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Introduction

The Open University — Fri, 24 Jun 2011 15:21:32 GMT

This unit is from our archive and it is an adapted extract from Understanding Health and Social Care (K100) which is no longer in presentation. if you wish to study formally at The Open University, you may wish to explore the courses we offer in this curriculum area.

To set up a care relationship that works well is a delicate matter, whether you are at the giving or the receiving end. In this unit we explore the very varied meanings of care relationships and how these meanings arise. Millions of care relationships are going on as you read this, and each carries its own particular meanings for those involved. But where have all those people picked up their ideas of how to relate to each other? How does any of us know where to begin?

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Learning outcomes

The Open University — Fri, 24 Jun 2011 15:21:32 GMT

After studying this unit you should be able to:

demonstrate your understanding of the importance of negotiating the meaning of care relationships;
identify ways in which people play the roles of ‘carer’ and ‘receiver of care’.

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1 Playing roles together

The Open University — Fri, 24 Jun 2011 15:21:32 GMT

Care relationships are seldom just a matter of ‘doing what come naturally’. For one thing, you may be caring for, or being cared for, by someone you would not otherwise get on with. A care relationship has to adapt to circumstances: it may be brief, as in an acute hospital ward, or it may be very long lasting; it may be flexible according to need or it may involve a high degree of regularity. It is a distinctive relationship with unique elements. Some of the things you and the other person have to do together are very different from what goes on within other relationships. What is more, you need to be able to conduct a care relationship in a calm and consistent way, without the fallings out and reconciliations that can occur in many other kinds of relationship.

In other words, a care relationship has to be specially ‘constructed’. This is true even when the care relationship is built on an existing family relationship. You are not simply relating to someone according to your personal inclination. You have a particular kind of role to play. Moreover, the other person has a role too. In fact, your two roles go together as a matching pair – carer and receiver of care. The one role implies the other. A care relationship involves both parties enacting their roles together in a co-ordinated way.

But this role-playing is not necessarily harmonious. Take Reg Martin and his home helps, for example (click on the link below to read a transcript of Reg's thoughts on his home helps). According to him, a new person would come in and say something like, ‘I’m your home help. Now what do you want me to clean?’ This might seem a very reasonable question to ask but Reg did not like it at all. He said, ‘I could never understand a home help asking such a question … you shouldn’t need to ask. But they insisted and I couldn’t cope … I decided that this was a bad no go.’ Reg seems to have developed such a hostility to this question that he was about to give up the home help service. How can we make any sense of such a strong reaction to an apparently polite and helpful question?

Click on 'view document' to read an excerpt of an interview with Reg Martin.

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1.2 Defining the scene

The Open University — Fri, 24 Jun 2011 15:21:32 GMT

Let us first consider what kind of ‘scene’ the home help was proposing that she and Reg should play out together.

0 hours 5 minutes

When the home help asked, ‘What do you want me to clean?’, she was, in effect, proposing a ‘definition’ of the ‘scene’ that was opening up between herself and Reg.

What kind of ‘scene’ a work or social scene, was she suggesting?
What role was she giving herself in this ‘scene’? What role was she giving Reg? Consider if their preferred roles were more managerial, social or servile.

Spend a few minutes thinking about this and quickly jot down your notes.

Discussion

It seems that the home help was proposing a ‘scene’ in which one person organises the work of another and tells them what to do.
She would have the role of being told what to do and Reg would have the role of organising and telling. Perhaps you described it as ‘servant and master’ relationship, or ‘employee and manager’.

It seems that in his state of sickness Reg did not feel up to playing a role as ‘manager’. He felt weighed down by having to remember what needed cleaning and having to write out shopping lists. It seems he experienced the home help’s question as oppressive, because it thrust him into a role he did not feel comfortable playing.

How can one person push another person into playing a role? The home help did not say, ‘I want you to act as my manager’, so why did Reg feel under pressure? In fact she did something more subtle. She started to act out a scene in which she was a person needing to be told what to do. In such a scene the matching role is clearly someone who tells that person what to do. Since the scene was already beginning and Reg was the only other person there, what else could he do but play that matching role? He found himself absorbed into the action of the scene the home help had initiated. Through her opening question she had both ‘defined the scene’ and begun to act her role in it, and Reg the found himself drawn in.

Glenda, however, presented herself to Reg quite differently as we can see reading the following extract from an interview with Reg in the attached pdf.

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1.2.1 A different definition

The Open University — Fri, 24 Jun 2011 15:21:32 GMT

Click on the 'view document' link to read the interview excerpt with Reg Martin

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Activity 2: A different definition

0 hours 10 minutes

How was Glenda’s presentation of herself different from the previous home helps? Having read the interview with Reg answer the following questions.

