How would you define the term medicalisation?

“Medicalisation is the process by which human conditions and problems come to be defined and treated as medical conditions, and thus become the subject of medical study, diagnosis, prevention, or treatment” (source http://en.wikipedia.org/wiki/Medicalization)

 

Our every day concerns, lifestyles, issues, bodily changes become the interest of medical and psychiatric practitioners who seek to identify, classify, diagnose and then sell a treatment or cure for conditions that actually arise within everyday social life. This becomes the “pill for every ill’ approach. It also of course involves surgery.

 

Pharmaceuticalisation’ is a related term whereby drug companies engage in research, development and marketing of drugs to deal with what might otherwise be social, personal or political problems.

 

 

Ben Goldacre (2008), has argued that medicalisation may be a:

 

  “….reductionist, bio-medical explanations for problems that might more sensibly and constructively be thought of as social, political, or personal…..this medicalisation of everyday life isn’t done to us; in fact, we eat it up.” 

 

 

So what does he mean by this phrase? The first word is ‘reductionist’. This means to reduce complex phenomena down to simpler parts. That is to say we break it down in an attempt to understand or explain it.

 

Take the phenomenon of depression. If we reduce it down and say it is something that occurs in the brain, to say that it results from imbalances in brain chemistry, and that is all it is, we have reduced it down to chemical reactions.

 

The second word he uses is ‘bio-medical’. This means that we understand a phenomenon by referring to biology, physiology, anatomy and the knowledge generated by medical science. Again take depression. I have already reduced it to a bio-medical explanation by referring to it brain chemistry. This is a reference to physiology and the anatomy of the brain to explain depression.

 

Medicalisation then, is to take the social, political or personal problems that people have and turn them into medical conditions. This then allows us to seek a medical explanation and or treatment for what otherwise might be social ‘problems’ requiring social solutions.

 

Obesity: is this a social or medical problem? Think about the root causes. Are the solutions surgical or social or political or a mixture of all? What might result if we only see it as medical/physiological issue? Orlistat as the solution?

 

Consider, Insomnia: the subjective experience of not getting enough sleep. A reductionist bio-medical view might seek answers in the imbalances in hormones, perhaps caused by stress, which releases corticosteroids. The medical answer may be the prescription of a sleeping pill. The word itself ‘Insomnia’ is a medical term, people talk about lack of sleep but because the word is so well known we have adopted a medical term for an experience that might not be medical in origin.

 

Goldacre talks of personal problems…what if long hours at work and money worries is the root cause? These are not medical problems, they are social, personal, and some would argue political in a culture that values long hours.

 

 

Consider hair loss. Male pattern baldness, is this a medical problem? Is it a problem at all? In so far as it is, it may be due to ideas about the ideal male body than any medical deficit. Yet baldness is discussed in terms of ‘cure’ in some magazines as if it were a disease.

 

So, are we taking normal human behaviour and normal stages in human development and making them into new medical conditions? Drug companies investigate and create products (antidepressants) to deal with ‘normal’ sadness, or childhood behaviours (e.g. Ritalin).  

 

 

 

Health journalist John Naish asks if we are turning normal human behaviour and normal stages in human development into medical conditions. It is estimated that 10 per cent of British people take anti-depressants and 10 per cent of American children take Ritalin to control their behaviour. It seems that a new mental illness is invented every week, covering every potential quirk in the human condition, such as Restless Leg Syndrome, Social Anxiety Disorder, Female Sexual Dysfunction and Celebrity Worship Syndrome.

 

http://www.bbc.co.uk/programmes/b00jcjc5

 

 

 

 

Medical Intervention and Counter productivity.

 

 

Ivan Illich:  iatrogenesis and counterproductivity.

 

Iatrogenesis means ‘brought forth by the healer’ (greek: iatros = healer; genesis = brought forth by) and so an iatrogenic disease/injury is one caused by medics. Illich argued (1976, p 24):

 

‘the pain, dysfunction, disability and anguish resulting from technical medical intervention now rival the morbidity due to traffic and industrial accidents and even war related incidents and make the impact of medicine one of the most rapidly spreading epidemics of or time.’

 

 

 

Counterproductivity

 

Counterproductivity occurs when the institutions of advanced industrial society reach a certain threshold and cease to be useful; their activities begin to go against their stated aims. Consider the medicalisation in large hospitals of childbirth, of death and of mental distress, which often resulted in outcomes that were far from helpful for many people. The counterproductivity of dealing with these issues may have been recognised, as arguments began to be put forward in the late 20th century for death, childbirth and mental illness should be taken out of large institutional care.

 

A modern case may be care of the elderly. Many frail elderly people are now ‘cared for’ in larger and larger care homes as costs rise and families can no longer cope. The transformations in society that have required families to be mobile in search of work, now results in the isolation of many elderly people from mainstream society while society itself is struggling to come to terms with the costs of social care (Dilnot 2011). The ‘care industry’, as it is becoming, may soon become counterproductive in the sense that the aim of providing a home and social care occurs in a context which militates against providing those aims to acceptable standards.

 

Care home companies state that the care their residents receive is more than adequate and that the Care Quality Commision provides a measure of protection and quality for all residents. These companies would be unlikely to accept accusations of counterproductivity. However, it is the social institution and the social devaluation of care, which they are a part of, that could become counterproductive.

