) states
"this objectification o f knowledge.. .has exercised power over nurses' thoughts and
behaviors " (p.383), and she asserts, "the nursing profession has suffered by buying into
science that is ethnocentric, racist, classist, heterosexist, and positivistic in nature" (p.383).
In her analysis o f psychiatric nursing discourse, Keddy (1996) writes, "social control through
language and knowledge generation is a primary mechanism by which nurses remain

14

oppressed by the patriarchal structures within which they are educated and work" (p.390). As
a result o f attributing greater value to beliefs and practices that belong to the dominant group,
nursing is suffering an identity crisis and a rejection o f what makes nursing unique from
medicine. The less precise, more intuitive and holistic approach to care that nurses can offer
has been forsaken in this misguided pursuit o f respect and power.
This rejection o f the unique nature o f nursing reflects the rejection o f self that
typically occurs within oppressed groups. It is in fact disempowering nurses, rather than
gaining them the increased credibility they seek. Roberts (1983) has observed nurses
exhibiting "self-hatred and dislike for other nurses" (p. 27), which is apparent in the lack of
unity within the nursing profession. "It is as if to align with other nurses is to align with
other powerless persons - something that has been shown to be unwise" (Roberts, 1983,
p.27). There is also a general reticence within the nursing profession to challenge authority,
although there tends to be a significant amount o f complaining about physicians and
administration within nursing groups. This reflects the passive-aggressive behaviour that
often typifies oppressed groups, stemming from a fear o f change and freedom (Freire, 1987;
Roberts, 1983). As previously described, it is a double-edged sword. Autonomy is necessary
to live authentically, but the internalized oppression maintains one's fear o f it (Freire, 1987).)
Evidence o f the depth o f nursing's oppression lies in the lack o f autonomy, power and control
that nurses possess (Roberts, 1983), in spite o f the fact that they comprise the largest
professional group within healthcare.
Once oppression is internalized, freedom from its clutches is dependent upon a shift
in attitudes and actions within the oppressed group (Freire, 1987). Relying upon the
oppressing forces to grant autonomy is simply another manifestation o f deference to
authority. Roberts (1983) submits, "the oppressor is not able or willing to grant autonomy,
but rather it must be acquired" (p. 25). Freire (1987) identifies two phases which he
considers essential to the liberation from oppression: The first involves exposing and
acknowledging the oppression. The oppressed person needs to become conscious o f his/her

15

own perception o f reality and critically examine the contradictions in it. rejecting those that
belong to the oppressor (Freire, 1987). As Foucault (1980) purports, knowledge equals
power; therefore, increasing awareness o f one's plight is the first step toward emancipation.
Freire's second phase involves taking action to challenge and eliminate the institutionalized
belief systems that are perpetuating oppression. "To surmount the situation o f oppression,
men (and women) must first critically recognize its causes, so that through transforming
action they can create a new situation, one which makes possible the pursuit o f a fuller
humanity" (Freire, 1987, pp. 31-32).
It has been hypothesized that nursing leadership has been a powerful force in the
perpetuation o f oppression in nursing (Huston & Marquis, 1988; Roberts, 1983; Sinda,
1984). "Nursing leaders have represented an elite and marginal group who have been
promoted because o f their allegiance to the maintenance o f the status quo" (Roberts, 1983,
p.28). This allegiance contributes to the further negation of nursing characteristics, through
identification with the oppressor groups rather than one's own group. "This kind of
leadership leads to divisiveness and competition among nurses and does not foster united
efforts to change the system" (Roberts, 1983, p.29). Acknowledging the existence of
oppression and rejecting the status quo are essential at all levels o f nursing in order to move
toward greater autonomy and power.
Power in healthcare
The western healthcare model is structured around hierarchical divisions of power
based on professional status. The healthcare consumer, given his/her lack o f professional
status, usually has the least amount o f power in the system. The professional is considered
the expert and the patient the passive recipient o f care. A Funk and Wagnalls (1989)
definition o f patient is "anything passively affected by external actions or impressions"
(p.988). The medical model that underlies this approach to healthcare reinforces the
supremacy o f the objective over the subjective. This places a tremendous amount o f
responsibility onto the healthcare team to diagnose the patient's problem and find a cure for

16

it. Physicians, being the most dominant professional group in healthcare, possess the greatest
responsibility for the patient. When they do not have the answers for a patient, doctors will
often experience a sense o f powerlessness. This will manifest in attempts to bolster personal
power, often through the domination o f subordinate groups, such as nursing (Dykema. 1985).
Nursing will, in turn, dominate its subordinates, the patients (Hewison, 1995; Huston &
Marquis, 1988; Kavanagh, 1991; Lanza, 1997a). It is the patients at the bottom o f the
hierarchy who experience the greatest powerlessness.
Hierarchy
The institution o f healthcare is a microcosm o f society. Within it, lie sanctioned
power differentials, human inequities, and complex reinforcing structures that maintain the
I

status quo. This structure is perpetuated by the hierarchical nature o f healthcare which
mirrors the patriarchal social hierarchies that have existed in every area o f public life for
centuries. Hierarchy is a vertical structuring o f power that relies on the traditional model o f
power to maintain itself. That is, the level o f power experienced by one group depends on its
ability to exercise power over a 'lower' group in the hierarchy. Hierarchy, then, forms a
central aspect o f power within and between healthcare professions.
Hugman (1991) suggests that hierarchy is power embedded in organizational
language and structures, and he warns, "the overt exercise o f power is only one o f its forms in
hierarchical organisations., the structure may operate through the mobilisation o f bias, for
example, in the day-to-day work o f caring professions" (p. 40). He states further,
"hierarchical power is exercised through routinised sets o f expectations about work, about
objectives, methods, scope, and so on, in a context in which some professionals are defined
as having the right and the capacity to influence and at times direct how that work should be
undertaken" (Hugman, 1991. p. 66). Unless social hierarchies are made visible, power

'

relationships cannot be honestly examined and altered.
If hierarchies are based on descending degrees o f power, who or what is at the top o f
the healthcare hierarchy? Hugman (1991) suggests that the state is at the top, controlling

i
i

17

healthcare to meet the needs o f dominant social groups. The state's needs then are
inextricable from those o f the dominant groups within it. The real clients for whom health
care is engineered are the dominant groups in society. The majority o f actual service
recipients do not exist in these upper levels of the hierarchy, and are therefore subject to a
model o f care that is dictated by and for the more powerful groups (Hugman, 1991).
Hugman (1991) suggests that the concept o f patient, as a distinct social group, has been
constructed by healthcare professionals, creating "a pattern o f exclusion, and the beginnings
o f usurpation" (Hugman, 1991, p.42). He argues that patients are more often objects rather
than subjects within the healthcare system. "They may be researched, but they are not
consulted or involved in the definition o f needs which caring professionals address, either
generally or specifically" (Hugman, p. 43). Diagnoses, then, reflect the biases o f the
healthcare provider (Hall, 1996). From this perspective, health care can be seen as an
expression o f patriarchy delivered under the guise o f beneficence,
Hugman (1991) contends that ongoing maintenance o f the existing power structure in
healthcare is leading to a conflict between economics and ideology. The government gives
senior healthcare professionals the authority to define needs and allocate resources and, as a
result, many o f the structures and processes in healthcare reflect the needs o f the professional
rather than the community at large (Hugman, 1991). This suggests the need to examine the
philosophy underlying healthcare in the western world - the medical model. It is actually the
major controlling force residing at the top o f the healthcare hierarchy, influencing all levels
o f healthcare provision. Physicians fall under this dominant ideology as the next major
influential layer in the stratified health system. Below this group are nurses. At the bottom
o f the hierarchy are the healthcare consumers or patients.

18

Medicine and the western medical model.
As a culture we ascribe to the western medical model, a philosophy o f healthcare in
which health is defined by the absence o f disease and success is defined by the avoidance of
death. This model involves "the assumption that human behavior, like physical illness, can
be diagnosed and classified as a disease. This view produces an overreliance on objectifying
behavior through diagnosis and focuses decision making almost exclusively on problems
identified by the professional" (Hall, 1996, p. 17-18). This, in turn, leaves the healthcare
professional responsible for creating change and improving the patient's situation through
prescription. Freire (1987) claims that "one o f the basic elements of the relationship between
oppressor and oppressed is prescription. Every prescription represents the imposition o f one
man's [sic] choice upon another, transforming the consciousness o f the man [sic] prescribed
to into one that conforms with the prescriber's consciousness" (p. 31 ).
Central to the western medical model is a focus on pathology and on objectifiable
biological causes o f human difficulty. In the past century, very little acknowledgement of
sociocultural, emotional, spiritual, or political infiuences on health has existed. The absence
o f a holistic perspective o f the human experience limits the scope o f the medical model;
however, this reality is rarely acknowledged. Instead, healthcare delivery has come to rely on
inherent power relationships (Liburd & Rothblum, 1995). The act o f diagnosing can be
considered a powerful act in itself, as it "separates the knower from the known, because it
invites the health professional to focus on the diagnosis rather than the person with the
diagnosis. Diagnosed people then lose control o f their own destiny, since the most powerful
judgments o f them as people are controlled by experts" (Hall, 1996, p. 18). Hugman (1991)
asserts that a central component o f the professional/patient relationship is "the structural
capacity o f the professional to have the final word' on what constitutes cooperation"
(Hugman, 1991, p. 37). He suggests that 'cooperation' means that patients behave in
accordance with the expectations o f the professional. Such a dynamic automatically elevates
the power o f the professional while diminishing that o f the patient.

19

The medical model has become so entrenched In our approach to healthcare delivery
that its power often goes unacknowledged, and its perpetuation is ensured through the
education o f healthcare professionals who are indoctrinated with its ideology. As well,
healthcare consumers have come to embrace and perpetuate its tenets through their
expectations o f modem medicine. The general public tends to deify physicians, attributing to
them an inordinate amount o f power and demanding that they be omniscient and able to cure
all ails. Physicians, being mere mortal beings, cannot fulfill all o f the expectations that
society has come to demand from them. Reality suggests that people do die in spite o f
modem medicine, and there will always be problems that do not fit neatly into diagnostic
categories. Because such a denial o f the complexity of humanity is inherent in the medical
model, its dictates will, at times, create a sense o f powerlessness for physicians.
The strategies often used to counter this powerlessness are patemalism and
objectification. "Attempts to become masters o f knowledge about people come from a
patriarchal way o f thinking o f them as objects to be described, explained, predicted, and
controlled and are more often informed by issues o f power and economics than by positive
regard for patients as unique persons" (Hall, 1996, p. 26). In spite o f this negation o f the
subjective human experience, and the unrealistic expectations placed on healthcare providers,
the medical model continues to survive in westem societies. This is a result o f the power and
authority embedded within it, such that the authority o f the physician is seen as an integral
part o f the patient's healing (Liburd & Rothblum, 1995). With this model guiding the
delivery o f healthcare, the platform is set for a sequential cascading o f powerlessness down
through the layers o f the healthcare system (Mgoduso & Butchart, 1992).
Family systems theorists would describe such a cascade o f powerlessness in terms of
deflected or misdirected expressions o f emotion or experience (Walters, Carter, Papp, &
Silverstein. 1988). An example o f this is a family who experiences violence: A husband
feels powerless at work but does not feel able to address this directly with the source; rather,
he attempts to gain a sense o f power at home by dominating those he perceives to be less

20

powerful than himself, his wife and children. Often, children from violent families then
pursue a sense o f power themselves by becoming aggressive with other children (Walters,
Carter, Papp,& Silverstein, 1988). An analogy can be drawn to power-driven behaviours in
healthcare. The doctor can be viewed similarly to the father in the example, feeling
controlled by the dictates o f the medical model; the position o f the nurse parallels that o f the
mother; and the healthcare consumer has the least power, like the child in the family. Much
o f the anger and litigation that is levelled against the healthcare system by patients, stems
from a lack of personal and professional empowerment and responsibility that is fostered by
the system.
Nursing and power
Hugman (1991) articulates the essence o f the difference between prescribed nursing
and medical roles: "the doctor may care about the well-being o f the patient, through skills
and knowledge devoted to the diagnosis and treatment o f disease and illness, whereas the
nurse both cares about and cares for the patient in skills and knowledge devoted to the
tending o f the person" (p. 15). A key difference is that the caring work o f the nurse involves
a greater degree o f intimacy with the patient, requiring that the nurse acknowledge, at least to
some degree, the individuality of the person receiving the service (Hugman, 1991).
Medicine, on the other hand, strives for distance and objectivity. As a result, physicians
often see things in more general, categorical terms (Hugman, 1991). Will (1995) views
nursing and medicine as very different cultures, and she asserts that "the basic assumptions
made by nurses and physicians, those which underlie their practice decisions, can produce
cross-cultural conflict. This results in an inability to collaborate" (p. 30). which negatively
impacts patient care. It is in this difference in orientation to patient care that nurses and
doctors experience the greatest conflict, and it is here that a sense o f powerlessness is most
salient for nurses.
In an effort to increase their sense o f power, nurses, like those above them, will often
try to control those below them, namely their patients (Hewison, 1995; Huston & Marquis,

21

1988; Kavanagh, 1991; Lanza, 1997; Mgoduso & Butchart, 1992). Keddy (1996) writes,
"patients' lives are ruled, ordered, and organized by nurses, who are themselves subject to the
relations o f ruling" (p. 388). In a study on the use o f language between nurses and patients,
Hewison (1995) found that nurses exert power over patients by controlling the frequency o f
nurse/patient interactions and the content o f those interactions. Nurses will often use
inaccessible language to relate to patients, playing on the fear and helplessness that
frequently accompanies illness. As well, nurses seem to exert power through unnecessarily
controlling the routine and agenda o f patient care (Hewison, 1995). Hugman (1991) suggests
that the general acceptance by patients o f treatments administered by nurses is evidence o f
nursing power.
Not only is power socially structured, but because it is socially and culturally located
it may have the appearance o f consensus. That patients may be in full agreement with
nurses' administration o f drugs may in itself be considered as part o f the exercise o f
power by nurses collectively, for example; it may be a 'normal' part o f everyday life
(pp. 32-33).
Thus, nurses exercise power by influencing and even determining their patients' desires in a
given situation (Hugman, 1991). This coerced agreement between patient and nurse often
leads to a distortion in the perception o f power differentials (Hugman, 1991). A more
collaborative nurse/patient relationship, which is promoted by some nurse theorists as an
alternative to patemalism is. in reality, "constrained by this pre-existing power relationship"
(Hewison, 1995, p. 81). Although nurses may appear to be involving patients in decision­
making, Hewison found that "the sub-text o f the interactions reveals them to be performing a
controlling role" (p. 81). Kavanagh (1991) claims that having control does not necessarily
increase one's power; rather "control allows an illusion of power" (pp.256-257). Handy
(1995) suggests that psychiatric nurses are actually perpetuating their own powerlessness by
adhering to the dominant mandate o f control in hospitals, as opposed to adhering to a patientcentered mandate espoused by nurses. She observed a great deal o f stress in psychiatric

22

nurses based in the contradictions between the ideology o f nursing which suggests promotion
o f patient autonomy, and the control-oriented environment o f hospitals.
Mgoduso and Butchart ( 1992) suggest that "a redefinition o f health and illness...
I would create the conceptual and political ground in which a less authoritarian and more
I preventively oriented system o f health care could flourish" (p. 200). What they are implying
is that our current model o f health is handicapping our healthcare system. With the medical
j model sitting powerfully at the top o f the healthcare hierarchy dictating our approach to care,

I all healthcare providers and consumers are affected by and, to some degree crippled by, its
essentially unchallenged doctrine. However, because oppression is multi-layered in the
system, it is unlikely that change will occur at the highest level o f the hierarchy until the
professional groups below it reject the social roles imposed on them by their titles.
As suggested by Freire (1987). freedom from oppression must come from within the
oppressed group. A shift in nursing attitudes and behaviours has the potential for creating a
cascade o f changes throughout the healthcare system. Holden (1991) purports that if nurses
truly desire more power and autonomy, they must undergo "rapid shifts in attitude" ( p. 398).
If nurses are to advocate for patients by helping them to assert their needs, they must find
their own voice. Huston and Marquis ( 1988) assert that "patient advocates must have a
power base in order to meet their patient's needs" (p.40).
Nurses need to begin modeling effective use o f personal power if change is to occur
in the healthcare system. Keddy (1996) cites psychiatric nurses as having particular potential
to create significant change in mental health care, as "nurses are responsible for the everyday
social ordering o f the psychiatric milieu" (p.385). "Psychologists, psychiatrists, and social
workers are all professionals whose work depends on the nurses mediating their work for
them" (p. 385). She urges nurses to challenge established knowledge and social
constructions, emphasizing that they are humanly produced, and as such, can be humanly
altered. "New paradigms and discourses can create psychosocial, political and economic
change" (Keddy, 1996, p. 383). It is important to note, however, that real and lasting change

23

is a complex, multi-level process, that must be nurtured and prodded against multiple
resistant forces. Keddy warns that "old theory and knowledge can be modified and dressed
up to give the semblance o f change while maintaining the status quo" (Keddy, 1996, p. 383).
Actual change at the level o f psychiatric nursing, leading to more effective patient advocacy,
can have profound effects on the experience of the mental health patient.
Patient advocacv
Patient advocacy is central to the role o f the professional nurse. Gadow (1980)
suggests that "the philosophical foundation and ideal o f nursing is that o f advocacy" (p. 80).
A universal definition o f advocacy is lacking however. Gadow (1980) views advocacy as the
opposite o f patemalism, contending that "paternalistic acts and attitudes are those that limit
the liberty or rights o f individuals for their own interest" (p. 82). She asserts that selfdetermination is a fundamental human right and this belief underlies the concept o f advocacy.
Gadow states, "the right o f self-determination ought not to be infnnged upon even in the
interest o f health" (p. 84), and she perceives the nurse's role as that o f intervenor when the
patient's rights are violated by the system. Barton (1987) states simply; "Advocacy involves
assisting the patient in choosing among treatment options and supporting the patient
regardless o f what his or her decision may be" (p.87). Murphy (1979. in Millette, 1993. p.
607) suggests that advocacy entails supporting and defending the autonomy o f the patient.
She identifies three types o f advocacy; bureaucratic advocacy, in which the needs o f the
institution are the priority; physician advocacy, in which the needs o f all others, including
nurses and patients, are secondary; and client advocacy, in which the needs of the client or
patient are the ultimate priority. In current nursing discourse, patient advocacy is the
promoted ideal; however, in practice, bureaucratic and physician advocacy prevail (Yarling
& McElmurry, 1986).
The barriers to the actualization o f patient advocacy by nurses are multidimensional,
and are perpetuated by factors both internal to nurses, such as beliefs, feelings and values, as
well as external, such as those o f the social and bureaucratic structures in which nurses work.

24

Murphy (1979, in Millette, 1993) observed that nurses are less likely to advocate for their
patients when they are feeling vulnerable and powerless. Gadow (1980) found that most
nurses' desired loyalty is to their patients; however, they are caught working within a
paternalistic model. She states "the conflict between advocacy and paternalism is felt most
acutely by the nurse, since it is the nurse who must reconcile nursing's traditional alliance
with the patient and the modem allegiance to medicine" (Gadow, 1980, p.81). Nurses who
may truly wish to place patient needs at the forefront o f their practice often experience
conflicts o f loyalty with colleagues, physicians, administration, and themselves (Millette,
1993; Sines, 1993; Yarling & McElmurry, 1986). Millette (1993) captures the essence o f this
conflict: "As long as there is no disagreement on what the patient wants and what is best for
the patient, there is no problem. When there is disagreement, however, nurses are in the least
powerful position and are the least likely to prevail" (p.661). Millette ( 1993) found that a
more patient-centered approach is desired by most nurses, yet the practise o f client advocacy
remains limited. For those nurses who (unction from a primarily caring orientation as
opposed to adhering strongly to external rules and regulations (a justice orientation), a sense
of frustration and impotence predominates in their practice, and it is this group o f nurses who
is most likely to leave nursing altogether (Millette, 1993).

Psyçhiatriçjiurstng
This study is concerned specifically with the experience o f psychiatric nurses. The
field o f psychiatry is unique within healthcare as it defies formulaic approaches to medicine
more than any other area. In spite o f tireless efforts, science has been unsuccessful in its
attempts to conclusively establish cause and effect relationships in mental illness. Human
thought and behaviour is simply too variable and complex to be confined to a single
conceptual paradigm in which it can be objectively understood. Yet. in spite o f this,
formulae exist and attempted applications have been made in almost all cases o f mental
illness. Hall (1996) observes that diagnoses o f mental illness are too often "arrived at fi'om a
simple and narrow understanding o f patients' lives" (p. 17), resulting in limited treatment

25

approaches. Kennedy (1981) confers, stating it is a "shaky intellectual basis on which the
concept o f mental illness rests" (p. 109).
An imbalance o f control and power is particularly evident in the psychiatric setting.
The elusive nature o f mental illness lends itself to moral and ethical judgement by the
dominant social order (Szasz, 1991). Szasz suggests that the foundations o f psychiatric
diagnoses are value judgements, based on the belief systems o f healthcare professionals.
Keddy (1996) confers, describing the purported progression to cure for mentally ill patients:
Individuals who need psychiatric treatment are expected to change their behavior
until a transformation has occurred and they are able to tit into society. These patient
behavioral changes must meet with the approval o f the psychiatric nurses who. in
turn, notify the psychiatrists o f the transformation. It can then be said that a patient is
cured (p. 385).
Because this power structure is integral to mental health care, psychiatric nurses are
presented with unique challenges and opportunities. Psychiatric nurses possess significant
power to coerce their patients into the dominant constructs o f health and normalcy.
Alternately, nurses can interrupt the power imbalance by genuinely including patients in care
decisions and advocating for them throughout their hospital stay. Glenister and Hopton
(1995) state that psychiatric nurses need to play an active role in addressing the oppression o f
mental health patients. They suggest that "to talk of empowerment without recognising the
reality o f oppression is simply hot air" (Glenister & Hopton, 1995, p. 63). They assert
further, "nurses could strive to end the social exclusion o f people who act, think and feel in a
different way to others, rather than accepting legal coercion and back-door eugenics"
(Glenister and Hopton, 1995, p. 63).