Discussion

Glenda began by announcing her name rather than her job title. What difference would that make to the way the scene between the two is defined? Consider if it would be more likely to create a work or social scene.
By opening with her name, Glenda presented herself to Reg as a person first and a home help second. She opened up a line of ordinary person-to-person communication, rather than speaking to him only through her formal role. Her ‘great big smile’ backed up this invitation.
What were the next things Glenda said and did? How did they create a different kind of relationship with Reg?
Glenda said such things as ‘I’ve come to do some shopping’, rather than asking, ‘What do you want me to buy for you?’ This is a more flexible way of defining the scene, because it leaves open who should decide what to buy. It offers scope to Reg to take on the ‘deciding’ role if he wants to, or pass it over to Glenda. Reg’s first reaction was that he ought to make a list, so she let him get on with it. But when he started getting into difficulties she offered to ‘have a look’. Then she made a few suggestions and Reg felt tremendously relieved. Gradually, after that, she took over a lot of the decision making about shopping, although she made a point of buying him ‘special’ things, which made Reg feel she was including him. Broadly she defined a scene in which she and Reg would sort out Reg’s needs together.
How would you describe the scene she presented for herself and Reg to play? What was her role and what was Reg’s role?
Subsequently, she played her role according to how well Reg was feeling. She did not define their relationship as purely functional with the roles fixed and formal. She left scope for Reg to change the definition of the scene according to his mood. Yet she was far from passive within the relationship. She took an active role in judging his needs. Beyond her helping work she also took time to sit down and chat at times. This extended the definition of the scenes they played out together, giving Reg a role as a person with a life and interest beyond his immediate illness and disabilities.

Key points

Your opening remarks tend to manoeuvre another person into a particular way of relating to you.
You can play a role either in a way that leaves the other person’s options open, or in a way that ‘closes them off’.

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1.2.2 Everyday scenes

The Open University — Fri, 24 Jun 2011 15:21:32 GMT

Activity 3: Openings to everyday scene

0 hours 5 minutes

Think of examples of everyday scenes, at home or a work, which could be radically reshaped by an opening remark

For example, say you surprised a guest snacking from your fridge
- You could take any tension out of the situation by saying, ‘While you’re there could you pass the milk’, and then chat about something else.
- You could ask, ‘Are you hungry? Can I get you anything?’ hinting that you don't mind, but you would rather she asked first.
- You could say, ‘I'm so sorry there wasn’t enough to go round at lunch’ – to make her feel guilty at slighting your generosity as host.
- Or you could raise the emotional temperature by asking, ‘Do you normally help yourself in other people’s houses?’
How does each of these ways of opening the scene define you?

Your role may be to ignore, act resentful, be aggressive or request appropriate behaviour if this situation arose.

(Notice the significance of questions. Asking a question puts pressure on the other person to answer – to join in the scene with you, on the terms you have set up in your question.)

How does each define your guest?
You are sitting with family, or friends. The TV is on and you say, ‘Is anyone watching this rubbish?’ How does this question define you and how does it define the others present? What pressure does it exert on them? What alternative questions could you ask, which would define the scene differently and have a very different impact of your companions?
Stop and think of one or two other examples from your everyday life, where you could ‘change the scene’ by what you choose to say.

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1.3.1 Social interactions

The Open University — Fri, 24 Jun 2011 15:21:32 GMT

The sociologist Erving Goffman studied how people relate to each other across a wide range of situations. According to him, each of us enters into ‘social interactions’ with an interest in trying to control what goes on. A social interaction is any kind of situation in which people communicate with each other or do things together. After all, much of what we do in life, we do through dealings with other people. We negotiate the routine business of daily life through interactions with family members, friends, shop assistants, work colleagues, clients, carers, and so on. In order to handle these various social interactions we need to have ways of influencing how other people behave towards us. We do this by trying to influence how situations are defined.

… it will be in … [the individual’s] interests to control the conduct of the others … This control is achieved largely by influencing the definition of the situation which the others come to formulate …
(Goffman, 1971, p. 15)

Goffman says the main way you can influence the definition of a situation is through the way you present yourself within it. You are capable of presenting yourself in many different ways. But within given situation you have to choose just one way. Interactions do not work unless everyone ‘agrees’ to play a specific part within the scene and stick to it. You have to opt for a version of yourself which will (you hope) be effective within that situation. Goffman allows that there is scope for shifting the definition of a scene while it is playing and for modifying the roles of participants. But he says that such changes have to be consistent with what has gone before. This strictly limits the scope for change. Consequently, it is in the opening ‘projection’ of yourself that you have most opportunity for influencing the way others treat you.

Click on the 'View document' link below and read the first paragraph of the extracts from Erving Goffman's The Presentation of Self in Everyday Life.

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1.3.2 Unsuccessful presentations

The Open University — Fri, 24 Jun 2011 15:21:32 GMT

Activity 4: Unsuccessful presentations

0 hours 5 minutes

Can you think of a recent situation where you felt uncomfortable because you did not manage to ‘project’ yourself as you would have liked (too shy say, or too loud, or just stupid)? Can you think of how you got stuck with that definition of yourself? Did you try to change it? How could you have presented yourself differently at the outset?

