The Social Organisation of Health Visitor Training

By Robert Dingwall

Robert Dingwall's classic and original study of the training of health visitors (public health nurses) in the UK is now available in a convenient ebook edition, featuring linked notes, all tables from the print edition, linked subject index, and active Contents. This book has not been easily available in print for many years but has long been regarded as an important contribution to the study of professional socialization. It was one of the first studies to incorporate ideas from ethnomethodology into an ethnographic approach to studying health visitors, proposing that education should be thought of as the production of competence rather than the internalization of knowledge. The training programme is examined as an organization, to which both faculty and students contribute. This programme is also embedded in a wider set of social relations as the students--predominantly women--negotiate the place of their studies within the other demands on their lives in the context of the 1970s. In the process, the book reveals the efforts and possible success of the professionalisation process of this subset of medical service providers; its qualitative empiricism is a model for research that opens up the health visitor position (much like the "physician assistant" or PA in the US who travels to patients and implements the medical practice of a larger network) to a broader conceptualisation of its location in the medical profession.

'The Social Organisation of Health Visitor Training' is rich in data from extensive interviews and participant observation that sympathetically convey the transformative experience of advanced education and the hopes of progressive professional practice in its time and place. Its republication will interest anyone concerned with research and policy on professional education, on the possibilities of public health interventions, on the visions of welfare at the eve of the neo-liberal takeover of public policy discourse, and on a similar but later process emerging in the US over the professionalisation of physician assistants and other traveling, hands-on medical providers.

• Language: English
• Publisher: Quid Pro, LLC
• Release date: Dec 26, 2013
• ISBN: 9781610272216

Robert Dingwall

Robert Dingwall is a consulting sociologist and part-time Professor at Nottingham Trent University. His first degree was in Social and Political Science from the University of Cambridge (1971) and he then completed a PhD in medical sociology at the University of Aberdeen (1974). He worked for the Centre for Socio-Legal Studies at the University of Oxford from 1978 until 1990, when he became Professor of Sociology at the University of Nottingham. He was the founding director of the Institute for Science and Society at that university in 1998, a post that he held until restructuring in 2010. He has written widely about issues in health care and health policy, professions, law and society, science and technology studies and research methods.

Book preview

PREFACE

To the 2014 Digital Edition

It is a dangerous proposition for an author to re-release his or her early work. One of my early mentors once remarked to me that he had more or less stopped writing because he realised that anything new was more likely to subtract from his reputation than to add to it. There is a real risk that a new edition of a book that has been out of print for thirty years will seem a simple vanity project. I think, though, that there are two justifications for publishing this new edition and making the work available again in an accessible format. The first is the decline of professional socialization as a topic for sociology and the second is the social history that is now to be found in the book.

When this project was first conceived, professional socialization was a core topic in medical sociology. Students were routinely invited to compare and contrast two great monographs, The Student Physician by Robert Merton and his colleagues (1957) and Boys in White by Howard Becker and his colleagues (1961). These accounts of how US medical students became doctors during the 1950s took on an iconic significance, not least because they also came to stand for fundamentally different approaches to sociology. While these differences became exaggerated with each successive re-telling, the debate between broadly functionalist, faculty-oriented accounts of enculturation and interactionist, student-oriented accounts of acculturation framed a generation’s work in the field. However, empirical work did move on. This particular project was strongly influenced by Olesen and Whittaker’s (1968) study of Californian student nurses in The Silent Dialogue, which drew on phenomenological thinking to explore the life-worlds of the students in a much broader way. Their research participants were not just students but young women seeking to navigate the new choices about career, family and lifestyle emerging in the 1960s.

Although my own study took a slightly different turn, it also responded to the same debates in the sociology of education that influenced Paul Atkinson’s (1981) work on the transmission of medical knowledge through clinical teaching. While Atkinson drew on Foucault and Bourdieu for inspiration — more obviously in some of the spin-off papers than in his book — my own mentors were turning towards ethnomethodology in a way that is reflected here. Indeed the title plays explicit homage to Cicourel’s (1968) The Social Organization of Juvenile Justice, although his earlier book on educational decision-making (Cicourel and Kitsuse 1963) was probably a more direct influence. Ethnomethodology has subsequently evolved in a very different direction but, at the time, it provided an inspiration to see the recognition of competence as crucial to the process that had come to be called socialization. Perhaps the real challenge was not to find out what was happening inside students’ heads but to understand how their actions came over time to constitute evidence of their readiness to be certified as professionals. How did faculty determine who could safely be let loose on the public?