 

 

While developing the theory of counterproductivity, Illich collected statistics to support his case, so what is the evidence for this phenomenon today? The rise of evidence-based medicine (Sackett et al 1996), it could be argued, is in part (or primarily) a response to practices that had not only little in the way of evidence to support their efficacy but also as a result of a growing awareness of the damage some practices inflicted.

 

It is important to distinguish between illness and injury caused by negligence and incompetence (e.g. surgical swabs left in situ after surgical closure), and that caused by the very practice of medicine itself when undertaken by its own rules and procedures. In addition a distinction could be made between harm to individuals and harm to society. The latter may result in focusing on medical answers to (social) problems, which deflect attention away from social answers.

 

An indication of the scale and types of harm caused to patients can be seen on the National Patient Safety Agency (NPSA) website: http://www.npsa.nhs.uk/. Consider two areas that feature in the literature: medication errors and nutrition in hospital.

 

The first type of iatrogenesis is clinical, and involves physicians, surgeons and other healthcare professionals causing harm by negligence, incompetence and the application of techniques with questionable efficacy.

 

 

Illich also argued for the existence of social iatrogenesis, which:

 

“obtains when medical bureaucracy creates ill health by increasing stress, by multiplying disabling dependence, by generating new painful needs, by lowering the levels of tolerance of discomfort or pain, by reducing the leeway that people are wont to concede to an individual when he suffers, and by abolishing even the right to self-care. Social iatrogenesis is at work when healthcare is turned into a standardised item, a staple; when all suffering is hospitalised and homes become inhospitable to birth, sickness and death; when the language in which people could experience their bodies is turned into bureaucratic gobbledygook; or when suffering, mourning, and healing outside the patient role are labelled a form of deviance.”  (1976 p49.)

 

Social iatrogenesis refers to the process by which ‘medical practice sponsors sickness by reinforcing a morbid society that encourages people to become consumers of curative, preventive, industrial and environmental medicine’. It makes people hypochondriac and too willing to place themselves at the mercy of medical experts—a dependence on the medical profession that allegedly undermines individual capacities. The way society deals with death and dying are topics which may fall into this category and we will return to this later.

 

Cultural iatrogenesis implies that societies weaken the will of their members, by paralysing ‘healthy responses to suffering, impairment and death’. Here, the whole culture becomes ‘overmedicalised’, with doctors assuming the role of priest, and political and social problems entering the medical domain.

 

Palmieri et al (2007), outline technological iatrogenesis (in addition to Illich’s clinical, social and cultural iatrogenesis) in which modern healthcare has been characterised by a plethora of technologies including information technology. These technologies of course enhance healthcare practice but, they argue, have introduced new ways of causing harm which needs addressing by risk management.

 

Doctors themselves are aware of the process (Moynihan et al 2002)

 

 

An editorial in the British Medical Journal warned of inappropriate medicalization leading to disease mongering, where the boundaries of the definition of illnesses are expanded to include personal problems as medical problems or risks of diseases are emphasized to broaden the market for medications. The authors noted:

 

 ”Inappropriate medicalisation carries the dangers of unnecessary labelling, poor treatment decisions, iatrogenic illness, and economic waste, as well as the opportunity costs that result when resources are diverted away from treating or preventing more serious disease. At a deeper level it may help to feed unhealthy obsessions with health, obscure or mystify sociological or political explanations for health problems, and focus undue attention on pharmacological, individualised, or privatised solutions.”

 

Citing anecdotal case studies they were familiar with, the authors suggested further systematic research into this field to better understand the extent of influence this inappropriate medicalization has on public perception and the medical field.

 

 

 

 

 

The patient as willing consumer

 

However, as Goldacre suggested above “we eat it up”. We, the public, often demand medical interventions to ease our social problems. Illich’s work might overplay medical dominance and underplay our modern connivance as consumers of health services and practices.

 

 

Ballard, K. and Elston, M. (2005) Medicalisation: A multi dimensional concept. Social theory and Health 3: 228-241

 

Originally, the concept of medicalisation was strongly associated with medical dominance, involving the extension of medicine’s jurisdiction over erstwhile ‘normal’ life events and experiences.

 

More recently, however, this view of a docile lay populace, in thrall to expansionist medicine, has been challenged. Thus, as we enter a new era with increased concerns over risk and a decline in the trust of expert authority, many sociologists argue that the modern day ‘consumer’ of healthcare plays an active role in bringing about or resisting medicalisation.

 

Earlier accounts of medicalisation over-emphasized the medical profession’s dominating (imperialistic) tendencies and often underplayed the benefits of medicine.

 

With a consideration of the social context in which medicalisation arises, we argue that medicalisation is a much more complex, ambiguous, and contested process than the ‘medicalisation thesis’ of the 1970s implied.

 

As we enter the 21st century where expertise is being challenged and health is being seen as commodity to be bought and sold, where patients are customers, understanding medicalisation as a one way process (doctor to society) as the result of medical dominance alone is clearly insufficient.

 

 

 

 

 

 

 

 

 

 

 

 

References

 

 

Goldacre, B. (2008) The Medicalisation of Everyday life. Bad Science. [online] http://www.badscience.net/2008/09/the-medicalisation-of-everyday-life/

 

Illich, I (1976) Limits to medicine; medical nemesis, the expropriation of health. Marion Boyars. London

 

 

Moynihan, R., Heath, I., Henry, D. (2002). “Selling sickness: the pharmaceutical industry and disease mongering”. BMJ 324 (7342): 886-891.

