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psychological element of the illness state
Inl. 1. Nurs. Stud. Vol. 16, PP. 267-213. OPergamon Press Lid.. 1919. Printed in Great Britain.
00204878/79/08010267$02.00/0
One aspect of the social/psychological element of the illnessstate F.A.McGILLOWAY,
B.A., S.R.N., B.T.A.Cert.,D.N.(Lond.),
R.N.T.
Director of Nursing Studies, The New University of Ulster, Coleraine, Co. Londonderry, Northern Ireland, BT52 ISA.
Introdactlon
Parsons (195 1) described illness as a state of disturbance in the normal functioning of the total human individual, including both the state of the organism as a biological system and of his personal and social adjustments. This definition of the illness state seems to concur with the present-day vocabulary of nurses who, when discussing whole patient care or meeting the needs of any ill person, refer to the physical, social and emotional aspects of patient care. A difficulty arises, however, when one attempts to examine these perspectives and explain their meaning. For many, it is little more than jargon. It sounds good and “You’re expected to say this sort of thing . . . We understand the physical aspect and to some extent the emotional. But the social thing is something else.” This present theoretical study sets out to identify one aspect of the social/psychological element of the illness state, by exploring the situation of any new patient in a general hospital ward. It considers the likely situation in which any person finds and presents himself in his attempts to interpret a different way of life and to orient himself within it. The study reveals that any new patient carries into the nurse/patient situation, in a hospital ward, important features which may be stressful and which may not be obvious to members of the ward team. It reveals, briefly, that stress has a disease-kindling effect, and argues that the features of the patient situation presented in this study clearly fall, and are dimensional, within the process of nursing practice. This work simply calls attention to an aspect of the illness state which offers another point from which to begin assessing the needs of any new patient. The study does not give details of the nursing process. For our purposes the ‘process’ is considered to be known. It does not consider the reason for admission to hospital and is not concerned with the processes of social adjustment, but with what Schutz (1971) termed “the situation of approaching” which precedes every possible social adjustment and which includes its pre-requisites. For the purpose of this paper, the term ‘patient’ shall mean an adult whose degree of helplessness and gravity of illness do not affect his rational judgement during his stay in a 267
268
F. A. MCGILL0 WA Y
general hospital ward. The offered analyses are worked out with this instance in view but it is argued that their validity need not be restricted to this special case. The individual before he becomes a patient As a convenient starting point, the study considers how the cultural pattern of life presents itself to the common sense of any man who lives his everyday life in familiar surroundings and with his usual acquaintances. The culture of his group provides a ready-made standardized scheme for almost any situation which normally occurs within his social life. His socialization provides a blue-print for action, thought and feeling for the normal happenings of everyday existence. Most people arrange their daily experiences according to this scheme of reference, and their personalities, individual characteristics and values all belong to its reality. Lynd and Lynd (1963) described “. . . points of view so familiar and so commonly taken for granted that. . . they pass from person to person like smooth familiar coins which everyone accepts and no one examines with fresh eyes”. The individual organises knowledge in terms of relevance to his actions, and is interested in those elements of his social world which may serve as means or ends for his use and enjoyment, and which are within his actual or potential grasp. As Schutz (1971) put it, “The world seems to him at any given moment as stratified in different layers of relevance, each of them requiring a different degree of knowledge”. Yet socialized man is incapable of becoming acquainted with all relevancies with equal thoroughness, regardless of their degree of significance. The ready-made standardized scheme of reference is inadequate under special conditions in the cultural and social systems, and the management of problems which fall within the scope of these special conditions cannot be taken for granted. The reality of the ‘readymaoe is inadequate within the social world of the hospital ward.
