Authoritarianism and Autonomy. 2. Power, Politics and Alienated Nursing Care in a South African Primary Health Care System

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Abstract
In this paper the authors extend the predominantly etic analysis of the Soweto Community Health Centre System's macrostructural and managerial factors presented in Part 1 (Seedat & Nell, this issue), to an emic analysis at the microlevel of interpersonal processes and practices among nursing staff. Content analysis of interviews with 18 nurses one year after they had completed a psychological skills-training programme revealed five key constraints on the development of nurse autonomy and integration of psychological with biomedical treatment modalities: (1) Dichotomization of biomedical and psychosocial treatment modalities; (2) Inadequately explained instructions; (3) Contradictions between official roles and organizationally determined powerlessness; (4) Time-limited effects of psychological skills training on patient referral patterns; and (5) Invasion of nurse-patient boundaries by superiors. Positive effects of training were evident in only two areas: (a) Improved conflict resolution skills in relationships with family and peers; and (b) Attempts at self-initiated application of psychological skills during routine treatment of patients. The findings are discussed in relationship to the wider organization, and in particular the attitudes and actions of matrons toward nursing staff. This suggests that in the absence of organizational changes to reduce the ambiguity of role definitions and power relationships between nurses, matrons, doctors and management, the development of holistic and empowering primary health care cannot prosper. In conclusion, some suggestions are presented as to the nature of these changes at the conceptual and organizational levels of primary health care provision.

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