The Dilemmas of Care: Social and Nursing Adaptations to the Deformed, the Disabled, and the Aged by Ronald Philip Preston, New York, Elsevier North Holland, Inc, 1979, 220 pages, $14.95.
At first reading, I was not impressed by the idea that another sociologist had been fascinated by the "inner world" of nursing and the social structure of hospitals. However, I was impressed with the philosophical approach upon which the book was based.
The central theme of the book is the Gregor Effect, the reaction of normal men to abnormal men or the concept that people in general are both drawn toward and repulsed by ambiguous or less than normal men. The author proposes the Gregor Effect based on Gregor Samsa, from Franz Kafka's fictional The Metamorphosis, who overnight changes from a young traveling salesman to become a giant cockroach in appearance. This change in his life affects his family's approach to him and he is eventually outcast and dies. The Gregor Effect is seen, for example, when strangers who happen on a tragic automobile accident stop to see what is happening, but if they get too close and witness a severely traumatic injury, they want to run away. So it is with professional health care personnel and family members who become responsible for the physical, mental, and emotional support of those who are deformed, disabled, or elderly and need the help of others. Family members and health care personnel cannot easily run away, however, so although they are very supportive and caring at first, they may eventually become less than humanitarian, if not hostile and angry.
The author labels this conflict between repulsion and attraction of abnormal men as manifest human ambiguity. Ambiguous men repel others because of their abnormal condition, but they also attract because they are a challenge and a mystery. Reactions to ambiguous men involve feelings of insecurity, ambivalence, and denial since abnormal men remind normal men of their own mortality. Thus, normal men seek to make abnormal men normal. How a society treats abnormal men tells something about its moral development and how an individual reacts to ambiguous man is an indication of how he/she reacts to life itself.
Ways people lessen their perception of manifest human ambiguity are impulsive reaction (flight); prejudiced reaction (ambivalence and denial); obscenity reaction (overconcern and contact with abnormal men to enhance one's own power and normalness); ritual separation (banishment or isolation of the abnormal); humanitarianism (concern and love for ambiguous men as a trial and penance); spiritual transcendence (a higher form of humanitarianism); normalization (efforts to change abnormal to normal); diversionary focus and actions (focus on something away from the abnormal man); MASH (the use of humor); and induration (fatiguing repression). The author describes clinical situations and discusses how nurses utilize these various types of actions in an attempt to assuage manifest human ambiguity.
Some degree of competence with a variety of these methods of assuagement is essential in order to care for abnormal men over a period of time. A number of ways and environments in which competences are learned and used are discussed. Confronting the mystery of ambiguous men with competence produces a sense of power and status. Auxiliary personnel (aides and technicians) who often haveclose and extended contact with extremely abnormal men utilize different methods of assuagement than professionals, perhaps, at least in part, because of the different ways in which these competences are learned.
After a detailed explanation of the Gregor Effect, in the next section of the book the author summarizes an exploratory study that he conducted in a 300-bed general hospital where he had previously worked as an attendant for five summers. Using a participant-observer technique, he worked as a volunteer attendant on the 7-3 shift on five nursing units (coronary care unit, intensive care unit, emergency department, surgical unit, and medical unit) for one year, observing, interviewing, questioning, and recording the reactions of personnel (primarily registered nurses, but also other health professionals) to manifest human ambiguity.
Most of the author's observations of patient situations and nursing care are detailed and undoubtedly accurate. Some descriptions demonstrate astute perception of patient situations (ie, the reaction of family and hospital staff to the gradual physical and mental deterioration of an elderly man who had had a stroke). Others were described in such a dramatical form (resuscitation efforts) that they read like a second-rate novel.
Although I disagree with many of his comments and assumptions about nursing (ie, the use of the word "senile" to describe the confused elderly; that nurses are "hardly perturbed at the graphic conditions of their patients"; that "they are not likely to give him more than a fleeting thought"; and that "health professionals should not become 'emotionally involved' with their patients"), the concept of the Gregor Effect is thought-provoking. Many of the horrid examples of nurse behavior in the presence of ambiguous men are all too true. Exaggerated and jocular talk about the weather and the patients' flowers over a gaping purulent wound, waltzing a tiny elderly "senile" patient out to the nurses' station to the tune of "Look who we have here! Isn't she cute," and open hostility toward highly anxious, gross-appearing, difficult, complaining, dying patients are only a few of the depressing examples described. He presents an old and traditional view of the "limited" role of the nurse and portrays a dismal picture of nursing with but a glimmer of hope for change through suggestions.
Observations of nursing care of the elderly, especially the confused elderly, are particularly perceptive and repulsive. The author observed that nurses do not stay any longer than they have to in the rooms of patients who are confused, unaware, or feeble, and that they treat them like babies. On the other hand, nursing staff sometimes congregate together in the rooms of severely confused elderly patients when they want to get away from their immediate responsibilities and enjoy each other's company, acting as if the patient(s) in the room did not even exist.
The last section of the book relates the Gregor Effect to the moral development of nursing and medicine, particularly discussing how specific competences used in dealing with ambiguous men could make health care more humane. Nurses should understand the concept of the Gregor Effect, although understanding it will not resolve it. Competence in dealing with it is important for the well-being of nurses as well as for the improved care of patients. Perhaps some cues to the problems of nursing might be found in a study of nursing competences needed to care for ambiguous men.
Finally, I cannot help but recommend this book for those who might want to have their minds and vocabularies stretched a bit and for those who are looking for cues to the problems of nursing staff malaise and turnover in hospitals and nursing homes. The total impact of the book is tremendous, but all of the facets are not particularly easy to comprehend. The book offers a somewhat depressing view of the current status of nursing as seen by a sociologist, but it also offers much food for thought for the nurse who is concerned about improving the care of the deformed, disabled, and aged.