Social Theory and Nursing

Martin Lipscomb, Martin Lipscomb

• Publisher: Routledge
• Year: 2016
• ISBN:
  9781317287889
• Edition: 1
• Topic: Medicine
• Subtopic: Health Care Delivery

Despite noteworthy exceptions, nursing's literature largely disregards the ways in which social and sociological theory permeates, guides and shapes research, education, and practice. Likewise, social theory's ability to position nursing within wider structures of healthcare and educational provision is similarly and puzzlingly downplayed. The questions nurses ask and the problems they face cannot however, adequately be addressed without engaging with social and sociological theory and, to progress this engagement, contributors to this book explore how social theories are used by and might apply to nursing and nursing practice.

The book draws on a wide range of perspectives – philosophical, theoretical, empirical and political – to offer a robust and wide-ranging critique and analysis. Social Theory and Nursing is essential reading for nursing researchers, academics and educators, as well as scholars and researchers in medical sociology, medicine and allied health.

1 Introduction

Martin Lipscomb

Nurse researchers frequently employ concepts that originated or have undergone subsequent development in the social sciences; nurse educators make extensive use of ideas derived from sociology; and clinical practitioners justify actions using socialised vocabularies. However, while a great deal of consideration is given to, for example, methods and methodologies, substantially less interest is shown in social and sociological theory. Nurses habitually employ terminology and back ground assumptions that emanate from or can be tied to these theories. Yet the demonstrable and latent capacity of social and sociological theory to guide, shape and inform research, education and practice receives less overt attention. This is puzzling.

Many of the phenomena that nurse researchers investigate and many of the activities that clinical nurses undertake have been explored by social theorists, and nurses have much to learn from the arguments and understandings that these theorists propose. Underestimating theory and its products is therefore problematic. Social theory speaks to nursing’s role and place within healthcare structures and, since the quality and nature of patient care is determined, in part at least, by the understandings that nurses possess, disengagement with or ignorance of theory threatens the sophistication, relevance and usefulness of understanding. Put another way, nurses who ignore social theory’s ability to advance comprehension may deliver suboptimal patient care and/or they might fail to grasp important insights about their position within the ‘bigger picture’.

To illustrate theory’s bearing on comprehension, imagine you are reading about the impact of nineteenth-century industrialisation. Self-evidently it matters if the historian whose work you are considering is a Whig, a Conservative or a Socialist. Each position embodies different sets of suppositions and historians taking up these positions produce radically dissimilar interpretations of the same events. Moreover, political theory and the beliefs that theory encapsulates and structures do not ‘bias’ the results of research. Rather, theory stipulates or scaffolds how events and event sequences are identified and given meaning. Interpretation does not occur outside of theory and, therefore, history writing cannot take place in the absence of theory. This is not to claim that historians necessarily employ grand narratives or metatheories. Most do not. (At least not deliberately.) It merely recognises that, with a nod to the hermeneutic circle, description involves interpretation and interpretation is thoroughly theory-laden.

Similarly, when reading about the causes of and remedies for the financial crisis of 2008, it clearly matters if the author is an interventionist Keynesian or a free-market Austrian. These contrasting perspectives classify and explain what occurred and what should now occur differently. Theory here is not extra or external to Keynesian and Austrian economic thinking. It instead just is what these positions and those who hold them describe, and while ‘the facts’ are important, what counts as a fact is not easily discerned apart from theory. Of course, theory is never totalising; theory development is constrained by what is, and events can and some times do repudiate our best ideas. Nonetheless, fallible and contingent understandings of what is do not come about in the way that crude empiricists imagine. That is, meaning is not discovered by simply agglomerating or piling up atheoretical facts.

With this in mind, when I read a research report with a view to establishing whether its findings can inform clinical decision-making, or when I read a paper relevant to my role as an educator, I want to know if and how that research or paper has been influenced by, among other things, social-scientific thought. I want to grasp how social and sociological theory constitutes or underwrites the claims being advanced. In this process we do not need to suppose that good (acceptable) and bad (unacceptable) social or sociological theory exists. This possibility need not be rejected. However, to those of a generous spirit, it may be that something valuable can be learnt from many or even all theories or theoretical orientations.