26

Reseatçh.in nursing
Because there is no universal conceptualization o f power or powerlessness, there is a
significant lack o f clarity regarding its use in research studies. There have been a number o f
studies claiming to look at power and powerlessness in nursing; however very few provide
clear definitions o f these concepts. In spite o f this, most o f the studies utilize a deductive
method o f inquiry, and many neglect the subjective experiences o f nurses. In a review o f
cross-disciplinary literature on power and powerlessness, Pieranunzi (1997) made four
observations:
The first is the relative lack o f research studies which examine these concepts. The
second observation is the overwhelming focus on a reductionistic and narrow
perpective o f power and powerlessnes. The third is the predominance o f an
intrapsychic view o f power and powerlessness, even though much o f the literature
itself agrees that the concepts are relational. And last, there is an almost complete
absence o f any phenomenological or hermeneutical studies o f power (p. 156).
The lack o f inductive research on power and powerlessness in nursing may reflect the
widespread adherence to the dominant conception o f power. The lack o f understanding about
nurses' subjective experiences may be contributing to the perpetuation o f nursing
subordination. Pieranunzi (1997) observed that most o f the literature on power in nursing
views power from the perspective o f administration, and it treats power as a commodity that
is finite. He asserts that this view may act to limit the study o f powerlessness in staff nurses'
because it is driven by the belief that in order to empower another, one must relinquish some
o f one's own power (Pieranunzi, 1997). Thus, giving voice to subordinate groups such as
staff nurses may be perceived as threatening.
Studies focusing specifically on power and powerlessness in psychiatric nursing are
scant. Most o f the research in nursing focuses on medical, surgical or intensive care nurses.
It is o f value to consider these studies, as psychiatric nurses are a part o f the larger nursing
culture; however, the unique experiences o f psychiatric nurses warrant more attention. This

27

section describes four research studies on power and powerlessness in the general nursing
population (Attridge, 1996; Chandler, 1992; Erlen & Frost, 1991; Groves, 1992), and one
study on the experience o f power and powerlessness in psychiatric nursing (Pieranunzi,
1997).
Perceptions o f power and powerlessness in general nursing
Erlen and Frost (1991) explored the relationship between nurses' perceptions o f
powerlessness and ethical decision-making. They examined how nurses perceive their role in
the resolution o f ethical dilemmas, hypothesizing that nurses may be limited in their ability to
affect healthcare decisions because o f perceptions o f powerlessness. Data were collected
through in-depth interviews with 25 (22 female, 3male) acute care nurses, ages 20 to 49
years. The interview tool used was the "Perceptions of Nursing Ethics interview schedule,"
which asks participants to describe a specific situation involving an ethical dilemma.
Participants were asked why the situation was difficult, what nursing action was taken, and
what factors influenced that action. Data were categorized according to both the nurses'
words and the context o f the situations described. Content analysis revealed that 84% o f the
nurses interviewed described perceived powerlessness in relation to ethical decisions
involving patient care. The specific themes related to a perception o f powerlessness were:
( 1) physician control or dominance; (2) lack o f knowledge or information regarding
alternatives in a given situation; and (3) ineffectiveness regarding influencing the outcome of
an ethical dilemma.
Erlen and Frost (1991) found that nurses' sense o f powerlessness may relate to a
difference between doctors' and nurses' perceptions of, and approaches to, ethical dilemmas,
and to a very real lack o f influential power next to physicians. They found that when
physicians "exerted power and dominance, nurses perceived themselves to be powerless"
(Erlen & Frost, 1991, p. 404). "Without power, nurses may be unable to influence patient
care decisions" (Erlen & Frost, 1991, pp. 404-405). Further studies aimed at uncovering and
challenging the forces inhibiting a sense o f empowerment in nurses are essential, in order to

28

move toward more effective patient advocacy in healthcare, and the personal and professional
empowerment o f nurses.
My study extends Erlen and Frost's research, broadening the scope from which
participants were able to relate their stories o f powerlessness. That is, although many
powerless situations involve ethical dilemmas, my study is not limited to this domain. Thus,
a further understanding o f the varying types o f situations affecting nursing power are
exposed. Erlen and Frost accessed nurses' perceptions o f power and powerlessness, but the
actual impact o f feeling powerless was not addressed. My study explores the personal and
professional impact o f powerlessness on nurses, specifically those working in psychiatry.
Erlen and Frost (1991) mention a limitation o f time in their study. However, they do
not specify the time lapse between conducted interviews and the actual occurrence o f the
reported events. This lapse in time may have led to memory distortions in the nurses' reports.
For this reason. 1 have limited my participants to the identification o f situations that have
occurred in the past six months to one year.
Groves (1992) explored the attitudes o f general hospital nurses toward the meaning of
power, speculating that nurses' perceptions o f power or powerlessness impact their nursing
practice. The Power Orientation Scale (Goldberg, Cavanaugh & Larson, 1983 as cited in
Groves, 1992) which quantitatively measures attitudes toward power using six different
power orientations, was administered to randomly selected, acute care hospital nurses in
British Columbia. O f 200 mailed questionnaires, 112 were returned. Contrary to her
expectations. Groves found that the participants' attitudes toward power were moderate to
high on all six scales, reflecting a positive view o f power overall. However, she notes a
continued reluctance by nurses to exercise power in the workplace. She suggests that this
may "reflect the absence o f a clear conceptualization o f power in the context o f nursing
today" (Groves, 1992. p.52). Nurses may view power positively, but they may not be clear
on what power means to them in terms o f action, nor how its use or lack thereof manifests in
the workplace. Groves suggests "the need for nurses to re-examine their understanding o f

29

power in order to recognize and affirm power as an inner strength" (p. 26), adding that
increasing the discourse on nursing attitudes toward power has the potential to "inspire a
unification o f nurses to mobilize the potential and strength o f professional nursing" (p. 27).
My research adds to an understanding o f what inhibits nurses from utilizing greater power in
the workplace.
Groves also assessed demographics in relation to power orientation, and found that
there were no significant differences in attitudes toward power between demographic groups,
based on nursing education level, age, marital status, primary area o f practice, and status o f
employment. This is consistent with Erlen and Frost's (1991) findings regarding
demographics.
This study obtained its data through mail-out questionnaires. The response rate was
very high, suggesting a good representative sample. However, ths method limits the depth
and breadth o f data that can be obtained, and it precludes the opportunity for participants to
ask questions and receive clarification. Thus, the accuracy o f some responses may have been
affected. Groves concedes that her study did not "capture the concept o f power within the
context o f the complexities o f clinical nursing practice" (p. 62). A qualitative research
approach can provide the richness that cannot be obtained in such a quantitative study.
Circumstances o f empowerment and powerlessness in general nursing
Chandler (1992) explored the nature o f staff nurse empowerment and powerlessness,
using an exploratory, descriptive design. She based her study on a definition o f
empowerment that involves enabling individuals to feel effective so that they can act
successfully. She differentiates this from traditional understandings o f empowerment, in
which "managers have assumed that to empower subordinates is to delegate power by
parcelling out some control, authority, and influence" (p.65). A convenience sample o f 56
staff nurses from a variety o f acute care areas, was used. Individual interviews were
conducted, and the data was then content analyzed to identify key terms and themes related to
situations o f empowerment and powerlessness.

30

O f the participants, 57% experienced empowerment through their interactions with
the patient and family. They described feeling effective when they felt as though they made a
difference for the patient. The next largest group o f nurses (23%) felt empowered by positive
nurse-physician interactions, in which they felt trusted and respected. "When physicians
asked for the nurses' opinions, considered their input, collaborated in making patient care
decisions, and verbally acknowledged the nurses' input, the nurses experienced
empowerment" (p.68). In the remainder o f empowering accounts, 7% described working
well as a nursing team, 7% referred to recognition and compliments from their head nurses,
and 6% felt empowered when they felt good about themselves.
In descriptions o f powerlessness, 52% related to negative nurse-physician
interactions. "The negative interactions ranged from the physicians' ignoring the nurses when
there should have been nurse-physician collaboration for the benefit o f patient care, to the
,

physicians' listening to nurses and either not responding to, or verbally abusing, the nurses"

1

I

(p.68). The remainder o f powerless experiences include; "when a patient dies unexpectedly
(12%)...when the patient or family is not appreciative o f the nursing care
(1 l%)...shortstaffing (10%), floating (7%), dictums from administration (5%), and an
ineffective supervisor (2%)" (p.68).
This study suggests that empowerment for nurses is derived from interpersonal
interactions, rather than from receiving power from another, or having power over another.
"Staff nurses are closer to the relalionally oriented, feminist model o f empowerment " (p.71).
Chandler speculates on the cascade o f powerlessness from physicians to nurses: "One can
only surmise that the harsh situations described in the negative nurse-physician interactions
may have been a result o f the physicians' perceiving the nurses as threatening to their
autonomy and control: therefore, the physicians cut off the relationship by ignoring or
attacking the nurses" (p.70). The impact on the nurses, when the relationship was obstructed,
was an inhibition o f nursing action and a feeling of powerlessness. Chandler also notes that a
sense o f isolation characterized most o f the nurses' descriptions o f powerlessness. She

31

suggests "if the nurse had garnered support front colleagues the effect o f powerlessness might
have been dissipated" (p.70).
Chandler's study addresses circumstances in which nurses feel powerless and unable
to act. My study extends this understanding by asking not only what are the circumstances,
but also what specifically happens for nurses which fuels an inability to act.
Similarly, Attridge (1996) explored the circumstances o f powerlessness in general
hospital nursing. She drew her data from two previous studies in which the notion o f power
in relation to nursing was explored (Attridge & Callahan, 1987,1989). The original purpose
o f these studies was to explore nurses' view o f a quality workplace and how it could be
achieved, taking into account that female-dominated professions have traditionally endured
stark inequalities in the workplace. The data were originally collected within workshop
settings in which two primary methods of data generation were used, nominal group
technique and critical incident technique. The first study (1987) involved 19 research
'subject' participants, including representatives from nursing education, administration.
British Columbia Nurses Union, Registered Nurses Association o f British Columbia, staff
nurses, and middle management. The second study (1989) was designed to replicate the first,
using a larger sample size (N=45), drawn from general staff nurses in three acute care
hospitals in British Columbia. In the present study (1996), Attridge analysed the data
specifically obtained in the critical incident technique portion o f both prior studies (Attridge
& Callahan. 1987. 1989) to identify common themes in nurses' experiences o f powerlessness.
The decision criteria and method used for delineating these themes has not been included in
the research report. Seven interrelated themes emerged that characterized the circumstances
in which nurses experienced powerlessness. Nurses felt powerless in the following
situations: (a) in incidents that involved "very basic, almost primal, fundamental human
situations" (Attridge, 1996, p. 44), that is, in situations that stimulate strong emotion in all
those involved. When nurses perceived that such a situation did not go favourably due to
factors outside o f their control, they described a sense o f powerlessness; (b) in incidents

32

characterized by nurses' sense o f being in an unsafe or potentially unsafe situation, regarding
patients or others; (c) when the nurses felt out o f control o f the work situation, including
situations in which others have control or situations which are uncontrollable; (d) when
"competing, very serious demands" occurred, such that there seemed to be a no-win solution;
(e) when the nurses felt alone or abandoned; (f) during incidents that required the nurse to
make a choice or act resulting in visible negative consequences; and (g) when a lack o f
resources was evident.
Attridge (1996) addressed nurses' definitions o f power, observing that a sense o f
power for nurses seems to include control over one's work situation such that one can
successfully do one's job and achieve effective patient care. She notes that this conception o f
power differs considerably from that found in the traditional power literature, as it does not
suggest control over others, but rather, control over one's situation in order to achieve
success. As well, "nurses sought to be powerful rarely for themselves, but instead almost
always for patient or group advancement" (Attridge, 1996, p. 50).
In her suggestions for change. Attridge (1996) suggests that the necessary
components to nurses' sense o f power are respect and value, collegial support, and autonomy.
She found that if nurses' judgements are seriously considered and they feel successful in
influencing quality patient care, they are much less likely to describe feeling powerless.
Thus. Attridge emphasizes the necessity o(''respect and value for the nurse herself, the
importance o f her work and the quality o f her clinical judgment in the performance o f that
work" (p. 52). She also found that collegial support "by peers, administrators, physicians and
others" (p. 53) is a critical variable for nurses in reducing a sense o f powerlessness. Thirdly,
Attridge stresses the necessity o f "support for the autonomy o f the nurse in her definition o f
the nursing work situation" (p.53). She urges nurses to make the absence o f these elements
visible "to our managers, to our employers, to our profession, to the union, to the public, and
to the government" (Attridge. 1996, p. 55). My study will contribute to increasing the
visibility and value o f psychiatric nursing work. Again, Attridge did not distinguish between

33

nurses working in different specialty areas, and given the uniqueness o f psychiatry from most
acute care areas, it is o f value to look specifically at nurses working in this field.
Experiences o f power and powerlessness in psvchiatric nursing
Using a Heideggerian hermeneutical approach, Pieranunzi (1997) explored the
meanings o f power and powerlessness in the lived experience o f psychiatric nurses. He was
particularly concerned with the role power plays in the psychiatric nurse-patient relationship.
The basis of this method o f inquiry is described as follows: "Heideggerian philosophical
perspective sees the essence o f being, or Dasein, as embedded in day-to-day experience and
thus needing hermeneutical extraction, hermeneutics being the process o f interpretation
(Heidegger, 1927/62)." The intent o f Heideggerian hermeneutical phenomenology, then, is
"to uncover meanings embedded in descriptions o f everyday lived experiences" (p. 158). In
this approach, emphasis is placed on the language used by participants to create personal
narratives. Pieranunzi interviewed ten psychiatric registered nurses from diverse
backgrounds, using semi-structured interviews which were taped and later transcribed. A
team o f people were involved in the preliminary analysis o f the transcripts, followed by
further analysis by the author's dissertation chair and committee. In the third phase o f
analysis, participants were given the study outcomes and they were encouraged to offer
feedback regarding the accuracy o f the results. Pieranunzi claims that the involvement o f
various individuals in the analysis process ensured "truthful interpretation" (p. 158). The
process o f data analysis involved using hermeneutic methods based on Heideggerian
phenomenological philosophy.
Pieranunzi (1997) presented the findings in terms o f a dominant "constitutive pattern"
which permeated all data, capturing the relationships among themes and subthemes. The
constitutive pattern is "the power o f knowing." Pieranunzi found that for his participants,
power did not have much to do with control and influence; rather nurses "related power to an
ontological ability to understand and respond to clients based on an intuitive and personal
mode o f knowing" (p. 158). Participants talked about different ways o f knowing, and o f

34

struggling with trying to justify their intuitive ways o f knowing with linear, observable
means. The main theme within this constitutive pattern is "power as connectedness in
relationships." The nurses experienced power between themselves and others, not over
others. Pieranunzi writes "power is centered in knowing - not knowing 'how,' but knowing
'to '.. it was the knowing which connected them (nurses) with people in deep, mutual, and
profound ways" (p. 159). He found that the nurses wished to know their patients in mutually
empowering ways, and he describes this as "an intuitive and esthetic knowing and connecting
which transcended mere intervention" (p. 160).
Three subthemes o f "power as connectedness in relationships" were identified: "the
personal versus the professional," "the power o f mutuality," and "the contextualized nature o f
relationships." In the personal versus the professional subtheme, emphasis is on the personal
connectedness between nurse and patient that enhances healing. The relationship is mutually
beneficial and moves beyond the ideal o f objectivity as essential to professional practice.
Pieranunzi suggests that this way o f knowing
calls us to reach out to the humanness in other persons and open ourselves to the
meaningfulness in their lived experience and share the meaningfulness o f our lived
experience with th em .. .Powerful knowing involves the whole nurse and the whole
patient and ulitmately empowers them both (p. 160).
The power o f mutuality extends from this, emphasizing that the nurse-patient relationship is
one in which both parties grow and learn equally from one another. The final subtheme contextualized nature o f relationships - challenges traditional role theory which suggests that
people can move easily in and out o f different roles. Pieranunzi found that "to exist mutually
and connectedly with another implies an honest)' and authenticity that contradict the notion
o f operating within a certain role" (p. 160). He concluded that nursing is more than "just a
job" for participants, it is a way o f being.
This study sheds light on psychiatric nurses' conceptions

power as inextricably

relational and associated with intuitive knowledge. It suggests that nurses seek greater power

35

in order to enhance therapeutic relationships with patients, which they perceive as
foundational to healing and mutually beneficial. Pieranunzi concludes that the nurses'
"caring created a link, a bridge that allowed one human being to cross over and experience
another human being. Power (is) part o f human creativity, rooted in intuitive and esthetic
knowing, and focused on enabling one to 'be' and 'be with'" (p. 161). This study suggests that
nurses may be inhibited by inappropriate conceptions o f power that do not really fit their
lived experience o f power, and that embracing misfit ideas o f power is perpetuating nurses'
view o f themselves as powerless.
Summary
The research literature contributes to an understanding o f nurses' perceptions o f
power and powerlessness, generally and in relation to specific, personal experiences (Erlen &
Frost, 1991 ; Groves, 1992). As well, the situations in which nurses feel most powerless have
been described (Attridge. 1996; Chandler. 1992; Erlen & Frost, 1991). Pieranunzi's (1997)
study offers an understanding o f how psychiatric nurses experience power and powerlessness
in the context o f the nurse-patient relationship. Chandler (1992) addresses how a sense o f
powerlessness creates an inability to act. What is o f interest in the current study is what is
going on for psychiatric nurses in powerless situations that fuels this inability to act, and
what is the impact o f powerlessness on them. Notably absent from the literature are studies
on the personal and professional impact o f feeling powerless on psychiatric nurses.
Research purpose
The purpose o f this study is to explore the circumstances in which hospital psychiatric
nurses' most often feel powerless, and the impact this has on them, both personally and
professionally. An understanding o f the psychiatric nursing experience can facilitate the
development o f new structures and strategies with which to minimize powerlessness. As
well, this may lead to increasing discourse among psychiatric nurses, potentially creating
greater unity within the profession. My hope is that the visibility o f psychiatric nursing work
will be increased and the devaluation o f nursing care will be exposed. This study may

36

enhance awareness o f the power relationships between psychiatric nurses and other groups
within the healthcare system. An ultimate shift in these relationships may advance the
empowerment o f mental health patients.
Research questions
The research questions driving this study are:
1. What are the situations in which acute care psychiatric nurses fee! powerless?
2. How does feeling powerless affect the personal and professional experiences o f
psychiatric nurses?

37
CHAPTER THREE
Methodology
The current study employs an exploratory, focus group design to examine the
circumstances in which acute care psychiatric nurses experience powerlessness, and the
impact o f this powerlessness on them. A feminist theoretical framework guided the research,
in terms o f viewing all experiences as context-driven and subjective. The descriptive data
were analyzed for situational and experiential themes o f powerlessness.

ReseaEcb.dgsien
A qualitative research design was used for this study in order to access the complexity
o f psychiatric nurses' experiences, while taking into account the diversity within nursing. As
nurses have both a collective voice as well as many individual voices, it is important to
investigate both the common themes and the variations in their experiences o f powerlessness.
As I believe that nurses' sense o f powerlessness stems, in large part, from their having to
work within a positivist framework that impinges on their right to challenge existing
knowledge and create alternative knowledges, a research methodology that allows multiple
realities is appropriate. Thus, understanding the experience o f powerlessness from the
participants' perspective is paramount (Carey, 1994; Kirby & McKenna, 1989; Palys. 1992;
Reinharz, 1992).
Feminist framework
Feminist research challenges taken-for-granted realities imposed by the dominant
orders in society, and it attempts to offer new paradigms with which to understand
phenomena (Kirby & McKenna, 1989; MacPherson, 1983; Reinharz, 1992). This is based
on the belief that the human experience is very subjective; there is not one objective truth or
reality, but many. While feminist research encompasses both quantitative and qualitative
approaches, qualitative methods are frequently used to allow room for the voices and actual
experiences o f the research participants to be known. This contrasts with the more traditional
positivistic approach to research, which attempts to fit participants' experiences into pre­

38

existing constructs. Positivism is the position that there is one reality that can be discovered
and observed through objective means (Stevenson, 1996).
A feminist approach questions the power base that researchers have traditionally
enjoyed as the creators o f knowledge. It attempts to interrupt the perpetuation o f dominant
ideologies that can occur through traditional research. MacPherson (1983) asserts that
although the positivistic method o f research can offer useful information "it can
simultaneously function to provide rationalizations for existing power distributions, since the
paradigm is devoid o f any analysis o f the inferior status and oppression o f women" (p. 18).
Kirby and McKenna (1989) confer with this, asserting that "subordinate groups have been
structurally blocked from the process o f selecting, naming, disseminating and evaluating
knowledge" (p.28). As a result, feminists feel a responsibility to make research findings
meaningful and accessible to those groups who are being studied (Kirby & McKenna, 1989;
MacPherson, 1983; Reinharz, 1992).
It is important to note that although most research based on the concept o f
"experience” intends to dislodge accepted knowledge constructs, it runs the risk o f
perpetuating existing ideological systems. This is because it often treats experience itself as
the foundation for new knowledge, neglecting the multiple contexts influencing the
experience (Oleson. 1994; Scott, 1992). Scott (1992) speaks to the importance o f
contextualizing experience, “it’s categories o f representation...its premises about what these
categories mean and how they operate, its notions o f subjects, origin, and cause” (Scott,
1992, p. 25). She asserts
we need to attend to the historical processes that, through discourse, position subjects
and produce their experiences. It is not individuals who have experience, but subjects
who are are constituted through experience. Experience in this definition then
becomes not the origin o f our explanation. . . but rather that which we seek to
explain, that about which knowledge is produced (Scott, 1992, p.25-26).

