Journal of Advanced Nursing, 1997, 25, 844–852
Assimilating sociology: critical reflections on the ‘Sociology in nursing’ debate Jon Mulholland MSc BA(Hons) Senior Lecturer in Sociology, Thames Valley University, Wolfson School of Health Sciences, Slough, Berkshire, England
Accepted for publication 1 April 1996
MULHOLLAND J . (1997) Journal of Advanced Nursing 25, 844–852 Assimilating sociology: critical reflections on the ‘sociology in nursing’ debate We are witnessing the emergence of a ‘new nursing’. In part, this has been associated with the adoption of a ‘holistic’ model of health and a commitment to a holistic curriculum within nurse education. The role of sociology within the nursing enterprise has been the subject of much debate. This paper seeks to further this debate by arguing that sociology is invaluable to nursing for many reasons but that its value may be undermined as a consequence of being overly constrained within the nursing arena, at the mutual expense of both sociology and the long term interests of nursing itself. This paper will suggest that central to an understanding of how this ‘surplus constraint’ of sociology occurs is an understanding of the manner in which the holistic model has been adopted in much of nursing and nurse education. The ‘indeterminacy’ of the holistic model is such that it has empowered a questionable eclecticism, marginalized philosophical controversies within nursing theory, disguised difficult epistemological and ontological conflicts associated with competing claims to truth and facilitated the operation of a form of power whereby sociology has been excluded, at the very moment of its apparent inclusion. This paper goes on to argue that the value of sociology to nursing is dependent upon: firstly, a more systematic and rigorous discussion of its relationship to, and role within, nursing and secondly, a movement away from an implicit ‘assimilation’ model regarding the incorporation of sociology into nursing towards a more ‘multicultural’ approach. Only under such circumstances may sociology’s value to nursing be realized but in a manner that places an importance on maintaining the ontological and epistomological integrity of the sociological tradition.
NURSING AND THE ‘INVITATION’ OF SOCIOLOGY Project 2000 preregistration courses have been presented as a watershed within nurse education in the United Kingdom, marking a new direction for nursing in its struggle for professionalization (Pendleton 1991). Such professionalization, it was frequently argued, rested upon the transformation of nursing’s educational base. Nurse Correspondence: J. Mulholland, 16 School Terrace, Reading, Berkshire RG1 3LS, England.
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education came to define both the fetters holding back the necessary process of professionalization and the opportunity for its realization. The discourse surrounding Project 2000 has taken the form of a dialogue with this ‘traditional’ form of training, with the former personifying that which must be reconstructed along a more ‘higher educational’ model (ENB 1987). The adoption of Project 2000 has brought nursing into a far closer relationship with academic disciplines that had only a minor role within nursing and pre-existing nurse training. This ‘invitation’ of academic disciplines into the nursing arena appears to mark a quite notable shift © 1997 Blackwell Science Ltd
The ‘sociology in nursing’ debate in the philosophical and educational basis of nursing generally and nurse education specifically. It would, however, be a mistake to assume that this ‘invitation’, particularly with regard to sociology, has been wholly consensual or unproblematic: in fact it has been the subject of some quite considerable debate (Porter 1995, Sharp 1995, 1994, Cooke 1993). At this point it may be valuable to selectively review the discussion about the vexed question of the value of sociology to nursing within the relevant literature.
