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Power and empowerment: Critical concepts in the nurse–client relationship



Two key concepts in health promotion within the nurse-client relationship are power and empowerment. Theorists and researchers have not achieved consensus on how they are to be defined and addressed. However, both power and empowerment are recognized to occur at macro and micro levels, and as such need to be addressed at each level. Using a critical nursing perspective, this article explores these concepts it identifies concerns that arise around power and risks that arise in empowerment practice. Nurses are challenge to develop a new way of seeing empowerment practice, and encouraged to focus on 'being with' clients, rather than 'doing to' them.
Within my own practice I have witnessed
how power is enacted within the nurse–
client relationship. As well, I have seen how bar-
riers exist that can impede empowerment prac-
tice. Working at a health centre for people
experiencing homelessness, I have had the
opportunity to observe and be a part of a prac-
tice model that is based on the concept of
empowerment. In this setting individuals come
to receive healthcare, but also may receive assis-
tance with the necessities of life. However, there
are a limited number of system resources to
provide to clients, and nurses are therefore the
gate-keepers for the system. Within this rela-
tionship power becomes clearly delineated as
nurses hold, and may refuse, the very necessities
required for individuals to survive.These same
nurses are then encouraged to empower clients
and address the inequalities that perpetuate
their marginalization. How are nurses to
empower these individuals while at the same
time wielding power over them? In this manu-
script I will critically analyze the concepts of
power and empowerment, specifically within
the context of the nurse–client relationship. In
doing so, some questions may be answered, and
others will likely be raised.
This manuscript will apply a critical theoretical
perspective, and specifically a critical nursing
Key Words
relations; critical
theory; nursing
practice C
Volume 20, Issue 1, September 2005 CC
Copyright © eContent Management Pty Ltd. Contemporary Nurse (2005) 20: 57–66.
Power and empowerment:
Critical concepts in the
nurse–client relationship
ABSTRACT Two key concepts in health promotion within the nurse–client relationship are
power and empowerment.Theorists and researchers have not achieved consensus
on how they are to be defined and addressed. However, both power and
empowerment are recognized to occur at macro and micro levels,and as such
need to be addressed at each level. Using a critical nursing perspective, this
article explores these concepts – it identifies concerns that arise around power
and risks that arise in empowerment practice. Nurses are challenged to develop
a new way of seeing empowerment practice, and encouraged to focus on ‘being
with’ clients,rather than ‘doing to’ them.
Received 23 January 2005 Accepted 1 July 2005
School of Nursing
The University of
Western Ontario
London, Ontario,
perspective.This is informed by critical social
theory, which holds to the following tenets:
there is a possibility for a future free of domina-
tion, exploitation, and oppression; domination is
structural; structures of domination are repro-
duced through a false-consciousness; social
change begins at home; and people are responsi-
ble not to perpetuate domination themselves
(Agger, 1998).Within the critical perspective,
taken-for-granted assumptions are challenged, as
they may be oppressive to individuals and groups
(Berman, Ford-Gilboe and Campbell, 1998).
Additionally, it is recognized that we must move
beyond the generation of knowledge to the cre-
ation and facilitation of change. This change
should include the elimination of oppressive
structures, and may be addressed by individuals
empowering themselves and through the genera-
tion of knowledge.These critical theory goals
coincide with many of the goals of empower-
ment practice that have been postulated.
Power is simply the ability to do or to act. How-
ever, this definition lends little to the under-
standing of the concept, so more elaborate
definitions will be considered. Before exploring
how this concept is defined, it is important to
note that no single definition of power exists
(Hewison, 1995), and many of the definitions
put forward conflict with each other. Expanding
on the idea of power as an ability to act, it may
be considered as the ability to produce a specific
effect and is a possession of control, influence
or authority (Du Plat-Jones, 1999; Hewit-Tay-
lor, 2004). Likewise, Hokanson Hawks (1991:
754) found that power is an ability to achieve
objectives or goals, which ‘are mutually estab-
lished and worked towards’. The concept of
resources is also relevant, as power has been
seen as the ability to use resources in order to
achieve desired objectives or outcomes (Hokan-
son Hawks 1991; Jones & Meleis 1993). In the
preceding definitions the concept is viewed
from the perspective of ‘power to’ rather than
‘power over’, which corresponds with a con-
ceptualization valued by many theorists (Hokan-
son Hawks 1991). However, other definitions of
power have focused more on ‘power over’, the
ability to persuade and influence situations or
others (Hokanson Hawks 1991; Jones & Meleis
1993). Many definitions take into consideration
the concept of knowledge, and focus on the idea
that knowledge is power (Falk-Rafael 1996; Du
Plat-Jones 1999). In this way, Pyne (1994) con-
ceptualizes power as an application of knowl-
edge to exercise authority or influence. In
addition, power is often seen as non-zero sum
(Gutierrez, DeLois & GlenMaye 1995), which
means that when someone gains power it does
not imply that someone else is losing it. Rather,
power is relational (Gutierrez, DeLois & Glen-
Maye 1995), therefore there is an infinite
amount available. A more unique definition of
power is described by Gibson (1991) as some-
thing that is felt rather than something that is
possessed.This builds on the idea that power is
more than a quantifiable attribute of individuals.
Therefore, there are many definitions of power,
but most are based around the idea that it is the
ability to have some form of control over one’s
life. Because of the variety in definitions of
power, it is important for researchers to expli-
cate their personal conceptualization if the term
‘power’is used in their study.
A broader understanding of the concept of
power may be developed through an exploration
of potential sources of power. The use of the
terms ‘macro’ and ‘micro’ is beneficial to assist
in the understanding of both power and empow-
erment. Macro refers to systems, organizational
or societal levels, while micro refers to inter-
personal or relational levels. In this way, sources
of power can be seen as being both macro and
micro (Hokanson Hawks 1991), and macro level
power filters down into micro level relationships
(Hewison 1995). From a critical perspective
macro level power can be seen as stemming
58 Volume 20, Issue 1, September 2005
Abram Oudshoorn
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Critical concepts in the nurse-client relationship CC
from oppression or marginalization (Cohen
1998), which is perpetuated by the dominant
class. Micro level power exists within interper-
sonal relationships (Hokanson Hawks 1991;
Foucault 1980) and is therefore interactional
(McWilliam et al. 2001). At the micro level
power has also been seen as existing within rela-
tionships with persons of authority (Skelton
1994). Five historically identified sources of
power are reward power, coercive power, legiti-
mate power, referent power, or expert power
(Hokanson Hawks 1991), which are all concep-
tualized as being located within relationships.
