Poverty Privilege and Health

In two of the richest nations ever to have existed on planet earth we have a separation which allows affluent whites to exist in a bubble of privilege; a bubble of privilege which survives the shooting of police, deindustrialisation, poverty, precarity and the social gradient in health. Privilege understands and sees how radical losers exploit poverty and exclusion, but does not want to address social and economic structures; privilege understands that pain and anger can be turned both inward and outward but looks for solutions in the individual and ‘security’; privilege sees the transmission of poverty and exclusion only in the personal agency of the poor themselves.

Washington Heights is a suburb of the most segregated city in America. Charles lives in a part of Milwaukee where the residents are 99% white, yet a few blocks up are black neighbourhoods where shops are boarded up, many houses have repossession notices on their front doors, and the air is one of decay and poverty. The separation of black and white in Milwaukee is replicated in big cities right across the US, and separation breeds a lack of empathy.”

“Local authorities which report the highest rates of people facing severe and multiple disadvantage are mainly in the North of England, seaside towns and certain central London boroughs”

“Women who live in the least deprived parts of Kensington & Chelsea can expect almost a quarter of a century more of good health than their female counterparts in the most deprived part of the borough. For females at birth, the number of years an individual could expect to live in good health based on current rates – known as healthy life expectancy – differed by an average of 24.6 years between the most and least deprived parts of the borough” (ONS, 2015)

…and yet politicians like to focus on a ‘moral underclass’, blaming them for their behaviour that causes poverty. Drink and drugs are key factors in this regard:

“Ian Duncan Smith, Secretary of State for Work and Pensions, shocked readers of the Daily Mail with: ‘Addicts and alcoholics cost us £10billion a year, says Duncan Smith: Blitz launched to help people with drink drug problems find work’ “. (Glen Bramley LSE Blog)

There is a very old debate about whether poor people owe their circumstances to structural economic factors or to moral/behavioural failings. Sandra Carlisle in 2001 argued that there are ‘contested explanations, shifting discourses and ambiguous policies’  for health inequalities: there is the ‘Moral Underclass’ discourse, the ‘Social Integrationist’ Discourse and the ‘Redistrubutive’ discourse. Each has its own explanation as to why there are inequalities and then what to do about them.

Since Sandra Carlisle wrote her paper, there has been a a good deal of evidence to suggest that structural/economic forces are a major factor in people’s health and illness. There is some evidence also of ‘transmitted poverty‘ due to adverse childhood experiences. The misuse of Alcohol and Illegal substances (they are all drugs) are of course correlated:

“There is a huge overlap between the offender, substance misusing and homeless populations. For example, two thirds of people using homeless services are also either in the criminal justice system or in drug treatment in the same year”.

Many people faced with adverse social situations learn to cope, or they become fatalistic,  or they cling together in supportive communities or they become activists fighting for social justice.  Some self harm, some drink to excess, some go to University and become doctors or lawyers or politicians.  They exercise their personal agency and succeed or fail within structurally determined circumstances. They succeed, despite not because of, the activities and ideology of the privileged. A few of the successful however, then refuse to provide more ladders while shouting “I did it so can you”.

The lack of empathy, the total separation of lifeworlds, arises partly from moral intuitions that both blinds many politicians and commentators to alternative explanations pf poverty and binds them together in a bubble of privilege that prevents them from analysing the evidence. As we all do, they engage in post hoc rationalisations – in their case that that the poor are a moral underclass who are less intelligent, lazy, and hard working than the successful – to explain and justify their own positions.  This is almost a moral imperative, because not to blame the poor opens one up to the need to justify or critique the structural and economic privileges one has unequal access to. Placing the focus on the work, drinking and drug taking habits of a ‘moral underclass’ provides one with a sense of superiority and entitlement so much on show in both US and UK politics. No doubt the same occurs in Russia and China. To acknowledge that there are structural and economic conditions, for example the public school system or the service sector low wage economies,  or the inverse care law, opens up the middle class to accusations of champagne socialism.