THE ‘SOCIOLOGY IN NURSING’ DEBATE ‘The case for’ Cooke’s (1993) seminal paper, ‘Why teach Sociology?’ acknowledges the fact that sociology had traditionally been rather marginalized within nursing and nursing curricula, and that in part this could be explained by the ambivalence and at times negativity of many nurse educationalists towards the subject. This in turn was a product of the hegemony of the biomedical model within nursing which she claims sits rather uncomfortably with a ‘sociological imagination’ (Wright Mills 1970). A lack of familiarity with, and commitment to, critical and theoretical reflection on the part of nursing, combined with a largely individualistic frame of reference, militated against the utilization of sociology within the nursing arena. The adoption of the holistic, or often termed ‘biopsycho-social’ model, marked a philosophical and practical shift in nursing away from a stress on hygiene towards a humanistic concern with communication. This conceptual shift was central to the project of professionalisation in which nursing was engaged. Sociology became seen in this context as central to the ‘humanization’ of nursing care, enabling the nurse to relate to the whole client. However, Cooke (1993), drawing upon a Foucauldian frame of reference, makes the insightful comment that the adoption a communicative model by nursing ought not to be taken for granted as demonstrating a discarding of power; rather it ought to be seen as the adoption of an alternative mode of power vis-a`-vis clients and other professionals. Sociology has become important to nursing in so far as it has facilitated an exercise of power immanent within the communicative model of care. To put it simply, sociology is perceived as a valuable tool for nursing because in certain forms it empowers nurses to exercise particular modes of power over clients. Given the fact that this basic instrumentalism has dictated the level at which sociology has been engaged within nursing, it is not surprising to find that the forms taken by sociology within nursing have been carefully constrained and restrained under the guise of ‘relevance’. The criteria for determining ‘relevant’ sociology owe much to largely unacknowledged political and ideological assumptions.
The principal effect of this has been the production of a sociology within nursing that is firstly, individualistic in its frame of reference, secondly, micro-sociological rather than macro-sociological and thirdly, demonstrative of a resistance to critical sociological reflection on the nature of professional practice itself. As regards this latter point sociology is more likely to be used to examine ‘them’ than ‘us’. In contrast to the instrumental manner in which sociology has been incorporated within the nurse arena, Cooke (1993) posits an incorporation of sociology within the nursing curriculum that empowers an ‘emancipatory’ potential immanent within the ‘sociological imagination’ (Wright Mills 1970). For Cooke (1993), the historical, anthropological and critical dimensions of sociological analyses offer the potential of ‘new ways of looking’ at old nursing problems, and as such facilitating the relative emancipation of nursing from a biomedical frame of reference. However, sociology is only capable of having a progressive, transformative and emancipatory role if it is a theoretically informed sociology capable of challenging ‘taken-for-granted assumptions’. However, Cooke (1993) says little about the precise mechanisms by which sociology is constrained within nursing generally or nursing curricula specifically, and even less about the means by which a more meaningful role for sociology may be achieved.
‘The case against’ In two key papers, Sharp (1995, 1994) offers a radical critique of Cooke’s position and an explication of his claim that sociology is of little value to nursing and potentially even harmful to the true interests of nursing practice. Sharp (1995) claims that nursing is a discipline that operates within a natural science paradigm, and as such conforms to a particular set of ontological, epistemological and methodological assumptions. Nursing is in essence action-based, and fundamentally non-reflexive. Nursing action is rational action directed towards the achievement of particular quantifiable outcomes and as such has need only of knowledge that directly contributes towards the achievement of those outcomes, namely ‘knowing how’ knowledge, rather than ‘knowing why’ knowledge. The only knowledge truly valuable to a nurse is concrete knowledge that provides nursing with a foundational certainty and offers unambiguous, incontestable guidance for action. Nursing, being a professional body whose practice is apparently devoid of complex decision-making, is therefore inherently non-reflexive, and as such has no need of being theoretically informed in the manner suggested by Cooke (1993). Given Sharp’s (1995, 1994) characterization of nursing, it follows that sociology is of little value to the nursing enterprise, and may at times be positively counter-
