Critical emancipatory reflection on a practice-based issue in relation to the working relationship between doctors and nurses in China

I have been working in the Urology Department for >8 years, and normally, I am in charge of >10 postoperative patients on a daily basis. My work is fully occupied because of the overloaded intravenous transfusion prescribed for each patient, resulting in lack of time for me to interact with patients. Some of the patients could eat a normal diet, but doctors still prescribed too much nutritional intravenous fluid for them. I used to recommend doctors to reduce unnecessary transfusion treatment; however, they would refuse to do so. When I expressed my concerns to the doctors, they would respond with impatience and even label me as a troublemaker. Eventually, their tactic effectively silenced me. I felt guilty and upset as I was incapable to meet patients’ needs in time. Meanwhile, I felt powerless, frustrated, and thwarted as my voice was not heard.

This practice-based issue is a common occurrence, and there does not appear to be enough attention given to it.⁵ I feel it is worthwhile to explore this issue in terms of fulfillment of patient-centered care. To unearth my involvement in this scenario, I look at my part with the eyes of an observer standing back from the action, and I realize that this situation is awkward since the nurse– patient relationship is very negative in this scenario. For example, if I come across a cancer patient who is in tears, undoubtedly, I should spend a period of time just being there to support the patient’s needs. However, I might have to head to another task when the call bell rings, since I need to complete so many transfusion treatments.

In this case, I realized that I was aware of my patients’ psychological needs, but I did not take immediate action, which is incongruent with delivering patient-centered care.⁶ However, staying with the patient is in conflict with task demands. These irreconcilable demands made me feel embarrassed and upset, as I believe failing to meet the patient’s individualized needs is not delivering appropriate psychological care.⁷ Darbyshire et al.⁸ clearly state that “nurses should adopt the role of the sentinels of yesteryear and systematically ‘watch’ for occurrences of substandard care” (p. 2). Ignoring patients’ feelings and letting them down are inconsistent with compassionate care and conflict with nurses’ values, such as compassion and empathy, leading to care erosion.⁷ Additionally, it seems as though I act according to the belief that completing various tasks required by my work setting is of top priority. Nonetheless, as a nurse, I am expected to be competent to provide patient-centered care in my practice,⁶ which not only can enhance patients’ satisfaction in terms of care but also can promote their sense of well-being and help to establish a therapeutic environment.⁹ I therefore agree with Priest¹⁰ that, as a nurse, I should provide “expressive care” for patients rather than “instrumental care”. Hence, it is my responsibility to recognize patients’ needs and assess the risk to fulfill the desired healthcare outcomes. I felt guilty not being able to spend time interacting with and comforting the patients as needed.

Furthermore, I believe it is my obligation to advocate patients’ interests and express my concerns to doctors.¹¹ Overuse of intravenous infusions may put patients in danger, lead to patients losing their appetite, and cause unnecessary financial burden.^5,12 However, because of the doctor–nurse hierarchy, I found that there is no avenue for me to express my concerns for my patients. Since teamwork and collaboration are essential to ensure high-quality health-care service delivery,^13,14 I put much value on interprofessional collaboration within my health-care team. Nevertheless, I found that there are few opportunities of utilizing my specialism to contribute to the patient care plan. I routinely scrutinize and execute medical prescriptions and communicate with doctors if I have any query about the prescriptions. I always respect them and believe that we should have mutual respect. However, I am not responded to in the same way and my concerns about patient safety are not heard and respected. I hoped to collaborate more with doctors,¹⁴ but I felt like I was just a robot that implements their orders since no one would value my voice. Sometimes, patients complained about the endless intravenous infusion to me and I wanted to question doctors’ decisions, but I did not because I worried that if I insisted on questioning their orders, it might seem as if I were challenging their knowledge. I also feared that my opinions were not the common beliefs within the team, so they would perceive me as an eccentric and antipathetic colleague. I felt it was pointless to discuss and argue with them anyway. Therefore, my self-efficacy was constrained strongly by these powerless feelings.

