Negotiated care-fundamental to nursing practice

b e s t

p r a c t i c e

Negotiated care fundamental to nursing practice This paper focuses on negotiation in nursing. It suggests that negotiation, in the form of negotiated care, is a key element of nursing practice in the many contexts in which it takes place. To support this statement the process of negotiated care is illustrated by three examples. These examples portray negotiated care as it occurs between nurse manager (or leader) and nurse clinicians, in an interdisciplinary context, and between nurses, other health practitioners and patients/relatives. These examples demonstrate that negotiation which is aimed at achieving quality patient care pervades nursing practice. Nevertheless, it is suggested that nurses often do not recognise the centrality of negotiation in their nursing practice, nor are its implications for long-held beliefs about the role of the nurse considered. This paper also suggests that the successful outcome of negotiation in the context of nursing is dependent on nurses' confidence in, and their ability to articulate their knowledge about, nursing practice. It also relies on their commitment to the therapeutic nature of nursing practice and nurses' awareness that their practice is an essential component to patient care. The specialist nature of negotiation in nursing care, and its fundamental role in the care process, suggests that negotiation in nursing is more accurately termed negotiated care. By Diana Keatinge, RN, RSCN, MAdmin, PhD, FCN (NSW), FRCNA, associate professor, clinical nursing research Hunter Area Health Service and The University of Newcastle.

Introduction

to the importance of negotiation in com-

The focus of this paper is the notion that

munication between nurse and patient

negotiation, in the form of negotiated

and/or relative (Trnobranski 1994, Gallery

c:are, is a key element of nursing practice.

and S m i t h 1991, Krouse and Roberts

1 his is true whether negotiation takes

1989). Much less consideration has been

place between nurses and patients or their

g i v e n to n e g o t i a t i o n as an essential

relatives, between nurses and nurse man-

component in communication between

agers (or leaders) or between nurses and

nurse and nurse, or nurse and other health

health practitioners from other disci-

practitioners.

plines. It is also true whether negotiation takes place in the emergency department,

ly described, this paper identifies the

the operating room, in other clinical con-

central role of n e g o t i a t i o n in nursing

texts, during interdisciplinary interaction

practice and demonstrates, through the

or during exchanges between nurse man-

three examples, that n e g o t i a t i o n in

agers and nurses.

nursing is essentially concerned w i t h

The conclusion that negotiated care is

negotiating care.

at the heart of the caring process has

It is suggested that power, interests

become apparent to me during my experi-

and goals, well recognised as elements to

ence as a nurse clinician and manager and

be considered in any negotiation process,

h i g h l i g h t e d as a result of c o n d u c t i n g

are also present in negotiation in nursing.

several studies. I his paper draws on

However,

the specialist

nature

of

examples from t w o of these studies,

negotiation in nursing care, and its funda-

as well as on my nursing experience, to

mental role in the care process, suggests

illustrate negotiated care as it takes place

that negotiation in nursing is of increased

within the clinical environment.

c o m p l e x i t y and is more appropriately

Considerable attention has been given 3 6 Collegian Vol 5 No 1 1998

Discussing negotiation as it is general-

termed negotiated care.

Three examples are given which illus-

in a given context, on a player's ability lo

Negotiated care illustrated in the

trate negotiated care as it lakes place in

understand and analyse w h o makes these

management of change

different clinical contexts.

rules, in w h a t c i r c u m s t a n c e s t h e y are

T h e first example illustrates the c o m p o -

In ihe discussion it is suggested that

invoked or allowed to lie forgotten, who

nents of negotiated care as they were used

r e s p e c t for a n o t h e r ' s i n t e r e s t s t o w a r d s

sides with who in order to achieve a cer-

in the management of major change. Ibis

achieving shared goals, a process that is

tain goal and how power is manifested.

e x a m p l e a r i s e s from a s t u d y ,

which

the core ol negotiated care, is the antithe-

!t is acknowledged that the attributes

focused on t h e m a n a g e m e n t of m a j o r

sis ol a d v o c a c y with its c o n n o t a t i o n ol

of negotiation so lar d e s c r i b e d are also

c h a n g e inherent in relocating a neonatal

power differential and dependence. Thus,

present in the process of negotiated care.

intensive care unit (NICL1) and its staff

the r e c o g n i t i o n a n d a c c e p t a n c e of t h e

Nevertheless, it is apparent that the care

(Kealinge 1993), which 1 had the opportu-

ccnlrality of negotiated care in Nursing

orientation of nursing and the context in

nity to undertake during my appointment

has significant implications for long held

which negotiation in nursing takes place,

as a senior nurse manager of a paediatric

beliefs about nurses' roles.

makes 'negotiated care' more than 'negoti-

d e p a r t m e n t . T h i s a p p o i n t m e n t required

Negotiation, a component of

ation' as it is considered in its everyday

me lo assist in the commissioning of a new

usage. In addition, the focus on care that

hospital in which the paediatric depart-

negotiated care

is central to negotiations between nurses

ment is situated and included the manage-

T h e Macquaric Dictionary (1985) defines

and other health practitioners provides a

ment of the relocation ol stall and patients

n e g o t i a t i o n as ' m u t u a l d i s c u s s i o n a n d

shared purpose which distinguishes them

from other hospitals to the new hospital.

arrangement of the terms of a transaction

as examples ol negotiated care.

