Critical emancipatory reflection on a practice-based issue in relation to nurses’ communicative role with unsatisfied clients in Chinese hospitals

From my personal experience, respect, collaboration, equality, and knowledge are crucial values in my life. Historically, these values came from my family and work experience. I am the eldest in the family. When I was young, I used to take care of my younger sisters and, therefore, I developed a sense of sharing and respect for one another. Moreover, I have been working in a big-scale hospital for 16 years, and I became a nursing specialist and the manager of ICU in 2009. I am a respected member of the health-care team, especially the nurses, who often seek my assistance in solving complex clinical problems.

According to the Quality Improvement Division,³ “patient-centred, safety, effectiveness, timeliness…” have become the new requirements for medical services. To ensure better medical service and patient outcomes, it is crucial to build a multidisciplinary team for patient care and outcome.^{1, 4} Collaborating with doctors, therapists, and other medical staff, I believe I can deliver a better patient-focused service. Furthermore, I consider that if I show people how to be respectful, treat others as equal, and work collaboratively, they might treat me in the same way. These mentioned values motivate me to move on.

If there are some unsatisfied clients admitted into the ICU, as a nursing manager, I would follow these cases with the doctors and meet family members in the communication room. However, sometimes, patients’ family members prefer to talk to the doctor than to me. I have even experienced worse situations, such as rude behavior from family members. Honestly, I feel embarrassed and upset because they do not respect my knowledge and skills. I would like them to know that I am just as worthy of acknowledgment as doctors. However, I do not think that they would listen to me.

I act according to my belief that the patients’ family members and the doctors should respect my opinion. I take part in the communication meeting in order to provide further help for them. However, I feel disappointed that family members might just want to find the most reliable resource from the doctor to change the situation. I am indignant that family members think that only the doctors know everything. In fact, nurses stay with patients for 24 hours in the ICU. Nurses are the ones who complete most of the medical treatments and communicate with the patients. All nurses who work in the ICU are professional and skillful.⁵ Very often, after a doctor had explained the outcome to a patient’s family, the nurse would stay for a while to ensure that family members understand the information given and would provide continuous support to them. Nurses observe and communicate with patients, record information of the equipment, and read the human response, including the physical and psychological changes of the patient.⁵ Above all, nurses understand the clients’ needs and emotions in the first place. In most cases, I can get this information during the morning ward round. I act as the interface between the family and the hospital system. However, I do not think that patients’ family members understand how much effort I have to put in.

As a nursing specialist, I develop my experience and confidence in my work place. In 2008, I received specialist training in Hong Kong. I found that clients respect both nurses and doctors in the hospital of Hong Kong, and I think it should be the same in my ward. Nurses and doctors have different groupings in the work place.⁶ I am pursuing my master’s degree in nursing in Ireland, and I notice that Irish nurses have higher social status⁷ than Chinese nurses.⁸ If nurses are treated unfairly, they would easily lose job satisfaction and motivation in the work place, resulting in shortage of nurses.⁸ As a nursing specialist and manager, I have the responsibility to promote work equality among Chinese nurses.

From Fook and Gardner,⁹ critical social theory recognizes that power, or domination, is personally experienced and structurally created. This is because individuals are social beings and their personal characteristics are formed and re-formed during interactions with the real world.⁹ In this sense, I care about respect from my colleagues and clients because I am enthusiastic, possess high educational background, and have rich working experience. Traditionally, nurses seem to be the oppressed group with lower social status, whereas doctors have dominating power. However, the development of nursing care and nurses’ professional competencies is aimed at promoting the position of nurses and their social status.¹⁰ According to the critical social theory, Fook and Gardner⁹ claimed that individuals can take part in their own domination, by holding self-defeating beliefs about their place in the social structure, their own power, and possibilities for change. For me, I want to make an effort to provide effective services for my clients and reflect the value of a nurse. I hope doctors and clients can clearly and distinctly recognize the achievement of nurses and eventually change their view of the traditional relationship between the dominant expert and the oppressed nurse.

As reported in previous research, if effective social change is to be achieved, it must occur on both personal and collective levels.⁹ This means that I need to make the change as well as work together with other nurses in order to inform our effort and achievement in the work place. For collective levels, it involves an exchange of views and ideas that consider the perspectives of all the collaborators, irrespective of whether agreement is reached in the interaction.¹¹ Additionally, communication and dialogue are the key elements for practices to be effective.¹² In order to minimize misunderstanding, especially for unsatisfied clients, mutual respect is essential and doctors, nurses, patients and even family members should reach a consensus.

