Why do nurses abuse patients? Reflections from South African obstetric services

Nurse-patient relationships are a substantially neglected area of empirical research, the more so in developing than developed countries. Although nursing discourse usually emphasises "caring", nursing practice is often quite different and may be more strongly characterised by humiliation of patients and physical abuse. This paper explores the question: why do nurses abuse patients, through presentation and discussion of findings of research on health seeking practices in one part of the South African maternity services. The research was qualitative and based on 103 minimally structured in-depth individual interviews and four group discussions held with patients and staff in the services. Many of the patients reported clinical neglect, verbal and physical abuse from nursing staff which was at times reactive, and at others, ritualised, in nature. Although they explained nurses' treatment of them in terms of a few 'rotten apples in the barrel', analysis of the data revealed a complex interplay of concerns including organisational issues, professional insecurities, perceived need to assert "control" over the environment and sanctioning of the use of coercive and punitive measures to do so, and an underpinning ideology of patient inferiority. The findings suggest that the nurses were engaged in a continuous struggle to assert their professional and middle class identity and in the process deployed violence against patients as a means of creating social distance and maintaining fantasies of identity and power. The deployment of violence became commonplace because of the lack of local accountability of services and lack of action taken by managers and higher levels of the profession against nurses who abuse patients. It also became established as "normal" in nursing practice because of a lack of powerful competing ideologies of patient care and nursing ethics. The paper concludes by discussing avenues for intervention to improve staff-patient relationships.