SOClAf IPSYCHOf OGICAf

ESPITE evidence of the dominance of the principles of D cooperation and conformity in human affairs many of us still insist, on the belief level at least, that individuals are totally in control of their behavior and are not or should not be influenced by the groups of which they are members or to which they seek an affinity. These ideas, although oversimplified here, are part of the concept of rugged individualism - a concept that constitutes the basis €or the popular but naive conception that human behavior is largely random and if you wish to see behavioral change you must change the hearts of individuals. Hence many people, including students of nursing, seem to assume that conflict is not structured and any problem which arises between physician and nurse or between other health personnel should be blamed on individuals and dealt with accordingly.'

Behavioral scientists and other students of health personnel relations have frequently found the contrary. The perspective depicted by the idea of rugged individualism has been found

20 VOLUME VII NO. I I968

A n examination o f values, attitudes, beliefs and

sociociiltural .striictiires which influence the work relationships

o f physicians and nurses.

to be misleading and, in fact. has blurred the vision of those whose hopes are to understand and improve relations between health co-workers.’

The modern nurse, then, is being summoned by the character of our times to develop another new skill. She is being asked to learn to make the distinction between conflicts originating in social and cultural structurc and those, which are in the main, caused by individual psychodynamics.

Being prepared to recognize repeated acts early in their evolution as patterned behavior gives the health professional the alternatives of purging wcial patterns nhich obstruct effec- tive working relationships and reinforcing behavior which serves to integrate and improve working situations. In fact, simply being able to recognize conflict when it is present is a step in the right direction. Unfortunately, too many workers in and out of the health field are not yet able to see patterns of conflict as conflict even when they are in the midst of it.

What then are some of the social-psychological and cultural factors which deter effective team work? These factors can be

N U R S I N G F0RUh.I 29

divided into two categories: problems of social s t r ~ c t u r e ~ , ~ and problems of attitudes and beliefs.

PROBLEMS OF SOCIAL STRUCTURE

In our society there are a number of mechanisms or social structures which contribute to the stratification and separation of people in their associations and ideas. Following is a brief discussion of six such structures or configurations of human behavior which the authors observe to be influences on the nurse-physician relationship.

The Occicpational Cap. - This is a natural schism between physicians and nurses simply because of the expected differ- entials between the goals, training, technology, attitudes, and population composition of the two occupations.5 Despite this obvious fact many nursing students, in their initial relations with physicians, assume that the doctor is prepared to under- stand the nurse-orientation and what constitutes the content of nursing. Likewise, many physicians presume that the nurse not only understands a great deal about his job but also that she comprehends and concurs with his perception of nearly every- thing, including the needs of patient^.^,^

A corollary of this occupational gap is the similarly natural schism found between the subdivisions of occupations. They, too, tend to form in-group qualities and raise the probability of inefficiency in relationships between such occupational groups and their respective out-groups. For example, in medicine we need only to compare the perspective and clustering of attitudes within surgery with those in psychiatry. Within nursing, in- group qualities become very clear and inter-group conflict becomes very real in instances involving nursing education versus nursing service.

30 VOLUME VII NO. I 1968

Social Class Orientation. - There tends to be a breach between nurses and physicians in terms of differences in values, attitudes and beliefs associated with their respective class origins. Doctors tend to come from the higher classess in our society while nurses tend to come from the middle and working cla~ses .~ Given the differences in the occupation schism, modes of thought and behavior for different social classes also tend to be different leading to differentials in perspectives and variations in perceptions of any number of health and medical care situations. O

Although no individual conforms identically to the values, attitudes, and beliefs of his parents and other sources of values, there is evidence that all individuals are strongly influenced in both internal values and overt behavior by the groups which they value or to which they aspire to belong. Many of us, under the influence of the rugged individualism notion in our culture, assume that we come independently to revere certain things. The fact is that most everything we hold dear is appreciated because it was valued by people in our groups of origin or because it is something of value to our current reference groups. Social class is one of these important sources of values."