Discussion

One example might be sitting in the living room while teenage children watch TV with their friends. You might like to appear less old and boring – to have joined in, commenting on the programmes, without seeming to be trying too hard; to have been seen as having a worthwhile point of view, and not just lack of insight into today’s popular culture.

Key points

Goffman’s argument runs like this

Each of us has an interest in exerting some control over what goes on within social interactions we are involved in.
We try to achieve this control through influencing the ‘definition of the situation’.
A key way of influencing the ‘definition of a situation’ is through the way you present yourself within the situation.
Your greatest opportunity for influence lies in your opening ‘projection’ of yourself, since after that you have to maintain a consistent ‘front’.

Erving Goffman (1922–1982) made a major contribution to the way we understand relationships within the medical and caring worlds. He was Canadian, but was based at Edinburgh University from 1949 to 1951 when he carried out research in the Shetland Islands exploring the way islanders related to each other. After returning to the USA he was involved, as a ‘participant observer’, in detailed studies of relationships within mental hospitals. Goffman wrote several influential books.

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1.4.1 Taking on a role

The Open University — Fri, 24 Jun 2011 15:21:32 GMT

You can only succeed with a projection of yourself which other people are prepared to accept. And you then have to play out the scene the way others in the situation expect it to be played.

Reg and Glenda did not start their opening scene from nothing. They were working within widely shared understanding of home help work, which views it as version of ‘housework’. Cleaning and shopping are seen as traditional ‘women’s work’ – low in status, poorly paid and weakly defined in terms of what has to be done and to what standards. It would be difficult for Glenda to project herself to Reg as, for example, a high-powered, career-oriented woman. And Reg would probably feel uncomfortable if she tried. It fits much more comfortably if Glenda projects herself as a homely woman, who enjoys putting the house straight. If she accepts ‘housework’ as the broad frame of reference, she can draw on traditions of everyday relationships between ‘housewives’ and ‘menfolk’, knowing that Reg will be familiar with playing the other side. It is as though they have a ‘script’ to guide them.

Since their relationship is acted out within Reg’s own home, where he has a sense of being ‘in charge’, and since Glenda’s work is of relatively low status, they are on a fairly even footing. (On her side, she has the authority of a paid role for the social services department and the advantage of being the physically able member of the relationship.) Neither of them is in a clearly passive or subordinate role. Both sides have a basis from which to negotiate the terms of the relationship. The ‘script’ they are playing to is not very tightly defined. (In this context the term ‘script’ does not refer to something written down, but rather the kind of language to be used and the general lines along which participants will expect a scene to develop.)

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1.4.2 The doctor–patient relationship

The Open University — Fri, 24 Jun 2011 15:21:32 GMT

However, some care relationships are more tightly defined and more hierarchical, for example a doctor’s relationship with a patient. Within the biomedical model, the doctor’s role is to focus on the patient’s body and its functioning. The patient’s role is to report clearly and accurately on the body’s functions and the feelings it transmits. There is relatively little scope for the patient to influence the definition of this scene. The doctor generally makes the opening moves, while the patient waits to be asked questions.

Activity 5: Departing from the script

0 hours 5 minutes

Think ahead to your next consultation with your GP. Are there opening moves you could make which would change the definition of the scene?

What would happen if you sat down with a pad and said, ‘Doctor, before starting on me, there are some details I’d like about your training and experience’? Or what if you breezed in and said, ‘I’m going to tell you exactly what’s wrong with me and what medicines I need you to prescribe’?

Discussion

Doctors might vary in the manner of their response, but it is hard to imagine any doctor conceding much ground. If you cut across their projection of themselves as ‘in control’ of the consultation, most would refuse to proceed. One person who tried, simply found the consultation terminated and was invited to return in a different frame of mind.

Doctors cannot let patients take the lead in defining the scene. They are invested with responsibility. They are professionally and legally accountable. It is important that they stay close to accepted practice in conducting their consultations, or they could find themselves in trouble. When you enter your doctor’s surgery, the scene you enact is not played ad lib. The ‘script’ is fairly tightly prescribed

In many respects the ‘script’ for consultations does its job well. With its well-defined roles for doctor and patient, it gets people through the surgery at a steady rate. It enables doctors to diagnose and prescribe. It gives patients an impression of confidence and knowledge on the part of the doctor. And it gives doctors some protection against the doubts and ambiguities of their work.

However, it can also give rise to difficulties, if the doctor is projected as the person who has the expert knowledge, the matching role is a patient who knows nothing. Yet, for example, it is vital to sufferers from Parkinson’s disease that they know as much as they can about the implications of the disease, so that they can be ‘in control’ of the illness. Within the traditional doctor–patient relationship this transfer of information can be difficult, as reported by Mrs P:

I would like to discuss a lot of things with him [Dr X] … I’ve never had the opportunity to discuss the symptoms. And what to expect. I’d like to ask him. It’s hard isn’t it.
(Quoted in Pinder, in the Reader)

When a well-defined scene is already rolling, it is hard to find the right moment and the form of words to shift its direction. So the doctor patient ‘script’ both provides a very useful framework and also constrains the relationship in ways which may sometimes be detrimental.