T h e study was informed by my philo-

or agreement'. I h e underlying notion of bargaining in this statement is reflected in

sophical stance, central to which is the

Examples of negotiated care

c o n c e p t of h o l i s m , in the sense of the

Strauss, Schatzman, Fihrlich, Bucher and

I hree examples of negotiated care serve

n e e d to c o n s i d e r a n d u n d e r s t a n d

Sabshin's (1963:148) description of nego-

to expand the concept. T h e lirst example

whole person. T h e process of understand-

the

tiation as "the process of give and lake, ol

illustrates an instance in which negotiated

ing meanings, interests and goals of those

diplomacy, of bargaining - which charac-

care, between a nurse manager (or leader)

people involved in the change process is

terises o r g a n i s a t i o n a l lile". O t h e r s , by

and nurses, facilitated t h r o u g h the devel-

explained t h r o u g h Silverman's (1970)

h i g h l i g h t i n g that " e v e r y o n e n e g o t i a t e s

o p m e n t of a h u m a n i s t i c e n v i r o n m e n t ,

i n t e r p r e t a t i o n ol t h e A c t i o n Frame of

s o m e t h i n g e v e r y d a y ' ' (Fisher and U r y

resulted in a change process which recog-

Relerence. W h i l e the complexity of the

1981:xi), suggest that n e g o t i a t i o n is an

nised and c o n s i d e r e d b o t h s h a r e d a n d

multi-faceted nature of the changes inher-

e v e r y d a y past t i m e . C o m m o n to these

individual values, interests and goals.

ent in the relocation, as well as the speed why

in which they took place, did not allow

p e o p l e , professionals or lay, n e g o t i a t e

negotiation between nurses and other

for the formal tise of the action research,

with the intent ol furthering their own

health practitioners, an essential process

the process of reflection, p l a n n i n g and

goals and interests.

to maintaining work How in the operat-

i m p l e m e n t i n g , evaluation and reflecting

ing room, is more correctly perceived as

again was central to the c h a n g e process

negotiated care.

that emerged. I litis action research in its

perceptions of negotiation is the lact that

W h e n discussing negotiation,

the

importance of understanding that participants in that process do so Irom their own

Ihe next example identifies

Finally, an example is given in which

broadest sense, which I termed

the

perceptions of the other participants, and

nurses use negotiated care to co-ordinate

'notion' of action research, was a useful

the situation in which the n e g o t i a t i o n s

and deliver care to a m o t h e r and her son.

m e t h o d of c o n c e i v i n g t h e r e l o c a t i o n

lake place, is acknowledged. I heir profes-

In this example, ihe nurses also use the

process in the study.

sional and organisational socialisation, in

n e g o t i a t e d care process to e n s u r e t h a t

T h e N I C l l r e l o c a t i o n involved the

turn, influences these perceptions. Power,

both m o t h e r and son are consulted and

relocation of staff from a hospital where

d e f i n e d by Luke ( 1 9 7 4 ) as w h e n A in

included, by all the health practitioners,

traditions and work practices were well

some way affects B, is an important con-

in the negotiation of care.

established, to a new hospital with no tra-

sideration in ihe context of negotiation,

Thus the following examples ol nego-

ditions. This relocation required both the

especially when considering the relation-

tiated care illustrate the process as it is

tailoring of existing work practices lo a

ship

used in t h e m a n a g e m e n t of c h a n g e , in

new e n v i r o n m e n t and t h e r e c o g n i t i o n

between

nurse

and

patient 1

N e g o t i a t i o n c e n t r e s on interest ;, goals

interdisciplinary work patterns and serves

that it is possible to do things dilferenlly.

and meanings ol individuals and groups. !l

as an illustration of the ideal of negotiated

In this instance of change, the collabora-

is also concerned with the rules that exist

care in nursing practice.

tion and collegiality that nurse leader and Collegian Vol 5 No I ]
best

p r a c t i c e

c l i n i c i a n s shared d u r i n g the change

and we have got to make the best of it -

individual interests occurs In the situation

process, stemmed from creating mutual

we've come through some rough patches

described, all professional staff had worked

trust, support and respect for knowledge

and we have survived and we are still

with each other many times for similar

and self-worth. This, in turn, empowered

together" (Keatinge 1993:280).

