However, even when doctors do not constrain nurses in the helping interventions they use, the nurses sometimes voluntarily constrain themselves. J McIntosh (1977) found that nurses working in the Oncology Wards of a large Scottish hospital positively advocated the restriction of information about diagnosis and prognosis to all patients. They stated that they believed this was essential to maintaining the morale of patients. In Midwifery, Kirkham (1987) found that midwives in one consultant-led unit consistently used optimistic assurances as a way of deflecting patients' requests for information which might have allowed them to exercise control over their labour. These midwives even had one of their number moved from the unit, when she did not conform with their approach. Menzies (1959) in a qualitative study of the way nurses were managed in a large London teaching hospital stated that: "By the nature of her profession, the nurse is at considerable risk of being flooded by intense and unmanageable anxiety." Menzies argued that nursing care was managed in such a way that this anxiety was constantly denied and avoided. Thus she noted that nursing work was organised into tasks to be performed on different patients, rather than entrusting the total care of a patient to one or a small group of nurses. Task allocation encouraged the nurses to see their job in terms of performing tasks rather than caring for people. She commented on the tendency to depersonalise patients by referring to "the hip in bed ten", rather than using the patient's name. She found that decision making was unnecessarily restricted, and nursing procedures were ritualised to allow little scope for creativity.
NEW SYSTEMS
Menzies has reviewed her 1959 conclusions about the nursing profession, asserting that they remain valid (Menzies Lyth 1988). However, the profession itself can point to certain theoretical, organisational and educational developments which have attempted to address the issues which Menzies raised. Soon after Menzies published her study, Virginia Henderson gave an influential re-definition of the role of the professional nurse:
"The unique function of the nurse is to assist the individual, sick or well, in the performance of those activities contributing to health or its recovery (or to peaceful death) that he would perform unaided if he had the necessary strength, will or knowledge. And to do this in such a way as to help him gain independence as rapidly as possible." (Henderson 1966: 15)
Building on this, the governing bodies in Nursing in the United Kingdom pressed for the universal adoption of the "nursing process" as the basis for the delivery of nursing care by professional nurses. In the nursing process, the role of the nurse is that of a problem-solver. With every patient, her approach must follow a cycle of assessment, planning, care-giving and evaluation (MacFarlane & Castledine 1982). This approach was integrated with theories or "models" of nursing which emphasised a very broad role for the nurse in meeting the physical, psychological and social needs of patients. Menzies' criticisms were influential in highlighting the inadequacies of task allocation, leading to experiments in primary nursing - where a named nurse is totally responsible for the nursing care of each patient (see Salvage 1990 for a detailed review).
STUDENT NURSES
Government accepted the Project 2000 Proposals (UKCC 1986), which greatly increased the theoretical content of nursing education and which made students supernumerary to staffing requirements during most of their training.
Nevertheless, the experience which student nurses will receive in the clinical area from the qualified nurses who act as their role models is unlikely to change radically overnight. Melia (1987) found that one important constraint on communication between student nurses and their patients was the students' uncertainty over the patients' diagnosis, prognosis and treatment. She labelled this "Nursing in the Dark". Melia noted that both doctors and trained nurses frequently restricted the amount of clinical information which was available to the student nurses. J McIntosh (1977) described the way in which doctors (at consultant level at least) were free agents in giving information to patients, or in withholding it. They were able to use information and uncertainty to influence patients to comply with the forms of treatment which they recommended. Several studies corroborate the suggestion that nurses generally accept a subordinate position with regard to disclosure of information, particularly if it is bad news (Faulkner 1985, Glaser & Strauss 1965, McIntosh 1977).
Melia (1987) regarded the socialisation of student nurses as a reflection of the accepted norms for trained nurses. On the basis of what the students said, she argued that Nursing may never claim the same degree of clinical autonomy as Medicine:
"The trappings of profession are present, but the autonomy, it seems, is unattainable so long as the profession of medicine dominates. One of the striking features of the students' accounts was this lack of concern to rid themselves of medical dominance: in fact, they seemed rather to cling to it and take the medical position as their point of reference, or indeed their sanction." (Melia 1987: 181)
If what Melia says is valid, then nurses will be constrained in their use of helping strategies. One can predict that uncertainty reduction strategies will be permissible when the news is good, but that in situations where the news is bad, nurses may not have the authority freely to disclose what they know. Patient control interventions will also suffer from this constraint, particularly in those hospital settings where a medical model is dominant. One is led to predict that on many occasions nurses may fall back on cognitive re-framing techniques as a way of managing the anxieties of patients, rather than resolving them. In some cases these techniques will involve the nurses in trying to induce patients to infer that their situation is safer than the nurses believe it to be. Bok (1978) reviewed the ethical arguments about deceiving patients in what is believed to be their best interests. She summarised the difference between the patients' viewpoint and that of the health care staff:
"The perspective of needing care is very different from that of providing it. The first sees the most fundamental question for patients to be whether they can trust their care-takers. It requires a stringent adherence to honesty in all but a few carefully delineated cases. The second sees the need to be free to deceive, sometimes for genuinely humane reasons. It is only by bringing these perspectives into the open and by considering the exceptional cases explicitly that the discrepancy can be reduced and trust restored." (Bok 1978: 241)
This tension between a respect for autonomy and a desire to act always in the best interests of the patient is a recurrent theme in debates over the ethics of health care (Beauchamp & McCullough 1984).