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J. Mulholland productive. The importance attached to sociology by Cooke (1993) cannot be justified either on the grounds of ‘personal education’ (namely the provision of generic analytical skills inherently valuable in and of themselves) or ‘semantic conjunction’ (namely, the existence of a substantive sociological body of knowledge regarding the nature of the empirical world, upon which nurses can reliably draw in their provision of nursing care). Regarding the ‘personal education’ justification, sociology is unable to offer nurses a range of inherently valuable analytical skills for two fundamental reasons. Firstly, with regard to research skills, sociology is in fact unable to offer a useful or reliable framework for nursing research. Sociology is multi-paradigmatic to the extent that there is, according to Sharp (1994), no common ground within which sociological research operates. Each of the mutually incompatible paradigms within sociology construct their own criteria of truth from within, so that what may be a truth within one paradigm is utterly fallacious within another. This relates to a second limitation as regards the ability of sociology to offer a personal education function for nurses. That is that sociology is essentially reflexive, implying that it endlessly questions the basis of all claims and statements, in terms of the epistemological and methodological assumptions from which such claims are derived. As such, all claims to truth are relative to the paradigms from which they are produced. In sociology, ‘relativity rules’. Nursing, being non-reflexive and in need of unambiguous guidance to action, requires a fundamentally different form of knowledge; a knowledge that can provide certainty and authority, rather than uncertainty and relativity. The multiparadigmatic and reflexive nature of sociology also undermines the ability of sociology to fulfil a meaningful role for nursing on the level of ‘semantic conjunction’. Sociology does not in fact offer nursing ‘truth’ regarding the nature of the empirical world, rather it offers ‘truths’, mutually incompatible conceptualizations of the social world that are inherently unverifiable except from within their own paradigm. Moreover, they are concerned with explaining why things happen, whereas a nonreflexive nursing need only concern itself in knowing that or how things happen. For nurses to enter the realm of reflexivity, i.e. the sociological realm, is to enter a realm that at best offers confusing guidance and at worst impotent inaction. The inherent pluralism of sociology, combined with the non-existence of any universal mechanism by which conceptual disputes may be resolved, represents a recipe for disaster in a non-reflexive, action-oriented arena such as nursing. Sharp (1995, 1994) asserts that Cooke’s (1993) relatively optimistic account of the value of sociology for nursing fails to acknowledge the multiparadigmatic nature of sociology itself, and the confusing and paralysing effect 846
that this will inevitably have on nursing practice. Furthermore, Cooke’s (1993) claim that sociology may offer valuable conceptual guidance for nursing and bring about progressive changes in nurses’ behaviour, is questioned by Sharp (1994, 1995), on the basis that the multiparadigmatic nature of sociology renders it peculiarly incapable of offering such guidance, or of being a consistent agent of change. Sharp (1995, 1994) also suggests that the constraints placed upon sociology within nursing and referred to by Cooke (1993) are symptomatic of the fact that so much sociology is practically useless to nursing as it fails to meet the instrumental requirements of the nursing profession. He also accuses Cooke (1993) of a sleight of hand; of disguising her essentially political agenda whereby she defines ‘valuable’ sociology (namely sociology informed by particular theoretical assumptions), in terms of the particular form of sociology to which she is personally committed.
‘The case for’ revisited The position articulated by Sharp (1995, 1994) has been extensively criticised by Porter (1995). Firstly, Porter questions Sharp’s rather ‘old-fashioned’ and perhaps patronizing characterization of nursing. Sharp (1995, 1994) is able to maintain this characterization as a consequence of his assumption that nurses in clinical practice do not need to make decisions. Porter (1995) in contrast, asserts that decision-making is in fact central to the nursing process and nurses have a need for theoretical frameworks within which the decision-making process must be located. As such they may indeed benefit from the theoretical frameworks articulated within sociology. Secondly, Porter (1995) posits that Sharp (1995, 1994) overstates the multiparadigmatic nature of sociology, or rather, exaggerates the incompatibility of various paradigms within sociology and the alleged conflict that ensues. Porter argues that the work of Giddens (1984) and Bhaskar (1989) is evidence of a general shift in sociology towards a greater level of paradigmatic synthesis and a commitment to multidisciplinary enterprises. Nursing is therefore in a position to make choices between alternative sociological approaches located on a conceptual continuum rather than being faced with a choice between mutually incompatible, dichotomous alternatives. Nurses may therefore feel a degree of confidence in being able to select from a range of sociological approaches, those most suited to their professional needs. Furthermore, Porter (1995) argues that although there are undoubted difficulties in discerning ‘truth’ in a discipline that offers legitimacy to a range of different criteria by which ‘truth’ may be produced and verified, nursing can gain confidence from the fact that it already possesses the means for making such judgements, a point not
