- Email: [email protected]
Towards a sociology of CAM and nursing
Towards a sociology of CAM and nursing PhilipTovey and Jon Adams Over recent years a sporadic, but not insignif|cant, sociology of complementary and alternative medicine (CAM) has begun to emerge. However, to date, the systematic sociological study of the apparent aff|nity between CAM, nursing as a profession and its practitioners has been absent from it. In this paper we argue for the need for a rigorous sociology of nursing and CAM and set out a provisional framework through which this might be operationalized.Three broad themes, as well as cross-cutting issues, are outlined. The way in which the challenges of CAM are mediated at the level of the individual and the profession are pivotal to analysis. An understanding of this mediation is crucial both as a means of extending knowledge, and as a means of engaging with complex issues such as the role of evidence, and the equity of provision, that are likely to accompany any extension of CAM mainstreaming. r 2002 Elsevier Science Ltd. All rights reserved.
TOWARDS A SOCIOLOGYOF CAM AND NURSING
Dr PhilipTovey, Principal Research Fellow, School of Healthcare Studies, Baines Wing, University of Leeds, LS2 9UT, UK. Tel: +44(0)113 2331186; Fax: +44(0)113 2331204; E-mail: p.a.tovey@ leeds.ac.uk Dr Jon Adams, Lecturer in Health Social Sciences, Centre for Clinical Epidemiology and Biostatistics, School of Population Health Sciences, University of Newcastle, Callaghan 2308, New South Wales, Australia. Email: hcsjada@ hotmail.com
Alongside the growth of interest in complementary and alternative medicine (CAM) over the last couple of decades has been a sporadic, but not insignificant, sociological analysis of its nature and evolution (Adams & Tovey 2000). Although far from providing a coherent body of knowledge this work has been wide enough to embrace a range of issues and incorporate a focus on a range of stakeholders – e.g. patients, general practitioner, non-medically qualified practitioners (Adams in press, Adams 2000, Rayner & Easthope in press, Tovey 1997). However, while nursing has from time to time figured in these discussions there has been no systematic attempt to study sociologically the apparent affinity between CAM, nursing as a profession and its practitioners. In this short paper, we argue for a rigorous sociology of nursing and CAM, and set out a provisional framework through which this might be operationalized. What we are arguing for is, in effect, a subdiscipline of the broader sociology of CAM. This sociological analysis will provide an examination of how the intersection of CAM and nursing is being constructed, and how social, cultural and organizational factors are impinging on this process. As discussed elsewhere (Tovey 2001) the sociology of CAM can be oriented towards
addressing inequalities and challenging practice, or towards elucidating emerging social processes as an end in itself. Whichever approach takes precedence at particular times, our position is that we must be wary of the partisan, overly sympathetic approach that has sometimes accompanied sociological work on nursing (Allen 2001). The area needs to be built on critical and distanced analyses. And, in turn, those analyses should draw on an appreciation of broader sociological theory (Adams & Tovey 2000), work carried out in the sociology of nursing more broadly (Morrall 2001) and, of course, existing work conducted within the sociology of CAM itself. Box 1 Three core areas of concern within existing sociology of CAM K The behaviour and motivation of CAM users K The organization and professionalization of lay
therapists K The interest and role of the conventional medical
community in the development of CAM Source: Siahpush (1999).
The sociology of CAM as a whole continues to be marked by a ‘paucity of empirical research’ (Siahpush 1999, p. 159). Despite this, three core themes are identified by Siapush in existing work. Firstly, users – who incorporates CAM into treatment regimes and why? By which processes is this being achieved? (Furnham &
ComplementaryTherapies in Nursing & Midwifery (2002) 8, 12^16 # 2002 Elsevier Science Ltd. All rights reserved. 1 doi:10.1054/ctnm.2001.0584, available online at http://www.idealibrary.com on
Towards a sociology of CAM and nursing
Kirkcaldy 1996) Second, (lay) practitioners – here the attention has more often than not been concerned with issues of professionalization (Saks 1999). And, third, and of direct relevance here, the conventional medical community. Although physicians have been the central focus of much of this work on orthodox practitioners, many of these studies emphasize the need to authenticate practice within their own professional community (Adams in press). This is something that can be drawn on for our purposes: to help examine how nurses attempt to authenticate CAM. Moreover, the essential interconnectedness of healthcare practice means that a sociology of nursing and CAM will need to be built around an acknowledgement of the importance of relationships between groups (both professional and lay), and on an appreciation of how practices and agendas are continually shaped through interaction. Clearly, at the moment, not only is the sociology of CAM patchy, but there is an imbalance in that part of it which deals with the conventional medical community. While medicine in general, and general practice in particular, has been at the centre of much attention, nursing simply has not. But the rationale underpinning a nursing – CAM focus rests on rather more than the need for a fully rounded analysis. We need to acknowledge that nursing constitutes perhaps the site of enthusiasm for integration with orthodoxy (Tovey 1997). How this develops, within the confines of established structures, will be instrumental in shaping the mainstreaming of CAM. In the following section we will set out what we consider to be the initial priorities for research. The framework is not intended to be either fixed or complete. It is inevitably shaped by our research interests and to some extent by our epistemological and methodological biases.