 

Palmieri, P., Peterson, L., and ford, E. (2007) Technological iatrogenesis: new risks force heightened management awareness. Journal of Healthcare Risk Management, 27 (4) pp 19-24

 

 

 

Defining health

The World Health Organisation’s definition

 

WHO definition of Health

Health is a state of complete physical, mental and social well-being and not merely the absence of disease or infirmity.

Preamble to the Constitution of the World Health Organization as adopted by the International Health Conference, New York, 19-22 June, 1946; signed on 22 July 1946 by the representatives of 61 States (Official Records of the World Health Organization, no. 2, p. 100) and entered into force on 7 April 1948.

The Definition has not been amended since 1948.

 

 

This is a pretty idealistic view of health and does not take into account people with a mental or physical disability, who by the above definition are not healthy. Athletes who took part in the Paralympics in London in 2012 may disagree with the above as perhaps would Stephen Fry, who publicly discussed his own Bipolar disorder. The word ‘complete’ is controversial

 

However it allows us to list the:

 

Physical

Mental

Social

 

These 3 aspects of health take us beyond a biophysical definition.

 

 

 

 

There are other classificatory systems in existence such as the WHO Family of International Classifications, including the International Classification of Functioning, Disability and Health (ICF) and the International Classification of Diseases (ICD). These are commonly used to define and measure the components of health.

 

The WHO’s 1986 Ottawa Charter for Health Promotion further stated that health is not just a state, but also “a resource for everyday life, not the objective of living. Health is a positive concept emphasizing social and personal resources, as well as physical capacities.”

 

So in this charter, health is seen as a ‘resource’.

 

The WHO also defines mental health as “a state of well-being in which the individual realizes his or her own abilities, can cope with the normal stresses of life, can work productively and fruitfully, and is able to make a contribution to his or her community”.

 

Again this might sound a bit too idealistic in that people with a mental illness can also live ‘normal’ (whatever that is) lives. Why are they not healthy then?

 

The New Economics Foundation (Aked and Thompson 2011) argue that there are 5 ways to well-being (‘well-being’ is a component of health):

 

1. Connect…

 

With the people around you. With family, friends, colleagues and neighbours. At home, work, school or in your local community. Think of these as the cornerstones of your life and invest time in developing them. Building these connections will support and enrich you every day.

 

2. Be active…

 

Go for a walk or run. Step outside. Cycle. Play a game. Garden. Dance.Exercising makes you feel good. Most importantly, discover a physical activity you enjoy and that suits your level of mobility and fitness.

 

3. Take notice…

Be curious. Catch sight of the beautiful. Remark on the unusual. Notice the changing seasons. Savour the moment, whether you are walking to work, eating lunch or talking to friends. Be aware of the world around you and what you are feeling. Reflecting on your experiences will help you appreciate what matters to you.

 

4. Keep learning

 

Try something new. Rediscover an old interest. Sign up for that course. Take on a different responsibility at work. Fix a bike. Learn to play an instrument or how to cook your favourite food. Set a challenge you will enjoy achieving. Learning new things will make you more confident as well as being fun.

 

5. Give…

 

Do something nice for a friend, or a stranger. Thank someone. Smile. Volunteer your time. Join a community group. Look out, as well as in. Seeing yourself, and your happiness, linked to the wider community can be incredibly rewarding and creates connections with the people around you.

 

Social Determinants of Health

 

The approach that has gained influence is that of understanding health as having social determinants (WHO 2008), while Barton and Grant (2006) have developed a health map illustrating the complex interplay of the physical and global environment, social relationships and individual biology.

 

The social determinants of health approach (WHO 2008) suggests ‘Social justice is a matter of life and death. It affects the way people live, their consequent chance of illness, and their risk of premature death. We watch in wonder as life expectancy and good health continue to increase in parts of the world and in alarm as they fail to improve in others’.

 

Thus we clearly see a link between ideas about what health is and social justice. Health is therefore inextricably bound up with how we organise our societies. It is no longer to be understood as a bio-physical concept only. WHO argues:

 

‘The social determinants of health are the conditions in which people are born, grow, live, work and age, including the health system. These circumstances are shaped by the distribution of money, power and resources at global, national and local levels. The social determinants of health are mostly responsible for health inequities – the unfair and avoidable differences in health status seen within and between countries’. 

 

See http://www.who.int/social_determinants/en/  (Commission on Social Determinants of Health 2008).

 

 

The Health Map

see: http://eprints.uwe.ac.uk/7863/2/The_health_map_2006_JRSH_article_-_post_print.pdf

 

Barton and Grant at about the same time produced a ‘health map’ and argued:

 

 

‘The environment in which we live is a major determinant of health and well-being. Modern town planning originated in the nineteenth century in response to basic health problems, but in the intervening years has become largely divorced from health. We have been literally building unhealthy conditions into our local human habitat.

 

Recent concerns about levels of physical activity, obesity, asthma and increasing environmental inequality have put planning back on the health agenda. It is widely recognised that public health is being compromised by both the manner of human intervention in the natural world and the manner of development activity in our built environment (Larkin, 2003). However, taking action is not necessarily simple. The links between health and settlements are often indirect and complex. A tool to improve understanding and foster collaboration between planning and health decision-makers is badly needed’.

 

 

 

 

 

The health map was inspired by theories about how the eco system interacts with biological species, which is clearly seen in the outer ring. An implication of seeing health in this manner is that the individual’s health is caught up in a web of complex systems and requires the ‘health’ of all manner of interacting physical and non-physical phenomena.

