Chapter IV Why Has So Little Changed?

The Reproduction of Nursing Knowledge: the sub-culture of back wards

Nursing students  located at the base of an authoritarian hierarchy, are taught to obey orders, not to question or show initiative. The student encapsulated in the micro-world of the ward, with fixed boundaries, membership and periods of time is socialised into taken-for-granted routines. Some colleagues are senior by years of experience rather than formal training or rank.  Attitudes towards patients exist along a continuum reflecting degrees of training: from optimistic patient-oriented staff, believing each individual has potential for rehabilitation and development, to pessimistic task-oriented staff believing their role is custodial care.

Back wards’ tasks, organisation and staffing differ from front wards; the proportion of untrained staff higher, length of service longer, doctors rarely seen.  Time-qualified staffs’ stock of knowledge carries more weight than novices’ own judgement, or training school theories. Their language and commonsense moral meanings construct the social reality of the student’s apprenticeship, mediating between organisational factors of authority, resources and staff responses. Staff upgrading themselves as normal, reinforce the downgrading of patients as abnormal.

Categorisations are based on three aspects of patient behaviour: incontinence, wandering and behaviour problems. These determine staffs’ concerns and activities.  Patients are ‘wetters’, ‘wanderers’, ‘uncooperative’, ‘have no brain’ or classified as ‘vegetables’ (cot and chair-bound), ‘animals’ (low-grade mobile) and at best ‘children’.  Lay beliefs, rooted in history continue in contemporary ward subculture. Animals, potentially more dangerous, and children share features of incompetence, irrationality, immorality. They are perceived as objects to be fed, cleaned, feared or controlled, but not as individuals with whom one converses or plays.   Interaction is minimal, without talk other than shouted orders, verbal abuse to demonstrate domination. Should order fail to be maintained, coercion, and  restraints are used legitimated by staff shortages.   Care,  control, treatment and discipline are conflated,   “Explicit teaching and implicit socialisation,… is accomplished through enactment of versions…. of the nature of patients which constitutes the ward’s work. What is reproduced are highly selective accounts of patients’ conditions, behaviour, prognosis filtered…by established staff and transmitted to the novice.”

This is particularly so in special and psychiatric hospitals where close surveillance of patients’ demeanor is routine. Given their affiliation to the POA, wearing their uniform reinforces staffs’ identity as custodians. It is surprising to learn that “special hospitals should have (no) penal function.”

Staffs’ “presumption of unawareness” –patients are insensitive, lack feelings, cannot discriminate or learn – leads to beliefs they won’t notice dirty clothes, missing buttons, sloppy food, being seen undressed and worse indignities. Consequences of these assumptions lead to conceptualising the nursing task as ‘body servicing’ and domestic chores, unskilled routine activities which don’t require training and can lower morale. Another consequence is frequent acceptance of very low hygiene standards.

Lack of time for more interaction with patients or better standards of cleanliness, is excused by staff shortages. That this is not so is demonstrated by observation of slack time. After completing essential tasks, staff converse with peers, drink tea, watch television, but never interact with patients. Even on acute medical wards, where technical nursing skills are used, nurses seem preoccupied with tasks, distancing themselves from interaction with patients. Some observers consider this a defence against anxiety. In back wards it is a defence against disgust.

In medical settings, despite 19th century origins for controlling deviants, one might expect current standards of hygiene to prevent infections and maintain patients’ physical fitness. The Sans Everything syndrome and worse is endemic in many back wards.   Conditions of 19th century poverty – chronic catarrh, discharging ears, crossed and sore eyes, skin and gastric infections, bad teeth and parasites are prevalent, and unsurprising given communal use of toothbrushes, towels, bath water   general uncleanliness and poor diet. What is surprising is tolerance by staff and occasional intruders’ (doctors, SNO, parent) At Normansfield, it required a strike by disgruntled staff to get attention. Breaking moral expectations to provide 24 hour cover   they were condemned by the Establishment.

“The quality of nursing service depends largely on the quality of the charge nurse or ward sister” who have an informal training role. This recognised wisdom seems haphazardly implemented. Little teaching activity was observed by Touell on geriatric wards.   The tradition of internal promotion, allied to slow turnover at senior nursing levels allows little opportunity for new ideas to penetrate.   Value conflicts arise between newer concepts, patient-centred objectives and training school’s methods and task-centred custodial realities on back wards. Rooted in traditions, these include exploitation of the system to staffs’ advantage, as the Rampton shift system.   For experienced staff “there is no conflict between…. reality and ….personal knowledge,…. apparent conflict is …between ‘reality’ and ‘theory’ or ‘fashion’..”   Some novices acquiesce to traditional practices, others comply feeling powerless to intervene, a few complain risking ostracism and victimisation.