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1.4.3 Structures that both enable and constrain

The Open University — Fri, 24 Jun 2011 15:21:32 GMT

Life within a society is made possible by structures. They operate at many levels, from the details of daily life (e.g. the routines of getting up in the morning, or the ritual greetings we use when we meet people) to the broader organisation of society (e.g. the channels through which mass media ‘news’ is generated, or the rules under which benefit payments are made). Even the language through which I am communicating now is a structured system of written symbols. But structures not only enable things to be done, they also impose constraints.

The doctor–patient relationship is a good example. This highly structured relationship gives you access to advice drawn from the large knowledge base and the long-developed practices of the medical profession. However, the very structures of the relationship which make it possible to supply the advice – the polite formality, the assumption of authority by the doctor, the diagnostic procedures, the understood confidentiality of information you give, the rapid decision making – also place tight limits on what can go on within the relationship. Much of the time we are unaware of the limits because we are very used to them. But if, for example, you want to challenge the doctor’s interpretation of your illness and bring knowledge to bear from different source, it can be very hard to do this within the established structuring of the relationship.

Key points

According to Goffman:

Our room for manoeuvre in negotiating the ‘definition of a scene’ varies.
Some situations are fairly evenly balanced and open-ended. Others are tightly defined and have well-established ‘scripts’ – or power is very much stacked on one side.
The term ‘script’ means the conventional ways of speaking and acting in a particular kind of situation.
‘Scripts’ provide a form of structuring within social situations. Like any structures they simultaneously enable things to happen and constrain what can happen.

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1.5.1 Agreeing who to be

The Open University — Fri, 24 Jun 2011 15:21:32 GMT

So far I have focused on one-to-one interactions. Yet ‘defining a scene’ is often a group effort. Goffman says this involves teamwork, with all participants, in effect, agreeing to act and speak within an overall frame of reference. He suggests that it works like a theatrical play in which everyone has taken on a part within the scene. To play your part means setting aside all those aspects of yourself which are not relevant to your role. The scene works only because everyone plays their part properly and avoids acting in ways which undermine or contradict other people’s performances. If anyone messes up their role-playing then it is embarrassing for everyone, because it threatens to break up the scene. This would expose the fact that everyone is acting and make it difficult to continue the scene.

But how can this work? How do people work out who is playing what? Goffman suggests that it happens through a process of people speaking (or doing) in turn and thereby projecting definitions of the situation and of themselves. But they do this in ways that avoid contradicting people’s projections that have preceded theirs.

Click on 'view document' below to read excepts from Erving Goffman's The Presentation of Self in Everyday Life.

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Activity 6

0 hours 15 minutes

Read the attached extract from Goffman’s The Presentation of Self in Everyday Life and highlight what you see as the main points. When you get to the end, look back at what you have highlighted and make brief notes for yourself of the main things the passage says.

Discussion

Here is my version

Every participant contributes by projecting a definition of the situation, even if mainly by their response to other people’s projections.
Normally participants’ definitions are sufficiently ‘attuned’ to each other so that contradictions do not arise.
This means ‘putting on a front’ – suppressing your ‘real’ feelings (e.g. don’t yawn while someone is telling a story) and acting in a way which suggests that you share common values with the other participants.
Usually you are allowed responsibility for defining aspects of the situation which are relevant mainly to your own role, on the general understanding that you respect other people’s definitions of themselves and do not undermine them. In other words, if someone makes a claim which seems to you improbable – for example, that they are twenty years younger than they look – so long as it doesn’t affect your own role, you say nothing.
In this way the group achieves and maintains a ‘working consensus’ as to what is going on and who is playing what role.

Long description

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1.5.2 Playing doctors, nurses and patients

The Open University — Fri, 24 Jun 2011 15:21:32 GMT

Activity 7: The doctor role

0 hours 5 minutes

It is easy to see how junior doctors can see themselves as being the centre of everything. The doctor arrives, decisions are taken, the action begins. Nurses, perhaps cross and impatient about any delay in the doctor’s arrival, will be critical of any failure to take a speedy decision. The doctor learns to act (and it is an act, in the beginning at least) quickly and decisively. The adopted persona of decisiveness becomes convincing, and the doctor rushes onto the wards, makes the necessary decision, and rushes off again, with smaller tasks perhaps left uncommunicated or undone.
(Mackay, 1993, p. 68)

... a continual effort is made to present a united front through which the patient is kept calm and protected. The way the performance is played is that the doctor has the leading role, the nurse acts as the assistant ... The doctor can question a nurse’s actions ... [but] ... if a nurse were to question a doctor in front of a patient, the doctor’s presentation of confidence and competence would be undermined.
(Mackay, 1993, p.112-13)

The above quotes from Mackay’s research on doctors and nurses present a strong idea of the doctor playing a role, with white coat flying and stethoscope dangling with the medical context described in terms of a little play being enacted in the presence of the patient, in which the doctor is omniscient (or all knowing) and everyone else awaits his wisdom. Does this suggest elements of a theatrical play?

