Journal of Advanced Nursing, 1997, 25, 1094–1100

The professional imagination:narrative and the symbolic boundariesbetween medicine and nursing

Carl May BScEcon PhD

Senior Research Fellow, Department of General Practice, University of Manchester,England

and Christine Fleming BA RGN RM

Research Associate, Health and Community Care Research Unit, School of HealthSciences, University of Liverpool, Liverpool, England

Accepted for publication 15 May 1996

MAY C. & FLEMING C. (1997) Journal of Advanced Nursing 25, 1094–1100The professional imagination: narrative and the symbolic boundaries betweenmedicine and nursingThe sociology of nursing, despite decisive interventions by recentcommentators, continues to take as its main focus the subordination of nursingto biomedicine. This view reflects analytic stability, as well as institutionalinertia. Far less attention has been paid by sociologists to the ways in whichnursing is constructing its difference from medicine, and the exercise of theprofessional imagination that this involves. This paper suggests a strategy bywhich this might be remedied, which would focus on professional narratives.

unfashionable to stress material inequalities as a basis forINTRODUCTION

social constructions (Mouzelis 1995), economic and cul-tural resources and the degrees of autonomy that stem fromThe sociology of nursing, despite decisive interventions

by recent commentators, continues to take as its main these are also crucial questions in any sociological accountof occupations. Davies (1995), for example, has empha-focus the subordination of nursing to biomedicine. This

view reflects analytic stability, as well as institutional iner- sised the extent to which both professional knowledge andorganisational rationality in health care systems are under-tia. Far less attention has been paid by sociologists to the

ways in which nursing is constructing its difference from pinned by attributions of gendered identity; a view alsoset out in detail by Witz (1992). Walby et al. (1994) showmedicine, and the exercise of the professional imagination

that this involves. This paper suggests a strategy by which how the shift from Fordist to Post-Fordist organisationalpractice in health care has both relied upon, and amplified,this might be remedied, which would focus on pro-

fessional narratives. The paper specifically focuses on the such inequalities.health professions in the United Kingdom, but also reflectson research conducted elsewhere, especially in the

MACRO AND MICRO-SOCIOLOGICALUnited States.

APPROACHES TO PROFESSIONALSociological accounts of nursing in relation to medicine

RELATIONShave to take as a first principle the extent to whichinequalities and contests between the professions are Recent years have seen rapid change and innovation in

the organisation of the British National Health Service, andfounded on deeply embedded and fundamental socialdifferentiation, especially by gender. While it is currently in the organisation of health care institutions in other

countries. These changes have had important, and some-times dramatic, implications for the health professions. InCorrespondence: Dr C May, Rusholme Health Centre, Walmer Street,

Manchester M14 5NP, England this context, sociological accounts of the professions and

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The professional imagination

of their knowledge bases and practices have needed numerous microsociological studies of inter- and intra-professional interactions and relationships may be set, asto become more responsive to fundamental changes in

the organisation and transformation of professional well as providing explanatory models through whichpolicy studies themselves may be conducted.distinctions and boundaries.

Of course, these two approaches are not quite as distinc-tive as might be supposed at first sight. Indeed, as Collins

Structure and meaning(1981) and Fine (1995) have observed, micro- and macro-sociological accounts are not just linked in terms of scale.For much of the period since the second world war, the

sociology of the health professions has taken as its focusAll microsociology has a macrosociology, contrary to the sharp,

stability and contiguity rather than dynamic change. Forfrequently political, division of sociology into rival camps. These

example, drawing on a Weberian framework, Freidsontwo sides, beyond meriting each other’s respect, depend upon