On the other hand, not every combination or application of ideas makes sense and, therefore, theory and theory use require appraisal. Assessment or evaluation describes the process whereby reason and intuition (prior learning) regulate rather than determine the manner in which the readers of research or scholarly texts decide whether they will accept and act on, or reject and decline to act on, what is proposed. This is not to suggest that social theory and its products can be applied or used in the same way that clinical randomised control trial data can supposedly be applied/used. It does, however, recognise that understanding and action or behaviour are linked (albeit sometimes tenuously), and gauging theory’s role in and contribution to argument influences whether I ‘listen to’ or heed the claims being made. Further, I assume that appropriate levels of theory assessment vary with context. Comparatively advanced skills should be evidenced by researchers who, often, develop views on which theories best suit particular questions or topics or, more resolutely still, formulate beliefs that strongly incline them to favour certain theoretical traditions or positions while rejecting or being suspicious of others. Alternatively, when educationalists invite students to think about their activities in relation to society and ‘the social’, while it is necessary that contrasting and occasion ally incommensurable explanations of the social world be differentiated, a simple or basic proficiency in assessment is probably the best that can be hoped for.

Yet herein lies a problem. Nurses are not, generally speaking, social scientists or sociologists. Our literature is steeped in social theory and sociological ideas. However, nurse research, education and practice focuses on care-related activities and busy research agendas, crowded curricula and the immediacy of clinical demands means that scant attention is given to theories from non-nursing disciplines even when those theories provide underpinning rationales or potentially informative ideas that are pertinent to nursing. The profession of nursing is thus ill equipped to meet the epistemological demands sketched above. That is, while social and sociological ideas richly infuse or permeate nursing’s literature and thinking, nurses are rarely prepared (i.e. educated) to engage meaningfully with the theoretical concepts they employ at advanced or even basic levels.

The corollary of under-preparation is that social and sociological concepts tend, in our literature, to be presented and discussed in an ahistorical and decontextualised manner. This poses difficulties for, not only can the same theory be used by different scholars in different ways in different studies (Palmér and Roos, 2016) but, also, theoretical ideas may and often do evolve over time. Thus, while Bourdieu’s notion of habitus is popular with some nurse academics, readers of the outputs of these scholars are seldom told which version of habitus is being introduced. This notoriously dense concept arguably changed over the course of Bourdieu’s career yet, without clarification, readers cannot know which version of habitus is being referenced (Lizardo, 2004), or how an account resembles (or not) alternative accounts offered by other scholars. Ambiguity hampers evaluation. However, to complicate matters further, because readers are almost never given an explanation of why Bourdieu’s theory is preferred above other ‘close’ competitor theories (e.g. those of Margaret Archer), the relative merits of Bourdieu’s position cannot adequately be judged. Many similar examples could be cited.

Insofar as nursing practice focuses on patient care rather than abstract theory, this absence of detail might be excused. But, since ideas derived from social and sociological theorists are incorporated into nurse writing and discourse, and use suggests these ideas are valued, engagement with the sources from which ideas are taken is warranted. Moreover, engagement cannot easily escape entanglement with the people and problems that gave birth to the theories being utilised and, if we want to understand the strengths, weaknesses and potential of any theory, we need at some level to understand its history and place within what might be termed broader constellations of meaning. This, I would stress, is not an argument in favour of strict or formal ‘Quentin Skinner’ historicism, and the phrase ‘at some level’ recognises that not all nurses want or are able to immerse themselves in sociological history. However, in the absence of background contextualisation, readers cannot comprehend fundamental features of whatever theory is being considered, and their ability to evaluate that theory’s usefulness or influence is once more hobbled.

