Health & Place 7 (2001) 81–92

Back to the old house? ‘sick role’ and biographical narrativesof the housing needs of short-stay hospital patients

Chris Allen*

Housing and Urban Studies Unit, School of Environment and Life Sciences, University of Salford, Allerton Building, Frederick Road,

Salford, M6 6PU, UK

Received 27 March 2000; received in revised form 25 September 2000; accepted 1 October 2000

Abstract

This paper examines how decisions are made about the housing needs of short-stay hospital patients. Two narrativetypes of patients’ housing needs are identified. The ‘sick role’ narrative emphasised patients’ ongoing medical needs andtended to prescribe ‘sick role’ placements in residential care or nursing homes instead of a return home. Conversely, thebiographical narrative emphasised the importance of home as an integral element of ‘elective biography’ (Beck and

Beck-Gernsheim, in: Heelas, Lash and Morris (Eds.), Detraditionalization, Blackwell, Oxford, 1996) and thus a highlyemotional ‘psychic warehouse’ (Gurney, Ph.D. Thesis, Bristol, 1996) that was integral to post-discharge recovery andwell being. # 2001 Elsevier Science Ltd. All rights reserved.

Keywords: Hospital discharge; Community care; Needs assessment; Housing; Home; Biography; Emotions

Introduction

Housing researchers have long lamented the inade-

quate attention that they claim has been given to theconcept of ‘housing need’ in health and community carepolicy and practice (for example, Arnold et al., 1993;

Watson, 1994; Leigh, 1994; Clapham, 1994; Claphamand Franklin, 1994; Franklin, 1998). Research attentionhas therefore focussed on the incorporation of housingneed into community care planning (for example,

Arnold and Page, 1992; Leigh, 1993; Lund and Foord,1997; Macfarlane and Laurie, 1996; Oldman, 1998), theassessment of housing need in hospital decommissioning

programmes (for example, Crosby et al., not dated;Barry et al., 1992; Etherington, 1995) and care manage-ment and assessment practice for people already living in

their own homes in the community (for example,Kestenbaum, 1995; Hudson et al., 1996; Allen et al.,1998). Beyond Clark’s research into the role of occupa-

tional therapists (Clark et al., 1996), however, littleattention has been given to the way in which housingneed is assessed at the point of short-stay hospital

discharge. This is despite a 506% (i.e. from 18,000 to109,000) increase in the discharge of short-stay patientsfrom hospital to nursing homes over the period 1982–

19911 being the main reason for the increased policyemphasis that has been given to the provision of ‘care inthe community’ since the 1990s, and thus hospitaldischarge being the point at which most people’s

housing and community care needs are likely to beassessed.There are a number of points of interest in contrasting

housing need assessment at the point of short-stayhospital discharge with housing need assessments under-taken in a community care context. For example, when

community care assessments are conducted in the home,social workers undertake relatively uncomplicated solo

*Tel: +44-161-2952173; fax: +44-161-2952184.

E-mail address: c.allen@salford.ac.uk (C. Allen).

1This compares with a 30% (i.e. from 39,300 to 155,300)

increase in placements made to residential care homes from

1981 to 1991 (Health Committee, 1993).

1353-8292/01/$ - see front matter # 2001 Elsevier Science Ltd. All rights reserved.

PII: S 1 3 5 3 - 8 2 9 2 ( 0 0 ) 0 0 0 3 8 - 1

investigations of housing need by asking a series ofquestions and making observations about the housing

situation of the ‘client’ (Allen et al., 1998). In contrast, atthe point of hospital discharge the situation is muchmore complex. Here, persons representing a range of

professions are involved with the patient prior to, duringand following their hospital discharge and are (or, atleast should be) involved in assessments of housing needas a matter of routine. Yet, little is known about the

manner of the discharge assessment, whether conflictsarise between the different professionals involved, thesource and subject of such conflicts, how conflicts are

resolved and in whose favour they are resolved. Forexample, are housing need assessments integrated with(and thus considered alongside) patients’ treatment

programmes during their hospital stay or conductedseparately? More specifically, is a housing need assess-ment undertaken when patients are admitted to hospital,

at the point when they are about to leave hospital oran ongoing process continuing throughout their stay?And, ultimately, how are housing needs assessed, whatassumptions are used, and what effect do these assess-

ments have on patient well being following theirdischarge from hospital?