39

Historical and social influences on nursing practice have been identified in this study in an
attempt to contextualize the participants’ experiences.
Integral to feminist theory is the idea that the personal is political. Feminist research
is personal in that it accesses the actual experiences o f individual people; it is political in that
it offers new perspectives on the experience o f oppressed groups, and it challenges the status
quo.
Focus groups
Focus group research is increasingly utilized in the social sciences as it provides a
unique combination o f the elements o f both individual interviews and participant
observation, thus providing kinds o f data that cannot be accessed easily through one o f the
other two methods alone (Morgan, 1988). Focus groups are interviews in the sense that a
researcher asks a few key questions (see Appendix A); however, the direction o f the
discussion is essentially left up to the participants. Wliat differentiates focus groups from
other group interviews is "the explicit use o f the group interaction to produce data and
insights that would be less accessible without the interaction found in a group" (Morgan,
1988, p. 12). Focus groups provide rich data by tapping into genuine interactions between
people, which allows the researcher to access perceptions, attitudes, and beliefs that underlie
behaviour (Carey, 1994; Krueger, 1994). This method o f inquiry is particularly useful for
studying issues that involve complex feelings, beliefs and experiences (Carey, 1994). Focus
groups provide a forum for participants to "describe the rich details o f complex experiences
and the reasoning behind their actions, beliefs, perceptions, and attitudes" (Carey,
1994,p.226).
As the intent o f this study was to access nurses' subjective experiences o f
powerlessness, an approach encouraging participants to describe situations in their own
words is most appropriate. "In the history o f the feminist movement, the primary means o f
empowerment has been women's telling o f their own stories" (Ristock & Pennell. 1996. p.3).
The group format is particularly useful as "the participants' interaction among themselves

40

replaces their interaction with the interviewer, leading to a greater emphasis on participants'
point o f view" (Morgan, 1988, p. 18). Because individuals do not form opinions and
reactions in isolation, the interaction found in a group can facilitate clarification and
expression o f thoughts and feelings. Kingry, Tiedje and Friedman (1990) suggest "the
synergy o f the group has the potential to uncover important constructs which may be lost
with individually generated data" (p. 125). As well, the group setting allows the researcher to
observe the interaction among group members, noting areas o f contention and agreement.
Moreover, this method o f inquiry is meant to stimulate discourse amongst participants,
something that is sorely lacking and very necessary for psychiatric nurses. Such a goal is
concordant with the goal o f feminism "to transform the competitive and exploitative relations
among women into bonds o f solidarity and mutuality" (Reinharz, 1992, p.264-265). As well,
public access to the knowledge gained in focus group research tends to be greater than in
traditional research, as both the method and results are fairly easily understood. Finally, this
approach enables the researcher to interview a relatively large niunber o f people in a short
period o f time.
Interview questions
Although participants determine the content o f discussion in focus groups, the group
facilitator needs to create a framework for the discussion. This is done through the use o f key
interview questions. The questions used in this study were arrived at in response to prior
studies on powerlessness in nursing. A number o f studies have identified situations o f
powerlessness for the general nursing population (Attridge, 1996; Chandler. 1992; Erlen &
Frost, 1991), but there is a lack o f information regarding situations o f powerlessness
specifically in psychiatric nursing. Thus, it was important to access this information. In
addition to identifying the circumstances o f powerlessness, I am interested in what inhibits
nurses from acting more powerfully and how they are affected by feelings o f powerlessness.
This interest underlies the remainder o f the questions. In all o f the groups, the key questions
were answered, whether they were asked by the researcher or not. In some groups.

41

participants provided the sought information spontaneously in their discussions. See
Appendix A for key interview questions.
Researcher's assumptions
In qualitative research, it is important to account for the impact o f the researcher on
the construction o f understanding about the investigated phenomena (Lincoln & Cuba, 1985;
Morse & Field, 1996; Stevenson, 1996). Self-reflection enables the researcher to gain clarity
about his/her preconceptions and biases, and to make these explicit to the reader o f the
research. Thus, I have included a list o f assumptions which I bring to this study, in appendix
B.
Leader and co-leader
The focus groups were facilitated by the principal researcher, and three o f the groups
were co-led by an assistant graduate student in counselling. She was not a nurse, and had
experience in both individual and group counselling.

Participants
Seventeen female nurses were interviewed in four different focus groups. Three
groups had four participants and one had five. All o f the nurses were currently working in
inpatient psychiatry, and they were interviewed in focus groups with only those nurses from
their same workplace. As the majority o f nurses continue to be women, and in order to
attain some consistency o f information as well as increasing the participants' comfort with
expressing themselves, participation was limited to women only. Krueger (1994) states that
focus groups are best with people who are similar to each other in order to increase comfort
with speaking up. "The focus group is characterized by homogeneity but with sufficient
variation among participants to allow for contrasting opinions" (p.77). Participants were
recruited from three acute care psychiatric inpatient units in three different hospitals in
British Columbia. Two hospitals are in the lower mainland o f British Columbia, and one is
outside o f the lower mainland. Krueger suggests that "multiple groups with similar
participants are needed to detect patterns and trends across groups" (p. 17), as a single group

42

may be influenced by very specific factors unique to it such as those related to the institution
o f employment. Recruitment occurred through posters that were displayed on each
psychiatric unit. As well, the managers spoke to their staff, encouraging their participation.
Participants volunteered by contacting either their manager, who then contacted me, or by
phoning me directly.

Pemographigg
Participant ages ranged from 30 to 59 years, with a mean age o f 48 and a median o f
4L O f the seventeen participants, ten were married, two divorced, two single and three were
unmarried but living with a partner. All were Caucasian. Educational background varied
considerably; nine nurses had RN diplomas, five had RPN diplomas, two had both RN and
RPN diplomas, and one had a bachelor’s degree in nursing. In addition, two o f the
participants had post-graduate diplomas in nursing, one had a diploma in a non-nursing field,
three had non-nursing bachelor’s degrees, and one had a non-nursing master’s degree. The
majority o f nurses (65%) had ten or more years experience in psychiatric nursing, one nurse
had 5-10 years, three had 2-5 years, and two nurses had under 2 years experience. Thirteen
nurses worked full-time, two worked part-time, and two were casual. Within each focus
group, there was approximately equal variation on all demographic variables. See Appendix
C for more demographic details.
Procedure
The focus groups were held in meeting rooms within each individual hospital setting,
in order to increase participants’ ease o f participation in the study. Each group interview was
60 to 90 minutes in length.
All o f the focus groups were facilitated by myself, the principal researcher, and in the
first three groups, a graduate student in counselling. All groups were video and audio taped.
As well, a few informal written notes were taken during each group. My role as group leader
was to facilitate the group discussion as non-directively as possible, while still guiding the
discussion so that key questions were addressed. The role o f the student assistant was to take

43

care o f logistical concerns, such as operating the video camera and tape recorder. As well,
she took notes during the group and offered her observations at the end o f each session.
Occasionally, the student assistant also asked some clarifying questions during the group
discussion. Each group began with an explanation o f the procedures and purpose o f the
group, along with a discussion o f the researcher and assistant roles. As well, informed
consent was reviewed and obtained (see Appendix D). Participants were encouraged to
speak openly, and the value o f diversity o f ideas and experiences was emphasized. A few
key questions (see Appendix A) were used to guide the discussion, but for the most part, the
participants determined the direction o f the discussion and the areas o f emphasis. All
questions were asked in an open-ended way in order to encourage rather than limit the
sharing o f a wide range o f ideas. "Open-ended interview research produces nonstandardized
information that allows researchers to make full use o f differences among people" (Reinharz.
1992, pp. 18-19).
At the beginning o f each group, the participants were asked to take a moment to think
about and write down at least one specific situation in the past six months in which they felt
they lacked power. Each participant was then given an opportunity to share her experience
with the group, and group discussion followed. At the end of the group session, key points
from the discussion were summarized, and participants were encouraged to validate, clarify,
or challenge the content o f the summary. They were also given an opportunity to add any
other thoughts at this time. Upon completion o f the group interview, a questionnaire was
distributed, primarily eliciting demographic information but also including questions about
how nurses feel supported or unsupported by their colleagues when they attempt to act more
powerfully in their specific workplace (see Appendix E).
Ethical considerations
Before initiating recruitment o f participants and data collection, ethical approval was
obtained from the University o f Northern British Columbia's graduate research ethics

44

committee. Ethical approval was also obtained from the hospitals in which the focus groups
were conducted.
The rights and privacy o f research participants were assured by providing information
on the purpose and use o f the study, encouraging any questions, and ensuring strict
confidentiality. Informed consent was obtained to ensure participants were informed and
willing to participate in the focus groups. All o f the audio and videotapes have been securely
stored. Two o f the audio tapes were transcribed by university secretaries who did not have
access to the names or places o f employment o f the participants. The remainder o f the tapes
were transcribed by the principal researcher. Only the principal researcher had access to the
videotapes. Participants have been identified solely by code, on the tape transcriptions. In
the results and discussion chapter, pseudonyms have been used to identify the participants.
Data Analysis
The audio tapes o f the focus groups were transcribed verbatim. The transcripts were
then reviewed in conjunction with the videotapes, to confirm the content and to identify
significant non-verbal communications. Data from all four groups were considered together.
The data were originally approached using content analysis. However, there was an
incompatibility between the data and preconceived categories o f powerlessness, which
inhibited this process. Thus, a more inductive approach to data analysis was required. A
theme analysis was conducted, in which four categories o f powerless situations emerged
from the data. The specific impact o f these situations on the nurses was then identified. As
well, significant differences between the groups were identified.
Seven factors identified by Krueger (1994), were incorporated in the analysis o f the
data. They include: (a) Consider the words. The words used by participants were analyzed
from the transcripts, in terms o f apparent meanings. The videotapes were then reviewed in
conjunction with the transcripts to incorporate non-verbal and speech pattern clues regarding
intended meaning, (b) Consider the context All the data were kept intact in the original
transcript form throughout the analysis, in order to maintain an understanding o f the context

45

in which comments were made, (c) Consider the internal consistency. The transcripts were
reviewed to determine whether individuals alter their positions on an issue after interaction
with others, or whether they remain consistent in their comments. Where participants
seemed to alter their opinions, clues suggesting the reason for the change were sought. In
many cases, participants views did not alter radically; rather, they evolved after being
influenced by the ideas o f others. This is suggestive o f the need for professional discourse
among nurses in order to clarify and advance nursing ideas, (d) Consider the frequency or
extensiveness o f comments. Both the topics which were discussed by more participants, as
well as the comments which were made more often than others, were noted. This was done
within individual focus group data, and across all groups. Those topics addressed by many
participants across all groups were identified as shared themes. Those topics which were
addressed most frequently were considered to be o f most pressing concern to the participants

I

at the time the groups were conducted. Individual differences between the groups were
acknowledged, and may be reflective o f varied staff cultures, institutional differences,
regional differences, or simply differences in the individual nurses who volunteered at each
site, (e) Consider the intensity o f the comments. The videotapes and the notes taken in the
focus groups were used to pick up variances in speaking patterns and non-verbal displays,
which were suggestive o f strong feelings. For example, voice tone, rate o f speech, volume of
speech and emphasis on specific words were all noted, and were considered in conjunction
with the actual words used. (0 Consider the specificity o f responses. Specific comments,
based on personal experiences were given more weight than more general, vague comments,
(g) Consider the big ideas, or trends that cut across all o f the data. Although individual
voices have been acknowledged, emphasis has been placed on the shared ideas that emerged
from the data as a whole.
Krueger's seven analytic factors were incorporated into a series o f steps in the process
o f data analysis. Initially, immersion in the data as a whole was necessary, to gain a general
sense o f the overall content o f the data within context (Morse & Field, 1996). Following this,

46

individual pieces o f data, consisting o f 1-2 sentences o f participant comments, were
highlighted if they were considered to be central to the nurses' experience o f powerlessness.
These included descriptions o f situations, as well as feelings and thoughts about them.
Following this, commonalties between the participants were identified. Morse and Field
(1996) state "it is these inter-participant themes that constitute the 'essence' o f the
phenomena" (p. 173). In order to better manage the data, I dealt with the specifics o f the
situations o f powerlessness separately from the nurses thoughts and feelings about them.
First, I developed the situational categories o f powerlessness. Following this, I identified the
nurses cognitive and emotional experiences in relation to these situations. As well, I
explored the interrelationships between categories. The specific process o f data analysis is
outlined below in more detail.

^tagc One
Data analysis began with a review o f all o f the transcripts to acquire a general feeling
for them. This involved reading the entire transcripts through twice, noting key areas o f
emphasis in the participants' comments. The transcripts were then reviewed again, and
individual pieces o f data were identified with a highlighter. The pieces o f data consisted o f
participant quotations that related to experiences o f powerlessness. These included
descriptions of powerless situations, as well as feelings and thoughts about them. After
multiple readings o f the transcripts, the key situations o f powerlessness were identified.
Initially, an attempt was made to fit the identified situations into categories o f powerlessness
that had been previously observed in studies o f the general nursing population (Attridge,
1996; Chandler, 1992; Erlen & Frost, 1991). This was unsuccessful, as the experiences o f
the participants were similar but not identical to those previously described in the literature.
Thus, the transcripts were re-examined for situations o f powerlessness emerging solely from
the data. This was done by reviewing the pieces o f data for suggested themes. From this, I
identified six categories o f powerless situations, with seven subcategories. These were: (a)
When feeling out o f control o f the work situation (i) related to physicians' dominance and

47

control, (ii) related to bureaucratic structure and hierarchical organization, and (iii) related to
the patient situation; (b) when there is a lack o f effective communication and teamwork; (c)
when there is a lack o f support and a sense o f isolation; (d) when there is a lack o f respect
and trust; (e) when there is a lack o f resources such as (i) physical on-site resources, (ii)
funding, (iii) staff and time, and (iv) community support services; and (f) when there is a lack
o f consistency in care. There were 272 pieces o f data at this point in the analysis. Next, the
pieces o f data were cross-referenced across all categories, and commonalties and repetitions
between the categories were identified. The categories and subcategories were then collapsed
into four broader categories: (a) Physicians' dominance and control, (b) caught between
meeting the needs o f the patient and the needs o f colleagues or the system, (c) structural or
organizational problems, including a lack o f resources, and (d) lack o f communication,
teamwork, support, trust, and respect. All o f the data were then reviewed again in terms of
the new categories, and pieces o f data were eliminated once saturation o f each category was
reached. "Saturation occurs when added information does not reveal new understanding
about relations or abstractions" (Kirby & McKenna, 1989, p. 138). At this point, 114 pieces
of data were being used. A graduate student in counselling who had not attended the focus
groups sorted identified data pieces from one focus group transcript into the four categories.
She was provided with a description o f the categories and was asked to sort each o f the
provided data pieces into one o f the four categories. This was then compared to the
organization o f the data done by the principal researcher. Interrater agreement was 56% at
this stage. Thus, the categories were refined once more through a further review o f the data
for descriptive themes. Four revised categories which seemed to more effectively capture the
essence o f the data, were created: (a) Medicine's dominance and control, (b) no-win
situations, (c) system problems, and (d) lack o f communication and support. These
categories were then surveyed for saturation, and the data were reduced further to 95 pieces.

48

Intênater rgiiability
A graduate student in counselling who had been previously uninvolved in the study in
any way, sorted the 95 pieces o f data from all four focus group transcripts into the four
identified categories. This coding was then compared to that done by the primary researcher
and 89% agreement was reached. Where there was disagreement, the two coders discussed
their differences and came to a mutual decision on how to code the data, thereby creating
100% interrater agreement.

St^gglvvQ
In this stage o f analysis, the transcripts were reviewed specifically for expressions
indicating attitudes, feelings, and experiences, in relation to the four situational categories.
Each piece o f data that was assigned to a situational category was scanned for key words,
phrases or nonverbal behaviours that indicated some personal or professional impact on the
nurses. All pieces of data were reviewed in their original context. Specific words and
phrases that described feelings and thoughts relating to each situation o f powerlessness were
identified as new pieces o f data. Twenty-one to twenty-six data pieces suggesting experience
were identified within each situational category. These data pieces were also crossreferenced across all o f the categories o f powerless situations, and experiences common to all
categories were identified. The data pieces were then grouped with others that were similar,
and eight themes on the experience o f powerlessness for psychiatric nurses were identified.
These include (a) frustration and anger, (b) helplessness, impotence, and feeling out o f
control, (c) apathy and hopelessness, (d) feeling pressured and stressed, (e) compromising
personal values, (f) feeling isolated and lacking trust, (g) feeling undermined, demoralized,
and invalidated, and (h) concern for the patient.

49

CHAPTER FOUR
Results
In this section, the types o f situations in which participants most often felt powerless
are described. This includes a discussion o f the impact o f these situations on the participants,
both personally and professionally. Descriptions and direct participant quotations are used to
illustrate the categories and experiences o f powerlessness.
Situations o f powerlessness
Participants identified four types o f situations in which they experience the greatest
sense o f powerlessness (impotence or inability to act with effect, related to a lack o f
authority). Although these categories o f powerlessness are addressed individually, this is not
meant to suggest their mutual exclusivity; rather, they overlap and interact with one another
in a variety o f ways. The division between categories was created to provide a stnicture for
understanding and communicating the research findings.
The four situations o f powerlessness involve circumstances related to:
(a) Medicine's dominance and control. This includes negative interactions between nurses
and physicians, as well as issues related to the more global professional dominance of
medicine in healthcare.
(b) Feeling caught in a no-win position. These situations involve the nurse feeling tom
between her allegiance to the patient and her allegiance to physicians and the system in
which she works.
(c) System problems. This includes issues related to the Canadian healthcare system, as well
as to organizational or institutional concerns.
(d) Lack o f communication and support. These situations are characterized by nurses feeling
isolated and alienated from colleagues.
Although each type o f situation created different feelings and responses in the nurses,
there were shared experiences across all categories. For example, feelings o f fhistration and
anger permeate the nurses' accounts in all situations. Many o f the stories shared by

50

participants reflect a feeling o f lack o f control, most often related to decisions made by more
powerful groups. As well, a predominating concern for the patient was expressed
consistently. One nurse explained,
I think sometimes the patients, when whatever stress it is in the system, whether it's
getting somebody in here inappropriately and slapping certifications on them just to
get them in here, or trying to find a place for them to go when they leave here, or
whether it's a miscommunication between staff members, it is the patients who feel
the effects o f all o f that mostly anyways, most directly.
Generally, the nurses expressed decreasing satisfaction with their work, and increasing burn­
out, exhaustion, and almost a sense o f defeat against the system in which they work.
Comments like "I've allowed myself to let my spirit break" and "you'll never win" are not
uncommon. Many nurses cite support from their nursing colleagues as the major positive
influence on their experience at work.
Medicine's dominance and control
Many of the situations described by participants relate to feeling powerless against the
control and authority o f the medical profession. These accounts can be understood in terms
o f two categories o f situations, which are each characterized by two themes. The first
involves nurses' individual interactions with physicians, in which they feel (a) unheard, and
I

(b) belittled or undermined. The second type o f situation involves reactions to the more
global professional dominance o f medicine in healthcare, and is characterized by nurses

I

either (a) feeling forced to participate in care they do not agree with, or (b) feeling limited in
their practice and decision-making power. In situations involving nurses interactions with
individual physicians, the impact seems to be o f a very personal nature and one in which the
nurses' sense o f self is most often threatened. Nurses used such words as "demoralized,"
"humiliated," "shamed," and "stamped down." Situations relating to the general dominance
o f the medical profession seem to create more feelings o f frustration and hopelessness.

