Journal of Advanced Nursing. 1992,17,941-950
The drama of nursing Colm Adnan Hobnes RPN BA(Hons) TCCTt MPhil
Lecturer in Nursing. Faculty (^Nursing. Deabn University. Waum Ponds. Vtctona 3217, Australia
Accepted for |niblic3bon 18 Dec«nber 1991
HOLMESCA (1992) Journal of Advanced Nursmg 17,941-95 0 The drama of nursing This exploratory paper considers a few possibilities for conceivmg nursmg as a form of aesthetic praxis More specifically, drawmg on the works of Ervmg Gofftnan on dramaturgy, and Elizabeth Bums on theatre, it makes some suggestions concemmg nursmg as a form of dramatic performance, and bnefly attempts to relate this to concepts of praxis drawn from the wntmgs of Hannah Arendt and mtical soaal theonsts In contrast to Gofeian's dramaturgy, which stresses the artifice of social relations and suggests a cyrucal view of human interactions, a cnhcal theory of dramatic praxis mtroduces a nonnahve dimension m which performance may become self-reahzmg and emanopatory as it aspires to the status of aesthehc praxis Conceived m such terms, nursmg practice becomes a powerful form of self-expression which has the potential to become hberatmg for the nurse and the patient PROLOGUE
aesthehaan and soaal psychologist, Kenneth Burke (1937, 1945,1950, Rueckert 1969), and gamed new significance at The author's expenence is that nurses often thmk of the hands of Ervmg Gofiinan Its wider ongms, through the nursmg as a form of drama, and find it easy to identify soaal mterachorusm of G H Mead, and its relahonship to the costumes, roles and scnpts assoaated with the meta- the soaologies of Weber and Durkheim, are well docuphoncal stage which is the cbrucal settmg The hospital mented (e g Permbanayagam 1974), and its posihon m may be seen as the theatre, and the nurses, patients, rela- relahon to other soaal theones has been assessed by a hves and others as actors or spedators, whose scnpts and number of authors (e g Tumer & Edgley 1975, Geertz dialogues are enshrmed m the 'discourse of nursmg', the 1980) 'discourse of pahenthood', and so on A vanety of quite A number of substantial sourcebooks are available to well-defined roles are encountered, mdudmg vanations of readers approachmg dramaturgical perspechves for the Parson's side role, the role of dispassionate professional, first hme, most notably Bnssett & Edgley (1975) and and tiie roles assoaated with different degrees of semonty Combs & Mansfield (1976), which mdude excerpts fi-om among medical staff and administrators Nurses, them- a large number of key conhibutors to the field It has selves, may well be caught up m the dramas they enad and generated a number of developmenb and several altematiie illusions they aeate tives to Gofiftnan's approach to conceivmg the relahonshtp between performarux m the theatre and m soaal bfe have been elaborated, most notably that of Vtdor Tumer, a INTRODUCTION companson of his and Goffenan's theones is provided by Deegan (1978) Turner's ideas on soaal drama have also The commonplace notion that the world is a stage and ath-aded a substantial bterature applymg them to speafic its populace the dramatis personae m some spedacular contexts, and Frankenberg (1986) and Prout (1989), for h'agicomedy has a long and mtereshng history (see Bums exanple, apply them to notion of llbiess as a culhired 1972) It was initially fomiabzed mto a theory by the perfomance, relating it to Susan Sontag's (1983) 941
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exammation of tibtess as metaphor (see Nelson 1980 and Sdieper-Hughes & Lock 1986 for cntiques) Dramaturgy Begmrung wtth more general 'dramaturgical' accounts of soaal mteradion (Goffman 1959), and movtng toward the symbobc mterachorusm of later theonsts, the approach came to inform many areas of soaal analysts dunng the 1960s, and has been applied to cnme and deviance (e g Lofland 1969, Douglas 1970), supershtion and rebgion (e g Davis et al 1984), busmess pradices (Rosen 1985), symphony concerts (Small 1987), sport (Gluckman 1977), pobhcs (e g Gusfield 1966, Nimmo 1974, Merebnan 1969, Welsh 1985), conversahon (eg Scott & Lyman 1968), mamage and the fanuly (eg Berger & Kellner 1964), and soaety generally (Young & Massey 1978) Goffinan's nohon of role-distance has also been applied to an mterestmg range of soaal adors, as diverse as taxi dnvers (Davis 1959) and jazz mustaans (Stebbms 1969), and Davts et al (1984) appbed dramaturgtcal analysts to the prachces of fortune tellers, creahng potenhal for some tntereshng parallels with the prachces of nurses Turning to studies conduded m health contexts, dramaturgical accounts have been construded m relahon to mediane (e g Strong 1979, Haas & Shaffir 1982), llbiess and hosphals (e g Goffman 1961, Scheff 1966, Szasz 1961, Messmger et al 1962, Frankenberg 1986), and dying, death and funerals (e g Glaser & Strauss 1965, Sudnow 1967, Tumer & Edgley 1976, Harvey 1985) By way of an example, consider the study by Haas & Shaffir (1982), which analysed the socialization of medical students The authors pomt out that newcomers, professionals and the profession are required to develop a protechve carapace 'm order to mamtain control of professional roles, relationship and ldentihes' (Haas & Shaffir 1982) Whilst, from a Foucauldian perspedive, these unexplicated pobtical fimchons may be seen as strategies of professionalism embodied m the rules underlymg the assoaated 'discourse formation', from the dramaturgical perspedive they are formal means by which performances are authenticated and legihmated to actual and potenhal partiapants and spectators Such broad conclusions are based on a sopbshcated analyhcal framework, and it is necessary to consider the sort of procedures by which they have been reached, how these dramaturgical accounts are construded