Additionally, recalling that knowledge is often
seen as power (Henderson 1994; Pyne 1994),
nurses have power by having professional knowl-
edge (Gibson 1991). Nurses also have power
due to their professional position within the
health care system (Du Plat-Jones 1999; Hug-
man 1991). This power, in the context of the
nurse–client relationship, is dialogical in that it
is mediated through language (Hewison 1995).
That is, power occurs in relationships, and par-
ticularly within interactions in relationships.
Nurses themselves can be a source of power for
clients within the health care system (Pyne
1994).Therefore, there are multiple sources of
power, at both the macro and micro level, and
determining the source of power depends on
one’s definition of power.
To avoid the misuse of professional power in
nursing, a variety of strategies have been identi-
fied.A certain mindset or attitude is required by
nurses, which includes openness to the client,
and their values and beliefs (Hokanson Hawks
1991). Hokanson Hawks also suggests that a
positive view of power is a good starting point
for nurses.Though power is often conceptual-
ized as the source of domination and oppres-
sion, it may also be the means of confronting
this oppression. For power to be a positive con-
cept in nursing it must be shared.An equal shar-
ing of power occurs when there is collaboration
between the nurse and client (Hewison 1995),
and when goals are mutually determined
(Hokanson Hawks 1991). Nurses may achieve
this through the open provision of information
and through the provision of support (Hender-
son 2003). This requires the nurse to possess
certain skills, including trust and effective com-
munication (Hokanson Hawks 1991).A further
assessment of what nurses can do to avoid the
misuse of power will be conducted in the sec-
tion of this manuscript that explores nursing
and empowerment.
Problems with power stem from the fact that it
may be abused (Pyne 1994). The misuse of
power in the health care setting diminishes the
nurse’s own power by decreasing their effective-
ness as a health care provider (Crawford Shearer
& Reed 2004). Problems with power can origi-
nate at the societal level, the health system
level, the individual level or within nursing
practice.At the societal level, those who are in
control and currently hold power are often
unwilling to give it over (Skelton 1994). As
well, in our patriarchal society the concepts of
power and caring are considered to be polar
opposites (Falk-Rafael 1996). This leads to
ambiguity of whether nurses should pursue per-
sonal power or focus only on caring for others.
In addition to this, the concept of power has
been associated with masculinity, leading some
nurses to feel that ‘they must assimilate mascu-
line characteristics’ in order to gain power in
society (Falk-Rafael 1996: 11).
At a health care systems level clients are
objectified (Henderson 2003) and disempow-
ered through a health care system that afflicts
them with an objective assessment gaze, strip-
ping them of their identity (Henderson 1994).
An empirical study found that clients are aware
of this objectification (McWilliam et al. 2001),
and found that the system attempts to fit them
into norms (Henderson 1994). Another sys-
temic problem with power is that nurses’ con-
trol over clients is supported by the system
(Hugman 1991) in the guise of resource man-
agement. In some cases this is to an extreme,
with nurses having power over clients’ necessi-
ties of life (Cohen 1998). However, in addition
to a bureaucracy that disempowers clients,
nurses are themselves often powerless within
the healthcare system (Falk-Rafael 1996; Mc-
William et al. 2001).
Nurses’ individual mindsets may also con-
tribute to problems with power and the disem-
powerment of clients. Falk-Rafael (1996) found
that many nurses are uncomfortable with recog-
nizing the power they have over clients within
the healthcare system.Without recognizing the
power that exists nurses will be unlikely to
change. Some nurses also have a condescending
idea that they are in possession of knowledge
that clients are in need of, so they must pass this
power on (Scott 1999). Other nurses have been
found to feel that they need to maintain power
and control within the healthcare interaction for
the best interests of clients (Henderson 2003).
This is due to an idea that they hold expert
knowledge and therefore know what is best for
clients experiencing a certain health concern.
Nurses must find a difficult balance between
feeling they know what is best for the client and
involving clients in the control of their care
(Payle 1998).
Specific nursing practices have also been
identified that disempower clients. Hewison
(2004) identifies four ways that nurses exercise
power within the healthcare relationship: overt,
persuasive, controlling the agenda, and terms of
endearment. Hewit-Taylor (2004) similarly
identifies four means of control, and labels them
coercion, reward, charisma and control. In
addition to these forms of control, nurses may
also exert linguistic control over their clients
(Hewison 1995), which relates back to the idea
that power is dialogical. Other means by which
nurses maintain power over clients have been
identified, with the act of maintaining a social
distance being particularly detrimental to thera-
peutic relationships (Hugman 1991; Du Plat-
Jones 1999). This is a means by which nurses
enhance their personal image and seek to gain
respect or grow to respect themselves. Addi-
tionally, individuals who resist the control of the
nurse may be labeled as uncooperative, ungrate-
ful or obstructive (Hugman 1991). Nursing
practices that disempower clients have also been
explored from the perspective of the client,
with clients expressing fear of challenging the
nurse, concerned that this may lead to a
decrease in the quality of care they receive
(Henderson 2003).
Overall, power as a concept has been concep-
tualized in a variety of manners. There is dis-
agreement over the basic definition of the
concept, such as whether power is an attribute
of individuals or exists within relationships.
Other disagreements have arisen over whether
power can be given or must be shared. Howev-
er, it is known that power exists, and more
specifically it exists within the nurse–client rela-
tionship. Therefore, theorists and researchers
have looked at how nurses can assist clients in
accessing and utilizing that power for the better-
ment of their health, and how abuses or detri-
ments stemming from this power may be
minimized. This leads into the concept of
Empowerment is simply the gaining of power.