This is a common tactic to deflect the argument away from an examination of causes to one of ‘ad hominem’.  Another tactic is to argue that the best way to address structural and economic factors is more of the same economic policies that have held sway especially in the US and UK. Indeed on a global scale the numbers of people living in absolute poverty is decreasing. Inequality is also decreasing with in the UK (gini coefficient). However these two factors are not the only issue.  Both the UK and the US are rich and other measures of inequality have increased, see for example the use of the Palma ratio. It matters greatly for very poor people to get incomes, and mortality rates, enjoyed by the poor in the UK and the US, but that is not enough as the social, health and political problems in both countries testify.

Privilege looks around and is satisfied knowing that the ‘have nots’ only have themselves to blame. They reach for the moral underclass theory and publish it relentlessly in their newspapers and commentary. They also have the wealth and political power to ensure this ideology is accepted by the poor themselves. However, many do not. In this context:

The losers get sick.

The losers get poor.

The losers get defeated.

The losers get mad.

The losers get even.

‘Many professions take losers as the object of their studies and as the basis for their existence. Social psychologists, social workers, nurses, doctors, social policy experts, criminologists, therapists and others who do not count themselves among the losers would be out of work without them. But with the best will in the world, their clients remains obscure to them: their empathy knows clearly-defined professional bounds’ (Enzensberger 2005). Enzensberger (2005) goes on to argue:

‘one thing is certain: the way humanity has organized itself – “capitalism”, “competition”, “empire”, “globalisation” – not only does the number of losers increase every day, but as in any large group, fragmentation soon sets in. In a chaotic, unfathomable process, the cohorts of the inferior, the defeated, the victims separate out. The loser may accept his fate and resign himself; the victim may demand satisfaction; the defeated may begin preparing for the next round. But the radical loser isolates himself, becomes invisible, guards his delusion, saves his energy, and waits for his hour to come’.

Shoots a Policeman, drives a truck through a crowd, blows himself up in an airport…..all the while privilege looks on in dumb uncomprehending horror calling for more security and economic crackdowns on the moral underclass upon whom the often middle class radical loser preys.

Our social environment encourages obesity

our social environment encourages obesity

Your health depends in where you live

Your health depends in where you live

What doctors don’t know about the drugs they prescribe

What doctors don’t know about the drugs they prescribe

Child Mortality, poverty, globalisation

Global Perspectives on Child Health.

 

It might be a little trite and clichéd to state that our future is bound up with the current health and welfare of our children. Nonetheless, it is a matter of ethical practice how the next generation is faring. This is not about creating a healthy workforce for the economy, that is a secondary (and possibly questionable) ethical aim. It is a good in itself, to care for children. As a society in our concerns for children, we should not rely on utilitarian ethics (i.e. the consideration of ‘what good comes of doing it’), this is about a ‘universal good’, one that applies in whatever time in whatever culture.

 

 To consider the issue of child health I would like us to think about:

 

1.  Issues – ethical practice what is our responsibility? To whom are we ethically responsible?

2.  What is the role of the nurse as a global citizen for health ?

3.  What are our actions that flow from this?

 

Issues:

 

“Considerable evidence suggests that neocolonialism, in the form of economic globalization as it has evolved since the 1980s, contributes significantly to the poverty and immense global burden of disease experienced by peoples of the developing world, as well as to escalating environmental degradation of alarming proportions. Nursing’s fundamental responsibilities to promote health, prevent disease, and alleviate suffering call for the expression of caring for humanity and environment through political activism at local, national, and international levels to bring about reforms of the current global economic order” (Falk-Rafael 2006).

Falk-Raphael implicitly draws upon a social determinants of health approach which 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”.

Globalisation results in large capital flows, labour movement and displacement and the increasing dominance of TransNational Corporations (TNCs) on economic, social and political life. The demise of state power – its withdrawal from public services, the rise of TNCs and the primacy of the market are three voices guiding politics.

 

I would argue that there is a need for a fourth voice to defend global public goods such as health. This voice is civil society, which includes nurses. Collier (2008) suggests that we have a bottom billion stuck in poverty. Even for the Rich, threats to survival are not domestic but global. Perspectives are changing from local to global, the ethics of healthcare thus need to be discussed in this context. The WHO’s Millennium Development Goals also set a global policy framework.