Discussion

Mackay is talking in terms of a little play enacted in the presence of the patient, in which the doctor is omniscient and everyone else awaits his wisdom.

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1.5.3 The doctor-nurse relationship

The Open University — Fri, 24 Jun 2011 15:21:32 GMT

In reality, however, the nurse spends much more time with patients and often knows a lot that the doctor does not. Somehow the nurse needs to be able to communicate essential knowledge to the doctor, in the patient’s presence, without appearing to undermine the doctor’s ‘omniscient’ status. According to Leonard Stein’s research in America, they achieve this through playing ‘the doctor–nurse game’.

The cardinal rule of the game is that open disagreement must be avoided at all cost. Thus, the nurse can communicate her recommendation without appearing to be making a recommendation statement. The physician, in requesting a recommendation from a nurse, must do so without appearing to ask for it.
(Stein, 1978)

The doctor–nurse game

Nurse to patient:	This is Dr Jones.	An open and direct communication.
Nurse to doctor:	Dr Jones, this is Mrs Brown, who learned today of her father’s death. She is unable to fall asleep.	This message has two levels. Openly it describes a set of circumstances: a woman who is unable to fall asleep and who that morning received word of her father’s death. Less openly, but just as directly, it is a diagnostic and recommendation statement: Mrs Brown is unable to sleep because of her grief, and she should be given a sedative.
Doctor to nurse:	What sleeping medication has been helpful to Mrs Brown in the past?	Dr Jones has accepted the diagnostic and recommendation statements but, not knowing the patient, is asking for a further recommendation from Nurse Smith, who does know the patient, about what medication should be prescribed. Note, however, that his question does not appear to be asking her for a recommendation.
Nurse to doctor:	Pentobarbital mg 100 was quite effective the night before last.	Nurse Smith makes a disguised recommendation statement.
Doctor to nurse:	Pentobarbital mg 100 before bedtime as needed for sleep, got it?	Dr Jones replies with a note of authority in his voice.
Nurse to doctor:	Yes I have, and thank you very much, doctor.	Nurse Smith ends the conversation with the tone of the grateful supplicant.

(Source: adapted from Stein, 1978)

Through subtle teamwork, doctor and nurse together sustain the presentation of an ‘omniscient’ doctor

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1.5.4 The patient’s role

The Open University — Fri, 24 Jun 2011 15:21:32 GMT

Activity 8: The passive actor

0 hours 5 minutes

The patient is entirely passive in this scene. Does that mean that she has no role and is unimportant to the scene? Does her silence contribute anything?

Discussion

The patient is actually essential to the scene. It would be unnecessary to play the doctor–nurse game without the patient. But the patient also contributes, simply by accepting her passive role. Her contribution is to defer to both doctor and nurse. Her silence accentuates the busy and assured professional performance going on beside her. Perhaps Mrs Brown did not want to be sedated, but in the presence of an ‘expert’ nurse, who defers to an even more ‘expert’ doctor, she does not voice an opinion. She seems to understand her role and plays it faithfully.

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1.5.5 The modern day relationship

The Open University — Fri, 24 Jun 2011 15:21:32 GMT

However, things have been changing since Stein outlined the doctor-nurse game. A more recent study in Sweden reported that:

In our investigation, the nurses who had been working for 15–20 years often emphasised that it was during the past 8–10 years that marked changes had occurred in their interplay with doctors. Relations in former times are described in terms such as: ‘one had to stand on tiptoe’, ‘the doctors were kings’, or ‘no questioning was allowed’. By contrast today’s relationships are portrayed as collegial; discussion together is common ‘they respect our job’, and ‘they listen and take our views into account’.
(Svensson, 1996, p. 383)

But even if the ‘script’ has changed, that does not mean the show has stopped running. It cannot. Nor does this talk of ‘play acting’ imply that what goes on is not serious. Far from it. The central point is that we human beings cannot function together in any other way. We are dependent on ‘making sense of the world’ together. Without shared meanings we cannot act together.

Key points

Goffman argues that playing the scenes of life involve teamwork, such that participants accept a ‘shared definition’ of what is going on.
Participants also accept that they should speak and act in ways which are consistent with this definition.
This means suppressing aspects of themselves which are not consistent with their role in the ‘scene’.
It also means not undermining other people’s playing of their roles within the scene.
One example of team playing is the enacting of hierarchical doctor–nurse–patient relationships on hospital wards.

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1.6.1 Working in ambiguous situations

The Open University — Fri, 24 Jun 2011 15:21:32 GMT

So far the focus has been on discussing scenes played out in the highly structured settings of hospitals and doctors’ surgeries. However, a lot of care takes place in settings where structures are much less clear – where the meaning of a scene can be highly ambiguous, and where any working consensus between participants is fragile.

