Sociology in Health Professional Education

Panel Paper presented at the International Sociological Association’s World Congress of Sociology, Montreal, 1998 Published in Sociological Abstracts, Chicago. (Proceedings)

Abstract

The value of sociology as a discipline is far greater than its substantive intellectual content. It has a great deal to offer other professionals in terms of their understanding of themselves, their clients, their occupational structure and the social context in which they practice. This paper discusses problems with the educational delivery of sociology in the context of training for health care professionals. To confront these problems notice must be taken of occupational insecurity, topical relevance, conceptual and theoretical clarity, and the examination of background philosophical and methodological assumptions. Exercises which encourage student participation and offer practical demonstrations of sociological applications to health care practice will be illustrated and discussed.

Introduction

I am a medical sociologist with a background in adult learning based in the Faculty of Health Studies, University of Wales, Bangor, UK, with a brief to conduct and support staff in their research and to facilitate curriculum development in professional health care. I teach pre- and post-registration nurses, midwives, radiographers and sports scientists from undergraduate level to PhD. My main goal is to demonstrate the relevance of sociology to health care professionals and to encourage them to use and apply sociological methods and perspectives in their research and in the care they offer for their clients.

In teaching sociology to adults for over twenty years I have long been convinced that the value of sociology as a discipline is far greater than its substantive intellectual content. The topics of concern in sociology are necessarily relevant to personal and social development. Only the more obtuse students fail to appreciate this, while only the most perfunctory courses fail to take advantage of it. Occasionally relevance has to be demonstrated by teasing it out of technically turgid literature, although this has been increasingly rare in recent years. Perhaps the need to "sell" one's discipline in a competitive higher education market chastens most course organisers as well as the writers of modern textbooks.

While the discipline can tell us much about ourselves it also has value for other professionals by enhancing their understanding of their clients and the social context in which they practice. Despite its intellectual and practical value, new knowledge is not always warmly received. Sensitivity to cultural, economic and occupational change allows us to appreciate why this might be so. Rapid and large scale change gives rise to insecurities arising from the challenge to established professional organisation and training. In recommending sociology in health care professional education, care must be taken with such insecurities. In this paper I suggest that reassurance comes from demonstrable understanding of the challenges facing health professionals, a willingness to engage in a shared critical evaluation of intellectual roots and boundaries and the employment of exercises which engage students and offer practical illustrations of sociological applications to health care.

Occupational Insecurity

The main stimulus to the recent growth in contributions from sociologists to the training of health professionals in the United Kingdom has been the concern to raise educational levels. Pressure for change in health care education has arisen from a series of demographic, economic, and political factors. Lowered recruitment set against an ageing population is expected to lead to serious shortages of all medical staff. Framed by a concern for clinical and cost-effectiveness, community health and social care provision has increased alongside a shift of resources into primary care (Department of Health 1992).

Education reforms have accelerated the professionalization of lower status caring occupations. In nursing and midwifery this policy is assumed to improve job satisfaction, reduce staff wastage and attract higher calibre recruits (United Kingdom Central Council for Nursing and Midwifery Education 1986 and 1990). Medical education is moving away from a didactic, factually-based approach toward enhanced problem-solving and critical evaluation skills, better communication and awareness of the sociocultural and environmental factors influencing the genesis and experience of disease and illness (Percy-Robb and Lloyd 1996; General Medical Council 1993). Such policies produce different occupational expectations and demand different skills on the part of students, skills which are uniquely contributed from within a sociological perspective.

This rate of change in health care systems and uncertainty about the precise future requirements of the job means that practitioners often have to work on an ad hoc basis and professional teachers have to second guess future trends. The need for multi- agency, multidisciplinary approaches in health care practice is evidently met by open- minded, flexible professionals who can learn quickly and effectively. Such flexibility has to be reflected in professional teaching styles and methods. It might seem obvious to sociologists that in attempting to answer questions about the nature of future health care practice, insights from sociology can provide answers to understanding sociocultural change, factors affecting the distribution of health resources and the inevitable changes in inter-professional dynamics. But the occupational threats perceived by teachers and practitioners alike suggests that all such contributions can only be offered delicately and after the tactful negotiation of space and time. Any threat to the perceived status of traditional teachers will naturally be met with resistance so the boundaries to respective territories will always need to be clarified (Cooke 1993b).