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The ‘sociology in nursing’ debate acknowledged by Sharp (1994). Nursing has access to three criteria by which it could make meaningful choices regarding the suitability or otherwise of particular sociological perspectives: firstly, the principle of ‘pragmatic utility’, namely the selection of sociological approaches that ‘work’ for nursing, secondly, ‘philosophical compatibility’, namely that nursing possesses its own philosophical principles from which to make judgements regarding the appropriateness of particular sociological approaches on the basis of their degree of philosophical compatibility with contemporary understandings of the nursing enterprise and thirdly, ideological sympathy. Nursing is inherently ideological or political in nature, in so far as values are central to nursing. As such, ‘ideological contours’ within nursing, such as feminism, resonate with the ‘ideological contours’ of sociology. Feminist-inspired nursing research and knowledge, finds a natural ally with feminist sociology on the basis of an inherent ideological sympathy. Finally, the fundamental limitation of Sharp’s (1994) position, according to Porter (1995), is his assumption that nurses do not need to be reflexive, and that such reflexivity may in some circumstances be counter-productive by rendering nurses uncertain regarding the foundations of their practice, and hence ineffectual. In contrast, Porter (1995) asserts that nursing has moved away from the forms of action referred to by Sharp (1994) as defining nursing per se, namely, action defined by Weber (1968) as ‘purposive-rational action’, and increasingly towards an inherently reflexive ‘communicative action’. ‘New nursing’ is grounded upon this ‘communicative action’, a mode of action characterized by egalitarianism between client and patient and reflexivity on the part of both. The nursing role is therefore increasingly one of the reflexive advocate. For Porter (1995), a recognition of the reflexive nature of nursing opens up a wealth of possibilities for the full utilization of a meaningful sociology within the nursing enterprise.
Summary The position adopted by Sharp (1995, 1994), although perhaps quite persuasive at times, is unconvincing for the reasons outlined by Porter (1995). The representation of nursing is patronizing and inaccurate. Nursing, being as much based upon communicative action as purposiverational action must be inherently reflexive. If nursing is not, then this is evidence of its need for greater reflexivity, rather than being symptomatic of any essential and proper disinterestedness in reflexivity. For example, it is most certainly not sufficient for nurses to know only that or even how discrimination against ethnic minorities takes place within the NHS (George: 1994). Nurses must be in a position to challenge such discrimination and this requires an understanding of why discrimination takes place. Only
once the dynamics of discrimination have been grasped may effective strategies be developed to reduce its prevalence. Sociology is relevant to nursing because nursing has a form of ‘situational dependency’ upon disciplines such as sociology from which they inevitably derive much of their knowledge. A distinction made by Hirst (1975) between primary and secondary knowledge forms is helpful in shedding some light on this situational dependency. He argues that What there are in abundance now, are new interdisciplinary areas of study in which different forms of knowledge are focused on some particular interest, and because of the relations between the forms, what is understood in each discipline is thereby deepened. Such new areas of study do not constitute new areas on a map of knowledge …. They are essentially composite, second order constructions, not to be confused with the primary forms of knowledge …. (Hirst 1975 p. 295)
As such, nursing knowledge is in part, a shifting and fluid ‘secondary knowledge’ form, constructed on, and inseparable from, the knowledge of academic disciplines such as sociology (‘primary knowledge’), with all their complexities and contradictions. As regards, the multiparadigmatic nature of sociology, it is undoubtedly true that sociology contains within it, numerous paradigms that do at times articulate quite fundamentally different world-views. However, Porter (1995) correctly asserts that Sharp (1995, 1994) exaggerates this phenomenon and fails to address the developments within sociology that are moving towards greater synthesis and a greater commitment to multidisciplinary projects. Furthermore, nursing is itself multiparadigmatic, in a manner not too dissimilar to sociology, and as such nursing and sociology may be disciplines whose respective ‘contours of debate’ are surprisingly familiar to each other. The multiparadigmatic nature of sociology does not discredit sociology; quite the opposite. The particular mode of sociology adopted by, and articulated within nursing, is likely to be a product of the paradigmatic debates taking place within nursing itself, to which sociology may make a valuable contribution. The outcome of these paradigmatic debates is effectively a product of what could be best be described as the ‘politics of nursing’ (Gibbs 1991, Glen 1990). A limitation of Porter’s (1995) argument however, is the implicit characterisation of sociology’s inclusion in nursing as rather unproblematic and consensual. As such, it does not go far in promoting an understanding of the complex and thoroughly problematic nature of sociology’s incorporation into nursing (Balsamo & Martin 1995). It is to this point that the remainder of this paper is addressed. Cooke’s (1993) account of the inherently political nature
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J. Mulholland of sociology’s inclusion in nursing is perhaps the point of departure from which further investigation may proceed.