51

Feeling unheard
Participants described feeling not heard by physicians, and as a result, they felt they
lacked significant influence on patient care decisions. There seems to be a general sense o f
helplessness when the physician involved is unwilling to listen to the nurses' ideas. One
participant described such a situation: "I suggested (a certain treatment for a patient), and
well she did end up getting (the treatment) and she did get better, she's not here any longer.
But it took forever from the time I thought o f suggesting it 'til the doctor decided to give it a
try." In this case, the description o f powerlessness is based around a concern for the patient.
The participant stated her biggest frustration with the situation was having to sit by and watch
the patient suffer. This is consistent with many o f the nurses' accounts o f powerless events:
the focus o f concern is usually the patient. However, this concern does not always seem to
be enough to motivate the nurse to intervene on behalf o f the patient. One nurse shared an
experience in which she felt unable to stop a treatment from being administered, even though
she felt it was damaging to the patient:
I did say to the doctor I thought that this procedure wasn't necessary, but he thought
that it was, and I thought that he used an approach that didn't leave room for
negotiation. . . I felt powerless and very disappointed in the therapeutic process and
not having that trust neither which I think is necessary.
These situations suggest that participants consider the power to alter the extent o f
nurse/physician collaboration, as residing with the physician. It seems as if the nurses feel
they have input only if the physician involved is willing to collaborate. If the physician is not
willing to collaborate, then the nurses seem to feel impotent. The nurses are aware o f being
discontent and undervalued, yet they are reluctant to challenge the authority o f the doctor
because o f a belief that they lack power. Instead, the nurses complain about the doctors to
each other, and at times give up, feeling hopeless. Further evidence that nurses perceive
doctors to be considerably more powerful, lies in the following kind o f comments. Liz
explained that she finds it difficult to provide consistent nursing care because of

52

so many inconsistencies between the psychiatrists and how they treat their patients ..
we as a team can't be consistent because we have no consistency here (using hands to
indicate a higher level for medicine and a lower level for nursing). . . The rules are
always different with every doctor, there are very few that you go well this is so-andso's patient, so in this situation I'll do this, but if it was so-and-so's patient in that
same situation, I would do this. So you spend years trying to figure out their little
idiosyncrasies.
Nora agreed that the degree o f input nurses have into patient care decisions, "depends on
which psychiatrist you work with" Petra added "it depends on the psychiatrist that's
involved; if you know you're going to be listened to, you're much more likely to speak up."
A number o f nurses suggest that challenging medical authority can make life very
uncomfortable and may even jeopardize one's job. One participant commented on the risks
that may result from expressing one's differences:
I've seen people actually quite damaged or have consequences, when trying to
(make change). It's a lot o f work, takes a lot o f emotional stress to really work on
making changes happen when you're still trying to keep your house going and your
income in and it's like another job.
Other nurses offered their experiences o f what keeps them from being more vocal and active
in their relationships with physicians. Iris suggested that challenging a doctor can make life
difficult; " .. .it is the doctors who make the final decision and they resent any challenge to
their pow er.. .from time to time, if you've challenged them and they don't like it, they won't
talk to you for days or weeks." She stated this inhibits her from acting because "you know
you could have to put up with this childish behaviour as a consequence." Liz has
experienced something she called "the passive-aggressive revenge factor," wherein
physicians will unreasonably refuse to cooperate with a nurse's request, "so you have a
patient getting sicker and sicker and sicker for no other reason than revenge."

53

Another participant, Jane, offered her understanding o f why nurses don't speak up
more, by likening their situation to "the abused wife syndrome; you get into a rut." This
suggests an understanding o f the dynamic o f oppression that occurs in the nurse-physician
relationship. With this understanding, Jane acknowledged that every participant in the
relationship has a responsibility to create desired changes, and that nurses cannot depend
upon physicians to create the changes they seek. She asserted " .. .it's not all the fault o f
doctors. I think we've all got our story as to why we shut ourselves down." Liz offered,
"we've learned to shut ourselves down, because we go okay why b o ther.. .It's safer to just
keep your head low." Iris conferred with this sense o f hopelessness regarding change:
"Well, you'll never win . . . So how are you going to feel, trying and trying and trying and
then being stamped down." When repeatedly dismissed, one's tendency is to stop speaking
up, which exacerbates the feeling o f powerlessness.
Such examples suggest that physicians are determining the nature o f nurses'
experiences in caring for their patients. Clearly, the nurses' ability to effectively advocate for
their patients is impaired when they feel blocked by the authority o f the physician. Nora
articulated the impact o f this power imbalance on the nurse and the patient:
you know you want to a c t.. .you can say what you want to say, but it's like you
don't get heard despite saying what you say .. .it's like you know what you want to
do, but you don't act upon it because there's not going to be a result o f that. And so
it's like an apathy or an ambivalence, or the advocacy that you ought to have to
empower your patients, to be supportive, is not there as it should be. And that's
scary that you don't follow it through, when you know that an injustice is being
done.
Feeling undermined and belittled
In addition to not feeling heard by physicians, many nurses feel their decisions and
input are sometimes undermined and belittled. Even when policies are in place, a number of
nurses expressed distrust that physicians will adhere to them. One nurse explained, "you

54

know running a ward like this, we set up procedure manuals so that there is some consistency
in following a plan. And what I find really undermining is that we (nurses) do follow it, and
yet a doctor will come in and say well I'm going to bypass that." Another participant
expressed her frustration at physicians' inconsistency in following an agreed upon plan: "I
find that really, really hard because you're supposed to be part o f a team, you're supposed to
be working with the patient, for the good o f the patient, with the physician and the rest o f the
planning team, and then they (doctors) change the rules, and I get really frustrated." So, even
when units have overt standards and policies, there seems to be a double standard in terms o f
adhering to them because some physicians feel their authority can override policies. This
creates a sense o f helplessness in the nurses, as their approach to care, even if it is following
an established protocol, may be subverted at any time. As well, some participants suggested
that nursing sometimes has to deal with any problems resulting from the physician's decision.
One participant referred to this as "secondary wounding," in which the nurse is blamed for
poor patient outcomes that result from medical supersession o f protocols or nursing
decisions. Nurses are asked questions like "well what did you do to set that off?...Or why
didn't you medicate him, or why didn't you prevent it?" Participants expressed frustration at
the expanding and contracting roles they are expected to fulfill when it suits the physician or
the system. In some circumstances, they are not considered capable o f certain decisions and
responsibilities; however, when things are not going well, ninses are often considered
responsible for the problems.
Some participants feel that doctors minimize what nursing work entails. One nurse
recalled talking to a physician about being assaulted, and his reply was "well, you went into
nursing" as though getting hit is an expected part o f the job. Another participant described a
situation in which she felt invalidated by a physician. She was assaulted by a patient, and the
psychiatrist involved minimized the impact the assault had on her, and he did not support her
in challenging the patient about his abusive behaviour. She recalled, "I asked him (the
psychiatrist) if there would be consequences, he walked away from me, and I walked down

33

the hall after him and he just sort o f waved me o f f .. .So then the patient went outside and
bragged about what he did. So, it was demoralizing." She described a process o f
"invalidating" and "shaming" that she has experienced as a result o f trying to communicate
observations or patient assessments to certain doctors. She viewed this as a tact by
physicians to keep nurses in a subordinate position: "let's embarrass you so you won't
challenge me again". She stated "your tendency is not to speak up if you're going to be
belittled or shut down." Helen recalled a situation in which she mentioned her concerns to a
physician regarding a potentially violent patient, and his response to her was, "you're being
histrionic, you just exaggerate." When the patient did act violently, the same physician said
to the nurse "1 thought this would give you some satisfaction (to be right)". Helen bemoaned,
he was treating it "like I've got some personal investment in it rather than the care o f the
patient, when consideration o f patient care is the most on our minds. It becomes like a power
struggle, that's what it does." Participants agreed that too much energy is spent on this power
struggle, which detracts from patient care.
Feeling forced to participate in care
Another way in which medicine's assertion o f power manifests is in pressure on
nurses to participate in treatment they may not agree with. Georgia described an experience
in which she refused to participate in a certain procedure, and the physician used his authority
to pressure her:
About a year ago, one o f the doctors, one o f the psychiatrists called late in the
evening and asked if I’d do a phone consent for a patient to have (a certain
treatm ent).. .The patient was quite elderly and I didn’t know if she h ad .. .cardiac
problems or respiratory.. .and I refused. I just felt that she that she was too frail to
have (this treatment) in the morning, basically because she hadn’t had a physical work
up. And so, needless to say, putting it mildly the doctor wasn’t very pleased and I
called my supervisor and she agreed with me. But the doctor called the supervisor
and the director o f nursing and several other people related to nursing, to complain

56

that I had refused. And it was a very traumatic experience. On the other hand I felt
that I did the right thing because I didn’t feel the patient was well enough to have this.
And since then, now we have a protocol where our patients have physical work ups.
which is great. But on the other hand, I certainly felt disempowered to say the least
. . .and it was a very negative experience for me.
As Georgia told this story, it was clear that this was very upsetting for her. Her voice
quavered and she looked anxious. Some o f her nursing colleagues who were familiar with
the example, validated how difficult this situation had been. She described the experience as
"demoralizing" and "demeaning", stating "I wouldn't wish it on any o f my colleagues."
Though Georgia held her ground in spite o f the pressure, numerous examples suggest that
nurses more oAen succumb to the pressure than resist it.
Feeling inhibited from providing the best care
In addition to feeling pressured to participate in care they do not agree with, many
participants stated that they oAen feel inhibited from providing the kind o f care they believe
would be most helpful, due to their lack o f authority and decision-making power. One
participant gave an example in which a patient was inappropriately admitted to her unit, and
she felt the patient was not receiving adequate care. However, she felt her hands were tied, as
she did not have the authority to transfer or discharge the patient. She expressed anger at
having to put in a lot o f work into admitting the patient, caring for her, and planning her
discharge, when she felt it was inappropriate: "It is frustrating because I don't have the power
to admit and I don't have the power to discharge. None o f that is mine, but somehow it's
become my responsibility to see that both o f those things get done. "
A sense o f defeat about their lack o f authority was present in a number o f the nurses'
stories. One participant stated.
Well, ultimately the doctor has the power and control. So you'll just get your hands
rapped or whatever (for making autonomous decisions): the more you do the more
negatives you get. It's sort o f a reversal as to how you get brownie points here. You

57

get a lot less hassle for custodial care than you do for voicing your opinion and doing
what you think is right.
Another nurse expressed the view that it is often not even worth trying to assert one's opinion
because "in the final analysis on this ward, it is the doctors who make the final decision and
they resent any challenge to their power." This sense o f defeat reflects a belief that it is
easier to maintain the status quo than to assert what one believes is right. In spite o f
injustices in patient care, nurses will still, at times, opt to be more passive than active in
advocating for patients. A sense o f impotence and hopelessness around change cut across all
the powerless situations, but it is particularly prevalent in situations characterized by
medicine's control and dominance.
When asked what would need to be different for you to feel more able to act in the
best way for the patient, a number o f participants suggested changes in the physicians'
behaviours. For example, one nurse stated "I think for the doctor to respect nursing opinion
or to listen, and not to feel like they have sole responsibility over the decision-making
process."
No-win position
For participants, being in a no-win position entails feeling caught between competing
demands. Often, succumbing to the demands o f one person or group means neglecting the
needs o f another. These situations fall into two categories: (a) Feeling caught between
patients' needs and the demands o f the healthcare and administrative systems in which nurses
work, and (b) feeling caught between meeting the needs o f the patient versus meeting the
needs o f the physician. It is important to note that when participants talked about physicians'
decisions, they often referred to them as though they were one and the same as those o f the
institution or the larger healthcare system. Thus, the separation between medical dictates and
systemic or institutional does not always appear to be clear to nurses. What is clear to them
is that they are experiencing a conflict with a more powerful group. This creates a
tremendous amount o f stress for nurses. In no-win situations, nurses most often describe

58

feeling out o f control, uncomfortable, and morally conflicted. A great deal o f their stress
stems from trying to balance the need to maintain collegial relationships while advocating for
patients' perceived and/or expressed needs. In all no-win situations, concern for the patients'
needs was paramount in the participants' experience.
Patient needs vs. physician needs
Intertwined with the issue o f medical dominance and control is the nurses' experience
o f feeling caught in a no-win position. Nurses describe feeling tom between providing the
best possible care to the patient, while avoiding excessive conflict and maintaining collegial
relationships. In situations in which medical demands conflicted with patient demands,
participants often felt helpless and hopeless. They described feeling in a position of'dam ned
if you do; damned if you don't.' Participants tend to believe they do not have a choice in
whether they participate in care decided upon by the physician. They feel they can offer their
opinion; beyond this however, they feel they must carry out the physician's plan even if it
might not seem in the best interest o f the patient. For many, the perceived costs o f
challenging a physician outweigh the benefits o f adhering to one's own principles.
Participants recognized that a lot o f the conflict regarding patient care decisions stems from
the indefinable nature o f mental illness and wellness. "I think there's a lot o f people coming
from a lot o f different places about what makes people healthy. " What frustrated participants
about this, is the fact that the physician's ideas about treatment always supersede the nurses
ideas. This created a sense o f hopelessness in participants; comments like "why bother" and
"what's the point" permeate their stories o f no-win situations.
As a result o f this hopelessness and helplessness, many participants have found
themselves participating in care that they do not believe is in the best interest o f the patient.
Consequently, some nurses have experienced a great deal o f guilt for contributing to the
potential harm o f a patient. In one example, a nurse described:
I see this patient's physical and mental condition just deteriorating and I think that it's
a bit because o f the amount of damage that we've done giving these pills over the

59

years.. .I've a very upset conscience that I'm contributing to this, that I'm being
forced to contribute towards this.
Clearly, this participant felt she lacked power in this situation, as evidenced by her statement
"I'm being forced". Many participants shared this feeling o f being forced to act in a way that
conflicted with what they felt was best. However, legally and ethically, nurses are not
required to carry out physicians' orders they disagree with (RNABC, 1992)
One area in which participants frequently expressed conflicted feelings and a sense o f
powerlessness was in the care o f patients with DSM IV axis-II diagnoses, particularly those
with borderline personality disorder. This seems to be an area in which there is a great deal
of room for divergent ideas in terms o f approaches to treatment. Edith expressed her
perspective:
We all know that the best way to treat these patients is crisis intervention.. .It has
been proven over time that it is far more therapeutic than enabling them and
keeping them here until they decompensate and actually do get to the point that
they’re so ill that they do need to be hospitalized. And I find that the doctors do
not respond to this because they put, in my opinion, put their own needs first.
It is much easier to treat an axis-II in hospital than being at h o m e.. .And I can't
help but think probably there's a financial aspect to why they do it. Certainly it's
much easier - they're very difficult patients - but also financially they're probably in
a better position, for the time expended to have them in hospital than out. And I
find this very frustrating, because I'm here for the patient. I have taken many
courses throughout my career in psychiatry an d .. .1 have done a lot o f work with it.
And yet it's frustrating, because you leam i t . . .and yet you can't apply it.
In this statement, a great deal o f frustration is expressed in relation to feeling inhibited from
acting in the best way for the patient. As well, a distrust in physicians' motives regarding
treatment decisions is evident. Edith identified the patient as her priority, and she indicates
skepticism about the priorities o f physicians.

60

In spite o f considering the patients' needs a priority, however, many nurses find
themselves acting in such a way that the physician's perspective and decisions actually take
priority. This is exemplified by the multiple situations the participants recounted in which
they administered medications against their better judgment. Liz shared, "we know there are
psychiatrists who have not kept track o f their medications, don't know how to medicate, and
we're forced to give out medications that we know better." Another participant's example
reflects her distress in feeling she has to subvert her nursing practice decisions to those o f a
physician:
We had a situation not too long ago where we had a patient who came down o ff o f
a medical ward on a large amount o f medication; it had been increased on a daily
basis, and the orders that came down with the patient were for me to give this large
amount o f med every four hours, and it was not a situation where I felt particularly in
control because it was outside the normal range for the medication in the CPS
manual, and it was not something we would normally do. And I felt that not only
giving them that much but also the fact that the plan was to keep increasing it, was
going to detract from the focus on the unit which would be to develop coping skills,
therapeutic alliance.. .1 thought they were stoned on the medication and they were
getting more stoned on an hourly basis. And there was a whole bunch o f orders from
a whole bunch o f different people and I felt really uncomfortable about that. So I
called the specific doctor, who is responsible for the unit, and I clarified 'was this
exactly what you meant to do?’ and he said ‘yes’. . .1 said I didn't feel very
comfortable with it and he said ‘well, it's a safe range.’ But I didn't feel we had a
proper discussion about what was the care plan for the patient, and then so 1 had to
give the meds even though I thought it was detracting from doing any kind o f
therapeutic work.
This participant expressed how difficult it was for her to administer the medication against
her best judgment:

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It felt completely wrong. I felt I was being manipulated by the patient. . . they kept
saying ‘well the doctor said this was OK, and this is what I want. No, I don't want
to talk, and I don't want to work on any o f these issues. I just want medication.’ I
felt quite angry at the doctor but not able to . . . I was trj'ing to keep that from
interfering with my relationship with the patient. At the same time, I felt like I’m not
helping this patient to work on anything, just letting them be completely sedated for
the whole weekend . . . It was very frustrating.
Because psychiatry is less precise and formulaic than other areas o f medicine, there is
a great deal more room for subjectivity in treatment decisions. The above example illustrates
this, with nursing and medicine disagreeing about the goals o f treatment. Rather than
functioning in a complementary way, physicians and nurses often spend a fair amount of
energy in power struggles, both claiming righteousness. One participant talked about the
impact o f this power struggle:
It hits the patients. That's where it's always going to be played out because if
you're angry at a physician, a physician is angry at you, you guys are not
communicating. So vital information about that patient and what that patient
needs is not being communicated.
Some participants described feeling trapped by the power o f physicians, wherein they
feel they not only have to participate in care they disagree with, but they may also have to
take responsibility for it. Liz offered:
We're being held hostage because some psychiatrists are afraid o f the para-suicidal
patients who say, hey, we might kill ourselves.’ And so. we keep them. And they
know that, and it feeds into their dependency and we watch them regress and get
worse and worse the longer they stay here. So, by the time we discharge them they're
twenty times sicker than they were when they first came in the d o o r. . . and the
nurses get blamed for it.

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Anna expressed her frustration in having to defend treatment approaches that she may not
even feel are justified. She gave an example in which patients are questionably committed
under the Mental Health Act: "Often patients will wake up in a seclusion room and say why
am I h e re .. .because the doctor didn't say I was going to be’. . .You know, they (doctors)
basically commit them to get them admitted which is very unfair, if they're not committable "
A s a member o f the professional team, she feels she needs to present a cohesive front to the
patient, but she is uncomfortable and angry with having to justify certain doctors' decisions to
the patient.
In some situations where participants were not required to be actively involved in
treatments they disagreed with, they still experienced guilt around their passivity in
advocating for patients.
I didn't think the approach was right for this particular patient. She had been certified
and de-certified and certified and de-certified over and over, and it seemed more like
a power play between the doctor and the patient, rather than what was really
addressing the patient's needs. And I guess I just felt really uncomfortable with the
whole situation. . . I felt really uncomfortable witnessing this and because I saw her
come in and out, she was here for a long period o f time, I thought this woman's
deteriorating, and it was hard to watch.
When asked if she took any action on the patient's behalf, she stated that she did not because
she found the doctor intimidating and because she only works occasionally, she did not feel
comfortable asserting herself.
Patient needs vs. svstem needs
The nurses described feeling caught in a no-win position between meeting their
patients' needs versus satisfying the demands o f the healthcare and institutional systems in
which they work. A number o f participants made reference to a "cover your ass" mentality
which is eroding patient care. They felt that this drives a lot o f medical decisions in
psychiatry, and that this really is a broad system problem. Jane explained:

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I was working with someone who was talking about giving up o f control and I was
trying to work with him on that, and put the responsibility on him to let me know
what was going on with h im . . . I was trying to put the responsibility on the patient
rather than just keep neigling and protecting h im . . . and I would work with him on
signing a sheet on his expectations, this was what he was committed to do, with his
family there. So about an hour later I got a phone call from the director questioning
what happened because his family had reported me, that I was not taking control o f
this patient. . . and that I'd made them sign something . . . So the story got totally
turned around. So I Just thought what's the point here, because I end up getting in
trouble. . . Now this patient's been on constant medications since because if there's
any kind o f hassle from the family or whatever- they don't want to take responsibilitythen the doctor gets hear o f i t . . . and he'll always do what's safe, or what covers his
ass, politically. So you get caught in the middle o f it and unsupported.
Jane's distress here is related to the unwillingness o f the patient and his family to take more
responsibility for his health care. What seems to be most frustrating for her, however, is the
lack o f support she received from medicine when trying to empower this patient. Many
participants claimed to be motivated by an intent to empower rather than disempower
patients and they often view physicians as operating oppositely.
Jane's efforts to empower her patient backfired because she was unsupported by the
physician. She felt caught in the middle, trying to provide what she believed to be the best
possible care for the patient while the physician seemed to be taking a "cover your ass"
approach, regardless o f whether it was helpful for the patient. She described the personal
impact o f this kind o f situation: "I feel like I'm giving myself up all the time...as to who 1 am
and what 1 believe." She also indicated an impact on her professionally, when she expressed
her hopelessness - "why bother" - about practicing autonomously. Clearly, this impact on
her nursing practice has significant repercussions for the patient. She suggested that it seems
easier to give up trying to make any autonomous practice decisions and go along with the

