Nursing Inqui?y 1996; 3: 30-35

Nurses, doctors and the body of the patient: medical dominance revisited

Claire Brown and Jennifer Seddon Centre for Nursing and Health Care Practices, Southern Cross University, Lisrnore, New South Wales, Australia

Accepted for publication 23 June 1995

BROWN C. AND SEDDON J. Nursinglnquiry 1996; 3: 30-35 Nurses, doctors and the body of the patient: medical dominance revisited Medical dominance is one of the most obvious features of the health care system and is particularly apparent in the relationship between doctors and nurses. Reasons given for the subordination of nurses to doctors have included matters of gender, class and state patronage of medicine. This paper, through an examination of university curricula and journal content, explores the notion that control over the model of the body is a major way in which medicine preserves its dominance over nursing. One reason for medicine maintaining its superior position is that nursing is not challenging this model of the body.

Key words: body, medical dominance, nurse education, research.

lNTRODUCTlON

Health care work is focused on the body of the patient. Depending upon the occupation, health care workers may touch, analyse, wash or in other ways interact with the body of the patient. Although the body is central to health care work, in many ways its very centrality has given it a silent role in health care simiIar to its unacknowledged status in sociology.’ The centrality of the body to health care prac- tice masks the processes through which it has become cen- tral* and the power that it gives to the medical profession. In order to understand the relationships between the occu- pations in health care, it is essential to understand the role of the body of the patient in defining health care work. The intent of this paper is to explore the place of the body in the medical and nursing literature and in university curric- ula in order to further understanding of the nature of nurs- ing’s subordination to medicine.

DEVELOPMENT Of THE BlOMECHANlCAl BODY IN HEALTH CARE

The history of the development of the biomechanical

Correspondence: Claire Brown, Centre for Nursing and Health Care Practices, Southern Cross University, PO Box 157, Lismore, New South Wales 2480, Australia.

model of the body is closely linked to the changing balance of power between the church and medicine. During the period when the church was dominant, the body was largely seen as its domain. This link was not broken until after Descartes’ declarations in the seventeenth century that the jurisdiction of the church extended only as far as the soul,3 and that it was possible to draw an analogy between the human body and a machine.4 Anatomy and physiology developed as disciplines focused on the biome- chanical body, a tradition carried forward in current textbooks.

Just as the structures, shapes, and organization of the parts of a machine - such as an automobile - are appropriate to their functions, so the structures, shapes, and organiza- tion of the parts of the body are intimately associated with their functions (p. 6).5

The analogy between the body and a machine allowed for an objectification of the body that became an essential part of medical education and practice.6

Medicine’s prestige was increased in the nineteenth century by the development of germ theory, and in this century by the popular assumption that medicine was responsible for the reduction in deaths from infectious dis- eases.’ However, the role of medical advances in this regard has been overstated as most of the decline in death rates from infectious diseases occurred before those interven- tions controlled by medicine became available.* The inter-

Medical dominance revisited

ventions that had the most positive effect in reducing the death rates from infectious diseases were those such as improved sanitation which were based on the public health movement’s social model of the body, not those based on medicine’s biomechanical b ~ d y . ~ , ~ * ~ J ~ Public health strate- gies were implemented based on the belief that illness was the result of miasmata, or bad air.7 ‘The body was visualized in terms of a central metaphor, one in which the organism was seen as a dynamic system constantly interacting with its environment’ (p. 117).11 This view, favoured by Nightin- gale,IO was a social model of the body, that is, the social interactions of bodies with their environments were thought to cause disease.

With the apparent transformation of medicine from an art to a sciencelz the nature of hospitals changed; they became places in which doctors could use patients’ bodies for teaching and research.eJsJ4 Simultaneously, within the hospitals, modern nursing discourse was developing under the influence of the reforms of Nightingale, and nursing maintained that control of the social body was the prime requirement for health.14 In the nineteenth century, nurs- ing discourse recognized disease as a general state of dis- equilibrium (p. 117).11 The nurse became ‘constantly engaged in maintaining that harmony of bodies which alone produces recovery’ (p. 87) .I4

Nursing developed its care of the patient upon a social model of the body, maintaining that, to deal with illness, the environment of the patient must be treated, not just the physical body. Nightingale accepted the miasmata theory of the public health movement and based her prin- ciples of nursing on this belief. Nursing thus developed its basic practice upon a social model of the body, not a bio- mechanical model. However, owing to the spectacular advances in medicine and its apparent contribution to the improvements in health in the late nineteenth century, the ‘biomechanical’ model of the body became accepted above the ‘social’ model. Medicine’s importance, prestige and power as the provider of a cure for disease became estab- lished as the key component of health care.