 

 

 

 

 

 

 

 

 

Healthy Planet, Healthy Lives?

 

 

Another view firmly connects the planet to people as a unitary whole arguing that as a result an individual is not healthy if the planet is not. This critiques a dualist view of reality in which we can separate physical human bodies from the physical universe, seeing them as two distinct entities. This may seem obvious to those of us living in western societies, as this is how we are brought up to consider how the world is. This has a long tradition but other philosophical traditions make no distinction between ‘man’ and ‘nature’:

 

“In this century it has become clear that the fundamental social problem is now the relationship between humankind as a whole and our global environment” (Loy 1988 p 302).

 

David Loy (1988 p140) argues, when contrasting Eastern traditions (nondualist) with mainly Western (Cartesian) dualism, that

 

“….there is no distinction between “internal” (mental) and “external” (physical), which means that trees and rocks and clouds, if they are not juxtaposed in memory with the “I” concept, will be experienced to be as much “my” mind as thought and feelings”.

 

This then is a non-dualist viewpoint in which ‘us’ includes the biosphere, we are indivisible as human beings from all life forms and all matter.

 

Industrialization has required the control of nature to serve humanities purposes. This control is based upon seeing ‘the self’ in opposition to nature, which Yagelski (2011) calls  ‘the problem of the self ‘:

 

“My argument here is that the prevailing Western sense of the self as an autonomous, thinking being that exists separately from the natural or physical world is really at the heart of the life-threatening environmental problems we face”.

 

These problems include: Ocean acidification, fertile soil erosion, species loss and the loss of biodiversity, fish species depletion, imbalances in the nitrogen and phosphorous cycles, fresh water scarcities, chemical pollution and stratospheric ozone depletion.

 

Rockström et al (2009) suggest that we need to urgently consider these issues to ensure there is a ‘safe operating space for humanity’.

 

 

 

 

Another view on health stemming from philosophers such as Aristotle who discussed eudaemonia or ‘flourishing’, or Amartya Sens’ views on ‘capabilities’ as an aspect of human health welfare:

 

Sen argued for five components in assessing ‘capability’:

 

1. The importance of real freedoms in the assessment of a person’s advantage.

2. Individual differences in the ability to transform resources into valuable activities.

3. The multi-variate nature of activities giving rise to happiness.

4. A balance of materialistic and nonmaterialistic factors in evaluating human welfare.

5. Concern for the distribution of opportunities within society.

 

 

This really stretches definitions of health to include ideas around welfare and the social and economic conditions for it.

 

 

Summary

 

Health involves our physical selves, the biology of our bodies which does not have to ‘perfect’. However health also involves our mental well-being, our abilities to cope with the world. Health involves social relationships and communities. Health involves our relationship to eco systems and other species. Health is therefore a complex concept that can be defined in various ways according to the perspectives we care to take on it.

 

 

 

 

 

Aked, J., and Thompson, S. (2011) Five ways to wellbeing. New applications, new ways of thinking. New Economics Foundation. London http://www.neweconomics.org/sites/neweconomics.org/files/Five_Ways_to_Wellbeing.pdf

 

 

Barton, H. and Grant, M. (2006) A health map for the local human

habitat.  The Journal for the Royal Society for the Promotion of

Health, 126 (6). pp. 252-253. ISSN 1466-4240

 

Larkin, M., (2003), Can cities be designed to fight obesity, The Lancet, 362, pp1046-7

 

Rockström, J., W. Steffen, K. Noone, Å. Persson, F. S. Chapin, III, E. Lambin, T. M. Lenton, M. Scheffer, C. Folke, H. Schellnhuber, B. Nykvist, C. A. De Wit, T. Hughes, S. van der Leeuw, H. Rodhe, S. Sörlin, P., K. Snyder, R. Costanza, U. Svedin, M. Falkenmark, L. Karlberg, R. W. Corell, V. J. Fabry, J. Hansen, B., Walker, D. Liverman, K. Richardson, P. Crutzen, and J. Foley. (2009). Planetary boundaries: exploring the safe operating space for humanity. Ecology and Society 14(2): 32. [online] URL: http://www.ecologyandsociety.org/vol14/iss2/art32/

 

 

World Health Organization. (1986) The Ottawa Charter for Health Promotion. Adopted at the First International Conference on Health Promotion, Ottawa, 21 November 1986 – WHO/HPR/HEP/95.1.

 

World Health Organization (2004). Promoting Mental Health: Concepts, Emerging evidence, Practice: A report of the World Health Organization, Department of Mental Health and Substance Abuse in collaboration with the Victorian Health Promotion Foundation and the University of Melbourne. World Health Organization. Geneva

 

Yagelski, R. [online] Computers, Literacy and Being. Teaching with technology for a sustainable futurehttp://www.albany.edu/faculty/rpy95/webtext/

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

How might social factors influence experiences of health & illness?

…and ‘How might this be relevant to the work of the nurse’?

 

 

What do we mean by social factors? This term covers a multiple meanings, but lets start by thinking about what people and society do and the categories we place ourselves, and others, into. A social factor then is something that might have an effect on us as we go about our daily lives as social actors. Emile Durkheim in ‘The Rules of Sociological Method’ (1895) wrote about ‘social facts’ as almost having a life of their own:  “treat social facts as things” existing outside of our individual consciousness. The common categories or factors include things like:

 

 

Socio economic status.