procedures, thus the general atmosphere was relaxed with each professional group

all involved in the change process. This culture ol caring and respect relies on

Negotiated care in

being well versed in the procedure and

nurse leaders and nurses being able to

interdisciplinary work patterns

t r u s t i n g of each others' competency.

view each other as people rather than just

The second example illustrates negotiated

Initially, after general greeting, each group

clinicians and managers.

care as it exists in an interdisciplinary situa-

talked technical details, relevant to the

I concluded as a result ol the study that

tion. An existing interest in the notion of

case, amongst themselves. During prepara-

change, such as was inherent in the reloca-

negotiation crystallised when I was working

tion, draping and initial opening of the

t i o n , is f a c i l i t a t e d t h r o u g h creating a h u m a n i s t i c caring environment

that

promotes trust and respect between those -.!,-" f>

people involved in it (Keatinge 1993). This humanistic environment facilitates understanding ol meaning and sharing of goals between nurse manager (or leader) and nurse clinicians. Achieving this environment is dependent on a process of negotiation between nurse leader and clinicians.

in the operating suite ol a large children's

patient, conversation was general and light

A new model termed the Z o n e ol

hospital. This interest led me to undertake

but principally held between anaesthetists

Understood Negotiation (Keatinge, 1993)

a study in w h i c h the question about

and surgeons.

resulted I mm the instance ol change man-

whether a nurse was likely to retain the

Requests (though few were needed)

agement, shared by nurse leader and ntirse

position of manager ol the operating suite,

for instruments were given by the stirgeon

clinicians, which is described in the study.

or whether this would be taken over by a

to the scrub nurse.

I he essence ol the Zone of Understood

person who was not from a health profes-

Negotiation is that a management process

sion, was examined (Keatinge 1987).

Discussion centred around such subjects as the Adelaide Grand Prix, discussed

that is based on understanding, communi-

Silverman's (1970) interpretation ol

amongst males present (there was also a

cation and mutual reliance laciiitates

the Action Frame of Reference, as well as

female anaesthetic registrar as well as the

openness and the flow ol knowledge,

Strauss, Schatzman, Ehrlich, Bucher and

nursing staff)... Conversation then became

tears and p e r c e p t i o n s between nurse

Sabshin (1963) were used in the sttidy to

technical, as a teaching situation for the

leader and clinicians.

explain the differing and shared interests

surgical registrar and resident present. The anaesthetists talked between themselves.

In this relocation the change process

and goals of the actors who participated

was facilitated through negotiation based

in the operating theatre process. T h e

Very little conversation was held during

on understanding meanings, trust, open-

framework also assisted in explaining the

the difficult part of the operative proce-

ness, respect and shared goals. The latter

existence, origins and use ol power by

dure. Scout nurse and scrub nurse did not

were essentially foctised on care of both

these actors.

have general conversation between them-

patients and staff. The process of negoti-

The operating suite arena is an excel-

selves at any time (during my period of

ated care between nurse leader and clini-

l e n t example of a c l i n i c a l c o n t e x t in

observation). At one stage, during the more

cians f a c i l i t a t e d the change process

which people from dillering professional

complex part of the procedure, the scrub

because it became a shared experience,

and lay backgrounds act according to

ntirse made signs to the scotit ntirse to close

b LI i 11 on m u t ti a I ti n d e r s t a n d i n g andtheir differing and competing interests,

the door ol an adjoining sterilising area,

respect, that was achieved together. This

to achieve favourable outcomes. T h e

anticipating the surgeon's impatience with a

n e g o t i a t e d care process, f o u n d e d on

negotiated care process in this context is

noisy instrument cleaner in that area...

shared goals, enabled a senior nurse clini-

illustrated by the process of a surgical

Some bantering about the instruments

cian from the unit to say 10 months after

procedure that 1 witnessed during the

next required by the surgeon took place at

her unit had relocated: "I think our unit's

sttidy. This description assists in illustrat-

low pressure moments between the regis-

growing - 1 think they (her colleagues)

ing negotiated i n t e r d i s c i p l i n a r y work

trar and scrub nurse but all members of

are starting to really think this is our unit

patterns, in which negotiation based on

the team took orders Irom the stirgeon.