The hollowness of the holistic model
NURSING AND THE HOLI STIC MODEL The holistic model has been widely adopted to facilitate the undeniably complex process of integrating sociology into a nursing curriculum. Inspired by the holistic model, nurse educationalists and practitioners have generally felt optimistic about the capacity of such a model to facilitate this complex integration. The model is presented as both a means of establishing an ontological and epistemological foundation for nursing, distinct from a biomedical model, and also as a mechanism for the integration of disciplines such as sociology into the nursing curriculum (cf ENB: 1987). The World Health Organization’s ‘positive’ definition of health as a? … a state of complete physical, mental and social well-being and not merely the absence of disease or infirmity. (Seedhouse 1986 p. 31)
has become central to the nursing curriculum of most colleges of nursing, serving to secure the legitimacy of its content and the co-operation of all those present. This paper claims however, that there may be some important limitations in the way in which the holistic model has been adopted and utilized and that these limitations may impact directly upon the role and value of sociology to nursing. The point is not that the holistic model is without value, as in many ways it defines the ultimate aim of all knowledge to find its place and its relation to other knowledge forms. Rather, it is with the manner in which the model has been utilized, and with some of the consequences of its mode of operation that this paper is concerned. There is a need to scratch the surface of the holistic model as it has manifested itself in nursing and nurse education particularly, and to consider some of its ‘actually existing inadequacies’ and furthermore, to question whether there may be a ‘darker’ side to its implementation, particularly in relation to the inclusion of sociology in nursing curricula. This paper argues for the need for all those involved in the shaping of nursing curricula to ‘scratch’ this ‘surface’ and look good and hard at what lies beneath.
A critique of the holistic model At this point, some potential and extant limitations of the holistic model will be considered, with particular reference to its utilization within nurse education. Particular regard will be given to the impact of these limitations on the incorporation of sociology into nursing. The core claim made here is that there is an indeterminacy about the holistic model and that this may have a key strategic role in 848
facilitating the assimilation of a potentially impoverished sociology, bereft of its dynamic value within nursing.
All too often the holistic, ‘Bio-Psycho-Social’ model is rendered almost meaningless by its hollow and purely rhetorical nature. It often becomes an excuse for ‘throwing in’ any and every conceivable variable vaguely relevant to a particular problem. It has at times empowered an often unquestioned eclecticism. Such eclecticism operates as an active obstacle to the rigorous, critical reflection that must surely be a prerequisite of sensitive and appropriate health care interventions, lulling those involved into a false and unjustified sense of security. Of course, few things happen entirely by accident and one should be willing to think about the raison d’eˆtre of the holistic model as it has so often been implemented. It could be suggested that a central function of the holistic model has been served by its ambiguity. This ‘sugar coating of ambiguity’ (Seedhouse 1986) is such that it may become anything and everything to all without at the same time having to justify its own existence. It is precisely this indeterminacy that gives the holistic model its utility, in enabling a potentially infinite flexibility in the organisation of nursing knowledge.
Philosophical tensions within nursing The adoption of a holistic approach is often presented as both necessary and sufficient to the successful integration of diverse knowledge forms within the nursing arena. However, in practice, its ability to provide both solutions to ongoing philosophical conflicts within nursing and a framework for the satisfactorily bringing together of disparate disciplines into some cohesive and meaningful whole is more apparent than real. The debate over whether nursing’s interests are best suited through the adoption of a medically informed scientific positivism or a more humanistic existentialism is not really advanced in any way by the adoption of an eclectic holistic approach (Mulholland 1995). The vigour of the humanistic critique regarding the influence of scientific positivism within nursing is an illustration of ongoing philosophical tensions over the rightful ontological, epistemological and methodological foundations of nursing (Holmes 1990). For those who feel that the model in and of itself, by definition constitutes a foundation for an independent nursing knowledge base which is internally consistent and intellectually rigorous and is capable of resolving some of the most intractable philosophical and political dilemmas, this paper would argue that under present circumstances, it most certainly is not.