management of others, or of an audtence These techruques mdude, among others, bebef m the part bemg played, tfie aeahon of stable performance components ('front'), the tdealtzahon of Self m f)erformance, 'soaal dtsapbne' mmtmtzmg faux pas and rrustakes, creatmg a believable performance by moderatmg the degree of manifest stncerity, and adjusting soaal distance through mystificatton Whilst these techruques focus on the mdividual soaal ador, Goffidian acknowledges that Self is also a member of a team — it is a soaal Self As Ebzabeth Bums (1972) says m her book on theatncality, 'equivalences between role playmg, mside and outside the theatre, between marupulahon of settings on stage and off, and between themes m the drama and ntual in ordinary life, suggest that the dramahsahon of bfe is an adivity m which everyone is mvolved' Thus, Goffman (1959) wntes, 'we commonly find that the defirution of the situation projected by a particular partiapant is an integral part of a projection that is fostered and sustamed by the mtimate cooperahon of more than one partiapant' Consequently, any member of a team has the power to 'give the game away' to an audience, and sobdanty is cruaal to success, as Gofifman (1959) says, 'lejadi team-mate is forced to rely on the good condud and behaviour of his fellows, and they, in tum, are forced to rely upon him' Attenhon is drawn by Bums (1972) to the role of those who are not part of the team, the spedators, as mdivtduals who are 'outside' the drama, witnesses to events from which they are excluded or over which they have no control She suggests that their role is pivotal because 'although the ads which are, for those who are mvolved, mstruments directed at accompbshmg an immediate objechve, that accomplishment is often only complete if the full meanmg and mtentton of thetr adtons is apprehended by others' As Rogers (1984) reiterates, it is only then that the consequences the adors wish to achieve can in fad be accompbshed
Goffinan's theory suggests that social bfe is a dramahc performance, but whether it is construded with the degree of self-consaousness that justifies charges of wholesale subterfuge or deceit ranains undear Nevertheless, the charge of cyruasm is a substanhal one to which we will return because it does raise the issue of smcenty — that is, the relahonship between theory and prachce, or between the performance and the performer—which suggests a role for some notion of 'praxis' To what extent a Goffiman's dramaturgy dramaturgtcal analysts is actually analogical, exadly how According to Gofiftnan (1959), the fully soaabzed Self has far the analogy can be pushed, what it tells us and how acquired a number of techruques for the successful perform- useful it IS, are auaal issues for us if we wish to explore the ance of roles, which is achieved through the impression relahonship between nursmg and the performing arts 942
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For his part, Goffinan admitted that his dramaturgtcal account of human soaal behaviour 'was m part a riietonc and a manoeuvre' (Goffitnan 1959), and a number of authors explore the sigruficance of thts manoeuvre (eg Permbanayagam 1982, Wilshtre 1982a, Bums 1972) Whtlst also displaymg a degree of spontaneity and creativity not nonnally associated with theatre, however, everyday life IS peppered wtth sigruficant 'set pieces' of social mteradion, often mvolvmg routimzed verbal exchanges and stylized behaviours, forms of ntual, hidden agendas, multiple layers of mearung, and symbobc forms, which are dearly components that it shares with dramatic performance What, then, is the relationship between theatre and everyday bfe?
THEATRE AND EVERYDAY LIFE Perhaps it is most useful to begin, like Eltzabeth Bums (1972), by considermg the anaent ongms of drama and the theatre Whereas tt tiught be tmagtned that theatre has tt ongins m the simple reproduchon of sigruficant aspeds — or dramas — of daily bfe, perhaps via children's play, following the work of the Cambndge anthropologists (pnmanly Gtlbert Munay, Jane Hamson and Franas Comford, descnbed m Sdiechner 1988a), tt is generally agreed that it actually emerged from soaal and magicorebgious ntuals (Hurmingher 1961, Bums 1972, Tumer 1982, 1985, Morgan & Brask 1988) Scheduler (1988b) pomts out that the ongm of the theatre, dance and music 'could well be healmg, or fun-makmg, or story-tellmg, or mittahons, or nothing at all [pjerformance may be coexistent with the human speaes (Sdiechner 1988c) Whatever its ongms, drama represents a 'pubbc portrayal of approved and of reprobate behaviour and of the consequenhabty of mtended and unmtended achon' (Bums 1972), and can serve as a regulative mechanism which serves to mamtam the stabibty of the normahve order of soaety What, thea is the difference between theah-e and social bfe? Bums (1972) suggests three kmds of difference first, what happens on stage may affed the audience at the time but IS otherwise uncormeded with their lives, second, composed behaviour is considered normal on stage but not elsewhere, and tbrd, 'the performance m the theatre displays paradigmatic values which cannot be distinguished m the midst of adion m ordmary bfe, where too much or too little is known about mohves, mtenhons or consequences' (Bums 1972) These suggeshons do not seran plausible, however, smd each will be bnefly dealt with mtum First, Ae view that what happens on stage results in only a transioit, contextualized response fi-om the audience is