Official reports mentioning these conflicts comment on lack of guidance and supervision by senior medical, nursing and administrative staff,   assuming high status guarantees knowledge and commitment to a therapeutic orientation, and immunity from victimisation should radical change be attempted. Reports also remark on lack of in-service training, professional isolation (not synonymous with geographical isolation) and long services by senior staff in the same institution. Teaching hospitals’ curricula rarely include psychiatry and geriatrics as compulsory for all medical students, sub-normality is virtually non-existent. It is not surprising that consultants and N.Os-.appointed are inappropriately qualified or Area and Regional M.O.s and N.O.s have little knowledge or interest. Members of management   with a capacity for non-action are content to defer to professional autonomy.

Somewhere along the line complaints get lost

Essential to claims of professional expertise is the occupational groups’ ability to control selection, recruitment, training and regulation of standards of competence and performance of practitioners. For nursing, this is accomplished by the GNC. Monitoring and supervision of performance may reveal mistakes making competence questionable. “Rituals emerge to normalise mistakes and routines which would otherwise become a professional emergency.”   Such rituals include recording drugs prescribed, use of seclusion, patients’ injuries. That these rituals serve to conceal malpractice rather than reinforce approved standards is demonstrated by official inquiries.

There is often a conspiracy of silence lest the GNC discover malpractice and withdraw approval from the training school. In 1980 out of 183 schools, 37 had provisional approval (euphemism for gross dissatisfaction).   Schools are inspected every two to five years, but the hospital knows well in advance, preparing accordingly.   GNC inspections seem to be another ritual to reduce visible deviance.

The dilemma is institutionalised as the service relies on student labour. Apprenticeship training emphasises worker not student role. Formal training affects students’ understanding of nursing roles, patients’ needs as individuals, thus patient care; apprenticeship leads to a reproduction of the status quo. Inquiries into a hospital’s deficiencies further reduces morale, discouraging potential recruits by creating the impression all wards are deviant,   leading to reliance on more immigrant labour.

An analysis of studies and official reports provides a range of putative causes of the exploitation of patients’ vulnerability. These include ineffective management, lack of resources, incompetent or sadistic staff, geographical isolation. One cause is both necessary and sufficient to allow malpractices to remain institutionalised and relatively invisible -the blockage of complaints by staff perceiving moral rules are violated. The treatment ideology they affirm is denied in everyday practice. Given conflicting values, such staff must either lower their standards, alter ongoing reality, complain to superiors or leave.

Relations among members of a role set are organised to delegate, spread or concentrate risk and guilt of mistakes on scapegoats.   Any complaints by juniors are investigated by seniors having considerable power to discredit and victimise. Should external inquiries be held, ranks close with unwillingness to admit anything. It is a mechanism operative “in every group (with) a sense of group reputation. To break silence is considered ….a sort of treason.” To keep silent results from fear of victimisation and misplaced loyalty. Institutions develop powerful instruments of defence for their perpetuation and protection, denial, discounting evidence, low profile,  – the Watergate syndrome.

Beardshaw’s study documents how hospitals seem unable to be self-regulating by allowing genuine internal criticism. For this, senior staff and management “would have to put patients’ inter­ests before their own loyalties…”   The series of official reports indicate the ritualised nature of external regulation when legalistic inquiries are used. A witness alleging abuse, without legal aid or advice, faces  libel action for repeating hearsay. It is exceedingly difficult to prove guilt and secure convictions.

“The procedures for pursuing complaints are now pretty good; the remaining problem, perhaps not soluble, is that of generating complaints…”   Procedures are better, but not good. Since 1974, as well as the GNC Disciplinary Committee, the Health Service Commissioner and CHCs are operative, HAS and DT still functioning. A diluted version of Davies’ recommendations was implemented 1-9-81, relating to patients’ complaints. There is “no information… . for staff….to make complaints on patients’ behalf.”   There is no evidence the present government takes malpractice seriously or intends to do anything constructive.

Given the obstacles to change at local levels when imposed from above, there is little evidence that government genuinely wanting change is capable of achieving it. There seems no understanding of the sociological factors involved.

Methodological Considerations in Investigating Back Wards

Limitations of legalistic retrospective inquiries to discern processes within hospitals has been indicated above. The most recent official investigation used semi-sociological methods. Nursing and medical members of the Rampton review team, lived in for nine weeks as participant observers. Unlike other inspecting bodies, they had keys allowing unannounced access to all parts of Rampton. They had  informal conversations with staff, patients, ex-patients and others, and access to all records. Additionally they consulted other organisations, MIND, BASW, PROPAR, and visited hospitals in Britain and Netherlands.