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dominant mentality - "just cover your ass." Without an advocate for their concerns, patients
are in a very vulnerable position.
Nurses often experience conflicts between what they wish to do for the patient and
what the system demands o f them. Influenced by a litigious mentality, along with shrinking
resources, the system is moving in the direction o f validating only tangible, measurable
actions. This is quite incompatible with the intangible nature o f psychiatric nursing, and it is
pressuring nurses to be more task oriented, and to spend an increasing amount o f time away
from direct patient care. One participant stated, "we’re so busy worrying about the politics
and the paperwork and getting things, arranging, changing, getting beds y’know, you forget
that there’s a patient involved." Another participant gave an example o f how the changing
emphasis creates pressure to take action regardless o f whether this is what is most
appropriate:
1 feel like (giving lots o f medications) is part o f the way our system operates and so as
part o f the system, I enable it and keep that happening. . . I have to Justify why 1
didn't give a medication as opposed to why I did, so for me it's ass backwards in what
I'm doing here and this is where it goes against. . . who I am and what I believe.
Liz characterized the system as having "a lack o f caring." Jane suggested that this has a
preservative function for healthcare professionals: "Ultimately the system works because it
provides us with our income o f patients. I mean what would happen if they all got well? The
system works."
Svstem issues
In many o f the described situations, participants attributed their sense o f
powerlessness to problems with the health care system, and with the institutional systems in
which they work. The term, system, was used to include organizational structure, at both the
ideological and practical levels. With the recent massive changes in the healthcare system,
participants' sense o f powerlessness has been heightened. Particular emphasis was placed on
resource availability and allocation within the system, and the impact o f this on psychiatric

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nursing. Many o f their descriptions o f powerlessness relate closely to (a) inadequate
resources, and (b) the driving values underlying current health care delivery, which many
participants consider incompatible with good patient care. Participants acknowledge long­
standing system problems, but emphasize that recent healthcare cuts and organizational
changes have exacerbated these problems. Liz explained:
1 think the key is system, and what's driving the system right now. A lot o f what we
talked about here was what we used to have - used to, used to, used to. And that's
system driven because the system is underfunded as far as I'm concerned . . . It's
health care money, it's do more with le ss. . . We're doing a lot less . . . So when you
talk about system it's not ju st-th e system has been a problem since the system
became a system, and communication has been a problem since there has been the
need to communicate . . . This has made all those issues so much more difficult to
deal with because you don't have the energy. You're fatigued, you're tired, you're
burnt out. And if you don't have an optimum sort o f workplace ..when you have a
system that's putting this much pressure on you. you aren't going to have healthy
employees and you aren't going to have healthy patients, and you aren't going to
have healthy psychiatrists. Nobody's ahead o f the game.
Inadequate resources
The emphasis in many participant comments on system problems focused on
diminishing resources and the resultant pressures o f working within such a strained
environment. Participants typically described high levels o f stress, burn-out, and depression
in relation to system issues. As well, there was a perceived decrease in the standard o f care
that is now possible, and an accompanying decrease in nursing job satisfaction. One
participant described this:
I've been really frustrated by the downsizing o f healthcare and the fact that we
can't provide the kind o f care we should be providing because the dollars aren't
there. We've been forced to move to heavier workloads, more unsafe work

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situations and less time for patients. Our level o f care has changed, we're putting out
fires. We aren't counselling people anymore, we're trying to stop them from
exploding, that's it. We're fireworkers. . . So your quality o f work has gone down,
your workload has gone up, and the safety o f where you work has been
compromised a great deal. So you add those things together and you know it's all
because the money isn't coming into healthcare. So from that point o f view that's
where I get the most frustration. Because I can see the evolution and we're just going
down. It's kind o f like going down the sink, you know. Like where's it going?
This sense o f doom was very common in the nurses' accounts, regarding both the direction o f
the health care system and the potential for positive change. Liz referred to the speed o f
changes which have made adjustment very difficult, and she articulated what a decreased
standard o f care means for her in terms o f altered expectations. Referring to recent changes
on her unit, she stated
there was no time for adjustment, it was just frantic, a whole change and your
expectations . . . it takes a long time before you can go 'okay. I'm going to work
today, and if I know my patients' names and where they are by the end o f the shift
and they haven't run away, that's my standard o f care'...That really is sometimes all
you can get out o f the d a y . . . I've not just lowered my expectations o f what I'm going
to do on the ward, but also lowered my expectations o f how much o f my needs my
job meets. So I look for my needs to get met outside o f work. And basically I'm
probably a lot more distant with people, my colleagues; I tend to sort o f do my thing
and get out o f here. I find it much more harder to get connected with my colleagues
anyways because o f the size of the ward we so seldom have any chance to work with
anybody.
Participants talked about the impact on them o f the increasing barriers to good patient care:
"It can keep you feeling down quite a lot;" "it's quite depressing , you feel helpless, you feel
hopeless.. Like why bother or why try."

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Along with heavier workloads and increasing pressures, participants have experienced
decreasing support at all levels o f healthcare. Some participants talked about having to take
on more responsibility in terms o f patient care and administrative decisions; however, they
continue to lack the official authority for such decisions. This puts nurses in a very difficult
position, as they feel forced to make decisions when those with higher authority are
unavailable, but they do not trust that they will be supported in their decisions. One
participant described this:
We’ve had to take a lot o f responsibility or the appearance o f having to, like in the
last what, two years we’ve lost our head nurses, our supervisors. I can remember the
first time 1 worked nights after that. There's nobody to phone, there’s nobody.

I’m

it you know. There’s no supervisors, there’s no head nurse.. Oh my gosh, you
know you have this awful feeling what if something dreadful happens tonight like
there’s nobody.. .And it was just lik e.. .sink or swim. So you had to kind o f look at
your knowledge, like you had to take more responsibility for what you were doing.
It’s quite a scary feeling after you’ve had years o f .. .’Oh I’ll phone the supervisor and
ask her what we should do here’. You know, you can’t do that now. She ain’t there.
She went on to talk about how nurses have been dumped with responsibility as it suits the
system, but they have not been truly empowered and endowed with greater authority. She
laughingly recounted how management tried to convince them they were empowered.
I don’t know if you remember when we lost the head nurses and the supervisors.
Remember, they were coming around speaking to us about empowerment, we were
all going to be empowered?.. .The catchword, the empowerment, to make our own
decisions a n d .. .basically 1 think what frustrated most people was you weren’t
empowered. You had to make lots more decisions but you didn’t really have the
power to. Like, you had a lot more responsibility because there’s nobody to ask

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But you didn’t have the power to make the decisions.. .so that was a very, very
frustrating time.
Another nurse added:
And what kind o f back-up would you get if something did happen and you were
forced to make a decision then and you’d just have to make a decision, there’s no
supervisor, there’s no head nurse, there’s nobody, so then if you made the wrong
decision well then what. You know, is the hospital going to back you up, is
administration? 1 don’t know. And you know that’s kind o f scary, because if you
make a m istake. . .
Concerns were also expressed regarding the societal value placed on psychiatric care
and the impact o f this on the competition for healthcare resources. Betty stated:
I don’t think there’s enough money spent on the over all health budget, but 1 think
that our patients are pretty low priority. Psychiatric patients are nobody’s favourites
in the system. In fact, they just wish they’d go aw ay. . . (they are) marginalized.
None of them are very wealthy. That’s what I think anyway.
For most participants, when they talked about the need for increased funding, concern for the
availability of patient resources was paramount. Dorothy offered a typical comment:
There isn’t enough here for any o f our patients; there’s not enough haltVvay houses,
there’s not enough places to discharge them to, there’s not enough mental health
workers, there’s not enough psych outpatients workers, there’s no day hospital here,
there’s none o f those programs.
Values driving healthcare
A number o f participants expressed concern that some changes in the healthcare
system are affecting psychiatry more negatively than other fields. As described earlier, there
is a growing emphasis on creating hard evidence to validate one's productivity in the
workplace. One participant used the label "outcome measurement" to describe the approach
being used in her workplace to measure work efficiency. She argued that because mental

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health care requires a more subjective approach involving less tangible interventions than
other areas o f health care, psychiatric nursing work is often difficult to measure. She
articulated the problem:
You've this program thing (outcome measurement) that sounds really good. And the
idea was really good, but all it's done is, it's cost driven. It's totally cost driven and
time utilization, and if you look at health care workers, and you say okay so much o f
our time is sp en t. . . You can't measure what we're doing because it might b e . . .
you're talking to somebody, a family member on the phone for 45 minutes because
their kid that they've raised that they thought was fine, has his first psychotic break.
And you're busy, there's things we can't measure, so we look really unproductive
statistically.

Other participants agree that nursing, especially the field o f psychiatric nursing, is really
unpredictable, and the emphasis on tangible, objective measures o f productivity is
invalidating nursing work. Liz asserted, "we don't know what's going to happen, 'cause we re
dealing with people, not things. We're not building cars; we're dealing with people. And
with people, you never know." Nurses feel like they are running around, with barely time to
think, yet statistics would suggest that psychiatric nurses are not doing enough. One nurse
described the impact on her: "that is really disheartening.. You aren't making any more
money, you're working harder and you're achieving less. And it's exceedingly frustrating,
and you're going home exceedingly tired, exhausted. Like the burnout is happening a lot
faster."
Participants suggested the need for greater flexibility in the system, and expressed
concern about the growing rigidity that is occurring with the tightening o f budgets and the
emphasis on outcome measurement. With shrinking resources, comes increasing competition
for territory, and increasing pressure to justify the validity o f one's work. Betty expressed her
frustration at the multi-level bureaucracy that impacts nursing work:

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.. .there’s an inflexibility about the bureaucracy.. .that’s particularly annoying...
because it’s like a maze o f trying to get to the appropriate place you want to be, when
different powers and people have different territories and you can’t just say this
patient needs to go there.
A number o f participants talked about the political dance they feel they must participate in in
order to provide the best possible patient care. Many talked about the inefficiency o f the
current multi-level hierarchy. Here’s one conversation between Anna and Dorothy, as they
reflect on the time spent by those in power:
A - Those meetings in that little room. There’s a big frustration. What are they all
about? I’m looking in this window and I figure that they’re sitting in there planning
discharges for what, two hours? And I’m looking at all the people - five
psychiatrists, so many psychologists, and I think that is a $5000 meeting and when
they walk out o f that door, who is discharged? Nothing has happened!
D - Well they have a $5000 meeting and whose shoulders does it fall baek onto but
the charge nurse? Then the lowest paid person in the ro o m .. who has the least
amount o f pow er.. .is set to do the most amount o f work!
Anna talks about the incompatibility o f some o f the restructuring decisions with
patient care. She states. " .. one night I had a crisis, and who did I have to call? The
accountant, because she was the administrator on-call. She was in charge that night. That
was frustrating, let me tell you." Dorothy inserts " .. and you call the accountant and her
comment is 'so what do you think I can do about it?'" Because o f the lack o f administrative
support, nurses are forced to make decisions outside o f their authority, and they are often
then challenged on their decisions. Dorothy stated:
. . so then you sit and you write all this stuff out at the end o f a 12 hour shift so that
the administrator who’s coming on can know all the decisions that you’ve m ad e..
through the night and some o f them, they call you in the middle o f your sleep and say

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‘what do ya mean you did this?’ ‘Well I’m sorry but it’s all I had to go with at the
time.’
Many nurses expressed frustration at the inconsistencies in patient care related to an
inefficient system. Roberta described a situation in which she felt a patient's care was
"chaotic and out o f control." She recognized that a contributing factor was the acuity o f the
patient's illness, but she believed that the main problem was "too many people were involved
but not managing the care, and there wasn't sort o f a designated team." She stated "I felt very
powerless, first against the severity of her illness, but also I think, as my role as a nurse and
trying to interact with a team of physicians and a whole bunch o f other teams, and it was like
so many people were involved and so many people were doing other things." She stated it
was not clear who ultimately had responsibility for this patient's care and she felt she lacked
the professional power to take control. She stated "I felt a certain responsibility, but if you
looked in the chart and who was charting and who was writing orders and who was making
decisions, my name was rarely there (laughing)." When asked what kept her from trying to
advocate for the patient more strongly, she responded "well, iff had been less burned out, if 1
had been less tired..." Other participants agreed that they are just so stressed at work that
they often lack the energy required to really make a difference for patients. Feeling so
pressured and spread so thin at work, has contributed to feelings o f powerlessness for the
nurses. Francine explained:
We're more stressed than we used to b e .. .1 find that when I’m stressed I forget, you
know, 1 had an issue over here but now I’m preoccupied with something here and
over there, also something there. And I’m forgetting, I forget.. .And I don’t follow
up on i t . . .You know, so it hangs on whatever doctor is involved.
Another source o f frustration was the ideological changes that the decrease in
resources is driving. For example, Jane talked about how nursing has changed over the past
15 years, and how her job satisfaction has deteriorated; "I think if I keep comparing what I
do now to what I did when I first started in nursing. I'd be very angry. I'm angry now but I'd

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be enraged." She described the primary difference being a sense o f connectedness and
cohesion with other nursing and medical staff, as well as a different philosophy o f health care
that seemed to value the person more.
1 find the focus has changed. The human factor used to be a real big deal, the
heart factor used to be a real big d e a l.. .where now I find it very clinical, stats
.. .document your process or whatever that you've done, so that you show that
you've covered otherwise you're going to get sued, or reprimanded for something or
o th er.. .We're always on the paperwork.
Numerous participants gave examples o f the erosion and fragmentation of collegial
relationships that is happening as a result o f increasing workloads and decreasing time. Jane
talked about cost-saving restructuring changes that have occurred in her workplace recently:
"we have seen what doesn't work. And we have seen how impersonal it is and how that's
lost us connection." Karen concurred, "we're all spread too thin that of course your
relationship isn't so intimate when you're.. you know, quick, write that or do that. There's
no time for the niceties." Liz added,
you know when we talk about these things like how things used to be different, it
almost sounds like there were different psychiatrists at that point. There weren’t. Not
for the most p a rt.. .The difference was they had more time, less patients. That was
the biggest difference. We worked with these same people who had these same
inconsistencies and idiosyncrasies, and all the things that we’ve identified.
Francine attributed some o f the inconsistencies in care to the structure nursing has
developed for itself, which in conjunction with the frenzied pace o f hospitals today, is
perpetuating nursing powerlessness. She stated, "everybody has more patients.. .everybody
seems to be more busy. So it's difficult to get involved in the work. You're on a stretch o f
days and then there are nights and we are totally away from what happens everyday." With

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the increased stress on the system, nurses are feeling spread so thin, that they do not have the
energy to challenge problems. In addition, Francine's comment touched on the impact of
shift work on nursing disempowerment. O f course, shift work is an inevitable part of
hospital nursing; however, nursing schedules often contribute to this disempowerment. With
twelve hour shifts, nurses are often at work only two days in a week. It is very difficult to
provide consistent care and have significant input to treatment when one is away more often
than one is present. Petra described how her work schedule impacts the degree to which she
gets involved in patient care decisions: "I tend not to be as assertive as I might if I were here
all the time."
Nora suggested that having a more flexible work rotation that allowed greater access
to education would improve nurses’ sense o f power and autonomy. "It would be better if we
had more freedom in our rotation because 1 think it would be better if we could job share to
allow nurses to pursue education better. I mean more flexibility in our rotation would be
more autonomy and more able to get the education you want to get." A number o f nurses
referred to education as a significant component contributing to feelings o f power. Most
nurses agreed that having more information and knowledge makes a significant difference in
how much power they feel they have in terms o f patient care input. Dorothy asserted "the
more education there is, the better the system works."
Lack o f communication and support
As mentioned in previous sections, problems regarding communication and support
are closely linked to system issues and to the subordination o f nursing to medicine. In
situations in which participants felt powerless due to a lack o f communication and support, a
sense o f isolation and disconnection from colleagues occurred. A lack o f trust and respect
amongst colleagues characterized this disconnection, and the nurses described an absence o f
genuine collaboration and teamwork. Again, the patient suffers in these kinds o f situations,
as inconsistent care is provided. Participants described feeling manipulated, fragmented, and

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unhappy at work. Edith captured the importance o f communication to quality patient care;
"the success or lack o f (patient care) is based on communication, effective communication...
We can give all the reasons, too many doctors, big area, shifts, whatever, it's still a
breakdown of honest, clear, direct communication."
Trust and respect
Participants suggested that greater communication, trust, and respect between
medicine and nursing would be necessary, in order for them to feel more empowered. Nora
explained what she means by trust;

. .trust that what 1 said was appreciated and validated,

and that it made sense and that it would influence the situation, and that it would benefit the
patient.. .It's just communication and having someone respecting what you say, your
suggestions." She asserted that the issue is not who is right or wrong; it is about feeling
heard and having her input considered valid. She stated "we may agree to disagree, but then
we can understand where we are coming from."
Many participants related blocks in communication to issues o f medical dominance.
The nurses identified situations o f powerlessness in which they felt unheard, unappreciated
and disrespected by their medical colleagues. One participant explained the problem:
Sometimes there's a blockage, like you know, you deal effectively with a patient to
listen to them, to hear their needs, and then when the major link is coming to speak
to the doctor to keep the flow going, but then when you can't get across that bridge to
that next person who is so vital in the communication process and decision-making
process, it just cuts you off in half. And it's like you run back to the patient in a way,
but you're going aroimd in circles between you and the patient, but nothing is
changing there. Because the person that you need to talk to is not there to hear you. I
don't know, it's like going around in circles. You just don't get anywhere.
This description reflects a perception that nurses fulfill a liaison role between patients and
doctors, and emphasizes the importance o f communication between all three. For this
participant, a feeling o f powerless results when she feels unheard by physicians. Another

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participant described how she feels when she is blocked by medicine, from providing the best
care to patients:
It kind o f makes being a nurse a drag, y'know. It's one o f the worst things about
being a nurse, is that feeiing...impotence, powerlessness, inability to act; I think that
role o f advocacy, not being able to speak up for what you see as potentially being the
best thing for your patient.
Nora discussed the importance o f trust between the disciplines, in terms o f providing
safe and effective patient care:
It's like the trust that they put in you, the doctors, it's like we have the intimacy o f 24
hour care with patients, so we have such insight and levels o f maybe depth o f their
personality or what's important to that person, that we are the key, we are the key to
what, how a treatment plan could go. Because it's the way we communicate and how
we observe the patient to the doctor, that builds that trust in our ability to assess. So
the doctors have to rely on our abilities to assess, so we can keep the treatment
process going in a safe manner to get the person eventually discharged.
Although many participants maintained that medicine simply needs to trust nursing more,
some recognized that the issue o f trust is reciprocal. A mutual distrust exists between
medicine and nursing. Roberta spoke about the importance o f trusting the competency o f all
professionals:
If you have a team member o f any discipline who is incompetent or not performing
to their professional standards and all o f that, that causes difficulties.. .That can
make it really difficult, and stuff that you try and advocate for, then can get sort of- obstacles are thrown in the way or whatever
She felt it is equally disruptive to the team to have a nurse practicing incompetently, as it is to
have a physician practicing incompetently. She acknowledged that the two professions have
distinct roles, so the specific effects o f their incompetence may be different; however, any
weak link in the health care team is problematic. Most participants agreed that in order to

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function effectively as a team, all disciplines must communicate and have faith in the ability
o f others on the team.
Teamwork and consistencv o f care
The structure o f acute healthcare requires an interdisciplinary team approach.
Teamwork concerns were littered throughout the participants' comments about
communication issues. Primarily, the concerns were around inconsistencies in care that
result from a lack o f cohesion in the team. Many expressed that there is inadequate time and
energy spent on team building. Olive commented on the impact that a lack o f cohesion in the
care team can have :
If you have that discrepancy in the whole team where you feel like half o f the team
is doing one thing for a certain.. .and you’re doing something else, and it's not quite
together, it makes me just want to cut everything short and go back to doing what you
have to do, and it makes you not want to come in the next day and go through it all
again
She stated it makes her just want to provide minimal care; "get it done but no extras, and not
put any special little touches." Petra added, "you have to change the tone quite a bit, to OK
this is just a job. let's get through the shift. I'll do what I have to do and I'm going home."
When team members don't communicate effectively, there is more room for
misinterpretation o f treatment plans, leading to inconsistencies in care. Participants
described feeling frustrated and undermined when this happens, and some felt this puts them
in a position to be manipulated by patients. Anna expressed her frustration when she sets
limits with patients, adhering to the care plan, and another team member decides to expand
the limits. She gave an example:
I’ll say (to a patient) 'no you can’t have a smoke because there’s no smoking here and
you’re not allowed out right now,’ but some other nurse will come along, like on the
next shift and take them out for a smoke and they’ll say ‘well, she did, why can’t
you?’ You know, we get th a t.. .Well it kind o f blows your credibility and it’s

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frustrating.. .1 feel like a big tit if I don’t (take them out for a smoke) sort o f thing,
but it’s . . .it's hard especially when it's something you don't believe in, like smoking
or something.
Anna stated she feels really unsupported when her approach to care is undermined by other
team members in this way, and she asserts, it "is definitely not good for patients!".
Most participants agreed that their experience at work is strongly influenced by the
quality o f their professional relationships, particularly with physicians. Jane suggested that
the rift between medicine and nursing is self-perpetuating, and that a commitment to relating
to one another as individual people rather than groups o f professionals is important:
I just see so many doctors and nurses bumping heads with each other all the tim e...
I think sometimes that's what happens is there's a split going on and we're so angry
that we vent on them and they get so pissed off with us being angry with them all the
time that they just avoid us, and, 'we'll get you back'. So nobody connects. And I
think when you get the human factor, and people start respecting each other, and you
have a personal contact, and you actually talk to each other more then you can sort of
break through that. It's like, you know, you can't really go and kill somebody in a war
if you know them, if you can put a face on them. So if you make it personal,
somehow that helps break down a lot o f barriers.
The importance o f developing and maintaining interdisciplinary communication was
acknowledged by most participants, and a number o f people identified that the system lacks
structures to support team-building. When asked what would need to be different in order for
you to feel empowered, Nora responded:
We need to have more forums for nurse/physician dialogue, and maybe more team
building. For this ward, I think it's gone down over the years, deteriorated, and
team building isn't there lately. So I think nurses need to strengthen their power
amongst tliemselves somehow again.. .as a group.