THE RESEARCH FRAMEWORK In this initial formulation we have chosen to divide the research agenda into three main subject areas. Inevitably, both in terms of healthcare practice and in terms of the way they might be studied they are not mutually exclusive. Further, our interpretation of the themes is broad. It should be borne in mind that they are being used primarily as a heuristic device to facilitate further exploration of this area. At this stage our intention is to outline broad areas of interest rather than provide a detailed protocol in each case for how individual pieces of research should be conducted. Because we are essentially starting from a zero base (as there is no specifically sociological work on CAM and nursing at present), a wide range of research methods will be applicable. For instance, although many of
13
the most interesting issues concerning the processes of integration (of CAM into nursing practice) demand in-depth qualitative work, especially that which traces personal stories or engages with varying modes of presented narrative (e.g. focused life histories), there is an evident need for a rigorous quantification of trends in many areas. Relatively simple survey work will help contextualize more in-depth analyses. Taken in turn, the three broad themes of the framework are: interprofessional issues; intraprofessional issues; and, patient and public health issues. Box 2 Research framework for a sociology of CAM and nursing K Interprofessional issues K Intraprofessional issues K Patient and public health issues
Interprofessional issues Given that nursing practice is located within a web of professional interaction there is much to be gained from work that seeks to explicitly explore various points of interface with other stakeholders. We have argued elsewhere (Tovey & Adams 2001) that a neglected sociological theory, Social Worlds Theory (developed within the tradition of symbolic interactionism – Strauss 1993), provides both tools and structure that are well suited to the sociology of CAM. Work on nursing is perhaps the prime example of that utility. This theoretical framework introduces notions of authenticity, appropriation, legitimacy. These have direct applicability to everyday CAM practice and the study of it. Has nursing an essentially authentic relationship with CAM? If so why? And at the expense of whom? How and why is the appropriation of therapies (by nursing) occurring? And with what legitimacy? These questions and the concepts that underpin this theme are pertinent to each of the following areas. K
Nursing/medicine. Distinction from, and subordination to, medicine remain recurrent issues in nursing discourse (Miers 2000). There is some evidence (Adams & Tovey under review) to suggest that these same issues are directly impinging on CAM processes. There is substantial scope for work in this area, including studies that centre on professional reconfiguration and alignment, the operation of power relations at an everyday basis, the extent to which different professionals have power to direct the delivery and practice of CAM, and the interpenetration of gender with profession. The sociology of professions and the sociology of nursing provide a number of texts (e.g. Abbott
14 ComplementaryTherapies in Nursing & Midwifery
K
K
K
& Meerabeau 1998, Davies 1995) which may be profitably drawn upon here. Nursing/lay practitioners. This relationship is potentially complex. For example, the appropriation of therapies and the authenticity of providers are essential to the strategies of these groups and long-term viability of CAM provision by them. The desired end points may or may not be compatible. Beyond this the movement away from nursing into full-time CAM practice by many practitioners provides a specific research opportunity, for embedded within this process are questions about transition, the nature of nursing, what it is that is being sought by individuals and so on. Nursing and health management (the organizational context). Nursing operates within structural constraints. Existing research on CAM nursing has to date relied too heavily on identifying (somewhat de-contextualized) attitudes (Johnson 2000). We need to move beyond this to achieve an understanding of how the attitude-action progression is mediated and managed. Nursing and location: NHS, private, voluntary sector. The nature of such constraints will vary across sectors. The marginal status of CAM means that it continues to be provided in both the voluntary and private sectors, as well as in the NHS. How this impacts on the reality of CAM nursing, and how this relates to different models of provision, is not yet understood.