Sociology has to be presented as offering an aid to understanding in a climate of rapid change. This means that only those parts of sociology which are professionally relevant need be offered. A general introduction to "yet another" discipline would be ill-advised and, if strategically possible, contributions should be offered via an integrated curriculum policy. In such a way the threats to intellect, status and occupation can be minimised. I have found it necessary to reassure colleagues on many occasions that I am not "after their job", indeed I could not do their job. I hope to offer something extra of value. The best sociologists might even have to accept that when their job has been done really well they will become surplus to requirements. As health professional teachers acquire skills in sociological analysis as well as first and higher degrees in sociology our function will change. An ability and expressed willingness to do just that becomes a vital element of current collegiate diplomacy.

The Value of Sociology as a Discipline

It should not take much to convince fellow sociologists of the value of their discipline and their profession. While no profession can be entirely immune to a "cobbler's children" effect, in having to promote their disciplinary skills elsewhere questions of value and relevance become central and the sociologist may require all the skills of the accomplished salesperson. Demonstrating an ability to understand and influence one's own work situation by accurate analysis and manipulation of professional change as well as an improved service of one's client group is a key selling feature.

The sociological analysis of professional change has been extensively applied to health care occupations. Changes of relative status within communities, political and economic empowerment and the regulatory and statutory roles of professional associations are among the processes of significance (Carr-Saunders and Wilson 1933, Friedson 1994). Changes in occupational structure include more flexible inter- professional working arrangements (Walby et al. 1994). Nursing and midwifery, for example, are now less ancillary to medicine. Both have increased practitioner autonomy, assume basic paramedical duties and engage in interdisciplinary team working. This has helped with the challenge to the professional and intellectual dominance of medicine in health care. Not that nurses, midwives and others have not been critical of medical practice and practitioners for some time. Rather that, when better armed with evidence and the communicative competence arising from experience of engagement in sociological discourse, they are better able to speak openly and confidently from their own disciplinary perspective.

Professional empowerment is only one of the many gains from an injection of sociological competence which have been considered in detail elsewhere (Iphofen and Poland 1997; Allan 1991; Grams and Christ 1992; Porter 1994; Rothman 1984; Willis 1990). Doubts will remain about whether such improved analytic skills about occupational change are transferable to other contexts, such as an awareness of similar stresses and strains on the client group - one's patients.

For this to occur health professionals have to become autonomous learners with a critical research awareness (Alexander and Hunt 1996). An increased premium has been placed on such learning with emphasis on evidence based practice. In the modern globalised economy health professionals need to be analysts, decision makers, collaborators and problem solvers with the sort of flexible outlook that will allow them to operate across increasingly diverse post-Fordist work settings (Reich 1991, Walby et al. 1994). They may have to operate as portfolio workers and they will have to adjust to working in a variety of formal, informal and even virtual organisations in the future (Handy 1989). In the past, uniformities in National Health Service provision led to standardised practice settings. Combined changes in the service and in the community require greater insight and preparedness. The importance of such changes in the social context of practice might be best understood if we consider in more detail the sociological topics which transfer easily into health care practice.

Substance and Relevance

Health professionals need to understand their interactions with clients and with colleagues. They need to understand their own motivations and the range of influences on their behaviour as well as on their clients' behaviour. They need to understand the value of being able to adopt a variety of perspectives on the human condition (Hegarty and DeCann 1988). This means that they need to study how communities and neighbourhoods work, professional-client relationships and interactions, the growth of medical knowledge, and the social influences on the effectiveness of health promotions, on risk-taking behaviour, and on life chances. A thread common to each of these is a concern with socially structured inequality. An appreciation of the origins and consequences of social inequality is essential to professional empowerment and client empowerment alike.

