An article from University of Oslo
Powerful health care
Is power always an evil to be minimized, or can it be a means of ensuring that a patient in need of help gets the daily care he or she needs?
University of Oslo
Truls Juritzen has studied power and power relationships in the healthcare profession - and has chosen a slightly different approach than most.
He has analysed the daily interactions between care providers and users of nursing homes and tried to understand them from a power perspective. Through participatory observation he has followed the staff and users for six months, as well as interviewed the staff in focus groups.
The study reveals that the staff are not at all comfortable with the classical power situations. They want as few as possible of these.
Usually we think of power as something negative, as an evil to be eliminated. But is power always something we should eliminate? Perhaps power is also something positive. For who wants to be left to a powerless and impotent health professional if one is in need of help?
Power to change
"I try to see power as an unresolved phenomenon that is always there and shouldn't necessarily go away. I do not take a position on whether it is good or bad. Power is also about being empowered - to achieve something, to make a change, start something new," says Juritzen, who uses the French philosopher and idea-historian Michel Foucault's theories as the basis for his analyses.
The staff see power as a clearly defined concept. Power is when they have to force a user to do something he or she does not want to do. But, is power only forcing someone to do something against their will? What about the power that is there all the time, like a variegated backdrop that blends in with the surroundings?
The unavoidable power
According to Foucault, power is always present and unavoidable. The minute we define power as a delineated phenomenon, we define everything that is not power as powerless. And anything that is not viewed as power slips under the radar for the exercise of power. Thus, we do not reflect critically on this as possible exercise of power, Juritzen points out.
He believes we have an engrained aversion to power as a concept and against allowing ourselves to use power. This may originate from the fact that we traditionally look at power as a hierarchical and asymmetrical phenomenon, chock full of negative associations.
But power can also be a productive force, according to Foucault. And Juritzen's study follows in the same vein. His analyses show how power is an inevitable force in healthcare.
Power must be used, but it can also be misused. Care at the nursing home is about solving necessary care-providing tasks where the user and their families have had to give up.
"It is good that someone is able to take care of someone who is so confused that if they go out in the cold they will freeze to death," says Juritzen.
An effective good
The language we use creates the reality we see. That which we call power, becomes power, claims Juritzen.
He is concerned about the "how" of power.
"I focus on how something happens, concretely, rather than asking why it happens. How does power flow within relationships? I think this is more interesting than who has the power and where the power is coming from."
Juritzen tries to help us see power at its most effective. When a care-provider at the nursing home ensures that residents have got their hair washed, got dressed, got food and that nothing has gone wrong - then the employee has the power to carry out these actions. The study points out that productive power is concerned with working with the user, and creating movement and direction in everyday situations. The power may be at its most effective when it goes under the name of something else, for example, caring.
"I analyse all the times when the care-providers do not need to physically force users to do something they don't want to do," explains Juritzen.
"Everything that happens during the course of a day can be understood as different degrees of exercising power. I look at the power that exists in normal daily interactions. We must examine these as power practices, and evaluate whether they are good or an bad."
When the user cooperates
Most agree that the power that restricts, hinders and is a hierarchical top-down power is something that should be minimized. But power can also be a productive force.
"When power is at its most effective we accept it gladly. An example of productive exercising of power is government awareness campaigns," says the researcher.
"Here, knowledge and science are coupled with power to make us citizens want to do the right thing."
Instead of forbidding for example fat or alcohol, the authorities try to get us to want to reduce our consumption, because we understand that these substances can be harmful to us if consumed in excess.
Juritzen has also challenged the idea of thinking unilaterally of power as a hierarchical structure of superior and subordinate relationships. Unequal power should be distributed equally, we think, and introduce user participation. But is power absent when the user is participating?
He thinks that we are not talking necessarily about evening out the power, but rather that the power assumes a slightly different form.
"Users should contribute, but it is often quite clear what the result of their participation will be. There is a limit to what kind of participation we want - and this goes where the user draws in a different direction than what professionals think and want."
Reflections on intervention
The researcher, who is educated as a psychiatric nurse, hopes that we can be more aware of the power that is exercised in the health sector in general. In psychiatry, there is much attention to how the treatment interferes with other people's lives. He thinks there should be more reflection on this also in the other health disciplines.
"We must take a critical look at the power involved in our actions. If we do not consider something as having power, it simply fades into just another grey, normal day."
- Juritzen, Truls I; Engebretsen, Eivind & Heggen, Kristin (2012). Subject to empowerment: The constitution of power in an educational programme for health professionals. Medicine, Health care and Philosophy. ISSN 1386-7423.