49 Socialisation, or becoming a health professional

‘The ultimate goal of nursing education’ Joseling Mariet wrote in 2016, ‘is to teach a student to think and act like a nurse’ ^[1]. This is socialisation, or what is sometimes called ‘professional identity formation’ ^[2]. Socialisation refers to any occasion when an individual takes up and internalises context-specific collective rules, distinctive skills, particular group values, attitudes and behaviours, or ethical standards of conduct, and in so doing, transforms their identity ^[3]. This process does not refer only to professional groups, but many sociologists believe that the professions provide some of the most refined and sophisticated examples of socialisation at work.

Some sociologists have seen socialisation as a way for people to learn the ‘rules of the game’ ^[4], suggesting that there is a pre-existing culture made up of norms and core values that the person must adapt to. Others have argued that people will not always respond in the same way to the same rules because people are not equally constrained by them. Critical theorists, for instance, argue that rules and standards established in white, Western, male culture, present greater barriers to some than others. Marxists suggest that socialisation is more about legitimating a class-based system that continues to favour those in power, using techniques of socialisation to instil the ‘false consciousness’ necessary for people to believe the situation is natural and inevitable ^[5][6]. What functionalists and Marxists share in common is a belief in the importance of institutions like schools, families, governments, and religions in defining social norms. Perhaps not surprisingly, sociologists have shown that it is these institutions that practice socialisation most aggressively.

Socialisation can take many forms, including:

• Specific approaches to learning that encourage deference to authority, ‘detached concern’ and the ‘supple balance’ of equanimity and compassion Gabe J, Kelleher D, Williams G. Challenging medicine. London: Routledge; 1994 favoured in Western healthcare;
• Unacknowledged reliance on an extensive hidden curriculum;
• Extensive use of ’status passages’ as compulsory steps to prove the student has inculcated appropriate knowledge, skills and attitudes;
• Deliberately maintaining distance between academic theory and ‘real’ clinical practice, to encourage practice humility and the belief that the true professional exceeds even what the formal qualification can offer;
• Having expectations that the students will develop complex humanistic skills, without significant curriculum support, reinforcing the belief that biomedical beliefs about health and illness are more complex and powerful.

Socialisation plays a crucial role in professional projects because occupational groups use it to perpetuate their profession’s legacy, shared skills, knowledge, and culture ^[7][8][9]. Professions that have the weakest or least ‘natural’ claim to a particular field, or face the greatest boundary pressure, need to work the hardest to establish and maintain their professional cultures, and socialisation can play a key role in this. Socialisation emphasises the point common to all social action perspectives, that it takes much more than knowledge of particular theory or technical competence to become a professional ^[10].

Socialisation does not only deal with the ‘positive’ aspects of becoming a skilled professional, though. It has also been deployed as a tool to better understand how Western medicine continues to favour patriarchal, white, ableist, coercive male values, after decades of criticism ^[11]. For example, if male doctors occupy vastly higher numbers of certain medical specialties, like orthopaedics, neurosurgery, and other ‘heroic’ specialties, and female doctors tend to gravitate towards areas that, like nursing, reflect socialised values about women’s domestic preferences (public health, general practice, family medicine), then socialisation must be playing a part in the way doctors are trained to think about health and healthcare. From a sociological point of view, what is particularly interesting is that while Western medicine does not set out to actively promote misogyny, heterosexism, racism, ableism, or any other form of discrimination, these discourses persist, despite the fact that well-trained health professionals are supposed to be champions of objectivity, value-neutrality, and disinterest in culture and history.

Symbolic interactionists argue, therefore, that socialisation must be a process of dynamic meaning-making that occurs between members of a particular community ^[12]. Professional values are not obtained or acquired, but created, developed and constantly re-performed. Competence is, at best, a fleeting, temporary state, always open to change and challenge. And because professional values exist within their own cultural context, it is impossible to anchor any particular set of values to professionals, without making them so generic that they become meaningless. In SI, the individual practitioner is ‘an active, constructive and transforming agent who shapes and is shaped by their experience of participation in cultural practices’ ^[13].

The performative dimension of socialisation became a particular interest to sociologist Harold Garfinkel in the 1960s. Garfinkel was interested in the way people negotiated their everyday lives, and in doing so, crafted personal and professional identities. Garfinkel developed an approach to social action called ethnomethodology, and he used this to better understand the skill and creativity needed to navigate everyday life.