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April 23, 2008

On Power, Abuse, and Disability

Kay Olson, proprietor of the outstanding disability blog, The Gimp Parade, has an absolutely phenomenal pathblogographical post up on power, abuse, and disability.  The setting is Kay's initial stint at a rehabilitation hospital following a month-long stay in an ICU.  The post details Kay's requests for help in order to avoid a pressure ulcer, made to a nurse's assistant Kay names "The Russian" (for the assistant's accent):

She understood I needed to be repositioned and she told me she needed to go get another person to help. It is commonly a two-person job in acute care settings and may even be required procedure, but when she didn't return and my butt began to ache badly from laying in one position too long, I rang the bell again.

The Russian returned alone to tell me she was trying to get help, then left again. I don't know exactly how much time passed, though it was easily 30 minutes since my first call for assistance, and it may have been as long as an hour. My butt was throbbing painfully now, sparks of nerve pain shooting down my leg. In desperation, I spent significant energy wrestling the pillow wedged behind my back away enough that I could shift slightly and ease the sharpest of pain to buy some time.

Shortly after, The Russian returned. Again alone. She saw the pillow had been moved and began berating me: "Why you bother me? You don't need help! You did this yourself after bothering me? If I catch you ever moving by yourself again don't expect me to do anything for you!"

Kay's situation was complicated by her limited ability to speak.  She concludes:

Abuse doesn't really need much space to thrive, and it needs even less to occur only once. Probably not everyone would consider this abuse. But it was a verbal threat to deny me assistance while lying helpless in a bed from someone charged to show up if, say, my ventilator quit giving me air. Like any sort of intimate violence (domestic violence, date rape, etc.), violence against disabled people is contextual and opportunistic and can happen to anyone.

The power of narrative is exemplified in this post.  As they say, go read the whole thing. 


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This example provides the basis for the value of the argument to use professional nurses to pprimary nursing and comprehensive nursing to patients. Both unskilled, but trained and educated professional nurses can effectively turn and reposition a paitnet. But only the professional nurse understands the mechanism of tissue oxygenation, tissue damage and repair, and understands and has the education to assist the patient in planning and implementing a plan of care which will lead to mutually determined optimal patient oputcomes. In this case, those would have included a repositioning schedule with the dependency of the patient and the assistive role of the nurse predetermined, the restoration or maintenance of skin and itssue integrity, the relief or absence of pain and discomfort, and the trust of the patient that when help was requested, that it would be forthcoming in a timely and efficacious manner. Using nursing assistants in the place of professional nurses lead to just this scenario with these preventable outcomes:

-unnecessary pain and discomfort
-tissue degradation and breakdown
-prolonged immobility and joint conractures
-slow and delayed recovery and rehabilitation period
-respiratory complications such as pneumonia from prolonged immobility, failure to maximize chest excursion and respiratory endurance
-anxiety and depression from loss of trust in healthcare provider

In some cases, death results.

All to save a buck and not use the number of baccaluareate educated nurses which are required to deliver professional nursing care to patients who require it.

Hi Annie,

I think you raise a number of excellent points, but I do think it's important to note that the potential abuse inheres in the power dynamics of the context. These imbalances are certainly present in the nurse-patient relationship, and so the potential for abuse remains present even with nurses.

To be sure, this is not inconsistent with your point, and I agree completely that the odds of this kind of abuse taking place is lower with well-qualified nursing care than with paraprofessional care, but I think it is important to note that the potential for abuse inheres in the encounter itself, given the power differential.

Hi Annie,
I do understand your point and generally support it. However, I did have a repositioning schedule. I don't remember if it was in play that first night, but such plans were a general habit in the vent wing of the rehab hospital where I was and every patient in my wing was, to my understanding, supposed to be repositioned frequently. The rehab hospital had a unit especially for healing people with decubitus ulcers and other persistent wounds, so it was a policy all were aware of and supposed to be committed to. This wasn't about lack of education, it was about power and abuse.

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