When a social worker goes into a family home, for example, the members of the household may not agree at all with the social worker’s definition of what the visit is about, or what should take place during it. Far from co-operating, they may vigorously resist the ‘script’ the social worker is trying to work to. In fact, a frequent requirement of a social worker’s job is to work with clients to try to arrive at a redefinition of their situation.

For example, where parents’ beliefs and practices regarding child rearing appear to be damaging to their children, the social worker cannot simply play along with the parents’ definition of their behaviour as ‘normal’ and ‘proper’. Instead, the social worker has the very difficult task of entering into a relationship with the parents in which their presentation of themselves is open to question – where their claims to competence as parents are not taken for granted. Since this is potentially undermining of the parents, an obvious tactic for them is to try to undermine the social worker first – to shore up their own definition of the situation by discrediting the social worker’s claims to understanding and authority.

Long description

Working with ‘definitions of situations’ and ‘self-presentations’ is critically important aspect of a social worker’s job, but it is a far cry from the clear role structures and well-established ‘scripts’ of the medical world. Coping with ambiguity, with contested definitions, and wit weakly established ‘scripts’ is in the nature of the work.

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1.6.2 Assessing risk

The Open University — Fri, 24 Jun 2011 15:21:32 GMT

Dev Sharma’s arrival at the Durrants’ home, following an incident involving a knife, is an example of an ambiguous situation. The morning after the incident he has to visit the Durrants, having received a telephone call from the home carer, reporting a claim by Arthur that his daughter, who has learning difficulties, has threatened him with a knife. Dev has to initiate a risk assessment. But what exactly happened and how should he set about his duties?

As a social worker Dev Sharma is expected to follow guidelines. The General Social Care Council’s Code of Conduct for workers will need to guide Dev’s actions. For your convenience they are reproduced here.

Protect the rights and promote the interests of service users and carers.
Strive to establish and maintain the trust and confidence of service users and carers.
Promote the independence of service users while protecting them as far as possible from danger or harm.
Respect the rights of service users whilst seeking to ensure that their behaviour does not harm themselves or other people
Uphold public trust and confidence in social care services.
Be accountable for the quality of their work and take responsibility for maintaining and improving their knowledge and skills.

You can see that Dev is not required simply to arrive at his own personal interpretation of events in the Durrants’ home. He is expected to work within a code of practice, and also within a partnership of service users, carers and other professionals. Nevertheless, he has to begin by trying to establish the facts of the knife incident and to gather relevant opinions as to its meaning. Was there a genuine threat to attack, or was it just an angry gesture when Lynne happened to have a knife in her hand? Was this an early incident in a cycle of escalating abuse against a frail older person? Or was it a ‘normal’ dispute in a family where relationships are difficult – a brief moment of assertiveness by Lynne within a lifetime of oppression by Arthur? However, before he can find out anything, Dev’s first challenge on entering the Durrants’ home is to ‘communicate and engage’ (another core competency).

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1.6.3 Communicating and engaging

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Audio: click below to listen to Dev's visit to the Durrant's home.

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Activity 9: Communicating and engaging

0 hours 10 minutes

Listen to the audio of Dev’s visit. Think about Dev’s handling of the Durrant case, the way he communicated and engaged with those involved on the morning after the knife incident. Then answer these questions.

What kind of ‘scene’ is Dev playing out with Arthur? Do you have any worries about how he should relate to Arthur?
How well is Dev establishing the facts of the knife incident?
Is Dev ‘working in partnership’?

Discussion

Dev plays a scene with Arthur in which he is an efficient investigator of facts and circumstances, and a seeker of solutions. At the same time he is sympathetic and reassuring when he says, ‘Of course it must have been very upsetting’. This is probably helpful in encouraging Arthur to open up to him, but is Dev running the risk of becoming absorbed into Arthur’s definition of the situation? If he plays ‘supporter’ to Arthur does he compromise his relationship with Lynne? Is he allowing Arthur to blame everything on Lynne, instead of steering him towards accepting shared responsibility for what goes on in the family?. Note his discriminatory attitude towards Lynne’s learning difficulties.
Dev has checked whether similar events have happened before. He may need to hear more from the home carer who reported Arthur’s claim about the knife incident. But he will obviously need to hear Lynne’s side of the story too – which seems to be a problem.
At the stage we join them Dev is having difficulty engaging Lynne in a working partnership. There seems to be some danger that he is being drawn into Arthur’s view that Lynne is ‘the problem’. To reach a balanced assessment he will need to consult with the home carer and talk to Lynne. After that, an effective working partnership will need to involve the three of them, as well as Arthur.

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1.6.4 Difficult communications

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Audio: click below to listen further to Dev's visit to the Durrant's home.

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Activity 10: Difficult communications

0 hours 5 minutes

Listen again to the audio of Dev’s attempted conversation with Lynne. Dev tries twice to speak to Lynne through the door. But what ‘script’ can you work from when someone is not even prepared to be in the same room? Think about the scene and the roles cast for Dev and Lynne and how his scripts may be locking her into her role behind the door.

