Tag: Mid Staffordshire NHS Foundation

Nurse -patient ratios – what is the evidence?

Peter Griffiths of Southampton University wrote on the researchgate site:

“…..this is an area with a massive literature. The positive association (between more nurses and better patient outcomes) has been demonstrated against a range of quality and safety measures – primarily safety. Linda Aiken is not the only researcher in the area but possibly the best known. 

Try : Kane, R.L., Shamliyan, T.A., Mueller, C., Duval, S., Wilt, T.J., 2007. The Association of Registered Nurse Staffing Levels and Patient Outcomes: Systematic Review and Meta-Analysis. Medical Care 45 (12), 1195-1204 1110.1097/MLR.1190b1013e3181468ca3181463.

…for a comprehensive if slightly dated overview of the safety literature.

Recent reports from the RN4CAST study show associations with other outcomes e.g.:

Ball, J.E., Murrells, T., Rafferty, A.M., Morrow, E., Griffiths, P., 2013. ‘Care left undone’ during nursing shifts: associations with workload and perceived quality of care. BMJ Quality & Safety.

Aiken, L.H., Sermeus, W., Van den Heede, K., Sloane, D.M., Busse, R., McKee, M., Bruyneel, L., Rafferty, A.M., Griffiths, P., Moreno-Casbas, M.T., Tishelman, C., Scott, A., Brzostek, T., Kinnunen, J., Schwendimann, R., Heinen, M., Zikos, D., Sjetne, I.S., Smith, H.L., Kutney-Lee, A., 2012. Patient safety, satisfaction, and quality of hospital care: cross sectional surveys of nurses and patients in 12 countries in Europe and the United States. British Medical Journal 344.

Aiken, L.H., Sloane, D.M., Bruyneel, L., Van den Heede, K., Sermeus, W., 2013. Nurses’ reports of working conditions and hospital quality of care in 12 countries in Europe. International Journal of Nursing Studies 50 (2), 143-153.

…although limited as they are all self report.

The translation of this to specific ratios is difficult – largely for the reasons highlighted above and the evidence on that policy is less clear cut. Try

McHugh, M.D., Brooks Carthon, M., Sloane, D.M., Wu, E., Kelly, L., Aiken, L.H., 2012. Impact of Nurse Staffing Mandates on Safety-Net Hospitals: Lessons from California. Milbank Quarterly 90 (1), 160-186.

For a favourable gloss.

Some of the limitations are covered in:

Griffiths, P., 2009. RN+RN=better care? What do we know about the association between the number of nurses and patient outcomes? International Journal of Nursing Studies 46 (10), 1289-1290.

…one issue that is very germane for many health sectors is the absence of medical staffing from this literature. See

Griffiths, P., Jones, S., Bottle, A., 2013. Is “failure to rescue” derived from administrative data in England a nurse sensitive patient safety indicator for surgical care? Observational study. International Journal of Nursing Studies 50 (2), 292.


I would add:

This question is rooted within a wider context – that of managerialist control of care environments (Traynor 1999, Lees 2013) in which efficiency, effectiveness and economy are to the fore. This approach can militate against the consideration of qualitative, non measurable, outcomes which make a real difference to patients’ experience (Tadd et al 2011, Dixon-Woods et al 2013, Hillman et al 2013). The reality is that many health and social care sectors, in the UK, are under such financial pressure and managerialist control,  that the quality of the care experience is squeezed. Given current narratives of austerity, female undervalued labour and ‘private = good public = bad’, UK society has accepted that for example long term care of older people, and mental health, have to fight their corner for government and personal funding. I suspect that funders (e.g. DoH and FTs) ignore evidence, in any case, of staff-patient ratios, viewing it as idealistic and costly. However, they will not frame it in this way – the response will be that ratios are a blunt tool and should not be set down in terms of basic minimums. While I think it is imperative that evidence comes forth on this topic, we might need to consider that the translational model of evidence to policy is flawed. In the context of climate science,  Pielke (2010) describes the actual relationship between public policy and scientific research as problematic; it is not a linear ‘evidence to policy’ model.  The translational model, or ‘knowledge translation’ (Kerr and Wood 2008), in which scientists come up with answers which are then put into practice by policy makers (Wynne 2010) is contextualised within political and ideological frameworks such as that of neoliberalism and its adjutant, managerialism.  Naively we may think that the job of scientists, and their allies, is to improve the process of knowledge translation so that policy makers, guided by clear evidence, can make the right decisions. Drugs policy research is another example of the failure of this model. In nursing, even if we had irrefutable evidence, there is no necessary link to this and health policy on nurse staffing. The UK’s NHS is a ‘highly politicized setting’ (Traynor 2013), staffing of wards is as much a political as an empirical question.