The culture of the ward
“A general hospital ward may be described as a locale which holds working personnel and patients. The work force comprises people, drawn from different health care professions and non-professions, brought together to provide and maintain facilities for, and to specifically meet the needs of, the patients” (Strauss, Schatzman, Ehrlich, Bucher and Sabshin, 1973). The culture of the ward is its customary and traditional way of thinking and doing things, which is shared to a greater or lesser extent by all its members. It is part of second nature to those who have been members over a protracted period of time. New members must learn the cultural pattern and at least partially accept it in order to be accepted into the system. It operates under special conditions in the cultural and social systems. It is characterized, therefore, by a distinctive set of meanings shared by groups and sub-groups of people whose forms of behaviour differ to some extent from those of wider society. Two groups are immediately .obvious within a conceptual framework, namely; the ‘patient group’ and the ‘work group’, each having its distinctive cultural pattern. These groups comprise sub-groups whose cultural patterns are made up of distinctive patterns, perceptions and values associated with reasons for being in the ward, time spent there, and other social sub-divisions. There is no clear cut disparity within each group, but there is dis-
ONE ASPECT OF THE SOCIAL/PSYCHOLOGICAL ELEMENT OF THE ILLNESS STA TE
269
parity between groups, that is, between ‘patient’ and ‘work’ groups. There is a clear-cut disparity between the cultural background of the patient and that of the staff member-in the ward setting; between, on the one hand, the cultural pattern which characterises the wider society and, on the other, the pattern of the ward. There is also a clear-cut difference between the normally structured round of daily experiences in the life of the individual before he becomes a patient and the new patient in a general hospital ward. Schutz (1971) argued that the cultural pattern of the approached group is, to the stranger, not a matter of course but a questionable topic for investigation; not an instrument for disentangling problematic situations but a problematic situation itself, and one hard to master. Otherwise stated, the problem-solving device (the ward) may be a problem-making device for the new patient. General knowledge of health care
The knowledge of the healthy individual with respect to the problem of health care is incoherent and lacking in detail. It was stated earlier that socialized man organises knowledge in terms of relevance, and that he is incapable of becoming acquainted with all relevancies with equal thoroughness, regardless of their degree of significance. In addition to this, Schutz (1971) stated that the relevance of objects selected for any form of in-depth enquiry are themselves not integrated into a coherent system. Parsons (1951) wrote, “ . . . a little reflection will show that the problem of health is intimately involved in the functional pre-requisites of the social system . . . by almost any definition, health is included in the functional needs of the individual member”. There is ample evidence, however, to support the argument that the possibility of ill-health and the certainty of death are not among the foremost interests of any ‘normal’ individual. The research findings of Hockey (1966) ‘Feeling the Pulse’ and ‘Care in the Balance’ (1968) revealed a surprising lack of knowledge about the nursing profession, within the ranks of other health caring professions. The Report of the Committee on Nursing (1972) (Briggs Report) highlighted a lack of interest in nursing- “the major caring profession” -even among relatively knowledgeable sections of the public, “ . . . like the teaching profession which should be in a position to know. . . “. The interest priorities of the ordinary person fit, in a general way, into a short-term strategy, and interests are only partially organized under plans of any kind. Plans of life, plans of work and leisure, and plans for the various social roles assumecl are not integrated into a coherent system. Furthermore, the hierarchy of interests and arrangements changes with situational change. In other words, the knowledge of socialized man is incoherent. Socialized man does not normally quest for certainty under normal or everyday circumstances. He tends to accept the ready-made pattern of living handed down to him as a guide in all the situations which normally occur within the concrete social world. All he wants is information of likelihood and insight into the chances or risks which the situation potentiates. Man’s lack of clarity of knowledge is admirably illustrated by Wrong (1961), who de-
210
F. A. McGILLO WA Y
scribed how Gertrude Stein, bedridden with a fatal illness, is reported to have suddenly muttered, “What then is the answer?“. Pausing, she raised her head, murmured, “But what is the question?“, and died. The new patient
For the new patient a crisis arises; the cultural pattern reveals that the applicability of the ‘ready-made’ is now confined to a specific historical situation. McGillowayand DOMdy (1977)stated that it is only when he is confronted with breaking points in the so&By structured round of daily behaviour, for example, when admitted to hospital; when events of crucial significance for his well-being are beyond his prevision; “ . . . when important aspects of self-tmderstandingand self-identificationare disturbed . . . “, and his future prospects are uncertain that socialized man is importantly and seriously challenged. The new patient becomes essentially the person who has to place in question nearly everything that seems to be unquestionable to the members of the group he has just left, and the group he is now approaching. For the new patient, the system of knowledge acquired, incoherent and only partially clear but generally adequate within the concrete social world, is no longer sufficiently coherent and clear to give him a reasonable chance of understanding relevant phenomena within the social world of the ward. It is seen that, for