Person, Group, an cl Organization Dimensions

of Nursing Care

by Ruth Pendfston Camp, R.N., M.S.N.

A reuiew of the literatwe on organization, interaction, and role relevant to the care and treatment of psychiatric fiatimts.*

A REVIEW of recent literature in the field of psychiatry clearly indicates

a trend toward a focus on sociological concerns: social structure, interaction, and role. The study of illness has be- come complicated beyond the mere di- agnosis and classification of a disease, and the quest for areas of intrapsychic conflict is now accompanied by a con- sideration of social factors relevant to ongoing behavior within the therapeu- tic setting. The reciprocal nature of interaction, now well recognized, has brought added interest to the patient’s activities outside the therapeutic hour. For many, the patient has become an actor in a situation, expressing his ill- ness through his behavior, which in turn is partly dependent upon the responses

of other patients and staff members to his behavior.

Individual case studies imply that there is much conflict between the ex- pression of needs and individuality on the part of both the patient and the staff member and the available chan- nels for such expression within the or- ganization framework. This premise suggests that there may be important factors of impingement inherent in or related to the organizational structure. It further suggests that changes ifi the philosophy of care and new statements of policy may not be sufficient for alter- ations in the activities which are carried out, unless attention is given as well to the organizational means essential to their fulfillment.

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Parsons’ has attempted to examine the mental hospital as a type of organization and to compare it with other types of or- ganizations such as business firms and universities. Using Barnard’s concept of organizational purpose for the defini- tion of type, he sees the purpose or goal of the mental hospital as being *‘to cope with the consequences for the individual patient and for the patients as a social group, of a condition of mental illness.”2

Mental illness is institutionally de- fined as an’undesirable state. The pa- thology is seen as a malfunctioning of the patient in social relationships, a conflict between the patient and the social system. The patient is conceived of as having no blame or responsibility for his illness, but implicit in this def- inition is the patient’s responsibility to accept help.

To define the goal of the hospital, four categories of social responsibility are outlined: custody, protection, social- ization, and therapy. These responsi- bilities pertain to the potential or actual behavior of the patient.

acterized by “taking care of.” This as- pect is present in the organizational responsibilities of other types of hospi- tals. It is the acknowledgment of the hospital’s responsibility for accepting the patient in his state of illness, which may require custodial care. The protec- tive element involves protection of the patient from harmful acts against him- self and from the aggressive acts of others. It includes attempts to promote social participation in the face of “resist- ance from the patient.”

Socialization is related to the neces- sity of getting the patient to internalize

The custodial responsibility is char- ’

the value system of the hospital. A nec- essary aspect of the acceptance of a patient role is acceptance that he is mentally ill. The fact that some psycho- pathological conditions manifest them- selves by denial of illness complicates this function. Therapy is a “complex of processes oriented toward the recovery of the patient.”s

At present, many hospitals are classi- fied according to degrees of emphasis on custodial or therapeutic care. Parsons believes that this treatment is not com- prehensive enough because socialization and protection are also important com- ponents and that the four-category classification has merit for comparative studies with other institutions. He sees prisons as being primarily custodial, and schools as having important resemblan- ces to mental hospitals, but differing primarily with respect to the socializa- tion responsibility.

The second section of Parsons’ paper deals with the relation of the mental hospital to the community. Here the value system which is used as the major point of reference for the analysis of the structure and function of the hospi- tal is seen as deriving from the values of society as a whole. “As an organiza- tion, the hospital’s value system, like that of other organizations is concerned primarily with the definitions of its goals and secondarily with the defini- tion of institutional patterns (norms or rules) within the pursuit of the goal.”‘ There are two contexts in which the value system operates: the external func- tion, which relates the organization to the rest of society, and the internal func- tion, which relates the various structural parts of the organization to each other.

Perspectives in Psychiatric Care Volume iV Number 4 1968 11

The four main factors in the external functioning are legitimation of the oper- ation of the hospital in the community, the processes involved with the recipi- ents of the hospital’s services, the proc- ess of acquiring facilities necessary for carrying out its function, and integra- tion into the larger Community. Parsons comments on the regressive elements of the patient’s role and likens his status to that of a child under the guidance of parental authority. Finances are of utmost importance in the acquisition of facilities. Financial resources in this case differ markedly from those of business, since psychiatric hospitals are rarely financed by service charges. The hospital is seen as an institution necessary for providing health services to the society. Thus it seems consistent with the values of society to have funds for its mainte- nance provided from outside sources. There is, however, often some interme- diary organization between the sources of outside funds and the staff of the hospital. In terms of integration into the larger community, the hospital is charged with the responsibility of pro- viding adequate care - professional care, which the society has a right to expect, but which only the profession can evaluate.