(1970a,b) explored the professional dominance enjoyed byeach other for their theoretical infrastructure. Macrosociologi-

medicine; while Marxist critics (Navarro 1978, Doyal 1981)cal presuppositions inherent in microsociology concern phy-

have examined medicine in the context of its politicalsical realities, social structure, institutional connections,

economy. The primary focus of sociological research onorganizational power, history and tradition

relations between medicine and nursing, however, has(Fine 1995 p. 161)

been on two analytic levels.In this context, the kinds of studies to which we havealready referred reflect an analytic stability. By this weSocio-legal structures Especially externally constructed

attributions of professional identity; the regulation of pro- mean that studies of the dimensions of what Stein, in aninfluential article, described as the Doctor-Nurse Gamefessional knowledge and practice; and the maintenance

and perpetuation of institutional boundaries. These con- (Stein 1967), have focused on inequalities in the organis-ation of professional power in practice. Thus, whether incentrate on the activities of the State in initiating and

defining policy changes in the spheres of health care organ- terms of their approach to (macro) socio-legal structure, or(micro) localised parameters, sociological accounts ofisation and professional education, (Freidson 1970a,

Dingwall et al. 1987, Davies 1995). inter-professional relations continue to focus on empiricaldemonstrations that nurses are subordinate to doctors, butwhich tell us little about the ways in which — at someLocalised interactions Especially in terms of contest

about the organisation and attribution of professional levels at least — nursing is more concerned to constructdifference than to compete on the same terms, for theroles; professional responses to changes in organisational

structures and rationalities; and localised contests same turf.This construction of difference has been givenbetween professional interest groups. These have concen-

trated on the constitution and negotiation of organisational insufficient priority in sociological accounts. Indeed, thesociology of nursing has largely been defined — until quitepractices within institutions, (Strauss et al. 1985, Walby

et al. 1995). recently, at least — in (subordinate) relation to the soci-ology of medicine. The growth of a considerable body ofIn these two contexts, sociological accounts have

focused on the impact of general management (Strong and feminist scholarship (Witz 1992, Davies 1995) has gonesome way to rectifying this.Robinson 1990), the gendered organisation and definition

of the professions (Witz 1992, Davies 1995, Porter 1995)and on the shift from bureaucratic to post-Fordist models

Analytic stability and institutional inertiain the organisation of health care practices (Walby et al.1994). As these shifts have taken place, the sociology This remains the case, even in a health care system — like

the National Health Service in the United Kingdom — thatof nursing has become more prominent in relation tomedicine. This has reflected not only the growing impor- is undergoing radical change (Holliday 1995). The policy

shifts that have initiated dynamic changes in organis-tance of feminist scholarship, but also the ways in whichpolicy shifts have themselves engendered boundary ational structures and objectives may have the effect of

further securing patterns of subordination and control,contests between the professions at a practical level withinorganisations, as well as at macro levels. both within and between medicine and nursing. Thus, the

interactional dilemmas and problems negotiated by nursesand doctors, and described in recent studies (Hughes 1988,

Current approachesPorter 1991) would be depressingly familiar to those pro-fessionals observed by Stein in the mid-1960s.Current approaches to the sociology of the health pro-

fessions stress policy and structure as the key determinants It is not our intention to review in any systematic waythe theoretical and research literature on professional clos-of change. Such macrosociological analyses are vital, in

that they provide a location or context in which the now ure and power in health care, (see Davies 1995, Turner

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C. May and C. Fleming

1995, for useful discussions). Instead, we want to direct deployed it as a device to distinguish their work from theirhospital based colleagues (Nettleton 1995).attention to another arena in which the doctor-nurse

game is being played out. There are alternative ways toexplore and conceptualise professional changes and to

Models and practiceunderstand their impact not just on macro-level struc-tures, but also at the level of the everyday and pragmatic The principal claim that the professions of general practice

and nursing now make for themselves is that they seek tonegotiation of professional boundaries and work. One ofthese is to examine the ways in which medicine and care for the ‘whole’ person. This claim is made across a

wide variety of rhetorical devices, (training materials andnursing conceptualise the patient — not through thestudy of the differences and distinctions that arise from textbooks, policy documents, professional codes and

Department of Health (England) documents). But, it ischanges in organisationally constituted role bound-aries — but rather through the strategic language which important to disentangle the different senses in which the

idea of holism is deployed by each: for two quite differentis used to ‘package’ professionals’ work. In other words,to look at the professional and professionalising dis- ways of identifying the patient underpin them.courses through which medicine and nursing do morethan just project their authority and organise the objects A biopsychosocial model of medical practice Here, indi-

vidual pathology lies at the centre of a concentric arrange-of their knowledge and practice.ment of ever more diffuse biological, psychological andsocial factors, each of which impinge in some way on the