This still seems an interesting way of looking at the problem of socialization — to see it as the acquisition of competence — although it has had relatively little traction since. In part, I suspect, this is because it is quite difficult to access some of the processes involved. Studying up, with a focus on faculty, is less straightforward than studying down, with a focus on students, since faculty are typically the gatekeepers to such projects. The study of socialization has become largely subsumed by the applied study of medical education, which reflects faculty problematics. Large-scale, long-term ethnography has also become more difficult with the pressures on graduate students to complete more rapidly and the increasing focus on shorter research grants that will deliver more immediate results from faculty. I suspect that this study would also be hard to get past modern ethical regulators. Readers can judge the ethical practice for themselves but no-one signed consent forms and large numbers of people passed through on the margins of the study, particular the families that I visited with the students, without necessarily being fully aware that the research was going on. I have described these marginal actors as the spear-carriers in the drama, whose contribution would rarely be more than incidental and did not justify the full rigour of human subjects review (Dingwall 1980).

With the passage of time, the book has also acquired some historical interest. The students were mostly women, and somewhat older than those studied by Olesen and Whittaker. Their envisaged role in public health nursing was very different from that envisaged in the hospital-oriented training that nurses received at the time. Many of them faced issues about the balance between careers and relationships, and conceptualizing what would constitute a fulfilling life for a woman in a context where these things were changing very rapidly. The male students received somewhat less focus because of my concerns with anonymizing the participants, but they also faced critical issues as men doing ‘women’s work’, especially when called upon to give advice on maternal and child health problems. The exploration of these issues is still a necessary corrective to studies that focus solely on students as students, forgetting that they are also people embedded in a wide range of other relationships and identities that co-exist or compete with those of primary interest to problem-oriented sponsors.

The book is also something of a testament to a particular place and time, on the eve of the oil price shocks and economic crises of the 1970s and the loss of faith in social democracy that they occasioned. There has never been much secret that the fieldwork was carried out in Aberdeen, before it was transformed into an oil services centre. It depicts the very end of a pioneering vision of integrated health and social care services, linking hospital, community and primary care with a range of social services that had been created since the late 1930s by a small network of charismatic figures, particular Sir Dugald Baird, Regius Professor of Midwifery 1937–1965; his wife, Lady May Baird, who was a city councillor from 1938, Chair of the council’s public health committee and Chair of the Regional Hospital Board 1947–1960; and Dr Ian McQueen, Medical Officer of Health 1952–1974. This experience is only partially documented — the most useful account is Diack and Smith (2002) — but resulted in a small, remote and comparatively poor city having some of the best mortality and morbidity figures in Europe. The health visitor training course described here was created to feed McQueen’s vision of a public health service that would extend surveillance and support to an entire population, searching for health and social need wherever it might be found and triaging this between appropriate referral services. The training for preventive work with older adults is particularly striking in this book, given the extent to which health visiting is now targeted so narrowly on families previously identified as at-risk: the authentic public health philosophy represented here did not rely on scorecards of uncertain specificity and sensitivity but on the systematic — and non-stigmatizing — review of populations defined purely by demographic criteria.

This account may also serve as a reminder that models of intervention currently fashionable in England have had to be rediscovered from elsewhere. There has been considerable interest among English politicians and health care providers in the visiting nurse programmes created in Denver (Olds et al. 2013) without realising the extent to which these were influenced by the Aberdeen experience: C. Henry Kempe, the Denver paediatrician who led much of the ‘rediscovery’ of child abuse in the 1960s and 1970s, had been a visitor in Aberdeen and wrote several papers promoting the concept of health visiting to his US colleagues (Kempe 1976). Some of them, it should be said, were profoundly shocked that the British state should presume to intervene so much in the lives of ‘respectable’ families and considered that this would be entirely unacceptable in the political culture of the US. There is undoubtedly a debate to be had about values and preferences in relation to social policy. What is offered here, however, is a rare picture of the high water mark of traditional public health intervention as reimagined for a modern society.