Intraprofessional issues The second theme is concerned with intraprofessional issues – how the challenges of CAM are being affected by wider ‘nursing issues’ and how CAM as an entity and a practice is being mediated in different ways by those within the profession. This is an area that might profitably draw on debates about the future of nursing being conducted within the profession (Watson 1998), the sociology of nursing (Morrall 2001), and work which has examined tensions within other orthodox professions on this issue (Eastwood 2000). Thus some of the immediate priorities are: K
The need for systematic quantification of practice, experience and core beliefs. Some large-scale survey work is beginning to appear, both in the UK and elsewhere, in other areas of CAM research, such as patterns of consumption (Eisenberg et al. 1998, Thomas et al. 2001). However, when attempting to assess the extent of use and interest in nursing we are currently forced to draw on small-scale work (Rankin-Box
K
K
1997), rely on proxy measures such as membership of the Royal College of Nursing (RCN) Complementary Therapies in Nursing Forum, or fall back on anecdote. There is an urgent need for work that identifies exactly what is being carried out, where, and crucially what variables seem to be correlated with use. In isolation, such quantitative work can only provide a starting point – a partial, even superficial, understanding of action. Qualitative work is necessary to explore the processes of CAM integration within the context of professional debate. Central to such work may well be how CAM is conceptualized by different actors and how this relates to varying ideas about the essence of nursing. For instance, central to initial studies might be a focus on how the role of evidence and the quest for professionalization and autonomy on the one hand, form a point of contestation or conflict with principles such as holism and spirituality on the other. Beyond this we need to examine how CAM fits into broader debates about the extension of role; and crucially, the significance of internal hierarchies: similarities and differences between institutional positions and grassroots action. As a counter-balance to the risk of determinism (seeing actors purely in terms of their professional role) inherent in work with an emphasis on professional strategy, research that explicitly recognizes the importance of individual life trajectories and personal accounts (Scott 1990) should be a priority. Of particular interest here would be the way in which narratives are constructed by individuals and the way in which they are embedded within a panoply of interactions, not simply those in the workplace. Of course, in practice these two strands of qualitative work may well be integrated.
Patient and public health issues Insofar as rhetoric can be relied upon (Adams and Tovey, under review), the patient can be seen to be integral to the assimilation of CAM into nursing. This opens up two lines of enquiry: the one-to-one interaction between practitioner and patient; and, the patient/service user/citizen (Tovey et al. 2001) conceived of in rather broader (public health) terms.
Patient–practitioner interaction There is a considerable history of work on expert/non-expert interaction and communication that will provide a useful starting point here
Towards a sociology of CAM and nursing
(Lunn et al. 1998, Rimal 2001, Wynia et al. 1999). In addition, work investigating the perceptions of patients and their conceptualizations of both conventional care (Ruusuvnori 2001), and CAM (Luff & Thomas 2000, Oths 1994), and the degree to which such conceptualizations challenge existing professional models (Budd & Sharma 1994) will also be relevant. We can identify the following immediate research priorities: K
K
Patient–practitioner decision-making about practice and use. While there is a general body of sociological literature on pathways to care (Berg 1997, Charles et al. 1998), as yet there is no work examining decisionmaking processes surrounding nursing and CAM. Such work will require reference to both patients’ and practitioners’ perspectives and to an appreciation of contextual influences. Extending our gaze somewhat we can also examine the influence of family, friends and other informal carers and networks. There is also the need to consider processes resulting in the non-use of CAM and ask why CAM is not introduced in these cases, why certain patients do not take CAM on board, and what factors influence these processes. Nature and role of the patient in CAM nursing practice. We need to explore the nature of patient involvement in CAM nursing interaction, examining both its qualitative nature and the extent to which this differs from, or mirrors, that found in conventional nursing practice. Again, this exploration can build upon both patients’ and practitioners’ experiences and understanding. The extent to which the patient role and involvement in CAM nursing challenges existing professional nursing philosophies and models of practice (remaining mindful of the numerous groups in nursing and their corresponding ambitions) is a further area of interest.
Patient–population issues The second part of this theme extends attention somewhat towards a public health agenda, and indeed a political agenda of equity and (in)equality. Initial concerns might include: K
K
Demographics. Again, as with other themes, there is surprisingly little baseline data (Johnson 2000). This is a point that needs addressing if we are to establish an understanding of CAM nursing services within wider social and economic context. What is the impact of age, ethnicity, socioeconomic status and gender on service use? What geographical variation is there? Equity and access to CAM nursing services. Relating closely to the above, are the issues
15
of equity and (in)equality in CAM nursing services. Currently, CAM availability within nursing remains ad hoc and patchy (Kohn 1999). There is some evidence of iniquitous patterns of CAM use more broadly (Ernst & White 2000) and we need to explore this further. Large-scale statistical surveys can be augmented by in-depth explorations of patient and practitioner action. This exploration should be informed by an awareness of the cultural, economic and political constraints and opportunities that impinge on processes.
