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Judgement on the road to advocacy

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VOL: 97, ISSUE: 12, PAGE NO: 35

Phil Barker PhD RN

Twenty years ago, some nurses at an English psychiatric hospital were dismissed for their part in an uprising. They harmed only themselves, but the fire from their insubordination lit up the psychiatric sky, albeit briefly. Their senior nursing officer answered their call for support and was also dismissed.

Twenty years ago, some nurses at an English psychiatric hospital were dismissed for their part in an uprising. They harmed only themselves, but the fire from their insubordination lit up the psychiatric sky, albeit briefly. Their senior nursing officer answered their call for support and was also dismissed.

I came to know Paul Walsh, that SNO, quite well. We spent many an hour discussing psychiatric power games: especially nurses' potential for powerlessness.

The great offence committed by Mr Walsh and his colleagues was listening to a patient as if she was a person. They had been instructed to administer treatment to a woman who was clearly reluctant to have it and, on reflection, they realised she was probably right.

These were early days in the professionalisation of psychiatric nursing and the development of concepts such as advocacy, empowerment and working in partnership. If they had defaced a coin of the realm or burned the Union Jack in front of Buck House, they could not have behaved more unconstitutionally. Medical orders were not to be trifled with.

The need to confirm the power relationship between 'us' (professionals) and 'them' (patients) was best achieved by making an example of the nurses. And so they walked the road of no return.

Recently, someone asked me for advice about a vulnerable patient in similar circumstances. A medical treatment had been prescribed, and was rejected. The patient had the wisdom of hindsight - he had received it before, knew the damaging after-effects and wanted no more.

The doctor had the wisdom of 'evidence-based practice' - he knew what worked for other people, albeit anonymous ones. God (or at least science) was on his side.

The nurses soon acquired a powerlessness that matched that of the patient. The more they tried to support him, the more impotent they became.

Weren't they meant to be the patient's advocate? They couldn't decide which metaphor was most fitting. Was their advocacy falling on stony ground, destined to wither; or were they running, full tilt into the old brick wall of institutional resistance, only to emerge with bloody noses?

Their dilemma reminded me that advocacy has no place in nursing. Nurses have relationships with patients and therefore have feelings for and about them.

We need advocates who aren't involved with us, but will represent us steadfastly. Where there is serious conflict in human affairs we need the judgement of Solomon, not rational evidence.

The only way to resolve conflicts between professionals and patients over the 'right' treatment is to take the third way.

Every psychiatric patient should have access to an independent advocate, should he or she desire one. It will be an expensive service, but will also be far more realistic than calling on Solomon.

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