3 8 Collegian Vol 5 No I l<)98

r i v e n he, h o w e v e r , was aware o f c e r t a i n

t h i n k s J o h n is worse a n d t h a t he is n o w

S o o n the specialist and John's m o t h e r

constraints o n his behaviour, a l t h o u g h he

v o m i t i n g and appears e x h a u s t e d . She

c o m e out of the r o o m and go into an office

was w i l l i n g to test those c o n s t r a i n t s . For

thinks he should be in I C U . Jane tells me-

across the hall to talk. John's m o t h e r looks

e x a m p l e , he t o o k a delicate needle h o l d e r

d i a l the registrar has rung the staff special-

f r i g h t e n e d b u t her face appears

to try t o b e n d a malleable retractor. T h e

ist w h o is l o o k i n g after J o h n . T h i s doctor,

c o n t r o l l e d . T h e intensivist comes out and

scrub nurse i m m e d i a t e l y r e a c h e d l o r the

w h o n o r m a l l y looks a l t e r a d u l t p a t i e n t s ,

sits w r i t i n g at the nurses' station. Jane and

i n s t r u m e n t e x p r e s s i n g her c o n c e r n a n d

nevertheless has had a n u m b e r o f patients

her c o l l e a g u e , b o t h n o w i n John's r o o m ,

the surgeon laughed, b e i n g fully aware of

in the Adolescent U n i t so the nurses k n o w

talk to h i m and each o t h e r quietly as t h e y

t h e c o n s e q u e n c e s o f hi s a c t i o n o n t h e

h i m quite well.

try to restore some order to the r o o m

needle holder, the care ol w h i c h was the responsibil ity

ol

the

scrub

nurse...

A f t e r a lew minutes I g o r o u n d again

tightly

T h e n i g h t staff arrive and they begin to

His

attend to the other patients. Both the spe-

m o t h e r , w h o has been s t a y i n g w i t h h i m

cialist a n d John's m o t h e r c o m e out of the

negotiation

b o t h because he is so ill a n d because the

office. The specialist is reassuring the m o t h -

is e s s e n t i a l t o t h e s m o o t h f l o w o f t h e

f a m i l y is f r o m the c o u n t r y , also l o o k s anx-

er about John's impending move to I C U . As

( K e a t i n g e 1987:39,40). T h e s t u d y i d e n t i f i e d that

to the U n i t . John looks anxious.

w o r k process carried out w i t h i n the oper-

ious and t i r e d . 1 tell lane t h a t I w i l l wait to

1 hear this I t h i n k to mysell 'this seems to be

a t i n g suite. In retrospect, I suggest that a

sec if J o h n does go t o I C U b c l o r c I g o

going to happen then'. John's m o t h e r goes

part of this n e g o t i a t i o n process, becatise it

h o m e because, ii he doesn't, extra nurses

back i n t o John's r o o m . T h e specialist dis-

is essentially c o n c e r n e d w i t h patient care,

w i l l have t o be f o u n d t o w o r k o n

cusses John's transfer to I C U w i t h the inten-

also comprises n e g o t i a t e d care.

already busy Adolescent U n i t .

the

sivist a n d Jane Jane's colleague reassures

I sit, w a i t i n g , s l i g h t l y a w a y I r o m the

John's m o t h e r in his room.

The ideal in negotiated care,

nurses' station in an area usually used by

S u d d e n l y the nurse and John's m o t h e r

T h e t h i r d example o l negotiated care c o n -

parents, but n o w vacant a n d in semi-dark-

c o m e o t i t o f t h e r o o m , the nurse g e n t l y

cerns a scenario that o c c u r r e d i n a large

ness. F r o m here I can see b o t h the nurses'

h o l d i n g the mother's arm. John's m o t h e r is

teaching hospital. It is stiggested that this

station and John's r o o m . O n e o f the I C U

q u i e t l y s o b b i n g and she leans towards the

illustration reveals the o n t o l o g y of negotiat-

i m e n s i v i s t s comes to see J o h n . H e looks

nurse, apparently tor support. I hey stand in

ed care and demonstrates it at its most ideal.

at J o h n s most recent chest x-ray a n d asks

the shadows outside John's r o o m in silence

Pseudonyms arc used lor all those w h o

Jane, w h o is at the desk, w h a t has been

for a few minutes, the nurse now w i t h her hand resting o n John's mother's shoulder.

participated in this instance of negotiated

happening

care. T h e action is t o l d in story f o r m as this

T o g e t h e r t h e y g o i n t o John's r o o m , a n d

to

John.

Jane

explains.