Ethnicity.

Gender.

 

We might also want to consider social structures such as:

 

Family.

Leisure, Work and Occupations.

Education.

Politics.

Military–Industrial Complex.

Religion.

Consumer-Industrial Complex.

 

Before we proceed just consider how the above social structures have changed over time.

 

The following will discuss obesity and a heart attack using our sociological imagination. I will then consider the relevance for nursing.

Obesity

 

To illustrate how any of these affect health we could take the issue of Obesity. Why are populations globally all getting fatter over the past couple of decades? A biological explanation founders in that it requires some biological mechanism that has changed for billions of people. Evolution does not work that fast. As there are differences between groups of people and individuals there is something psychological and or sociological happening.

 

It might be linked to one’s socio-economic status, as we know that poverty and economic and social deprivation are correlated to increased weight in populations. McLaren (2007) argues that obesity is a social phenomenon. That is to say it is just not a physical or biological condition to be explained or dealt with only in physical terms (e.g. the injunction to eat less and exercise more). Action on obesity includes targeting both economic and sociocultural factors. McLaren illustrates the varying social patterns involved in level of obesity in this review of studies.

 

Roberts and Edwards (2010) suggest that world-wide, over a billion adults are overweight and 300 million are officially obese. Their book ‘The Energy Glut’ suggests that how energy is both sourced, e.g. oil, and used, e.g. car driving, is directly linked to growing obesity. They suggest ‘fatness’ and climate change, are manifestations of the same fundamental cause. It is down to how oil based fossil fuel energy, after being discovered, started not only the process of catastrophic climate change, but also propelled the average human weight distribution upwards.

 

In addition they suggest that the food industry uses sophisticated marketing techniques to sell us mountains of energy-dense food whilst at the same time we are ‘functionally paralysed’. We just don’t move about as we used to, partly because the opportunities to do so diminish. This could be seen especially in the UK with increased car use, road building, living miles from work and the growth of retail outlets built out of town to exploit car use, poor public transport and poor cycling infrastructure. The accumulation of body fat is therefore a political, not a personal, problem.

 

 

 

 

 

 

 

The Information Centre has published Statistics on Obesity, Physical Activity and Diet: England 2012. The topics covered in the report include, overweight and obesity prevalence among adults and children, physical activity levels among adults and children, trends in purchases and consumption of food and drink and energy intake and health outcomes of being overweight or obese.

 

http://www.ic.nhs.uk/pubs/opad12

 

Key facts

         In 2010, just over a quarter of adults (26 per cent of both men and women aged 16 or over) in England were classified as obese (BMI 30kg/m2 or over). For the same period, around three in ten boys and girls (aged 2 to 15) were classed as either overweight or obese (31 per cent and 29 per cent respectively).

         In 2010, 41 per cent of respondents (aged 2+) said they made walks of 20 minutes or more at least 3 times a week and an additional 23 per cent said they did so at least once or twice a week in Great Britain (GB). However, 20 per cent of respondents reported that they took walks of at least 20 minutes “less than once a year or never” in GB.

         In 2010, 25 per cent of men and 27 per cent of women consumed the recommended five or more portions of fruit and vegetables daily.

         The number of Finished Admission Episodes (FAEs) in NHS hospitals with a primary diagnosis of obesity among people of all ages was 11,574 in 2010/11. This is over ten times as high as the number in 2000/01 (1,054).

 

 

In 2010, there were 1.1 million prescription items for the treatment of obesity, a 24 per cent decrease on the previous year when 1.4 million items were dispensed. This is the first recorded decrease in seven years.

 

 

 

Heart Attacks

 

Wright Mills (1959) wrote:

 

 ‘…men (sic) do not usually define the troubles they endure in terms of historical change…’ (p3).

 

A middle aged man has a heart attack but he does not consider that his illness may be linked to living in the 21st century, or that the roots of his illness may lie in current society.

 

He is:

 

 ‘…seldom aware of the intricate connection between the patterns of their own lives and the course of world history.’ (p4).

 

Lying in a hospital bed, with ECG electrodes stuck to his chest, the man may curse his luck or put his condition to being overweight, his smoking habit and lack of exercise.

 

He does not:

 

‘…possess the quality of mind essential to grasp the interplay of man and society, of biography and history…’  (p4). 

 

In addition he:

 

‘..cannot cope with their personal troubles (his heart attack) in such ways as to control the structural transformations that lie behind them.’  (p4).

 

(my italics).

 

What ‘structural transformations’ (social factors) might lie behind the heart attack, or an eating disorder or binge drinking? What is a ‘structural transformation?’

 

If we think of society has having ‘structures’, which vary from society to society and which varies within the same society over time (history), we may begin to understand that society ‘works’ when individuals, groups, communities and populations decide to act out their relationships one with another and in doing so create (and are created by) social ‘structures’.  I have listed some structures on page 1.

 

In the above heart attack case what structures are there and what are those structures that lie beneath his personal trouble?

 

To help answer that question Wright Mills argued that:

 

‘what they need…is a quality of mind that will help them to use information and to develop reason in order to achieve lucid summations of what is going on in the world and of what may be happening within themselves…this quality…(is) the sociological imagination.’ (p5).

 

So we need to use information and reason to start making the links between society and illness. A heart attack results from a variety of sources. Some may be genetic, but others are patterns of living which are subject to social structure. The middle aged man just happened to have been born in the 1950’s into a working class background in Liverpool. His father worked as a docker and he in turn followed in his father’s footsteps.

