(Re)Thinking Violence in Health Care Settings: a critical approach


Holmes, D., Rudge, T. and Perron, A . ( eds .) (Re)Thinking Violence in Health Care Settings: a critical approach . Farnham, Surrey : Ashgate , 2012 , £65.00 (hbk ) xxiv+342 pp . ISBN 978-1-4094-3266-1

Violence is a pervasive if at times subtle aspect of health care settings. This edited collection aims to make overt these subtleties and the ways in which they manifest themselves in the health sector so that they can be opened up for discussion and analysis. The book is organised in three parts, starting with the ways in which institutions contribute to violence through administrative rules, policies and procedures and the bureaucratisation, and technocratisation of health care work. This is followed by sections on horizontal violence among health care providers (and from such providers towards patients), and violence manifested by patients towards health care professionals.

As the editors note in their introduction, defining violence in the work place is a tricky business. The term may be used interchangeably with aggression and is context specific, in that what may be tolerated in some contexts may not be in others. There is also the question of whether it should be broadly defined to include verbal abuse or limited to physical threats and assaults. The editors opt for a broadly based definition, drawing particularly on Foucault, where violence is seen as an instrument of power. From this perspective, violence is more than inflicting harm on individuals; it is also a way of constructing such individuals.

The first section on institutional and managerial violence is the most original. Of particular interest for readers of this journal is Cooke’s chapter on the changing discourse of blame in nursing and health care, drawing on Mary Douglas’s work on how blame is systematically used in the micro politics of institutions. Cooke argues that bullying, conflict and blaming of nurses can be related to institutional changes. The replacement of professional self-regulation with state directed bureaucratic regulation, where hospital management plays an increasingly dominant role, has resulted in nurses losing their independence and becoming increasingly fragmented. Such fragmentation has allowed for a growing culture of blame, with nurses carrying the blame for systemic weaknesses. Other chapters in this section cover topics ranging from the violence of tolerance in a multicultural workplace to a discourse analysis of hospital policies about violence prevention.

In the second section the focus shifts to what the editors call horizontal violence amongst health care professionals, mainly nurses and nurse managers. However it also includes chapters focusing on violence by nurses towards student nurses and towards patients, which would seem to be more suggestive of vertical violence: a point which is acknowledged by one of the contributors to this section when she talks about nurse to student vertical violence.

In the final section attention shifts to patients’ violence, especially in the context of forensic psychiatric nursing. The focus here is not so much about violence itself but about its impact on the therapeutic relationship. An illustration of such a concern is Mercer’s chapter on policing pornography in a high security Personality Disorder Unit. Taking a discourse analytic approach Mercer explores how forensic nurses and mentally disordered sex offenders construct accounts of pornography and offending. His conclusion is that the performative talk of staff and patients contributes to the cultural texturing of a masculine and sexist world, which marginalises female nurses and undermines the unit’s therapeutic ideals.

One of the striking things about this collection of papers is how many of them are informed by theoretical positions, ranging from Foucault to Sacks, and by a variety of disciplines or fields of study including anthropology, gender studies and sociology. While the willingness to embrace such theoretical pluralism is appealing it does have the effect of making the volume less coherent. At the same time some chapters were not explicitly informed by any social or cultural theory, adding to the unevenness of the book. It is also the case that the primary focus is on nursing with little consideration given to other professions in the health care work force. While this is not surprising given the backgrounds of most of the contributors, it does restrict the volume’s contribution to the literature and should have been explicitly acknowledged. Of the eighteen chapters in the book, the majority are written by Canadian or Australian authors, with three coming from UK authors and a similar number from those based in the US. This geographical spread could have provided the basis for making comparisons between health care systems regarding the way in which violence is manifested, but the editors did not explore this opportunity. Finally it is noteworthy that the health care workplace under consideration here is mainly hospital or psychiatric facilities, thereby ignoring how violence impacts on health care workers who practise in the community.

Overall this collection’s main contribution is to reveal the subtle nature of violence for nursing, and the contribution of institutions to this process. Although uneven in quality and narrowly focused on one specific health care profession, it provides a resource for those who are interested in researching the issue of violence in health care and raises important issues for further consideration.