so·ci·ol·o·gy (ss-l-j, -sh-) KEY
The study of human social behavior, especially the study of the origins, organization, institutions, and development of human society. Analysis of a social institution or societal segment as a self-contained entity or in relation to society as a whole.
Nursing practice without sociology is akin to sexual congress without orgasm - possible to enact, but highly unsatisfactory. It is the equivalent of entering a strange country without a map to explain the contours and pitfalls of the land. The traveller may eventually find the desired journey's end, but the route taken will be meandering and hazardous. There is a dynamic and fundamental role for sociological knowledge within nursing (and health care generally). Sociology demystifies the nature of health and illness, highlights the social causes of disease and death, exposes power-factors and ethical dilemmas in the production of health care, and either directly or indirectly helps to create a discerning practitioner who then becomes capable of more focused and competent decision making. Starting in the latter part of the twentieth century, unprecedented discoveries and 'reshaping' of human knowledge about the physical world have taken place. In the fields of physics, chemistry, mathematics, molecular biology, computing, pharmacology and medicine (both in terms of diagnosis and treatment), the accumulation of and transformation in knowledge have been nothing short of incredible. Through its foundations in critical thought, it is the task of sociology to examine just how authentic these changes are. We study certain areas where Sociology and Nursing interface: Imagination
to understand the changes of many personal milieux we are required to look beyond them. … To be able to do that is to possess the sociological imagination. (Mills 1959:10/11)
Sociologists imagine the world differently compared with the way it is viewed for example, by psychologists, and biologists, or by those who proffer 'common sense'. In this chapter 'the sociological imagination' is delineated through an exploration of three major theoretical frameworks. I am using the term 'theoretical framework' to describe the grouping of perspectives which may have subtle differences that distinguish them, but which have similar philosophical routes, and complementary observations to make about the organisation of society and human action. The first theoretical framework I have chosen regards society as both existing and having a set of configurations that to a greater or lesser extent induces humans to behave and think in preordained ways, including that of 'being sick'. As an alternative to this structural understanding of human behaviour and thinking, which can be interpreted as viewing all thought and behaviour as 'determined' by society, the second explanatory genre projects the notion of individual volition. That is, it is argued that humans can and do direct their own lives. The third theoretical framework has gained popularity in nursing literature in the last couple of decades, and has been extracted from a range of sociological theorising that aims to 'deconstruct' reality (including the actuality of 'disease') in one way or another. There is nothing totally 'natural', 'God-given' or inevitable about personal and social behaviour. Falling in love, committing a crime, achieving success in a career, or being ill, are all influenced by social factors. The basis of the 'sociological imagination' is to look beyond the obvious, and to challenge both our own preconceived ideas and those of others. This is of particular importance when those with power in society hold prejudicial views about already vulnerable and dispossessed people. Above, all, it is to always ask the question 'why', and to keep on asking the question 'why'! It was C. Wright Mills (1959) who pointed to the connection between 'private troubles' and 'public issues'. Whatever we undergo as individuals (and this applies to emotions, pain, disease and cognition) our social surroundings have either helped create, or are affected by, these experiences. For example, the private trouble of losing a loved one in a car accident is a public issue in that both the amount of money governments put into road safety, and the degree to which a society values commodities such as cars, are linked to the number of people who are killed on the roads. The private trouble of being diagnosed as having cancer is also a public issue as either directly or indirectly it relates to health policy and health-service resources, which in turn are connected with social values. Better health promotion strategies installed by government and health agencies, a greater political will at local and national levels to improve the physical environment, more money ploughed into cancer research and treatment rather than, for example, arms technology, may have prevented that person's malignant tumour. The private issue of depression is a public issue in the sense that this 'internal' condition may have been precipitated by alienating and dehumanising social circumstances. Social events and social relationships are not taken at face value by the sociologist. Conventional wisdom is tested to see whether or not it stands up to the scrutiny of research and well-worked-out theorising. Many prevailing ideas do not. For example, it was 'common sense' for white imperialists and colonialists from Europe to believe that black Africans were sub-human. Another 'commonsense' judgement was made by the ruling elite in the Victorian age that the mad should be locked up in asylums, the poor put in workhouses and criminals transported to Australia. The work of the American sociologist Amitai Etzioni on 'communitarianism' (1998), and that of the German social theorist Ulrich Beck on 'risk society' (1992) have also been influential in Western politics. These commentators, in different ways, have pointed to the consequences of immense social change and the need for communities and social systems to adjust in order to reduce the damage to society and its inhabitants from these changes. Moreover, Ian Christie has argued that while the pronouncements of sociologists may still not be at the forefront of the public's consciousness, issues affecting the lives of individuals and communities (for example, crime, the disintegration of traditional family life, poverty, unemployment, stress at work, patterns of disease) are defined in terms of their social causes and consequences, and social solutions are sought (Christie 1999). Classical sociological research techniques (i.e. the survey and interviewing) are routinely employed to assess crime rates, explore family dynamics, analyse voting habits and in assessing the health needs of communities and individuals. Nursing has incorporated social factors into most if not all of its educational programmes. Whether it be the study of childbirth, breast cancer, coronary vascular disease or schizophrenia, the inclusion of social factors in the aetiology, care and treatment of patients and their families are de rigueur. Medicine, whilst far more resistant to the 'contamination' of its natural scientific foundation, has accepted sociology in its undergraduate training for decades. Furthermore, apart from the obvious case of psychiatric medicine, heavily influenced by Sigmund Freud's sociological account of the effects of culture and the family on the unconscious psychological mechanisms of the individual (Bocock 1976), postgraduate medical education specialising purely in social science applied to disease is now not unusual.