Likewise, it matters that key figures and movements in social and sociological thought are ignored by the nursing literature. Weber, for example, is, despite his status, effectively snubbed. Nurses talk to topics that he examined – namely, the impact of impersonal powers of various types in and on decision-making, dehuman ising and bureaucratic organisational arrangements, the unpleasantness of certain forms of technical rational human relationships and issues around the benefits and dangers inherent in charismatic and other forms of leadership. However, Weber is rarely mentioned by name and this is perplexing for, if we grant that he spoke to these issues in a sophisticated and nuanced manner, if his writings still stimulate fresh thinking regarding these topics, then his near-invisibility from our literature is disquieting. Significantly, one does not have to accept or even agree with Weber to realise that his thinking continues to resonate with present-day concerns and, just as ethicists do not need to be Aristotelians to read and take inspiration from Aristotle, nurses interested in the themes addressed by Weber can gain much from his work while recognising and perhaps preferring modern theorists. Alternatively, despite the fact that cohesion, solidarity, conflict and anomie are discussed under a variety of names and guises by contemporary nurses in their exploration of roles and role hierarchies, Durkheim is scarcely referenced. Or, while Talcot Parsons’ development of the sick role is noted, the place of this idea within functionalist sociology is mostly overlooked. One could easily go on here, and there is indeed no logical or simple path through what could be a very long list. For example, although Habermas’s theory of communicative action is discussed by nursing scholars, engagement with the subject is largely superficial, since communicative action is infrequently situated amid ideas concern ing emancipatory communicative acts or evolving debates and refutations of these concepts. Foucault and Marx have an established niche in nurse writing. But Alfred Schütz, Anthony Giddens, Charles Wright Mills, Erving Goffman, Georg Simmel, Harold Garfinkel, Herbert Marcuse, Herbert Spencer, Jean Baudrillard, Ludwig Von Mises, Peter Winch, Robert Merton, Roy Bhaskar and Zygmunt Bauman are, to name at random just a few of the great and the good, less celebrated.

This lack of interest is curiously difficult to fathom. No serious ethicist ignores Aristotle. Yet nurses utilise ideas from social and sociological theory without reading ‘back’ into the subject and this, in my opinion, is troubling. All the aforementioned theorists advanced arguments and outlined concepts that, possibly, might productively inform nurse thinking and, by implication, patient care. Some have generated ideas and evidence directly bearing on nursing practice or nursing’s place within wider health and educational structures. However, in the absence of deep and sustained interest and instruction, nurses – and especially nurse researchers – lack the capacity to make informed decisions about the relative merits or value of ideas associated with old-school Frankfurters, or structuralists, or Chicago school ethnographers, or social realists, or non-realists, or reconstructed or unreconstructed Marxists, or methodological individualists, or public choice theorists, or postmodernists or post-postmodernists, or any of the many brands of, for example, feminist, black or gay social writing (see e.g. Andrea Dworkin, Eric Anderson, Judith Butler, Laud Humphreys, Patricia Hill Collins or W.E.B. Du Bois).

The work of each theorist and perspective emphasises different sets of assumptions, including evaluative or normative assumptions. Each includes and excludes different objects from inquiry and each reaches potentially different conclusions. Furthermore, while, arguably, anyone who ignores the influence of social and socio logical theory on the form and content of research, scholarly outputs, educational curricula or practice does not understand key elements of what it is they are reading or engaging with, nurse researchers, educationalists and practitioners are, as stated, not trained to make informed choices about social and sociological theory or, one might add, the implications of theoretical usage. If this somewhat sombre critique is accepted, nursing’s ability to substantively engage with social and sociological theory is severely compromised, even though the benefits of doing so seem obvious.

To ignore the place and use of social and sociological theory in nursing is thus to ignore something vital. Yet, for a variety of reasons, nursing and sociology’s ‘well established association … is far from harmonious’ (Allen, 2001, p.386), and:

Unfortunately, while the aspiration of integrating sociology into nursing knowledge is easy enough to state … in practice their relationship has not been as productive as some might have hoped. Notwithstanding a number of works that have successfully applied sociological tools to nursing problems, there remains a gulf between the two disciplines…

Miers, Porter and Wilkinson (1998, p.xi)

Fawcett (2007, 2015), for example, might stand as the representative of a strand of opinion that holds that nursing knowledge should be generated by and within nursing and, if this is accepted, imported or borrowed forms of understanding – that is, understandings derived from, for example, non-nursing social and sociological theory – will be viewed hostilely. The grip that this perspective retains over current nurse academics and researchers is difficult to measure and the idea may be historically and geographically specific since, while the notion remains live, entrenched reticence towards the use of imported ideas was probably always stronger among a subset of North American writers of the 1960s, 70s and 80s than elsewhere. Nonetheless, as will be noted, several contributors to this volume (myself included) continue to speak to the borrowed status of social theory in nursing, and this topic clearly retains some salience. Alternatively, even when this negative orientation is rejected, nurses favourable to the social sciences must acknowledge that, first, it may simply be unfeasible to imagine that nurses can adequately engage with theory in the manner suggested above, and second, rightly or wrongly, social and sociological theory stand accused of not generating the sorts of action-guiding evidence that applied disciplines such as nursing are presumed to require (Sharp, 1994: Porter, 1998: Mowforth, Harrison and Morris, 2005). Criticism regarding this latter point focuses on the abstractness, contradictory nature and evaluative content of much social-scientific discourse, whereas, it is frequently supposed, nurses primarily need access to unambiguous and settled bedside or clinically focused instruction.