predicated on a very narrow concept of the theatre and its fundions Whilst it may easily be imagmed that the theatre IS a medtum through whtdi potenttally destabtltzmg or dangerous unpulses or concems can legitirrwtely be charmelled or expressed, there ts a reflextve relattonship between these and the theahe Certainly, audiences can participate more or less m symbobc representations in which the dangerous becomes safe, the uncontrollable becomes controlled, and the illegitimate becomes legitimate, theatre thus ads as a catharhc focal pomt of suppressed and repressed opmions and desires However, m so domg, it also becomes a forum for the exammahon of matters of social concem, a medium of cntique, and a potential source of revoluhonary unpetus In this way a full-circle is completed whereby the legitimate once more becomes illegitimate Thus, theatre, and with tt any form of performance, becomes pobttcal (Martm 1990) Powerful dramattc performances may have lashng effects not only upon mdtviduals, but also upon their understandmg of, and parhapahon m, social processes Second, if by 'composed behaviour' Bums (1972) means behaviour proceedmg from a consaously formulated plan, it IS clearly not confined to the stage, and is accepted as normal on many occasions m everyday life Rehearsal of one's part, mdudmg one's 'costume', the 'lmes' one mtends to use, the posihons and postures to be adopted, and matters of timmg and voice control, are familiar to all of us who have faced important job mterviews, partiapated m academic conferences, in committees, or m media mterviews, or who have had sigruficant roles m ceremorues such as weddings, funerals, baptisms and pnzegivmgs This rehearsal may go so far as to involve other players or may be 'subvocal' affairs conducted m the pnvacy of one's bathroom or m the car CTI route to the 'theatre of operations'' This seems to me to be the very foimdahon of any dramaturgical account of soaal bfe Third, the fact that much of everyday life is conduded m relative ignorance of 'real mohves, intentions or consequences' has actually informed some contemporary theatre, which has sought to reproduce the unacknowledged confusion, distortion, misunderstandmg and subterfuge which characterizes some aspects of our soaal bfe The neat structures and mtemal logic of traditional theatncal drama have long been complemented by unpalatable ambiguities, fi-actured texts and mdeasiveness, which, m the absence of dearly defined diaradenzations and marufest plots, often leaves the audtence perplexed and vaguely uncomfortable So much for the 'paradigmatic' nature of the stage, what of the 'unparadigmahc' nature of everyday life? There are dearly some situahons m which submerged bebefs and 943
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Tiiese rhetoncal conventions mdude the outward signs of autiionty wbdi confircmt visitors to mshtuhons, sudi as formal tiles and modes of address, elaborate procedures for mihally accessing members of the team, convenhons ccmcenung manner and dress, clearly delmeated areas of expertise and responsibility, and convenhons concxmmg the style and content (rf communicahcms, mdudmg the use of technical language and the nght to deade what should and should not be disdosed, aU OKiicahve of stnd divisions of labour and a more-or-less ngid hierardual system Authenhcatmg convenhons, on the other hand, obtam between pwformers and the diaraders m the play, they ccKnpnse modes of speech, demeanour and action wbch serve to authenticate the play In the context of nursmg, we rtught usefully treat tbs as mdudmg all the techruques by which we are convmced of our own legitimacy Tbs includes- both techniques wbch we have developed unconsaously, such as our tendency to converse with pahents m ways wbch confirm our bebefs about our respechve roles, and techruques whidi we anploy consaously, sudi as our determmahon to embody and enact Given the complexity and confusioa and the occult parhcular ideals withm our style of commurucahon — sudi nature of mohves, mtenhons and conseqiKnces to which as consaously adoptmg the open stance and regular eye we have referred, what strategies do parhapants deploy m ccHitad descnbed m the counselbng texts order to organize and make sense of the soaal events of everyday bfe? Bums (1972) suggests that 'the language and Code of rules gestures one teams at home, at school and m groups to which one later belongs m the context of work or re- Together, both types of convenhon conshtute 'a grammar aeahcm, are denved fi-om taat agreements amstantly of theatncal presentahon', and the constramts they enad renewed or adjusted about the constaiKy and modificahcm amount to 'a code of rules for the transrrussion of specific of rrwanmgs These agreements, denved m tum from bebefs, athtudes and feebngs m terms of orgaruzed soaal norms accepted by those mvolved, conshtute 'convai- bdiaviour' (Bums 1972) Once agam, tbs ts remiruscent of hons', and we could Fegard them as Fegulahve components Foucault's nohon of a discourse formahon Scsnehmes, of the 'discourse formahon' of the assoaated context The however, these convenhons need to be supplemented by nature of these convenhons will now be considered other devices Gratht^'s (1970) development of some of Goffinan's ideas, for example, suggests that all performances are preceded by a 'strategy' anhapatmg potenhal RHETORICAL AND AUTHENTICATING mconsistenaes or gaps m the performance These gaps are CONVENTIONS parhculariy bable to occur m b ^ y charged soaal dramas, Bums (1972) distmguishes two d^ses of convenhcHis espeaally those mvolvmg danger or emohonai trauma, 'rhetoncd' and 'authoihcatmg' Rhetoncal convenhcms ard lead to the development of elabcn-ate ntuals, and obtam between performers and spedators, they 'are the behavioural and verbal taboos These will be famibar means by wbdi the audi«Ke is persuaded to accept to nurses- consider, for exanple, the complex communicadiaraders and situahons whose vabdity is ephemeral and honal taboos usually surrtnmdmg death, dymg, suicide bound to the theatre In addihcm to the convenhcms of and euthanasia Whentiteseare enccnmtered m the dmical spaang, timmg and settmg, they mdude the means, verbal situatioa f>arhapants tend to abide by a complex senes of fflid otherwise, by which the players ccmunurucate with and taboos and ntuals Even the pahoit adheres to tiwm, convinproach is to conceive art as a form of value-expression. If arhshc creahon is share of critiques, generaUy sjmnptomatic of weaknesses 946