Robert Dingwall

Nottingham 2014

References

Atkinson, Paul. 1981. The Clinical Experience: The Construction and Reconstruction of Medical Reality. Farnborough: Gower.

Becker, Howard S, Blanche Geer, Everett C. Hughes, and Anselm Strauss. 1961. Boys in White: Student Culture in Medical School. Chicago: University of Chicago Press.

Cicourel, Aaron V. 1968. The Social Organization of Juvenile Justice. New York: John Wiley.

Cicourel, Aaron V., and John I. Kitsuse. 1963. The Educational Decision-Makers. Indianapolis: Bobbs-Merrill.

Diack, Lesley, and David F. Smith. 2002. Professional Strategies of Medical Officers of Health in the Post-War Period — 1: ‘Innovative Traditionalism’: The Case of Dr Ian MacQueen, MOH for Aberdeen 1952–1974, a ‘Bull-Dog’ with the ‘Hide of a Rhinoceros.’ Journal of Public Health 24 (2): 123-129.

Dingwall, Robert. 1980. Ethics and Ethnography. The Sociological Review 28 (4): 871-891.

Kempe, C. Henry. 1976. Approaches to Preventing Child Abuse: The Health Visitors Concept. American Journal of Diseases of Children 130 (9): 941-947.

Merton, Robert K., G. Reader, and Patricia L. Kendall, ed. 1957. The Student Physician: Introductory Studies in the Sociology of Medical Education. Oxford: Harvard University Press.

Olds, D., N. Donelan-McCall, R. O’Brien, H. MacMillan, S. Jack, T. Jenkins, W. P. Dunlap, et al. 2013. Improving the Nurse-Family Partnership in Community Practice. Pediatrics 132 (Supplement): S110-S117.

Olesen, Virginia L., and Elvi Waik Whittaker. 1968. The Silent Dialogue: A Study in the Social Psychology of Professional Socialization. San Francisco: Jossey-Bass.

Other outputs from the study

As with many dissertations, the monograph was forced to omit or abbreviate material that was otherwise publishable. The following chapters or journal articles arose directly from the same project, which also fed into a stream of work on agency decision-making in child protection, which is not listed here.

‘Collectivism, regionalism and feminism: health visiting and British social policy 1850–1975’, Journal of Social Policy, 1977, 6; 3: 291-315.

‘Atrocity stories and professional relationships’, Sociology of Work and Occupations, 1977, 4; 4: 371-96. Reprinted in Atkinson, P. and Delamont, S., eds., Narrative Methods, Sage, London, 2006.

(Jean Mcintosh and R. Dingwall) ‘Teamwork in theory and practice’. Pp. 118-134 in Dingwall, R. and Mcintosh, J., eds., Readings in the Sociology of Nursing , Churchill Livingstone, Edinburgh, 1979.

‘The place of men in nursing’. Pp. 199-209 in Colledge, M. and Jones, D., eds., Readings in Nursing, Churchill Livingstone, Edinburgh, 1979.

‘Problems of teamwork in primary care’. Pp. 111-137 in Lonsdale, S., Webb, A. and Briggs, T., eds., Teamwork in Personal Social Services and Health Care, Croom Helm, London and Syracuse University Press, Syracuse, NY, 1980. Reprinted in Clare, A.W. and Corney, R., Social Work and Primary Health Care, Academic Press, London, 1982.

‘In the beginning was the work... Reflections on the genesis of occupations’, Sociological Review, 1983, 31; 4: 605-24.

‘The certification of competence: assessment in occupational socialization’, Urban Life, 1986, 15; 3/4: 367-93.

INTRODUCTION

To the Original Edition

This book operates at two levels; at one, it is about training health visitors, at another, it forms a case study in the sociology of work and occupations, and the sociology of education. It draws upon contemporary theorising and the revival of interest in ethnography to re-examine a number of traditional sociological concerns like socialisation, social order, professions and education processes. It also develops American writing on topics such as record keeping which have been somewhat neglected in this country and extends them into new areas, as in my discussion of examination systems. Beyond these substantive areas, the work also has interest in its critical but sympathetic use of a large body of ethnomethodological writing which remains relatively unfamiliar in Britain, and, I suspect, many parts of the United States and other English-speaking countries.