Income Breach. - Another factor closely related to social class is income differentials when educational investment is taken into account. The nurse holding a baccalaureate degree has studied four years beyond high school, while the physician has studied from nine to twelve years beyond high school. This means that collegiately educated nurses invest between one-third to nearly one-half of the time that the doctors invest while the nurse's return is only approximately one-fifthl* of what physicians earn. l 3

NURSING FORUM 31

General Slatzrs Disparity. - Closely tied to the occupational gap is the difference in status ascribed to the nurse and that assigned to the physician. The doctor enjoys the most esteemed social position in our nation. The nurse is way down on the hierarchy of status, considerably below occupations of com- parable education and re~ponsibi1ity.l~ This prestige of the physician, seen by competing or aspiring occupations as status obesity, breeds competitive conflicts for many nurses who view their occupation as suffering from status anemia. Relative disparity between both status and income, when viewed against a largely egalitarian society, implies many structured-in conflicts between the nurse and physician, including the problem of curtailed enthusiasm and motivation for the nurse.15

The Technology Factor. - The health occupations tend to suffer from a lag in the redefinition of their respective tech- nological provinces. Occupations within the same work settings find it difficult to divide effectively the technical material and knowledge between themselves because of the rapid pace of technological developments. Technology and general cultural change tend to move at a rate faster than each occupation can find consensus on the limits of its technological boundaries. Examples include the clinical psychologist as a therapist versus the psychiatrist; the nurse clinical specialist versus the physician and the licensed practical nurse versus the diploma nurse. Where one occupation’s technology ends and the other begins are important questions to be answered in some medical care settings. lG

The Occupational Identity Struggle. - Closely akin to prob- lems of the occupational gap is the special problem of the maintenance of an integrated and complete sense of occupational identity. An occupation must present to its new initiates, its

32 VOLUME VII NO. I 1968

clients, and its public a clear picture of what it is. To get and keep optimum loyalty and commitment to an occupation, the occupation must reduce ideological ambivalence; i.e., it must establish and maintain an undergirding of consensus on such things as the goals of the occupation and the methods of orienting novices to the occupation. It must also project to adjacent occupations a modern and consistent image of itself.

Regardless of whether the image is a completely accurate characterization of the occupation it must appear to have clarity, unity, and consistency for the public to perceive it with respect or for adjacent occupations to understand it. Nursing, victim- ized by rapid sociocultural changes in technology, the status of women, public perceptions of health and illness, and the further division of labor in medical care, has failed to project a clear image of the competence of modern professional nurses nor has it made plain their contemporary and independent functions. Some of this confusion is also a result of changes within nursing, some of which ought to subside within the decade with further clarification on the question of the direction for nursing education. Meantime, confusion persists in the minds of most physicians and much of the public about nurses and nursing.17

PROBLEMS OF ATTITUDES AND BELIEFS

There are many attitudes and beliefs held by the public regarding medicine and nursing which exert important influences on the nurse-physician relationship. These attitudes and beliefs function as reference points for behavior toward nurses and thus tend to retard the full acceptance of nursing as a profession. Since few people accept all of these beliefs in their entirety they might be described as modal beliefs.

N U R S I N G FORUM 33

Florence Nightingale Stereotype. - Closely related to the problem of the occupational identity struggle is the disparity still found between the popular image of the nurse with residues of her nineteenth century character and the image of the modem college-educated nurse who has foundations in most of the medical care-related sciences.ls

Nursing: The Work of Females. - This belief holds that nursing is feminine in character while medicine, dentistry, and pharmacy have a masculine character. This tends to enhance sex segregation which, in turn, like other forms of segregation, creates barriers to communication and therefore to the under- standing and full appreciation of the problems of the out-group.

Nursing: Work for the Soft-Hearted. - Closely associated with the belief that a nurse should be female is the notion that nursing is mainly the capacity for being tender and sympathetic. There are some obvious ramifications that this belief has for the relationships between nurses and patients. Although most physicians probably do not hold this belief, it does influence the nurse-physician relationship.

Task Status Differential. - The work tasks of the physician, though many of them may be relatively simple operations, have high status in the minds of patients and other onlookers in the medical setting. Nursing tasks are often looked upon as routine and requiring less specialized competence to perform. For example, the surgeon’s work is viewed with high esteem though Americans usually view tasks of manual dexterity as having low prestige. On the other hand, the behavioral science-naive public is almost completely oblivious of the complex skills required of nurses in the care of persons with psychophysiologic illnesses.

34 VOLUME Vl l NO. 1 1968

The Fantasy of Medicine and the Idealization of the Phy- sician. - The hospital and the work of physicians tend to be regarded by laymen, and even many ancillary medical personnel, as a glamorous drama in which physicians lead a grand assault on disease. Nurses are seen in the fantasy as depending entirely on the perception and orders of the physician. Although these beliefs about medicine may aid the doctor in helping his patients, they often have dysfunctional implications for the nurse- physician relationship.l9

The Perfection of Scientific Medicine. - This popular notion regards the practice of medicine as almost completely scientific. Gaps in medical knowledge are not perceived and the proba- bilistic nature of medical principles is seen as absolute. Thus, medicine is viewed and revered as a science and not as an art of the application of science. On the other hand nursing is often seen as having little or nothing to do with the application of science.?"