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in the symbobc mterachomst perspechve (Lofland 1970, Ditton 1980, Shan-on 1981, Hopper 1981, Sedgwick 1982, Wilshu-e 1982b) Some cnhdsm, mixed wtth praise, has come fi-om unexpeded quarters (Blumer 1972, Marming 1976) and some has been parhculariy trenchant (Dawe 1973, Gouldner 1971) Apart from the disquiet concemmg Goffinan's inherently cynical view of relationshtps (Cuzzort 1969), a major cnttcism has been that b s focus on the miaosocial order results m an emasculated soaology wbch IS at a loss to understand and explain the maaosoaal These have provoked a number of successful rejomders (e g HaU 1977, Williams 1986) It has been claimed that Goffinan's work is politically conservative and enjoms soaal stahsm (Gouldner 1971, Fletcher et al 1974. Marx 1984), although there have been daims that he was a pobttcal radical (CoUms & Makowsky 1972), and the truth seems that he was pobticaUy ambivalent (WiUiams 1986) Whether Goffman's charadenzations are accurate, however, and whether he regarded the nature of soaal relations as unchangeable or such diange as not the task of soaologists, is not perhnent here The aim, rather, is to cut aaoss these controversies, first by frarrung a dynamic notion of dramaturgy wbch is expbaty creative and self- and other-affirrrung, and, second, by linkmg it, through Marxist cnhcal theory, to the notion of a normahve aesthehc praxis which is indisputably bstoncal, contextual and maaosoaal
SUMMARY AND PROSPECTS By bnngmg together the notions of 'nursing as praxis' and 'nursmg as drama', it is bemg suggested that nursmg may perhaps be regarded potentiaUy as a form of praxis expressed tbough dramatic performance — that is, a aeahve means of overcoming mearunglessness and alienahon — and of affirrrung one's humanity and that of others through aesthehc adivity In hamessmg a cnhcal concept of praxis to that of soaal life as theatre, the author is labounng to illuminate a way of understandmg the notion of nursmg as drama that offers t b e e unique strands First, the author wants to avoid the charges of cyruasm mevitably associated with Goffman's view that social bfe amounts to bttle more than a charade, and that the Self IS simply a senes of converuent masks In contrast, he is seeking a cntical emanapatory dramaturgy which, whilst founded on 'reaUy existmg conditions', emphcisizes the
tragoly, gravity and splendour of human bfe, the unity and conhnuity of Self, the mportana of genumeness, and the pursuit of the reabzahon of the best potenhals of self and
others In other words, a dramaturgy which is concemed with the potenhality as weU as the actuality of life Second, consistent with a Marxist account m wbch aesthehc activtttes are not accorded a pnvtleged status distmguishmg them from other humiin activities, and m which artistic and literary praxis are thus an integral part of genume human praxis, the author wishes to hold that our engagement with reality as nurses, mdudmg our dmical practice, can have a profound aesthetic quality which marks it out from alienatmg activittes Tbrd, conststent with Marx's famous dictum that what IS needed is not simply to mterpret the world but to transform it, the author wishes to postt a concept tn wbch nurstng practice is conceived as reflexively transformative, m that nurses are able to act upon, as weU as be aded upon by, their arcumsteinces To consider nursing as emblematic of a cntical emancipatory dramaturgy suggests some exahng possibibties for the conttnued exploration of the relationship between nurses and their pradice
Exploration A nijmber of ways for beginning such an exploration may be mentioned in closmg Nurses have a very nch source of msights hidden away m the exishng wntten discourse of nursmg, a discourse which is contmuously expanding, and the possibibty of mterpretmg matenal in terms of a theory of cnttcal dramaturgy is £in excitmg prosped Two contemporary trends add fuel to tbs possibtbty Ltttleknown or neglected aspects of nurses' discourse are being redtscovered tbough the developmg sdiolarsbp m the history of nursing Secondly, refledive accounts m the form of stones, poetry, dianes and anecdotes, are maeeismgly finding a place in pubbshed bterature (Bermer 1984, Deikebnann 1989, Sandelowski 1991, Wnght 1991) The narrahves contamed in t b s discourse refocus our interest on the charactenstically human (Antaki 1988, Plattner & Bruner 1984, PoUanghome 1988, Sarbm 1986), and offer opporturuties to dtscover, through cnhcal dramaturgtcal analysts, fresh insights mto our prachces, ourselves and our relationships with others Similarly, practitioners may lnihate systematic reflective processes wbch focus upon their professional expenences, usmg the vanous methods descnbed m the literature on the 'reflechve practtttoner' (Brown 1989, Carr & Kemrrus 1986, Cox 19W, Cox et al 1991, Holly 1984, Powell 1989, Schon 1987, Smyth 1986) These mcreasmgly familiar
methods might prove valuable mfleshmgout the skeletal concephon of nursmg as cntical dramaturgy which has been tentatively and bnefly descnbed here 947
CA Hohnes A Disaphne of Nurstng (Gray G k Pratt R eds), ChurchiU Livn^stone, Sydney Allen D (1987) Cnhcal soaal theory as a model for analyzmg Crocker D (1983) Praxis and Eknuxrattc Soaahsm The Cntical Soaal Theory of Markovic and Stojanovic Humaruties Press, ethical issues m family and ccMrunuiuty health Famtly and AHantic Highlands, New Jersey Community Health 10(1), 63-72 Allen D (1990) Cntical soaal theory arui nursing educahon In Cuzzort Ri* (1969) Humanity and Modem Soaologtcal Thought Remhart k Wmston, New York. Cumcuhmi Revolution Redefintng the ^udent-Teacher Relationship Nahonal League for Nursing Pubbcahon N 15-2351 Davis F (1959) The cabdnver and his fare facets of a fleeting Nahonal League for Nursing, New York. relahonship Amencan Journal of Soaology 65, 158-165 Antaki C (ed) (1988) Analysing Everyday Explanation A Casebook Repnnted m Ltfe as Theatre A Dramaturgtcal Sourcebook of Methods Sage, London (Bnssett D & Edgley C eds), Aldme, Chicago, 1975 Arac J (ed.) (1988) After Foucault Humanistic Knowledge. Post- Davis P W , Boles J k Tatro C (1984) Dramaturgy of occult modem ChaUer^es Rutgers University Press, New Brunswick. prachtioners m the treatment of disease and dysfunction Aroidt H (1958) 77K Human Condition University of Chicago enhties Soaal Saence and Medtane 19(7), 691-698 Press, Qucago Dawe A (1973) The underworld of Ervmg Goflrnan Bnttsh B«mer P (1984) From Novice to Expert Excellence and Power Journal of Soaology 24, 246-255 tn Chmcttl Nurstng Practtce Addison-Wesley, Menlo Park, Deegan M J (1978) Interachon, drama, and freedom the social California. theones of Ervmg Gofifman and Victor Tumer HumanityBerger J & Kellner H (1964) Mamage and the constrwrtion of Society 2(1). 