Competing truths The indeterminacy of the holistic model may also enable educationalists to side-step full recognition of the com-
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The ‘sociology in nursing’ debate plexity of formulating a nursing curriculum. It encourages a form of naivete´ regarding the conflicts and contradictions found within the diverse epistemological foundations of disciplines such as sociology, physiology, psychology and philosophy. Again, according to Hirst what we need in curriculum planning is as specific and detailed a characterisation of objectives as possible, using as logically simple terms as are available. But these terms must reflect the proper character of the objectives and not distort them. (Hirst 1975 p. 290)
It is precisely this distortion of ‘objectives’ that follows from the crude eclecticism which is so often a feature of the holistic approach. Such hollow eclecticism leads to a failure to recognize that disciplines such as sociology and physiology are in many cases founded upon quite distinct conceptual claims implying different criteria for establishing truth and validity, and exist in some cases as mutually exclusive approaches to understanding (Rose et al. 1984). Again, for Hirst
social phenomena, the indeterminacy of the holistic approach gives little guidance as to the relative weighting or importance to be given to any particular mode of explanation. Establishing the relative importance of particular explanatory variables requires an understanding of their complex inter-relations. These inter-relations must be established in each case through critical analysis, a task that is rarely fulfilled when the alternative is an unchallenged eclecticism. The resolution of such debates and dilemmas requires a recognition of the inseparability of knowledge and power, and of the inevitably political nature of knowledge itself (Manley 1991). The indeterminacy of the holistic model is such that the educationalist and/or practitioner may be empowered to elevate explanatory frameworks to which they are ideologically sympathetic without being required to explicate these sympathies or confront the challenge set by competing explanatory frameworks. It may be suggested that in the light of the recency of ‘new nursing’ (Porter 1994), this may in fact let more ‘traditional’, ‘common-sense’ understandings in through the back door.
… one cannot, in pursuing the ability to solve scientific problems, assume one is thereby pursuing the ability to solve moral problems or historical problems as well. (Hirst 1975 p. 298)
The nature of the inter-relations between these diverse epistemological traditions has to be established through detailed, reflexive and self-conscious analysis with full recognition of the complexity of such a task. These inter-relations cannot be assumed as unproblematic or irrelevant a priori. On the contrary, one must set out with a full expectation of the profound difficulties and challenges immanent in such a project. In reality, nursing students are often the first to highlight the contradictions, superficialities and limitations of a simple eclecticism. An example may help to illustrate the limitations of simple eclecticism. Feminist and anti-racist analyses have for many years emphasized the frequent irreconcilability of accounts founded upon biology and those emphasizing processes of social construction (Miles 1993, Walby 1990). Moreover they have highlighted the politically conservative and even oppressive implications of the use of biological accounts of the nature and experience of women and black people in society. Arguments founded upon a biological analysis have a tendency to lead to a kind of biological determinism (Segal 1994). Social relations become natural relations and are consequently stamped with an inevitability that serves to legitimate the existing order of things. An eclectic holistic approach gives little or no serious attention to some of these most intractable epistemological difficulties and their political concomitants, due to the imperative placed upon merely ‘collecting’ explanations, the relations of which are rarely examined. Furthermore, in striving to achieve an understanding of
THE HOLISTIC MODEL, I NDETERM INACY AND THE EXERCISE OF POWER An interesting, and largely unexpected aspect of the holistic model, certainly in its most under-theorized and indeterminate form is that in practice it may be used in such a way as to exclude, rather than include, subjects such as sociology and those who teach it. How is it that a model that appears to imply an open invitation for such disciplines to participate fully in the construction of nursing knowledge, may in fact act as a mechanism of exclusion? The answer lies in understanding that the indeterminacy of the model creates an interpretive uncertainty that in turn requires the attention of appropriate ‘experts’ whose role it is to make definitive judgements regarding the relative importance of diverse explanatory variables and the value of a range of theoretical frameworks. Expertise derives from the acquisition of ‘relevant experience’, and this experience becomes the exclusive property of a few, unavailable to others through other means. This ‘experience’ here becomes a ‘condition for membership’, the sole means by which relevant understanding may be achieved and relevant judgements made. The holistic model facilitates an indeterminacy regarding the interpretation of reality that in turn creates the need for an ‘expert’ to make conclusive interpretive judgements. Such ‘experts’, by virtue of their direct nursing experiences, have access to forms of power unavailable to those lacking such ‘relevant’ experience. This raises important issues for the role of sociology within nursing. Being a nurse, becomes the ‘condition for membership’; the sole avenue through which legitimate and relevant experience may be accessed. Sociology may