In our country today, too many people suffer from poor health. Too many people are ill for much of their lives. Too many people die too young from illnesses which are preventable. But at the same time, many people realise the value of better health. (British Prime Minister, Tony Blair, 1999)
What is health? Is a person healthy if she or he unknowingly has a tumour growing internally but regularly runs a marathon? At what point does that person stop being a 'runner' and become a 'terminally ill patient'? If my general practitioner, on the basis of a medical examination, informs me that I am healthy, but I 'feel' unwell, who is right? Can a low-caste child from the Indian subcontinent ever be described as healthy if she or he eats half the amount of food and lives for only two-thirds of the life span of a child born into a North American middle-class family? British citizens generally now live well into their seventies. Does this mean they are much healthier than British people were a hundred years ago, when most died much younger? Will it also mean that in one hundred years' time, when the British will on average live even longer, people today will be considered to have been unhealthy? The difficulties in establishing a definition of 'health' are examined in this chapter. In tackling the question of 'what is health?', definitions of 'illness' and 'disease' need also to be discerned, as does the question of 'who is doing the defining?' For centuries, people believed sickness have caused suffering to the individual concerned, incapacity in her or his daily activities, or were distressful to that person's family or community. That is, health has been for centuries defined negatively. Furthermore, part of this negative interpretation of health centres... self-taught medical practitioner, was to formulate a taxonomy of diseases, delineating such conditions as syphilis, measles, gout and dysentery. In doing so, he emphasised the objectivity of disease, separate from the sufferer. That is, the trend had been... German scientist Robert Koch (1843-1910). These developments formed the foundation of scientific medicine. However, whether health is viewed as being obtained through the calming of generalised disturbances, the excision of renegade spirits, or the curing of identifiable and localized interventions by health workers. Members of the institute's board will offer advice to the Department of Health and Welsh Assembly on the benefits and costs of existing and new medical and surgical treatments geared to disease prevention rather than a 'state of complete well-being'. For example, he recommends a reduction in the amount of cigarettes smoked or stopping altogether, a diet rich in fruit and vegetables, increased physical exercise, attendance at screening clinics 'unnatural' on the basis that the latter refer to human activity and the former everything else is erroneous. Lay health
Whilst health can be defined either as an ideal state or the absence of disease (and disease is what doctors describe), illness is the subjective experience of 'feeling' unwell: Illness can be...