The research context and study setting

The research on which this paper is based emerged outof a concern that housing need remained an absent, ifnot, marginal consideration in community care assess-ments undertaken at the point of short-stay hospital

discharge. In particular, previous studies had allegedthat both hospital staff and hospital social workers wereneglecting to consider housing need in their discharge

assessments and that, consequently, they were continu-ing to discharge patients to nursing homes (Allen et al.,1998). Given the lack of research in (and understanding

of) this area of health and community care practice,ethnographic research methods (see Hammersley andAtkinson, 1995; Howarth, 1993) were used, in 4 case

study areas2, to examine:

(a) the social organisation of hospital care needsassessments and subsequent post-discharge place-

ment needs assessments,(b) how the professional–patient relationship develops

from the point of hospital admission to the point of

discharge,(c) how (a) and (b) influence professional perceptions

of patients’ housing needs at the point of hospital

discharge,

(d) why conflicts of professional perception arise, howthey are resolved and in whose favour.

Participant observations of professional–patient inter-actions were undertaken at every stage of the hospitalprocess, from admission to discharge and either

recorded ‘on the spot’ or immediately after in afieldwork note book. To complement this initialobservation work, one of the project researchers (this

author) spent time ‘‘hanging out’’ with a sample of theward nurses and social workers involved in the pre-viously conducted participant observations. ‘Hangingout’ involved ‘shadowing’ my nursing and social work

‘colleagues’ and thus accompanying them to ‘wardrounds’, assessment meetings, home visits and visits toresidential care homes as well as more informal events

such as ‘going to the pub after work’.3 Whilst hangingout with them, my ‘colleagues’ almost always introducedme to others as a ‘student’ nurse/social worker. Field

notes were either made ‘on the spot’ or at the firstavailable opportunity during the day.An ‘unanticipated consequence’ (Giddens, 1984) of

‘hanging out’ was that my ‘colleagues’ appeared to

invest a great deal of trust in me and, as such, self-selected themselves as the ‘key informants’ that are soimportant to the ethnographer (Gurney, 1996). This

occurred gradually, as higher levels of trust wereinvested in me over time, whereupon my ‘colleagues’became more and more candid with me in (mainly) ‘off

the cuff’ discussion (for example, on car trips toassessment meetings). I was subsequently able to askquestions of key informants (throughout the 18 month

duration of the study) that might not have been possibleprior to the establishment of this trust and ‘candid talk’.The participant observations and ‘hanging out’ elementsof the field work were then followed up by in-depth

interviews with ward nurses, social workers and otherrelevant actors, such as consultants, hospital managers,occupational therapists and family members. These

interviews covered general issues pertaining to nursingand social work knowledge as well as the service deliveryand assessment practices observed.

The analytical categories that emerged are derivedfrom a (non-medical) sociologists ‘grounded theoretical’(Glaser and Strauss, 1968) reading of transcripts andfield notes from each of the hospitals involved in the

study. However, I will follow Gurney in makingparticularly extensive use of the empirical materialcollected from the two case study wards where by far

the least (time, access, etc.) restrictions were placed on

2Case study areas were based on social services authorities,

because of their after-care funding responsibilities to patients

being discharged from a short stay in hospital.

3Respondents were informed about the ethnographic method

and gave permission for me to ‘poke around’ (Howarth, 1993)

and record any aspect of their nursing or social work talk,

whatever the situation.