In his first attempt to speak to Lynne what kind of scene between them does Dev project? What kind of reply from Lynne does this script ‘expect’?
He adopts a different ‘script’ the second time. What kind of scene does Dev project this time? What kind of reply from Lynne does this new script ‘expect’?

Discussion

Dev is projecting a scene in which Lynne is frightened, confused and looking for a way out. He’s saying, ‘You are frightened – it’s all OK – not very serious – we can sort it all out with a talk’. He seems to be inviting Lynne to reply alone the lines, ‘Oh, all right, I lost my temper. I didn’t mean it. I’m sorry and I won’t do it again.’
The second time he seems to be raising the stakes, projecting a scene where Lynne is in trouble and had better co-operate: ‘You have done something bad – you need to join in sorting out what we are going to do about it, or things will get bad for you.’ He seems to be inviting a reply along the lines, ‘Please don’t send me away – I’d really sorry – I can’t think what came over me – I’ll do whatever you suggest, if it keeps me out of trouble.’

Dev’s second ‘script’ seems to backfire when Lynne storms out. Her parting insult suggests that she does not see Dev as a potential partner in working out a resolution to the situation. Did this second ‘script’ sound too much as though Dev was on Arthur’s side, and treating her threat as an extremely dangerous incident? Obviously, Dev will have to find another approach and really needs to engage with all those involved with the incident. In such an ambiguous situation assessing risk is going to be very difficult and Dev will need all the support he can draw from the other care workers involved.

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1.7 ‘Care values’ in relationships

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In his dealings with Lynne and Arthur, Dev is expected to speak and act in accordance with the basic values of the social work profession. CCETSW guidelines include the requirement that he should:

Identify, analyse and take action to counter discrimination, racism, disadvantage, inequality, and injustice, using strategies appropriate to role and context; and
Practise in a manner that does not stigmatise or disadvantage either individuals, groups or communities.
(CCETSW, 1995, Part 2, p. 18)

Activity 11: Promoting care values

0 hours 5 minutes

In the light of these requirements, what is Dev’s responsibility when Arthur says, ‘She’s not really all there’ and ‘She should have been put away years ago’? What should he identify and analyse? What actions might he take?

Discussion

If he is to comply with the values base, Dev ought to identify that Arthur is displaying a discriminatory attitude towards Lynne’s learning disability. He is speaking from a well-established ‘script’ which defines people with learning disabilities as not proper people – less than full members of adult society. He is positioning Lynne as someone whose actions are not rational, whose interests do not need to be taken into account, who should be ‘put away’ from the society of ‘normal’ people.
Dev should also analyse the situation in the Durrants’ home and recognise the impact on Lynne of Arthur’s attitudes, since the two of them are cooped up together in their small flat.
Taking action to counter Arthur’s attitudes could involve working with all parties to discuss Lynne’s needs, give recognition to her contribution to Arthur’s welfare, and encourage Arthur to see Lynne’s point of view. (It would not include talk along the lines of ‘sending Lynne away’.)
Although his attention is focused on the risk of violence to Arthur, Dev should be careful not to practise in a manner which stigmatises Lynne.

Lynne’s disability raises one set of difficult values issues. Her final cry to Dev raises another – there is no difficulty here in identifying racism. However, having analysed the situation, Dev may feel inclined to make allowances for Lynne’s learning disability. And when it comes to taking action to counter it, Dev may be very accustomed to racism; prejudice and threats are hazards many care workers encounter regularly. To assume he has an obligation to take action himself is actually adding to his burden. He might well regard combating racism towards himself as a responsibility shared with his colleagues and supervisors, and choose to ignore Lynne’s taunt.

Key points

Some care situations are highly ambiguous.
Care workers’ interpretations of them may be actively contested by clients.
Care work may require renegotiating the meaning of a care situation in partnership with clients and other care workers.
Care workers are responsible for trying to ‘define situations’ in ways which uphold their professional value base

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1.8.1 The experience of Hillsborough

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We have explored the challenges of entering into situations which are ambiguous and open to competing interpretations. But what happens in a situation where nobody knows what is going on, where established meanings have collapsed altogether? Tom Heller gives a graphic account of such a situation in his description of his experience of the Hillsborough football stadium disaster.

Click on 'view document' below to read Tom Heller's account of his experiences at Hillsborough.

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Activity 12: The experience of Hillsborough

0 hours 20 minutes

Read through the recollections of Tom Heller, then read through it again looking for answers to these questions. Remember what you have learned about scenes, roles, scripts and props in terms of how clearly defined they are in this context.

Why did Tom Heller feel so helpless?
How did he manage to define a role for himself?
What made the situation begin to seem more under control?
What was the impact of returning to his children playing in the garden?

Discussion

In spite of his years as a doctor, Heller found himself stranded without any working definition of the scene. He says

Nothing could have prepared me for the scenes inside

He had no guidelines as to what to do – what role to play

My God, what could I do? Who was going to tell me what to do?
The tools of his profession helped, desperate to do something, he took out his stethoscope:

… grateful to have the time at last to do something that I knew how to do. I often use ‘stethoscope on the chest time’ to think during consultations. It’s a good ploy really; the patient thinks that I am being ever so thoughtful and thorough, and I have time to think about what the hell to do next. Panic overtook me on this occasion.