CONCLUSION We introduced this paper by noting that, to date, there has been no systematic sociological study of the apparent affinity between CAM, nursing as a profession and its practitioners. The purpose of this paper has been to sketch out a framework by which this might be rectified. We have highlighted three main component themes of this framework: interprofessional issues; intraprofessional issues; and, patient and public health issues. Cutting across these themes and their theme-specific questions have been recurrent concerns: identity, boundaries and roles; and, in addition, processes of negotiation, legitimation and authentication. They provide points of access for a sociological study of the CAM–nursing axis. The framework provides an agenda that makes sense within the knowledge/change dichotomy underlying the sociology of CAM introduced earlier (Tovey, under review). For while the starting point for many of the questions raised might be academic curiosity, there are very real implications involved, not least for service users. As, and when, CAM services attain greater mainstream acceptability, nursing will be pivotal to their operationalization. It is nave to expect evidence to be uniformly applied, or currently ad hoc and iniquitous patterns of use to be challenged, without an understanding of how the challenges of CAM are being mediated at the level of the individual and the profession, and why this is so. Gaining insight into these processes of mediation is a primary objective for an emerging sociology of nursing and CAM. REFERENCES Abbott P, Meerabeau L 1998 The sociology of the caring professions. UCL Press, London Adams J in press Enhancing holism? GPs’ explanations of their complementary practice. Complementary Health Practice Review 6(3) Adams J 2000 General practitioners, complementary medicine and evidence-based medicine. Complementary Therapies in Medicine 8(4): 248–252
16 ComplementaryTherapies in Nursing & Midwifery
Adams J, Tovey P 2000 Complementary medicine and primary care: towards a grassroots focus. In: Tovey P (ed.) Contemporary primary care: the challenges of change. Open University Press, Buckingham Adams J, Tovey P (under review) Nurses’ use of professional distancing in the appropriation of CAM: a text analysis. Complementary Therapies in Medicine Allen D 2001 Review article: nursing and sociology: an uneasy marriage. Sociology of Health and Illness 23(3): 386–396 Berg M 1997 Problems and promises of the protocol. Social Science and Medicine 44(8): 1081–1088 Budd S, Sharma U 1994 The healing bond: the patient – practitioner relationship and therapeutic responsibility. Routledge, London Charles C, Redko C, Whelan T 1998 Doing nothing is no choice: lay constructions of treatment decision-making among women with early stage breast cancer. Sociology of Health and Illness 20(1): 71–95 Davies C 1995 Gender and the professional predicament in nursing. Open University Press, Buckinghanshire Eastwood H 2000 Why are Australian GPs using alternative medicine? Postmodernisation, consumerism and the shift towards holistic health. Journal of Sociology 36(2): 133–156 Eisenberg DM, Davis RB et al. 1998 Trends in alternative medicine use in the United States, 1990–1997. Journal of the American Medical Association 280: 1569–1575 Ernst E, White A 2000 The BBC survey of complementary medicine use in the UK. Complementary Therapies in Medicine 8(1): 32–36 Furnham A, Kirkcaldy B 1996 The health beliefs and behaviours of orthodox and complementary medicine clients. British Journal of Clinical Psychology 35: 49–61 Johnson G 2000 Should nurses practise complementary therapies? Complementary Therapies in Nursing and Midwifery 6: 120–123 Kohn M 1999 Complementary therapies in cancer care. Macmillan, London Luff DF, Thomas KJ 2000 Getting somewhere, feeling cared for: patient perspectives on complementary therapies in the NHS. Complementary Therapies in Medicine 8: 253–259 Lunn S, Williams S et al. 1998 The effects of gender upon doctor – patient interaction. Psychology and Health 13(6): 975–986 Miers M 2000 Gender issues and nursing practice. Macmillan, Basingstoke Morrall P 2001 Sociology and nursing. Routledge, London
Oths K 1994 Communication in a chiropractic clinic – how ADC treats his patients. Culture, Medicine and Psychiatry 18(1): 83–113 Rankin-Box D 1997 Therapies in practice: a survey assessing nurses’ use of complementary therapies. Complementary Therapies in Nursing and Midwifery 3: 92–99 Rayner L, Easthope G in press Postmodern consumption and alternative medication. Journal of Sociology Rimal RN 2001 Analysing the physician – patient interaction: an overview of six methods and future research direction. Health Communication 13(1): 89–99 Ruusuvnori J 2001 Looking means listening: co-ordinating displays of engagement in doctor – patient interaction. Social Science and Medicine 52(7): 1093– 1108 Saks M 1999 The wheel turns? Professionalisation and alternative medicine in Britain. Journal of Interprofessional Care 13(2): 129–138 Scott J 1990 A matter of record. Polity, Cambridge Siahpush M 1999 A critical review of the sociology of alternative medicine: research on users, practitioners and the orthodoxy. Health 4(2): 159–178 Strauss A 1993 Continual permutations of action. Aldine de Gruyter, New York Thomas KJ, Nicholl JP et al. 2001 Use and expenditure on complementary medicine in England: a population based survey. Complementary Therapies in Medicine 9(1): 2–11 Tovey P 1997 Contingent legitimacy: UK alternative practitioners and inter-sectoral acceptance. Social Science and Medicine 45(7): 1129–1133 Tovey P 2001 On use and purpose in the sociology of CAM. Complementary Therapies in Medicine 9(3): 134–135 Tovey P, Adams J 2001 Primary care as intersecting social worlds. Social Science and Medicine 52: 695–706 Tovey P, Atkin K, Milewa T 2001 The individual and primary care: service user, reflexive choice maker and social actor. Critical Public Health 11(2): 153–166 Watson J 1998 Postmodern nursing and beyond. Churchill, Edinburgh Wynia MR, Eisenberg DM et al. 1999 Physician – patient communication about complementary and alternative medicine: a survey of physicians caring for patients with human immunodeficiency virus infection. Journal of Alternative and Complementary Medicine 5(5): 447–456