C. Allen / Health & Place 7 (2001) 81–9282

me and where the trust invested in me appeared to be atits highest:

It is not the task of the ethnographer to generateresearch with validity for a wider universe, but toconstruct an internally coherent case study which

discovers the variables which have explanatoryvalue in specific cultural contexts. (Gurney, 1998)

The analytical categories are based on the notion of‘patient narratives’, i.e. internally coherent ‘stories’

about patients and their housing needs. Two types ofnarrative are identified from the transcripts; ‘sick role’and ‘biographical’ narratives. The main difference

between these two narratives concerns the extent towhich they incorporated } or excluded } an emotionalconception of housing need on top of the physical (i.e.

access, utility) aspect of housing need. This reflects theextent to which emotional importance of place to healthand well being was one of the most controversial aspects

of housing need, and the frequency with which it placedthe professions in conflict with each other.4

Ward nurse rhetoric and the social organisation of

the ward round

Although the role of the ward nurse is to manage the

environment of, and care for, sick patients (Olesen andBone, 1998), and involves ‘emotion work’ (Hochschild,1979, 1983), the extent to which emotional labour has

been considered a key element of nursing theory andpractice has varied. Olesen and Bone (1998. p. 318) notethat, in the early 20th century, nursing educators reactedto the devaluation of their ‘soft’ role by playing down

the importance of emotional labour and, instead, soughtto professionalize nursing ‘‘by aligning themselves with[modernist medical] rationality and efficiency’’. More

recent ‘post-modern’ nursing texts have, however,played up the importance of ‘emotional labour’ (e.g.Ray, 1987; Cooper, 1993; Walters, 1995). Contemporary

nursing practitioners now similarly emphasise thesalience of the psychosocial aspects of their practice(Meerabeau and Page, 1998; Olesen and Bone, 1998)

and, in particular, the psychosocial importance ofdischarging a patient to their own home:

We always try and get them home, rather than in anursing home. With the patient’s charter, patients

and carers have the right to exert choices and havethe right to take risks and we go along with that, ifthey want to go home. Ward Nurse #1

Using the in-depth interviews and participant observa-tional research methods, we were able to unravel the

processes involved in translating these rhetorical utter-ances (about taking the patients desire to return home asthe starting point of the assessment) into practical

occurrences. In doing so, it became apparent that theward nurses constructed ‘sick role’ narratives (cf.Parsons, 1951) of patients. The nursing staff began toconstruct their ‘sick role narratives’ at the point of

hospital admission, when patients were at their mostvulnerable. At this stage, the ward nurses used a varietyof activities of daily living (ADL) assessment tools to

extract what they regarded as objective informationabout patients. Each of these assessment tools addressedissues such as bathing, dressing, continence, feeding,

mobility, communication and behaviour from whichpatients were categorised according to the score theyobtained. One assessment tool categorised patients as‘‘below 10 } low risk’’ until, at the highest score of

20+, patients were considered to be at ‘‘very high risk’’of restricting or putting back their recovery if theyreturned home. Using another admission-based assess-

ment tool, patients could be categorised as ‘‘below 5,own home’’, ‘‘6–12, residential’’, ‘‘13–21 residential ornursing home’’ and ‘‘22 upwards nursing home’’.

The ward nurses’ would then ‘work up’ the sick rolenarratives emerging from the nursing assessments byusing their observations and experiences of each

individual patient, though only in their role as Mrs. X‘the hospital patient’ and not in their role as Mrs. X ‘theperson’ who had non-medical needs and desires (such asto return home). Decisions about ‘appropriate’ post-

discharge placements were then deduced from theindividualised sick role narrative of each patient, ratherthan their vocalised desire to return home:

Yeah, of course you have to take into account

patient’s choice and things like that but I think . . .their [patient’s] idea of what they can manage istotally different from our experience of what theycan manage. Ward Nurse #2

The ward nurses did not, then, use weekly ward roundsas forums in which the patients’ wishes (to return home)could be incorporated into the process of constructing