He was still unable to work out a useful role:

If only someone would arrive who knew what to do.

Then at last equipment began to arrive:

… and we started working together, putting up drips on everyone

Then later:

I decided to use my newly refound skills to put up drips on everybody who was going to be transferred to hospital … It was … a sign to the hospital doctors that we general practitioners could do something right after all …
Towards the end there is a sense of ‘meaningfulness’ and control being gradually restored:

By this time the routines were more established. Someone was writing down the obvious major damage to each person and what he or she had received in the way of drugs, etc.

A kind of pattern had been constructed. Collective action became possible again. Roles could be allocated. The horror of the death remained, but the blind panic of the total collapse of collective meaning receded a little
There was a further shock when Heller returned home. Having experienced normality totally shattered, he found himself stepping back into a domestic normality which had continued completely undisturbed. How do you play ‘normal’, when you have just been exposed to the insubstantiality of normality's foundations?

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1.8.2 ‘Props’ to support a performance

The Open University — Fri, 24 Jun 2011 15:21:32 GMT

Heller leaves no doubt about the horror and panic produced by a situation where action was urgently called for, yet there was no framework within which to construct action. He found himself desperately casting around for things to do, falling back on his trusty stethoscope as a way to ‘play doctor’, but finding it inadequate for the circumstances. He was clearly relieved when the drip equipment arrived, giving him a structured role. And even in this desperate situation he was concerned to be seen to put on a good performance. He cared what the hospital doctors thought.

This account shows how helpless we can feel without the ‘social meanings’ which we normally project on to the world around us. It also shows how hard we work to put meaning back together when it has collapsed. Normality is not allowed to be out of service for long.

Key points

Some of the clearest demonstrations of the central role of ‘shared meaning’ in making daily life possible occur when for some reason that meaning collapses.
If meaning does collapse, we can no longer act purposefully we know neither who we are supposed to be within the situation, nor what we should do.

Heller casts light, in passing, on the ‘play acting’ which goes on within the normal work of being a doctor. Goffman says that we add credibility to the roles we play by dressing the part and using ‘props’ (as they are called in the theatre). The doctor's stethoscope is a good example. Unambiguously associated with medical examination, it gives authenticity to a doctor's performance. Heller says he uses his stethoscope so that he can pretend to be ‘thoughtful and thorough’, when actually he is racking his brains about what to do next. Doctors are meant to appear knowledgeable and decisive. So, instead of sitting scratching his head, Heller goes through a few examination routines.

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1.9 Conclusion

The Open University — Fri, 24 Jun 2011 15:21:32 GMT

In this Unit you have seen the importance of the shared meanings that we construct together – how they enable us to act collectively within social situations. In particular, you have explored Goffman’s ideas about how those meanings are constructed through:

the way we present ourselves within social situations
the way we respond to other people’s presentation of themselves and help to shore up their performances.

It is particularly important in a care context to understand the way meanings are negotiated within relationships. Caring activities often cut across the ordinary everyday meanings we project into relationships. This is particularly the case when care activities involve the body. So awkward situations can arise, where there is confusion about who is supposed to be doing what, and for what reason. Understanding the scenes set for relationships, the roles people adopt, and the scripts and props used to create the meanings that impact on caring relationships is helpful for understanding the difficulties and supporting an effective relationship.

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Next steps

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References

The Open University — Fri, 24 Jun 2011 15:21:32 GMT

CCETSW (1995) Assuring Quality in the Diploma in Social Work – 1, Rules and Requirements for the Diploma in Social Work, Central Council forEducation and Training in Social Work, London.

Goffman, E. (1971; first published 1959) The Presentation of Self in Everyday Life, Penguin, Harmondsworth.

Mackay, L. (1993) Conflicts in Care: Medicine and Nursing, Chapman & Hall, London.

Stein, L. (1978) Readings in Sociology of Nursing, Churchill Livingstone, Edinburgh.

Svensson, R. (1996) ‘The interplay between doctors and nurses – a negotiated order perspective’, Sociology of Health and Illness, Vol. 18, No. 3, pp. 379–98.

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Acknowledgements

The Open University — Fri, 24 Jun 2011 15:21:32 GMT

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Grateful acknowledgement is made to the following sources for permission to reproduce material in this unit:

Text:

Stein, L. (1978) Readings in Sociology of Nursing, Churchill Livingstone, Edinburgh.

Offprint 6:

Interview with Reg Martin (b1935), by Wendy Rickard for the HIV/AIDS Testimonies Project at the British Library National Sound Archive (ref: C743/02);

Offprint 8:

Heller, T. 'Personal and medical memories from Hillsborough', British Medical Journal,pp.1596-8, Vol.299, No 6715, December 1989.

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