Micro-powers in the daily work of hospital nursing: an approximation to the thinking of Foucault
Silvio Arcanjo Matos FilhoI; Norma Valéria Dantas de Oliveira SouzaII; Francisco Gleidson de Azevedo GonçalvesIII; Ariane da Silva PiresIV; Thereza Christina Mó Y Mó Loureiro VarellaV
Nurse. Master. Student of the Ph.D. Nursing Course. Adjunct Professor of
the State University of Southeast Bahia. Brazil. E-mail: email@example.com
II Nurse. Ph.D. Associate Professor, Nursing School, University of Rio de Janeiro State. Brazil. E-mail: firstname.lastname@example.org
III Nurse. Master in Nursing. Nursing School, University of Rio de Janeiro State. Brazil. E-mail: email@example.com
IV Nurse. Master in Nursing. Assistant Professor, Nursing School, University of Rio de Janeiro State. Brazil. E-mail: firstname.lastname@example.org
V Nurse. Ph.D. Adjunct Professor, Nursing School, University of Rio de Janeiro State. Brazil. E-mail: email@example.com
Objectives: to examine and discuss micro-powers in the daily work of hospital nursing, in the light of the thinking of Foucault. Content: the point of departure was a historical analysis of the division of labor at hospitals and in nursing, which evidenced features in common with the concepts of micro-powers discussed by Foucault. Patterns of behavior and discipline were found to exist in the practice of nursing that are compatible with Foucault’s theoretical assumptions. Conclusion: this issue needs to be discussed in greater depth for a broader understanding of the professional practice of hospital nursing, as well as to establish mechanisms that enable workers to examine their daily activities with a view to modifying postures and behavior. Mobilization and collective involvement are also necessary for processes of change to take place in the power relations that permeate the nursing profession.
Descriptors: Nursding; work; hospitals; Foucault’s thought.
The French philosopher Michel Foucault is the author of numerous works that follow a structuralist line. However, his narrative of counterpoint to the ideas of truth, objectivity, and reason, especially with the publication of Micro-physics of power1 (1979) and Discipline and puish2 (1987), he began as a contemporary representative of post-structuralism. Such categorization is due to the fact that all the works explain that the mechanisms of power are exercised outside, alongside the state institutions, as well as problematizing that the relation of power and knowledge in modern societies aims to produce truths, whose essential interest is the domination of man through the political and economic practices of a capitalist society.
Power is a term that originated from the Latin possum, which means to be able to, the right to deliberate, act and command and, also, depending on the context, the faculty of exercising authority, imposing obedience, sovereignty, or empire of a given circumstance. According to sociology, power is the ability to impose its will on others even if there is resistance, being exercised in several areas such as social power, economic power, military power, political power, public power, among others.3
Power was constituted as one of the subjects that permeated, quite intensely, the work of Foucault, approached in one form or another, in almost all his writings.
Over the years, power relationships between members of the nursing team and medicine can be shown in discourses about the truth of the disease/sick binomial, or of manual/intellectual work. The knowledge/power of medicine has always been related to a real narrative focused on the disease and a work considered intellectual, to the detriment of nursing knowledge, evaluated as predominantly manual and focused on health promotion, especially in the hospital field4.
It is essential to emphasize that knowledge and power have an intrinsic relationship. Knowledge is not neutral, it has a political character that the constitution of a particular knowledge brings added a sense of power. Institutions such as the school, the prison, and the hospital have legitimized the instituted power over the years5.
Historical medical supremacy in hospital organizations exemplifies the relationship between knowledge and power. The assignments of diagnosis, indication of therapy, examination, hospitalization and hospital discharge give institutional political power to the medical professional. In contrast, nursing, numerically the largest category in these organizations, whose knowledge implies attributions in the quality and safety of care and the reduction of the risks of care provided, there is still a low accumulation of power in institutions, in spite of the advances in their autonomy.
The Taylorist-Fordist model of health work organization, especially in hospital nursing, with a striking division between intellectual and manual labor, among nurses and nursing technicians, reveals the relationship of power within this category6,7.
This model of organization, whether in a public or private institution, transmits power relationship between those who prescribe the work and those who perform it, either between professional categories or within the same category as in nursing, in which nurses plan to assistance and the nursing technicians develop their actions linked to the planning.