After informing my practice-based issue, it is evident that there are contradictions between my espoused and enacted worldviews, which have been in conflict within me for years. Schön¹⁵ pointed out that there is a gap between espoused and enacted values for many professionals. As indicated by Fook and Gardner,¹⁶ the most effective way of change is to explore and learn what worldviews actually rule your practice and how they are different from your espoused theories. This could be achieved by using the critical reflection theory, which integrates analyses of personal values and beliefs regarding the way power is exercised and the impacts of socially dominant thinking accordingly.^17,18 Briefly, critical reflection would allow me to unearth my hidden assumptions, which in turn would help me to bring about practice changes.^19,20

From my story, I can see that my espoused values and beliefs are respect, collaboration, compassion, and equality. Historically, these values are rooted in my large family, which has a strong belief in these values, requiring cooperation with and caring for one another. In addition, my 17 years of schooling and 10 years of work experience also have a significant impact on me in upholding these values, leading me to believe that as a senior nurse, I should respect and collaborate with coworkers. As stated by Shahriari et al.,²¹ compassion and collaboration are the key values of a nursing professional; thus, I bear this in mind and try to uphold and embody these values in my working relationships with doctors. Similarly, I hope doctors will treat me in the same way and communicate with me in a professional and respectful way, as well as value my knowledge and skills.¹⁴ Yet, this scenario illustrates that I am not an equal member of the team and I am powerless because of the doctor–nurse hegemonic structure, which is at odds with my “espoused theory”.¹⁵ Consequently, I am not always able to maintain my rights for my espoused values to be reciprocated in the face of enacted values.

It is reported that teamwork in the health-care system is essential to ensure high-quality health-care service delivery,^14,22 but if medical professionals in the team do not value equality and collaboration, then these values cannot be exercised.³ Interprofessional collaboration only exists where practitioners are willing to trust coworkers and recognize their knowledge and skills.^22,23 However, in my story, doctors utilized their power to exercise superiority over me. My willingness to establish rapport and share these values with them was inspiring, but the reality was far from these ideals. Evidently, effective interprofessional collaboration has not filtered down in my workplace. I believe that values including respect, collaboration, and equity should serve all stakeholders’ interests in the multidisciplinary teams within hospitals, since it is beneficial for all of them, especially for patients.²⁴ It is imaginable that if every professional in the hierarchy endorses these values, then everyone’s awareness will be in check, and my job satisfaction will be much higher.

When I explore tensions between the doctors and me, it becomes necessary to classify theories related to power. Modernists believe that power is owned by someone who is at a higher position in the social structure, while postmodernists view power as knowledge.¹⁶ To explore the power relations and constraints that are involved in this scenario, critical emancipatory theory, which is based on the work of Smyth³ and Street,²⁵ is selected. This theory will help me to critique the status quo in the power relationship and increase my awareness of a sense of personal autonomy, and ultimately, will bring about a positive change in practice.^3,19 Essentially, I found that my sense of powerlessness could be related to various constraints.

The cultural constraint has deeply influenced my actions in practice. Specifically, China is an ancient country and has been deeply affected by Confucianism for >2000 years. The Confucian culture is characterized by a strong legacy of patriarchy²⁶; consequently, paternalism is prevalent within Chinese organizations.²⁷ It is unsurprising to see that doctors exercise paternalism within organizations.^28,29 Hegemony, which refers to the demand for undisputable compliance from subordinates, is perceived as one of the significant characteristics of paternalism and is prevalent within organizations; as a result, subordinates’ autonomy is not highly valued.²⁸ Likewise, a doctor-dominated culture has been formed in health-care settings, and doctors have exercised a disproportionate degree of power and hegemony over nurses for a long time, resulting in a tradition of nurses being subservient to doctors.²⁹

Moreover, due to the pervasiveness of patriarchal culture in Chinese societies, the notion of masculinity is entrenched.²⁶ In the health-care system, males have a vested interest as they dominate medicine.³⁰ Doctors’ professional knowledge is acknowledged and valued, while the nursing profession is undervalued;³¹ i.e., nurses’ (women’s) work is generally less appreciated than doctors’ (men’s) work.³² Hence, doctors have enjoyed plenty of professional power in the hospital hierarchy, and the nursing profession has culturally compromised its professional standing.³³