However, like the concept of power, a simple
definition of empowerment does little to assist
with understanding it. And, like power, there
are many varying, and sometimes contradictory,
definitions of the concept. If one is looking at
‘power over’, then empowerment is the ability
to have an influence upon others (Bernstein et
al. 1994). If looking at ‘power to’, and power
being an ability to act, then empowerment can
be conceptualized as gaining the ability to act or
create change in the way that one desires (Bern-
stein et al. 1994). If power may be gained, then
it can be seen as an attribute (Gibson 1991);
60 Volume 20, Issue 1, September 2005
Abram Oudshoorn
however, if power is simply an expression of
relationships, then it is not an attribute inherent-
ly possessed (Bernstein et al. 1994). Similarly to
power, empowerment may be conceptualized on
the macro and the micro levels, with empower-
ment beginning at the macro level and ‘trickling
down’ into the micro level (Bernstein 1994;
McWilliam et al. 2001; Gutierrez, DeLois &
GlenMaye 1995). In this way power is an intri-
cate web that exists throughout society and
social relationships (Falk-Rafael 1996). Because
power is non-zero sum, when empowerment
occurs all who are involved gain from the
process (Bernstein et al. 1994) in that there is a
collective gain of power (Cohen 1998). Because
of this, the health care system should be set-up
so as to simultaneously empower both the nurse
and the client (McWilliam et al. 2001). Due to
the variety of definitions and conceptualizations
around the term empowerment, some theorists
consider that it is easier understood in its
absence, as marginalization (Gibson 1991; Jones
& Meleis 1993).
If a variety of definitions exist for the term
empowerment, what then is it? Empowerment
may be considered both an outcome and a
process (Gibson 1991; Jones & Meleis 1993;
Labonte 1994; Bernstein et al. 1994) or a form
of intervention (Gutierrez DeLois & GlenMaye
1995). Empowerment as an outcome is seen as
producing a positive self-concept, personal sat-
isfaction, self-efficacy, self-esteem, mastery,
control, a sense of connectedness, a feeling of
hope, an improved quality of life, well-being,
and, not least of all, health (Gibson 1991; Jones
& Meleis 1993; Crawford Shearer & Reed
2004). As a process, empowerment is a collabo-
ration with individuals that strengthens rather
than weakens (Gibson 1991) and that helps indi-
viduals gain control (Du Plat-Jones 1999; Craw-
ford Shearer & Reed 2004). Empowerment is
helpful in creating a more equitable distribution
in the forms of power (Bernstein et al. 1994),
helps people to assert control (Gibson 1991),
and assists them in gaining a sense of mastery
(Rappapport 1981). It is a participatory process
(Crawford Shearer & Reed 2004) that involves
collaboration, interaction and the sharing of
resources (Jones & Meleis 1993). Or, it may be
conceptualized as any variation of these factors,
or others not mentioned. However, in relation
to a critical nursing perspective, it is a means by
which to address the problems of marginalized
populations (Gutierrez DeLois & GlenMaye
Empowerment is most often understood as
being contextual (Bernstein et al. 1994). It is
therefore grounded in an individual’s or group’s
understanding of their reality (Freire 1970), and
must be defined by those involved in the process
(Gibson 1991).Theorists have stated that it is a
positive concept in that it focuses on strengths
(Gibson 1991; Gutierrez, DeLois & GlenMaye
1995); however, researchers have found that in
reality empowerment practice has often focused
on limitations, and this is how many nurses see
their practice (McWilliam et al. 2001). De-
pending on the perspective taken, empower-
ment may be the imparting of power (Du
Plat-Jones 1999) or sharing of power (Gutier-
rez, DeLois & GlenMaye 1995), but overall it
should be enabling (Falk-Rafael 1996).
Further clarification of the concept may be
gained by exploring some of the common values
in empowerment practice. One of the core val-
ues of empowerment practice is that in all of us
there is capacity for empowerment, due to the
fact that empowerment is relational (Bernstein
et al. 1994). Of course, even this core value is
dependent on the definition of empowerment
subscribed to.As in all healthcare practices, the
interests of the client and society as a whole
should be first and foremost (Pyne 1994).
Empowerment is often seen as valuing power as
shared rather than having power over others
(Bernstein et al. 1994; Labonte 1994), and it
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Critical concepts in the nurse-client relationship CC
should be recognized that there is a difference
between these two perspectives (Cohen 1998).
‘Power over’ leads to further disempowerment,
whereas ‘shared power’ leads to power being
gained by both the client and the nurse. This
shared power implies consensus, participation,
shared decision-making, openness, reciprocity
and collaboration (Bernstein et al. 1994; Du
Plat-Jones 1999; Henderson 2003; Hewit-Tay-
lor 2004). In addition, there should be mutual
respect and trust (Gibson 1991), and clients
should be respected as autonomous beings
(Henderson 2003).The knowledge and experi-
ence of clients is valued in that there is a recog-
nition that knowledge comes from clients,
rather than experts (Freire 1970), due to the
fact that clients have more experience with their
personal or collective situation (Hewit-Taylor
2004). Additionally, empowerment practice is
not a matter of clients feeling that they have
more power than the nurse, but feeling that
they have power over their own situations (Hen-
derson 2003). Research has found that clients
want to be in control of their situations and
health (Cohen 1998), and this should be valued
as all individuals have a right ‘to make decisions
about their care’ (Henderson 2003: 502). How
then does this practice take shape and can these
values be met?
If there was a simple answer as to how empow-
erment occurs then there would not be such a
wealth of literature on the topic. However, vari-
ous, and sometimes conflicting, methodologies
have been proposed for empowerment practice.
A number of theorists and researchers have
focused on the idea that individuals and groups
must empower themselves (Gibson 1991; Bern-
stein et al. 1994; Du Plat-Jones 1999), and in a
case-study analysis of empowerment one
research participant stated that, ‘empowerment
has to come from within’ (Gutierrez, DeLois &
GlenMaye 1995: 537). If people are to empow-
er themselves they must take power (Bernstein
et al. 1994), but they should do so in a way that
does not produce strife or anger the dominant
class (Labonte 1994).To empower themselves,
individuals may also come to understand the
power they already possess (Bernstein et al.
1994; Gutierrez, DeLois & GlenMaye 1995)
and assert this potential for power (Hugman
1991; McWilliam et al. 2001). Examples of the
power that clients already possess are the ability
to refuse services and the ability to self-advocate
(Skelton 1994). Individuals may also exert
moral power through civil disobedience and
non-violent protest (Bernstein et al. 1994).