the new patient, the reality of the standardized socialization scheme becomes unworkable when former experiences fail to suffice for future situations; when former solutions fail to meet problems and the knowledge handed down by significant others ceases to be reliable; when it is not enough to know ‘just something’ about dealing with problems in order to manage or control them. Parsons (1951) argued that the patient is not only generally not in a position to do what needs to be done, but he does not know what needs to be done or how to do it, and how to judge what needs to be done. However, the fmdings of Stockwell (1972)and Raphael (1977) reveal that the patient is conscious of his ignorance of the justification for care offered on his behalf. As one patient put it, “The don’t-you-worry-let-us-do-your-worrying-for-youidea” is not accepted by many in these days of better education and dislike of paternalism. In short, there are problems concerning information to the patient who might be in a state of bewilderment because nobody will tell him anything that will ‘make sense’to him. There is, that is to say, a ‘communication gap’. The communication gap and stress Eisenstadt (1965) explained that in situations of transition in which the routine of a given role is endangered or disrupted, problems of communication arise. “ . . . the individual is placed in a potentially ambiguous, undefined and conflicting situation, in which his whole identity, status image, and continuity of perception and action are endangered . . . thus we see that such situations are indeed of potential stress”. Katz (1%9) argued “ . . . if we are talking about social psychological stress . . . it is not unusual for things to be a little wrong all the time. Everyone is a little sick or disturbed most of the time . . . “, He described this state of affairs as ‘normal’ but claimed that crisis or abnormal stress is one of the main reasons for illness. It is widely accepted that for any normal person the fact that he is in a hospital bed means
ONE ASPECT OF THE SOCIAL/PSYCHOLOGICAL
ELEMENT
OF THE ILLNESS STATE
27 1
that he is in a crisis situation. Autton (1968) stated, “It must be remembered that there is no such thing as a minor operation to a patient”. Katz (1969) wrote that “such patients often feel nervous about the success of the operation. This is normal. But in extreme cases the patient is so immobilised by his fear that he becomes a poor surgical risk and has a poor chance of recovery”. Groen (1971) considered social stress as a “situation caused by social circumstances or cultural rules which frustrate or threaten to frustrate an individual or group, that is, which prevents him or it from developing or acting according to inborn or acquired gratifying behaviour patterns”. Lazarus (1971) argued that it would be well to allow the term ‘stress’to extend to the whole area of problems, sociological, psychological and physiological, in which individuals are taxed by stimulus demands up to the limits of their potential ability to adapt. Stress refers, therefore, to a class of problems too broad to consider within the scope of this present work. It is sufficient to state that many important sources relate stress, behavioural change and pre-disposition to illness, to situational transitions which are not unlike that which is experienced by the new patient in a general hospital ward. The new patient and nursing practice
Eisenstadt (1971) stated that in the situation of transition the individual may become especially sensitive to broader, charismatic appeals and communication-especially in so far as these tend to define the situation both morally and perceptually; to describe the proper norms of behaviour; to relate the individual to collective identification; to reassure him of his place in a given collectivity. This present work purports that the characteristics of transition from one ‘way’of life to another for any new patient in a hospital ward are problematic, not only in the fact that the situation of change may prove to be stressful, but, beyond this, that the existing system of communication within the strange situational complex may be ineffective and potentially harmful unless it is recognised within, and entrusted to, the sphere of some organized practice. The study argues that the most appropriate sphere of organized practice for the purpose of provision of the required communciation and appropriate action in the given setting is the process of nursing practice. The nurse practitioner is the principal communicator in relation to specific aspects of problems of the ward’s social structure. She is the principal communicator in relation to activities which involve the special skills of other professionals, and of non-professionals, in the direct and indirect delivery of personal care within the ward’s system. In her relationships with patients and their relatives, she is constantly made aware of the local and wider aspects of the social world of every new patient. The nurse practitioner holds the central and controlling role in the system of communication, not only in relation to activities pertaining to ward management, and those which involve the functions of other ‘work’ subgroups, but also including, in a specific way, intimate relations to the social/psychological needs of all new patients (and other in-patients). The effectiveness of communication with the new patient must include the recognition and acceptance of communication as a ‘function’-falling within the range and focus of nursing care-by nurses and other health care workers. The effectiveness of the function of communication with the new patient must depend