TOWARDS A SOCIOLOGYOF CAM AND NURSING
Dr PhilipTovey, Principal Research Fellow, School of Healthcare Studies, Baines Wing, University of Leeds, LS2 9UT, UK. Tel: +44(0)113 2331186; Fax: +44(0)113 2331204; E-mail: p.a.tovey@ leeds.ac.uk Dr Jon Adams, Lecturer in Health Social Sciences, Centre for Clinical Epidemiology and Biostatistics, School of Population Health Sciences, University of Newcastle, Callaghan 2308, New South Wales, Australia. Email: hcsjada@ hotmail.com
Alongside the growth of interest in complementary and alternative medicine (CAM) over the last couple of decades has been a sporadic, but not insignificant, sociological analysis of its nature and evolution (Adams & Tovey 2000). Although far from providing a coherent body of knowledge this work has been wide enough to embrace a range of issues and incorporate a focus on a range of stakeholders – e.g. patients, general practitioner, non-medically qualified practitioners (Adams in press, Adams 2000, Rayner & Easthope in press, Tovey 1997). However, while nursing has from time to time figured in these discussions there has been no systematic attempt to study sociologically the apparent affinity between CAM, nursing as a profession and its practitioners. In this short paper, we argue for a rigorous sociology of nursing and CAM, and set out a provisional framework through which this might be operationalized. What we are arguing for is, in effect, a subdiscipline of the broader sociology of CAM. This sociological analysis will provide an examination of how the intersection of CAM and nursing is being constructed, and how social, cultural and organizational factors are impinging on this process. As discussed elsewhere (Tovey 2001) the sociology of CAM can be oriented towards
addressing inequalities and challenging practice, or towards elucidating emerging social processes as an end in itself. Whichever approach takes precedence at particular times, our position is that we must be wary of the partisan, overly sympathetic approach that has sometimes accompanied sociological work on nursing (Allen 2001). The area needs to be built on critical and distanced analyses. And, in turn, those analyses should draw on an appreciation of broader sociological theory (Adams & Tovey 2000), work carried out in the sociology of nursing more broadly (Morrall 2001) and, of course, existing work conducted within the sociology of CAM itself. Box 1 Three core areas of concern within existing sociology of CAM K The behaviour and motivation of CAM users K The organization and professionalization of lay
therapists K The interest and role of the conventional medical
community in the development of CAM Source: Siahpush (1999).
The sociology of CAM as a whole continues to be marked by a ‘paucity of empirical research’ (Siahpush 1999, p. 159). Despite this, three core themes are identified by Siapush in existing work. Firstly, users – who incorporates CAM into treatment regimes and why? By which processes is this being achieved? (Furnham &
ComplementaryTherapies in Nursing & Midwifery (2002) 8, 12^16 # 2002 Elsevier Science Ltd. All rights reserved. 1 doi:10.1054/ctnm.2001.0584, available online at http://www.idealibrary.com on
Towards a sociology of CAM and nursing
Kirkcaldy 1996) Second, (lay) practitioners – here the attention has more often than not been concerned with issues of professionalization (Saks 1999). And, third, and of direct relevance here, the conventional medical community. Although physicians have been the central focus of much of this work on orthodox practitioners, many of these studies emphasize the need to authenticate practice within their own professional community (Adams in press). This is something that can be drawn on for our purposes: to help examine how nurses attempt to authenticate CAM. Moreover, the essential interconnectedness of healthcare practice means that a sociology of nursing and CAM will need to be built around an acknowledgement of the importance of relationships between groups (both professional and lay), and on an appreciation of how practices and agendas are continually shaped through interaction. Clearly, at the moment, not only is the sociology of CAM patchy, but there is an imbalance in that part of it which deals with the conventional medical community. While medicine in general, and general practice in particular, has been at the centre of much attention, nursing simply has not. But the rationale underpinning a nursing – CAM focus rests on rather more than the need for a fully rounded analysis. We need to acknowledge that nursing constitutes perhaps the site of enthusiasm for integration with orthodoxy (Tovey 1997). How this develops, within the confines of established structures, will be instrumental in shaping the mainstreaming of CAM. In the following section we will set out what we consider to be the initial priorities for research. The framework is not intended to be either fixed or complete. It is inevitably shaped by our research interests and to some extent by our epistemological and methodological biases.