In suggesting how empowerment occurs,
other theorists have focused on the concept of
empowerment as relational, or relationships as
the vehicle through which empowerment
occurs (Gibson 1991; Cohen 1998); when
empowerment is relational, it is also dialogical
(Freire 1970; Cohen 1998).Within empower-
ing relationships, power is given and taken
simultaneously (Labonte 1994). One of the
major concepts that arise within relational em-
powerment is the development of critical con-
sciousness (Jones & Meleis 1993; Bernstein et
al. 1994; Gutierrez, DeLois & GlenMaye 1995).
This is developed when individuals or groups
critically reflect on their situation (Freire 1970)
and come to a new sense of awareness (Gibson
1991).This coincides with the critical nursing
perspective, one of the key tenets of which is
developing this critical consciousness through
reflection. Another example of relational
empowerment is when one names one’s experi-
ence and has this ‘naming heard and legitimized
by others’ (Labonte 1994, p. 257).
However, though empowerment can occur in
the context of relationships, for people to be
truly empowered there is a need for it to take
place at all levels, macro and micro (Gutierrez,
DeLois & GlenMaye 1995). If power is an
attribute, those who hold the objective sources
of power must be willing to let them go (Bern-
stein et al. 1994) and a subsequent redistribu-
62 Volume 20, Issue 1, September 2005
Abram Oudshoorn
tion of power must occur (Gutierrez, DeLois &
GlenMaye 1995). Due to the variety that exists
in definitions, values and methods of empower-
ment, one must be comfortable with ‘gray
zones’ in order for one’s practice to be located
in this concept.
More specific ideas have been developed as to
how nurses may be involved with empower-
ment.Various strategies are suggested that focus
on macro actions, micro actions, and changes of
one’s mindset. Addressing issues at the macro
level is important (Skelton 1994; Crawford
Shearer & Reed 2004) in order for changes to
move beyond ‘band-aid’ solutions. To address
these macro issues nurses must develop an
understanding of how organizations and systems
function (Gibson 1991). Once this understand-
ing is developed nurses may challenge the struc-
tures within the health care system that are
perpetuating inequality (Falk-Rafael 1996), and
may find new ways of practicing that reduce
inequity (Labonte 1994).
At the micro level, nurses are encouraged to
be empathetic, supportive, community organiz-
ers, coalition developers, political activists
(Bernstein et al. 1994), helpers, educators,
counselors, resource consultants, resource
mobilizers, facilitators, advocates (Gibson 1991;
Jones & Meleis 1993; Crawford Shearer & Reed
2004). If knowledge is power, nurses are
encouraged to pass on their knowledge
(Labonte 1994; Du Plat-Jones 1999; Henderson
2003) and to assist in the raising of conscious-
ness (Bernstein et al. 1994). Nurses may take
the first step by surrendering control and mini-
mizing their own leadership roles (Gibson
1991) in order to shift the focus of healthcare
from the nurse’s leadership to the client (Craw-
ford Shearer & Reed 2004). Due to the dialogi-
cal nature of empowerment, nurses should
communicate effectively (Gibson 1991) and use
empowerment language (Bernstein et al. 1994).
In addition to actions nurses may take in
order to promote empowerment, changes in
mindsets are required to facilitate these actions.
Nurses must move away from the expert-driven
model of care and resist the need to ‘do for’
clients (Cohen 1998). This will come about
when nurses are willing to trust in those who
are marginalized and their ability to reason
(Freire 1970). In this way, nurses can recognize
the skills that clients possess, and assist in devel-
oping them further (Gutierrez, DeLois & Glen-
Maye 1995). Nurses must value individuals
control in their own lives, and recognize that
‘health belongs to the individual’ (Gibson 1991:
357).This change in mindsets may be achieved
through critical reflection, as nurses come to
understand their own position of privilege (Gib-
son 1991), despite personal feelings of disem-
powerment within the health care system
(Bernstein et al. 1994). This reflection will
include recognizing the imbalance of power
within the nurse–client relationship, reflecting
on what is disempowering about nursing prac-
tice (Bernstein et al. 1994; Hewit-Taylor 2004),
and acknowledging these reflections with the
client (Cohen 1998).These are just some of the
strategies that have been suggested in order for
nursing practice to be empowering.
Despite the positive connotations of the concept
of empowerment, there are both barriers to,
and risks involved with, the implementation of
this concept.A number of barriers to empower-
ment practice exist at both the macro and micro
levels. At the macro level there is a need for
limited resources within the healthcare system
to be controlled, and it falls on nurses to be the
gate-keepers of these resources (Hewit-Taylor
2004). Theorists have postulated that many
nurses are stuck in the micro level and miss the
macro (Gutierrez, DeLois & GlenMaye 1993),
therefore they fail to realize that their micro
plans may be inhibited by what is occurring in
the macro (Skelton 1994). Nurses are also lim-
ited in their practice by the organizational envi-
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Critical concepts in the nurse-client relationship CC
ronment (Labonte 1994; Cohen 1998), and are
required to follow the rules and expectations of
the system (McWilliam et al. 2001).Additional-
ly, many theorists feel that nurses must be
empowered in order to empower others (Du
Plat-Jones 1999) and nurses are currently dis-
empowered within the current health care sys-
tem. However, Skelton (1994) suggests that this
is a naïve concept due to the fact that power
comes from outside of professionals.There is
also a concern with the inadequacy of ‘band-aid’
solutions, in that resources do not lead directly
to health (Jones & Meleis 1993). Therefore,
empowering others by simply providing them
with resources does nothing if they are not col-
laboratively involved.
At the micro level there is a very basic limita-
tion to empowerment in that not all people feel
they require empowerment (Gibson 1991) or
want to be empowered at all (Scott 1999). As
well, in the same way that resources do not lead
directly to health, knowledge does not necessari-
ly lead to change (Gutierrez, DeLois & Glen-
Maye 1995); therefore, something more is
required than the sharing of resources and
knowledge. Empirical research has shown that
current treatment plans are often not client-driv-
en (Cohen 1998) and that clients’ knowledge
is undervalued, leading to disempowerment
and dependence (McWilliam et al. 2001). Re-
searchers have also found that nurse–client com-
munication is frequently one-way, from the nurse
to the client (McWilliam et al. 2001), and that
nurses were mostly unwilling to share decision-
making power with clients (Henderson 2003).
In addition to the barriers involved, inherent
risks have been identified in empowerment
practice. Empowerment practice itself can be
disempowering if it is expert-driven (Scott
1999) and if it conforms to the dominant
modality (Skelton 1994).This is due to the fact
that health care practices may create rather than
eliminate hegemonic power (Bernstein et al.