 

Social class is a form of social structure. Living in working class Liverpool during the 1950’s to the 1970’s means engaging in certain eating habits, wearing certain clothes, taking holidays in certain places (in the UK) and following certain football teams. And, of course, smoking. Smoking is as natural an activity as breathing, even Division One footballers smoke. The ‘metrosexual’ man does not exist yet, there are no ‘Men’s Health’ magazines, cigarettes are cheap, there are no laws banning smoking in public places. The idea of working out in a gym does not feature except in the working class boxing clubs. Olive oil and the Mediterranean diet exist only in the Mediterranean. Eating (saturated fat) red meat is masculine. ‘Jogging’ has not entered into the English language yet, exercise is for athletes or only takes place when playing Sunday football for the local pub team. Car use is becoming more common and cycling is in decline. Margaret Thatcher was soon to say that a 30 year old man on a bus is a failure so public transport is only for those who have to.

 

The social structure of this man’s early years involve lifestyles that increase his chance of a heart attack but he was not aware of all the connections. He thinks all his choices are his own, but he is unaware that choice is limited and results from those chances handed out to him. His choices are also based on imperfect information and also upon the wishes of others who want him to make certain choices (e.g. the cigarette manufacturers). If the society in which he lives offers him the choice of A, B and C and he chooses A, he may think he has made a real choice. But what if there is choice F, G and H that he is not aware of through circumstance or that history has not yet provided?

 

in 1950, one could choose to smoke anywhere and the lack of a strong public health campaign and research evidence did not point to the deadly nature of the practice. The personal trouble of smoking has to be seen in the context of that history.

 

Fast forward to 2010 and a new historical period. The public issue of millions dying of lung cancer has affected change in society and now impacts differently upon the individual. Social structures have been transformed since the 1950’s. For example, we now think of smoking not as glamorous but as a ‘filthy habit’. Men no longer congregate in pubs where everyone smokes inside.

 

‘The sociological imagination enables its possessor to understand the larger historical scene in terms of its meaning for the inner life….’ (p5).

 

Thus, the middle aged heart attack victim who has this ‘quality of mind’ would understand his present trouble as linked to the context of 1950’s Britain where working class life took smoking for granted. He knows that all his friends smoke and that the likelihood of him smoking is high, given the social context and the time in which he lives.

 

 

Nursing relevance

 

This depends on where the nurse works. In an intensive care unit or in many acute settings, it is irrelevant to the everyday clinical practice of giving physical care. In primary care however, understanding how social factors impact on people’s lives may suggest strategies for mitigating them and for engaging in health promotion and health education. The obvious is knowledge for healthy eating habits or exploring personal physical activity levels.

 

However, certain issues will require action at the community or political level. This calls into question the social and political role both for the individual nurses and for nursing as a profession. Public health is a core part of nurse education and thus understanding social causes for ill health is part of the public health role for nursing. Wright Mills argues that it is the job of the social scientist or the liberal educator to foster the sociological imagination so that people become aware of how social factors (in our case) affect health and illness. We could argue that this applies to nurses in that once we know what causes disease we might have a duty to do something about it at the social level if it is caused by social factors (i.e. the ‘Social Determinants of Health’).

 

At the very least we should be very wary of victim blaming or accepting wholesale simplistic arguments over personal responsibility, see for example Wind Cowle (2012), while at the same time we do very little to curb fast food outlets, regulate the food industry, curb car use through urban planning or encouraging active travel alternatives such as cycling. 

 

Nursing has various elements to it: giving direct patient care, working in a team, managing oneself and personal development. To that we could add the need for networking and political awareness to exercise nursing leadership. Therefore I suggest that developing an understanding of the social factors involved in health and illness can assist a nurse in developing in these various elements to various degrees regardless of where one works.

 

 

Benny Goodman 2012

 

 

 

 

References.

 

McLaren, S. (2007) Socioeconomic status and obesity. Epidemiological Reviews 29 (1): 29-48.http://epirev.oxfordjournals.org/content/29/1/29.abstract

 

Roberts, I. and Edwards P (2010) The Energy glut. The Politics of fatness in an overheating world. Zed Books

 

Wind Cowle, M (2012) The NHS needs people to be more responsible http://www.guardian.co.uk/society/2012/sep/25/nhs-needs-people-be-more-responsible

 

World Health Organisation (2008) Closing the Gap in a generation. The Social Determinants of Health. http://www.who.int/social_determinants/en/

 

Wright Mills, C. (1959) The Sociological Imagination. Oxford University Press. Oxford.

 

 

 

 

 

 

Society, Socialisation and Culture

Sociology in Nursing

 

This short paper discusses the meaning of three key words:

 

·         Society

·         Socialisation

·         Culture

 

There will be other words in blue and bold which also have specific meanings. These are hyperlinks to Wikipedia which is a useful introduction, however you will have to access books and journals if you wish to discuss these terms in academic writing.

 

 

What does the terms ‘society’ mean?

 

A large group of people who relate to each other. That is to say they work, interact, live in a shared ‘space’ be that geographical, occupational or recreational. They of course are not all in kin or family relationships, with the nature of the relationship often being transactional (‘for a purpose’) rather than emotional. Therefore human societies can be characterized by a shared and distinctive culture and institutions.  A society may be described as the sum total of such relationships among its members. A society can be a particular ethnic group, such as for example those who grandparents may have been from the Indian subcontinent; a nation state, such as Scotland; or a broader cultural group, such as a Western (Anglo-American) society.