THE RESEARCH FRAMEWORK In this initial formulation we have chosen to divide the research agenda into three main subject areas. Inevitably, both in terms of healthcare practice and in terms of the way they might be studied they are not mutually exclusive. Further, our interpretation of the themes is broad. It should be borne in mind that they are being used primarily as a heuristic device to facilitate further exploration of this area. At this stage our intention is to outline broad areas of interest rather than provide a detailed protocol in each case for how individual pieces of research should be conducted. Because we are essentially starting from a zero base (as there is no specifically sociological work on CAM and nursing at present), a wide range of research methods will be applicable. For instance, although many of
13
the most interesting issues concerning the processes of integration (of CAM into nursing practice) demand in-depth qualitative work, especially that which traces personal stories or engages with varying modes of presented narrative (e.g. focused life histories), there is an evident need for a rigorous quantification of trends in many areas. Relatively simple survey work will help contextualize more in-depth analyses. Taken in turn, the three broad themes of the framework are: interprofessional issues; intraprofessional issues; and, patient and public health issues. Box 2 Research framework for a sociology of CAM and nursing K Interprofessional issues K Intraprofessional issues K Patient and public health issues
Interprofessional issues Given that nursing practice is located within a web of professional interaction there is much to be gained from work that seeks to explicitly explore various points of interface with other stakeholders. We have argued elsewhere (Tovey & Adams 2001) that a neglected sociological theory, Social Worlds Theory (developed within the tradition of symbolic interactionism – Strauss 1993), provides both tools and structure that are well suited to the sociology of CAM. Work on nursing is perhaps the prime example of that utility. This theoretical framework introduces notions of authenticity, appropriation, legitimacy. These have direct applicability to everyday CAM practice and the study of it. Has nursing an essentially authentic relationship with CAM? If so why? And at the expense of whom? How and why is the appropriation of therapies (by nursing) occurring? And with what legitimacy? These questions and the concepts that underpin this theme are pertinent to each of the following areas. K
Nursing/medicine. Distinction from, and subordination to, medicine remain recurrent issues in nursing discourse (Miers 2000). There is some evidence (Adams & Tovey under review) to suggest that these same issues are directly impinging on CAM processes. There is substantial scope for work in this area, including studies that centre on professional reconfiguration and alignment, the operation of power relations at an everyday basis, the extent to which different professionals have power to direct the delivery and practice of CAM, and the interpenetration of gender with profession. The sociology of professions and the sociology of nursing provide a number of texts (e.g. Abbott
14 ComplementaryTherapies in Nursing & Midwifery
K
K
K
& Meerabeau 1998, Davies 1995) which may be profitably drawn upon here. Nursing/lay practitioners. This relationship is potentially complex. For example, the appropriation of therapies and the authenticity of providers are essential to the strategies of these groups and long-term viability of CAM provision by them. The desired end points may or may not be compatible. Beyond this the movement away from nursing into full-time CAM practice by many practitioners provides a specific research opportunity, for embedded within this process are questions about transition, the nature of nursing, what it is that is being sought by individuals and so on. Nursing and health management (the organizational context). Nursing operates within structural constraints. Existing research on CAM nursing has to date relied too heavily on identifying (somewhat de-contextualized) attitudes (Johnson 2000). We need to move beyond this to achieve an understanding of how the attitude-action progression is mediated and managed. Nursing and location: NHS, private, voluntary sector. The nature of such constraints will vary across sectors. The marginal status of CAM means that it continues to be provided in both the voluntary and private sectors, as well as in the NHS. How this impacts on the reality of CAM nursing, and how this relates to different models of provision, is not yet understood.
Intraprofessional issues The second theme is concerned with intraprofessional issues – how the challenges of CAM are being affected by wider ‘nursing issues’ and how CAM as an entity and a practice is being mediated in different ways by those within the profession. This is an area that might profitably draw on debates about the future of nursing being conducted within the profession (Watson 1998), the sociology of nursing (Morrall 2001), and work which has examined tensions within other orthodox professions on this issue (Eastwood 2000). Thus some of the immediate priorities are: K
The need for systematic quantification of practice, experience and core beliefs. Some large-scale survey work is beginning to appear, both in the UK and elsewhere, in other areas of CAM research, such as patterns of consumption (Eisenberg et al. 1998, Thomas et al. 2001). However, when attempting to assess the extent of use and interest in nursing we are currently forced to draw on small-scale work (Rankin-Box
K
K
1997), rely on proxy measures such as membership of the Royal College of Nursing (RCN) Complementary Therapies in Nursing Forum, or fall back on anecdote. There is an urgent need for work that identifies exactly what is being carried out, where, and crucially what variables seem to be correlated with use. In isolation, such quantitative work can only provide a starting point – a partial, even superficial, understanding of action. Qualitative work is necessary to explore the processes of CAM integration within the context of professional debate. Central to such work may well be how CAM is conceptualized by different actors and how this relates to varying ideas about the essence of nursing. For instance, central to initial studies might be a focus on how the role of evidence and the quest for professionalization and autonomy on the one hand, form a point of contestation or conflict with principles such as holism and spirituality on the other. Beyond this we need to examine how CAM fits into broader debates about the extension of role; and crucially, the significance of internal hierarchies: similarities and differences between institutional positions and grassroots action. As a counter-balance to the risk of determinism (seeing actors purely in terms of their professional role) inherent in work with an emphasis on professional strategy, research that explicitly recognizes the importance of individual life trajectories and personal accounts (Scott 1990) should be a priority. Of particular interest here would be the way in which narratives are constructed by individuals and the way in which they are embedded within a panoply of interactions, not simply those in the workplace. Of course, in practice these two strands of qualitative work may well be integrated.