In the internal functioning of the hospital, the high status and authority of the physician override lines of au- thority of lay members in administration and at times appear to impede other disciplines from making decisions about themselves which would rightfully seem to be theirs. However, because of the physician’s power and authority he may be used as a scapegoat and blamed for the malfunctioning of the organization.

The traditional submissiveness to the physician by other personnel categories often helps to block adequate up-and- down flow of communication. Another interesting feature of the hospital is that positions in one category of personnel can never be filled by those of another. Hierarchal differences between and within classes of workers tend to form- alize channels of communication and to promote movement up and down within a given class with little cross reference.

One of the dilemmas in the internal structure is the conflict between the new employee and the old-timer. This con- flict is often present when the new- comer assumes that the policy in print is the one which is carried out. The incorporation of new employees and new patients is something which appears worthy of attention.

Goffman; in his work on “total” in- stitutions brings considerable insight in- to the elements involved in the initia- tion of patients to the hospital system and directs his attention in one section to organizational typology. He defines a total institution as one which puts up a barrier to social intercourse with the outside and to departure from the in- stitution. The mental hospital is the type of total institution whose purpose is to care for persons who are incapable of looking after themselves. Large num- bers of “inmates” are handled by a small supervisory staff within a bureaucratic framework. There is a marked degree of social distance between the inmates and the staff.

Inmates are excluded from knowl- edge of decisions which affect their fate, are alienated from their family, and in

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general are barred from a responsibility for self-determination or a choice of activity and personal goals. The inmate’s initiation includes stripping him of per- sonal belongings and denying him ex- pression of the prestige and authority which he had in the world outside. Goffman sees the dominant themes of the patient culture as personal failure, wasted time, and anxiety about conse- quences of release.

The institution is run for and by the staff. Rewards, if any, come to those who conform to the rules. The rules are tested and validated through experi- ence, since few are ever clearly or accurately stated.

Goffman’s rather harsh but clear treatment of life within the mental in- stitution makes it questionable whether a change in philosophy or even in written policy might accomplish any- thing. One almost has the feeling that the hospital as an organization is a monster, undefiable and unalterable, and is reminded of the grim picture many social scientists have painted a b u t the increasing growth and indestructa- bility of a bureaucracy.

John and Elaine Cummings, in “Social Equilibrium and Social Change in the Large State Hospital,”a describe the re- sults of careful study and planned change. The hospital selected was a typical large state hospital which had the formal structure of a bureaucracy. The Cummings found that the social structure was bureaucratic on paper only. In practice the organization was a traditional society ruled by cliques of the elite, whose power transcended their legitimate authority. Informal power was evidenced by remarks that so-and-so

really ran the place and the like. The informal organization recognized sen- iority as important for the power-holder. One of the striking findings was that both nursing and medical personnel were unaware of basic sociological con- cepts or ways of viewing their roles as relevant to the functioning of the total organization.

The traditional orientation frowned on change and enforced the idea that things were as good as they could be. Further resistance to change came from the lack of integration among the vari- ous departments. Lack of exchange of information between and even within departments led to further isolation and inhibited the opportunity for coordina- tion and autonomy of the total organ- ization. The Cummings hypothesized that any change in the system must be preceded . by provision for horizontal communication between departments and vertical communication within de- partments.

The Cummings were specifically in- terested in changing the chronic service of the hospital. They wanted to reorient the staff toward the concept of mental illness as one of remission and recur- rence similar to concepts of such medical diseases as arthritis. In remission, home was the best place to be. These ideas were antithetical to the traditional con- cepts held by the staff.

Two previous attempts at change had been made prior to the study. The first was a basic aide training course for new employees. The basic philosophy of the program was humane treatment. It em- phasized the importance of interper- sonal relations. After several years the program was considered only an aca-

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demic success. The carrier group was small, The program did not reach the previously employed aides. Attempts to supplement the teaching of the new concepts on the ward were abandoned in the face of resistance from the nurs- ing hierarchy.

The second attempted change came from two doctors who worked unceas- ingly on a chronic ward to demonstrate that deteriorated schizophrenic patients could show improvement if they were placed in an improved social environ- ment. As soon as the doctors left the hospital, the traditional patterns ap- peared again.

According to the Cummings’ opin- ion, in any planning to institute change three important principles should be kept in mind. (1) New programs are better introduced by norm-bearers than by deviants. (2) In a stable society, when all else is equal, the best criterion for promotion is seniority. ( 3 ) Very few roles in any society should be struc- tured so that they have to be filled by exceptional people.

Following the application of these principles and the gradual provision of new channels of communication within and between departments, a change oc- curred. Leaders in each type of work category came to accept new ideas and began to implement them in their own departments.

