EDITORIAL
What should we believe and how should we think about health? A central problem for the profession of nursing
Thinking about the concept of health might seem to be something of a diverting but mostly irrelevant activity for those involved in the highly practice-focused profession of Nursing. As Alan Cribb writes:
Health professionals tend not to think much about 'health'. This is for a very good reason. They are normally too busy doing specific things with specific ends in sight, for example, reassuring someone, making them more comfortable, vaccinating them, excising a tumour, prescribing pain killers, or giving dietary advice . There is an important sense in which thinking about health in the midst of this is beside the point .(1).
My own position is rather different. I hold the view that unless we take questions about the concept of health, its nature and value, seriously at all levels of our involvement in health care, we will be running blind in the field of which Nursing forms such a significant part. The central question, What is health? requires careful deliberation and thoughtful answer if we are to move towards addressing a whole set of further questions on which, I argue, the effectiveness and the worth of our practice depends. These include questions such as, What is the nature of the relationship between individuals, society and levels of health (or disease)? What can be done to produce more health? And so on(2).
Of course, addressing this central question of What is health? is not easy. Debate in the area is primarily characterised by dispute. Competing accounts of the truth about health and health care- related concepts and practice abound. Discourses of health that promote it as an objectively describable concept and easily amenable to quantitative measurement attempt to face down constructionist conceptions rooted in qualitative understanding. More often than not, agreement appears impossible and reconciliation between different positions highly unlikely.
My argument here is that a major part of the reason for this dispute and disagreement lies in the professional training we will have undergone and the professional identities that we will have assumed. The question, What is health? and the others I began with demand that we think flexibly. Yet our professional persona makes it very hard to do just that.
Becoming a professional nurse involves two different, and reciprocal, learning processes. We learn what to do and we learn what to believe and value. Thinking about almost any example of professional Nursing activity will confirm this. Take a relatively straightforward action such as washing a patient. At one level, this simply involves the activity of washing someone. At another, though, there is a skill and expertise involved (for example, assessing and taking care of pressure areas, or observing for visible signs of infection). At yet another level, all of this is being done in a way that we could characterise as caring and entailing respect for the patient being cared for. It is difficult to conceive of this as an activity of professional Nursing unless all these components-the action, its implicit skill, the values underlying it- are present.
Crucially, the professional values we possess are what might be called intrinsic values(3). We can't reduce them to personal preferences, or to thoughts about their usefulness in helping us to get the job done. They are an embodiment of our occupation, representations of what it actually means to be a professional nurse. If we were to remove the value of caring (for example) from Nursing, we would be removing a part (probably a large part) of the very meaning of Nursing itself.
So the values we hold, and their nature, form an essential part of our professional Nursing identity. One of these values is the value of health itself. Although I agree with Alan Cribb that while we are engaging in the daily practices of reassuring someone or vaccinating them or whatever, we are hardly likely to be thinking about the nature of health; nevertheless our assumptions about it continually underpin our actions and practice. And as nurses we are likely to understand the value of health in a particular way. Our training (the process as I've described it of learning both what to do and what to believe or value) takes place in a world preoccupied with illness and disease, a world of hospital wards and casualty departments and intensive care units. We mostly learn what to do and what to value in these highly charged environments. This learning what to do largely involves caring for patients so that they recover from disease and illness. So the nature of the value of health becomes for us disease absence, a conception acquired and constantly reinforced through our long, often highly emotive and all-embracing experience of professional training and socialisation into professional values(4).
Is my account of how nurses see health and how they acquire such a conception correct? There are at least two objections to what I have said. First, a raft of changes in health care education policy and practice have required professionals to take much more holistic views of the nature of health; training curricula embrace conceptions of health that extend beyond disease absence to positive notions of well- being at individual, social and environmental levels. In this context, then, how can health be seen as no more than disease absence?
I agree that this is not an unfair representation of the policy and education context, at least to some extent. However, there is also a need to consider the notion of the hidden curriculum(5)- of formal policy requirements to change meeting resistance in the shape of heavily embedded, traditional conceptions of the nature of professional values. The idea of health as disease absence and its reproduction as a value in this form has an enduring history that policy alone may be finding hard to dispel.
The second objection to my assertion about the nature of the value of health for nurses is that it's no more than my own construction. In talking about our training as nurses taking place in a world of hospital wards and casualty departments and intensive care units preoccupied with illness and disease (and learning what and how to value from these contexts), I am only constructing my own version of the world.
At one level, I have to agree with this; I was that nurse (as it happens), experiencing those things and constructing them in that way. However, at another level, this experience and these perceptions are not unique. Some, at least, will have shared them or had very similar experiences(6). And if this is so, then why should my constructionist account of the nature of nurses' valuing of health be superseded by an objectivist account based on what policy says should have happened? We return to our initial debates on positivist versus interpretivist positions in the health arena. Once again, everything is contestable and up for grabs.
If the nature of the value of health for nursing professionals is, as I've asserted, disease absence, what implications does this have? The most obvious is that it might well become harder for those who are, or are in the process of becoming, professional nurses to grapple and come to terms with more flexible notions of health. How possible will it actually be to engage in critical analysis and reflection on the variety of academic and other accounts of health that exist? A number of these accounts(7) fundamentally challenge dominant conceptions of health and health care practice. Their careful construction demands our attention. But will we be able to give it, in the light of my analysis above?
In some senses, the analysis is a dispiriting one. The process of socialisation into professional values seems to condemn us to seeing the nature of health in a fixed and determined way. On the other hand, recognition and further exploration of the way in which our professional education and experience frames our understanding of health is the fundamental first step in re-evaluating our conceptions.
Peter Ducan
Department of Education and Professional Studies,
King's College London - Grã-Bretanha
Doctor of Philosophy (PhD)in Educational Studies
REFERENCES
- 1. Cribb A. Health and the good society. Oxford: Oxford University Press; 2005.
- 2. Duncan P. Critical perspectives on health. New York: Palgrave Macmillan; 2007.
- 3. Dworkin R. Life's dominion: an argument about abortion and euthanasia. London: Harper Collins; 1995.
- 4. Hoyle E. Professionalization and deprofessionalization in education. In: Hoyle E, Megarry J, editors. World yearbook of education. London: Kogan Page; 1980.
- 5. Cribb A, Bignold S. Towards the reflexive medical school: the hidden curriculum and medical education research. Stud Higher Educ. 1999;24(2):195-209.
- 6. Armstrong D. Political anatomy of the body. Cambridge: Cambridge University Press; 1983.
- 7. Seedhouse D. Health: foundations for achievement. 2nd ed. Chichester: Wiley; 2001.
Publication Dates
-
Publication in this collection
20 Feb 2008 -
Date of issue
Dec 2007
