Sociology of Health and Illness: SOC 325 The hospital as an organisation

1
Sociology of Health and Illness SOC 325The
hospital as an organisation

• Built facilities social environment
  organisation.
• As experienced by
• patients
• families / friends of patients
• different groups of staff.
• Purpose?
• the provision of healthcare
• A E / out-patient clinics / surgery /
  in-patient care / intensive and terminal care
• generating income (e.g. PFI hospitals)
• advancing science / careers

2
Characteristics of an organisation

• A structure to carry out a particular purpose on
  a regular basis.
• Exists independently of individuals.
• Ensures continuity.
• An organisation generally has
• a specific goal
• a defined membership
• understood rules of behaviour
• relationships characterised by authority. 
• Variety of theoretical models how applicable to
  hospitals?

3
Bureaucracy

• Weber (1914)
• Ideal type
• Specialist expertise
• Hierarchy
• Impersonal rules
• Discipline
• Salaries
• Careers
• Bureaucratic nature of hospitals limits freedom,
  autonomy and initiative (Turner 1995)

• Gouldner (1954)
• Enforcement of rules varied according to
  relationships between interest groups.
• Mock bureaucracy rules enforced in presence
  of outsiders.
• Representative bureaucracy rules enforced
  through consent.
• Punishment-centred bureaucracy rules that one
  group tries to enforce on another.

4

• Kathryn Ehrich (2006) Telling cultures
  cultural issues for staff reporting concerns
  about colleagues in the UK NHS, Soc of Health
  Illness, 28(7)
• Policy concern with creating a no blame
  culture.
• Case study of the Three Enquiries.
• Mistakes, failures, crimes and misdemeanours
  technical and moral transgressions
• Shared fallibility and personal vulnerability
  -gt private hearings by peers.
• Informal rather than formal processes.
• Gender issues.
• Contributing to climate of anxiety in which
  secrecy flourishes.
• Public service versus loyalty to colleagues
• Effects of financial constraints on ability to
  serve the public.

5
Goffman - Total Institutions

• Asylums (1961)
• Mental hospitals, prisons, boarding schools,
  monasteries, merchant ships, military barracks.
• Large group. Place of residence and work.
• Disappearance of private life.
• Communal activities highly structured.
• Activities provided according to plan for the
  organisation.
• Divisions between staff inmates stereotypes.
• Mortification of the self loss of external
  roles.

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Response of inmates within a total institution

• Colonisation acceptance without enthusiasm
• Conversion acceptance with enthusiasm
• Withdrawal / intransigence
• Reorganised concept of self
• Institutionalization
• Similarities with Foucaults notion of the
  carceral organisation but different aspects of
  interest.
• If applied to a hospital, who is the inmate?

7
Career of a patient

• David Weir The moral career of the day patient
  (in Davis and Horobin 1977)
• Pre patient ? patient ? outside world
• Career (Goffman)
• regular sequence of changes (sense of self
  framework of imagery)
• turning points in career
• contingencies which move career in one direction
  of another.
• The wise e.g. parents informal carers.
• Variable meaning of time.
• Reduction in social value.

8
Surgical discourses

• Fox (1993) Discourse, organisation and the
  surgical ward round
• Organisational strategy.
• Conversation limited to physiology, wound
  condition and recovery/discharge.
• Deny patients access to alternative topics.
• Techniques of power.
• Organisational strategy.

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Subjectification of the patient

• May (1992) Nursing work, nurses knowledge, and
  the subjectification of the patient, Soc of H
  I, 14(4)
• Role of nurses in ensuring patient compliance and
  satisfaction.
• Knowing patients as individuals opportunities
  to formulate relationships patient at home.
• Social relations as a site of work.
• Good and bad patients (e.g. Jeffery 1979).
• Good and bad doctors.
• Involvement of nurses in the clinical gaze.

10
Doctor-nurse interactions

• Formerly understood in terms of doctor-nurse
  game (Stein 1967).
• Studies demonstrating situations where nurses
  offer advice more overtly e.g. Hughes 1988.
• Anticipation.
• Advice offered openly.
• Contradiction - junior rank of doctor, senior
  nurse, ethnicity of doctor.
• Effect of setting e.g. casualty department.

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Negotiated order (Svensson 1996)

• Interaction between doctors nurses on medical
  surgical wards.
• Negotiated order created through continuous
  negotiation.
• Occur in instances where rules and policy not
  definite e.g. discharge.
• Boundaries between medical and social.
• Changing conditions of work.
• Changing status of nurse profession e.g.
  defining patients medical status.