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J. Mulholland exist within nursing, but its participation and contribution is circumscribed as a result of potentially exclusionary strategies operating at the crucial point when the relevance and appropriateness of particular forms of knowledge and experience, and of those who represent them, is being determined. There is a real danger that nurse ‘experts’ may come to define their experience as representative of all relevant experience. If others express alternative concerns, agendas and experiences, it becomes incumbent on those others to recognize their false consciousness or lack of relevant experience. In the micro-political world of the college of nursing, the formal appearance of a healthy and stimulating ontological and epistemological diversity, may obscure a reality altogether more homogenous and mundane, due to the hegemony of a nursing world-view less inclusive of sociological approaches than might at first appear. The value of sociology to nursing is dependant upon its ability to offer an ‘alternative’ interpretation of reality (Perry 1991). It is the capacity of sociology to take nurses temporarily ‘out of nursing’ that represents one of its strongest attributes. It is precisely this process that makes sociology an invaluable aid to nurses in the development of both self-awareness, and an awareness of others (Perry 1991). The dynamic and comparative qualities of sociology become impoverished when sociology becomes merely an instrumental extension of pre-existing nursing agendas. It is largely through this operation of power that sociology becomes potentially constrained, assimilated and essentially undermined within the nursing arena.
nursing arena more inviting to diverse academic disciplines such as sociology. As a symbol it possesses many positive associations and implications. Within the micropolitical world of the college of nursing (Gibbs 1991), various educational ‘interests’ organized around competing ontological and epistemological models, seek to secure ownership over the symbol of integration and by association become its representatives. In contrast, and by juxtaposition, those ‘interests’ unsuccessful in securing an effective association with the valued symbol of ‘integration’ are vulnerable to being labelled as ‘purists’, and accordingly discredited. This is, in the sense implied by Glen (1990), a fundamentally political process. It is essential that in discussing integration in nursing curricula we move beyond a rhetorical level of ‘integrationists’ and ‘purists’ and engage in a fuller and more frank discussion of our aims, needs and choices, and most importantly our competing notions of how an effective and meaningful integration of sociology may be achieved. Those labelled as ‘purists’ may differ from ‘integrationists’ only in their notions of how a meaningful sociology can be successfully incorporated into the nursing arena. The very indeterminacy of the concept of integration has a certain functionality in enabling the exercise of a specific form of power, namely, a power whereby those interests, who have been successful in legitimizing their exclusive definition of ‘integration’ as constituting integration per se, may be in a position to marginalize or exclude those interests with different, yet valid notions of how sociology may be best integrated within the nursing context.
‘Integrationists’ and ‘purists’
Anti-intellectualism
The holistic model suggests disciplinary integration, and in the educational context the integration of sociology into nursing curricula. But what does this integration mean? The indeterminacy of the holistic model may engender a climate in which the meaning of integration becomes assumed and taken for granted and as a consequence rarely spelt out. In the absence of a thorough debate over the integration of sociology into nursing, ‘integration’ may become a kind of panacea rarely in need of explication or clarification, yet at the same time operating as a powerful organizing principle within the nursing arena. It is imperative that nursing curricula models informed by a holistic approach are subjected to rigorous debate within the nursing arena such that criteria may be established by which the nature of sociology’s incorporation into nursing may be objectively and overtly assessed. A greater understanding of the competing models utilized with regards to the incorporation of sociology into nursing would undoubtedly result, with the consequent clarification of the underlying ontological and epistemological assumptions informing these models. ‘Integration’ has become a powerful symbol within a
There is a particular form of anti-intellectualism immanent in this indeterminate notion of integration, in the way in which it side-steps important theoretical debates. Integration becomes dependent upon those with certain exclusive forms of experience. Although experience is centrally important, it is doubtful that any form of experience removes the philosophical and curriculum challenges implicit in the integration of sociology into nursing. The way in which this ‘experience’ is invoked suggests a quality of experience that renders important dilemmas invisible, marginal and irrelevant. This is worrying as Hirst argues
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… we must firmly reject the anti-intellectualism of certain contemporary movements in education… this means that we must get away completely from the idea that linguistic and abstract forms of thought are not for some people. (Hirst 1975 p. 296)
One of the central roles of sociology is undoubtedly its ability to challenge ‘common-sense’, taken-for-granted assumptions (Giddens 1987). Indeterminacy in the understanding of what we mean
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The ‘sociology in nursing’ debate by integration creates the space in which such ‘commonsense’, taken-for-granted assumptions may continue to flourish and exercise an ongoing influence.