1994), and therefore nurses may be seen as
being involved in disempowerment (Skelton
1994). Nurses may also subscribe to thinking
that for clients to be empowered they must
agree with what the nurse ‘knows’ is best for
them (Crawford Shearer & Reed 2004).Anoth-
er concern is that there must be a balance
between client autonomy and leaving people to
fend for themselves (Bernstein et al. 1994).The
risk is that with the desire to promote autono-
my, marginalized individuals or groups are left
fighting power systems that they do not have the
resources to address. Then, when they fail to
create the change they desire, the individuals
are blamed for their inadequacy, hence perpetu-
ating victim-blaming. Lastly, one theorist raised
the question as to how far the health care sys-
tem may go in allowing a service to be provided
for clients simply because it is what the client
desires, while failing to recognize limited health
care resources available to the collective
(Hewit-Taylor 2004).
A variety of definitions and sources of power
have been identified. Additionally, the role of
the nurse in relation to power is explored, and
various problems with power are explained. If
power is the ability to act or produce a change
in the way one desires, empowerment is the
facilitation of this power. A number of defini-
tions of empowerment are identified, as well as
values that underlie empowerment practice, and
forms that empowerment practice may take.
Specifically, nursing practice has been explored
within the context of the nurse–client relation-
ship, and risks and barriers to empowerment
are explored.These risks and barriers coincide
with the example of personal practice given at
the outset of this manuscript. These problems
occur at both the macro and micro, or systems
and relationship, levels.They involve concerns
with professional power and resources, and may
include more covert problems with stigmatiza-
tion and marginalization. In light of these prob-
lems, the issues of power and empowerment
may be discouraging.
64 Volume 20, Issue 1, September 2005
Abram Oudshoorn
Recent solutions to address the risks and bar-
riers of empowerment practice, coinciding with
the growing eminence of critical nursing theory,
have focused on consciousness-raising through
collaboration. Nurses are encouraged to work
with individuals and communities, and to allow
the client to direct their practice. In this way, the
nurse simply serves as a catalyst and is available
as a resource person when the client desires.
Nurses are encouraged to reflect upon their
practice, and how their professional power can
be a detriment to the nurse–client relationship.
Similarly, nurses encourage clients to reflect on
their situation and identify areas of power or
powerlessness.Through this practice, both the
consciousness of the nurse and the consciousness
of the client are raised, and a platform for
change is established. However, even this very
practice has been identified as being detrimental
to empowerment, in that nurses still have a pre-
conceived notion that clients must acquire a new
type of knowledge and use this to address inher-
ent areas of powerlessness.
But, within the variety of discourses and the-
ories around empowerment, a unique concep-
tualization has arisen. This conceptualization
takes a more fundamental look at the nature of
nursing practice. It involves a new way to
understand empowerment practice as grounded
in ‘recognizing our common humanity’ (Scott
1999: 140). In this way there is no need to focus
on the giving of power to individuals or groups,
but simply a focus on ‘being’ with others (Bern-
stein et al. 1994).This idea is well illustrated in
a quote from an Australian aboriginal woman ‘If
you are here to help me, then you are wasting
your time. But if you come because your libera-
tion is bound to mine, then let us begin’ (Val-
varde 1991). This conceptualization moves
beyond reflection on one’s power to reflection
on the very nature of one’s purpose and exis-
tence. If nurses wish to practice empowerment,
they must search their very core to understand
their motives for seeking to care for and with
others (Skelton 1994).
I would like to gratefully acknowledge Dr.
Helene Berman for her editorial assistance and
expertise, and Dr. Cathy Ward-Griffin for her
ongoing mentorship and support.
Agger, B. (1998) Critical social theories:An
introduction Boulder CO:Westview.
Berman, H., Ford-Gilboe, M. and Campbell,
J.C. (1998) ‘Combining stories and numbers:
a methodologic approach for a critical
nursing science’ Advances in Nursing Science
21(1): 1–15.
Bernstein, E.,Wallerstein, N., Braithwaite, R.,
Gutierrez, L., Labonte, R. and Zimmerman,
M. (1994) ‘Empowerment forum:A dialogue
between guest editorial board members’
Health Education Quarterly 21(3): 281–294.
Cohen, M.B. (1998) ‘Perceptions of power in
client/worker relationships’ Families in Society
79(4): 433–442.
Crawford Shearer, N.B. and Reed, P.G. (2004)
‘Empowerment: Reformulation of a non-
Rogerian concept’ Nursing Science Quarterly
17(3): 253–259.
Du Plat-Jones, J. (1999) ‘Power and
representation in nursing:A literature
review’ Nursing Standard 13(49): 39–42.
Falk-Rafael,A.R. (1996) ‘Power and caring: A
dialectic in nursing’ Advances in Nursing Science
19(1): 3–17.
Foucault, M. (1980) Power/Knowledge: Selected
interviews and other writings 1972–1977 (C.
Gordon,Trans.) New York NY: Pantheon.
Freire, P. (1970) Pedagogy of the Oppressed
London UK: Penguin Books.
Gibson, C.H. (1991) ‘A concept analysis of
empowerment’ Journal of Advanced Nursing
16: 354–361.
Gutierrez, L.M., DeLois, K.A. and GlenMaye,
L. (1995) ‘Under standing empowerment
practice: Building on practitioner-based
knowledge’ Families in Society 76(9): 534–42.
Henderson, A. (1994) ‘Power and knowledge
Volume 20, Issue 1, September 2005 CC
Critical concepts in the nurse-client relationship CC
in nursing practice:The contribution of
Foucault’ Journal of Advanced Nursing 20:
Henderson, S. (2003) ‘Power imbalance
between nurses and patients:A potential
inhibitor of partnership in care’ Journal of
Clinical Nursing 12(4): 501–8.
Hewison, A. (1995) ‘Nurses’ power in
interactions with patients’ Journal of Advanced
Nursing 21: 75–82.
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of power: Patient empowerment’ Nursing
Standard 18(22): 33–7.
Hokanson Hawks, J. (1991) ‘Power:A concept
analysis’ Journal of Advanced Nursing 16:
Hugman, R. (1991) Power in Caring Professions
Hong Kong: Macmillan.