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upon its conferring and maintaining patient status and identity in a positive way, that is, in allowing him to have a view of himself which is compatible with his view of himself in wider society. Effective communication must also serve successfully in mediation, with regard to broader problems of the illness situation and impart information about shortterm and ultimate objectives in regard to the design of the caring process. It must enable the new patient to understand the new social and cultural system, and enhance his sense of participation and belonging in the new setting. The form of communication must be compatible with the cultural orientations, social and professional interests, and general endeavours of the ward team; the many people brought together to meet the needs of the patient. If a high degree of compatibiity between these various factors fails to exist, the effectiveness of any communication is minimized. If these few selected features of communication for the patient, his intimates and ward staff are taken together, it becomes clear that-in ways which are not true of other professional functions-the situation of nursing practice is such as to involve the nurse in the affairs of communication to a significant degree. It is important, therefore, that this function of nursing practice receives the recognition and promotion it demands in the interests of the social/psychological needs of any new patient. Conclllsion
This study has sought to summarize central factors relating to problems of situational change. It simply calls attention to an aspect of the illness state which offers another point from which to begin assessing the needs of any new patient. Although there are important differences in regard to cause and effect issues-and of detail and emphasis-in the range of factors discussed in this paper, the problems faced by the new patient and the influences of nursing practice in the present system of communication situations are, nonetheless, substantially the same. The paper stresses the recognition and promotion of communications as a ‘function’ falling within the range and focus of nursing care, by nurses and other health care workers, in the interests of the social/psychological needs of any new patient. The nurse practitioner will continue to require the support of other specialist workers to help those patients who need their services, but the nurse is clearly the professional most suitably placed to receive and offer information to the new patient, and to organise the management of his social/psychological requirements in a socially and culturally accepted manner. How this is to be achieved properly, presents a set of complications of the functions of nursing practice. These complications present another order of problems which fall outside the scope of this work. It should suffice to state that further analysis will show that nursing practice already provides a communication system-for the benefits of ‘patient’ and ‘work’groups-but that it is open to recognition, proper definition and improvement. Any analysis will also reveal an absence of any comparative system within the total personal care system. It will also reveal a possible series of ‘ways’of overcoming any obstacles to effective nursing practice in this area of patient care. This paper does not attempt to provide a formula for communication. It simply offers a feature of the social aspect of patient care which is meaningful in the context of nursing practice. It points out that a major requirement in approaching the new situation for any
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ELEMENT
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new patient is appropriate information and reception through a proper communication system, supported by recognition-unspoken or other-of the patient’s dilemma, despite its covert nature, and the ability to ease the person (who is already ill) into the experience in a way which reduces its stressful effects as far as possible. References Autton, N. (1968). Postorol Core in Hospitok. SPCK, London. Eisenstadt. S. N. (1965). Communication and reference group behaviour. In Esuys on Cotnporotive Institutions, pp. 32340. New York. Eisenstadt, S. N. (1971). Problems in theories of social structure, personality, and communication in their relation to situations of change and stress. In Society, Stress ond Diseose: The Psychosocial Environment ond PsychosomaticDiseases. L. Levi (Ed.). Vol. 1. University Press, Oxford. Groen, J. J. (1971). Social change and psychosomatic disease. In Society, Stress and Diseos: The Psychosocial Environment ond Psychosomatic Diseoses. L. Levi (Ed.). Vol. 1. Oxford University Press, London. Hockey, L. (1966). Feeling thePuke. Queen’s Institute of District Nursing. Hockey, L. (1968). Core in theBolonce. Queen’s Institute of District Nursing. Katz, A. H. (1%9). The social causes of disease. New Society 13, No. 330. Lazarus, R. S. (1971). The concepts of stress and disease. In Society, Stress and Dkeose: The Psychosocial Environment and Psychosomatic Diseases. L. Levi (Ed.). Vol. 1. Oxford University Press, London. Lynd, R. S. and Lynd, H. M. (1963). Middletown in Transition. Harcourt, Brace&World, New York. McGilloway, F. A. and Donnelly, L. (1977). Religion and patient care: the functionalist approach. J. odv. Nursing. 2. Parsons, T. (1951). Social structure and dynamic process: the case of modern medical practice. In The Social System. Chapter 10, pp. 428479. Free Press, New York. Raphael, W. (1977). Potients and Their Hospitals. 3rd Edn. King Edward’s Hospital Fund for London. Schutz, A. (1971). The stranger: an essay in social psychology. In School ond Society. Open University Press, Milton Keynes. Secretary of State for Social Security, Secretary of State for Scotland, Secretary of State for Wales (1972). Report of the Committee on Nursing. Cmnd. 5115. H.M.S.O., London. Stockwell, F. (1972). The Unpopular Patient: The Study of Nursing Core. Series 1. Royal College of Nursing, London. Strauss, A., Schatzman, L., Ehrlich, D., Bucher, R. and Sabshin, M. (1963). The hospital and its negotiated order. In The Hospitol in Modern Society. E. Friedson (Ed.). Macmillan, New York. Also in (1973) People ond Orgonisotions. G. Salaman and K. Thompson (Ed%). No. 20. Longman, Open University Press, Milton Keynes. Wrong, D. H. (1961). The oversocialized conception of man in modern sociology. Am. Social. Rev. 26, 182-93. (Received 20 November 1978; occeptedforpublicotion
7 February 1979)
00204878/79/08010267$02.00/0
One aspect of the social/psychological element of the illnessstate F.A.McGILLOWAY,
B.A., S.R.N., B.T.A.Cert.,D.N.(Lond.),
R.N.T.