 

The fact of children dying under the age of 5, and the concentration of that statistic in certain countries, is largely preventable. The developed rich nations of the West have achieved huge gains in child mortality, despite a socioeconomic gradient still evident. By that I mean the children of the poor are over represented in mortality statistics. This will be true in countries with high mortality rates (Nigeria, India and China). It is the children of the poor who die young.

 

Globalization cannot be the cause of poor child mortality rates, rather it is the poverty that existed before global capitalism that is the main cause. Therefore efforts at eradicating poverty will bring down the rates (along side simple things like fresh water, malaria nets and vaccinations). Global capitalism is producing the goods we need and improving the living conditions of many so that many countries will eventually join the developed west with their low mortality rates. However, we must not lose sight of the socioeconomic inequalities in health in the rich West. However, there is an ideology attached to globalization that would rather spend trillions of $s and £s on bank bail outs, military spending (estimated cost of the UK’s trident replacement  – anything between £20 and £100 billion) and the mismatch between research funding and the research need of low and middle income countries remains. This has been referred to, by the Global Forum for Health Research, as the 10:90 gap (10% of global funding going towards 90% of global needs –research favours the rich in the rich world).

 

Ethical practice. Paul Ricoeur suggested that ethics are about “aiming at the good life”, and so if this is the case we ought to consider the good for all. If everyone has a right to the opportunity for a good life, what should the Nursing response be? 

 

Consider the codes of Ethics that govern nursing practice. Where are they, and what do they say? Consider the international nursing codes of ethics rather than just the Nursing and Midwifery Council’s.

 

As stated above, child health should be a matter of universal concern to us all. To focus only on the children of the rich in the rich world, who already have a surfeit of resources and health access, may be an abrogation of our moral obligations as global citizens for health. There is therefore a need to think differently about our role in the world as a nursing community.

 

Acting Ethically as a nurse in a global community requires a need for Transformative thinking.

 

 

 

Part of that thinking involves seeing our selves as interconnected in systems on a finite planet. We have been told that climate change is the biggest threat to public health this century. Children already at risk in the developing world could face, some say are already facing, health threats from changing climates. Food shortages, droughts and crop failures have affected many parts of the world in 2012. Current economic practices are implicated in carbon emissions. Thus mitigating and adapting to climate change will be on the agenda in the developed world if we are to keep our gains. In the United Kingdom carbon reduction already is an NHS aim.

 

 

Child Mortality: the facts:

 

Use the websites below to gather a fuller picture of current trends in child mortality and the factors that reduce child deaths. Consider what role nurses can play in this. Think about the relationship between maternal health, family size, female education and child mortality.

 

Websites:

 

http://www.globalissues.org/about – facts about global health issues. Click on issues and then health issues for an overview.

 

http://www.un.org/millenniumgoals/childhealth.shtml – the WHO’s Millennium Development Goals.

 

http://www.gapminder.org/videos/reducing-child-mortality-a-moral-and-environmental-imperative/ -Hans Rosling on child mortality

 

 

Levels and Trends in Child Mortality 2012 http://www.unicef.org/videoaudio/PDFs/UNICEF_2012_child_mortality_for_web_0904.pdf   UNICEF.

 

Every Woman Every child is a United Nations campaign which acknowledges that the health of women and children are priorities, as reflected in the Millennium Development Goals (MDG 4 and 5). See box 1.

 

 

MDG 4 Reduce Child Mortality

MDG 5 Improve Maternal Health

 

By focusing on the maternal and child health it is hoped that we will help to maximise global health gains.

Box 1

 

What is Every Woman Every Child?

 

 

Launched by UN Secretary-General Ban Ki-moon during the United Nations Millennium Development Goals Summit in September 2010, Every Woman Every Child aims to save the lives of 16 million women and children by 2015. It is an unprecedented global movement that mobilizes and intensifies international and national action by governments, multilaterals, the private sector and civil society to address the major health challenges facing women and children around the world. The effort puts into action the Global Strategy for Women’s and Children’s Health, which presents a roadmap on how to enhance financing, strengthen policy and improve service on the ground for the most vulnerable women and children.

 

‘Every Woman Every Child’ http://www.everywomaneverychild.org/about

 

http://www.everywomaneverychild.org/images/content/files/global_strategy/full/20100914_gswch_en.pdf

 

Conclusion.