1 are highly visible and recognizable
2 are regarded as dangerous
3 disrupt working or social routines
4 occur repeatedly or persistently
5 are not tolerated due to a low-pain threshold or perceived offensiveness
In the sphere of thought, sober civilisation is roughly synonymous with science. But science unadulterated, is not satisfying; men need also passion and art and religion. Science may set limits to knowledge, but should not set limits to imagination. (Bertrand Russell 1961:36)
Much of nursing and medical practice is predisposed to an uncritical acceptance of science. Nursing and medicine (and all other health-care disciplines) are engaged in the exposition of scientific suppositions and methods to justify the care and treatment that is dispatched to patients in the health service. Research-based 'evidence' is given priority over other approaches to understanding the patient's condition. The sociology of science, however, aims to analyse critically the foundation of scientific knowledge. At the core of this critique is the constructionist proposition that knowledge of any sort, whether emerging from a traditional source (for example, magic, witchcraft), co-existing lore (such as alchemy, metaphysics, celestial prophecies, psychoanalysis, paranormality, and religion), or science, is bound by temporality and culture. But, whilst superstitious beliefs may still be held by some people in the West, and 'new-age' ways of viewing the world are growing in popularity, scientific thought has become the predominant epistemology, and therefore the most successful construct in determining what is considered to be legitimate knowledge. However, sociological thinking has challenged the authenticity of the pre-eminent status of scientific knowledge. At its most virulently post-modern, sociology claims that science is not factual
Nurses, doctors, other health-care professionals and patients all have and use power in their relationships with each other. Power, as a social and personal endowment of authority, mediates and controls these relationships. It is essential, therefore, to understand the nature of power in practitioner-patient associations, and in interactions between practitioners. Without such an understanding, power differentials in health care may either continue uncontested, and this may be to the detriment of a particular discipline (for example, nursing) or gender (i.e. women health-care workers), or can undermine the movement to empower consumers of health services (i.e. patients). Social power
Power is a complex phenomenon, involving a multitude of interconnected factors existing on a variety of different levels. Moreover, power loci can shift as a consequence of personal, interpersonal and social change. The twenty-first century has inherited global political and economic instability from the previous century, therefore identifying and defining who is powerful and where power is located is problematic. The power of an individual rests upon such personal factors as volition, knowledge and physical and intellectual capacities. An individual's power is affected also by the norms and mores of the Professions
Medicine is a profession, and nursing wants to be one. Why? In this chapter I examine the role of the professions in society, the historical and present-day position of medicine as a professional occupation, and the potential for nurses to be enshrined as fully fledged professionals. Within this evaluation is a recurrent theme that professionalisation for doctors is an occupational tactic, founded on the principle of self-interest, which has been extremely successful. This tactic, however, whilst embraced enthusiastically by nursing (or at least the elite managerial and educational section of the discipline) has not been so useful in achieving leverage in the occupational division of labour as it has been for medicine. Indeed, it is the very existence of medicine as a profession that attenuates, if not thwarts, the ambition of nursing. At the beginning of the twenty-first century, the Western world and its institutions are undergoing rapid change as a result of the globalisation of the capitalist market and communications technology. This has led Stephen Jones (1995) to suggest that the Western world's 'post-industrial' phase, where the large manufacturing base of the economy has been replaced by service industries and finance corporations (Bell 1973), has entered a new period of development, 'cybersociety'. The professions as social organisations are also mutating. A multitude of occupations are asserting that they are professions. Medicalisation
The medical profession is (still) powerful, and in part this power is reified through the dissemination into the public's consciousness of medical ideas and technologies. This in turn shapes views of what is normal and acceptable in terms of behaviour and health. From a constructionist perspective, medicine is fabricating reality to advance its own interests. Whilst at times antagonistic towards the profession of medicine for what is considered to be undue interference in their own sphere of work, nurses reproduce medical constructs of psychological and physical dysfunction. Nurses may object to the paternalistic, patronising and arrogant ways of their medical colleagues, but essentially embrace and duplicate the medical discourse. Hence, where in this chapter the effect of the medical enterprise on society is noted, it should be taken for granted that nurses are co-conspirators with doctors in the medicalisation of society. Moreover, the medical enterprise is not just made up of doctors and nurses (and other paramedical disciplines such as physiotherapy, occupational therapy, pharmacy and radiography), but also includes the industries that manufacture the accoutrements of medical practice. In particular, the pharmaceutical companies are vigorous in the promulgation of medical hegemony. The spread of medical predilections does not merely benefit its perpetrators. The profession of medicine is given licence by the State to infiltrate the thoughts of the population, and conduct its affairs with (relative) impunity, because there is a reciprocal advantage for society - stability. But purely bio-medical explanations of reality are being superseded by an overlapping system of constructing the world. The ideological and technological forces of medicine, the paramedical Sex
Nurses are associated inescapably with sex. First, there are the sexual stereotypes. Female nurses are portrayed if not as virgin angels, then as sexual libertarians, libidinous, busty and adorned with starched aprons, black stockings and suspenders, and a coy manner. Alternative images present them as sexual prudes in the role of the middle-aged, overweight, domineering and repressed 'matron' figure. Male nurses are stereotyped as effeminate, homosexual, sexually incontinent, camp and in the wrong job because only female biology is thought to be capable of proliferating caring. However, even though sexual connotations abound, nurses have perennially avoided the sexuality of their patients. At best lip-service has been paid to the sexual needs of those people who have been hospitalised, who are physically disabled, mentally disordered, suffer from learning difficulties, or are elderly. Illness disrupts sexuality. Health-care professionals customarily evade the question of how to compensate for the fundamental need for sexual expression. No matter how much attention is paid to 'holistic' nursing or medicine, this is one of the aspects of the patient's biological, psychological, social and spiritual needs spectrum that is neglected. Second, nurses have a prime responsibility in the prevention and treatment of sexually transmitted disease. Sexual disease kills millions of people throughout the world. But sexual behaviour is tied to social practices. Therefore, to promote sexual health and prevent death by sex, knowledge of sexual pathology must be complemented by an understanding of the social context of human sexuality. Moreover, the promotion of sexual health goes beyond dealing with disease.