Patient and public health issues Insofar as rhetoric can be relied upon (Adams and Tovey, under review), the patient can be seen to be integral to the assimilation of CAM into nursing. This opens up two lines of enquiry: the one-to-one interaction between practitioner and patient; and, the patient/service user/citizen (Tovey et al. 2001) conceived of in rather broader (public health) terms.
Patient–practitioner interaction There is a considerable history of work on expert/non-expert interaction and communication that will provide a useful starting point here
Towards a sociology of CAM and nursing
(Lunn et al. 1998, Rimal 2001, Wynia et al. 1999). In addition, work investigating the perceptions of patients and their conceptualizations of both conventional care (Ruusuvnori 2001), and CAM (Luff & Thomas 2000, Oths 1994), and the degree to which such conceptualizations challenge existing professional models (Budd & Sharma 1994) will also be relevant. We can identify the following immediate research priorities: K
K
Patient–practitioner decision-making about practice and use. While there is a general body of sociological literature on pathways to care (Berg 1997, Charles et al. 1998), as yet there is no work examining decisionmaking processes surrounding nursing and CAM. Such work will require reference to both patients’ and practitioners’ perspectives and to an appreciation of contextual influences. Extending our gaze somewhat we can also examine the influence of family, friends and other informal carers and networks. There is also the need to consider processes resulting in the non-use of CAM and ask why CAM is not introduced in these cases, why certain patients do not take CAM on board, and what factors influence these processes. Nature and role of the patient in CAM nursing practice. We need to explore the nature of patient involvement in CAM nursing interaction, examining both its qualitative nature and the extent to which this differs from, or mirrors, that found in conventional nursing practice. Again, this exploration can build upon both patients’ and practitioners’ experiences and understanding. The extent to which the patient role and involvement in CAM nursing challenges existing professional nursing philosophies and models of practice (remaining mindful of the numerous groups in nursing and their corresponding ambitions) is a further area of interest.
Patient–population issues The second part of this theme extends attention somewhat towards a public health agenda, and indeed a political agenda of equity and (in)equality. Initial concerns might include: K
K
Demographics. Again, as with other themes, there is surprisingly little baseline data (Johnson 2000). This is a point that needs addressing if we are to establish an understanding of CAM nursing services within wider social and economic context. What is the impact of age, ethnicity, socioeconomic status and gender on service use? What geographical variation is there? Equity and access to CAM nursing services. Relating closely to the above, are the issues
15
of equity and (in)equality in CAM nursing services. Currently, CAM availability within nursing remains ad hoc and patchy (Kohn 1999). There is some evidence of iniquitous patterns of CAM use more broadly (Ernst & White 2000) and we need to explore this further. Large-scale statistical surveys can be augmented by in-depth explorations of patient and practitioner action. This exploration should be informed by an awareness of the cultural, economic and political constraints and opportunities that impinge on processes.