S l o w l y the c r y i n g subsides a n d Jane

"is a w a y o f h i g h l i g h t i n g t h a t m o r e is

|ane i n t r o d u c e s the i n t c n s i v i s t to John's

walks s o f t l y over to w h e r e the nurse and

i n v o l v e d i n t h e a c t i v i t i e s of c a r i n g f o r

m o t h e r , w h o b a r e l y l a k e s h e r eyes o l t

John's m o t h e r are standing. T o g e t h e r they

patients than the a d m i n i s t r a t i o n a n d t i t r a -

John.

b e g i n t o discuss John's transfer to I C U .

t i o n of drugs, the m a n a g e m e n t o f i n t r a -

J o h n , for w h o m a n s w e r i n g

venous lines or the measuring o f b i o l o g i -

appears j u s i t o o d i f f i c u l t .

cal p h e n o m e n a " ( W i l t s h i r e 1995:76)

I he i n t e n s i v i s t s t a r t s t o e x a m i n e questions

Jane and 1 have agreed that it m i g h t h e l p

S u d d e n l y J o h n v o m i t s , the intensivist

d u t y to transfer t h e m t o I C U and to see

b o t h J o h n a n d his m o t h e r if she stays o n

T h i s story is about an adolescent boy,

grabs the b o w l beside J o h n and the nurse

that

his m o t h e r a n d t h e nurses a n d m e d i c a l

purs her arm a r o u n d John's b a c k t o sup-

E v e n t u a l l y John's m o t h e r goes b a c k i n t o

they

are

both

settled

there.

staff w h o cared l o r h i m . T h e i n t e r a c t i o n

p o r t h i m . A l t e r some t i m e t h e v o m i t i n g

her son's r o o m a n d once m o r e sits beside

c o n t a i n e d in the story is related as I, the

subsides. Jane hands a tissue to John and

h i m h o l d i n g his h a n d .

nurse manager t o r the after hours manage-

takes the b o w l away. John's staff specialist arrives. I le stops Jane as she is about to

Discussion

g o b a c k i n t o John's r o o m w i t h a c l e a n

A l l t h r e e i l l u s t r a t i o n s of n e g o t i a t e d care

manager l o r the hospital. A l l evening lane,

b o w l . T h e registrar, lane a n d the staff spe-

emphasise that integral to this f o r m of

the nurse in charge of the Adolescent U n i t ,

cialist t h e n disctiss John's c o n d i t i o n . A f t e r

n e g o t i a t i o n is a l o c u s o n u n d e r s t a n d i n g

has kept in contact w i t h me about J o h n , a

a w h i l e they all c r o w d i n t o John's r o o m .

meanings, a n d n e g o t i a t i n g and c o o r d i n a t -

15-year-old b o y in the U n i t . J o h n is expe-

T h e specialist m o m e n t a r i l y pats the b e d

i n g d i f f e r i n g and shared interests towards

riencing increasing respiratory distress and

c l o t h e s c o v e r i n g John's legs as he passes

a c h i e v i n g shared goals o l patient care. In

appears e x t r e m e l y i l l . Both Jane and I are

the e n d o f the bed. A l t h o u g h 1 hear the

each of the illustrations nurses play the key

w o r r i e d about h i m . I receive a further tele-

specialist q u i e t l y ask J o h n h o w he is feel-

c o o r d i n a t i n g and negotiating role

p h o n e c a l l f r o m Jane. She says that she

ing i can't hear John's reply.

achieving negotiated care. It is apparent in

m e n t of the h o s p i t a l , observed it. It's late at n i g h t and 1 am the after hours

in

Colk-Mian Vol 5 No 1 1998 3 9

best

practice

each illustration that negotiated care is fun-

an adverse effect on the nurses' ability and

which lo blend "traditional management

damental to the nurses' practice in the dil-

w i l l i n g n e s s to n e g o t i a t e care w i t h t h e

views and the nursing perspective" (Ray

fering contexts in which it takes place.

patient,

(989:31).

[his author attributes these

deficits to nurses having been socialised

Facilitating negotiated care

within hierarchical, bureaucratic organisa-

Powerplays obstructing

T h e first illustration demonstrates negoti-

tional slaictures in which the autonomy for

negotiated care

ated care as it takes place in the manage-

nurses to negotiate is absent (Trnohranski

T h e second illustration highlights issues

ment of change. C h a n g e was negotiated

1994). H o w e v e r , it has been s u g g e s t e d

of power in organisational structures such

on the basis of u n d e r s t a n d i n g meanings

elsewhere (Keatinge 1995) that managers'

as exist in operating suites and elsewhere

a n d interests t o w a r d s a c h i e v i n g shared

attitudes and m a n a g e m e n t styles have a

in the health care arena. This illustration

goals and group cohesion built on trust

greater impact on w h e t h e r cohesion and

d e m o n s t r a t e s h o w p o w e r impacts upon

and r e s p e c t . An e n v i r o n m e n t in w h i c h

the n e g o t i a t i o n of s h a r e d goals can be

n e g o t i a t i o n . P o w e r , in t h e c o n t e x t ol

t r u s t a n d r e s p e c t are e m p h a s i s e d a n d

achieved between nurses, or between nurs-

w h e n A in s o m e way affects B, (Luke

shared goals have a care orientation, is

es and other health practitioners, than do

1974) is manifest in this illustration as the

fundamental to the negotiated care thai

organisational structures. In this regard, the

m e m b e r s of different g r o u p s of h e a l t h

occurs between nurse managers (or lead-

first example of n e g o t i a t e d care clearly

practitioners seek lo influence the action

ers) and nurse clinicians.