From a sociological perspective, a larger society often manifests stratification and/or dominancepatterns among the groups that make it up. For feminist thinkers, many societies are dominated by men and male ways of thinking (Patriarchy), for those of a marxist persuasion societies are dominated by ruling class elites and their ideologies.

In nursing, there is discussion that society is patriarchal. This results in male values and ways of doing things becoming to be seen as more important than female. Also because nursing is female dominated and medicine male dominated these male values often result in nursing being understood as an inferior profession (Goodman and Ley 2012 p36-41).

If it is a collaborative society, the members can benefit in ways that would not otherwise be possible if they remained as individuals. British society since 1948 generally agreed on the social funding, out of personal taxation, of a health care system we call the NHS. Currently British society is showing less cohesiveness (what Zygmunt Bauman calls ‘liquid modernity’) and arguments now arise on how the NHS should be funded or delivered. 

A society can also consist of like-minded people governed by their own norms and valueswithin a dominant, larger society. This is sometimes referred to as a subculture. For nursing we can think of subgroups, especially our professional subgroups, who may have shared norms and values and who may develop quite distinct views, knowledge and attitudes towards health. This means we need to examine our relationship as professionals to our patients and clients and to other professional groups.

In sociology a key issue for understanding how societies work was whether societies arise from the collection of individual actions of ‘free agents’ and therefore if this is the case we need to investigate these social actions at the small group and individual level; or whether societies are characterised as having groups and institutions within them all fulfilling various functions such as child rearing and therefore we need to investigate the functioning of society; or whether societies are riven with group conflict (be they class or gender conflicts) and therefore we need to investigate the nature of this conflict.

From the first viewpoint we could investigate the ‘presentation of self in everyday life’, (see the work of Ervin Goffman) that is to say, how do we go about our daily business ensuring we know what ‘actions’ we need to undertake, for example as a nurse, and how do we manage the impression people have of us? This involves the wearing of uniforms and ways of speaking so as to play the role of ‘professional’. From the second viewpoint we might want to investigate what being sick means for the functioning of society and thus what role should be played by a sick person (see the work of Talcott Parsons). What are the rights and responsibilities of the sick person in a proper functioning society? From the last viewpoint we would want to investigate if health care professionals really serve society as they say they do or whether they actually serve themselves and are in conflict with other groups in society. We would look at the structure of rewards and status in society of, for example, doctors and/or men as doctors (see the work of Ivan Illich).

 

 

 

Case study: Mid Staffordshire NHS Foundation Trust Inquiry March 2010

 

In 2010, Emily Cook (a health correspondent for a daily paper) reported that up to 1,200 patients may have died as a result of “shocking” treatment at Stafford Hospital. This story was based on a report by the Healthcare Commission which stated that Mid Staffordshire NHS Foundation Trust had an appalling and chaotic system of patient care.

The Healthcare commission (now the Care Quality Commission) had a role in examining the quality of care delivered by NHS organisations. The Commissions’ report argued that between 400 and 1,200 more people died than would have been expected during 2005 to 2008.

According to Cook, families described ‘Third World’ conditions in the hospital with some patients resorting to drinking water from flower vases because they were so thirsty.  Some of the conditions reported included filthy, blood and excrement crusted wards and bathrooms, patients being left in pain and needing the toilet, and being left sat in soiled bedding for hours and not given their regular medication. In one ward, 55 per cent of patients had pressure sores when only 10 per cent had sores on arrival.

The health minister at the time was concerned enough to order an inquiry. In a 452 page report, Robert Francis QC outlined the shortcomings in care in and argued “It was striking how many (patient’s) accounts related to basic nursing care as opposed to clinical errors leading to injury or death”. The conclusion was that patients were ‘routinely neglected’ in the context of cost cutting, targets and processes that lost sight of the basic need to provide safe care.

 

Many patients had their basic needs neglected:

 

·      Calls for help to use the bathroom were ignored.

·      Patients were left lying in soiled sheets.

·      Patients were left sat on commodes for hours.

·      Patients were left unwashed – at times for up to a month.

·      Food and drink was left out of reach.

·      Family members had to feed patients.

·      There was a failure to make basic observations.

·      Pain relief was given late.

·      Patients were discharged inappropriately.

·      There were poor standards of hygiene.

·      Families removed dressings and had to clean toilets.

 

 

 

The reasons outlined in the report for these deficiencies in care were as follows:

·      A chronic shortage of staff, particularly nursing staff, was largely responsible for the substandard care.

·      Morale at the Trust was low.

·      Many staff did their best in difficult circumstances, others showed a disturbing lack of compassion (my emphasis) towards their patients.

·      Staff who spoke out felt ignored and there is strong evidence that many were deterred from doing so through fear or bullying.

 

The Trust’s board was found to be:

 

“ disconnected from what was actually happening in the hospital and chose to rely on apparently favourable performance reports by outside bodies such as the Healthcare Commission, rather than effective internal assessment and feedback from staff and patients.

The Trust “failed to listen to patients’ concerns”, the Board did not “review the substance of complaints and incident reports were not given the necessary attention”.

 

Quotes are from   http://www.midstaffsinquiry.com/news.php?id=30

See http://www.midstaffsinquiry.com/ for the report into Mid Staffordshire NHS Trust.