PATIENT CENTRED PRACTICEobjective reality of the patient’s disorder. This model relieson disease being seen at the centre of a biosocial ecology.For some time now, scholars drawing on the work of

Michel Foucault (Armstrong 1983, Silverman 1987, Lawler The disease may only be effectively understood andtreated in this wider context (Engel 1981).1991, May 1992, Nettleton 1992, Atkinson 1995, Turner

1995), have emphasised that the grand narratives of thehealth professions — the ways in which they publicly rep- An holistic model of nursing care Here the boundaries

between objective pathology and subjective experience ofresent and mediate their work — have radically shifted inthe period since the second world war. Silverman (1987) illness are deliberately blurred, the ‘lived experience’ of

illness and health are the crucial components of a modelhas characterised this as a discourse of the ‘social’, shiftingaway from the scientific objectification of the body that that locate disease only as one part of a complex matrix.

In other words, it is the phenomenology of patienthoodfocused on disease as a ‘thing’ disconnected conceptuallyfrom the person suffering from illness. that requires attention (Porter 1995).

Grand narratives of professional differentiation andIn place of scientific reductionism there have beenattempts to restate the importance of the experience of moral purpose stem from the adoption of these kinds of

ideas: which in general practice are derived from the psy-illness, and to try to apprehend the patient not simply asthe object of clinical procedures and practices, but as a chotherapeutic approach to the doctor-patient interaction

promulgated in the 1950s by a small but influential grouppsychosocial self — disaggregated by biomedical knowl-edge and practices. In part this can be seen as a response led by the psychoanalyst Michael Balint (Balint 1957); and

in nursing by a proliferation of nursing theorists (Mayto emerging knowledge that psychological and social fac-tors have important effects on the trajectory of some dis- 1995a). At the same time, both professions have exploited

theoretical and empirical critiques from the human sci-eases and recovery from them.However, such a view has also served professional inter- ences, to show how patients demand to be treated as ‘indi-

viduals’ and as ‘whole’ people. Nursing has madeests. Since the 1950s biomedicine has become increasinglydominated by large scale hospital based practices that have phenomenological sociology and the qualitative research

methods that derive from this a mainstay of its concernemphasised high technology solutions to variant patho-logies. While hospital doctors may have become more with the ‘lived experience’ of health — as well as illness.

While medicine has traditionally relied on survey tech-focused on the possibilities presented by technologicalinterventions, nurses have shifted their attention towards niques which question patient satisfaction and associated

concepts, a similar approach to researching the ‘livedtheir ‘relationships’ with patients, while general prac-titioners have focused on their conversations with patients experience’ of health and health care is increasingly being

adopted by general practice (Murphy and Mattson 1992,as being intrinsically therapeutic. In this context, the shifttowards holism has been part of a programme of occu- Kinmouth 1995).

Our approach, so far, has suggested some parallelspational differentiation and closure. For nursing, this hasbeen a vital part of constructing professional knowledge between general medical practice and nursing. Both seek

to provide care for patients-as-people rather than definingin a way that secures its distinctiveness from biomedicine(May and Purkis 1995); while general practitioners have the patient narrowly in terms of pathology. Both therefore

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The professional imagination

represent their work in terms of holism, but the profession tice — for example Porter’s (1991) account of powerrelations between nurses and doctors — such a focus onof general practice can only differentiate itself so far from

the rest of medicine. Its central focus must remain pathol- the professional imagination seems hopelessly idealistic.Doctors and nurses may represent themselves as having aogy. Moreover, there is good evidence to question how far

‘holism’ actually informs the work general practitioners different core business, but they are subject to powerfulpressures to conform to organisational and institutionalactually do. The strategy of nursing, on the other hand,

has been to discursively close itself off from biomedicine, norms.One effect of these normative pressures is the construc-and it is to this that we wish to turn next.

tion of an artificial ‘theory/practice’ gap in nursing: inwhich codified ideas about what nursing ought to be, (for