It is important to emphasize that the problematic of the social and technical division of nursing work has historical roots, because, when laying the foundations of modern nursing, Florence Nightingale instituted that nursing work would be developed by nurses - who would do the manual work of hygiene and developments of other less complex techniques - and lady nurses - that would do the intellectual task of supervision, planning, evaluation. The lady nurses were of more affluent social strata and had refined education. On the other hand, nurses came from less privileged social strata with little education and social treatment8.
Such a social and technical division eventually blurred the view of the general public and the media about the nursing profession because they did not clearly see the roles and responsibilities of each component of that professional category. In this sense, there is a strong discomfort by the nurses when they are confused by the media or by patients, especially in some fact with disadvantages or impairs in the image of the nurse 9.
In the hospital environment, the centralizing figure of the physician is the one who dominates the productive activity and relegates to the other health professionals an auxiliary role, since the assistance model is the biomedical one, centered in the drug and surgical therapy. This medical hegemony determines that the nurse seems to be short of the necessary knowledge in health therapeutics in the view of the other health professionals and the patient, which is untrue10.
According to the theoretical contextualization approached and based on the writings of Foucault, Microphysics of Power1 and Discipline and Punish2, and authors who re-read his works,5,11,12 this study aimed to discuss and analyze the existing micro-powers in daily life of hospital nursing work, according to Foucault's thinking.
The power and the hospital organization
Until the 18th century, the history of the creation of hospitals shows that these institutions sheltered poor people who were dying, and for this purpose, such buildings were built in places far from the city for the purpose of segregation and exclusion, aiming to protect the other people of the contagion, for the unawareness of the etiology and ways of transmitting the diseases1.
Its main function was to provide the isolation and confinement of sick people, aiming much more the protection of those who were outside the hospitals than the care of patients, in such a way that the Catholic Church was the main responsible for the expansion of these institutions that also had the character of orphanage, asylum, and leprosarium13.
From the eighteenth century, a change in hospital architecture took place, whose buildings were built in the urban space with pavilions, with an evolution of the physical space, implying an improvement in the movement of people, also in terms of bed separation, in the isolation of the most severe patients, so the hospital architecture became a healing mechanism, characterized as: "a healing instrument of the same status as a diet instrument, a bleeding or a medical gesture"1:108.
In Foucault´s point of view, when the hospital gained such a conception and the distribution of space became a therapeutic mechanism, the physician became the main responsible for the hospital organization, with the implementation of techniques of disciplinary power and intervention on the environment.
In the Crimean War, in the nineteenth century, in a similar way, Florence Nightingale introduced the vision of nursing performance beyond the patient, extending the scope of action to the environment in the functions of organizing the services of kitchen, laundry, cleaning and storage, controlling them by observation and supervision and hierarchy and discipline in nursing14.
In the contemporary world, it is observed that "today´s hospital is a social organization built in cities, together with the technological transformations of the world of work"15:47. It is also emphasized that the arrival of the modern hospital led to the change of the domain of religiosity to scientific rationality, from which the power system within the hospital began to be exercised by the medical category, which defined the hierarchy of the hospital and established a permanent registration system. Thus, the medical hospital emerged, centered on the individual physician and patient relationship, and based on techniques of disciplinary power and medical intervention techniques on the environment.
Such intervention has remnants of patterns of behavior and discipline in its relationships15,16, observed in the use of the white coat and name tag by health professionals, in the identification of beds and medical records, in the control of equipment, materials and medication, mealtime and visits, on call, distribution of patients due to pathologies, in the standardization of patients´ bed sheets and clothes; all linked to medical power/knowledge.
In Foucault´s conception, power is conceived as a set of social practices and historically constructed discourses that discipline the body and mind of individuals and groups, so such behaviors are built up, embodied and very difficult to suppress. To incorporate changes within this cultural system of precepts and established powers is how to deal with its stable characteristics15.
It should be emphasized that the hospital work process is defined as being "complex and multiple, little articulated, with differentiation and hierarchy between the professional groups involved in the work process and the dominant medical-hospital discourse by the body"15:52.
The historical construction of power within hospital institutions can also be observed in nursing practice. The nurse has the power to coordinate the care sectors, to decide where and in which bed the patient will stay, the time of the bath and the dressing, the place of custody of materials and medicines, the service scale of nursing technicians and assistants, the control of the keys of the cabinets, conditions that translate into the exercise of power.