Various sociological studies in Britain and USA have used participant-observation.   Rosenham’s study is unique as the observers posed as patients, being treated as such. The nursing assistant’s diary recorded from memory whilst he was working as a genuine staff member, made available to Ryan also provides an insider’s account of typical malpractices from which a researcher might be excluded. Towell spent over three years as a lone researcher; Morris and Jones (K) had teams. The former interviewed registered nurses only, the latter, spending 3-5 months in each hospital interviewed registered sisters/charge nurses, staff nurses, enrolled and trainee nurses. Both studies aimed to observe gaps between the existential, normative and phenomenological ‘realities’ of ward life.

All data whether observational or from interviews is highly  selective. Arluke comments on the usefulness of having another observer cross-check recorded data, and observations taken from documents. Video-recording is undoubtedly the most complete method of permanently recording an ongoing situation, but is selective unless the camera can capture the entire scene. Video and tape-recording can be obtrusive. The case of unruly Colin observed for a day by the psychological assistant, demonstrates how behaviour can alter when watched.

Participant observation gives access to a range of data, including the ongoing social processes in everyday settings and the meanings the sub-culture has for members. Towell notes that development of enduring relationships between researcher and staff is necessary to expand background knowledge. When senior staff have confidence, they facilitate access to records, whilst juniors converse freely. Attendance at training school complemented ward observations. “The process of analysis and inference continually accompanies fieldwork….(from which) progressive expansion and modification of …theory emerges…. snapping) further… activity.. and…recording..” However objective the researcher tries to be, inevitably inferences from observations influence the selection of further data used as evidence. If the point of view of a specific subgroup is taken, it will be selective from this perspective.


The Rampton team noted 122 patients were waiting for transfer to other hospitals, some for over two years. “We think this is a scandal.”   Most people applying the term to moral infractions situated in chronic hospitals would imagine more violent events. The team considered the main function of Rampton is rehabilitations and normalisation not punishment and secure custody. “The basic problem common to the majority of patients is….they are undersocialised. … lack normal values, goals and restraints…. necessary to avoid conflict with others and ensure social acceptance.” The means advocated for developing social skills are “psychotherapy, chemotherapy, social training, remedial education, workshop training and recreation.”   Other than administering chemotherapy, the means listed seem more appropriate for teachers, social workers, behavioural therapists and other newer ‘professions’ than for doctors and nurses.

It was no accident of 20th century history which called custodial institutions hospitals, placing them under medical jurisdiction but a consolidation of medical imperialism. There are obvious contradictions in DHSS policy which allowing some improvements in chronic hospitals, simultaneously decarcerates some residents without allocating resources to community services. The Secretary of State’s powers are limited when responsibility to provide health services are delegated down a chain of authorities. Control over LASSDs, charged with providing welfare services is indirect; their resources undermined by DoE and Treasury power. Departmental representatives of social services are few and politically weak compared to the entrenched medical/nursing lobby. Research interests whether via the MRC or DHSS funding are or­iented towards the medical paradigm.

That isolating people in total institutions, conferring total power over their daily existence, creates problems for staff and ‘patients’ seems little understood. There is increasing role ambiguity for staff whose training lies within the medical tradition, yet whose tasks are seen as largely social/ educational by researchers and inquiries operating with a diff­erent paradigm of care. Resistance to policy changes threatening professional and union interests, necessitates appointment of new specialists whose power base is weak and whose ideology is antagonistic to medical control.

Psychiatrists give lip service to possibilities of moderate change including concepts of normalisation, using the hospital as the normalising environment. The impossibility of reconciling incompatibles leads to nonsense pronouncements, demonstrating little understanding of socialisation processes and inter­personal relationships. “An intensive training environment which whilst not normal in itself will nevertheless help normalise people.”   Other statements give a more accurate reflection of the underlying power struggle implicit in any radical change, “..the clinician must remain coordinator…. to ensure “training” principles do not take precedence over medical needs….no hospital…can be run non-medically. ”

Whilst political interests and economic costs preclude the abolition of chronic hospitals and their replacement by community based health and welfare services, a new trend can be discerned. The problem of custodial vs. community care for the mentally disordered and growing numbers of infirm elderly reflect the personal concern of the public, lacking adequate support services, to ‘push them in’ and government and professional concern to ‘push them out’ because medicine cannot cure and would allocate resources to more deserving causes.

In USA the ‘privatisation of profit’ by which ‘social junk’ is commodified allowing medical professionals and nursing home entrepreneurs to flourish   is further advanced than in Britain. Are we moving full circle towards the 18th century?