Dixon-Woods, M., Baker, R., Charles, K., et al (2013) Culture and behaviour in the English National Health Service: overview of lessons from a large multimethod study. BMJ Quality and Safety (published online) http://www.ncbi.nlm.nih.gov/pubmed/240195079th September 2013 accessed February 25th 2014
Hillman, A., Tadd, W., Calnan, S., Calnan, M., Bayer, A., and Read, S. (2013) Risk, Governance and the experience of Care. Sociology of Health and Illness. 35 (6) pp 939-955
Kerr, T., and Wood, E. (2008) Closing the gap between evidence and action: the need for knowledge translation in the field of drug policy. International Journal of Drug Policy 19 (3) pp 223-234
Lees, A., Meyer, E., and Rafferty, J. (2013) From Menzies Lyth to Munro: The problem of Manageralism. British Journal of Social Work. 43 (3) 542-558
Pielke, R. (2010) The Climate Fix. Basic Books. New York.
Tadd, W., Hillman, A., Calnan, S., Calnan, M., Bayer, T., and Read, S. (2011) Dignity in Practice: An exploration of the care of older adults in acute NHS Trusts. NIHR Service Delivery and Organisation Programme. Project 08/1819/218. NETSCC – SDO: Southampton
Traynor, M. (1999) Managerialism and Nursing: beyond profession and oppression. Routledge. London
Traynor, M. (2013) Nursing in Context. Policy, Politics, Profession. Palgrave Macmillan.
Wynne, B. (2010) Strange Weather, Again. Climate Science as political art. Theory Culture and Society 27 (2-3): 289-305

Government, managerialism, leadership and poor care in the NHS

Today the government responds to the Francis Reports into the care failings between 2005-2009 at Mid Staffordshire NHS Trust. What can we expect?


I suspect that there will be a good deal of initiatives and new regulatory effort but little in the way of actual practical relevance.


In March 2013 the government published its initial response Patients First and Foremost in which David Cameron apologised to the families involved through parliament acknowledging systemic failures. It is to these systemic failures we must look to find some answers, but I suspect that my definition of a systemic failure may not be the same as Cameron’s. First lets consider where we are so far.


Jeremy Hunt’s foreword in March focused on creating a culture of safety, compassion and learning that is based on cooperation and openness. He identified four key groups who are essential in providing this culture:


  • Patients, service users, families and friends.
  • Frontline staff.
  • Leadership teams – Trust boards.
  • External structures: commissioners, regulators, professional bodies, local scrutiny bodies and Government.


The government’s response was, through the CQC, to appoint a new chief Inspector of Hospitals. Secondly, making hospital performance more transparent through a system of ratings. Then, something called a ‘single failure regime’. There would also be a Chief Inspector of Social Care. In addition the government would ‘foster a climate of openness’. How it would do that when it has no control at all over NHS organisations seems moot.


That was 8 months ago and so we cannot expect too much to change in a group of organisations that make up the NHS brand, a brand that is now a complex system of public and private provision distinct in organisational form from each other and from social care provision. What remains of the complex system is the underpinning Health and Social Care Act 2012.


Many of the 12 points in this March response are hard to critique, for example who does not want ‘Respect and Dignity?’ However there is a little nugget, point 8:


“We will work together to minimise bureaucracy, enabling time to care and time to lead, freeing up the expertise of NHS staff and the values and professionalism that called them to serve”.


This goes to the heart of the process of care, but there are no short cuts to doing this. Minimising bureaucracy requires leadership to address certain managerialist cultures. Prior to Mid Staffs, Leadership was seen as a key aspect of NHS culture changes. However, Leadership operates in certain organisational cultures and that rests mainly with management and can be strangled by a managerialist culture putting organisations into a catch 22: we need leadership to change cultures but we need culture change to allow leadership. However, it is bureaucratic management chasing non care oriented targets in order to maintain or gain Foundation Trust status which have distorted the care process and hampered frontline staff’s ability to deliver. This operates in wider socio-political context of the devaluing of care in that we accept the need for care but will not provide financial and social structures to allow it to flourish. Instead we have individualised care, leaving it mainly to families and women who are often provide it for free or for low pay.