illustrates both the impact and importance

that takes place so as to further their own

components

ol management style in facilitating a sup-

interests and goals. In addition, the power

described as the basis for the negotiated

portive organisational environment. In this

differential between players, which mim-

cohesion between nurses in the first illus-

i l l u s t r a t i o n t h e trust and r e s p e c t built

ics traditional power structures belwcen

tration, are in contrast to reasons more

between the nurse leader and nurse clini-

doctors and nurses (Duffy 1995), is obvi-

c o m m o n l y suggested (Lawler [991,- 1 lay

cians, enabled negotiations lo take place

ous in this scenario. Thus, the scrub nurse

and O k e n 1972). T h e s e olten pertain to

on the basis of shared goals (or staff and

dcmonslrales responses towards the sur-

'survival' in a stress-filled work environ-

patient care facilitating c h a n g e s on t h e

geon that reflect behaviour manifest in

ment rather than cohesion

basis of negotiated care.

o p p r e s s e d g r o u p s (Duffy

H o w e v e r,

the

key

achieved

1995,- S t e i n

1967). In the interdisciplinary c o n t e x t ,

through negotiating shared goals and outcomes. In addition, these reasons centre

Skills in negotiated care

Stein (1967) suggests that such behaviour

on nurses' suppression of irritation with

Several authors have highlighted the need

is the basis of the now infamous 'doctor-

colleagues because there is no time to be

for nurses to have the ability to negotiate

n u r s e ' g a m e , a g a m e in w h i c h n u r s e s

angry or because "cooperation is essential

in the corporate context of health if they

ensure that their knowledge is attributed

for the Unit cooperation'' (Hay and Oken

arc lo contribute to the current 'business'

to m e d i c a l staff. Such b e h a v i o u r is in

I972:1'I5). T h i s behaviour in nurses has

orientation of health care organisalions

opposition to the openness, respect and

been described as the 'tyranny of niceness'

(Keatinge 1995 ; Davidhizar 1990, Shaw

trust that is crucial in an environmenl that

by S t r e e t ( 1 9 9 5 ) . T r u s t a n d r e s p e c t ,

1989). Some have called this the ability to

facilitates negotiated care.

described as key components in negotiat-

'horsc-lrade' (del Bueno 1989). However,

In this second illustration the initial

ed care, appear absent in the reasons for

il nurses recognise the key role that nego-

relaxed atmosphere that existed between

cohesion that these authors describe.

liation plays in their nursing practice, and

players stems from their familiarity wilh

Rather, they portray antagonism between

practice the components that facilitate it,

each other and their knowledge that each

nurses. This antagonism, attributed large-

they do not have to acquire new skills in

is competent in their contribution to the

ly

behaviour

o r d e r lo n e g o t i a t e at a c o r p o r a t e level.

surgery. Nevertheless, the manifestations

1992) is

R a t h e r , t h e a b i l i t y to n e g o t i a t e c a r e ,

of power, and the pattern of conversation

labelled by hanon (1963) and others as

learned in the clinical c o n t e x t , e n a b l e s

and negotiation during the surgical proce-

to

o p p rc s s e d

(Wilkinson

group

I992; Ormiston

horizontal violence and depicts a deep rill

nurses to utilise the components ol nego-

dure make evident that the contribution of

between colleagues and a need to under-

tiated care successfully in a variety of are-

each different health practitioner while

mine and disadvantage them.

nas. In addition, this application of nego-

competent, is not considered to be of equal

Identifying negative aspects of a lack of

tiated care and its key components to all

worth. Thus, while in this illustration each

c o h e s i o n b e t w e e n nurses, T r n o h r a n s k i

contexts in which nurses negotiate offers

health practitioner's work contribution is

( 1 9 9 4 ) s u g g e s t s t h a t an o r g a n i s a t i o n a l

a mechanism t h r o u g h w h i c h to address

d i r e c t e d at a c h i e v i n g a s h a r e d goal of

structure in which support and empower-

Ray's ( 1 9 8 9 : 3 1) o b s e r v a t i o n t h a t nurse

patient care, respect, in the sense of respect

ment of nurses is lacking, is likely to have

executives require a mechanism through

between equals is limited and power differ-

4 0 Collegian Vol 5 No I 1998

entials are manifest. Therefore, it is sug-

Numerous

authors

highlight

the

Negotiated care integral

gested that this illustration is of negotiated

increasing pressure on nurses to encourage

to practice

care at its most marginal.