Director of Nursing Studies, The New University of Ulster, Coleraine, Co. Londonderry, Northern Ireland, BT52 ISA.
Introdactlon
Parsons (195 1) described illness as a state of disturbance in the normal functioning of the total human individual, including both the state of the organism as a biological system and of his personal and social adjustments. This definition of the illness state seems to concur with the present-day vocabulary of nurses who, when discussing whole patient care or meeting the needs of any ill person, refer to the physical, social and emotional aspects of patient care. A difficulty arises, however, when one attempts to examine these perspectives and explain their meaning. For many, it is little more than jargon. It sounds good and “You’re expected to say this sort of thing . . . We understand the physical aspect and to some extent the emotional. But the social thing is something else.” This present theoretical study sets out to identify one aspect of the social/psychological element of the illness state, by exploring the situation of any new patient in a general hospital ward. It considers the likely situation in which any person finds and presents himself in his attempts to interpret a different way of life and to orient himself within it. The study reveals that any new patient carries into the nurse/patient situation, in a hospital ward, important features which may be stressful and which may not be obvious to members of the ward team. It reveals, briefly, that stress has a disease-kindling effect, and argues that the features of the patient situation presented in this study clearly fall, and are dimensional, within the process of nursing practice. This work simply calls attention to an aspect of the illness state which offers another point from which to begin assessing the needs of any new patient. The study does not give details of the nursing process. For our purposes the ‘process’ is considered to be known. It does not consider the reason for admission to hospital and is not concerned with the processes of social adjustment, but with what Schutz (1971) termed “the situation of approaching” which precedes every possible social adjustment and which includes its pre-requisites. For the purpose of this paper, the term ‘patient’ shall mean an adult whose degree of helplessness and gravity of illness do not affect his rational judgement during his stay in a 267
268
F. A. MCGILL0 WA Y
general hospital ward. The offered analyses are worked out with this instance in view but it is argued that their validity need not be restricted to this special case. The individual before he becomes a patient As a convenient starting point, the study considers how the cultural pattern of life presents itself to the common sense of any man who lives his everyday life in familiar surroundings and with his usual acquaintances. The culture of his group provides a ready-made standardized scheme for almost any situation which normally occurs within his social life. His socialization provides a blue-print for action, thought and feeling for the normal happenings of everyday existence. Most people arrange their daily experiences according to this scheme of reference, and their personalities, individual characteristics and values all belong to its reality. Lynd and Lynd (1963) described “. . . points of view so familiar and so commonly taken for granted that. . . they pass from person to person like smooth familiar coins which everyone accepts and no one examines with fresh eyes”. The individual organises knowledge in terms of relevance to his actions, and is interested in those elements of his social world which may serve as means or ends for his use and enjoyment, and which are within his actual or potential grasp. As Schutz (1971) put it, “The world seems to him at any given moment as stratified in different layers of relevance, each of them requiring a different degree of knowledge”. Yet socialized man is incapable of becoming acquainted with all relevancies with equal thoroughness, regardless of their degree of significance. The ready-made standardized scheme of reference is inadequate under special conditions in the cultural and social systems, and the management of problems which fall within the scope of these special conditions cannot be taken for granted. The reality of the ‘readymaoe is inadequate within the social world of the hospital ward.
