Jewkes R, Abrahams N, Mvo Z
CERSA, Women's Health, Medical Research Council, Pretoria, South Africa.
Soc Sci Med. 1998 Dec;47(11):1781-95. doi: 10.1016/s0277-9536(98)00240-8.
Nurse-patient relationships are a substantially neglected area of empirical research, the more so in developing than developed countries. Although nursing discourse usually emphasises "caring", nursing practice is often quite different and may be more strongly characterised by humiliation of patients and physical abuse. This paper explores the question: why do nurses abuse patients, through presentation and discussion of findings of research on health seeking practices in one part of the South African maternity services. The research was qualitative and based on 103 minimally structured in-depth individual interviews and four group discussions held with patients and staff in the services. Many of the patients reported clinical neglect, verbal and physical abuse from nursing staff which was at times reactive, and at others, ritualised, in nature. Although they explained nurses' treatment of them in terms of a few 'rotten apples in the barrel', analysis of the data revealed a complex interplay of concerns including organisational issues. professional insecurities, perceived need to assert "control" over the environment and sanctioning of the use of coercive and punitive measures to do so, and an underpinning ideology of patient inferiority. The findings suggest that the nurses were engaged in a continuous struggle to assert their professional and middle class identity and in the process deployed violence against patients as a means of creating social distance and maintaining fantasies of identity and power. The deployment of violence became commonplace because of the lack of local accountability of services and lack of action taken by managers and higher levels of the profession against nurses who abuse patients. It also became established as "normal" in nursing practice because of a lack of powerful competing ideologies of patient care and nursing ethics. The paper concludes by discussing avenues for intervention to improve staff-patient relationships.
护患关系是实证研究中一个被严重忽视的领域，在发展中国家比在发达国家更是如此。尽管护理话语通常强调“关怀”，但护理实践往往大相径庭，其特点可能更多地表现为羞辱患者和身体虐待。本文通过展示和讨论南非部分产科服务中关于就医行为的研究结果，探讨了这样一个问题：为什么护士会虐待患者。该研究是定性研究，基于对该服务机构的患者和工作人员进行的103次结构松散的深度个人访谈以及4次小组讨论。许多患者报告称受到了护理人员的临床忽视、言语和身体虐待，这些虐待有时是反应性的，有时则是习惯性的。尽管他们将护士对他们的治疗解释为少数“害群之马”的行为，但数据分析显示，其中涉及包括组织问题、职业不安全感、认为需要对环境“施加控制”以及为此批准使用强制和惩罚性措施等一系列复杂的问题，还有一种认为患者低人一等的潜在观念。研究结果表明，护士们不断努力维护自己的专业和中产阶级身份，在此过程中对患者使用暴力，以此来制造社会距离，并维持身份和权力的幻想。由于服务缺乏地方问责制，以及管理人员和行业高层未对虐待患者的护士采取行动，暴力行为变得司空见惯。此外，由于缺乏强大的患者护理和护理伦理竞争观念，暴力行为在护理实践中也被确立为“正常”现象。本文最后讨论了改善医患关系的干预途径。