To teach such topics to non-sociologists and to convince them of the importance of studying such topics, the sociologist needs a fair amount of knowledge about health care. This is best achieved by ensuring that sociologists teaching health professionals are medical sociologists or have professional interests in the sociology of health and illness. There may be some dilemmas here in the need to teach the basic sociology upon which to build the more sophisticated knowledge of health applications. But this can be done with the choice of aptly constructed exercises and examples as discussed below.

It is in the subtly embedded messages contained in practical exercises that non- sociology students can learn the value of knowledge domains that do not appear immediately relevant to their purely technical needs. The full motivation to treat social factors as interesting and important can only come from seeing those factors in operation in practice.

Theory and Method

There has been ongoing debate for some years about the relevance of the study of sociology to professional health care (see Cooke 1993a; Girot 1991; Kilvington 1984; Kornreich 1977; Theodore 1989; Webster 1991). Several developments more recently are working in favour of the tone and style of sociology as a discipline being accepted by health professionals; these include holism, problem-centredness, evidence-based health care and clinical effectiveness. The multi-paradigmatic range of theoretical perspectives in sociology and the potential for qualitative research methods are more easily embraced in such a climate although some commentators fear that it is still too soon to expect some health care trainees to cope with too much theoretical diversity (Sharp 1994 and 1995).

The notion of treating the "whole" patient requires a willingness to consider problems as being explicable on many different levels from the organic to the psychological. Medicine has conventionally adopted a bioanatomical reductionist approach to problem solving. The recognition of the importance of identifying the appropriate level of "cause" as opposed to mere symptom alleviation is essentially holistic and something which sociological epistemologies have encompassed for some time (Campbell 1992). Health caregiving is not solely an interaction with organic elements, but with people who have their own, often contrasting, cultures and personal ideas with which practitioners must engage (May 1993).

An orientation to the individual case as presenting features specific to their own situation leads to treating patients as individuals with specific problems which emerge in specific contexts. A more humanistic qualitative methodology draws attention to personal biographies and to the minutiae of professional/client interactions. Nursing knowledge is eclectic and its emphasis on caring requires the practitioner to draw on a humanistic epistemology as much as on positivistic natural science (Luczun 1990, Thorne 1991). The challenge to the methodological dominance of the randomised control trial in medicine has grown to such an extent that much recent research from the caring professions is of a qualitative nature. By no means does this rule out true experimental designs but broadens the range of research possibilities and gives credence to an essentially sociological research methodology.

Questioning the philosophical and methodological assumptions of health and medical science has become more acceptable with the emergence of a concern for testing the evidence base of health care practices. An interest in the philosophy of science and the history of ideas is endemic to sociology, it has remained something of a curiosity in medical education. A need to instil confidence about procedures leads to a certain dogmatism, even intellectual arrogance on the part of traditionally trained practitioners, yet much of their practice has been shown to have grown out of custom rather than to have been founded upon incremental rigorous and systematic research.

It is the drive toward clinical effectiveness which completes the circle. Sociologists have long debated issues related to social engineering and public welfare. Having to estimate treatment costs against outcomes has stimulated a concern for public health policy which was once thought to be confined to politicians and bureaucrats. The choice of particular treatments is increasingly subjected to cost/benefit analyses of individual and collective welfare.

In confronting such issues health professionals have had to raise their critical awareness and become much more methodologically self-conscious. Most sociological theories from the classical to the post-modern, if introduced gently, can offer conceptual frameworks with which to address issues of structured social inequality, welfare delivery, health consumption, assumptions about human nature and intention, cultures of risk and attitudes to the human body among many other themes. This can only be accomplished at a very basic level in introductory courses, but appropriately extensive sociological knowledge will be sought as students discover their own specialisms and refine their research questions. A legacy of an introductory sociology which fulfils initial professional requirements will become more fully legitimated when tested in practice or employed within postgraduate research.

There is a great deal of compatibility of epistemological stances between nursing and sociology (Cameron and Turnbull 1992) and socially aware physicians do possess an appreciation of the dilemmas, constraints, ambiguities, and choices of health care practice (Needleman 1985). Physicians and sociologists alike claim their discipline to combine the rigours of science with the creative and intuitive skills of the artist (Morrell 1991). Studying both in parallel at the introductory level can give the novice health professional a good idea of their surprisingly similar problematics.