Madness is everywhere. Nurses, doctors and other health-care workers come across madness throughout their careers. This may be in the specialist area of mental health (where the health-care worker may be on 'placement' during training, or is employed permanently) or whilst working in a hospital or in primary care. Accident and emergency departments and general practitioner surgeries abound with madness. The mental health worker, operating in a very stressful area of care delivery, may herself or himself suffer a 'mental health problem' (a modern-day euphemism for madness). It is highly unlikely that she or he has not had a mad loved-one or relative, although in the past this may have been a family secret with the affected person mysteriously concealed from view and perhaps institutionalised beyond the gaze of 'normal' society. But what is madness?
In Britain a survey of the incidence of psychiatric symptoms, using a sample of 10,000 adults living in private households, found that one in seven adults aged between sixteen years and sixty-four years had a 'neurotic' illness during one specified week (Meltzer et al. 1994). The researchers reported that women were much more likely to suffer from neurosis, but that men suffered from alcohol and drug dependency in far greater numbers. Fatigue, disturbed sleep, irritability and worry were found to be the most common symptoms of mental disorder, with anxiety and depression the most prevalent disorders. Up to 30 per cent of Australians may have a mental disorder, and 3 per cent of the population can be described as being serious. Death
We are all going to die. All of our friends and family will also die. There is nothing so factual than the inevitability of our demise. Moreover, the predetermination of our death means that we are all in the process of dying. That is, dying is not something that happens only to those who will do so within a particular period of time. Nurses wrestle with death throughout much of their working lives. They are part of an industry that has traditionally purported to have as its mission the alleviation of suffering and the preservation of life. They care for the dying, and help lay the dead to rest. However, on occasions the abatement of physical or emotional distress may actually lead to nurses and doctors killing their patients, either as a consequence of iatrogenesis, neglect or as a deliberate measure to end a patient's pain. The latter may involve (rarely) murder, the surreptitious removal of treatment or food, or the administration of types and dosages of medication that are known to induce death. However, death is not all it seems. To begin with, some scientists (i.e. those persuaded by the logical positivism of Karl Popper 1959) may argue that not even death can be guaranteed. We may believe that people (as with all life forms) have always died. But, just as we cannot state categorically that the force of gravity, although it appears to have always worked in the past, will continue to make objects of any size drop to the ground at the same rate, death cannot be predicted (in the scientific sense) for everyone who is living now or who may be born in the future. Moreover, the notion that death is certain for all living creatures depends on how 'life' and 'death' are defined, and who is doing the defining. That is, there is at times great ambiguity, both in terms of how the biological state of an organism is interpreted, and what social meaning is attached to that organism's condition.
Making anthropology clinically relevant to nursing care.
Information from Industry
Transcultural nursing is generally seen as the interface between anthropology and nursing. A prime objective of transcultural nursing has been the translation of concepts from anthropology and nursing into the nursing process to guide a culturally informed clinical practice. To date, there has been a general inability of transcultural nursing to operationalize the concept of culture to develop culturally competent clinicians; that is, nurses who are capable of knowing, utilizing, and appreciating the effects of culture in the resolution of an individual, group, community, and/or family problem. A model of transcultural nursing is described, for incorporating the concept of culture into patient care. It includes the concepts of cultural brokerage, simultaneous dual ethnocentrism, multiple clinical realities, the patient as cultural informant, and cultural assessment of patient views of clinical reality. The problems of making anthropology and transcultural nursing clinically relevant through the transcultural nursing model are presented and methods are recommended for addressing such problems.