 

We know there is a huge disparity in the under 5 mortality rate (U5MR) and that this is linked to socioeconomic status. This may well be exacerbated by climate change. There are variances within countries as well as between them. We know that rates are falling on a global basis and many countries are making good progress. We also know that nurses are charged with having a health promotion and public health role to play. This could go beyond a medical approach (e.g. vaccinations) and adapt the social model of health. As global citizens nurses could address social determinants through individual actions as well as through their socio-political roles, the least of which means developing political awareness of such things as the UN’s ‘Every women every child’ campaign.

 

Benny Goodman 2012

Class divide in health widens

Class Divide in Health Widens

http://gu.com/p/3av95

 

What is the mechanism at play which prevents poor people from changing their lifestyles? Why do many not ‘take responsibility’ for unhealthy choices? The structural issues (e.g. unemployment which leads to sickness which leads to unemployment; another is long term low pay and part time work) are some mechanisms. Try living on <£12,000 pa on a monthly rent of £450 to see just how hard it is…so why smoke and drink and eat junk food then, all activities which eat into the funds that are available?? The evidence suggests that relative social status is a key mechanism (Wilkinson and Pickett 2010), i.e. living in a social group means also comparing oneself to those around us, a negative appraisal results in stress and physiologically this means corticosteriod release as well as adrenaline.  It sets up anxiety (physical stress as well – it makes the body unwell), now it just so happens that smoking, drinking and high sugary junk foods are great at hitting the pleasure centre in the brain, and giving us a shot of the pleasure hormone dopamine (the same hormone that ecstacy floods your system with). The advertising industry and corporate activity manufactures demand in the population, it needs you to buy stuff and one mechanism it subliminally uses is social comparison, you are invited to consider how your present self is and how your future self could be if you had this product. This also involves comparison with other social groups. So a lack of resources to engage in that activity advertised as a ‘good thing’ paradoxically leads to precious resources going into activities that relieve the stress and provide instant gratification. Smoking, drinking a junk food are excellent at instant gratification. Add to that mix a sense of fatalism, long term sickness, poor education, a lack of ‘self efficacy’, poor social capital and a perceived and often actual lack of a means to address these issues and hey presto you have an underclass mired in poor health and the cycle begins again. These are just some of the mechanisms at play. We are living in an insane society (see Erich Fromm ), which also creates this underclass and ensures this class has the mechanisms to self defeat. Social mobility in the UK has all but halted, so my advice is: choose your parents very carefully.

 

http://www.guardian.co.uk/news/datablog/2012/may/22/social-mobility-data-charts

http://www.dailymail.co.uk/news/article-2137585/Britain-worst-social-mobility-Western-world.html

http://www.guardian.co.uk/politics/blog/2012/may/30/milburn-social-mobility-politics-live-blog#block-10

Goffman on Stigma

“Undesired different-ness from what we had anticipated”.

“reduced in our minds from a whole and usual person to a tainted, discounted one”

1. Medical conditions which give rise to stigma can be:

·         Discrediting conditions (visible).

·         Discreditable conditions (invisible).

2. The experience of stigma can be:

·         Felt – your subjective experience.

·         Enacted – when discrimination takes place, moral judgments made.

·         Courtesy – when friends and family are involved and feel the discrimination or stigma.

3. Sources:

·         ‘Abominations’ of the body.

·         Blemishes of character. weak will, domineering or unnatural passions, treacherous and rigid beliefs, or dishonesty. Blemishes of character are inferred from, for example, mental disorder, imprisonment, addiction, alcoholism, homosexuality, unemployment, suicidal attempts, or radical political behaviour.

·         Tribal, e.g. arising from race, nation and religion. beliefs that are transmitted through lineages and equally contaminate all members of a family.

4. According to Goffman, diseases associated with the highest degree of stigma share common attributes:

·         The person with the disease is seen as responsible for having the illness.

  • The disease is progressive and incurable.
  • The disease is not well understood among the public.
  • The symptoms cannot be concealed.

Goffman, E. (1963) Stigma: Notes on the management of spoiled identity. Englewood Cliffs, Prentice Hall.

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