Applications and Exercises - Some Principles

The full exercises upon which the issues briefly discussed here are based will be available for examination at the International Sociological Association's World Congress of Sociology in Montreal in July 1998. In combination these exercises attempt to embody the recommendations referred to earlier for developing critical awareness of health-relevant topics. Some of these and more can be found in further detail in Iphofen and Poland (1998). No one exercise deals with any one skill or issue. Most exercises overlap in both topic and method.

1) Discursiveness This is a first principle. Sociology is best taught in a discursive format. Practice in analytic debate helps build transferable skills of argument and persuasion that are useful in any professional context. For health professionals the debate over the precise nature of "caring work" offers an apt focus. Controlled discussions which separate questions about the nature of work, what it means to be a carer and what it means to be cared-for take the student in a step-by-step manner through the issues so as to allow an overview to be constructed.

2) Experience Similarly, drawing on students' experiences helps to promote reflective learning (see Palmer, Burns, and Bulman 1994) . Given the range of variables affecting the work site of health care, the diversity of clients' problems and the mix of disciplines involved, imaginative flexibility is essential to the application of social scientific knowledge. Experiences familiar to the student can be introduced via role play, simulation and discussion, communications exercises, and problem solving. (For related examples see Hafferty 1990; Kelly 1981; Lambert 1993; Leininger 1990; Morrall 1988; Nottingham Conference Papers 1993). Placement or internship experience permits student reflection on the degree of professional activity encouraged in real work situations. A role play of professional client interactions or even the detached analysis of the role setting and the mutual expectations involved helps understand potential outcomes for both professional and client. Role analysis can vary in degrees of sophistication and so can be employed at any stage in the education process. The role of medical or nursing student is readily exploited by students eager to engage in analysis of a setting full of novelty and challenges to expectations.

3) Multiple voices and perspectives Dialogues about health care situations can be promoted and examined with appropriate exercises. The effective communication of a health message to a particular person or group or attempts to change health-related behaviours depends upon understanding the different priorities, perspectives, meanings, and values held by a range of groups of people. We have used a video and handbook for a "community placement" exercise with many groups. It encourages sociologically informed observation and enquiry with a focus on health in different communities in which the students were sent for one week placements. It is methodologically driven by participant observation but also encourages ethnographic interviewing skills which adds to competence in patient history-taking.

4) Tolerating difference A particularly memorable exercise for encouraging awareness of cultural difference and community tolerances employs some "blackboard or whiteboard cursing". At least one student can be cajoled into writing a curse or swear word on the board. Others then are encouraged to write something "worse". The exercise entails indicating the social processes involved in permitting the act of "deviance" and then how the community (i.e. the class or group) controls and tolerates the degree of obscenity or offensiveness that may then follow. It requires sensitive handling so as not to offend individuals excessively but it certainly replicates the language of the A&E(ER) on a Saturday night in most urban environments. It has a secondary gain in accustoming students to a range of slang words about parts of the human body, sexual functions and sexual relationships which they are likely to encounter as problematic in their professional work.

5) Stereotyping and prejudice Building on this last exercise one is better able to understand stigmatisation as leading to problems of identity management in the face of potentially prejudicial actions and attitudes within a particular community. Out of very natural desires to conceal or reveal certain things about ourselves in order to retain control of our own destinies, some individuals have no choice but to reveal socially disabling characteristics as a result of visible or evident physical features. Others face existential dilemmas about revealing and concealing. One can draw on students' own experiences of potentially stigmatising conditions - either directly or indirectly - and tease out the elements of information handling available to the stigmatised individual and consider likely societal responses to such techniques (Iphofen 1990).