These disciplinary practices, widely disseminated in schools, the army, asylums, hospitals, and even in capitalist enterprises, are power strategies that become discursive practices that discipline the body, establishing gestures, attitudes, behaviors, and postures; regulate the mind and order attitudes and behaviors16,17. Thus, in the contemporary world, the increase in the complexity of organizations as well as their importance for societies increases the number of studies about power and its relationships in the scope of organizational theory.
Micro-powers and the work of hospital nursing
When analyzing the current situation in the world of work, it is understood that the way capitalist society is organized - socially, economically and politically - establishes control over the means of production and the labor force, increasing the demands on the worker that is subjected to situations under pressure in the workplace that generate risks to their health.
In Brazil, nursing professionals, especially those working in hospital institutions, have recognized long working hours. The shifts allow these professionals to dedicate to more than one productive activity, which can lead to exhaustion and consequent illness and may affect the quality of patient care18. Also, hospital services have a hierarchical and vertical organizational model, which maintains the centralization of power, and a rigid hierarchy19.
This centralization of power in the organization of labor does not occur by chance. The capitalist system interests the worker subordinated to the hierarchical power to fulfill the orders and determinations for the production, inducing him to think that producing more, he will gain more, and remains with low capacity of critic and alienated by the system.
Corroborating the Marxist thought, it is evident that "the laborer works under the inspection of the capitalist, who, by buying this labor force for a day, a week, obtains in exchange the right to exploit it for a day, a week"20:160.
Then, despotism becomes mixed with the manipulation of labor, with the involvement of the workers, through an even deeper process of internalization of alienated labor. The worker must think and do for the capital, deepening his subordination to it21.
Also, the power of convincing capital is verified, which makes the worker believe that he is capable of fulfilling multiple tasks and constructing an image of professional growth22,23.
Such power confers on dominant classes (or dominant areas) symbolic capital, disseminated and reproduced through social institutions and practices, which enables them to exercise power as a referendum in Bourdieusian theory. This is "a kind of almost magical power, invisible, because with it, the equivalent of what is obtained by force is obtained, without, however, uses it"24:982.
In the hospital organizations, the articulated knowledge for the control of bodies is evidenced, that is, the discipline as a mechanism of power. In hospital nursing, the applied discipline in the issue of compliance with the schedules and in the execution of the various procedures performed by the workers is observed.
In Foucault's conception, the objective of power is at once economic and political, and for this purpose discipline is used to diminish resistance and make men docile politically; the discipline manufactures submissive and exercised bodies, docile bodies; discipline increases the strength of bodies (in economic terms of utility) and decreases their potential in political terms by determining obedience2.
In the performance of hospital nursing, it is perceived that the body has to take strength to withstand physical and mental fatigue from day to day, besides to being subject to the economic power that imposes every day new equipment or material to be used under the argument for being the best for the patient. Obey administrative rules, the Hospital Infection Control Commission (CCIH), the Ministry of Health (MS), the National Agency for Sanitary Surveillance (ANVISA) are more examples of submission to the logic of power, with the aggravating of the impossibility to reflect critically on this process of domination.
For this reason, the power relationships generate manifestations of resistance, expressed in subterfuge to an authority or law, in strategies of manipulation, in silences, in relationships with moral codes. Subjectivity would be the liberation itself, through the subject's knowledge of the mechanisms of power25.
Thus, "once there is a relationship of power, there is potential resistance, so we are imprisoned by a homogeneous form of power since the shocks between power and resistances generate new and endless configurations of power"26:120.
However, Foucault's theory also seeks to demonstrate that power carries not only repressive pretensions. That is its negative aspect of intervention, arbitrariness, control, and submission. There is also positive power "We have to admit that power produces knowledge; that power and knowledge are directly involved"27:150.
The fact is that power is a social practice historically constituted and manifested at different levels of society and is not exercised only by the State, but also by institutions and people in the daily life of their relationships.
Knowledge and actions were built to maintain the status quo, privileging the ruling class to the detriment of the social and health needs of most Brazil's population28.
Foucauldian thought illuminated the analysis of nursing practice as historical and a practice based on certain social contexts directly involved with medical knowledge/power and power relationships in society as a whole, whether in the social, political, cultural and economic areas.
It is recommended that members of the nursing team seek to grasp the knowledge produced around organizational change and to use it to exercise power in certain areas and reconfigure their positions in the political arena of organizations.
The need for mobilization and collective involvement for the processes of change to take place, because it is up to social actors, with all their singularities and interests, not only to define priorities but also to construct strategies and mechanisms for overcoming contradictions in the world of work that feed power relationships.
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