Jones, P.S. and Meleis,A.I. (1993) ‘Health is
empowerment’ Advances in Nursing Science
15(3): 1–14.
Labonte, R. (1994) ‘Health promotion and
empowerment: Reflections on professional
practice’ Health Education Quarterly 21(2):
McQueen, D. (2002) ‘Discomfort of patient
power. Patients are not doctors’ equals’
British Medical Journal 324(7347): 1214.
McWilliam, C.L.,Ward-Griffin, C., Sweetland,
D., Sutherland, C. and O’Halloran, L. (2001)
‘The experience of empowerment in in-
home services delivery’ Home Health Care
Services Quarterly 20(4): 49–71.
Payle, J.F. (1998) Health professional’s views on
patient participation:Treading a fine line, in:
4th Qualitative Research Conference Vancouver,
Conf. Proc. Sage,Thousand Oaks CA.
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the Code of Professional Conduct’ British
Journal of Nursing 3(12): 631–4.
Rappapport, J. (1981) ‘In praise of paradox:A
social policy of empowerment over
prevention’ American Journal of Community
Psychology 9: 1–25.
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control in palliative care’ Cambridge Quarterly
of Healthcare Ethics 8: 139–147.
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Concepts and strategies’ Journal of Advanced
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66 Volume 20, Issue 1, September 2005
Abram Oudshoorn
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... Professional support aims to be empowering, which can be considered as both a process and an outcome (Oudshoorn, 2005). As a process, empowering support (i.e. ...
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Background Professional support in childbearing has beneficial effects on childbirth experience, interactions within the family, breastfeeding and medical outcomes. However, more knowledge is needed about prerequisites for professional support to be valuable and satisfactory during childbearing. Aim The aim of this discourse paper is to describe and explore prerequisites for professional support that are of value for women and their families during childbearing as well as how healthcare organizations can be formed to facilitate these prerequisites. Design Discourse paper. Methods This discourse paper is based on our own experiences and is supported by literature and theory. Results Well-functioning structures and processes facilitate professional support that leads to safe, secure, calm and prepared parents with the ability to handle the challenges of childbearing and parenting. When organizing care in childbearing, prerequisites for support needs must also be considered.
... Finally, the increasing and progressive use of Information Communication Technologies in medical practice and healthcare services (Timmermans and Berg, 2003) has attracted attention to telemedical technologies and the consequent changes they bring for professionals (Berg, 1999;Aanestad, 2003;Mort et al., 2003;Oudshoorn, 2005;Lehoux et al., 2002;Bruni, 2005) and patients May et al., 2005;Oudshoorn, 2008;Langstrup 2013;Mort et al., 2013). Devices for self-monitoring entail a redistribution of responsibilities (Willems, 2010) negotiated by doctors with patients and their relatives (Piras and Miele, 2017). ...
... -My action was constrained by the nursing management system. 63,64 The evaluation system for efficiency, which was invented by the management department of my hospital, put the amount of practical nursing tasks first and foremost. In the context of the Chinese market-oriented economy, the amount of tasks and the profits that I produced determined my income and promotion. ...
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Objective This study aimed to demonstrate and promote the skill of critical emancipatory reflection through reflecting on a nursing practice-based ethical issue about nurses’ paternalistic decision-making for patients. Meanwhile, critical awareness will be developed and the underlying issues of paternalism in nursing decision-making will be analyzed. Then, by applying the procedure, improvement in nursing decision-making practice will be expected. Methods Taylor’s model of emancipatory reflection with four steps, including construction, deconstruction, confrontation, and reconstruction, is utilized to guide the author’s reflection. Results Guided by the socialization theory, the author’s personal and professional socialization is seen to be associated with the formation of the value of paternalism. The theory of reflexivity is applied to unearth the related issues, including deeper personal value, work environment, as well as historical and cultural contexts. Moreover, the power derived from policy, work relationship, and nursing administration, which could induce paternalism in the author’s nursing decision-making practice, was critically debated using the hegemony theory. Finally, new insights into paternalism will be achieved, which enable change in terms of how to facilitate patients’ autonomous decision-making. Conclusions The process of refection makes it clear that respecting patients’ right and performing patient-centered caring are the bases to change the paternalism existing in the nursing decision-making practice currently. The reconstruction step assists the author in terms of how to value the patients’ autonomy and balance patients’ safety and choice, rather than being overprotective; carry out risk assessment, and search for strong evidence to counterbalance the positive and negative aspects of risk-taking; communicate with patients appropriately in a manner that they can comprehend; spend more time to explore patients’ preference and choice; make every effort to elevate the patients’ decision-making capacity; implement patient-centered care and shared decision-making in nursing practice; consult with other colleagues and obtain the required support when limitations or challenges exist; try to justify and avoid hidden paternalism behind policy or guidelines; deal with the power in hand well and fairly; and also positively face the powers that constrain the author.
... Although professional commitment has a positive relationship with job satisfaction, patient safety, high-quality care and a lower intention to quit (28), in the present study, it appears to have a direct and positive relationship with gaining professional power in nurses. A nurse's knowledge and skills make up the principal base of her individual power, as discussed in many other studies (29)(30)(31). Strengthening the nurses' knowledge base is a responsibility of both the nurses and the organizations. Providing in-service training and giving periodical theoretical and practical tests can be helpful. ...
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Background Power in nursing is a broad concept that has a determining effect on the achievement of professional goals. Gaining power is essential for promoting the roles of nurses, improving their professional image and the consistent improvement of healthcare systems. Objectives This study was conducted to identify and clarify strategies for gaining power in the nursing profession through the experiences of Iranian nurses. Methods The present qualitative grounded theory study was conducted on fifteen participants selected through purposive sampling. Data were collected through individual, in-depth, semi-structured interviews. The data obtained were analyzed using the guidelines provided by Corbin and Strauss, (2008 edition). This study was carried out in Qazvin city of Iran and lasted fourteen months (2015–2016). Results The analysis of the data were classified under the main theme of gaining human-professional power based on individual and organizational capacities, divided into four main categories, including respecting human values and ethical principles (with two subcategories, keeping the human symbols of power and commitment to moral obligations of power), promoting professional interactions (with two subcategories, paying attention to intraprofessional communication and paying attention to interprofessional communication), attempting professional endurance (with two subcategories, raising self-confidence and having professional commitment), and valuing potential capacities (with two subcategories, regard for individual capacities and regard for organizational capacities). Conclusion The findings obtained suggest that success in gaining power in nursing, requires a cumulative focus on human, ethical, professional, individual and organizational capacities.
