Why do nurses behave as they do?

Subject Positions Theory.   Why do individual nurses behave as they do?

SPT tries to explain how ‘subjects’ will behave in certain situations. It can be used to explore what ‘positions’ we take up and what identities we either assume or refuse within a social context that is characterised by power relationships. It allows the question about how powerful ‘others’ (i.e. Health Secretaries, CEOs, Consultants, Managers) position the relatively powerless ‘subject’ (staff nurse, patient) into certain subject positions (e.g. handmaiden, passive recipient) simply through an unconscious, uncriticised and shared language, discourse and power. Objective formal power involving clear boundaries, sanctions and authority also operate in social relationships. Objective formal power needs to be called out, and its foundation clearly described as operating often on an unspoken ideology. In the current context of health care delivery, that ideology is founded upon the twin pillars of neoliberalism and managerialism. These are macro level positions, whereas SPT allows exploration of informal power at the micro level that might go otherwise unanalysed.

 

The ‘subject’ within this theory refers to the individual human being who engages in creating an identity and does so partly by being the ‘subject’ of language, discourses and power relationships. The subject position, or identity, one takes is created by language, discourse and power and in doing so also creates that identity. This operates within a set of social relationships that are characterised by differences such as ethnicity, sexuality, gender and class. These relationships are also relationships of power. They operate through and within language. Our subject positions are partly defined by others unless we recognise the process of positioning and resist it. However, a good deal of positioning by others can be successful because we take subject positions often unconsciously. We have already accepted the language, discourse and power of others. Within any social interaction, powerful ‘others’ may engage in ‘interpellation’ (Althusser 1989). They ‘call’ us into a subject position by our intersubjective acceptance of the language, discourse and power of the other.

 

When a doctor, or manager, calls upon a nurse to do something, they are often ‘interpellating’ the nurse into a subject position of obedience to a medical or hierarchical regime. This can only work if the nurse recognises and accepts the subject position of junior partner. This process of identification creates an identity. The doctor identifies the nurse and the ‘subject’ within the nurse becomes a nurse. The subjective ‘I’, which in other social situations is not identified as a nurse, now becomes one. This is not to be confused with the formal title that the qualification RN bestows upon someone. Merely having been registered with the Nursing and Midwifery council does not identify a subject as a ‘nurse’, it is merely a formal recognition of one’s status on a register. One becomes and assumes the identity of nurse through social interaction and the ‘interpellation’ of others. A nurse is a nurse only when others say so within a social context. Upon leaving the clinical setting, the subjective ‘I’ is now free to assume other identities such as mother, friend, runner or dancer.

 

When a nurse is called in this manner, it may well be the case that the nurse recognises this calling, and that the subjective ‘I’ is now the subject position of ‘me’ as nurse. This operates through the unconscious acceptance of that subject position. Through such mechanisms as ‘occupational socialisation’ the calling out of ‘me as nurse’ feels natural and in that acceptance further cements this identity. The nurse has been ‘recruited’ into that subject position and over time bonds with that identity and its underlying ideological sets of discourses and power relationships that go with it.

 

Within the occupation of nursing there may be a number of subject positions open to individual nurses. Some of those positions are overt and openly discussed, others operate within the covert, intersubjective, lifeworld of nursing. Thus, nurses assume certain subject positions, such as ‘nurse advocate’, and attempt to assume this identity to further patient care. In doing so, do other ‘powerful subjects’ may position the ‘nurse advocate’ identity into one of ‘whistleblower’ or ‘uppity nurse’, ‘non-medical care worker’ or ‘junior partner’.

 

Potential Subject Positions that might be open to nurses: they operate as binaries – one position is assumed other is an ‘abject’ position.

