July 19, 2016

Health Institutions as Bureaucracies

RaskoffBy Sally Raskoff

Have you ever been in the hospital? There’s a good reason sociologists use hospitals as one example of a total institution. One’s experience there can certainly match up nicely with the definition of a total institution.

Sociologist Erving Goffman had a lot to say about total institutions. They are places in which people live and work, cut off from the outside world, and perform routine activities, controlled by the rules of the organization.

We had a baby born into our family recently and I was reminded of the total institution typology when spending time in the hospital. Our family members, the new mom, dad, and their new baby slept in the hospital for a few days following the birth.

We all had to blend into the hospital’s routine. The nurses came in, welcomed the parents-to-be, and shared that this hospital had 12 hours shifts and many other policies to help the baby and the family get the care they needed with continuity and quality. Other medical professionals came in as their schedules meshed with the baby’s scheduled needs. Blood draws, coaching with nursing the baby, and many other medical procedures led health care workers to enter into the room as the parents coped with healing, sleeping, and taking care of their newborn.

The mom and baby were the focus of the visits. Thus the dad, who stayed the entire time as an advocate and support system for the mom ad baby, was not necessarily always acknowledged or automatically included by some of the medical workers. The physical layout of the room also served to put him in a secondary position since there was minimal seating. The small couch cushion that was supposed to be serve as a bed would not hold a child comfortably, much less a full grown adult male.

The baby-centered approach sounded promising, but soon proved to be undermined by the hospital administrators’ decisions about staffing. The nurses filled us in on how slow this particular week was. The week before, they had 32 new babies on the ward but this week, only eight. That sounded potentially wonderful, with more nurses and attendants on staff there to care of every need. But it soon became apparent that they had downsized the staff, perhaps too dramatically, since it sometimes took over an hour to get a response to a call. At one time, there were only two nurses on staff!

Hearing about the 12 hour shifts also sounded promising. On that first day, we had three nurses for 12 hours. But every day after, they seemed to change often and intermittently. We asked and were told that so and so was owed a day so she had left, and so and so had come over from another place and had some time to work off. So there was a lot of turnover in the nursing staff, which added to a very non-restful time in the hospital room. On the day with the most turnover, the new mom was asked about her nursing progress almost every two hours by each new person coming on shift.

While the “total institution” typology fits, it seems that Max Weber's discussion of bureaucracy also explains our experience.

Bureaucracy within the hospital setting was revealed within the organization’s hierarchy and aforementioned rules. The hierarchy was evident with the nursing staff and others who came in an out. The nurses had precedence over the food people and staffers who cleaned or delivered items. The doctors had precedence over everyone else. When the doctor appeared, everyone cleared out without having to be asked.

While everyone disparaged the hospital food, even the people bringing it, it was served to the mom at all mealtimes except one. Dad got no food from the hospital. So we (and others) were bringing food in as often as possible to feed him – and mom. Bringing in food from the outside broke the walls of the total institution. But the bureaucracy kept working, even dysfunctionally, as we sought ways to circumvent it.

If you’ve had experiences in a hospital, what other examples can you provide? What other organizations can you think of that could also be analyzed as a bureaucratic total institution?


The most striking example of hospital hierarchy I noticed while in a hospital ward for a week was when I woke up and realised I was surrounded by a group of doctors; their need to do their rounds was prioritised higher than the social rules outside of the institution which would have guided them to not enter my living space while I was not conscious!

very interesting

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