33-46 reabty Repnniedm Ltfe as Theatre A Dramatuigtcal Sourcebook Diekebnarm N L (1989) The nursmg cumculum bved expen(Bnssett D & Edgley C eds), Aldme, Chicago, 1975 ence of students In Cumadum Revolution ReconceptualBlumer H (1972) Action vs interaction review of "Relations in mng Nwsit^ Education Nahonal League for Nursmg, New Pubhc" by Ervmg Goflftnan 1971 Soaety 9, 50-53 York Bnssett D & Edgley C (eds) (1975) Life as Theatre A Dramaturgt- Ditton J (ed) (1980) The View from Goffman Maamllarv London. cal Sourcebook Aldme, Chicago Douglas J (ed) (1970) Deviance and Respectabtlity The Soaal Brown J (1989) Emanapahon through praxis the reflexive Construction of Moral Meanings Basic Books, New York relahonship between theory and prachce Paper presoited Fletcher C R , Mannmg P K, Reynolds L T & Smith J O (1974) to Nahonal Nursmg Tlieory Conferoice, South Australian TTie labellmg theory of mental illness In Explorations tn C o l l i e of AdvaiKed Educahon, Sturt, South Australia. In Psychiatnc Soaolc^ (Roman P M & Tnce H M eds), F A Theory and Practice — An Evolmng Relattonship (Koch T ed), Davis, Pbladelphia The School of Nursing Shidies, Shirt, South Austraba. Frankenberg R (1986) Sickness as cultural performance drama, Burke K (1937) Permanence and Change An Anatomy of Purpose trajectory, and pilgrimage root metaphors and the makmg of Bobbs-Memll, Indianapolis social disease International Journal of Health Services 16(4), Burke K (1945) A Grammar of Motives Prentice-Hall, 603-626 Englewood-Cbffs, New Jersey Garaudy R. (1970) Marxism in the Twentieth Century Colbns, Burke K (1950) A Rhetonc of Motives Prentice-Hall, EnglewoodLondon Cbffs, New Jersey Garfinkel H (1956) Condihons of successful degradahon cereBums E (1972) Theatncality A Stt4dy of Conventton tn the Theatre morues Amencan Journal of Soaology 61,420-^24 Reprmtoi and m Soctal Ltfe Harper & Row, New York Carr W & Kemmis S (1W6) Becoming Cnttcal Knotmng Through m Drama in Life The Uses of Communication tn Soaety (Combs JE k Mansfteld M W eds), Hastmgs House, New Yoric, Action Research 2nd edn Deakm Uruversity Press, Geelong, 1976 Victoria Geertz C (1980) Blurred genres the refiguration of soaal Chc^mian G E (1983) Ritual and rational ach
The drama of nursing Colm Adnan Hobnes RPN BA(Hons) TCCTt MPhil
Lecturer in Nursing. Faculty (^Nursing. Deabn University. Waum Ponds. Vtctona 3217, Australia
Accepted for |niblic3bon 18 Dec«nber 1991
HOLMESCA (1992) Journal of Advanced Nursmg 17,941-95 0 The drama of nursing This exploratory paper considers a few possibilities for conceivmg nursmg as a form of aesthetic praxis More specifically, drawmg on the works of Ervmg Gofftnan on dramaturgy, and Elizabeth Bums on theatre, it makes some suggestions concemmg nursmg as a form of dramatic performance, and bnefly attempts to relate this to concepts of praxis drawn from the wntmgs of Hannah Arendt and mtical soaal theonsts In contrast to Gofeian's dramaturgy, which stresses the artifice of social relations and suggests a cyrucal view of human interactions, a cnhcal theory of dramatic praxis mtroduces a nonnahve dimension m which performance may become self-reahzmg and emanopatory as it aspires to the status of aesthehc praxis Conceived m such terms, nursmg practice becomes a powerful form of self-expression which has the potential to become hberatmg for the nurse and the patient PROLOGUE
aesthehaan and soaal psychologist, Kenneth Burke (1937, 1945,1950, Rueckert 1969), and gamed new significance at The author's expenence is that nurses often thmk of the hands of Ervmg Gofiinan Its wider ongms, through the nursmg as a form of drama, and find it easy to identify soaal mterachorusm of G H Mead, and its relahonship to the costumes, roles and scnpts assoaated with the meta- the soaologies of Weber and Durkheim, are well docuphoncal stage which is the cbrucal settmg The hospital mented (e g Permbanayagam 1974), and its posihon m may be seen as the theatre, and the nurses, patients, rela- relahon to other soaal theones has been assessed by a hves and others as actors or spedators, whose scnpts and number of authors (e g Tumer & Edgley 1975, Geertz dialogues are enshrmed m the 'discourse of nursmg', the 1980) 'discourse of pahenthood', and so on A vanety of quite A number of substantial sourcebooks are available to well-defined roles are encountered, mdudmg vanations of readers approachmg dramaturgical perspechves for the Parson's side role, the role of dispassionate professional, first hme, most notably Bnssett & Edgley (1975) and and tiie roles assoaated with different degrees of semonty Combs & Mansfield (1976), which mdude excerpts fi-om among medical staff and administrators Nurses, them- a large number of key conhibutors to the field It has selves, may well be caught up m the dramas they enad and generated a number of developmenb and several altematiie illusions they aeate tives to Gofiftnan's approach to conceivmg the relahonshtp between performarux m the theatre and m soaal bfe have been elaborated, most notably that of Vtdor Tumer, a INTRODUCTION companson of his and Goffenan's theones is provided by Deegan (1978) Turner's ideas on soaal drama have also The commonplace notion that the world is a stage and ath-aded a substantial bterature applymg them to speafic its populace the dramatis personae m some spedacular contexts, and Frankenberg (1986) and Prout (1989), for h'agicomedy has a long and mtereshng history (see Bums exanple, apply them to notion of llbiess as a culhired 1972) It was initially fomiabzed mto a theory by the perfomance, relating it to Susan Sontag's (1983) 941