 

 

 

Please read the case study above and then think about what this says about our society, how we are socialised and what a culture may mean.

 

Next I will address two key concepts in sociology – socialisation and culture – and relate them to what was going on at Mid Staffordshire and how they apply to your own nursing practice.

 

 

 

What is socialisation?

 

Staff at the Mid Staffordshire NHS FoundationTrust may have been socialised into a particular culture that was detrimental to good care. But what is meant by ‘socialisation’? 

One possible definition is as follows:

We may understand the idea that we are born into a society that has certain rules of behaviour and we, as human beings, learn these rules through a process of socialisation. Socialisation simply means the various ways we learn how to be a human being and are taught the basic rules of society we live in. (Goodman and Clemow, 2008, page 78).

 

Therefore socialisation is the process by which we learn the customs, norms, values, attitudes, beliefs, mores and behaviours of our society, i.e. how we acquire our culture. However, socialisation provides only a partial explanation for the acquisition of culture. People are not blank slates to be written on by our society. We are not robotic social actors blindly learning culture. Scientific research provides strong evidence that people are shaped by both social influences and their hard-wired biological makeup Genetic studies have shown that a person’s environment (socialisation) interacts with their genotype to influence their behavioural outcomes. So, society shapes us through socialisation and we also act as agents to socialise others. Our genes do not determine our behaviour and are in fact affected by the social environment.  

The following activity asks you to consider your own socialisation.

 

Activity

 

a. Think back to your first day at secondary school. How did you know how to behave with other pupils and with the teachers. How did you learn the formal (and informal rules) for being a pupil in class (i.e. how were you socialised as a pupil)?  

 

b. Think about right now and what is happening to socialise you first as a student and secondly as a nurse.

 

c. Now identify just one aspect of your health and how it has been shaped by your socialisation. Consider, for example, your alcohol consumption and the likelihood of developing problems with alcohol.

 

 

Socialisation shapes our behaviour in quite fundamental ways to the extent that we begin to feel that we could not behave in any other way. Take a common student pastime: drinking.  The use of alcohol in western society is seen very differently from that in a Muslim society. People living in Muslim families, in the UK as well as abroad, may well be socialised into very different views on drinking. Young westerners ‘feel’ that going to the pub is very normal and to be expected, whereas their counterparts from a devout Islamic background may not feel the same way. However as this example indicates socialisation is not so strong that behaviour never changes as young British Muslims may feel themselves being socialized into two different cultures and this results in a tension that has to be resolved.

 

A related idea is that of ‘Occupational’ socialisation i.e. how one learns the customs of an occupation. The suggestion here is that many occupations (and professions) have their own ways of speaking, dressing and acceptable modes of behaviour. Melia (1987) described the occupational socialisation of student nurses, while over 30 years old, this study sheds light on how we become the nurses we are and illustrated the tension felt by students as they juggle the demands of education and the service needs of the NHS. The clinical area demands a certain behaviour (doing the work) while the University expects another (studying).

 

As student your focus may be on learning about medications; their administration, prescription, side effects and contra indications and so you may wish to spend time asking about drugs or reading the British National Formulary while you are in practice. Your University may highly value this activity. Your clinical practice setting may also value this knowledge but what may be of more immediate importance is that you assist the qualified staff in actually administering the drugs themselves, time being too short to look up every single one. The university may value knowledge, the practice setting may value ‘getting the work done’.  Of value also is that knowing how to find out a piece of information that is specific to a particular patient or situation is perhaps more important than carrying the complete contents of the BNF around in your head.

 

What is culture?

 

The shared beliefs, norms values, attitudes, mores and behaviours of a society is its culture. This involves language use, the way we dress, the food we eat, what leisure we like, whether work is valued …even what sports we value. Into this mix are ideas about dominant and subordinate cultures, or sub-cultures, within wider culture. Culture is dynamic and subjective. It changes over time (sometimes rapidly). It is defined by those who are experiencing it and will mean different things to different people. Therefore, and from an understanding of how we become socialised into a culture as described above, we may see that culture affects how we behave, our attitudes and our values. At Mid Staffs the organizational culture was described as having elements of:

 

·      Bullying

·      Target driven priorities

·      Disengagement from management

·      Low staff morale

·      Isolation

·      Lack of candour

·      Acceptance of poor behaviours

·      Reliance on external assessment

·      Denial

 

So it can be hypothesised that despite professional codes of conduct some nursing staff were or socialised into accepting poor practice. Although staff did raise concerns, the culture was such that not enough was done to prevent poor quality care.

 

Socialisation and culture can be viewed as strong social ‘forces’ that shape how we go about our business in an organization. We may think we are completely free agents making free choices, but the experiences of nurses at Mid Staffs shows that the culture can very seriously affect behaviour, in this case the reporting of and delivery of inadequate care. Sociology moves us on from blaming individuals as the sole reason for poor care. Instead it asks us to investigate the social processes that affect individuals in an attempt to devise solutions which go beyond the individual and focus as well on the nature and culture of organisations in which people have to work.

 

Benny Goodman. 2012

 

 

 

 

 

Goodman, B. and Clemow, R. (2008) Nursing and Working with other people. p78. Learning Matters. Exeter.

 

Goodman, B., and Ley, T. (2012) Psychology and Sociology in Nursing. Learning Matters. Exeter.

 

Melia K (1984) Student nurses’ construction of occupational socialisation. Sociology of Health and Illness 6 (2) pp 132-151