The biomechanical construction of the body also became the hegemonic model of the body.3 The model of the body used determines the model of illness that is accepted, and this in turn determines what are seen as appropriate health care interventions. Through the bio- mechanical model, medicine has largely maintained its power both in the wider society, and particularlywithin the health care system. It is through this model of the body that medicine maintains its relationship with the state,gJ5 and it is on this model that relationships between nurses and doc- tors are based.

THE NURSE-DOCTOR RELATlONSHlP

One of the major defining features of the biomedical model of health care is the position of doctors at the pin- nacle of its organizational hierarchy. Medical dominance is illustrated in the nurse/doctor relationship. The position of nurses as subordinates of doctors has been explained by describing nursing as an occupation in which most of the workers are female;”j-I* by the traditionally lower educa- tional and socioeconomic status of women entering nurs- ing;lg and by medicine’s patronage by the state.zOO.21 Nursing subordination is set within a framework of the biomedical model of health care within which doctors are presumed to have the knowledge to cure whereas nurses take the sup porting position of caring.14 This subordination revolves around the right of doctors to diagnose and thus to define who is a ‘patient’.2*

Doctors base their claim to authority over nurses on their greater knowledge of the processes of disease within the body. In a submission to the study of Professional Issues in Nursing (1988), it was stated that the doctor must have authority within the health care system and that this authority ‘derives from the particular understanding of management based upon a detailed study of the pathology of disease’ (p. 7).*3 Doctors claim to possess that knowl- edge of the body. The basis of this claim is that the biomechanical model of the body is accurate and that only doctors fully understand the workings of the body. The medical view stresses:

... the value of the primary and traditional nursing role, which is deliverance of patient care at the bedside under the guidance of a doctor. That is the nurse’s traditional role and the role they do best.24

Doctors possess knowledge of the body and nurses carry out the support role of caring for the patient under the instructions of the doctor. Society values the knowledge of the processes of the body far more than the ability to care for the diseased body; hence not only is medicine given more authority, it is also far more highly valued than is nursing. Doctors base their dominance within the health care system on their superior knowledge of the doctrine of specific aetiology. They claim the right to be seen as authorities as they understand the disease process better than anyone else. As the biomedical model of health care (based on the doctrine of specific aetiology) is so widely accepted, the dominance of the medical profession is acknowledged within society as justified.

Although the claim that knowledge of the biomechan- ical body led to the most effective health care was dubious,’O

C. Brown andJ Seddon

it meant that the social model espoused by Nightingale and the public health reformers was rejected. Germ theory more effectively explained the spread of disease than mias- mata and consequently the social body fell into disrepute. Nursing’s focus then shifted to a dualistic approach to the work of nursing, wherein the biomechanical body of medi- cine forms the ‘foreground’ of nursing knowledge, but is complemented with ‘background’ knowledge of the patient as a person.25 The latter is the work which is devalued as unscientific as it is not directly related to the biomechanical model of the body. Nursing work is centred upon the body,’ but nurses are concerned with the patient as a person as well as a biomechanical body. This has come to be known as an ‘holistic’ approach to the care of the individual.

Holism includes ‘the physical, psychological, social and spiritual aspects of personhood’ (p. 229)*6 and to a large extent underlies much current nursing theory.27 Holism incorporates knowledge of the biomechanical body, the physical, and the knowledge of the patient as a person. However, holistic care in the true sense of the word incor- porates not just the physical, emotional and spiritual aspects of a person as is commonly accepted, but also the person’s environment.28 This truly holistic care to a large extent replicates the care based on the nineteenth century social model of the body.

Medical dominance of health care is extended to dom- inance of the patient’s body, to how the doctor views the patient’s body and to what the doctor is permitted to do to the body. The patient is the body in the medical discourse and as such is represented solely by the biomechanical, objective, apolitical body. The individual, by becoming a patient, gives the doctor a licence to touch and prod, to break the surface and to cut away parts of the body.%

The body is, of course, central to nursing practice. Nursing is an occupation ‘in which care of the most inti- mate nature is given and received’, and which is deter- mined by the relationship of the nurse to the patient through the body (p. 59).1 Intimate care of the body often creates problems for the nurse as patients can feel threat- ened or embarrassed by nurses being involved in this way. However, the total invasion of the body by the doctor is not seen as so problematic.30 The doctor has greater licence with the patient’s body than the nurse and performs far more invasive procedures, yet this is rarely questioned. There is a greater power differential between a doctor and a patient than between a nurse and patient and this differ- ential is one of knowledge: knowledge - of the body and the power to construct the body in a specific way.