The culture of the ward
“A general hospital ward may be described as a locale which holds working personnel and patients. The work force comprises people, drawn from different health care professions and non-professions, brought together to provide and maintain facilities for, and to specifically meet the needs of, the patients” (Strauss, Schatzman, Ehrlich, Bucher and Sabshin, 1973). The culture of the ward is its customary and traditional way of thinking and doing things, which is shared to a greater or lesser extent by all its members. It is part of second nature to those who have been members over a protracted period of time. New members must learn the cultural pattern and at least partially accept it in order to be accepted into the system. It operates under special conditions in the cultural and social systems. It is characterized, therefore, by a distinctive set of meanings shared by groups and sub-groups of people whose forms of behaviour differ to some extent from those of wider society. Two groups are immediately .obvious within a conceptual framework, namely; the ‘patient group’ and the ‘work group’, each having its distinctive cultural pattern. These groups comprise sub-groups whose cultural patterns are made up of distinctive patterns, perceptions and values associated with reasons for being in the ward, time spent there, and other social sub-divisions. There is no clear cut disparity within each group, but there is dis-
ONE ASPECT OF THE SOCIAL/PSYCHOLOGICAL ELEMENT OF THE ILLNESS STA TE
269
parity between groups, that is, between ‘patient’ and ‘work’ groups. There is a clear-cut disparity between the cultural background of the patient and that of the staff member-in the ward setting; between, on the one hand, the cultural pattern which characterises the wider society and, on the other, the pattern of the ward. There is also a clear-cut difference between the normally structured round of daily experiences in the life of the individual before he becomes a patient and the new patient in a general hospital ward. Schutz (1971) argued that the cultural pattern of the approached group is, to the stranger, not a matter of course but a questionable topic for investigation; not an instrument for disentangling problematic situations but a problematic situation itself, and one hard to master. Otherwise stated, the problem-solving device (the ward) may be a problem-making device for the new patient. General knowledge of health care
The knowledge of the healthy individual with respect to the problem of health care is incoherent and lacking in detail. It was stated earlier that socialized man organises knowledge in terms of relevance, and that he is incapable of becoming acquainted with all relevancies with equal thoroughness, regardless of their degree of significance. In addition to this, Schutz (1971) stated that the relevance of objects selected for any form of in-depth enquiry are themselves not integrated into a coherent system. Parsons (1951) wrote, “ . . . a little reflection will show that the problem of health is intimately involved in the functional pre-requisites of the social system . . . by almost any definition, health is included in the functional needs of the individual member”. There is ample evidence, however, to support the argument that the possibility of ill-health and the certainty of death are not among the foremost interests of any ‘normal’ individual. The research findings of Hockey (1966) ‘Feeling the Pulse’ and ‘Care in the Balance’ (1968) revealed a surprising lack of knowledge about the nursing profession, within the ranks of other health caring professions. The Report of the Committee on Nursing (1972) (Briggs Report) highlighted a lack of interest in nursing- “the major caring profession” -even among relatively knowledgeable sections of the public, “ . . . like the teaching profession which should be in a position to know. . . “. The interest priorities of the ordinary person fit, in a general way, into a short-term strategy, and interests are only partially organized under plans of any kind. Plans of life, plans of work and leisure, and plans for the various social roles assumecl are not integrated into a coherent system. Furthermore, the hierarchy of interests and arrangements changes with situational change. In other words, the knowledge of socialized man is incoherent. Socialized man does not normally quest for certainty under normal or everyday circumstances. He tends to accept the ready-made pattern of living handed down to him as a guide in all the situations which normally occur within the concrete social world. All he wants is information of likelihood and insight into the chances or risks which the situation potentiates. Man’s lack of clarity of knowledge is admirably illustrated by Wrong (1961), who de-
210
F. A. McGILLO WA Y
scribed how Gertrude Stein, bedridden with a fatal illness, is reported to have suddenly muttered, “What then is the answer?“. Pausing, she raised her head, murmured, “But what is the question?“, and died. The new patient
For the new patient a crisis arises; the cultural pattern reveals that the applicability of the ‘ready-made’ is now confined to a specific historical situation. McGillowayand DOMdy (1977)stated that it is only when he is confronted with breaking points in the so&By structured round of daily behaviour, for example, when admitted to hospital; when events of crucial significance for his well-being are beyond his prevision; “ . . . when important aspects of self-tmderstandingand self-identificationare disturbed . . . “, and his future prospects are uncertain that socialized man is importantly and seriously challenged. The new patient becomes essentially the person who has to place in question nearly everything that seems to be unquestionable to the members of the group he has just left, and the group he is now approaching. For the new patient, the system of knowledge acquired, incoherent and only partially clear but generally adequate within the concrete social world, is no longer sufficiently coherent and clear to give him a reasonable chance of understanding