 

·       Advocate/Non advocate

·       Carer/patient

·       Empathiser/task completer

·       Doer/Organiser

·       Whistleblower/Compliant worker

·       Educator/Student

·       Trainer/Trainee

·       Supervisor/worker

·       Female/male

·       Good nurse/uppity nurse

·       Coper/Whinger

·       Emotional supporter/distant professional

·       Responder/avoider

 

 

‘Subjects’ have the ability to occupy and move between a variety of identities, or ‘subject positions’, within an interaction in the clinical setting but this depends on the power dynamics and context of that exchange. We can therefore try to analyse in any given interaction what those power dynamics are and what the context consists of. So, how do nurses either comply with or resist positioning for example as a ‘doer’ within a power struggle?

 

Lacan (1977) suggests we assume identities, or positions, in response to punishments or threats of punishment. In the clinical context that might include bullying, intimidation, snubbing, patronising language or lack of promotion. The fear of punishment arises out of ‘knowing’ the rules of interaction and being aware of power and the rules of hierarchy.

 

Once an identity has been assumed it is associated with a particular discourse, i.e. a stock of words, phrases, concepts, theories, that support and explain the position taken. The subject position of nurse, according, to society, should display feminine attributes based in an ethic of care. The discourse associated with this is about being a ‘good nurse’ emphasising nurturance, obedience, support, listening and helping. This recently has been given even more support through emphasising the 6 Cs. This sits in opposition to critical advocacy especially in relation to the medical profession and NHS management. The discourse available to critical advocacy emphasises challenge, assertiveness, rights, and standards. The subject position of whistleblower is similarly contradictory, at once being that of advocate and patient champion while the reality is also one of irritant, turncoat and rebel to the hierarchies of power. SPT requires a critical theory of power to move beyond analysis at the micro level to critique of power structures (be they gendered, class, managerial) at the macro.

 

Clinical decision making, such as advocating a certain course of action such as moving an older person within the hospital at night, or changing the operating list to avoid delays, or getting analgesia prescribed, operates within this matrix of subject positions involving negotiating the social order of hierarchy and power. Sundin-Huard (2001) argues the subject position of advocate is countered by the subject position of ‘good nurse’ in that in exercising advocacy the nurse threatens the identity of ‘good nurse’ and becomes the ‘uppity nurse’. A vignette illustrating this positioning is used as an exemplar. In the vignette, a neonatal nurse advocates, unsuccessfully, for analgesia as she is positioned and assumes the position of advocate and uppity nurse. In the training film ‘just a routine operation’, two nurses are similarly positioned as ‘junior without formal decision making power’ within a critical airway emergency in theatre. The resulting death of the patient in that scenario clearly demonstrates that this analysis is no mere sociological abstraction.

 

Conclusion

 

Nursing does not operate in a neutral power context. Nurses work in a gendered occupation underpinned by a range of discourses using certain languages that often position them into subordination. Those in formal power positions also understand these discourses and through language use can ‘call’ nurses into subordinate and contradictory subject positions. Hierarchies of gender, class and occupation provide the context for these positionings to take place. In order to minimise moral distress and the burden of emotional labour, nurses require an emancipatory understanding of these taken for granted power plays to enable practical resistance to develop. In this they can be aided by the discourse of humanism recognising the requirement for patient safety, comfort and cleanliness in the provision of quality care. The nurse who feels emotional and moral distress as a result of the actions and omissions of other power actors in the workplace, requires an analysis of the basis of this power relationship so that rather than turning in on oneself in defeat, a resistance can be mounted by creating alternative languages, discourses and power bases. Resilience in the face of threat in this context is not enough. Nurses need to find a language to speak truth to power and then forge political alliances with other actors, e.g. patient advocacy groups, to create alternative visions and structures to that which is advocated by neoliberals and the dead hand of managerialism.

 

 

 

 

 

 

 

Althusser, L. (1989). ‘Ideology and ideological state apparatuses’ in Lenin and Philosophy and other Essays: pp 170-186. London. New Left Books.

 

Lacan, J. (1977). Écrits: A Selection. Trans. Alan Sheridan. New York: Norton

 

Sundin-Huard D. Subject Positions Theory. Understanding conflict and collaboration in critical care. (2001). Journal of Advanced Nursing 34 (3) pp 376-382

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