Baccalaureate Nirrse: Technical Incompetent. - Although this belief does not seem to be as widespread or as firmly held as some of the others, it does represent an impediment in relations among health workers. Perhaps because of the baccalaureate nurse's sometimes more limited clinical experi- ence, as compared with the diploma graduate, she is regarded as unable to give good bedside care. She is seen as less skilled insofar as technical procedures are concerned. Although it is difficult to establish certain evidence for the falsehood of such a belief, it has most of the earmarks of being part of an over-generalized stereotype.

PhyJician: The Natitrul Leader of the Health Team. - Much evidence suggests that many physicians believe that despite the brief time spent with the patient he should be the health team

N U R S I N G FORUM 35

leader or coordinator and his conception of a patient’s illness is the one that should occupy the attention of the rest of the health workers. In other words, he should not be a consultant even though he may be the most important among many con- sultants. This belief is at the base of a number of conflicts between physicians and nurses.

Therapeutic and Somatic Medicine: The Definition of Health. - The belief that certain types of preventive medicine have no place in the repertory of the physician and a preoccupation with the physical aspects of medical problems seem to be prevalent notions among doctors today. Not too infrequently psychiatry, social service, and dietetics are among those practices regarded as near folly by some physicians; and therapeutic plans either deliberately ignore such referrals or their utilization is omitted out of ignorance. These prejudices on the part of physicians have important meaning for the nurse who wishes to practice holistic nursing.

We hope that this brief survey of some social-psychological obstacles to effective health team practice will suggest clues for the student of nursing and her teacher in their effort to relate more effectively with physicians and others in medical care settings.

REFERENCES

Williams, Robin M., American Society, New York: Alfred A. Knopf, 1962.

2 Haas, J. Eugene, Conception nnd Group Consensus, Columbus, Ohio: Bureau of Business Research, 1964.

SLundberg, G. A., et al, Sociology, New York: Harper and Row, 1963.

4 Wilson, Robert N., “The Social Structure of a General Hos- pital,” The Annals, p . 67, March, 1963.

5Caplow, Theodore, The Sociology of Work, New York: Mc-

36 VOLUME VII NO. 1 1968

Graw-Hill, 1954. MacGregor, Francis C., Social Science in Nursing, New York: Russell Sage Foundation, 1960. Smith, Harvey L., “Contingencies of Professional Differentia- tion,” Man, Work and Society, S . Nosow and H. Form (edi- tors), New York: Basic Books, 1962. Rosinski, Edwin F., “Social Classes of Medical Students,” Journal of the American Medical Association, p. 89, July, 1965. Hughes, C., et al, Twenty Thousand Nurses Tell Their Story, Philadelphia: J . B. Lippincott, 1958.

lo Kahl, Joseph A., The American Class Structure, New York: Rinehart, Inc., 1957.

l1 Newcomb, Theodore M., “Attitude Development as a Function of Reference Groups: The Bennington Study,” Readings in Social Psychology, E. Macoby, et a1 (editors), New York: Henry Holt and Company, 1958.

l 2 American Nurses Association, Facts About Nursing, New York: 1966. Harris, Seymour E., Econornicr of American Medicine, New York: Macmillan, 1964.

14 Kahl, op. cit. 15 Oxaal, Ivar, Social Stratification and Personnel Turnover in the

Hospital, Columbus, Ohio: Engineering Experiment Station, The Ohio State University, May, 1960.

16 Strauss, Anselm, “The Structure and Ideology of American Nursing: An Interpretation,” The Nursing Profession, Fred Davis (editor), New York: John Wiley and Sons, Inc., 1966.

I7 Burling, T., et al, The Give and Take in Hospitals, New York: G. P. Putnam’s Sons, 1956.

IsCorwin, G. and Taves, M., “Nursing and Other Health Pro- fessions,” Handbook of Medical Sociology, H. E. Freeman, e f al, Englewood Cliffs, New Jersey: Prentice-Hall, Inc., 1963. Observations of and interviews with staff and patients in five general hospitals, including one U. S. Naval Hospital; four nursing homes; two residential psychiatric treatment centers for children; one state psychiatric hospital: one tuberculosis sana- torium; one urban home care service for the medically indigent and one military psychiatric evaluation center.

20 Davis, Fred, “Uncertainty in Medical Prognosis: Clinical and Functional,” Medical Care, W. Scott and E. Volkart (editors), New York: John Wiley and Sons, Inc., 1966.

NURSING FORUM 37