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Petra added:
I think the onus, or not the onus but the trust for (nurse-physician dialogue).. .has to
come from nurses because a lot o f it seems contingent on which particular doctor is
interacting with the nurse, and that really is giving away the power to the doctor
involved, as opposed to, y'know if I want to be an advocate or autonomous or
competent, it has to be regardless o f my feelings, and that's part o f being assertive.
I'm not saying you don't monitor your approach depending on who you're with, but if
that's the kind o f nursing care that we want to give, we need to develop a forum to
facilitate that.

Isolation
The changes occurring in the health care system seem to be exacerbating
communication problems. Many participants commented on how shrinking resources and
the increasing pace o f acute psychiatric care, has led to the elimination of any team-building
activities, within nursing and between disciplines. There was a general feeling that working
on collegial relationships is considered a luxury that the system no longer supports. The
result o f this is has been a sense o f isolation for participants. Nora explained this:
It's a sense o f isolation because if you don't talk to your peers.. then you don't
know if they're feeling the same way. Then if you do, that really makes a big
difference...it validates your experiences. You need to talk to your peers; otherwise
you do get isolated. 1 mean the nurses are the main support for myself here.
Most o f the nurses described feeling very supported by other nursing staff, which they
considered critical to their continuing hmction at work. It was interesting that each group o f
nurses considered themselves unusual in the degree o f support they share. The following is a
typical comment; "we're a unique group o f nurses and we really, not everybody but the
majority o f us can really talk and share and be honest...we're very supportive."

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A number o f participants felt that along with supportive colleagues, it is really
important to have a supportive leader. Olive talked about her experience o f this:
It's true that having a powerful peer network and a powerful charge nurse, maybe
power is the wrong word, uh confident.. assertive, non-judgmental charge nurse
behind y o u .. certainly makes me feel more empowered to have someone I can
bounce ideas off and who supports y o u .. .1 have a strong voice, but part o f the
reason I think my voice is so strong is because I can grab a couple people and say
'these are my ideas', and you know, let's talk about the pros and cons.
Unfortunately, even this support among nurses is being eroded. Nurses are feeling so
stretched and splintered as a group, that any kind o f united power base they may have had is
being undermined by the restructuring o f health care. Participants stated they are spread so
thin that they don't always have time to support one another.
Numerous participants recognized the importance o f pulling together in these stressed
times. Nora gave an example o f something that her unit is doing that has made a difference
for her:
One thing we did do differently this w eek.. all the floor nurses are going to go
in to .. .the doctors' rounds, not only to share information but also to support each
other as nurses, because if there's an issue you want to bring up, it's better when you
have your other peers there so you can bring it there, you feel very supported,
they help you voice it, so we did that for the first time this w eek .. .Every nurse that
was on that day went to this particular doctor's rounds that day, for support and to
hear what was going on, so that was good. 1 felt good about th a t.. .We used to do
that years ago. I don't know why we got out o f the habit. I think it's really
important to do that. To have that support th ere.. .1 think it's important that
everyone goes at once. All the nurses go. You’re more courageous to say what you
want to s a y .. .

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A few participants identified the importance o f creating situations in which collegial support
can occur. Roberta emphasized the responsibility o f nurses to ensure that structures are in
place to ensure greater connectedness between staff.
I think structure is really important, and forums. Like you have to kind o f have
those things built in. And I think that that's what I'm hearing a lot from staff, is that
the forum that we used to have, which was rounds,' the goal o f that fonun has
shifted to medical teaching. And that's really silenced nurses because the role o f that
forum is not what it used to be. And I think that's part o f our responsibility is
participating and making sure that those kinds of forums and places are there.
When participants were asked to describe how their group o f colleagues supports
individual nurses in acting more powerfully, effective communication and gestures o f support
were cited most frequently. Nurses feel empowered when they receive verbal and physical
expressions o f support from colleagues. They value forums for regular exchange o f
information including sharing positive and constructive feedback. Consistent communication
with regard to patients was considered helpful, and participants felt empowered when their
input was expected, respected, and incorporated into patient care decisions. Participants also
described a sense o f support when colleagues are flexible with regard to providing coverage
to enable nurses to pursue educational opportimities.
When asked how their colleagues undermine their attempts to act more powerfully,
again participants identified mainly communication issues. Participants felt undermined
when their input was not considered or was belittled. They expressed the necessity o f open,
direct communication. Some described feeling undermined by their colleagues' gossiping
and indirect attempts to sabotage change efforts. Feeling an integral part o f an effective team
contributed to the participants' feelings o f power. Conversely, they described feeling
disempowered when colleagues do not pull their weight or do not comply with agreed upon
plans o f care. The nurses stated their sense o f power is jeopardized by the increased

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workload and accompanying burn-out that they are experiencing, as they are simply to busy
to work on collegial relationships or address emerging issues.

Summary
The circumstances in which participants typically experience the greatest
powerlessness can be understood in terms o f four categories o f situations; (a) situations
characterized by medicine's dominance and control, (b) no-win situations, (c) when there are
system problems, and (d) when there is a lack o f communication and support. These
categories exist across all four focus groups. The differences between groups lie in the areas
o f emphasis. For example, in the group o f participants who work in a hospital outside o f the
lower mainland, system and resource issues predominated in their stories o f powerlessness.
In the most urban hospital, issues o f communication and support were o f prime concern. In
the other two groups, participants cited medical dominance and control as the most
problematic issue underlying their feelings o f powerlessness. Differences between the
groups may be reflective o f varied staff cultures, institutional differences, regional
differences, or simply differences in the individual nurses who volunteered at each site.
Across all situations o f powerlessness, a number o f themes characterizing the nurses'
experiences o f powerlessness became evident. Frustration and anger were the most
frequently expressed emotions. Behind these feelings was often a sense o f feeling blocked in
terms o f providing effective nursing care. Participants also described feeling helpless,
impotent, and out o f control. They most often described these feelings in relation to medical
dominance and control. A sense o f impotence regarding taking alternative action was
expressed. This negatively affected the nurses' ability to advocate for their patients. As well,
a sense o f apathy and hopelessness permeated many o f the participants comments. They
described feeling disheartened, with little faith in anything changing. They talked about
providing minimal care to patients, as extra efforts don't make any difference anyway. Most
o f the nurses felt pressured and stressed. Although they experienced this in all types o f
powerless situations, this was most often described in relation to system problems. Nurses

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described feeling on edge, scattered, burned out, tired and depressed, with a decreased sense
o f work satisfaction. In addition, they described having little energy left for their personal
lives. In many o f the situations, participants felt they were compromising their personal
values. Many recounted incidents in which they participated in patient care activities that felt
wrong to them. They spoke o f having upset conscience, and a sense that they are giving
themselves up. The personal toll of acting incongruently with one's beliefs was perceived as
high; however, the toll from challenging authority was often perceived as higher.
A sense o f isolation and a lack o f trust was also common among participants. They
described feeling disconnected from colleagues, unsupported, and somewhat wary. The
distrust o f colleagues included both nurses and doctors, and resulted from a lack o f cohesion
and respect in the health care team. Participants felt that patient care suffers when team
members are isolated from one another, as there is a lack o f consistency. Nurses' recognized
that their stress levels increase when they feel isolated and distrustful o f colleagues.
Participants felt undermined, demoralized, and invalidated in some situations, particularly in
relation to medical dominance. They described feeling stamped down, belittled, demeaned,
minimized and shamed. A sense o f vulnerability and personal defeat often characterized the
theme o f medical dominance. Nurses described feeling depressed, and reluctant to continue
asserting their beliefs regarding patient care. Overall, participants' experiences o f
powerlessness centered around a concern for the patient. Rarely did participants express
wanting to be more powerful for themselves; their concern about their lack o f power was
usually focused on the patient.

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CHAPTER FIVE
Discussion
This final chapter will discuss the meaning o f the results, linking this research with
other literature. It will be organized in terms o f the interview questions used in the focus
groups (see Appendix A). The purpose o f this study was to explore the circumstances and
impact o f powerlessness for acute care psychiatric nurses, in order to offer an understanding
o f the nature o f psychiatric nursing powerlessness. It is my hope that the findings may
facilitate increasing awareness by nurses o f their work behaviours, while making the
constrained realities o f psychiatric nursing work more visible. Implications for both
counselling and nursing are discussed, and recommendations are offered.
Review o f situational categories o f powerlessness
As mentioned in chapter three, the nurses’ experiences in this study did not coincide
directly with those identified in previous studies o f the general nursing population (Attridge,
1996; Chandler, 1992; Erlen & Frost, 1991). My attempts to fit the data into predetermined
categories were unsuccessful. This is attributable to a variety o f factors. The population in
this study differed from that in other studies, as this research focused specifically on
psychiatric nurses rather than on general staff nurses. As well, the methods o f data collection
and analysis varied in the different studies, accessing different types o f information. The
results do share some similarities to prior studies, however, and these will be discussed.
The issue o f medical dominance and control has been cited in reference to nursing
powerlessness in a number o f studies (Attridge, 1997; Chandler, 1992; Erlen & Frost. 1991).
Chandler (1992) found that the majority o f her participants' descriptions o f powerlessness
related to negative-nurse physician interactions. Similarly, Erlen and Frost (1991) identified
physician control and dominance as a theme that related to nurses' perceptions o f
powerlessness. They found that nurses perceived themselves to be powerless in ethical
dilemmas when physicians acted with authority and control, and they suggest that nurses may
be inhibited by such perceptions o f powerlessness, in their ability to influence patient care

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decisions. Groves (1992) study on nurses' perceptions o f power also supports this idea. The
results o f my study are congruent with these findings; participants felt limited in their ability
to influence patient care decisions if they did not feel heard and respected by physicians. In
addition, the category o f medical dominance and control in my study is broader than that
offered in previous studies. U not only involves individual nurse-physician dynamics, but
also identifies the wider issue o f power imbalances between health care professions. Many o f
the nurses' descriptions o f powerlessness relate to general medical dominance in health care,
as well as to personal interactions with doctors.
A number o f authors have identified the difficult position in which nurses find
themselves, caught between their allegiance to the patient and their allegiance to medicine
and administration (Attridge, 1996; Gadow, 1980; Yarling & McElmurry, 1986). Attridge
(1996) found that nurses felt powerless when they were "exposed to competing, very serious
demands" (p.46), in which there was necessarily going to be a loser regardless o f the nurse's
decision. Attridge asserts that the nurse is always one o f the losers in tliese kinds of
situations. She also identified that some powerless situations "demanded some choice or
action on the part o f the nurse which resulted in very visible and negative consequences"
(Attridge, 1996, p.48). This theme aligns closely with the no-win category in my study. It
involves nurses either participating in care they disagree with, or not participating in
something they believe in, and feeling tom between loyalties. Attridge (1997) observed that
nurses often experience doubt and self-blame in such situations. The participants in my study
more frequently expressed guilt and hopelessness.
System issues were identified by participants as significant in determining their
experiences o f powerlessness. Concerns about system issues seem to have less emphasis in
studies on the general nursing population (Attridge, 1996; Chandler, 1992). This may reflect
an ever worsening health care climate in British Columbia. As well, it may reflect the unique
concerns o f nurses working in psychiatry. As suggested by some o f the participants, the
allocation o f resources may be influenced by the marginalization o f mentally ill patients. In

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Chandler's (1992) study o f staff nurses from a variety o f acute care areas, only 10% o f the
described powerless experiences involved a system issue, that o f shortstaffing. Attridge
(1996) found that nurses often experienced a sense o f powerlessness in relation to a lack of
resources, primarily human resources. She found that the impact o f inadequate resources was
"often superficial, even dangerous and unethical patient care and unquestionably more
complicated and harassing work" (Attridge, 1996, p.49). This is consistent with my findings.
In addition, the results o f my study suggest that system issues encompass not only human
resources, but also material resources and structural and organizational barriers to good
patient care.
Experiences o f powerlessness that tie into a lack o f communication and support have
been identified in a number o f research studies (Attridge, 1996; Erlen & Frost. 1991; Groves,
1992). This reflects the relational experience o f power for nurses. Nursing collegial support
was cited by most participants as the key element in helping them cope with feelings o f
powerlessness. Chandler (1992) also found that nurses felt empowered when they felt the
nursing team was working well together. Along with positive collegial relationships.
Chandler ( 1992) and Pieranunzi (1997) found that nurses feel empowered by positive
communications and interactions with patients. Pieranunzi (1997) suggests that psychiatric
nurses’ sense o f empowerment is based in knowing and connecting with their patients as
people. Thus, current health care restructuring, in which many psychiatric nurses feel they
have been forced to reduce their relationships with patients to simply ensuring patient safety,
may contribute to nursing powerlessness.
Participants also identified lack o f knowledge sharing and education as
disempowering. Erlen and Frost (1991) had compatible findings. This is understandable in
light o f Foucault's (1980) theory that knowledge equals power, and it suggests the necessity
o f communication and information sharing between nursing colleagues in order to enhance
feelings o f power. Participants described feeling increasingly isolated from their colleagues,
which feeds feelings o f powerlessness. Both Chandler (1992) and Attridge (1996) found that

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a sense o f isolation permeated nurses' accounts o f powerlessness. Groves ( 1992) asserts
there needs to be greater communication between nurses regarding attitudes and perceptions
o f power in order to "inspire a unification o f nurses to mobilize the potential and strength o f
professional nursing" (p.27). Attridge's (1996) findings support those o f my study in
suggesting that collegial support is critical for reducing a sense o f powerlessness.
Because psychiatric nurses' experiences o f powerlessness involve complex
interactions between many personal, social, and structural factors, the divisions between the
four identified categories o f powerless situations do not really reflect the interactive nature of
the categories. Many o f the participants' experiences o f powerlessness do not fall neatly into
one category to the exclusion o f all others. It is for this reason that 1 had difficulty
delineating categories o f powerless situations in my analysis, and I was forced to
acknowledge the fluidity o f the boundaries between categories, accepting that they are not
mutually exclusive. Because o f the interactive nature o f the categories, participants'
experiences o f powerlessness will be discussed generally here, rather than in terms o f the
specific categories.
What inhibited the nurses from acting more powerfully?
A variety o f factors inhibited the psychiatric nurses from practicing in a more
empowered and autonomous way. Oppression underlies many o f these factors, and it is
perpetuated by the oppressive hospital structure in which health care is delivered, as well as
nurses' internalized beliefs regarding their powerlessness. The participants' comments
suggest an external locus o f control with regard to affecting change in their work experience.
Their narratives reflect a belief that the power to alter their situation lies outside of nursing.
Although nurses are educated to believe they can practise autonomously and the patient is
their priority, they have been socialized by the health care system to subvert their practice
decisions to those o f more powerful groups, even if it means jeopardizing patient care (Sinda,
1984; Yarling & McElmurry, 1986). Nurses may claim a priority focus on the patient; in
practice, however, they will often place medical and administrative needs before patient

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needs. The diminishing resources and increasing stress in the health care system are
functioning to perpetuate nursing powerlessness.
Participants revealed incongruities between their ideals o f nursing practice and their
daily work realities. The nurses asserted that their primary allegiance is to the patient, and
they shared the understanding that patient advocacy is a nursing responsibility. However, the
extent to which the nurses were actually willing to advocate for their patients was limited.
The general feeling was that nurses can offer their opinions, but if their voice is not heard,
they have no choice but to participate in care that others dictate. This belief system is
contradictory to ideological and legal standards for nursing practice (RNABC, 1991; Yarling
& McElmurry, 1986). In nursing doctrine and official policies, nurses are considered
autonomous professionals and they are expected to accept the responsibility inherent in
autonomous practice. In reality, nurses are not free to practice autonomously because o f
social and organizational constraints (Rodney, 1997; Yarling & McElmurry, 1986). Yarling
and McElmurry (1986) elucidate the dilemma for nurses:
It is an indubitable fact for those who know the subculture o f the health care
professions and the power structures o f hospitals that nurses who openly challenge
established authority structures or powerful physicians in a hospital bureaucracy
most often put their jobs, their economic welfare, and their professional careers on
the line, even if they are acting on behalf o f the patient and have strong
justification for doing so (p.70).
This reflects the oppression that continues to be an integral part o f acute care nursing. A
number o f participants acknowledged feeling as though they are putting their jobs and
collegial relationships at risk by challenging the decisions o f authority, whether that be
physicians or hospital administration. Although many participants did not seem to be fiilly
aware of their participation in perpetuating power imbalances through continuing to advocate
for physicians and administration over patients, some did acknowledge their participation in

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maintaining the status quo, and they explained their behaviour in terms o f "playing it safe," in
order to ensure their continued survival at work.
A sense o f power and autonomy is necessary in order for nurses to fully advocate for
their patients (Huston & Marquis, 1988; Millette, 1993). Because the hospital structure is
based on hierarchical divisions o f power that restrict nursing autonomy, this creates a
dilemma for nurses. The more nurses feel disempowered and excluded from patient care
decisions, the more they feel unable to act autonomously. It is a self-perpetuating cycle.
Although participants vocalized their dissatisfaction with medical dominance and control
over patient care, there was a general reluctance to challenge medical decisions. Many o f the
stories shared by participants reflect feelings o f lack o f control related to decisions made by
medicine or administration. This finding is congruent with what Attridge (1996) found in her
study; nurses frequently feel out o f control of the work situation and this is often related to
"the imposition o f control by usually more powerful others" (p.45).
Feeling they lack power and control, nurses tend to place responsibility for change
outside o f themselves. When asked what would need to be different in order for them to act
in a more empowered way, a number o f participants suggested changes in the doctors or in
structures outside o f the nursing domain. Very few offered ideas for changes within nursing.
Thus, it seems nurses are essentially letting medicine and administration determine the nature
o f their experience as nurses. Nurses are uncomfortable in their position o f subordination,
but many comments suggest that the degree of nurse-physician collaboration in patient care
can only be determined by the doctor involved. By allowing physicians to determine the
degree o f nursing input into patient care, nurses attribute a tremendous amount o f control to
medicine. This internalized powerlessness by nurses and the apparent belief that the
dominant group's ideas supersede those o f one’s own group is suggestive o f oppressed group
behaviour (Dykema, 1985; Freire, 1987; Roberts, 1983). This oppressed behaviour
negatively impacts patient care, as nurses are not fully advocating for patients and patients
are not benefiting from a true interdisciplinary approach.