METHOD

The hypothesis for a partial explanation of medical domi- nance was that nursing has rejected the biomechanical model of the body of the patient whereas medicine func- tions with the biomechanical body as its focus. It was thought that this difference would be discernible in the curricula of the relevant university courses and journals.

Tertiary education is seen to be linked to the quest for nursing’s recognition as a profession as it is a step toward defining ‘an independent source of knowledge’ (p. 279) ,*” As such it was thought that in the nursing curricula, the knowledge of health which is distinctly related to nursing, particularly that based on the holistic model of the body, would be evident.

Four medical curricula and 14 nursing curricula were analysed from a random sample of University handbooks. This is approximately 30 per cent of nursing courses and 44 per cent of medical courses on offer throughout Australia. In examining the course outlines the amount of time ded- icated to subjects treating the body as a machine (such as anatomy, physiology, pathology) and the amount of time dedicated to other subjects (including social and behav- ioural studies, and communication) were compared by one of the researchers to ensure consistency. The theory behind this division was that the subjects treating the body as a machine support the biomechanical model of the body, whereas such subjects as the social sciences are more supportive of an holistic approach to the body.

Two journals for 1992 were also examined: the Aus- tralian Journal of Advanced Nursing (AJAN) and the Medicul Journal of Australia (MJA). There are other nursing and medical journals published in Australia but these two are comparable as each is the refereed publication of the organisation which represents the professional interests of its occupational group.31 (Only the leading and original articles in the Mediull Journal of Austrulia were examined as they constitute the refereed component.) The articles were classified into three categories according to the expecta- tions of the researchers. As with the curricula, the catego- rization was carried out by only one of the researchers. The types of articles classified as ‘holistic’ were those which dealt with the social factors affecting health, either solely or in combination with the physical aspects of health.

There is a marked difference in output of the two jour- nals. AJAN appears four times a year and publishes approx- imately 23 papers; the MJA has 23 editions each year and publishes approximately 240 papers. This difference most probably reflects the established research base of medicine

Medical dominance revisited

and the difficulties nurses have in publicizing their achieve- ments in practice. As noted in the United Kingdom:

It appeared that even where nurses had become nationally known within nursing for taking their work forward in cre- ative and imaginative ways, the local general managers and doctors could remain profoundly ignorant of such inn- vations (p. 5).32

Due to the difference in volume two different approaches were taken to compare journal content. First, all the 1992 articles from both journals were compared; sec- ondly, all 12 issues of AJAN for the period 1991-1993 and 12 issues of MJA for the same period (the first issues for Janu- ary, April, July and October), were examined.

RESULTS Courses

As can be seen in Table 1 and Figures 1 and 2, both groups of students spend similar proportions of their courses on clinical subjects, communication and social and behav-

Table 1 Analysis of course content

Course Body Clinical Commun- Social/ Other ication behavioural

sciences

Nursing A Nursing B Nursing C

Nursing D Nursing E Nursing F Nursing G Nursing H

Nursing I Nursing J

Nursing K Nursing L Nursing M Nursing N

AVERAGE

16% 22% 15% 27%

25% 13% 17% 13%

17% 31% 6% 17%

21% 42% 4% 17% 17% 41% - 17%

33% 29% - 6%

15% 40% 4% 7% 38% 13% - 21 % 27% 25% 5% 14%

25% 25% 4% 4%

14% 36% 3% 11%

17% 23% 7% 10% 21% 30% 3% 17% 13% 31% 6% 10% 21% 29% 5% 14%

20%

33% 30% 17%

26% 32% 34% 29%

29% 42% 36%

43% 29% 40%

31%

MedicineA 48% 33% 5% 6% 7% Medicine B 45% 31% 3% 12% 9%

Medicine C 71% 17% - 10% 3%

Medicine D 30% 46% 9% 8% 8% AVERAGE 48% 33% 4% 9% 7%

Bddy Communication Other Clinical Social/

Behavioural

F i i 1 Breakdown of average nursing curricula

ioural sciences, but nursing students spend, on average, approximately 21 percent of their time on subjects dealing with the biomechanical body whereas the comparable fig- ure for medicine is 48 percent. There is also a notable dif- ference- in the subjects in the. 'other' category. In the nursing courses there is an average of 31 percent of content related to subjects such as nursing history, issues in nurs- ing, nursing theories and the role of nurses in health care - the kinds of subjects that are conspicuous by their absence in medical courses. In medicine, 'other' courses included units such as statistics and research methods, whereas these are less evident - at least in unit titles and outlines - in nursing curricula.