CONCLUSION We introduced this paper by noting that, to date, there has been no systematic sociological study of the apparent affinity between CAM, nursing as a profession and its practitioners. The purpose of this paper has been to sketch out a framework by which this might be rectified. We have highlighted three main component themes of this framework: interprofessional issues; intraprofessional issues; and, patient and public health issues. Cutting across these themes and their theme-specific questions have been recurrent concerns: identity, boundaries and roles; and, in addition, processes of negotiation, legitimation and authentication. They provide points of access for a sociological study of the CAM–nursing axis. The framework provides an agenda that makes sense within the knowledge/change dichotomy underlying the sociology of CAM introduced earlier (Tovey, under review). For while the starting point for many of the questions raised might be academic curiosity, there are very real implications involved, not least for service users. As, and when, CAM services attain greater mainstream acceptability, nursing will be pivotal to their operationalization. It is nave to expect evidence to be uniformly applied, or currently ad hoc and iniquitous patterns of use to be challenged, without an understanding of how the challenges of CAM are being mediated at the level of the individual and the profession, and why this is so. Gaining insight into these processes of mediation is a primary objective for an emerging sociology of nursing and CAM. REFERENCES Abbott P, Meerabeau L 1998 The sociology of the caring professions. UCL Press, London Adams J in press Enhancing holism? GPs’ explanations of their complementary practice. Complementary Health Practice Review 6(3) Adams J 2000 General practitioners, complementary medicine and evidence-based medicine. Complementary Therapies in Medicine 8(4): 248–252
16 ComplementaryTherapies in Nursing & Midwifery
Adams J, Tovey P 2000 Complementary medicine and primary care: towards a grassroots focus. In: Tovey P (ed.) Contemporary primary care: the challenges of change. Open University Press, Buckingham Adams J, Tovey P (under review) Nurses’ use of professional distancing in the appropriation of CAM: a text analysis. Complementary Therapies in Medicine Allen D 2001 Review article: nursing and sociology: an uneasy marriage. Sociology of Health and Illness 23(3): 386–396 Berg M 1997 Problems and promises of the protocol. Social Science and Medicine 44(8): 1081–1088 Budd S, Sharma U 1994 The healing bond: the patient – practitioner relationship and therapeutic responsibility. Routledge, London Charles C, Redko C, Whelan T 1998 Doing nothing is no choice: lay constructions of treatment decision-making among women with early stage breast cancer. Sociology of Health and Illness 20(1): 71–95 Davies C 1995 Gender and the professional predicament in nursing. Open University Press, Buckinghanshire Eastwood H 2000 Why are Australian GPs using alternative medicine? Postmodernisation, consumerism and the shift towards holistic health. Journal of Sociology 36(2): 133–156 Eisenberg DM, Davis RB et al. 1998 Trends in alternative medicine use in the United States, 1990–1997. Journal of the American Medical Association 280: 1569–1575 Ernst E, White A 2000 The BBC survey of complementary medicine use in the UK. Complementary Therapies in Medicine 8(1): 32–36 Furnham A, Kirkcaldy B 1996 The health beliefs and behaviours of orthodox and complementary medicine clients. British Journal of Clinical Psychology 35: 49–61 Johnson G 2000 Should nurses practise complementary therapies? Complementary Therapies in Nursing and Midwifery 6: 120–123 Kohn M 1999 Complementary therapies in cancer care. Macmillan, London Luff DF, Thomas KJ 2000 Getting somewhere, feeling cared for: patient perspectives on complementary therapies in the NHS. Complementary Therapies in Medicine 8: 253–259 Lunn S, Williams S et al. 1998 The effects of gender upon doctor – patient interaction. Psychology and Health 13(6): 975–986 Miers M 2000 Gender issues and nursing practice. Macmillan, Basingstoke Morrall P 2001 Sociology and nursing. Routledge, London
Oths K 1994 Communication in a chiropractic clinic – how ADC treats his patients. Culture, Medicine and Psychiatry 18(1): 83–113 Rankin-Box D 1997 Therapies in practice: a survey assessing nurses’ use of complementary therapies. Complementary Therapies in Nursing and Midwifery 3: 92–99 Rayner L, Easthope G in press Postmodern consumption and alternative medication. Journal of Sociology Rimal RN 2001 Analysing the physician – patient interaction: an overview of six methods and future research direction. Health Communication 13(1): 89–99 Ruusuvnori J 2001 Looking means listening: co-ordinating displays of engagement in doctor – patient interaction. Social Science and Medicine 52(7): 1093– 1108 Saks M 1999 The wheel turns? Professionalisation and alternative medicine in Britain. Journal of Interprofessional Care 13(2): 129–138 Scott J 1990 A matter of record. Polity, Cambridge Siahpush M 1999 A critical review of the sociology of alternative medicine: research on users, practitioners and the orthodoxy. Health 4(2): 159–178 Strauss A 1993 Continual permutations of action. Aldine de Gruyter, New York Thomas KJ, Nicholl JP et al. 2001 Use and expenditure on complementary medicine in England: a population based survey. Complementary Therapies in Medicine 9(1): 2–11 Tovey P 1997 Contingent legitimacy: UK alternative practitioners and inter-sectoral acceptance. Social Science and Medicine 45(7): 1129–1133 Tovey P 2001 On use and purpose in the sociology of CAM. Complementary Therapies in Medicine 9(3): 134–135 Tovey P, Adams J 2001 Primary care as intersecting social worlds. Social Science and Medicine 52: 695–706 Tovey P, Atkin K, Milewa T 2001 The individual and primary care: service user, reflexive choice maker and social actor. Critical Public Health 11(2): 153–166 Watson J 1998 Postmodern nursing and beyond. Churchill, Edinburgh Wynia MR, Eisenberg DM et al. 1999 Physician – patient communication about complementary and alternative medicine: a survey of physicians caring for patients with human immunodeficiency virus infection. Journal of Alternative and Complementary Medicine 5(5): 447–456