the patient, and, or relative, to participate

A second deficit in the literature concern-

in c a r e d u r i n g a h o s p i t a l s t a y ( K n i g h t

ing negotiation between patient/relative

I 9 9 5 ; T r n o b r a n s k i 199-1,- P a l m e r 1993;

and nurse is the failure to identify that

- the ideal

Smith 1991 and Gallery and Smith 1991).

these negotiations are integral to nursing

In contrast to the continuing power differ-

Several authors suggest that negotiation is

practice. I hus, the literature appears to

entials thai are obvious in the second illus-

an i m p o r t a n t c o m p o n e n t of patient and

p o r t r a y these n e g o t i a t i o n s as requiring

tration, the third illustration demonstrates

nurse interaction involved in the process

a d d i t i o n a l e f f o r t on t h e n u r s e ' s p a r t .

t h a t true n e g o t i a t e d care c o m p r i s e s a

of care planning and information dissemi-

However, it is evident in the third illustra-

process in which interests of the partici-

n a t i o n ( l r n o b r a n s k i 1994; Gallery a n d

tion of negotiated care that this process is

pants are given equal respect in the nego-

Smith 1991,- Krouse and Roberts 1989).

integral to, rather than additional to nurs-

tiation process. T h i s is in opposition to

Nevertheless, increasingly, reservations are

ing practice. It is also evident in this illus-

Respect and recognition

tration (hat the negotiated care process that took place stemmed from respect and concern for, as well as openness to, others' interests, c o m p o n e n t s essential to, rather than additional to, expert nursing practice.

Conclusion Rssential to the practice of negotiated care nurses' c o m m o n l y held p e r c e p t i o n that

expressed about whether a partnership in

is t h e d e v e l o p m e n t of an e n v i r o n m e n t

patients/relatives are dependent upon the

care b e t w e e n patients a n d nurses d o e s

which is characterised by interest in anoth-

nurse to advocate for them. In this way

o c c u r in r e a l i t y ( T r n o b r a n s k i

1994),

er's values and meanings, understanding,

negotiated care is the antithesis of advoca-

whether patients really want to participate

self-worth, respect for another, commit-

cy. It is about caring actions which Street

in their care and, indeed, if they are given

ment, openness, tmst and a willingness to

(1995:36) observes are about empowering

the c h o i c e (Trnobranski 1994, Roberts,

work towards shared goals. Such an envi-

people, but which, given historical taken-

Krouse, and Midland 1995).

r o n m e n t is a h u m a n i s t i c o n e - o n e in which consciousness of one's own worth

f o r - g r a n t e d s in n u r s i n g , r e q u i r e " t h e restructuring ol (nurses') work loads to pri-

Nurses at the centre

and care and concern for another's is para-

oritise time spent with people". T h e latter

of negotiated care

mount (Keatinge 1995, Keatinge 1993).

is e s s e n t i a ! if n e g o t i a t e d c a r e is to b e

D e s p i t e the relevance of t h e s e a u t h o r s '

This environment, because it depends

achieved as this process is concerned with

views to this discussion, these views fail to

on h o n e s t y , o p e n n e s s and trust on t h e

creating an e n v i r o n m e n t in w h i c h each

reflect the lact that nurses not only nego-

part of all who participate in it, takes con-

party's m e a n i n g s and values are u n d e r -

tiate nursing care with t h e patient/rela-

s i d e r a b l e t i m e a n d effort to a c h i e v e .

stood, so that negotiation between patient

tive, but also negotiate and coordinate the

N e v e r t h e l e s s , o n c e a c h i e v e d a n d sus-

and nurse can take place on the basis of

care delivered by all the members of the

tained, this humanistic environment facili-

shared goals and effort to achieve them.

health care team. I hus, at the same time

tates respect and understanding between

T h e final example illustrates a situa-

as n u r s e s are n e g o t i a t i n g t h e p r o c e s s

people that promotes the sharing of val-

tion in which true commitment to negoti-

through which to deliver nursing care, as

ues, meanings and goals and a commit-

ated care results in smooth (lowing, inclu-

well as the patient's/relative's contribution

ment towards achieving shared goals.

sive care. T h e inclusive nature of this care

to that care, they are also giving consider-

is a t t r i b u t a b l e to t h e r e c o g n i t i o n a n d

ation to, coordinating and negotiating the

illustrate negotiated care, this paper has

respect that diflering interests are given in

interests and goals of the care delivered

sought to d e m o n s t r a t e that this form of

t h e n e g o t i a t i o n process. Nurses in this

by o t h e r h e a l t h

negotiation is a key component of nursing

practitioners.