DISCOURSES AND POWERexample, the nursing process); and what nursing actuallyinvolves are subject to a considerable disparity betweenAn analytic framework that focuses on discourse is, at first

sight, quite distant from the empirical studies that conven- aspiration and achievement (May 1990, Latimer 1995).Debate about the ‘theory/practice gap’ — which is by notionally have occupied the terrain of the sociology of the

doctor-nurse game. But discourses frame the material prac- means confined to nursing — reflects the analytic andinstitutional stabilities to which we have alreadytice of everyday work, giving it meaning and providing a

way of conceptualising professional relations, aspirations referred.and achievements. Moreover, such strategic language pro-vides a means of connecting professional identity, knowl-

PROFESSIONAL DISCOURSES AS STORY-edge and power. As Burr argues:

TELLINGWhat it is possible for one person to do to another, under what

So far, we have pointed to the apparent stability in doctor-rights and obligations, is given by the version of events currently

nurse relations revealed by empirical studies at both macrotaken as ‘knowledge’. Therefore the power to act in particular

and micro-levels, and have suggested that an alternativeways, to claim resources, to control or be controlled depends on

strategy for exploring change in those relations might be tothe ‘knowledges’ currently prevailing (…) Foucault therefore sees

examine the grand narratives, or discourses, which reflectpower not as some form of possession, which some people have

and project the professional imagination. Such an approachand others do not, but as an effect of discourse. To define the

would focus on the strategic language used by the pro-world in a way that allows you to do the things you want is to

fessions to characterise their moral purpose; rather than onexercise power (…) For Foucault, knowledge is a power over

the strategic practices that are employed to position themothers, the power to define others.

within contests about professional role and status (as have(Burr 1995 p. 64)

been described, amongst others, by Porter 1992).Although discourses do project power by defining the Sociological empiricism focuses on questions that are

fundamentally about what is. So, whether empirical stud-world in which nurses work and the objects of their prac-tice, they also reflect more than this. The definitions of the ies address the socio-legal context of professional relations

or their interactional effects, professional ideas about pos-world of professional knowledge and power that a dis-course of holistic care provides for nurses permit a set of sibilities — references to what ought to be — that are

revealed in the course of such studies can only be con-routine ideas about what, (as well as who), the patient is,what work needs to be done with her or him, and how strued as epiphenomena of concrete social relations. Our

argument in the rest of this paper is that such ideas, pro-this should be achieved. So they have a pragmatic purposeand utility within organisations. But, discourses or grand jected through grand professional narratives, are indepen-

dently worthy of interest. And not simply in thenarratives are also suggestive of the professional imagin-ation. Here, they reflect the creative impulse that must lie Foucauldian sense, as discourses that project power/

knowledge and construct the objects of professional prac-at the intellectual core of any occupational group. Whilemedicine is able to focus on scientific understanding and tice. Narratives are, as Maines (1993 p. 21) has observed,

‘inherently collective processes, they pertain exactly totechnical advances as the site on which its imaginativeimpetus is exercised, nurses represent themselves as being representations, and they frequently are political’.in a different business altogether. They care about — andget attached to the patient — while doctors stay detached

Narratives of holismand seek a cure. In other words, the professional imagin-ation provides a point of departure for the construction of The emergence of a way of codifying ideas about holistic

care in nursing during the 1970s and 1980s — drawing ona professional identity, its projection into interactions andrelationships, and the capacity to organise those relation- a proliferation of nursing ‘theories’ — is a useful represen-

tation of how narratives about practice work. Hagellships in a way that makes them meaningful.In relation to empirical descriptions of everyday prac- argues that

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C. May and C. Fleming

[N]ursing as a discipline, has a distinct knowledge base which isNarratives and professional identities

not grounded in empirico-analytical science and its methodology

but which stems from the lived experience of nurses as women A sociology of the health professions that engaged withnarratives — either institutional or personal — as reflec-and as nurses involved in caring relationships with their clients

(Hagell 1989 p. 226) tions not simply of practices that take place in ‘real time’(in a descriptive sense), but as projections of the pro-

