With increasing emphasis on preventative healthcare and public health, would nurses benefit from understanding the sociological influences on health and wellbeing? Although sociological education is currently limited within nurse education, there is a long-held argument for its relevance. With a growing emphasis on preventative and public healthcare, sociology may yet prove its usefulness.
Engel’s attack on the state of medicine during the late 1970s was arguably the catalyst for the emergence of the modern approach to healthcare. Engel (1977) argued that the weakness of medicine lay in its strict adherence to the biomedical model, which considers the origins of illness to be the biological dysfunction of the body. According to Engel the model failed to consider the social, psychological and behavioural aspects of illness.
The biopsychosocial (BPS) model, which emerged as an alternative to the biomedical model, acknowledges the domains of the biological, psychological and social as contributing to the development of illness. It proposes that ill health arises from the interaction of causal factors at the biological, individual and social levels, rather than being reduced to the single variable of biology (Borrell-Carrio et al, 2004).
The BPS model has become the dominant frame of reference since Engel’s (1977) criticism of the biomedical model, and the importance of psychological and social factors has gained greater acceptance. However, biological understandings of health continue to dominate the BPS approach (McPherson, 2008).
The emphasis on other factors tends, at best, to be broad, raising criticisms that the model is both hollow and meaningless (Mulholland, 1997). In terms of the social aspects of ill health it provides only a watered-down understanding of the significant influence social and material factors play in determining and contributing to the development and distribution of health.
While it has been acknowledged, most recently and significantly by Marmot (2010), that serious consideration must be given to the social causes of ill health, the BPS model does not equip nurses with the social knowledge to accurately do so. Health inequalities often have their roots in society, with biological factors rarely operating separately from the social context (White, 2009). However, the level of social content within nurse education is too limited to illustrate the extent to which the origins of health and wellbeing are found within our social structures.
Rather than relying on the BPS model to provide a social understanding of health and wellbeing, the nursing profession must engage with the social sciences separately. This should enable them to develop a better understanding of how society operates and its influence on health. Although the culture of the nursing is still dominated by a biomedical perspective, its increased emphasis on preventative healthcare and public health illustrates a steady recognition of the social determinants of health: the global ecosystem; natural and built environments; the local economy and community; lifestyles and people. If preventative and public healthcare are to become more effective and to have a greater role, it is essential that health professionals have a detailed sociological understanding of health and wellbeing.
Sociology and nursing practice
The role of sociology within nursing practice has long been a matter of contention, particularly during the 1990s, when it was the subject of heated debate. While sympathetic to sociology, Cooke (1993) argued that with nursing attempting to establish itself as an academic subject, largely drawing on the biomedical model for its knowledge base, sociology had become marginalised as it was incompatible with the ethos of the discipline.
A more trenchant critic was Sharp (1994), whose criticism revolved around his understanding of what nursing was. Arguing that it is an action-orientated profession, Sharp said nursing need only be concerned with knowledge that informs how to perform tasks, rather than accumulating theoretical knowledge to explain why. He argued that sociological knowledge was of the latter type, and that an understanding of sociology would be unlikely to provide any advantage to nurses.
Nursing knowledge is based on the assumption that “truthful” and “factual” knowledge about the world exists and can be drawn on to produce definitive courses of action. Sociology, however, is characterised by competing perspectives, which according to Sharp (1994) means it cannot provide nurses with the basis for concrete action. In fact, sociology could potentially be harmful - if there is no way of differentiating between competing perspectives, what would inform nurse practice? Sharp concluded that although the academic nature of sociology would allow nurses to develop intellectual and critical thinking skills, it did not provide a source of knowledge to inform practical action.
Arguing in favour of sociology, Porter (1998; 1995) said there was a growing understanding within the profession that health was determined by many factors, including cultural and social, and that nurses therefore need to understand the social determinants of health. This would allow them to understand the subjective experiences of patients, as individuals from different social groups experience the world very differently (Porter, 1995).
Porter was also critical of Sharp’s idea that nurses only need to know how to perform tasks, suggesting they have to make decisions and judgements about the actions performed and therefore need a body of knowledge to draw on. Given its benefits, he believed sociology offered an invaluable knowledge-base. Porter also disagreed with the extent to which Sharp argued that sociology was riven by differing perspectives, although he accepted that the discipline was not as coherent as the natural sciences. However, he believed this did not mean they could not draw on sociology when making informed decisions about how to perform their role (Porter, 1995; Sharp, 1994).
Finally, Mulholland (1997), in a criticism I would support, argued that the holistic nature of the BPS approach, which was an attempt to develop an enhanced knowledge-base for professions such as nursing, had failed. Its eclecticism or “melting pot” approach, meant its knowledge-base was ultimately vague, and lacked clarity and direction. If the true benefits of sociology are to be realised, it must not only be a significant feature of nurse education but must also exist as a discipline in its own right (Mulholland, 1997).
