Sociology in Nursing
This short paper discusses the meaning of three key words:
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.
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:
· Target driven priorities
· Disengagement from management
· Low staff morale
· Lack of candour
· Acceptance of poor behaviours
· Reliance on external assessment
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