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exammation of tibtess as metaphor (see Nelson 1980 and Sdieper-Hughes & Lock 1986 for cntiques) Dramaturgy Begmrung wtth more general 'dramaturgical' accounts of soaal mteradion (Goffman 1959), and movtng toward the symbobc mterachorusm of later theonsts, the approach came to inform many areas of soaal analysts dunng the 1960s, and has been applied to cnme and deviance (e g Lofland 1969, Douglas 1970), supershtion and rebgion (e g Davis et al 1984), busmess pradices (Rosen 1985), symphony concerts (Small 1987), sport (Gluckman 1977), pobhcs (e g Gusfield 1966, Nimmo 1974, Merebnan 1969, Welsh 1985), conversahon (eg Scott & Lyman 1968), mamage and the fanuly (eg Berger & Kellner 1964), and soaety generally (Young & Massey 1978) Goffinan's nohon of role-distance has also been applied to an mterestmg range of soaal adors, as diverse as taxi dnvers (Davis 1959) and jazz mustaans (Stebbms 1969), and Davts et al (1984) appbed dramaturgtcal analysts to the prachces of fortune tellers, creahng potenhal for some tntereshng parallels with the prachces of nurses Turning to studies conduded m health contexts, dramaturgical accounts have been construded m relahon to mediane (e g Strong 1979, Haas & Shaffir 1982), llbiess and hosphals (e g Goffman 1961, Scheff 1966, Szasz 1961, Messmger et al 1962, Frankenberg 1986), and dying, death and funerals (e g Glaser & Strauss 1965, Sudnow 1967, Tumer & Edgley 1976, Harvey 1985) By way of an example, consider the study by Haas & Shaffir (1982), which analysed the socialization of medical students The authors pomt out that newcomers, professionals and the profession are required to develop a protechve carapace 'm order to mamtain control of professional roles, relationship and ldentihes' (Haas & Shaffir 1982) Whilst, from a Foucauldian perspedive, these unexplicated pobtical fimchons may be seen as strategies of professionalism embodied m the rules underlymg the assoaated 'discourse formation', from the dramaturgical perspedive they are formal means by which performances are authenticated and legihmated to actual and potenhal partiapants and spectators Such broad conclusions are based on a sopbshcated analyhcal framework, and it is necessary to consider the sort of procedures by which they have been reached, how these dramaturgical accounts are construded
management of others, or of an audtence These techruques mdude, among others, bebef m the part bemg played, tfie aeahon of stable performance components ('front'), the tdealtzahon of Self m f)erformance, 'soaal dtsapbne' mmtmtzmg faux pas and rrustakes, creatmg a believable performance by moderatmg the degree of manifest stncerity, and adjusting soaal distance through mystificatton Whilst these techruques focus on the mdividual soaal ador, Goffidian acknowledges that Self is also a member of a team — it is a soaal Self As Ebzabeth Bums (1972) says m her book on theatncality, 'equivalences between role playmg, mside and outside the theatre, between marupulahon of settings on stage and off, and between themes m the drama and ntual in ordinary life, suggest that the dramahsahon of bfe is an adivity m which everyone is mvolved' Thus, Goffman (1959) wntes, 'we commonly find that the defirution of the situation projected by a particular partiapant is an integral part of a projection that is fostered and sustamed by the mtimate cooperahon of more than one partiapant' Consequently, any member of a team has the power to 'give the game away' to an audience, and sobdanty is cruaal to success, as Gofifman (1959) says, 'lejadi team-mate is forced to rely on the good condud and behaviour of his fellows, and they, in tum, are forced to rely upon him' Attenhon is drawn by Bums (1972) to the role of those who are not part of the team, the spedators, as mdivtduals who are 'outside' the drama, witnesses to events from which they are excluded or over which they have no control She suggests that their role is pivotal because 'although the ads which are, for those who are mvolved, mstruments directed at accompbshmg an immediate objechve, that accomplishment is often only complete if the full meanmg and mtentton of thetr adtons is apprehended by others' As Rogers (1984) reiterates, it is only then that the consequences the adors wish to achieve can in fad be accompbshed
Goffinan's theory suggests that social bfe is a dramahc performance, but whether it is construded with the degree of self-consaousness that justifies charges of wholesale subterfuge or deceit ranains undear Nevertheless, the charge of cyruasm is a substanhal one to which we will return because it does raise the issue of smcenty — that is, the relahonship between theory and prachce, or between the performance and the performer—which suggests a role for some notion of 'praxis' To what extent a Goffiman's dramaturgy dramaturgtcal analysts is actually analogical, exadly how According to Gofiftnan (1959), the fully soaabzed Self has far the analogy can be pushed, what it tells us and how acquired a number of techruques for the successful perform- useful it IS, are auaal issues for us if we wish to explore the ance of roles, which is achieved through the impression relahonship between nursmg and the performing arts 942
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For his part, Goffinan admitted that his dramaturgtcal account of human soaal behaviour 'was m part a riietonc and a manoeuvre' (Goffitnan 1959), and a number of authors explore the sigruficance of thts manoeuvre (eg Permbanayagam 1982, Wilshtre 1982a, Bums 1972) Whtlst also displaymg a degree of spontaneity and creativity not nonnally associated with theatre, however, everyday life IS peppered wtth sigruficant 'set pieces' of social mteradion, often mvolvmg routimzed verbal exchanges and stylized behaviours, forms of ntual, hidden agendas, multiple layers of mearung, and symbobc forms, which are dearly components that it shares with dramatic performance What, then, is the relationship between theatre and everyday bfe?