This

T h r o u g h the use of three examples to

scenario play a key role in n e g o t i a t i n g

process of negotiating the overall process

practice, and enhances nurses' ability to

and coordinating the differing interests of

of care delivery that comprises negotiated

negotiate

all t h o s e p a r t i c i p a t i n g in J o h n ' s c a r e ,

care is well illustrated in the third illustra-

humanistic

t o w a r d s a c h i e v i n g a s h a r e d g o a l of

tion where jane plays the key role in this

described as being essential for the devel-

achieving optimum care for him.

process.

o p m e n t of negotiated care is consistent

in v a r y i n g c o n t e x t s . environment

The

previously

Collegian Vol 5 No I 1998 4 1

best

practice

with nursing's orientation to humanistic caring for others as human beings. Thus respect for different, as well as shared, interests and goals and a commitment to working together in an environment of openness and trust, key components ol negotiated care, are also key elements in nursing practice. Through utilising their expertise in negotiated care nurses arc able to facilitate the coordination of care for patients and their relatives, and to contribute a Nursing perspective in negotiations that take place in the wider arena ol health care dclivciy. References Caller y Panel Smith L 1991 A study or the role of negotiation between nurses and the parents of hospitalised children. Journal of Advanced Nursituj 16(7) ; 772-781 Davidhizar R 1990 The best approach is doing 'nothing'. Nursing Management 21(3): '12-44 del Bueno D J 1989 Preparation ol nurse managers. international Nursing Review 36(4): 117-120 Dufry F_ 1995 Horizontal violence: a conundrum lor Nursing G>/Je<;i
New York. 1 ishcr M 1984 Surgeons and anaesthetists - a marriage of convenience. Australian Di 6lh July; I 213 Fishci Rand Ury W 19R1 Getting toyts. Hutchinson Business, Sydney I lay D and Oken D 1972 The psychological ol intensive care unit Nursing. Psychosomatic Medicine 34(2): 109-1 18 Kcatinge D 1987 Operating theatre manatjus -rtnrsfi or others? Unpublished Master in Administration thesis, Kuring-gai College of Advanced Liducation, Sydney Keatinge I!) 1993 And what about «s> Understanding meanings to facilitate people central change Unpublished Phi.) thesis, University of lechnology, Sydney Kcatinge D 1995 Collegiality and collaboration. attitude of structure? hi; Cray G, Pratt R, (eds) Issues in Australian Nursing t, Churchill Livingstone, Melbourne 407-42 I Knight L 1995 Negotiating care roles. Nursing Times 19(7). 31-33 Krouse H J and Roberts. SJ 1989 Nurse patient interactive styles power, control, and satisfaction. Western Journal of Nursing Research 1 1(6): 717-725 LawlcrJ 1991 Behind thesueens. Churchill Livingstone, Melbourne. Luke S 1974 Power. Macmillan Press, London Omiiston T 1992 Auto-immune syndwme — a Nursintl disiwe? Finn National Forum, Nursing Kaleidoscope: Sharpen the Focus, 1-2 June, 1992 Royal College of Nursing, Australia, Adelaide Palmer S ] 1993 Care of sick children by parents: a meaningful role. Journal of Advanced NursiniJ 18(2) 185-191

Ray MA 1989 I he theory or bureaucratic caring for Nursing practice in the organizational culture. Nursing Administration Quarterly 13(2): 31-42. Roberts S J and Krouse I I J 1988 Enhancing Self Care through active negotiation Nurse Practitioner 13(8): 44-52 Roberts S J, Krouse H J and Michaud P 1995 Negotiated and Non negotiated Nurse-Patient Interactions. ( linical Nursing Research 4( 1): 67-77. Shaw S 1989 Nurses in management: new challenges, new opportunities. International Nursing Review 36(6): 179-184 Silverman D 1970 The theoiy of organizations. Fleinmann Lducational Books, London Smith M 1991 Sharing the care Nimint) Times 87(8); 36-38. Strauss A Schatzman L Lhrlich D Bucher R and Sabshin M 1963 The hospital and its negotiated order. In friedson L (ed) The hospital in modern society. Lree Press, New York: 147-166 Stein L I 1967 1 he doctor-nurse game. Aichives of General Psychiatry 16:699-703 1 he Macquaric Dictionary (Revised Ld) 1985 Macquarie Library, Dee Why Street A 1995 Nursing Replay. Churchill I tvingstone, Melbourne "lrnobranski !' 1 I 1994 Nurse-patient negotiation: assumption or reality? Journal of Advanced Nuisini) 19(4): 733-737 Wilkinson J 1992 The caring dimensions of Nursing management. First National Nursing Forum Nursing Kaleidoscope: Sharpen the Focus, 1-2 June, 1992 Royal College of Nursing, Australia, Adelaide Wiltshire J 1995 Telling a story: writing a narrative terminology in health care. Nursing hujuiry 2(2): 75-82.

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