More optimistically, or more positively, contributors to this book accept that social and sociological theory have much to offer nurses and nursing and, despite the problems identified, we assert that it is not beyond the profession’s collective wit to harness at least some of this potential. We recognise that the knowledge and under standings produced by these theories differ from the sort of evidence commonly deemed desirable in clinical decision-making. Nevertheless, rebutting claims that theory is too intellectual, rarefied or difficult, we believe that, often, the questions nurses ask and the ‘real world’ problems they face cannot adequately be addressed without engagement with social and sociological theory, and, we suggest, meaningful engagement with theory is feasible. Further, this is clearly an important subject. Non-engagement with social theory may limit the development of understanding or knowledge by nurses and, hence, non-engagement threatens concrete patient care. If accepted, this claim places a heavy burden on researchers since they shoulder the main responsibility for knowledge-creation. However, insofar as theory and its products filter into practice via education, the assertion also applies, albeit to a different and perhaps lesser extent, to educators and clinically situated nurses alike.

Illustrating social theory’s promise, Mary Ellen Purkis and Christine Ceci begin the book (Chapter 2) by using a series of ‘everyday’ nursing examples to explore how the social realm is envisaged, misjudged and dismissed as ‘mere context’ when, they argue, it should be ‘interrogated as readings of pressures, prior to, during and after actions’. Purkis and Ceci propose that an appreciation of ‘the social’ may be productive for nurses and nursing since, they assert, this appreciation can be used to, for example, show practices and foster discussion about ‘what good nursing practice looks like’.

Thereafter, in Chapter 3, Gary Rolfe deploys Charles Wright Mills’ concept of the sociological imagination to argue that nurse researchers and academics have become captured by malign bureaucratising trends and forces that might possibly have been evaded had closer engagement with social theory occurred. It is suggested that resemblances exist between the state of sociology in the 1950s and present-day nursing and, to remedy the malaise that Rolfe identifies in nursing, a radical reappraisal of contemporary scholarly assumptions and practices is required. Rolfe’s thinking resonates with aspects of the work of Bluhm (Chapter 4) insofar as both authors point towards nursing’s failure to stay up-to-date with developments in, respectively, social theory and philosophy. Rolfe’s work also connects with wider commentaries where, for example, it is recognised that recent developments in social theorising and social methodologies may outrun the ability of sociologists and others to keep pace (Pearson, 2016).

Robyn Bluhm, in Chapter 4, examines ‘recent work in philosophy of science to address the relationship between sociological theories and nursing theory’. Bluhm proposes that nursing is still strongly influenced by an approach...

Table of contents

• Cover
• Half Title
• Title Page
• Copyright Page
• Table of Contents
• Contributors
• Foreword
• 1 Introduction
• 2 Accounting for knowledgeable practice
• 3 C. Wright Mills and the sociological imagination
• 4 Nursing theory, social theory, and philosophy of science
• 5 On cow-tapulting and raised drawbridges: an argument for strategic integration of social theory into nursing
• 6 Social and sociological theory: reimagining nursing’s disciplinary identity
• 7 Critical realism: a social theory for evidence-based nursing
• 8 Using theory in qualitative research: a realist perspective
• 9 The purpose and scope of sociological theory: implications for nursing
• 10 Foucault, social theory and nursing research: a critique
• 11 Contemporary political debates, social theory and nursing practice in mental healthcare
• 12 Feminism and nursing: an un/easy alliance of silences and absences
• 13 It’s all in the genre: sociological speculation and theorizing in the nursing literature
• 14 Lies, damned lies and stories: nursing, narrative, numbers
• Index