Understanding your service users
All professions must have an understanding of their client base if they are to deliver the best service. Nurses must understand who their service users are and who they are likely to be caring for in order to provide the best caring experience possible. Sociology can provide this understanding, and so constitutes valuable theoretical knowledge; one of its key advantages is that it prepares nurses for the challenges they will encounter as professionals (McPherson, 2008).
A detailed awareness of the social distribution of health provides practitioners with a greater understanding of the diversity of patients they are likely to come into contact with, and the health issues broadly associated with individuals from different social backgrounds. The benefits of this become clear when attention is given to the locality where a nurse is employed.
Knowing your social landscape
All regions have social characteristics, being dominated by particular social groups and social issues. For example, a hospital in a deprived area can expect a higher proportion of service users from lower social classes, single mothers, and possibly ethnic minorities, while drug and alcohol misuse may be more prevalent than in more affluent areas, along with the effects of poverty such as poor diet and substandard housing. Nurses need to be aware of the social make-up of the locality within which they work, as this provides an understanding of the types of individuals they are more likely to be caring for and the problems they are more likely to encounter as professionals.
Sociological knowledge also allows nurses to enhance the quality of patient care. Understanding individual patients’ social context provides a significant insight into how they experience the world, in particular their experience of health and care. This allows nurses to reflect on their actions towards patients from different social backgrounds (McPherson, 2008), taking into consideration what is important to them and trying to see the world from their perspective. Sociology is essential for this, as individuals from different social backgrounds view the world differently and may require different caring skills and practices.
While it has a valuable role to play within acute contexts, within the community a detailed sociological understanding is vital for practice (McPherson, 2008). It is of particular relevance to preventative and public health.
Preventative and public health
This approach to healthcare attempts to control and manage the development and distribution of ill health before individuals become susceptible to it. Philosophically it firmly endorses the social determinants of health model. On the one hand, it promotes modest efforts to encourage individuals to change their lifestyles, while on the other, it directs more radical efforts towards changing broader political, economic and social structures so as to reduce such issues as poverty, unemployment and inequality (Richmond and Germov, 2012).
Within the present political and economic climate of reduced public sector expenditure, increasing demands on the health service, and escalating costs of medical treatment, the promotion of preventative healthcare and public health has become more of a priority. It has been seen as a cost-efficient use of resources (Naylor et al, 2013).
Evidence suggests that over the last century the most significant developments in the health status of the population have been due to social progress rather than medical advancements (Germov, 2012), so the advantages of preventative and public health efforts seem clear. Further, given the present political and economic context, the use of such measures seems inevitable. As a result, nurses working in community settings have a vital role to play as key promoters of public health.
In the community, patients and service users remain within the environment contributing to their ill health. Having prior detailed sociological knowledge will give nurses a greater understanding of individuals and the factors contributing to their ill health. Understanding the social circumstances from which ill health arises, and how social groups are affected in different ways, community nurses can develop a more detailed knowledge of the lifestyles of different social groups, and can subsequently offer advice on changes patients and service users can make within their own environment to improve their health. In this way sociology is vital for the future development of preventative healthcare.
Social change and a fairer society
Despite the dominance of the BPS model, nursing and nurse education remain one dimensional (Goodman, 2011), being dominated by the biological perspective on health. The current weak focus on society means it lacks any critical edge and is not equipped to question existing social arrangements and their health implications (Goodman, 2011). Sociology, however, provides nurses with this knowledge, allowing them to develop a critical understanding of individuals’ social circumstances and what threatens their health. This provides the opportunity to promote social change. This should be more than simply suggesting lifestyle changes, which focuses on individuals having to modify their own behaviour (and may be interpreted as blaming them for their poor health). Attention should be directed to the wider social, economic and political circumstances causing health inequalities in the first place.
Armed with an understanding of how society works and its impact on health, nurses can become a powerful force advocating for a fairer and more just society to eradicate the social factors that contribute to the development of poor health and its uneven distribution. Similarly, while sociological knowledge prepares nurses for the challenges they will encounter, they can impart such knowledge to patients, allowing them to confront their own challenges. Patients become empowered to challenge their situation, enhancing their own wellbeing, both in terms of individual lifestyle changes and, more radically, by challenging the system causing their experience of health inequality.
The biomedical model of healthcare fails to consider the social, psychological and behavioural aspects of illness
The bio-psychosocial model accepts that biological, psychological and social factors contribute to the development of illness
Increased emphasis on preventative healthcare and public health illustrates a steady recognition of the social determinants of health
Sociology must not only be a significant feature of nurse education, it must also exist as a discipline in its own right
Knowing how society works and its impact on health, nurses can become a powerful force for social change
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Adapted from Sociology in nursing 1: can sociology help to improve nursing practice?, (2015) Nursing Times, Author: Matthews, David.