The change reported in the Cum- rnings’ study occurred within fifteen months. It would seem that one of the keys to their success was the concept that change can best be accomplished if those within the organization are convinced of its need and see that it is important to them in terms of new re-

sponsibilities and the improvement of their functioning within the organiza- tion. Pressures to change from outsiders may well increase adherence to the sta- tus quo. The temptations of consultants or researchers to experience a taste of victory is contrary to the basic principle of promoting change through the beliefs and actions of the norm-bearers. The charisma-like quality of the crusading consultant or researcher may well fade when his presence is not felt. The Cum- mings’ success seems to be related to their understanding and assessment of how the organization was functioning and their careful planning to the end that those within the organization could accept and implement the new ideas in their everyday work.

A very rewarding area of study might be follow-ups of so-called accomplished changes. How lasting is a change? How much of a lag should be expected be- tween changes in the intellectual or idealistic conceptions of the philosophy of care and the development of organ- izational structures which will allow this philosophy to be validated in the day- to-day experience of those (patients and personnel) who comprise the institu- tion? The work on bureaucracies and social systems and organizations would seem pertinent to insights in this area.

A number of studies which concern themselves with the social milieu of the therapeutic setting also have implications for the relation between the formal structure of the institution and the consequences for interpersonal relations as life is enacted in the ongoing activi- ties of the organization. Bruno Bettle- heim’ clearly indicates his recognition of the importance of the many subtle

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facets of interpersonal relations within the kind of therapeutic setting which demands an unconventional formal structure. He is much concerned with blame, responsibility, and authority, and views an organizational means of as- sessing conflicts of both personnel and patients as an essential factor in thera- peutic care.

In the study in which Caudill; an anthropologist, concealed himself as a participant-observer playing the role of the patient, much was learned about the process of learning to be a patient and considerable insight was gained about the world of the patients. The informal organization of patients was a potent force effecting their clinical progress, There was much evidence for questioning the merit of the hierarchal formal structure of the hospital and much for advocating the advisability of promoting more patient responsibility, particularly in such forms as patient government.

It is clear from the work which has been done that the organizational struc- ture of the therapeutic setting must be viewed as an important element in shaping the alternatives for action by both the st& and patients. It appears, as well, that the concepts of bureaucracy and organizational theory are most apropos for research in this area.

Aside from the questions concerning organizational structure, there are many questions concerning factors in the in- terpersonal aspects of activities within the setting. Goffman and Caudill have brought insight into the socialization process of becoming a patient. Others have been interested in the socialization process of becoming a nurse or doctor.

Beyond this is the question of examining the incidents that occur in the ongoing behavior of the institution.

For many years the primary focus was on the case study. Too often this was approached as if the patient were a pathological condition to be responded to in terms of medical prescription. With the recent trend toward viewing the patient as a person, sociological and psychological factors have come to com- plement each other.

In psychiatry, the classical concept of transference is still of import in the analysis of behavior. A broader concept has emerged which deals with the eval- uation of present experience. The view- ing of interaction in its ongoingness and its evaluation as an expression of shared symbolic activity are central to the work of Mead: Znaniecki,lO and Cooley.”

A definition is sought of the situation within the context of a given event in the present. Behavior becomes an ex- change of meanings between the people involved as they seek to communicate with each other. When the meaningful- ness of behavior in the here and now is emphasized, we move closer to the pa- tient, and it is hoped that he can move closer to us. Our behavior becomes ac- countable in terms of its participation in the events that occur when we are on the scene. Allied with this concept is the concept that reality is largely based on consensual validation. That which is real or true is that which we have had confirmed through evidence of agreement with others.

The sociological search for regular- ities and generalities leads us to a dif- ferent perspective from what might be called the particularization of psychol-

Perspectives in Psychiatric Care Volume IV Number 4 7966 15

ogy. There is beyond question room for both perspectives, and one can but hope that in time the contributions of each will merge into a general theory of behavior. However, it would seem that for too long psychiatry has looked at the particular and the unusual.

Duncan's book Conzrntmication and Social Order" is representative of a sym- bolic interactionist position. It presents the work of Kenneth Burke, in which the structure of the symbolic act is viewed as encompassing the scene, the agent, the act, the agency, and the purpose, Duncan also includes a com- mentary on and an analysis of the work of others in the area of the analysis of the act, particularly from the reference of action as a communication with a meaning for the actor and for the social system of which he is a part.

Duncan has a dramatistic point of view similar to that of Mead and also to that of Goffman in The Presentation of Self in Eueryday Life.13 This drama- tistic, or dialectic approach focuses on the here and now. It also has dynamic overtones which give interaction an emergent creative quality. It points to the possibility of change in interaction and personal role patterns. The actor becomes in part accountable for the roles he carries out and always has the alternative of attempting to deliber- ately carry out and validate new roles.