... It is an abstract concept, frequently used in the literature. The concept has been defined in a variety of manners; it has its roots in social, organisational, and psychological theories (Aujoulat et al. 2008, Bradbury-Jones et al. 2008, Gibson 1991, Kuokkanen & Leino-Kilpi 2000, Oudshoorn 2005. ...
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Background Arthroplasty is commonly used for an increasing population of patients with osteoarthritis, and the recovery process starts directly after surgery. Today’s shorter hospital stay may be a challenge for the patients and their spouses. Patient education is linked to and promotes the recovery process and can improve the outcome after elective hip or knee replacement. Fulfilment of knowledge expectations is essential for enabling people to become empowered during the period of recovery. Aim The overall aim was to explore the association between empowering knowledge and patients’ quality of recovery after elective hip or knee replacement. Methods The design of the four papers was descriptive, prospective and comparative. Consecutively included patients and their spouses from Cyprus, Finland, Greece, Iceland and Sweden answered questionnaires before surgery and at discharge from hospital. Data was collected during the years 2009-2012. Relationships and associations between a number of factors and fulfilment of knowledge expectations, and patients’ quality of recovery were investigated. Comparisons between patients undergoing hip or knee replacement and between patients and their spouses were made. Results Patients and their spouses had similar knowledge expectations, and these were not fulfilled during the hospital stay. Spouses had less fulfilled knowledge expectations compared with the patients. Swedish patients and spouses had less fulfilled knowledge expectations compared with the Icelandic and Finnish ones. Patients who experienced the hospital stay as meeting their general expectations had more fulfilled knowledge expectations compared with those who did not. Access to knowledge was the main predictor of the variance in fulfilment of knowledge expectations. Negative emotions, such as depressive state and impa-tience, were associated with less fulfilled knowledge expectations. For patients undergoing hip replacement, a higher level of professional education was associated with less fulfilled knowledge expectations. For patients undergoing knee replacement, a history of employment in social services or healthcare was associated with less fulfilled knowledge expectations. Patients’ experience of greater satisfaction with care was associated with better quality of recovery for both kinds of arthroplasty. Patients with fulfilled knowledge expectations experienced better quality of recovery. The spouse-related factors, namely uncertainty and depressive state, were associated with lower quality of recovery. Factors associated with greater quality of recovery among the patients were spouses with a history of employment in social services or health care, and nurses explaining matters concerning the care and treatment for the spouses. Conclusion Patients and their spouses had high knowledge expectations that were not fulfilled during the hospital stay. Patients’ emotional state and their access to knowledge were important for their fulfilment of knowledge expectations. Patients’ and spouses’ emotional state also played an important role in determining the patients’ quality of recovery, and greater satisfaction with care among the patients was associated with better quality of recovery. These results emphasise the need to detect patients and their spouses in need of support in their preparation and recovery process. It is therefore important to assess patients’ and spouses’ personal knowledge expectations, and adapt to their emotional state while fulfilling them. The content of patient education should be personalised in future care, and informal caregivers should be seriously taken into account during the period of early recovery. The results of this thesis can be used in the development and testing of person-centred educational interventions for patients undergoing elective hip or knee replacements.
Introduction Over the years, educational lines have focused on providing education and information to patients. The empowerment of the patient means involving him in his self-care and making it part of his disease process. Therefore, to improve our difficulties in education, it is necessary to identify the knowledge needs of patients in relation to their disease. Objective To explore the expectations of epilepsy patients regarding the health education received. Method design descriptive qualitative study from a hermeneutical perspective. Subjects: Intentional sampling of 18 patients with epilepsy volunteers to participate in health education sessions between January and July 2019. Data collection and analysis: Documentary technique through analysis of the wording to the question about their expectations in education sessions. Results We obtained 10 codes that are codified in 3 subcategories of expectations in education: learning and disease management, problems with mood and interaction and sharing with other people with epilepsy. The latter merge into 2 broad categories: Self-management and internal growth. Conclusions Patients with epilepsy, when attending group health education sessions, not only hope knowledge and management of the disease and crisis, but also hope and share their experiences with other patients, professional emotional support and know the treatment options and social resources.
Resumen Introducción Durante años, las intervenciones educativas enfermeras se han centrado en proporcionar educación e información a los pacientes. El empoderamiento del paciente supone involucrarlo en su autocuidado y hacerlo partícipe de su proceso de enfermedad. Por ello, para mejorar nuestras intervenciones en educación, es necesario identificar las necesidades de conocimiento de los pacientes en relación con su enfermedad. Objetivo Explorar las expectativas de los pacientes de epilepsia respecto a la educación sanitaria recibida. Método Estudio cualitativo-descriptivo desde la perspectiva hermenéutica. Sujetos: muestreo intencionado de 18 pacientes con epilepsia voluntarios que participaron en las sesiones de educación sanitaria entre enero y julio de 2019. Recogida y análisis de datos: técnica documental mediante análisis de redactados a la pregunta sobre sus expectativas en las sesiones de educación. Resultados Se obtienen 10 códigos que se codifican en 3 subcategorías de expectativas en la educación: aprendizaje y manejo de la enfermedad, intervenciones sobre estado de ánimo e interacción y compartir con otras personas con epilepsia. Estas últimas se fusionan en 2 grandes categorías: autogestión y crecimiento interno. Conclusiones Los pacientes con epilepsia, al acudir a sesiones grupales de educación sanitaria, no solo esperan conocimientos y gestión de la enfermedad y crisis, sino que también esperan comunicarse y compartir sus experiencias con otros pacientes, soporte emocional profesional y conocer las opciones de tratamiento y recursos sociales.
This study was conducted to explore issues of nurse managers' power and empowerment. Data were collected from nurse managers by way of a questionnaire consisting of background factors, work-related questions, and power-related questions at the unit and organization levels. The degree of empowerment was evaluated using 2 established instruments (CWEQ-II and Work Empowerment Questionnaire). The overall level of managers' personal power within their own units was relatively high. Nurse managers' perception of their power at an organizational level was found to be at a moderate level. Several factors related to an individual's professional background were correlated to power issues, both at the unit and organizational levels. Structural and psychological empowerment correlated with the overall level of power at a unit level and the overall level of power at an organizational level. Nurse managers self-reported their own general power at a unit level as high, which offers them possibilities to lead the development of nursing care in their units. Organizations may benefit more from nurse managers' leadership by more fully integrating them in the development processes of the entire organization.