The book begins with an overview of the general theoretical and methodological approach which I have adopted. I explain how I came to discard the notion of training as socialisation, whereby newcomers were inducted into the ways of a school and an occupation. I came to ask how newcomers acquired the skills to perform in ways which other people involved with them recognised as competent and, simultaneously, how the activities of other people involved with the training programme enabled them to produce, recognise and certify the competence of new recruits.

As a background to this particular instance of these processes, I set out a brief account of the current state of health visiting as an occupation, with particular reference to the localities in which this study was carried out. I suggest that certain features of the present situation to which health visitors have to pay attention, like staff shortages, poor salaries, low esteem and the nursing connection, are the products of historical processes in the development of a ‘welfare state’ and its relationship with its citizens. Parallelling this, I give descriptions of the biographies of the various people involved with the training programme, with particular attention to those of the students. I show how their status as adults creates certain kinds of problems for them in becoming students and discuss their negotiation of ‘student’ conduct with tutors. I then examine their relationships with people outside the formal setting of training and the way these intervene to shape their models of training. In particular, I demonstrate the significance of the notion of ‘getting through’ and its relationship to the wider social contexts in which the students found themselves, like their perception of the employment market for qualified health visitors and the interference of an excessive study commitment with other areas of their lives. I also suggest that we could recognise the origins of certain aspects of their concepts of the nature of organisations in the models of hospital nursing as an organisation which they had experienced. I argue, for example, that this is important for understanding the low level of evident conflict in the institution.

My discussion then turns to look in more detail at what might be involved in coming to be a competent health visitor and the ways in which training school staff, and others, passed this on to the students. I outline the kinds of ideas about the nature of man and society which were presented to the students from various quarters. In order to be recognised as competent, students have to be able to show that they are using these ideas in particular ways, to recognise which of their clients are normal and which are deviant, and to document this usage. Given the peculiar structural situation of health visiting, with the invisibility of its work to administrative review, the records kept by health visitors are particularly important sources of such documentation. Accordingly, considerable importance was attached to students’ acquisition of the skills of writing and reading records, particularly in being able to ‘fill in’ their elliptical contents. These social theories also inform the students’ relations with other occupations upon whom their work impinged. In particular, students are obliged to think of themselves as ‘professionals’ and to use this as a basis for organising encounters with both clients and fellow social and health workers. The idea of ‘profession’ allows health visitors to specify details of their own conduct and to interpret the conduct of others.

The whole programme is bound together by the activities I have called ‘the certification of competence’. The assessment procedures of the academic and fieldwork teachers formed the sanctions which underpinned the particular social order created on the training course and enforced particular ways of thinking and acting.

There are obvious problems in trying to direct particular readers to particular sections of the work. It is, after all, written as a continuous account and no one part can be clearly divorced from any other. Nevertheless, it is likely that those inclined towards the consideration of theory and method are likely to find most to interest them in Chapters One, Two and Three, those interested in professions and occupations will probably turn to Chapters Five and Six, those interested in work and organisations would look to Chapter Four and those interested in education would concentrate on Chapter Seven. Health administrators will probably find the material most relevant to their problems in Chapters Two, Four and Seven.

If there’s a hole in a’ your coats,

I rede you tent it

A chield’s among you taking notes,

And faith he’ll prent it.

Robert Burns

If, in one sense, this book is about certain aspects of health visitor training in Great Britain during the early 1970s, in another it is a contribution to a continuing debate among sociologists about the proper subject matter of their discipline, the methods which are appropriate to their research and the logical status of their data and conclusions. This chapter provides the necessary background to these twin themes. I offer a short summary of the principal tenets of the theoretical and methodological position which I have adopted and the theoretical and methodological position which I have adopted and the brief description of the nature of the health visitor’s work and offer an account of the origins and development of the occupation to its present form.