Of the four groups identified above by Hunt, it is the leadership teams, especially hospital management and their Boards, which carry the most responsibility for care in NHS Trusts. Patients can exercise their voices, frontline staff can advocate or try to exercise clinical leadership, external groups can respond to failures often only after the event and were largely ineffectual as they may continue to be. Roy Lilley suggested that weighing a pig does not make it fatter – you have to build in quality from the outset, inspection is a post hoc activity. Trust Boards however set the tone and provide the resources and thus have the primary responsibility for the provision of good quality hospital care.  The Secretary of State for health has now abdicated that responsibility in an increasingly market driven health care system.


John Robinson, age 20, died in 2006 as a result of a ruptured spleen after a mountain bike accident. He was discharged from Mid Staffs Accident and Emergency department and died less than 24 hour later. A second inquest is being conducted. Caution must therefore be exercised in making any conclusions about the quality of care John received and whether it was in fact deficient. Claims regarding negligent care require certain conditions to be met and this has not been established in this case.


John’s parents claim that he was examined by a junior doctor, and that a consultant was not available. They suggested that if a more senior doctor had examined John then the chance of a ruptured spleen might have been considered. The junior doctor may have been incompetent, or she/he may have been acting within the limits of his competence, we do not know. The point however is that staffing of accident and emergency, and the training and development of staff who could spot this condition, are ultimately the responsibility of the Trust Board. Professional staff have a duty to make known their concerns regarding staffing and the competence of the team they work with, but they need the confidence to act on their concerns and the recognition by management that the exercise of clinical leadership involves challenging structures of support for clinical practice.


Therefore, professional staff have to be able to exercise clinical leadership safe in the knowledge that issues will be listened to and acted upon. However, managerial leadership may militate against this because their aims and objectives may blind them to real clinical needs. This was a criticism of Mid Staffs management.  In John’s case, if it was the poor decision making of an inexperienced junior doctor that was a major contributor to his death, we do not know if clinical leadership was exercised to address any issues of the training and support for junior doctors.


John Edmonstone (2008) suggested that clinical leadership is distinct from managerial leadership and is often ignored or not addressed by those considering leadership in the NHS. In addition he describes a disconnected hierarchy operating in health care organisations: a clinical hierarchy and a managerial hierarchy. This disconnect results in differing objectives, visions and ways of working. This is reflected by Robert Francis (2013 p3) who argued that the failings at Mid Staffs was primarily caused by:


“a serious failure on the part of a provider Trust Board. It did not listen sufficiently to its patients and staff or ensure the correction of deficiencies brought to the Trust’s attention. Above all, it failed to tackle an insidious negative culture involving a tolerance of poor standards and a disengagement from managerial and leadership responsibilities. This failure was in part the consequence of allowing a focus on reaching national access targets, achieving financial balance and seeking foundation trust status to be at the cost of delivering acceptable standards of care”.


Prior to this Hewison and Griffith, in 2004 argued, “too much emphasis on leadership without an equal concern for transforming the organisations (nurses) work in may result in leadership being added to the list of transient management fads”. Hewison in 2011 went on to argue that the focus on leadership as a solution to organisational ills remains in the NHS. This is rooted in assumptions that leadership, changing cultures and producing effective leaders will result in improvements in management and organisations. Hutchinson and Jackson suggested in 2012 that discussions around leadership often fail to address the issues of power, politics, dominance and resistance in organisational cultures. Both pre date Francis comments about the nature of Trust management at Mid Staffs.


Faugier and Woolnough (2003) provided some evidence of what organisations feel like to work in. and thus illustrate how management cultures can distort care practices. They describes three types of organisation:


  1. The Machine
  2. The Choir
  3. The Living organisation.


In their research 45% of respondents stated that their organisation felt like a machine in which leadership is generally driven by senior management to establish order and control. Strategic decisions are made through a formal planning process and change is planned and programmatic. Employees feel like a ‘cog in a wheel’. Faugier and Woolnough concluded that there was serious work to do to ensure clinical staff feel engaged and empowered. They argued that too many staff felt like cogs with high levels of disengagement and disillusionment and that that the implications for patient care were obvious. This was written in 2003, before Mid Staffs made the headlines. One can’t help but think that the antecedents for poor quality care were already established and were being written about for some time.


Questions remain: Will the government be able to do anything about how individual Trusts are run and financed? Will the frontline be properly staffed and supported; will they feel free to express concern about poor quality care?


Is clinical leadership any better supported, and will staff feel empowered and engaged? Will today’s government response address any of the fundamental issues?



Issues to address to address in this regard:


  • In a public sector organisation, clinical leaders cannot easily affect, or redefine public policy or legislation set by politicians and so they operate within the conditions set by others. Since the Health and Social Care Act Government has released the reins of control and conditions to NHS organisations and can no longer provide or dictate such issues as minimum staffing levels without enacting new legislation.