6) Ability For many of these exercises to work students need to examine the degree to which their own experiences are mediated by peers, patients and mass communications. While it may be easy to identify the prejudices of others, it is less easy to detect one's own biases. Technical definitions of terms such as "social class", "status", "ethnicity", "institution", "family", or "household" have to be applied to differentiate these from commonsense, potentially prejudicial, usages of such terms. The same kind of technical nomenclature is applied to the human body - one's own body and one's own culture are things one should hold a great deal of common familiarity about. Exercises can be designed to bring out technically sophisticated understandings of mundane phenomena - such as eating or sleeping. Questioning routine and taken-for-granted uses and abuses of the human body can be particularly enlightening.

7) Engagement Commitment and involvement can be encouraged by practical research exercises, preferably in the form of group projects which help prepare students for the inevitable interdisciplinary teamworking and collective responsibility of professional health work. Sequential guidelines can help progress the work and structure the research activity. To some extent the topic and the outcome is less important than the engagement in the activity per se. 8) Controlled disclosure Sequenced questions about households, domestic responsibilities and leisure activities allow a degree of disclosure without being too threatening. Health professionals need to experience the potential for discomfort or release that comes with disclosure to understand how their clients might feel. Again that should not be so great as to cause excessive emotional pain. Even the simple mapping of family networks can cause distress. But that experience can enhance the student's understandings of similar traumas and vulnerabilities in their patients.

9) Problem-solving It is interesting that health trainee students can be clinical more easily about the human body than they can about human relationships. The alienated and vulnerable patient should be as much a problem for the health professional as the patient's presenting condition. Solving such problems are clearly more sociological than medical so the awareness of the possibilities of a clinical sociology can be cultivated by, say, conducting analyses of power differentials between the patient and the health care system and between patient and practitioner or, indeed, between doctor and nurse.

10) Modelling the communications process Constructing and applying models which offer analogues for human processes can focus attention on areas of significance. A particularly enjoyable exercise utilises a semiotic analysis of "health-related" products or health consumer goods. Students will offer analyses of health drinks, health magazines, healthy cereal packets, the packaging from various "sanitary" products and, of course, samples of a range of contraceptive devices.

Conclusion

It is argued elsewhere that placing self-contained sociology modules on the first year of health professional courses can encourage disciplinary distinctions and boundaries that are too neat and tidy. In that way sociology becomes a foundation subject to be assessed and, thereafter, largely forgotten (Iphofen and Poland 1997). Distinct introductory courses should be left to pre-professional educational programmes. Sociology must be seen to add value to a professional qualification by its application as a problem-solving discipline (Field 1988, Wong 1979). Simple and direct applicability to patient care, demonstrable relevance, and the use of multiple methods are the keys to successful integration (Hunt and Sobal 1990).

Sociology comes into its own when it is used to understand ourselves and the other social beings we have to deal with. It is particularly useful when making sense of change and of vulnerability - just the kinds of problem routinely encountered in health care. In a climate increasingly favouring the taking of responsibility and personal autonomy in work and social life, sociology offers means for drawing on and improving upon existing individual and collective resources.

Future teachers of sociology to health professionals would benefit considerably from specialist training. The sociologist teaching sociology to other professional groups needs to operate a special branch of clinical sociology. Their "problematics" will be the ability to develop an overview of the problematics facing the trainee profession. This is more than just possessing a knowledge drawn from occupational sociology. It requires the clinical sociologist's skills of empathy, detached analysis and goal- focused personal and organisational development (see for example Straus1985, Swan 1984, Bruhn and Rebach 1996). At the very least optional modules within sociology degree courses could deal with how to teach sociology. For example, given the anticipated health education and mentoring roles of modern nursing, modules on "Teaching and Assessing" appear fairly common in nursing degree courses.

At best degree courses in clinical sociology per se could be envisaged with the option of teaching sociology to other professionals as one of the core elements. What better way of "selling" one's discipline could there be? Instead of hoping that the general public will somehow magically come to realise the value of the sociological perspective on all areas of modern life, most significant professional stakeholders in social development will have studied it under the guidance of an expert dedicated to its application in their unique professional sphere. In this way sociology might appear less of an appendix to other professions and could take its rightful place as central to the informed understanding of contemporary living.

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