Abandoning ‘Socialisation’

Although this book deals with an area of social life which sociologists have traditionally studied under the rubric of ‘socialisation’, I am rather cautious about claiming that description for the present work. A detailed exposition of my doubts is furnished elsewhere (Dingwall 1974b) but a summary of that argument may be in order here. Broadly, I contended, with Olesen and Whittaker (1966, 1968, 1970), that ‘socialisation’, as a term, was inextricably bound up with ideas of enculturation. This model presents the process as one of a passive internalisation of an external normative order in abstraction from any broader social or historical context. ‘Socialisation’, with its connotation of ‘being rendered social’, has a clear affinity with such a perspective.

In this light, I was influenced, particularly by the work of Becker and his associates on Kansas medical students (cited in full in Bloom 1965) and Davis, Olesen and Whittaker on Californian graduate nurses (cited in full in Dingwall 1974b), to adopt a perspective on socialisation as acculturation, to see it as a process by which newcomers to a group worked to make sense of their surroundings and came to acquire the kinds of knowledge which would enable them to produce conduct which allowed established members of that group to recognise them as competent. Such a perspective views socialisation as an intrinsically more uncertain process and assigns students a more active role in constructing the prevailing social order.

This general position has been associated with a number of theoretical platforms in its time. Becker and his colleagues were primarily interactionists and Davis, Olesen and Whittaker seem to have been significantly influenced by existential phenomenology. All of these authors have claimed to be working under an interpretive paradigm.¹ The principal feature of the interpretive approach is that social interaction is to be understood as the construct of processes by which actors and observers make sense out of what is taking place and use this interpretation as grounds for ordering their own actions. The meaning of events is situated and cannot be settled by the literal application of some preexisting system of symbols or explanations. To understand social action, the sociologist must attempt to take the roles of actors and thereby impute intentions, purposes and background knowledge to them. These issues are developed more fully in Wilson’s (1970, in Douglas 1971) discussion of normative and interpretive paradigms.

Wilson also draws in a discussion of ethnomethodology and its relationship to interpretive sociology. Ethnomethodology is clearly the major theoretical development of recent years. This is not the place to summarise its various arguments or the controversies which it has aroused on both sides of the Atlantic. However, it is necessary to say a few words about it if we are to understand the context of the present work. Ethnomethodology is the study of the methods which are employed by members of any social group to produce order in their everyday social life. It may be usefully thought of as the study of the forms of social interaction. In this, as Wilson (1970; 707) shows, it complements the activities of interpretive sociology with its concern for content. Obviously, this is to some degree an artificial distinction, but it is an important one and a failure to appreciate it has caused much unfortunate misunderstanding in the past. Ethnomethodological work may be viewed as falling into two categories, which, following Douglas (1971; 32-4), we may call linguistic and situational. The linguistic ethnomethodologists, like Sacks and, in his recent work, Sudnow, have concentrated on the detailed analysis of conversations and an examination of the methods by which parties to those conversations can create and sustain their orderly character. They have looked at topics like greetings, turntaking, topic introduction and closings. The situational ethnomethodologists like Cicourel, Wieder and Zimmerman may, perhaps, be better thought of as a hybrid between some elements of the traditional concerns and approaches of interpretive sociology and the detailed work of the linguistic ethnomethodologists. They are concerned less with encounters as sources of talk than with them as situations. Their topic is less ‘how does the talking get done?’ than ‘what is going on here?’. If this book is to be thought of as a contribution to ethnomethodology, and it is not a claim I make, it is strictly in this latter respect, for myself, I merely claim to be an ethnographer who finds many of the reports of the ethnomethodologists creative and helpful ways of making sense of what I have observed.

This is not presented as a study of socialisation. It is, rather, about the social organisation of the acquisition of competent membership in some collectivity. These terms all require some explanation.