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Introduction: Power is a complex and extensive concept in nursing, which has a decisive impact on the accomplishment of duties, satisfaction and achievement of professional goals. Explaining the concept of power in nursing from the perspective of nurses and accessing its various dimensions may result in a better understanding of this issue. Aim: This study was aimed to explore the concept of power in nursing, using the views and experiences of Iranian nurses. Materials and methods: This study was a qualitative research which used a content analysis approach. Participants were selected from among nurses active in clinical, management, and educational practices using the purposive sampling method. Data were collected using a semi-structured individual interview. The results were obtained by analysing the data using an inductive approach and the constant comparison method. Results: The participants of this study regarded the power of nursing as a positive concept and the issue of power in nursing consisted of three classes, the genesis with the subclasses of "being purposeful", "being under the shadow of the profession nature", "being dependent on the source", strengthening with the subclasses of "being emotional and introverted", "being formed in the context of professional communication", "fluidity and flowing", and the evolution with the subclasses "based on human values", and "being a tool for professional excellence". Conclusion: The concept of power in nursing can be considered a purposeful issue based on the nurses' viewpoint which flourishes in the context of human, moral and caring nature of the nursing profession. According to its dependence on the nature of profession and on the basis of professional communication, Power of nursing grows with a fluidlike flowing structure, linked with human values, reaches maturity and results in outcomes such as improving the quality of care and professional excellence.
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Studied theoretical models of empowerment in mental health programs by identifying ways in which human service workers conceptualize and practice the concept. Six human service personnel engaged in empowerment practice with diverse ethnic clients were interviewed. Ss focused on the individual and psychological aspects rather than the personal or political elements of empowerment, and emphasized it as a process of self-awareness. Common themes could be identified, which emphasize the importance of working collaboratively with clients, the need to involve consumers in developing concrete skills for developing social power, the importance of education, and of recognizing and building on strengths. Education, participation and strengths orientation were seen as mutually reinforcing, and listed as the major elements of empowerment practice, though focusing on all 3 is difficult. (PsycINFO Database Record (c) 2012 APA, all rights reserved)
Professions, Caring and the State - Dimensions of Power - Hierarchy and Professions - The Struggle for Professionalism - Our Clients, Our Selves - Racism in Caring Professions - Gender in Caring Professions - Power in Focus
Recent literature on empowerment-oriented social work practice raises intriguing questions about the nature of power in client/worker relationships. This qualitative study explores client and worker perceptions of power in their relationships with each other. Individual and focus group interviews were conducted in residential settings serving men and women with histories of homelessness and psychiatric hospitalization. Staff and residents' experiences with helping relationships were probed, with particular attention to characteristics of mutuality, equality, and power. Client and worker preferences were conceptualized as ranging from partnership-oriented relationships to mentorship-oriented relationships. The author draws on empowerment and feminist theory in analyzing the study'simplications for social work practice.The question is posed as to whether social work practice can fully realize the goals of shared power, mutuality, and collaboration associated with feminist and empowerment-oriented practice models when client/worker relationships are embedded in a hierarchical power structure.
A consideration of health in relation to global and diverse social and economic contexts forces nurses to reexamine the centrality of health in the discipline of nursing and to confront the issue of whether health is a personal matter. In this article, the authors review development of the concept of health in nursing science, discuss the limitations of some current definitions in addressing diverse clients, and challenge members of the discipline to develop a contextualized definition of health congruent with societal needs and the mission of nursing.
In this paper, an objective concept analysis was undertaken to examine the attributes, characteristics and uses of the concept of empowerment A review of the literature and selected empirical referents indicated that empowerment is a complex and multi-dimensional concept Within a nursing context, empowerment can be conceptualized as a composite of (a) attributes that relate to the client, (b) attributes that relate to the nurse, and (c) attributes that belong to both the client and the nurse In a broad sense, empowerment is a process of helping people to assert control over the factors which affect their lives This process encompasses both the individual responsibility in health care and the broader institutional, organizational or societal responsibilities in enabling people to assume responsibility for their own health. Antecedents to and consequences of empowerment, from a nursing perspective, are presented. To adopt truly an empowerment model in nursing, a radical paradigm shift is needed. The final conclusion is that this concept has great utility for nursing practice, education, administration and research
This paper follows the Walker & Avant approach to concept analysis of the concept of power. For the purposes of the paper, power was defined as the actual or potential ability or capacity to achieve objectives through an interpersonal process in which the goals and means to achieve the goals are mutually established and worked toward. The distinction between the views of power as 'power to' versus 'power over' are addressed in the literature review. King's conceptual framework was used as a guide. Defining attributes, antecedents and consequences of power, demonstration cases, and assumptions are presented. A theorem and testable hypothesis are proposed. The final product is a conceptual map which illustrates the contents of the concept analysis.
The thesis of this paper is that the most important and interesting aspects of community life are by their very nature paradoxical; and that our task as researchers, scholars, and professionals should be to “unpack” and influence contemporary resolutions of paradox. Within this general theme I will argue that in order to do so we will need to be more a social movement than a profession, regain our sense of urgency, and avoid the tendency to become “one-sided.” I will suggest that the paradoxical issue which demands our attention in the foreseeable future is a conflict between “rights” and “needs” models for viewing people in trouble.
This paper explores the implications of Michel Foucault's philosophical analyses for understanding nursing practice. Foucault describes power within a given society as unfolding not through large-scale events but rather through a complex 'micro-physics'. Power operates upon the human body. With the increasing use of observation, in understanding both the natural and social world, the body has become the subject of the 'gaze'. The body as object, however, is neither a universal belief nor truth but a product of ways of perceiving and examining it. In relation to nursing, the subjection of the body to the 'gaze' and the practices of the institutional environment of the hospital are important for understanding the knowledge formulated. The power of practice is in the generation of knowledge. The nature and form of knowledge is instrumental in establishing the quality of nurse-patient relationships. This paper explores, through the particular exemplar of the patient in intensive care, the power of present practices to shape knowledge, and thereby dictate and limit the quality of the nurse-patient relationship.