Despondent nurse practitioners - disabling postmodern punishment

May 19 2008

The essence of postmodernism theme is that of an epochal shift, discontinuity, or rupture with modernity, bringing new social conditions and sociological principles with it (Baudrillard, 1988). Postmodernism views that the authority and status of the medical professionals does not exist anymore in the area of health care consistent with the postmodern message about the deconstruction of traditional centers of postindustrial authority (Cockerham et.al, 1997).

For example, postmodern theorists advocate deinstitutionalization of the mentally ill in the United States (Pescosolido and Rubin 2000). A recent publication on fitness and the postmodern self has described how people can pursue physical fitness to achieve a degree of independence from the medical profession and avert risks to their health with a sense of self (Glassner, 1989). More recent postmodern literature (Varga,2005) analyze the physical body as a sacred object under conditions of hypermodernity and describe the rise of alternative forms of healthcare as a postmodern view of culture (McQuaide,2005). A postmodern literature in nursing elucidates three dialectical layers of a postmodern ethical cornerstone, namely, subjective immersion, objective detachment, and relational narrative. The move from immersion to detachment is a turn from communitarian to rational ethics in nursing practice, replacing traditions with post modern universal principles (Gadow, 1999).

Thus, postmodernism utilizes the changing relationships between the health care professionals and patients, the recent public awareness and skepticism and legal backup to corner the medical professional's authority in their own domain. Postmodernism encourages practices like racial profiling to reduce errors improve efficiency of a system (Harcourt and Bernard, 2007).Postmodernism views that the individual is ultimately responsible for his or her own health and medicine has limitations. Thus, postmodern view of medical sociology defies and dislodges all the sublime role of nurses, the importance of nursing care, the ethical conflicts, emotional conflicts of nursing care arising out of extremely hostile patient situations like 'do not attempt resuscitation orders', 'end of life care', 'psychiatric nursing care' and 'intensive care unit nursing' in contrast to the first accepted theory in medical sociology of Parson (1951) that explains the concept of the sick role , the behavior of sick persons and their normative obligation to seek professional care.

Postmodern Punishment

A Post Modern Society is a one where there is no one, single, universally agreed principle of knowledge or organisation. Postmodernism does not accept punishment as a transformative practice and is based on self reference. Patient's perceptions of health care, particularly disagreements of various kinds with doctors and nurses have caught the attention of every one since 1980s and these disagreements have turned often into legal complaints (Annandale et.al 1998). These disagreements turned legal complaints have evolved into long medical litigations and punishments. Strangely, the medical or nursing process is a series of steps that lead to a usual expected conclusion called 'the cure'. Whereas, the legal process of medical litigation is a conclusion called 'the negligence' for which a series of steps are formulated towards the conclusion (Annandale et.al 1998).

Rising litigations against nurses and the return of punitively orientated punishments (Pratt, 2000) have given rise to a doubt if key defining characteristics of western penal modernity have been replaced with a qualitatively different postmodern penality in medical litigations. The increase in frequency of medical litigations can be attributed to five main factors; Greater public awareness of medical errors, Loss of confidence in health care delivery system, Technological advancement, Increased expectations of medical care and Reduced interest of the plaintiff in accepting compensations outside the preview of the jury due to higher compensation chances through jury. (Brennan, 1991). The Court has been found to award three types of damages in such medical litigations; 1. Compensatory damages - for an injured plaintiff's economic losses, costs of health care and lost wages. 2. Compensatory damages - for non economic losses including pain, suffering associated to injury and 3. Punitive damages - in cases where a defendant (here, a nurse) has been found to have acted in a fashion, demonstrating negligence with no regard for the patient's well being. Punitive damages aim to punish the defendants (nurses) and are very damaging to the nurses. Thus, today, medical malpractice law is part of tort, or personal injury law. The standard used to evaluate whether the breach in question rises to the level of negligence is called 'medical custom'. Medical custom is the quality of care expected of a medical professional. This custom is primarily based on the testimony of experts in the profession and practice guidelines. There has been a shift in recent years from the custom towards a more independent determination by the court (Brennan, 1991). Although, medical malpractice system functions theoretically well, the actual operation of the system is much more complicated.

Nurse's problems in post modern medical litigations

One should understand that there is a distinction between medical malpractice litigation and patient safety awareness, although they are interrelated. If is true that medical malpractice litigations threat makes a nurse more accountable. But, there are always situations in nursing practice which are beyond the control of human limitations. For example, the law always target individual nurses for their negligence. During the process of litigation, the circumstances surrounding the negligence are not probed into, especially the errors that arise of faulty systems in which proficient nurses work. Medical litigation threat diminishes interest of the nurse in patient safety/welfare activities, because they are offered no legal protection for the errors that may be an accidental outcome of the patient welfare activities.

Moreover, it is absolutely difficult on the part of the jury to have an absolute scale of negligence in nursing practice. One of the most difficult realities of the medical practice is that, despite efforts and good care, some patients will die, either due to the nature of the disease like cancer, AIDS etc, or due to developments related to patient's age, health conditions etc. Although technological advances in health care bring extended and improved quality of life, the ability of these technologies to prolong life beyond a meaningful point has raised ethical issues, especially in "nothing more can be done" patients (Mc Skimming et.al,1997). A nurse today is punished with a judicial contradiction of causing harm while acting for patients' good (Brennan, 1991).Thus, medico-legal procedures should end in punishments that are corrective in purpose and not just punitive, placing the adverse medical events as an exclusive event with reference to the field of medicine/nursing, where, patient care is the main element and not patient harm.

Conclusions

Although the dominance of economic interests in health care and their subsequent influence on service delivery and health care practices has the potential to increase unintended patient harm, there should be no such thing as a postmodern penality (Hallsworth, 2002), especially in the nursing domain when job stress and burnout have already a far reaching effect both for nurses in their clinical practice and personal lives.. The challenge for nurses and the nursing profession is to develop strategies to refuse to give in to the dominance of economic interests leaking out of corporate health care over the need to prevent harm (Heggen et al, 2004). With a shocking 1, 26,000 unfilled nursing positions in 715 hospitals in US (Trossman, 2002), it is vital to protect the interests of nursing professionals from such punishments treating nurses on par with other criminals kindled by postmodernism in the larger interests of the profession and the society .

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• Copyright 2008- American Society of Registered Nurses -All Rights Reserved

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