Such perspectives are not confined to elevated academic fessional imagination, clearly resonates with a widerimpetus towards apprehending and understanding soci-accounts of nursing practice. They are readily encountered

in everyday pragmatic descriptions of nursing work. For ally constructed meanings. In nursing, this has taken theform of qualitative examinations which focus on accountsexample, this Scottish charge nurse describes in general

terms his encounters with a terminally ill patient of being a nurse, or a patient, and the subjective construc-tions of events, times and places — and of interactions andrelationships with other categories of actors. But suchI think that the patient who, colloquially speaking, turns their

face to the wall [that is they manifest a state of denial when told accounts focus, as we have already noted, on what is,rather than on what might be.their condition is terminal] is very difficult — because it doesn’t

give the opportunity to do something: and nursing as a profession One way of achieving this might be to draw on some ofthe lessons of feminist literary criticism. Narratives —has to be seen to do something. So that can be a problem, because

at the same time you know that you might be able to offer the whether collected through qualitative data gathering, or asrepresented by the official and other documents whichpatient some kind of help — although not a cure — to ease the

pain a little bit. But they are detaching themselves from the situ- mediate professional discourses — could thus be treatedas stories. This involves a shift away from seeing exemp-ation and they won’t let you become involved in that, and that

can be difficult too, because you can’t actually perceive how lars of professional discourse as ‘data’ in a conventionalsocial scientific sense: instead, they can be seen not asthey feel

(May 1995b p. 558). direct representations of the world, but as things thatmediate and shape it (Greene and Kahn 1985). This need

For this nurse, the state of patienthood, attribution of not involve either pretending that narratives are fictions,or collapsing into a post-modern relativism. Rather, itself-identity by the nurse, and his attribution of pro-

fessional identity are intimately linked. The discourse of means that we can recognise the way in which story tellingis a key means by which the taken-for-granted world onholism — with its focus on the ‘lived experience’ or

phenomenology of patienthood — is reflected across the which interest in ‘lived experience’ is predicated comesto be constructed (following Maines 1993). Manningrange of narratives, institutional and personal, that charac-

terise the professional imagination. & Cullum-Swan suggest that the focus of a narrativesociology might be upon stories:In empirical terms, such accounts could be treated in a

number of ways. They could be ‘tested’ in terms of theirThese stories are seen as real, yet with a tenuous grip on a consen-

practical application (either by nurses, or in the experiencesually defined social reality that can be validly and reliably repro-

of patients). Studies which have done so, suggest thatduced by social scientists. Emphasizing the role of these

nurses are inevitably found wanting (often by othernarratives in empowering persons through more subtle under-

nurses), and are subject to the frequently unreasonablestandings of their life situations stands the structuralist concerns

demands of ‘theory’. Alternatively, this kind of accountwith the power of codes, rules and social functions of texts on

could be treated as representative of the surface effects ofits head

a deeper set of shifts about the social organisation of the(Manning & Cullum-Swan 1994 p. 465)

power inherent in relationships between the health pro-For Manning and Cullum-Swan (1994), the distinctionfessions and their patients.

However, we want to suggest that a narrative sociology between narratives constructed and mediated insti-tutionally and those presented by individuals is a falsecan treat this kind of account, (and the numerous similar

accounts that characterise professional discourse about one. One might add that although narratives do reflectwhat is they also offer an opportunity to go beyond this,what nursing is at the present juncture), in a different way:

that is, as representative of shifts in the professional and explore aspirations and moral imperatives. They frameagency (and are constitutive of it), and so project the pos-imagination. These three views are not inconsistent with

each other: it is perfectly proper to note that it can be sibilities for change. Moreover, they are constitutive of selfand professional identity. The discursive construction ofempirically demonstrated that contemporary nursing

theory finds nursing practice wanting; that such theory the nurse-as-carer and of the patient-as-person are thusmore than abstract attributions of identity. They reify, orconveys a particular set of ideas about professional power;

and that it also conveys a set of idealisations of nursing make concrete, sets of connections and practices in theeveryday world, and provide powerful representations ofknowledge and practice that perform a narrative function.

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The professional imagination

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