  • Nursing culture may inhibit clinical leadership development; issues of gender and medical power may continue to inhibit strong nursing leadership within Trusts and in clinical commissioning groups.  Has nursing got the respect of the public, politicians, policy makers and other professional groups to allow the to exercise strong leadership?


  • The focus on developing the person, their competencies and their traits, which are often based on male assumptions about what leadership looks like, may be in conflict with the exercise of leadership that focuses on relationships (shared leadership) within complex organisations.


  • The ratio of professional nursing staff to non-professional staff requiring training, supervision and regulation by clinical leaders is wrong. Not enough nurses, too many support staff.


  • Health care organisations may be risk averse and heavily regulated which counters leadership development that encourages risk and creativity and the challenging of the status quo.


  • Inspection and regulation are post hoc activities: are the CQC, Monitor and the Professional Bodies fit for purpose in terms of preventing poor quality care?

The Francis Report and poor quality care

Roy Lilley has argued:

Francis talks about ‘culture change’. Effectively making the people we have make the services we’ve got, work better. On that basis Francis fails. What we’ve got doesn’t work. Never will.  Think about it; nearly all the quality problems the NHS faces are around the care of the frail elderly. Why? Because the NHS was never set up to deal with the numbers of porcelain-boned, tissue paper skinned elderly it is trying to cope with. The NHS’ customer-base has changed but the organisations serving them have have stood still.


“Fund the front-line fully, protect it fiercely, make it fun to work there, that way you’ll make Francis history.”

A nurse was quoted on… wait for it….the ‘One Show’ saying that she came in on her day off to feed a patient, another story was that two male nurses laughed at a half naked elderly man with a catheter. Two ends of the same care story that is the NHS. There is a problem with attitude/culture but there is a problem with structure (e.g. poor staffing) which gives rise to poor culture. Cultures arise out of structures, they do not just appear out of nothing. The way people relate to each is influenced by so many variables but in an organisation set up with a purpose in mind, those variables start to filter down into the structures that are in place to fulfill the stated purpose. If the purpose is to diagnose and treat a minor illness in an otherwise healthy person, the structures you need are relatively straight forward. The structure of staffing: A doctor or suitable qualified nurse with enough time to take a history, carry out an examination, come up with a diagnosis and then initiate treatment. The structure of place: A clean, well lit, warm private space. The structure of resources: for example assessment tools, stethoscopes, sphygmomanometer, examination table….  These are the foundations to encourage a culture of respect and co-operation. Of course having the structure in place does not guarantee a patient centered culture. The reverse is true, take away the GPs structures and you will more than likely get a little less respect and quality care.

The emphasis on culture and NHS leadership has let society off the hook because we then don’t talk about structures. No doubt the culture and leadership in some Hospitals must change…in addition society has to accept that care work costs money. We just don’t seem willing to put in the extra resources to ensure that the vulnerable are not abused. Feminists have long argued that because patriarchal societies view ‘care work = women’s work’ and women’s work has been seen as ‘domestic’ and unskilled (i.e. required very little training because it is ‘natural’ to women) , care work receives little recogniton and value and sinks into invisibility. The structures to support care work in the UK and in many ‘advanced societies’ are creaking to breaking point, relying on armies of unpaid and unsupported family members.

The analogy is with motherhood and the structures that support it: unpaid, hard work, no training, no sick pay, little support…many mothers go the extra mile every single day, some crack under the strain and abuse or neglect. A minority of mothers abuse because they know no better, they are ill or have given up caring. Any care work that is not properly valued recognised and supported runs the risk of increasing the ratio of abuser to saints. Just as mothers need all the support they can get from society, so do nurses. If you isolate, divide, and undervalue their work do not be surprised when there is an increase in neglect. Society ascribes value to work through pay, status and perks….and so you can get an idea of what society values by examining who gets the pay, status and perks. Capitalism has long divided ‘proper’ work (men’s work) in the public sphere which it has paid for on the one hand, and ‘non’ work (female work) in the private sphere, i.e. the home, which it is unwilling to pay for, on the other. Socialists and feminists arguments have tried to get this private sphere work as being properly recognised in the patriarchal hiearchy and so we have child benefit etc. Historically, if men were nurses, and care work the preserve of men, this would have elevated its status and hence support, education and pay. Roy Lilley is calling for funding the front line, to support the structures of care. Watch however how we turn ourselves inside out trying to correct cultures.





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.




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





Skip to toolbar