Nurses, Patients and Families The Negotiation of Order on Acute Care Wards

Abstract

<p>In this thesis, the symbolic interactionist, control and negotiated order perspectives provide the theoretical framework within which to analyse how workers seek and maintain control over their conditions of work.</p> <p>The thesis is a secondary analysis of participant observation data from a primary study conducted on four wards of an acute care teaching hospital. The nurse-client relationship is the focus of investigation, with the patient viewed as the primary client and the patient's family conceptualized as a secondary client.</p> <p>The nurse-patient relationship is investigated, examining situations in which patients come to be perceived as behaviour problems by nurses and the ways in which nurses react to regain control over these problem patients. A group of 102 problem patients is analysed, and several distinct problem categories are discovered. Patients in each category are analysed according to age, sex and diagnosis. Sex is found to be a significant determinant of being perceived as a problem, with female patients comprising a large proportion of the problem group. Unlike other studies, age is not a determinant of being perceived as a problem in these data. Nurses' techniques of control are investigated. Implications of these techniques with respect to institutional goals of total patient care and psychosocial care are discus fled. It is see that patients who are perceived as behaviour problems are very likely to be defined as having social and emotional problems and to be seen by a psychiatrist or social worker.</p> <p>The relationship between nurses and patients' families is examined. It is argued that problems of control over families are heightened in the study hospital as a result of institutional policies of open visiting and family participation in patient care. Analysis of 46 problem families reveals the use of altercasting as a technique of interpersonal control. Nurses cast families into three roles -- visitor, worker and patient. Nurses prefer the visitor role but when this breaks down they cast the relative in a combined patient/worker role, with the patient role the preferred one. This contrasts with other studies which indicate nurses more commonly cast relatives in worker roles. It is argued that the emphasis in the study hospital on psychosocial care encourages the imputing of the patient role to the problem relative and provides the possibility of increased social control over clients.</p> <p>Information control is analysed and found to be pervasive and taken for granted in this setting. Difficulties created for nurses by information control are given particular attention.</p> <p>Patient satisfaction with nursing care and information is examined. High levels of satisfaction are found, placing in perspective the focus on problems which is taken in the thesis and raising questions with respect to policies of information-giving that would be most beneficial to patients.</p>