Journals

A content analysis of the article type shows, as expected, that the MJA concerns itself mainly with articles on the 'body as a machine' such as pharmacological reactions and pathology of disease. Also as expected the number of arti- cles on the biomechanical body is very low in AJAN. How- ever, contrary to expectations, AJAN contains articles

' Commu'nication ' Other Clinical Social/

Behavioural

Figure 4 Breakdown of average medical curricula

33

C. Brown and J. Seddon

Table 2 Analysis ofjournal content*

Journal Years Body as ‘Holistic’ Other machine approach

AJAN 1991-93 8% 27% 66%

MJA 1991-93 66% 12% 22%

AJAN 1992 9% 25% 66%

*J* 1992 69 % 8% 24%

* Proportion ofjournal devoted to each component

mainly on subjects such as nurse education or the history of nursing, rather than ‘holistic’ nursing. Papers discussing issues related to the social body, those dealing with the socioeconomic or political environment of the patient, were generally absent from both journals.

DlSCUSSlON

The expectation had been that this research would estab- lish that nursing has established an holistic model of the body, and that due to the primacy of science, the explana- tion for the subordination of nursing to medicine would be found in the perpetuation of this model in the journals and curricula examined. It was thought that nursing would be focusing on the holistic model of the body, or at least promoting a social view of the body and the contextual fac- tors that affect health, whereas medicine would retain its focus on the biomechanical model.

As hypothesized the biomechanical model of the body, although present, does not dominate either nursing cur- ricula or nursing literature. However, contrary to expecta- tions the ‘gap’ in curricula and professional discourse in nursing is not filled by an holistic view of the body, far less the social body. Rather nursing’s focus appears to be inward, upon defining what nurses do, with articles such as those which examine the clinical performance of differ- ently educated nurses or the journal reading habits of reg- istered nurses. While these concerns are perfectly valid, they do not serve to further the claim that nursing makes to be a valuable part of the health care workforce on the basis of a distinctively ‘holisitic’ approach.

The question that arises is, what are the factors that hin- der nurses from researching alternate models of the body and health, or conducting research within the biomedical model and thus providing evidence of nursing’s contribu- tion to mainstream health care? Instead of providing these alternatives:

It seems clear that nursing is not yet convinced about the precise nature of its discipline, and that the iptrospection which results from this lack of conviction is likely to sustain a good deal of literature for some time to come (p. 105) .33

This internal preoccupation3* would seem to be a feature of a discipline that has been denied full recognition within the health care system.

Although nursing may use an holistic model of the body in practice, this is not supported in nursing research or in nursing curricula. Instead, a self-contemplative per- spective is prevalent. Although medicine retains its focus on the biomechanical body, both within the universities and in its published research, nursing (while having far less emphasis on the biomechanical body) does not offer an alternative model. Medicine maintains its dominance not only through the primacy of the biomechanical body over the social body, but also through nursing’s failure to chal- lenge the dominance of the scientific model by offering a convincing alternative.

CONCLUSION

This research indicates that while the health care system remains centred on the biomechanical model of the body, doctors will retain their position of dominance as this is founded in part on their superior knowledge of that body. Nursing practice enables nurses to be aware, to a far greater degree than doctors, of the social and environ- mental factors that impinge upon health.34 Thus nursing is in a strong position to question the biomechanical model of the body and offer an alternative one. Not only would this affect the power balance within the health care system, it would also offer a broader base upon which to deal with illness.

ACKNOWLEDGEMENTS

This is a revised version of a paper presented at The Aus- tralian Sociological Association’s Annual Conference at Macquarie University, Sydney, in December 1993 and sub- sequently appearing in the Conference Proceedings.35 The authors would like to thank the many people at the con- ference for their comments on the paper and the two anonymous reviewers for their extremely helpful and con- structive criticism of an earlier draft.

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