THEATRE AND EVERYDAY LIFE Perhaps it is most useful to begin, like Eltzabeth Bums (1972), by considermg the anaent ongms of drama and the theatre Whereas tt tiught be tmagtned that theatre has tt ongins m the simple reproduchon of sigruficant aspeds — or dramas — of daily bfe, perhaps via children's play, following the work of the Cambndge anthropologists (pnmanly Gtlbert Munay, Jane Hamson and Franas Comford, descnbed m Sdiechner 1988a), tt is generally agreed that it actually emerged from soaal and magicorebgious ntuals (Hurmingher 1961, Bums 1972, Tumer 1982, 1985, Morgan & Brask 1988) Scheduler (1988b) pomts out that the ongm of the theatre, dance and music 'could well be healmg, or fun-makmg, or story-tellmg, or mittahons, or nothing at all [pjerformance may be coexistent with the human speaes (Sdiechner 1988c) Whatever its ongms, drama represents a 'pubbc portrayal of approved and of reprobate behaviour and of the consequenhabty of mtended and unmtended achon' (Bums 1972), and can serve as a regulative mechanism which serves to mamtam the stabibty of the normahve order of soaety What, thea is the difference between theah-e and social bfe? Bums (1972) suggests three kmds of difference first, what happens on stage may affed the audience at the time but IS otherwise uncormeded with their lives, second, composed behaviour is considered normal on stage but not elsewhere, and tbrd, 'the performance m the theatre displays paradigmatic values which cannot be distinguished m the midst of adion m ordmary bfe, where too much or too little is known about mohves, mtenhons or consequences' (Bums 1972) These suggeshons do not seran plausible, however, smd each will be bnefly dealt with mtum First, Ae view that what happens on stage results in only a transioit, contextualized response fi-om the audience is
predicated on a very narrow concept of the theatre and its fundions Whilst it may easily be imagmed that the theatre IS a medtum through whtdi potenttally destabtltzmg or dangerous unpulses or concems can legitirrwtely be charmelled or expressed, there ts a reflextve relattonship between these and the theahe Certainly, audiences can participate more or less m symbobc representations in which the dangerous becomes safe, the uncontrollable becomes controlled, and the illegitimate becomes legitimate, theatre thus ads as a catharhc focal pomt of suppressed and repressed opmions and desires However, m so domg, it also becomes a forum for the exammahon of matters of social concem, a medium of cntique, and a potential source of revoluhonary unpetus In this way a full-circle is completed whereby the legitimate once more becomes illegitimate Thus, theatre, and with tt any form of performance, becomes pobttcal (Martm 1990) Powerful dramattc performances may have lashng effects not only upon mdtviduals, but also upon their understandmg of, and parhapahon m, social processes Second, if by 'composed behaviour' Bums (1972) means behaviour proceedmg from a consaously formulated plan, it IS clearly not confined to the stage, and is accepted as normal on many occasions m everyday life Rehearsal of one's part, mdudmg one's 'costume', the 'lmes' one mtends to use, the posihons and postures to be adopted, and matters of timmg and voice control, are familiar to all of us who have faced important job mterviews, partiapated m academic conferences, in committees, or m media mterviews, or who have had sigruficant roles m ceremorues such as weddings, funerals, baptisms and pnzegivmgs This rehearsal may go so far as to involve other players or may be 'subvocal' affairs conducted m the pnvacy of one's bathroom or m the car CTI route to the 'theatre of operations'' This seems to me to be the very foimdahon of any dramaturgical account of soaal bfe Third, the fact that much of everyday life is conduded m relative ignorance of 'real mohves, intentions or consequences' has actually informed some contemporary theatre, which has sought to reproduce the unacknowledged confusion, distortion, misunderstandmg and subterfuge which characterizes some aspects of our soaal bfe The neat structures and mtemal logic of traditional theatncal drama have long been complemented by unpalatable ambiguities, fi-actured texts and mdeasiveness, which, m the absence of dearly defined diaradenzations and marufest plots, often leaves the audtence perplexed and vaguely uncomfortable So much for the 'paradigmatic' nature of the stage, what of the 'unparadigmahc' nature of everyday life? There are dearly some situahons m which submerged bebefs and 943
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Tiiese rhetoncal conventions mdude the outward signs of autiionty wbdi confircmt visitors to mshtuhons, sudi as formal tiles and modes of address, elaborate procedures for mihally accessing members of the team, convenhons ccmcenung manner and dress, clearly delmeated areas of expertise and responsibility, and convenhons concxmmg the style and content (rf communicahcms, mdudmg the use of technical language and the nght to deade what should and should not be disdosed, aU OKiicahve of stnd divisions of labour and a more-or-less ngid hierardual system Authenhcatmg convenhons, on the other hand, obtam between pwformers and the diaraders m the play, they ccKnpnse modes of speech, demeanour and action wbch serve to authenticate the play In the context of nursmg, we rtught usefully treat tbs as mdudmg all the techruques by which we are convmced of our own legitimacy Tbs includes- both techniques wbch we have developed unconsaously, such as our tendency to converse with pahents m ways wbch confirm our bebefs about our respechve roles, and techruques whidi we anploy consaously, sudi as our determmahon to embody and enact Given the complexity and confusioa and the occult parhcular ideals withm our style of commurucahon — sudi nature of mohves, mtenhons and conseqiKnces to which as consaously adoptmg the open stance and regular eye we have referred, what strategies do parhapants deploy m ccHitad descnbed m the counselbng texts order to organize and make sense of the soaal events of everyday bfe? Bums (1972) suggests that 'the language and Code of rules gestures one teams at home, at school and m groups to which one later belongs m the context of work or re- Together, both types of convenhon conshtute 'a grammar aeahcm, are denved fi-om taat agreements amstantly of theatncal presentahon', and the constramts they enad renewed or adjusted about the constaiKy and modificahcm amount to 'a code of rules for the transrrussion of specific of rrwanmgs These agreements, denved m tum from bebefs, athtudes and feebngs m terms of orgaruzed soaal norms accepted by those mvolved, conshtute 'convai- bdiaviour' (Bums 1972) Once agam, tbs