Critical emancipatory reflection helps me to analyze the constraints, including historical, sociocultural, political, and personal aspects. In my experience in a communicative role with unsatisfied clients, family members believed that doctors can use their knowledge to overpower me. I consider that the historical constraints are those that have been perpetuated from many years ago, when doctors were indisputable and no one dared to question them. Historically, doctors have professional power in the hospital hierarchy, and nurses only work as servants to them⁵. Doctors focus on the effectiveness of treatment via physiological parameters. Nurses emphasize caring, such as pain care, skin care, mouth care, wound care, and psychological care. These “clinically superficial” areas of knowledge are perceived and recognized poorly by doctors.^{5, 13}

Sociocultural constraints also result in this issue. In China, most nurses did not receive higher education for the past decades; they became nurses after graduating from high school.¹⁴ According to the critical social theory, knowledge comes from empirical and constructed experiences.⁹ Although nurses can get experience from clinical practice, the low implementation levels of educational policies has made it hard to achieve further professional qualifications. This is the reason why I pursued further education abroad, even though I am 38 years old. I believe that by working hard, I can be a role model to young nurses. Meanwhile, a number of medical universities have already set up advanced nursing education programs in China.¹⁵ Nowadays, clinical nurses have developed their professional knowledge and study further in different specialist areas. As on date, 60% of nurses in my hospital have qualified with bachelor’s degrees. However, I realize that patients and their family members and are still strongly influenced by historical factors. Most people tend to have the mindset that doctors with higher educational background are the only decision-makers. I think that doctors feel it is unnecessary to get help from a nurse in certain situations, even if she is willing to provide assistance. I also think that family members did not see me equally within the hierarchy.

The political constraints are decision-making and division of power in my work place. In clinical practice, doctors and I both use the knowledge gained from the biomedical model of health and illness. I feel that power and authority have been used to preserve the hegemony of the doctor’s position in the medical team. However, Coombs and Ersser⁵ found that medical hegemony had become a barrier to interdisciplinary working in the ICU. Moreover, it was reported that hegemony may lead to clinical nurses being unable to take part in the decision-making process, and it had fundamental ramifications for multidisciplinary cooperation in the ICU.¹⁶ The research demonstrated that nurses and doctors used and valued different types of knowledge and adopted different roles in clinical practice.⁵ Generally, nurses take care of the patient for 24 hours a day on a one-to-one level in the ICU. Therefore, nurses should know what is happening to patients as a result of the continuous care. Very often, I found that if some emergency had occurred to a patient, the doctors would speak to family members. As a manager, I always remind the nurses that they should be the ones who contribute the most in terms of updating and providing information on the patient to their family members. In order to ensure that family members can understand the information given by doctors, nurses could provide support whenever help is needed.

Finally, the personal constraints relate to my inability to assert myself in that situation because family members feel unsatisfied with the medical service. I hold the view that whatever I do is right and it is in the best interests of my clients. However, if family members feel unsatisfied, there must be some errors during the provision of medical service. Therefore, I may just act according to my own opinion and may unwittingly disadvantage the service users as a result. Another reason is because I fear being hurt. In China, there are some negative reports about unsatisfied patients acting violently toward medical staff. Hesketh et al.¹⁷ reported that there were three cases of unsatisfied patients stabbing medical staff in China in March and April 2012 alone. When I saw the report in the media, I was scared whether I would have the same experience. As a result, I lost the confidence to express my own opinion when clients feel angry. I think it is normal to doubt myself at times. I realized that the unsatisfactory outcome is way more than my personal inability to make the situation better; rather, it relates to the constraints operating in this situation, such as the social factors, including lack of trust and tendency of violence.

Actually, I realized that it is not always possible to live by these values of respect, collaboration, knowledge, and equality in my work setting although I put in these values since I started my work. From then on, I reflected on my previous experience and I started to think differently. I like my job and enjoy having the sense of achievement from my work. It is possible to understand the expectation of patients’ family members and predict their demands. Patients’ family members are sensitive, vulnerable, and helpless when they are making choices of life and death of the patient. The rude manner in which they used to respond to me could be affected by previous negative experiences or they may just be expressing their emotions. In the Chinese ICU, most doctors and nurses usually work about 10 hours every day. The doctors are very busy in their routine jobs while salvaging the relationship with unsatisfied clients. Thus, nurses are not welcome to join the meeting with the family because it is time consuming for the doctor to discuss the patients’ conditions in detail with me before the meeting takes place. Furthermore, the doctors do not want any disagreement from the medical team while communicating with unsatisfied clients, which would lead to misunderstanding and make things worse.

According to Jarvis,¹⁸ I need to renew my awareness and communicate actively. Firstly, I am required to develop clinical skills and knowledge over a professional lifetime. Secondly, developing attitudes and attributes allows me to care for and communicate with patients in a sensitive way. Learning communication skills and specific knowledge makes me develop a positive change with reference to my clients and doctors as well. Thirdly, for unsatisfied patients, I should inform the clients some information upon ICU admission, in case they carry a high expectation of recovery for critically ill patients. In China, although there are some negative reports about the poor relationship between patients and health-care providers, Cass et al.¹⁹ claimed that miscommunication often went unrecognized, including the lack of biomedical knowledge, inappropriate timing, and vague content. It is easy to understand that family members have less biomedical knowledge and have difficulty to accept the poor outcome of their family member. However, as long as I try, there is no limit to what I can achieve to build a harmonious relationship between patient and healthcare provider. On the other hand, there might be someone who feels upset or unsatisfied with my performance regardless of how professional or hardworking I am. It may or may not be my fault, but that is usually not the point. It is important for me to act quickly and according to their wishes. Following some effective measurements, the concerned persons will be more likely to help change their mood and turn that dissatisfaction into satisfaction. Once a negative issue happens, as a manager, I should be ready to lean back and think about nursing management: provide this feedback information to my team, make sure the team members learn from the mistake, and try avoiding it in the future.