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The participants' accounts suggest that power is experienced interpersonaily by
psychiatric nurses. The nurses described feeling empowered when they have positive
interactions with colleagues, such as receiving support. They cited forums for regular
exchange o f information such as sharing positive and constructive feedback, as essential for
increasing nursing power. Chandler (1992) found that nurses feel empowered when they
work in a well coordinated way with other nurses. Feeling an integral part o f an effective
interdisciplinary team contributed to my study participants' feelings o f power. Participants
felt powerless when their input was not expected, respected, and incorporated into patient
care decisions. Participants did not express wanting greater power over others, and none o f
the nurses seemed to be seeking power for their own gains. Rather, the nurses' frustration
with their lack o f power was based in their sense of helplessness regarding providing
effective patient care. Pieranunzi's (1997) study supports these findings; he found that
psychiatric nurses are empowered by positive nurse-patient interactions in which the nurse
feels connected to the patient and effective in helping them. In addition. Chandler (1992)
found that nurses feel most empowered by positive interactions with patients, physicians and
other nurses, and most disempowered by negative interactions with physicians.
The current economic realities impacting health care delivery in Canada, are having a
profound effect on the experience o f psychiatric nurses. Nurses are feeling too busy and
exhausted to address emerging issues or work on collegial relationships. They are feeling so
stressed that they are finding it difficult to support one another or engage in team-building
activities. The collegial support that was described by so many participants as critical to their
ongoing survival at work is being eroded. Changes in health care are splintering nurses and
undermining any kind o f united base o f power they may have. Jobs are no longer plentiful,
nurses are increasingly stressed, and the value o f psychiatric nursing work is being
diminished. During the nursing shortage o f the last decade, nurses were in a position to
assert themselves more forcefully, as the power o f institutions to threaten job loss had less
clout. Institutions were employing resources to retain nurses, and nurses knew that jobs were

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plentiful. Now, with shrinking resources and health care restructuring, nursing has lost
ground. The position o f the institution has regained its power, and nurses' willingness to
abide by its rules and those o f the established social hierarchy has increased once more.
Nurses are becoming increasingly reluctant to challenge authority for fear o f losing their jobs.
Along with decreasing health care resources, have come changes in the values driving
health care delivery. With the growing emphasis on objective measurement o f nursing care,
the essence o f psychiatric nursing is becoming increasingly invisible. Participants feel
frustrated and undermined by current strategies to measure nursing care, which neglect the
intangible, interpersonal nature o f psychiatric nursing. We have become a very litigious
society, in which the fear o f legal repercussions is ever present and seems to motivate the
decisions made by many professional groups. The medical model has fed into this mentality
with the creation o f the 'expert' and the patient' as mutually exclusive entities. Generally, the
public resists responsibility for its own health; it is not uncommon for people to place this
responsibility entirely onto the health care system. Professionals working within the system
tend to accept this position o f power, thereby perpetuating the problem. Although many
nurses contribute to maintaining such power relationships, there seemed to be a general
perception by participants, that physicians are the most integral force maintaining this power
imbalance. This may reflect the lack o f power that nurses perceive themselves to have.
Participants feel their sense of power is further jeopardized by the strain in the health
care system, with increasing workloads and accompanying burn-out. Participants feel they
are providing fragmented care to patients, and are fragmented in their connections with
colleagues. They are spread so thin that they do not have the time or energy to fully advocate
for patients. The nurses stated they do not always follow up on things because they are
spread so thin, they lose track o f what they were doing. One participant illustrates: "when
I'm stressed I forget; I had an issue over here but now I'm preoccupied with something here
and over there, also something there. And I'm forgetting, I forget it, and I don't follow up on
it." Generally, nurses feel they must adhere to the priorities dictated by the system, then if

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they have any time or energy left after this, they can then provide the kind o f nursing care
they feel is best. Many participants stated that they rarely provide that extra care anymore
because they are too exhausted and their efforts are often undermined or invalidated anyway.
They feel it is easier to maintain the status quo than to assert what they believe to be right or
in the best interest o f the patient, in spite o f the moral distress this creates for them. There
was a sense o f hopelessness regarding positive change and helplessness regarding providing
the kind o f nursing care they felt was best. This is typical o f the sense o f powerlessness that
exists for oppressed groups (Freire, 1987; Roberts, 1983).
The impact o f powerlessness
Participants identified numerous effects o f feeling powerless. The greatest impact is
on professional practice, and the implications for patient care. Collegial relationships are
affected, and participants also identified the impact on their personal lives.
Nursing practice and collegial relationships
When participants talked about the impact o f powerlessness on their nursing practice,
they usually did so in reference to quality o f patient care. Many expressed frustration and
anger in relation to feeling inhibited from providing the kind o f care they desire. One
participant expressed the impact o f feeling blocked by dominant groups: "It kind o f makes
being a nurse a drag. It's one o f the worst things about being a nurse, is that feeling . . .
impotence, powerlessness, inability to act. I think that role o f advocacy, not being able to
speak up for what you see as being the best thing for your patient." This comment captures
the essence o f the nurses' experiences o f powerlessness, in which they are impaired in their
ability to advocate for patients. This creates moral distress for nurses, as they feel their
loyalty should be primarily to the patient. Yarling and McElmurry (1986) comment on the
confusion that happens for nurses due to the multiple allegiances inherent in the nursing role.
The moral situation o f nurses is most poignantly revealed when they perceive that the
right to freedom and well-being o f patients in their care and treatment is threatened or
violated by a physician, another nurse, or some other health care provider for whom

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the hospital is responsible. In such instances, nurses experience conflict, with respect
to their choice o f action, between the prima facie right o f the patient and the prima
facie right o f the hospital. . . This produces conflict for nurses because their role
embodies obligations to both patients and the hospital (Yarling & McElmurry, 1986,
pp.64-65)
Feeling excluded from patient care decisions is particularly profound for psychiatric
nurses because it undermines their role in patient assessments and negates the therapeutic
relationship which is critical in psychiatric care. Patient assessments are not based on
numerical lab values and other objective means in psychiatry; one participant describes, "it's
like we have the intimacy o f 24 hour care with patients, so we have such insight and levels o f
maybe depth o f their personality or what's important to that person, that we are the key, we
are the key to what, how a treatment plan could go." As stated previously, psychiatric nurses
feel their role is being invalidated further and further by the move toward objective
measurement o f nursing practice.
The many references to the decreasing standards o f care that nurses are feeling forced
into, involve a sense o f defeat, with comments such as "why bother." This reflects the
powerlessness and internalized oppression experienced by nurses that creates passivity.
Rather than directing their aggression directly at the oppressor, they have turned inward and
express their anger and frustration indirectly. The focus o f their aggression is most often
doctors and "the system", as nurses attribute responsibility for many o f their workplace
frustrations to these groups. Congruent with oppressed behaviour, this aggression manifests
in a significant amount o f complaining about physicians and administration, but there is a
general reticence to actually challenge authority or try implement change in any kind o f
united way (Roberts, 1983).
Decreased job satisfaction was a common complaint o f participants. Many referred to
how nursing "used to be," when caring was a central aspect o f the nursing role. This reflects
the confusion nurses are experiencing, wherein nursing values and ideals are becoming

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increasingly dissonant with the practicalities o f the streamlined health care system. Nurses
talked about how they have had to come to expect less from their jobs in order to survive. As
one participant described "you have to change the tone quite a bit to OK this is Just a job. let's
get through the shift. I'll do what I have to do a n d .. I'm goin' home." Patient care is
deteriorating as a result, and it is no longer clear who the system serves.
Participants described feeling disconnected from colleagues, unsupported, and
somewhat wary. A sense o f isolation and a lack o f trust was also common among
participants. The distrust o f colleagues includes both nurses and doctors, and results from a
lack o f cohesion and respect in the health care team. Participants felt that patient care suffers
when team members are isolated from one another, as there is a lack o f consistency. One
nurse described how her nursing care is affected when the team lacks cohesion:
If you have that discrepancy in the whole team where you feel like half the team is
doing one thing for a certain.. .and you're doing something else, and it's not quite
together, it makes me just want to cut everything short and go back to doing what you
have to do and it makes you not want to come in the next day and go through it all
again.
Nurses recognized that their stress levels increase when they feel isolated and distrustful o f
colleagues, so it is a vicious circle perpetuating nursing powerlessness.
Participants asserted that collegial support is the key factor enabling their continued
survival in the workplace. The support they described appears to exist on an individual level
rather than on a broader professional level. The nurses support one another by listening and
offering words o f encouragement during difficult times. This is critical for nurses, in terms
o f coping on a daily basis. However, there also needs to be ongoing support for one another
as nursing professionals. Rather than succumbing to the power o f dominant groups, nurses
need to pull together and encourage one another to be assertive and proactive in their
responses to oppression. The lack o f power that nurses feel they have in spite o f their
numbers indicates a lack o f professional unity. Each group o f participants described their

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colleagues as unique because they are supportive. This suggests that nurses perceive
collegial support to be very inconsistent within nursing. With the current stresses and
changes occurring in the health care system, nurses are feeling increasingly isolated and
disconnected from colleagues, and this is exacerbating feelings o f powerlessness.

Personal life
A number of participants identified effects o f work powerlessness on their personal
lives, while others initially denied any impact. When stimulated by the focus group
discussions, however, most o f the nurses acknowledged some personal impact on them. This
may reflect a reluctance on the part o f some participants to acknowledge the significance o f
their work powerlessness. Lanza (1997a) comments on the dangers o f nurses' acceptance o f
powerlessness. "Nurses, failing to recognize the oppression process, do not often unite to
change the view o f reality imposed b y .. .more powerful groups. Further, nurses fail to
appreciate that an important source o f power is their numbers" (p.7).
In many o f the situations described, participants felt they were compromising their
personal values. In incidents in which they recounted their involvement in patient care
activities that felt wrong to them, they spoke o f having "upset conscience," and a sense that
they are giving themselves up. What seemed to be most distressing to the nurses was that
they felt they lacked the power to act congruently with their own beliefs.
Participants talked about feeling stressed, exhausted and burned out. For some, this
manifested in very little energy left for their personal lives. One participant coined this "the
post-work fatigue." Another described the effect o f this: "Y'know it's your day o ff and you
have your challenges o f your normal life and you don't have any resources left for those
things." Others admitted that their fhistrations get transported home: "I feel terribly bad that
my partner has to listen to me rant and rave.. I'm obviously in a bad mood." A number o f
participants commented on how their mood is negatively affected by feelings of
powerlessness. This is captured by the comment o f one nurse: "It's quite depressing.. .you

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feel helpless, you feel hopeless." This sense o f vulnerability and personal defeat permeated
many o f the nurses' experiences.
The nurses recognized the importance o f maintaining balance in their lives, by
involving themselves in relationships and activities outside o f work. Some explained that
they have had to create a bigger division between their professional relationships and their
personal relationships in order to cope. Most identified the necessity o f separating their work
and personal lives, in order to function in each. As one nurse explained, "I feel you have to
be very careful o f keeping your own emotional house clean and healthy.. .The patients
deserve to have healthy caregivers." For many, though, this is difficult. One nurse stated she
was only able to really regain balance in her life once she cut her work hours in half.
Needed changes
Psychiatric nursing in the hospital setting can only be viewed in light o f the
multidisciplinary team context in which it is practiced. Participants agreed that the degree to
which care is most effectively provided depends, in large part, upon the coordination o f the
health care team. Some might argue that 'team' does not accurately describe the collection o f
professionals who provide health care, given the power and status inequities inherent in the
health care hierarchy. However, the majority o f participants used this term when describing
the social context o f their nursing practice, so it will be used here. It is interesting to note
that most o f the participants' comments involved concerns about a lack o f team work.
Glenister and Hopton (1995) assert the importance o f teamwork in psychiatry: "shared
decision-making is the hallmark o f all good mental health services" (p.62). As previously
mentioned, the problem o f fragmented team care is compounded by recent stresses and
changes within the health care system.
When asked to reflect on a time when they felt they were able to act effectively on
behalf o f the patient, the nurses most frequently cited communication, support and teamwork
as the critical factors. One participant's comment typified the nurses' accounts o f how things
are different when they feel empowered.

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Things click...lt helps I think when you start to get to know the people.. .
that you’re working w ith .. .you develop some sort o f relationship with them, then
you can work together and things work properly and everybody sort o f tries to
cooperate, then it can go really smoothly and work really well. And sometimes it’s
just all o f a sudden, it’s like uh somebody, I don’t know, removed some kind o f jam
to the way things do work and it’s just maybe one person changes, an attitude or
somebody comes up with one different little idea and then everything will all o f a
sudden just fit into place.
This sense o f coordination involves staff cohesion, and the nurses said they feel empowered
when they feel they are an integral part o f the team. In turn, they function more proactively
than reactively in their nursing practice. A number o f participants also commented on the
importance o f supportive nursing leadership, in terms o f their sense o f effectiveness and
satisfaction at work. As one nurse stated, "having a pow erful.. .assertive, non-judgmental
charge nurse behind y o u .. certainly makes me feel more empowered, to have someone I can
bounce ideas off and who supports you"
Participants emphasized the need for greater communication, respect and support both
within nursing and between disciplines. One nurse stated that what is needed is
better communication, everybody listening a little more and giving. . . I'm saying
interdisciplinary communication, like doctors, nurses, OT's, everyone
communicating honestly to each other...The nurses are doing well, but we can still
improve and there has to be an open communication for the whole team to give
quality nursing care.
A possible key for enhancing interdisciplinary respect and collaboration lies in changing the
patterns o f inter professional communication. One nurse suggested that health care
professionals need to begin to relate to one another as people rather than as casted
professionals. By maintaining distance on the grounds o f professional divisions, each
individual profession is able to maintain its righteousness while avoiding personal

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accountability for his/her behaviours toward a member o f another profession. The following
comment captures the problem with this system o f relating, and offers a solution.
1just see so ma n y . . . doctors and the nurses bumping heads with each other all the
time . . . I don't want to be against the doctors . . . 1 don't really think they're bad
people and we're good people . . . I think sometimes that's what happens is there's a
split going on and we re so angry that we vent on them and they get so pissed o ff with
us being angry with them all the time that they Just avoid u s . . . So nobody connects.
And I think when you get the human factor, and people start respecting each other,
and you have personal contact and you actually talk to each other more, then you can
sort o f break through that. It's like, you can't really go and kill somebody in a war if
you know them, if you can put a face on t h e m. . . So, if you make it personal,
somehow that helps break down a lot o f barriers.
Rodney (1997) describes the need for "authentic presence" in communications between
members o f the health care team. "Individuals who are authentically present develop a sense
of trust in each other, which enables them to create a relational matrix that is mutually
supportive and that facilitates nurses' (and others') abilities to enact their moral agency"
(p.154).
A shared sense o f responsibility, and increased accountability at all professional
levels, is necessary in order for effective team functioning. As one participant stated
"everybody (needs to) come together instead o f this pass the buck thing all the time."
Participants expressed their frustration at the lack o f collaboration in the health care team,
particularly at the inconsistency in physicians' inclusion o f nursing input. The physicians'
behaviour may be driven by the "cover your ass" mentality identified by participants, in
which doctors may make decisions based more on ensuring their own professional survival
than what may be most helpful for the patient. So, similarly to nursing, medicine is bound by
legal and institutional constraints limiting autonomous practice. More significantly though,
the lack o f doctor/nurse collaboration may reflect medical behaviours meant to maintain the

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power imbalance between medicine and nursing, and nursing passivity related to an
internalized sense o f powerlessness to actualize change.
In some ways, the position o f nurses parallels that o f the opposition party in
government. They are in a comfortable position to challenge the decisions o f those in power
because they do not share the same responsibility for the outcomes o f their proposed
decisions. Lanza ( 1997a) states "that by attributing all of one's problems to a lack o f power,
one does not have to feel accountable for finding a solution" (p.6). Nurses need to commit to
active change in order to move toward equalizing responsibilities between all professional
groups and the patient. Although physicians are in the coveted position o f greatest power, 1
suspect that many doctors experience discomfort in the excessive degree o f control and
responsibility inherent in their title. If nurses truly desire increased power and control in their
nursing practice, they must be willing to assume greater accountability and responsibility for
patient care decisions. Lanza comments on nurses' tormented relationship with power;
"Nurses are challenged and obsessed with defining what it is and how to use it. However, in
the work place and political arena, they often recoil from applying it to advance the nursing
profession" (Lanza, 1997a. p.6).
As stated previously, many o f the nurses' suggestions for improving their work
experience involve changes outside o f nursing. In one hospital in which nurses had
specialized knowledge for a very specific patient population, participants seemed to possess a
greater internal locus o f control, as evidenced by their suggestions for change. It is
interesting to note that this group also had the highest percentage o f university educated
nurses. Their suggestions involved creating structures to facilitate staff communication and
nursing unity. As well, they suggested that ongoing education and professional development
are critical for enhancing nursing empowerment. One participant acknowledged that nurses
need to act more consistently assertive because in not doing so, they are relinquishing their
power.

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Limitations
The value derived from the content o f the descriptive data is the expansion o f general
theoretical possibilities, rather than generalization to other populations. The findings o f this
study add to a growing understanding o f powerlessness in psychiatric nursing. Lincoln and
Guba (1985) assert "that full information about a whole is stored in its parts" (p. 127);
therefore, there is value in exploring the particular. Although broad generalization cannot
occur, the presentation o f thorough descriptive accounts o f the participants' experiences,
allows the reader to fomi inferences that may be applicable to his/her own situation (Lincoln
& Guba, 1985). Reinharz (1992) suggests that "the very act o f obtaining knowledge creates
the potential for change because the paucity o f research about certain groups accentuates and
perpetuates their powerlessness" (p. 191).
Another limitation inherent in this type of research is the subjective nature o f data
collection and analysis. The researcher's own ideas and values will shape the treatment o f the
data and the appearance o f the findings. In order to counteract this effect, 1 identified my
personal assumptions (see Appendix B) before beginning the research. In addition, 1
provided the reader with personal background information that may influence the research.
This allows the reader to discern the impact o f the researcher's biases on collection and
analysis o f the data. In addition, 89% interrater reliability was established in the analysis
phase o f categorizing situations o f powerlessness.
The study may have also been limited by my personal proximity to the issue at hand.
It is sometimes recommended that the focus group leader be someone other than the
researcher, in order to enhance neutrality in data collection (Carey, 1994). In order to offset
this potential effect. 1 involved a non-nurse, graduate student co-leader, who had experience
in group and individual counselling. I instructed her to observe for any apparent biases in my
questioning, and we met at the end o f each session to discuss this. She participated in the
first three groups in which she offered useful feedback regarding areas in which I tended to
ask leading questions or paraphrased in suggestive ways. After receiving feedback. 1

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incorporated this into my approach in subsequent groups by consciously monitoring my
comments. By the third group, the effect had been minimized significantly. Thus, the co­
leader did not participate in the final group.
Implications and recommendations for nursing
Nurses play a critical and indispensable role in health care, providing twenty-four
hour care and nurturance to patients. Because their unique position allows them the privilege
o f knowing patients more intimately than other professional groups, they possess potential
for tremendous influence on patient care planning and decision-making. As well, nursing is
the largest professional group in health care, and if its influence reflected its numbers, nurses
would have a far greater impact on patient care delivery. Therefore, it is important for nurses
to expose and acknowledge their experiences o f oppression, in order to create foundations for
change. This is consistent with Freire's (1987) theory, in which the first phase in the
liberation from oppression requires insight into its sources and impact. Increasing dialogue
on oppression and powerlessness within nursing through regular forums, workshops and
literature is important. Until nurses acknowledge the existence o f oppression and begin to
reject the status quo on a broader level, they will be inhibited from possessing greater
autonomy and power.
It is important for nursing leaders to understand that empowerment for psychiatric
nurses is derived from interpersonal interactions, and cannot be received as a gift simply
through delegation o f increased responsibilities. Rather, as suggested by the participants in
this study, respect, validation, support and open communication are empowering to nurses.
Nursing leaders must build and maintain a strong power base rooted in nursing values and
knowledge rather than those o f dominant groups. Nurses must begin to recognize and truly
value their unique characteristics and practices. Lanza (1997b) stresses the importance for
nurses to "applaud the knowledge and expertise o f their own members and gain power, not
by association with those in the dominant group, but by forming liaisons and increasing
visibility in their own" (pp. 6-7).

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Regular acknowledgment and exploration o f the oppressive forces that impact nurses
need to be included in nursing education. Students would benefit from exposure to the idea
that the realities o f nursing practice are not always compatible with the academic notion o f
nursing autonomy and equality. By promoting a model o f nursing that is incompatible with
the realities o f nursing work, educators are blinding students to the issues o f oppression and
powerlessness in nursing, which ultimately disables nurses. Creating new, more empowering
models o f nursing are very important; however, it is essential that there is discussion around
the difficulties o f implementing them, so that new nurses do not feel disillusioned and
disheartened upon entering the workforce. Along with discussions o f oppression in nursing,
information regarding ways in which nurses can unite to increase their power, including
avenues o f political activism, are essential to move toward greater empowerment. Yarling
and McElmurry (1986) comment on the apolitical stance typical o f nurses, in which nurses
are "more concerned with serving individuals than with reforming institutions" (p.72). They
state further "this propensity is natural to a caring profession, but it is inadequate as a
professional style when social and political forces increasingly determine the context and
conditions o f practice" (Yarling & McElmurry, 1986, p.72).
For practicing nurses, ongoing discourse around nurses' limited capacity to act as
autonomous moral agents due to social and institutional constraints, is critical. Educational
opportunities, such as workshops, can provide forums for nurses to learn about and discuss
nursing ethics and the conflicts between nursing ideals and nursing practice. This may set the
stage for action toward reform o f institutional policies and nursing practice structures.
More research exposing the subjective experiences o f nurses is needed. Giving voice
to those who lack power challenges pre-existing paradigms through which phenomena are
typically presented and understood (Kirby & McKenna, 1989; Reinharz. 1992). Future
researchers might benefit from using a feminist approach in order to challenge taken-forgranted knowledge' that reflects the values o f the dominant order. Gilbert ( 1995) asserts that
if they are "to empower others, nurses have to develop an understanding o f the way in which

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the hegemony o f the present form o f rationality is produced" (p.870). Unless subordinate
groups expose and reflect on their own unique experiences, incorporating them into their
'knowledge' base, they "will continue to re-invent the wheel, and will remain divided and
powerless" (Kirby & McKenna, 1989, p. 168). This kind o f nursing research can pave the
way for the validation o f nursing knowledge as uniquely separate and equally as important as
medical knowledge. There needs to be increasing dialogue on the different expertise o f
nursing and medicine so they can function in a more complementary rather than competitive
way. University curricula involving courses that bring together medical and nursing students
may help to bridge the gap between disciplines. If each group began to trust the expertise o f
the other, true collaborative team care may be possible. It is critical that research findings be
made meaningful and accessible to nurses outside o f academia. To not do so, would make
researchers guilty of perpetuating nursing oppression through making new knowledge
property o f the elite (Kirby & McKenna, 1989; MacPherson, 1983; Reinharz, 1992).
Implications and recommendations for counselling
Counsellors need to develop expanded conceptions o f oppression, acknowledging that
oppression is alive and well in many workplace settings. This research provides insight into
the dynamics o f power within an oppressive work environment such as a hospital. It is
essential for counsellors to have an understanding o f the impact o f power distributions within
hierarchical structures, particularly when working with nurses. Counsellors must recognize
that work attitudes and behaviours are impacted by multiple social and institutional
constraints. In counselling oppressed clients, it is important to create the conditions for
empowerment, and incorporate strategies to support and facilitate the maintenance o f
empowered behaviours.
A feminist therapeutic approach involves acknowledging and managing the inherent
power differences in the client/counsellor relationship. It is critical that the counsellor model
effective use o f personal power, avoiding any replication o f power inequities that the client
may experience in his/her life (Rave & Larsen, 1995). A feminist approach is also useful in