ts remiruscent of hons', and we could Fegard them as Fegulahve components Foucault's nohon of a discourse formahon Scsnehmes, of the 'discourse formahon' of the assoaated context The however, these convenhons need to be supplemented by nature of these convenhons will now be considered other devices Gratht^'s (1970) development of some of Goffinan's ideas, for example, suggests that all performances are preceded by a 'strategy' anhapatmg potenhal RHETORICAL AND AUTHENTICATING mconsistenaes or gaps m the performance These gaps are CONVENTIONS parhculariy bable to occur m b ^ y charged soaal dramas, Bums (1972) distmguishes two d^ses of convenhcHis espeaally those mvolvmg danger or emohonai trauma, 'rhetoncd' and 'authoihcatmg' Rhetoncal convenhcms ard lead to the development of elabcn-ate ntuals, and obtam between performers and spedators, they 'are the behavioural and verbal taboos These will be famibar means by wbdi the audi«Ke is persuaded to accept to nurses- consider, for exanple, the complex communicadiaraders and situahons whose vabdity is ephemeral and honal taboos usually surrtnmdmg death, dymg, suicide bound to the theatre In addihcm to the convenhcms of and euthanasia Whentiteseare enccnmtered m the dmical spaang, timmg and settmg, they mdude the means, verbal situatioa f>arhapants tend to abide by a complex senes of fflid otherwise, by which the players ccmunurucate with and taboos and ntuals Even the pahoit adheres to tiwm, convinproach is to conceive art as a form of value-expression. If arhshc creahon is share of critiques, generaUy sjmnptomatic of weaknesses 946
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in the symbobc mterachomst perspechve (Lofland 1970, Ditton 1980, Shan-on 1981, Hopper 1981, Sedgwick 1982, Wilshu-e 1982b) Some cnhdsm, mixed wtth praise, has come fi-om unexpeded quarters (Blumer 1972, Marming 1976) and some has been parhculariy trenchant (Dawe 1973, Gouldner 1971) Apart from the disquiet concemmg Goffinan's inherently cynical view of relationshtps (Cuzzort 1969), a major cnttcism has been that b s focus on the miaosocial order results m an emasculated soaology wbch IS at a loss to understand and explain the maaosoaal These have provoked a number of successful rejomders (e g HaU 1977, Williams 1986) It has been claimed that Goffinan's work is politically conservative and enjoms soaal stahsm (Gouldner 1971, Fletcher et al 1974. Marx 1984), although there have been daims that he was a pobttcal radical (CoUms & Makowsky 1972), and the truth seems that he was pobticaUy ambivalent (WiUiams 1986) Whether Goffman's charadenzations are accurate, however, and whether he regarded the nature of soaal relations as unchangeable or such diange as not the task of soaologists, is not perhnent here The aim, rather, is to cut aaoss these controversies, first by frarrung a dynamic notion of dramaturgy wbch is expbaty creative and self- and other-affirrrung, and, second, by linkmg it, through Marxist cnhcal theory, to the notion of a normahve aesthehc praxis which is indisputably bstoncal, contextual and maaosoaal
SUMMARY AND PROSPECTS By bnngmg together the notions of 'nursing as praxis' and 'nursmg as drama', it is bemg suggested that nursmg may perhaps be regarded potentiaUy as a form of praxis expressed tbough dramatic performance — that is, a aeahve means of overcoming mearunglessness and alienahon — and of affirrrung one's humanity and that of others through aesthehc adivity In hamessmg a cnhcal concept of praxis to that of soaal life as theatre, the author is labounng to illuminate a way of understandmg the notion of nursmg as drama that offers t b e e unique strands First, the author wants to avoid the charges of cyruasm mevitably associated with Goffman's view that social bfe amounts to bttle more than a charade, and that the Self IS simply a senes of converuent masks In contrast, he is seeking a cntical emanapatory dramaturgy which, whilst founded on 'reaUy existmg conditions', emphcisizes the
tragoly, gravity and splendour of human bfe, the unity and conhnuity of Self, the mportana of genumeness, and the pursuit of the reabzahon of the best potenhals of self and
others In other words, a dramaturgy which is concemed with the potenhality as weU as the actuality of life Second, consistent with a Marxist account m wbch aesthehc activtttes are not accorded a pnvtleged status distmguishmg them from other humiin activities, and m which artistic and literary praxis are thus an integral part of genume human praxis, the author wishes to hold that our engagement with reality as nurses, mdudmg our dmical practice, can have a profound aesthetic quality which marks it out from alienatmg activittes Tbrd, conststent with Marx's famous dictum that what IS needed is not simply to mterpret the world but to transform it, the author wishes to postt a concept tn wbch nurstng practice is conceived as reflexively transformative, m that nurses are able to act upon, as weU as be aded upon by, their arcumsteinces To consider nursing as emblematic of a cntical emancipatory dramaturgy suggests some exahng possibibties for the conttnued exploration of the relationship between nurses and their pradice
Exploration A nijmber of ways for beginning such an exploration may be mentioned in closmg Nurses have a very nch source of msights hidden away m the exishng wntten discourse of nursmg, a discourse which is contmuously expanding, and the possibibty of mterpretmg matenal in terms of a theory of cnttcal dramaturgy is £in excitmg prosped Two contemporary trends add fuel to tbs possibtbty Ltttleknown or neglected aspects of nurses' discourse are being redtscovered tbough the developmg sdiolarsbp m the history of nursing Secondly, refledive accounts m the form of stones, poetry, dianes and anecdotes, are maeeismgly finding a place in pubbshed bterature (Bermer 1984, Deikebnann 1989, Sandelowski 1991, Wnght 1991) The narrahves contamed in t b s discourse refocus our interest on the charactenstically human (Antaki 1988, Plattner & Bruner 1984, PoUanghome 1988, Sarbm 1986), and offer opporturuties to dtscover, through cnhcal dramaturgtcal analysts, fresh insights mto our prachces, ourselves and our relationships with others Similarly, practitioners may lnihate systematic reflective processes wbch focus upon their professional expenences, usmg the vanous methods descnbed m the literature on the 'reflechve practtttoner' (Brown 1989, Carr & Kemrrus 1986, Cox 19W, Cox et al 1991, Holly 1984, Powell 1989, Schon 1987, Smyth 1986) These mcreasmgly familiar
methods might prove valuable mfleshmgout the skeletal concephon of nursmg as cntical dramaturgy which has been tentatively and bnefly descnbed here 947
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