The historical constraint also affects my responses in communication with doctors. Although the health service has been nationally reformed and calls for developing a climate of collaboration, team building, and equality within hospitals,³⁰ this situation has not changed substantially over the decades.^22,33 Molleman et al.³⁴ demonstrate that doctors commonly hold a strong view that collaboration might weaken their power over their work; thus, doctors endeavor to maintain the status quo to protect their privileges. Unfortunately, health-care systems have been tolerating ineffective interprofessional collaboration, and measures have not been taken to improve these unacceptable conditions,³⁵ although Coombs and Ersser²² and Baggs et al.³⁶ argue that this medical hegemony continues to impede the nurses’ contribution in decision-making processes. This is proven very well in my story, when the doctors’ prescriptions were not allowed to be questioned and challenged. Now, I realize that my interactions with coworkers have been deeply influenced by this historical constraint.

The social constraints can be identified by applying the symbolic interaction theory, which allows individuals to understand how they interact with people or professionals within the hierarchy.³⁷ Since doctors have a higher social class, receive higher salaries than me, live in luxury apartments, and maintain their own social circle, I believe that they do not treat me as their social equal. All these aspects serve as a social constraint to my practice in my workplace, where there is grandstanding about the equal contributions of members.

Concerning the political constraint, it is essential to understand that the vivacity of politics is deeply rooted in the structure of modern health-care organizations and is about the power plays engaged in by individuals.³⁸ It is particularly hard to achieve any sort of equality owing to bureaucratic and top–down supervision and control.³⁹ We cannot disagree that organizational support plays a greater role in establishing and sustaining healthy work environments than individual attributes;³⁸ therefore, the urgent need for bringing in change should not be constantly neglected by the health-care system. Unfortunately, we are still wearing nurse caps, which – in my opinion – is a form of power play within my organization.

Economically, health-care systems in China have been suffering from shortage of nurses for a long time due to many reasons, such as lack of investments in nursing education, high turnover rate among nursing staff, and so on.^40,41 From the story described herein, it can be seen that I was in charge of >10 patients on a daily basis, resulting in a lack of time to care for patients. Indeed, it is challenging for organizations to balance staff sufficiency and budget savings in the current economic situation. If these situations are not paid enough attention, holistic care delivery and patient safety could be threatened as overloaded nurses would lose a sense of agency, treat patients as objects rather than people, and often overemphasize the importance of getting the work done.^7,42,43,44 Consequently, patients’ communication needs may be ignored or even treated as an irritant⁴⁴; so sufficient nursing staff are needed to enable me to provide holistic patient care in a flexible and individualized manner.

Personal constraint should, however, not be neglected. I am an introverted person by nature, feeling shy and anxious to speak in front of people. Additionally, in the medical environment – where medicine is an ever-changing science undergoing continual development,⁴⁵ I must face the fact that my knowledge is inadequate and outdated over the past years, and I have become unconfident in my current professional role. Moreover, a lack of communication skills also contributes to my confidence deficit.

By confronting all these constraints in relation to my practice issue, I enter the final stage, namely, “reconstructing”, as described in Smyth’s model. Now, I realize my work contexts were so complicated that I was not the only determinant of the outcome. I ultimately understand that apart from my personal inability to make the situation better, many other factors can also contribute to this unsatisfactory outcome. According to the socialization theory, a professional identity could be internalized and developed via the acquisition of knowledge, skills, and ethical standards so that a professional role could be achieved,⁴⁶ and the achievement of effective social change must depend on individual change.¹⁶ Thus, it becomes especially important for me to equip myself with knowledge so that I can alter the doctors’ view that nurses are maidservants and know nothing. To remove personal constraints and gain confidence to fulfill my professional role, I must upgrade my knowledge and skills (especially, the communication skill) constantly. Furthermore, I need to create a lifelong learning habit to promote both personal and professional development.⁴⁷

Communication and dialogue between doctors and myself are important so that new shared understandings can be created.¹⁶ Taylor³ emphasizes that by setting a research group within organizations, the combination of reflective processes and action research can assist in creating effective communication and collaboration between coworkers. This ultimately facilitates the process of raising critical awareness of practice problems by the group members and uncovers constraints. Currently, I have finished my study in Ireland for the degree of Master of Science in Nursing and have gained the confidence and competence to conduct research in the future. A qualitative reflective research approach is an ideal way to bring about changes in practice since awareness, new insight, and potential for improvement could be produced by the research.³