relevant phenomena within the social world of the ward. It is seen that, for the new patient, the reality of the standardized socialization scheme becomes unworkable when former experiences fail to suffice for future situations; when former solutions fail to meet problems and the knowledge handed down by significant others ceases to be reliable; when it is not enough to know ‘just something’ about dealing with problems in order to manage or control them. Parsons (1951) argued that the patient is not only generally not in a position to do what needs to be done, but he does not know what needs to be done or how to do it, and how to judge what needs to be done. However, the fmdings of Stockwell (1972)and Raphael (1977) reveal that the patient is conscious of his ignorance of the justification for care offered on his behalf. As one patient put it, “The don’t-you-worry-let-us-do-your-worrying-for-youidea” is not accepted by many in these days of better education and dislike of paternalism. In short, there are problems concerning information to the patient who might be in a state of bewilderment because nobody will tell him anything that will ‘make sense’to him. There is, that is to say, a ‘communication gap’. The communication gap and stress Eisenstadt (1965) explained that in situations of transition in which the routine of a given role is endangered or disrupted, problems of communication arise. “ . . . the individual is placed in a potentially ambiguous, undefined and conflicting situation, in which his whole identity, status image, and continuity of perception and action are endangered . . . thus we see that such situations are indeed of potential stress”. Katz (1%9) argued “ . . . if we are talking about social psychological stress . . . it is not unusual for things to be a little wrong all the time. Everyone is a little sick or disturbed most of the time . . . “, He described this state of affairs as ‘normal’ but claimed that crisis or abnormal stress is one of the main reasons for illness. It is widely accepted that for any normal person the fact that he is in a hospital bed means
ONE ASPECT OF THE SOCIAL/PSYCHOLOGICAL
ELEMENT
OF THE ILLNESS STATE
27 1
that he is in a crisis situation. Autton (1968) stated, “It must be remembered that there is no such thing as a minor operation to a patient”. Katz (1969) wrote that “such patients often feel nervous about the success of the operation. This is normal. But in extreme cases the patient is so immobilised by his fear that he becomes a poor surgical risk and has a poor chance of recovery”. Groen (1971) considered social stress as a “situation caused by social circumstances or cultural rules which frustrate or threaten to frustrate an individual or group, that is, which prevents him or it from developing or acting according to inborn or acquired gratifying behaviour patterns”. Lazarus (1971) argued that it would be well to allow the term ‘stress’to extend to the whole area of problems, sociological, psychological and physiological, in which individuals are taxed by stimulus demands up to the limits of their potential ability to adapt. Stress refers, therefore, to a class of problems too broad to consider within the scope of this present work. It is sufficient to state that many important sources relate stress, behavioural change and pre-disposition to illness, to situational transitions which are not unlike that which is experienced by the new patient in a general hospital ward. The new patient and nursing practice
Eisenstadt (1971) stated that in the situation of transition the individual may become especially sensitive to broader, charismatic appeals and communication-especially in so far as these tend to define the situation both morally and perceptually; to describe the proper norms of behaviour; to relate the individual to collective identification; to reassure him of his place in a given collectivity. This present work purports that the characteristics of transition from one ‘way’of life to another for any new patient in a hospital ward are problematic, not only in the fact that the situation of change may prove to be stressful, but, beyond this, that the existing system of communication within the strange situational complex may be ineffective and potentially harmful unless it is recognised within, and entrusted to, the sphere of some organized practice. The study argues that the most appropriate sphere of organized practice for the purpose of provision of the required communciation and appropriate action in the given setting is the process of nursing practice. The nurse practitioner is the principal communicator in relation to specific aspects of problems of the ward’s social structure. She is the principal communicator in relation to activities which involve the special skills of other professionals, and of non-professionals, in the direct and indirect delivery of personal care within the ward’s system. In her relationships with patients and their relatives, she is constantly made aware of the local and wider aspects of the social world of every new patient. The nurse practitioner holds the central and controlling role in the system of communication, not only in relation to activities pertaining to ward management, and those which involve the functions of other ‘work’ subgroups, but also including, in a specific way, intimate relations to the social/psychological needs of all new patients (and other in-patients). The effectiveness of communication with the new patient must include the recognition and acceptance of communication as a ‘function’-falling within the range and focus of nursing care-by nurses and other health care workers. The effectiveness of the function of communication with the new patient must depend