They are all drawn, in the first instance, from Garfinkel’s work. His account of ‘social organisation’ is self-explanatory:

. . .the term ‘an organisation’ is an abbreviation of the full term ‘an organisation of social actions’. The term ‘organisation’ does not itself designate a palpable phenomenon. It refers instead to a related set of ideas that a sociologist invokes to aid him in collecting his thoughts about the ways in which patterns of social actions are related. His statements about social organisation describe the territory within which the actions occur; the number of persons who occupy that territory, the characteristics of these persons, like age, sex, biographies, occupation, annual income and character structure. He tells how these persons are socially related to one another, for he talks of husbands and wives, of bridge parties, of cops and robbers. He describes then activities and the ways they achieve social access to one another. And like a grand theme either explicitly announced or implicitly assumed, he describes the rules that specify for the actor the use of the area, the number of persons who should be in it, the nature of the activity, purpose and feeling allowed, the approved and disapproved means of entrance and exit from affiliative relationships with the persons there. (Garfinkel 1956; 181-2)

The term ‘collectivity’ is taken, by Garfinkel, directly from Parsons (1951) as a general term describing all social groups, of any size. ‘Competent membership’ is more complex. Garfinkel (1967) conceives of social actors as collectivity members. By this he means that any collectivity is produced as an observable phenomenon by a series of practical judgements made by social actors, which draw on their ideas about that collectivity and the actions which are appropriate to it. It is contrasted with a depiction of actors as ‘cultural dopes’, producing the observable features of the collectivity by acting in accord with pre-established courses of action laid out by some external and reified culture. Competence means that the actor’s conduct is recognised both by himself and by those whom he recognises as established members of the collectivity in question as normal, natural and quite unworthy of comment.

The question of how membership competence is acquired has, however, been relatively neglected. We know very little which might help us to understand how people come to be regarded as competent health visitors rather than, say, competent greengrocers or competent pork butchers, other than in the trivial sense that they have a certificate attesting to their competence. We still need to ask how that certificate is actually acquired. Obviously it cannot be entirely divorced from the issue of what is meant by ‘competence’ in any given situation, but it still requires some attention. We cannot understand how people come to be health visitors unless we have some notion of what health visitors are, but the converse is equally true.

On Observation

Given these theoretical interests, it was apparent that the only relevant research method would be an ethnographic one which concentrated on the detailed observation of everyday social life in the school of health visiting and other organisations, through which students passed. Such approaches to the study of social action have a long and distinguished history, although they have been somewhat neglected in recent years and have certainly suffered from a lack of explicit methodological discussion. I cannot pursue this point here but some brief notes on the method may be helpful, before I proceed to an account of my own experiences.

Participant observation has been defined by Schwartz and Schwartz as:

A process in which the observer’s presence in a social situation is maintained for the purpose of scientific investigation. The observer is in a face-to-face relationship with the observed and, by participating with them in their natural life setting, he gathers data. (Schwartz and Schwartz 1955: 344).

The observer forms an integral part of the social context which he is studying, and, in the course of such participation, records details of the social processes within which he is immersed. These records are usually written, either at the time or shortly afterwards, although recent experiments have been made with tape or video recording. At some later stage these data are then consulted and ordered into some kind of account which examines from an explicit theoretical stance the material recorded in the fieldnotes. The present work is one example of such an account.

Observation is particularly suited to the study of the subjective aspects of social interaction, the meanings imputed by actors to their situation. As Vidich puts it:

Participant observation enables the research worker to secure his data within the mediums, symbols and experiential worlds which have meaning to his respondents. Its intent is to avoid imposing alien meanings upon the actions of the subjects. (Vidich 1955: 354)

It permits us to examine the processes involved in the interpretive work of members as they make the situation observable and reportable for one another.

On the methodological or research side the study of action would have to be made from the position of the actor. Since action is forged by the actor out of what he perceives, interprets and judges, one would have to see the operating situation as the actor sees it, perceive objects as the actor sees them, ascertain their meaning in terms of the meaning they have for the actor, and follow the actor’s line of conduct as the actor organises it — in short, one would have to take the role of the actor and see his world from his standpoint. (Blumer 1966: 542)

Such methods allow us to examine behaviour as it occurs rather than as it might be reported. It would, however, be wrong to imply that there are no problems. These methods do raise scientific, political and ethical issues. This is not, however, the place for the detailed reply to these criticisms, which the interested reader may find in my original thesis. (Dingwall 1974b).

The Everyday Life of a Participant Observer

A participant observer can only be himself to a controlled degree. He is more or less continuously on stage, monitoring the reactions of others to his own performances and seeking to manage