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terms o f contextualizing and validating the experiences o f nurses or other oppressed clients.
To view the experience o f an oppressed individual outside o f the context in which the
oppression occurs, may simply reinforce the client's powerlessness. Feminist theory suggests
that the personal is the political; thus, in therapy, movement from the personal to the political
in terms o f action, is ultimately encouraged. Therefore it is very important for the counsellor
to act as an advocate for clients, which may, at times, involve addressing the broader issues
underlying the client's experience o f oppression. Freire (1987) contends that a necessary step
in the liberation from oppression involves taking action to challenge and eliminate the
institutionalized belief systems that are perpetuating the oppression.
Counsellors can help to facilitate clients' understanding and development o f assertive
behaviours by using a cognitive-behavioural approach. Clients can be assisted to challenge
and alter behaviours and belief systems which are sustaining their oppression. The oppressed
person needs to become conscious o f his/her own perception o f reality and critically examine
the contradictions in it, rejecting those that belong to the oppressor (Freire, 1987).
Incorporation o f stress management activities is recommended for counsellors who
are working with nurses. In order to prevent or minimize the burn-out that so many
participants referred to, the development o f self-care strategies is essential. Working with
nurses in groups may help to facilitate empowerment through creating a shared experience
rather than one o f isolation. "Groups generate a sense o f community, belonging, support,
acceptance, and assistance" (Johnson & Johnson, 1994, p.481). This can function to offset
the internalized frustration that is typical in nursing (Attridge & Callahan, 1987). In addition,
group work can be useful in facilitating the creation o f new group norms in nursing. Rather
than accepting the status quo and succumbing to social and organizational constraints on
nursing practice, nurses can use the group forum to explore alternate conceptions o f nursing
practice and strategies for change. Cash (1997) argues that the boundaries and status given to
nursing knowledge are defined by other disciplines, mainly medicine, and he asserts "to

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change the status o f that knowledge is to redefine nursing" (p. 143). Finally, positive group
experiences can counteract the divisiveness in nursing and function to increase nursing unity.
Conclusions
There are four types o f situations in which the psychiatric nurses in this study
typically experienced powerlessness. These include (a) situations characterized by
medicine's dominance and control, (b) no-win situations, (c) when there are system problems,
and (d) when there is a lack o f communication and support. The categories are interactive
with one another, and the nurses' behaviour within the situations often reflects oppressed
group behaviour. Nursing oppression parallels the oppression o f women in patriarchal
society. It is so widespread and insidious that it often goes unacknowledged. The oppression
of nurses is perpetuated by both the hierarchical structure o f health care, and by nurses'
internalized oppression. Consistent with oppressed group behaviour, nurses are not united
(Roberts, 1983). Thus, they are not capitalizing on the power inherent in their numbers.
Huston and Marquis (1988) assert: "To the extent that nurses abrogate their responsibility for
professional decision making and fail to collaborate with other nurses in exercising power,
they fail their patients, themselves, and the profession" (p.43). Shrinking resources in health
care and the increased pace o f acute care psychiatry are exacerbating the disunity of
psychiatric nurses.
Oppression in the study participants was exemplified by their sense o f helplessness to
create change against the power o f medicine, administration, and the larger health care
system. Many o f the nurses' comments suggest an external locus o f control, in terms o f
creating change. They expressed significant anger and frustration about feeling controlled by
authoritative bodies, but rarely did they describe situations in which they expressed
themselves directly to authority. A sense o f fear regarding repercussions often keeps the
nurses from speaking up. They are in a very difficult position, caught between their
allegiance to the patient and their allegiance to medicine and administration. Although
nurses are educated under the philosophy o f autonomous professional practice and patient

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advocacy, and legally nurses are bound to make autonomous practice decisions, the health
care system does not support this kind o f practice. It is structured such that nurses are still
expected to act under the authority o f medicine. Yarling and McElmurry (1986) comment on
the conflict between nursing ideology and the realities o f nursing practice.
Student nurses today are taught that nursing requires patient advocacy, that patient
care comes first. Yes, that is what they are taught verbally and overtly; but in a
thousand nonverbal and covert ways, they are taught by clinical example the limits
of that advocacy.. .They learn that their commitment to patients must be carefully
contained (p.67).
The participants’ accounts suggest that nurses are less likely to advocate for patients
when they are feeling powerless and blocked by the authority o f medicine or administration.
This creates a great deal o f distress for nurses because they feel inhibited from practicing
congruently with their ideals o f nursing. Many nurses seem to deal with this distress by
attributing the problem entirely to those in more powerful positions than themselves, and by
complaining amongst themselves. In this way, nurses can maintain idealistic and virtuous
views on their nursing practice, blaming other groups for their inability to provide the kind of
care they believe would be best. However, they are perpetuating their own powerlessness by
relinquishing control over their practice to dominant groups. Nursing oppression has a long
history that continues into the present; nevertheless, it is time for nurses to begin to
understand their participation in the perpetuation o f this oppression and to take greater
responsibility for challenging the status quo.
Power is experienced by the psychiatric nurses through their interactions with others.
They identified negative interactions with colleagues as disempowering, and they felt
empowered when there was respect and cohesion both within nursing and between
disciplines. Open communication and support were identified as critical to effective
functioning o f the health care team. Often, there seems to be a mutual distrust between
medicine and nursing. Each discipline is maintaining separation from the other by asserting

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their righteousness and negating the approaches o f the other discipline. A great deal o f
nursing energy seems to be spent on what participants called the "power struggle." Perhaps,
if nurses truly acknowledge and value their own unique skills and strengths, they will not
subvert them to those o f medicine, and the two disciplines may be able to function in a more
complementary way.

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References
Attridge, C.B. (1996). Analysis o f powerlessness in nursing work. Canadian
Journal o f Nursing Administration. 9 (2), 36-59.
Attridge, C., & Callahan, M. (1989). What nurses want: B.C. nurses redesign
their work and workplace. Victoria: University o f Victoria.
Attridge, C.. & Callahan, M. (1987). Women in women's work: Nurses
perspectives o f quality work environments. Victoria: University o f Victoria Press.
Bandura. A. (1989). Human agency in social cognitive theory. American
Psychologist. 44. 1175-1184.
Barton. A.J. (1987). Advocacy: Nursing's role in supporting the patient’s right to
refuse treatment. Plastic Surgical Nursing. 11 (2), 76-77. 87.
Becvar, D.S., & Becvar, R.J. (1996). Family therapy: A systemic integration
(3rd ed.). Boston, MA: Allyn and Bacon.
Carey, M.A. (1994). The group effect in focus groups: Planning, implementing,
and interpreting focus group research. In J.M. Morse (Ed.), Critical issues in qualitative
research methods (pp. 225-241). London: Sage Publications.
Cash, K. (1997). Social epistemology, gender and nursing theory. International
Journal o f Nursing Studies. 34 (2). 137-143.
Chandler, G.E. (1992). The source and process o f empowerment. Nursing
.Administration Quarterly. 16 (3), 65-71.
Dahl, R. A. (1957). The concept o f power. Behavioral Science. 2 . 201-215.

108

Dykema, L.L. (1985). Gaventa's theory o f power and powerlessness:
Application to nursing. Occupational Health Nursing. 33 (9), 443-446.
Erlen, J.A., & Frost, B. (1991). Nurses' perceptions o f powerlessness in
influencing ethical decisions. Western Journal o f Nursing Research. 13 (3), 397-407.
Ford, P., & Walsh, M. (1994). New rituals for old: Nursing through the looking
glass. Oxford: Butterworth-Heinemann Ltd.
Foucault, M. (1980). Power/ knowledge: Selected interviews and other writings.
1972-1977. New York: Pantheon Books.
Freire, P. (1987). Pedagogy o f the oppressed. (M B. Ramos, Trans.). New
York: The Continuum Publishing Corp. (Original work published 1970).
Funk & Wagnalls Canadian college dictionary (Rev, ed.). (1989). Toronto:
Fitzhenry & Whiteside Ltd..
Gadow. S. (1980). Existential advocacy: Philosophical foundations o f nursing.
In S.F. Spicker & S. Gadow f Eds.l. Nursing: Images and ideals (pp. 80-98). New York:
Springer Publishing Company.
Gilbert, T. (1995). Nursing: Empowerment and the problem o f power. Journal
o f Advanced Nursing. 2 1 .865-871.
Gilligan, C. (1982). In a different voice: Psychological theory and women’s
development. Cambridge, MA: Harvard University Press.
Glenister, D., & Hopton, J. (1995). The illusion o f progress. Nursing Times. 91
(31), 62-63.

109

Groves, M.M. (1992). Staff nurses’ attitudes toward power. Unpublished
master's thesis. University o f British Columbia, Vancouver, British Columbia, Canada.
Hall, B.A. (1996). The psychiatric model: A critical analysis o f its undermining
effects on nursing in chronic mental illness. Advances in Nursing Science. 18 (3), 16-26.
Handy, J. (1995). Rethinking stress: Seeing the Collective. In T. Newton (with
J. Handy, & S. Fineman), 'Managing' stress: Emotion and power at work (pp.85-96).
London: Sage Publications.
Hewison, A. (1995). Nurses'power in interactions with patients. Journal o f
Advanced Nursing. 21. 75-82.
Hugman. R. (1991). Power in caring professions. London: The MacMillan
Press Ltd.
Huston, C.J., & Marquis, B. (1988). Ten attitudes and behaviors necessary to
overcome powerlessness. Nursing Connections. I (2), 39-47.
Johnson, D.W., & Johnson, P.P. (1994). Joining together: Group theory and
group skills. Boston: Allyn and Bacon.
Kavanagh. K.H. (1991). Invisibility and selective avoidance: Gender and
ethnicity in psychiatry and psychiatric nursing staff interaction. Culture. Medicine and
Psychiatry. 15.245-274.
Keddy, B. (1996). A feminist critique o f psychiatric nursing discourse. Issues in
Mental Health Nursing. 17. 381-391.
Kennedy, 1. (1981). The unmasking o f medicine. London: George Allen &
Unwin.

110

Kingry, M.J., Tiedje, L.B., & Friedman, L.L. (1990). Focus groups: A research
technique (or nursing. Nursing Research. 39 (2). 124-125.
Kirby, S., & McKenna, K. (1989). Experience research social change: Methods
From the margins. Toronto, Ont.: Garamond Press.
Krueger, R.A. (1994). Focus groups. Thousand Oaks, CA: Sage Publications,
Inc..
Lanza, M L. (1997a). Power and leadership in psychiatric nursing. Directions
for the next century: Part 1. Perspectives in Psychiatric Care. 33 (1). 5-13.
Lanza, M L. (1997b). Power and leadership in psychiatric nursing. Directions
for the next century. Part II. Perspectives in Psychiatric Care. 33 (2), 5-9.
Liburd, R.. & Rothblum, E. (1995). The medical model. In E.J. Rave & C.C.
Larsen (Eds.). Ethical decision making in therapv: Feminist perspectives (pp. 177-201).
New York: The Guilford Press.
Lincoln, Y.S. & Guba, E.G. (1985). Naturalistic inquiry. London: Sage
Publications.
May, R. (1972). Power and innocence: A search for the sources o f violence.
New York: Dell Publishing Company.
MacPherson. K.I. (1983). Feminist methods: A new paradigm for nursing
research. Advances in Nursing Science. 5 (2). 17-25.
McLaren, P.L.. & Lankshear. C. (1994). Politics o f liberation: Paths from
Freire. London: Routledge.

Ill

Mgoduso, T., & Butchart, A. (1992). Authoritarianism and autonomy: II Power,
politics, and alienated nursing care in a South African primary health care system. South
African Journal o f Psychology. 22 (4), 194-201.
Miller, J.B. (1991). Women and power. In J.V. Jordan, A.G. Kaplan, J.B.
Miller, l.P. Stiver, & J.L. Surrey, Women's growth in connection: Writings from the
Stone Center (pp. 197-205). New York: The Guilford Press.
Millette, B.E. (1993). Client advocacy and the moral orientation o f nurses.
Western Journal o f Nursing Research. 1515). 607-618.
Morgan, D.L. (19881 Focus groups as qualitative research. Newbury Park, CA:
Sage Publications Inc..
Morse. J.M. & Field, P.A. (1996). Nursing research: The application o f
qualitative approaches (2nd ed.). London: Chapman & Hall.

Olesen, V. 1994). Feminisms and models o f qualitative research. In N. Denzin,
& Y. Lincoln. Handbook o f qualitative research (pp.159-174). Thousand Oaks: Sage
Publications.
Palys, T. (1992). Research decisions: Quantitative and qualitative perspectives.
Toronto: Harcourt Brace Jovanovich Canada Inc.
Pieranunzi, V.R. (1997). The lived experience o f power and powerlessness in
psychiatric nursing: A Heideggerian hermeneutical analysis. Archives o f Psychiatric
Nursing. II (31 155-162.
Podgorecki, A. (1993). Social oppression. Westport, Conn.: Greenwood Press.

112

Rave, E.J., & Larsen, C.C. (Eds.). (1995). Ethical decision making in therapy:
Feminist perspectives. New York: The Guildford Press.
Registered Nurses Association o f British Columbia. (1992). Guidelines for
specialized nursing skills and delegated medical functions. Vancouver, B.C.
Reinharz, S. (1992). Feminist methods in social research. New York: Oxford
University Press.
Ristock, J.L. & Pennell, J. (1996). Community research as empowerment:
Feminist links, postmodern interruptions. Ontario: Oxford University Press.
Roberts, S.J. (1983). Oppressed group behavior: Implications for nursing.
Advances in Nursing Science. 5 (4), 21-30.
Rodney. P.A. (1997). Towards connectedness and trust: Nurses' enactment o f
their moral agency within an organizational context. Unpublished doctoral dissertation.
University o f British Columbia. Vancouver, B.C.
Sagrestano, L.M. (1992). The use o f power and influence in a gendered world.
Psvchology o f Women Ouarterly. 16 (4), 439-447.
Scott, J.W. (1992). Experience. In J.Butler. & J.W. Scott. Feminists theorize the
political (pp. 22-40). New York: Routledge.
Seeman, M. (1959). On the meaning o f alienation. American Sociological
Review. 24. 783-791.
Sinda, M. (1984). The powerlessness o f the nurse and its effect on the client.
Philippine Journal o f Nursing. 5 4 14). 124-129.
Sines. D. (1993). Balance o f power. Nursing Times. 8 9 1461.52-55.

113

Stevenson, C. (1996). Taking the pith out o f reality: A reflexive methodology
for psychiatric nursing research. Journal o f Psychiatric and Mental Health Nursing. 3 (2),
103-110.
Surrey, J.L. (1991). Relationship and empowerment. In J.V. Jordan, A.G.
Kaplan, J.B. Miller, l.P. Stiver, & J.L. Surrey, Women’s growth in connection: Writings
from the Stone Center (pp. 162-180). New York: The Guilford Press.
Szasz, T. (1991). Ideology and insanity: Essays on the psychiatric
dehumanization o f man. New York: Syracuse University Press.
Walters, M., Carter, B., Papp, P., & Silverstein, 0 . (1988). The invisible web:
Gender patterns in family relationships. New York: The Guilford Press.
Will, R.S. (1995). Nurse-physician collaboration: Dilemma or opportunity.
Canadian Journal o f Nursing Administration. 8 (3L 30-41.
Yarling, R.R., & McElmurry, B.J. (1986). The moral foundation o f nursing.
Advances in Nursing Science. 8 (2), 63-73.
Yoder, J.D.. & Kahn, A.S. (1992). Toward a feminist understanding o f women
and power. Psychology o f Women Quarterly. 16 (4), 381-388.
Young, I.M. (1992). Five faces o f oppression. In T.E. Wartenberg (Ed.).
Rethinking power (pp. 174-1951 Albany, NY: State University o f New York Press.

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Appendix A
Key Interview Questions
1. Think about a situation in the last 6 months in which you felt you lacked the necessary
power to act in the way which would be best (in your opinion) for the patient or situation.
An example might be one in which you administered a medication to a patient in spite o f
the fact that you felt it was not necessary or may even be detrimental.
If you wish to take a moment to write down the situation, if that helps you clarify
the details, then please do so. And include how you fe lt in the situation. I will then ask
you to share this with the group.
2. What specifically inhibited you from acting in the above situation?
3. What would have needed to be different for you to feel more able to act in the 'best
way'?
4. How are you affected when your actions are restricted or your voice is not heard?
a) How is your nursing practice affected?
b) How are your relationships with colleagues affected?
c) How do you think other aspects o f your life might be affected by your feelings o f
impotence (or powerlessness) at work?
5. Reflect on a situation in which you felt you were able to act in what you considered to
be the best way for the patient or situation. What was different about this situation?
How did you feel differently, in this situation?
6. If there was one thing you could change about your workplace, what would it be and
why?

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Appendix B

Personal assumption?
The following list is a set o f personal assumptions that the researcher brings to the
study.
1. Psychiatric nurses feel powerless at times.
2. Feeling powerless is an undesirable experience, as all people desire a sense o f personal
empowerment and control in their lives.
3. Feeling powerless has both a personal and professional impact on psychiatric nurses.
4. The quality o f patient care is diminished when psychiatric nurses feel powerless because
nurses (a) are less likely to advocate for patients, (b) are less likely to encourage patients to
activate their own power, and (c) may make power plays over patients to increase their own
sense o f power.
5. Psychiatric nurses desire the following changes: (a) they want to feel they are a more
integral part o f patient care decisions, and (b) they want their nursing work to be valued and
validated.
6. Psychiatric nurses have ideas for change, but something inhibits them from acting on this.
7. Responsibility for creating change within the nursing profession lies with nurses.
8. Nurses possess a unique body o f knowledge and skills that differs from medicine.
9. The expertise o f nursing and medicine can complement one another rather than compete
with one another.

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Appendix C
Demographic Details

Agg (ygats)
30 - 59

Etbnicüy
All Caucasian
Marital status
10 Married
2 Divorced
2 Single
3 Unmarried but living with partner
Education
9 RN Diplomas
5 RPN Diplomas
2 Both RN and RPN Diplomas
1 RN Bachelor's Degree

Additionally:
2
1
3
1

Post-graduate Diplomas in Nursing field
Post-graduate Diploma in non-Nursing field
Bachelor's Degrees in non-Nursing fields
Master's Degree in non-Nursing field

Experience fvearsl
11 Ten or more
1 Five to ten
3 Two to five
2 Under two
Emplovment status
13 Full-time
2 Part-time
2 Casual

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Appendix D
Informed consent
Title o f study: The experience o f powerlessness for acute care psychiatric nurses.
Purpose o f the study: To explore the meaning and impact o f a sense of powerlessness on
acute care psychiatric nurses.
This is to certify that 1,________________________ , agree to voluntarily participate in
this study. 1 have been informed that this study is being conducted by Janice Cathcart as
part o f her thesis requirements for the Degree o f Master o f Education in Counselling at
the University o f Northern British Columbia. This study is being supervised by Dr.
Colleen Haney in the Education Programme, Faculty o f Health and Human Sciences,
University of Northern British Columbia.
1 agree to participate in one 2-hour focus group with three to six other psychiatric nurses
who work in the same hospital as I do. I agree to allow the interviews to be audiotaped
and videotaped. 1 agree to allow the tapes to be transcribed for the purposes o f data
analysis. I am aware that the information I provide will be analyzed for the purpose o f
identifying themes. I am aware that I may be quoted directly in the write-up o f this study,
but that my anonymity will be ensured. I understand that all data collected will remain
confidential with regard to my identity. Participants will be identified by code on the
transcription. 1 understand that only the investigator, her supervisor, and a transcription
clerk will have access to the tapes. The tapes will be securely stored.
I understand that 1 do not have to participate and that I am free to withdraw my consent
and may terminate my participation at any time. I may ask any questions 1 want about
this research project. Questions 1 ask will be answered to my satisfaction. 1 will receive
a copy o f this consent form.

Date:
Participant Signature

Faculty Supervisor:
Dr. Colleen Haney
Education Programme
UNBC (250)960-5639
e-mail: haney@unbc.edu

Investigator's Signature
Janice Cathcart RN, BSN
Master’s Candidate in Counselling, UNBC
(250)614-9018 (home);(604)985-7562 (msg)
e-mail: cathcaij@unbc.edu

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Appendix E

PgmQgraphlç Informatign
For the sole purpose of understanding the similarity or diversity o f participants, please
answer the following questions about yourself. Your answers will remain anonymous
and strictly confidential.
Please answer the following questions by CHECKING the most appropriate response(s)
unless otherwise indicated.

I. W hat is your age?

_________________

2. W hat is your marital status?
Single
Unmarried but living with a partner
Married
Divorced
Widowed

3. To which ethnic group do you be ongi
Western European
Eastern European
First Nations
Caucasian
Hispanic
East Indian
Asian
Middle Easterner
African
Other

( )

( )

specify.

4. W hat kind of education do you have?
RN diploma
RPN diploma
Bachelor’s degree in Nursing
Post-graduate degree in Nursing
Post-graduate diploma in Nursing
Diploma in non-Nursing field
Degree in non-Nursing field

specify,
specify.

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5. How many years have you worked in psychiatric nursing?
0 to 2
More than 2 but less
More than 5 but less
10 or more

than 5
than 10

( )
( )
( )
( )

6. In which job category are you?
Full-time, regular
Full-time, temporary
Part-time, regular
Part-time, temporary
Casual
Other

specify

7. How does your group of colleagues support individual nurses in acting more
powerfully?

8. How does your group of colleagues undermine nurses who attempt to act more
powerfully?