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upon its conferring and maintaining patient status and identity in a positive way, that is, in allowing him to have a view of himself which is compatible with his view of himself in wider society. Effective communication must also serve successfully in mediation, with regard to broader problems of the illness situation and impart information about shortterm and ultimate objectives in regard to the design of the caring process. It must enable the new patient to understand the new social and cultural system, and enhance his sense of participation and belonging in the new setting. The form of communication must be compatible with the cultural orientations, social and professional interests, and general endeavours of the ward team; the many people brought together to meet the needs of the patient. If a high degree of compatibiity between these various factors fails to exist, the effectiveness of any communication is minimized. If these few selected features of communication for the patient, his intimates and ward staff are taken together, it becomes clear that-in ways which are not true of other professional functions-the situation of nursing practice is such as to involve the nurse in the affairs of communication to a significant degree. It is important, therefore, that this function of nursing practice receives the recognition and promotion it demands in the interests of the social/psychological needs of any new patient. Conclllsion
This study has sought to summarize central factors relating to problems of situational change. It simply calls attention to an aspect of the illness state which offers another point from which to begin assessing the needs of any new patient. Although there are important differences in regard to cause and effect issues-and of detail and emphasis-in the range of factors discussed in this paper, the problems faced by the new patient and the influences of nursing practice in the present system of communication situations are, nonetheless, substantially the same. The paper stresses the recognition and promotion of communications as a ‘function’ falling within the range and focus of nursing care, by nurses and other health care workers, in the interests of the social/psychological needs of any new patient. The nurse practitioner will continue to require the support of other specialist workers to help those patients who need their services, but the nurse is clearly the professional most suitably placed to receive and offer information to the new patient, and to organise the management of his social/psychological requirements in a socially and culturally accepted manner. How this is to be achieved properly, presents a set of complications of the functions of nursing practice. These complications present another order of problems which fall outside the scope of this work. It should suffice to state that further analysis will show that nursing practice already provides a communication system-for the benefits of ‘patient’ and ‘work’groups-but that it is open to recognition, proper definition and improvement. Any analysis will also reveal an absence of any comparative system within the total personal care system. It will also reveal a possible series of ‘ways’of overcoming any obstacles to effective nursing practice in this area of patient care. This paper does not attempt to provide a formula for communication. It simply offers a feature of the social aspect of patient care which is meaningful in the context of nursing practice. It points out that a major requirement in approaching the new situation for any
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new patient is appropriate information and reception through a proper communication system, supported by recognition-unspoken or other-of the patient’s dilemma, despite its covert nature, and the ability to ease the person (who is already ill) into the experience in a way which reduces its stressful effects as far as possible. References Autton, N. (1968). Postorol Core in Hospitok. SPCK, London. Eisenstadt. S. N. (1965). Communication and reference group behaviour. In Esuys on Cotnporotive Institutions, pp. 32340. New York. Eisenstadt, S. N. (1971). Problems in theories of social structure, personality, and communication in their relation to situations of change and stress. In Society, Stress ond Diseose: The Psychosocial Environment ond PsychosomaticDiseases. L. Levi (Ed.). Vol. 1. University Press, Oxford. Groen, J. J. (1971). Social change and psychosomatic disease. In Society, Stress and Diseos: The Psychosocial Environment ond Psychosomatic Diseoses. L. Levi (Ed.). Vol. 1. Oxford University Press, London. Hockey, L. (1966). Feeling thePuke. Queen’s Institute of District Nursing. Hockey, L. (1968). Core in theBolonce. Queen’s Institute of District Nursing. Katz, A. H. (1%9). The social causes of disease. New Society 13, No. 330. Lazarus, R. S. (1971). The concepts of stress and disease. In Society, Stress and Dkeose: The Psychosocial Environment and Psychosomatic Diseases. L. Levi (Ed.). Vol. 1. Oxford University Press, London. Lynd, R. S. and Lynd, H. M. (1963). Middletown in Transition. Harcourt, Brace&World, New York. McGilloway, F. A. and Donnelly, L. (1977). Religion and patient care: the functionalist approach. J. odv. Nursing. 2. Parsons, T. (1951). Social structure and dynamic process: the case of modern medical practice. In The Social System. Chapter 10, pp. 428479. Free Press, New York. Raphael, W. (1977). Potients and Their Hospitals. 3rd Edn. King Edward’s Hospital Fund for London. Schutz, A. (1971). The stranger: an essay in social psychology. In School ond Society. Open University Press, Milton Keynes. Secretary of State for Social Security, Secretary of State for Scotland, Secretary of State for Wales (1972). Report of the Committee on Nursing. Cmnd. 5115. H.M.S.O., London. Stockwell, F. (1972). The Unpopular Patient: The Study of Nursing Core. Series 1. Royal College of Nursing, London. Strauss, A., Schatzman, L., Ehrlich, D., Bucher, R. and Sabshin, M. (1963). The hospital and its negotiated order. In The Hospitol in Modern Society. E. Friedson (Ed.). Macmillan, New York. Also in (1973) People ond Orgonisotions. G. Salaman and K. Thompson (Ed%). No. 20. Longman, Open University Press, Milton Keynes. Wrong, D. H. (1961). The oversocialized conception of man in modern sociology. Am. Social. Rev. 26, 182-93. (Received 20 November 1978; occeptedforpublicotion
7 February 1979)