THE NEED FOR ‘RELATIVE AUTONOMY’ This paper has argued that the hollowness and indeterminacy of the holistic model has lead to a rather indeterminate notion of the manner in which sociology may be incorporated into nursing. Almost by default, a form of ‘melting pot’ model has been adopted, in which it has been assumed that as long as the ‘right’ disciplinary ingredients were thrown into the pot, then the finished product would taste good. The absence of a clear and consistent recipe however, may have enabled some of the chefs, through both direct and indirect means, to impose their own recipe on the basis of their own previous culinary experiences and to their own personal tastes. The ‘melting pot’ model, although appearing to offer an equal participative role for all, in practice, enables disguised and not so disguised mechanisms of assimilation whereby apparent harmony in the relations between various interests actually disguises the domination of one set of interests and the subordination, almost to the point of extinction, of another. In the nurse education context, the indeterminacy of the holistic ‘melting pot’ creates the space in which nursing may become surprisingly selfcontained again, whilst incorporating and potentially prostituting sociology on the basis of a narrow reading of nursing’s interests. In such a strategy, the foundations of nursing become impervious to a sociological gaze that potentially offers so much. Of course, the assimilation approach is informed by a host–immigrant’ model which perceives the relationship between nursing and sociology as being between those who belong as of right and those who belong entirely on the terms of others, and only as long as they behave themselves, by which we mean, become indistinguishable from the ‘host’. Being a nurse becomes again a condition for membership, a direct manifestation and consequence of their exclusive experiences, a kind of filter through which all potential nursing knowledge must first be passed. This paper suggests that there is a very real chance that such an approach may close off, rather than open up important debates.
A ‘multicultural’ alternative The alternative model suggested here for the incorporation of sociology into nursing is not a ‘melting pot’ model, but rather a ‘multi-cultural’ approach. This assumes an essential process of negotiation in which the various parties develop a clear and rounded understanding of each other, their respective strengths and weaknesses, and of the contributions they are able to make. It also assumes the need
for sociology to be meaningfully involved in the crucial process of ‘defining’ nursing knowledge, i.e. that knowledge which nursing students ought to have access to. It recognizes the need for an understanding of the ‘conditions of possibility’ of both nursing and sociology, in such a way that their integrity is kept intact. It assumes the need for a formally established ‘relative autonomy’ for sociology within nursing curricula, although the degree of relativity is certainly an issue for debate. This paper has argued that if sociology is to be really useful to nursing it does require a form of ontological, epistemological and methodological ‘relative autonomy’. In defining its own interests too narrowly, nursing may find that in the very act of restraining, constraining and expropriating sociology, the latter loses an important degree of detachment that is essential to its ongoing utility and value. A sociology that is merely an instrumental extension of nursing is an impoverished sociology, bereft of its dynamic value and its ability to enhance nursing knowledge by locating nursing within a broader social and political context.
CONCLUSI ON It is not being argued here that the holistic model ought to be discarded. Rather, that the naive and indeterminate nature so characteristic of much of its implementation must be transcended in favour of a more thorough and rigorous dialogue between nursing and sociology, with full account being taken of the complexities immanent in the latter’s incorporation into the nursing curricula. Sociology may only be meaningfully integrated within nursing as part of a broader ‘multi-cultural’ model that will allow of sociology the degree of ‘relative autonomy’ from ‘immediate’ nursing agendas that will permit its integrity to remain intact and its value to nursing fully realized. The more nursing attempts to assimilate sociology without reference to the integrity of the discipline itself, the more impoverished that sociology will become. Only with its integrity intact may sociology fulfil its potential of offering nursing an invaluable source of reflexivity.
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