There has also been much interest in role studies. Role is the activity the in- cumbent would engage in solely in terms of normative demands of the po- sition or to the response of individuals in a particular situation. Role perform- ance is what occurs in the situation with role-others. The function of role is the

part it plays in the maintenance or de- struction of the system as a whole. The commitment of a person to a role de- mands engrossment in it, which results in self-identity with the role. This pro- duces behavior which tends to validate the role. The role becomes part of the self-image. Much of the work on role is particularized. Interestingly, however, most role studies seem aimed at the identification of areas of competence of a particular discipline; few answer the question of diiTerences of role in terms of variation in the social structure or philosophy of care. There appears to be much contradiction in role theory itself as Sarbin's" article suggests. The age- old dilemma of accounting for personal daerences versus the pressure to con- form still persists.

Levison'' defines role as related to a social position within society or within an organizational membership. Roles may be defined in terms of structural norms, individual role conceptions, or characteristics of the actor. He believes that these three levels of definition are interrelated. He further sees role-facili- ties (technological and sociological as- pects of the setting) as related to role enactment. Levison thus includes three major dimensions: the social setting, the intrapersonal, and the conceptual (role prototype of the actor and others).

Goffman, in E7tcowmrs,10 provoca- tively describes and illustrates factors relevant to focused interpersonal inter- action in which there is an agreement to sustain a single focus of immediate attention. Rules of irrelevance concern what action is to be excluded from the activity. Transformation rules allow cer- tain external attributes to be officially

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permitted. Euphoria (ease) is produced when the transformation rules and rules of irrelevance are easily accepted as valid. Recruitment of members who are ill at ease within the boundaries set by the rules is likely to cause disruption. These concepts seem applicable to the analysis of events occurring in the in- doctrination of new patients and new personnel to the hospital.

Goffman's discussion of role-distance as a protection from the engulfment by a role or from the intrusion of other roles in a role-conflict situation seems very useful. His examples of role-dis- tance, taken from a medical setting, help to illustrate the emergence of per- sonal roles as a mechanism for easing the tension in a professional role.

The sociological aspects of health care are challenging us to a new and better understanding of the human ele- ments in the process of caring for the ill and in the prevention of disease. Important advances will now be de- pendent upon tools for the analysis of the consequences of social structures and interaction patterns as well as new discoveries in the more objective fields of physiology and biochemistry.

REFERENCES

1 Parsons, Talcott, "The Mental Hospital as an Organization," in The Patient and the Mental Hospital, edited by Greenblatt, Levison and Williams, Glencoe, Ill.: The Free Press, 1957.

2 Ibid, p. 108.

:I lhid, p. 111.

lbid, p. 112.

,*, Goffman, Erving, Asylums, Garden City, N.Y.: Doubleday, 1961.

1 0 Cummings, John and Elaine, "Social Equilib- rium and Social Change in the Large Mental Hospital," in The Patient and the Mental Hos- pital, edited by Greenblatt, Levison and Wil- liams. Glencoe, Ill.: The Free Press, 1957.

7 Bettleheim, Bruno, Love is Not Enoggh, Glen- coe, Ill.: The Free Press, 1957.

Caudill, William, Frederick C. Redlich, Helen R. Gilmore and E. B. Brody, "Social Structure and Interaction Processes on a Psychiatric Ward," Am. I . Orthopsychiatry. x x l l ( 1952) 314-334.

Mead, George Herbert, major works /Mind, Self, and Society; Movements of Tholrght in the Nineteenth Century, and The Philosophy of the Act, published by the University of Chicago Press. Selections from these works are available in The Social Psychology of George Herbert Mead, edited by Anselm Strauss, Phoenix Books, Chicago, Ill.: The Uni- versity of Chicago Press, 1959.

l o Znaniecki, Thomas, wrote several books in- cluding The Social R o b of the Man of Know- ledge, New York: Columbia University Press, 1940; Social Actions, New York: Rinehart and Company, Inc., 1936; The Unadjusted Girl published by The Social Science Re- search Council. Selections of his works refer- ring to his "definition of the situation" and subjective meaning in social situations are to be found in collected works on sociological theory such as Coser and Rusenberg, Edt. Sociological Theory: A Book of Readings, New York: Macmillan Company, 1957.

I I Cooley, Charles Horton, Social Organization, Glencoe, Ill.: Free Press, 1956.

Duncan, Hugh Dalzail, Communication and Social Order, New York: The Bedminster Press, 1962.

Goffman, Erving, The Presentation of Self in Everyday Life, Garden City, N. Y.: Doubleday Anchor, 1959.

' 1 Sarbin, T. R., "Role Theory," in Handbook of Social Psychology, editor, Gardner Lindzey, Cambridge, Mass: Addison-Wesley, 1954.

Levison, D. J., "Role, Personality, and Social Structure," 1. Abnorm. and Soc. Psychology, V O ~ . 58, (19591, 170-180.

1 ' ; Goffman, Erving, Encounters, Indianapolis, Ill.: Bobbs-Merrill, 1961.

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