‘patient narratives’ as they had claimed. Rather, theward rounds were used to gather each of the profes-sionals involved with the patient (consultant, sister, care

assistants, social worker, community psychiatric nurse,occupational therapist and so on) together. This not

4The salience of emotional attachment was identified in the

transcripts through recurring (and unprompted) social work

talk about the psychological importance of ‘home’ being as} if

not more } important rather than the physical (i.e. access,

utility) aspects housing need. This confounded the initial

expectations of the researchers who (with one eye on the policy

and practice debate being conducted at the time of the

fieldwork) anticipated that social work talk would primarily,

if not solely, be about the physical aspect of housing need.

C. Allen / Health & Place 7 (2001) 81–92 83

only enabled the ward nurse to disseminate ‘objective’medical information about patients. It also enabled them

to disseminate their (nascent and developing) ‘patientnarratives’ to consultants and other professionals, whichwould then be discussed in the context of the impending

discharge. The following two ward rounds illustrate howward nurses dislocated ‘‘the case from the patientsbedside and [in the case of the mental health ward] fromthe patients physical presence’’ (Barker, 1996).

The mental health ward round in hospital A tookplace in an isolated room, away from patients. Here, theRegistrar read out case notes. Following this, members

of the team were invited to make comments} providingsupporting statements based on their own observationsand experiences of ‘the hospital patient’ being discussed

and, in unusual circumstances, disagreeing. Conversely,the physical frailties ward round in hospital B wasconducted in a more informal fashion. Here, ‘the team’

were taken around the ward by the ward staff. The teamwould stop at each bed, whereupon the ward nursewould divest ‘objective’ information about the patient’sneeds by reading selective extracts from their case folder

that substantiated their sick role narrative. Informationsuch as ‘‘Mrs. X has not slept all this week’’, or ‘‘Mrs. Yis still being administered with drug X’’ were typical

types of information. The ward staff then took theopportunity to disseminate their ‘sick role narratives’ ina lower tone of voice (so as to conceal their discourses

from patients). These comments were almost alwaysacknowledged by those involved as ‘interpretative’ andusually involved a conflict of perception between thepatient and the ward staff, such as ‘‘Mrs. X wants to go

home, but she’s too confused to do that. She’s going tobe a problem’’.The participant observations of ward rounds thus

revealed tensions between the rhetoric of ‘patient-centredness’ and the nurses’ view of patients’ housingneeds, and thus disparities between what, for example,

Mrs. X said she wanted and what the nurses said Mrs. Xneeded. In particular, there was a clear contrast betweenthe enthusiastic manner in which ‘emotional labour’ was

embraced as a key part of ward nursing (for example,when managing the care environment during thepatients short hospital stay), and the lack of primacythat the ward nurses in our study gave to the

psychosocial aspects of patient well being (notably,when patients’ housing needs were being considered). Inthis respect, whilst nurses were aware of the need to

embrace the psychosocial aspects of patient care, their(e.g. housing need) diagnostic practices remained lockedin a modernist ‘world view’. This was based on a nature/

culture dualism in which the ‘‘sick’’ or ‘‘healing’’ bodywas located on the nature side of the dichotomy (Turner,1992, 1995, 1996; Bates et al., 1997) and in which the

psychosocial ‘wrapping’ in which the recovering bodypresented itself was ignored (Barker, 1996) in post-

discharge placement decisions. Consequently, the psy-chosocial aspects (in particular the emotional impor-

tance) of patients’ housing needs were regarded asirrelevant to their post-discharge recovery and well being.From an ethnographic point of view, this raised the

following questions: Firstly, how did nurses react whenpatients would (or were likely to) contest their sick rolenarrative, and had (or were likely to) voice their dissentto the hospital social worker? Secondly, who won the

argument and how? In answer to the first question, wardnurses would try to secure patients compliance with theirimpending ‘sick role’ placement prior to the hospital

social workers involvement, since an open discussioninvolving the later might lead to the sick role narrativebeing contested:

By the time we meet [patients] that idea [of

residential care] is already put in their mind.Hospital Social Worker #1

Indeed, some ward nurses would also try to get families

‘on side’ with the idea of a sick role placement, andwould even take the first steps towards arranging theplacement, so that the hospital social worker was offereda fait accompli (rather than open discussion) when they

became involved:

They have quite often phoned up nursing homesoff their own bat. They’ve told the family ‘‘yes thisperson needs residential care’’ and they haven’t

actually given any thought as to what the problemsactually were. Hospital Social Worker #1

The ward nurses did not, therefore, involve the hospital

social worker in the process to seek their opinions onwhether the decision to make a sick role placement wasappropriate, or to enable them to listen to patientsdissent, but to:

. . . follow the nursing assessment when devising acare plan. Ward Nurse #3

Thus, in cases where patients were continuing to contestthe sick role narrative of their housing needs (despite the

nursing and family pressure that had been mobilised toconvince them of its authority), the ward nurses wouldinvolve the social worker to ‘‘change their minds’’:

We might well also, if somebody’s fairly sure that

they want to go home, nevertheless ask them ifthey would be prepared to go out with the socialworker and look at alternatives. And sometimes

people go around and perhaps they might see anice communal place where they’ll have a bit ofcompany and a bit of independence at the same

time and start to ponder on their ability to gohome. So we try to change their minds by showing

C. Allen / Health & Place 7 (2001) 81–9284

them what the alternatives are. After that, ifthey’re still adamant on going home, then we

might have to try them at home and that’s theirchoice. Ward Nurse #1

However, whether or not the patient’s recalcitrant viewprevailed was largely dependent on whether the hospital

social worker that assumed ‘‘responsibility for arrangingthe discharge on behalf of the ward staff’’ was anideological supporter or opponent of the sick role

narrative.

The sick role narrative and its supporters

In the mid-late 1970s, the sociological orientation ofsocial work education came under sustained politicalattack for breeding ‘radicals’ that were more concerned

with challenging societal institutions } such as medicine} than with meeting the needs of individuals(CCETSW, 1975; Jones, 1996; Webb, 1996; Allen,1998). To counteract this, the Central Council for

Education and Training in Social Work (CCETSW)engaged in the ‘‘theoretical stripping’’ of the social workcurriculum (Sibeon, 1991a,b; Allen, 1998). The then

Certificate of Qualification in Social Work (CQSW) wassubsequently replaced by the ‘‘professional’’ Diploma inSocial Work (DipSW) which was ‘‘intended as an

employer-led form of practical training’’ (Sibeon,1991a. p. 140; see also Webb, 1996; Jones, 1996). Thesechanges were designed to replace ‘‘radical critics’’ with anew breed of social workers that would ‘get-the-job-

done’ rather than question why they were doing it(Sibeon, 1991a). In line with this, the recruitmentpolicies of the social work authorities that we studied

were emphasising the need for job applicants to haveeither a ‘professional’ social work qualification orrelevant experience from the ‘university of life’ (see also

Sibeon, 1991a):

I’m probably more finance oriented. I’m more

careful about saving money and working tobudgets. I think the team manager . . . [recruitedme] . . . to use me to influence other care managers

. . . . There was no vocational training for me. Itwas based on past experience. I had experience ofclient interview. I had experience of financialassessment [of clients]. So a lot of the things I

had done were relevant to the job. Hospital SocialWorker #5

The first ‘ideal type’ of hospital social worker was

typically drawn from this pool of newer and less social-work-experienced recruits and will be referred to as‘performative’ social workers. This is because theygenerally saw their role as to ‘‘perform what was

required’’ and therefore to efficiently and effectively

implement } rather than criticise } the recommenda-tions deduced from the sick role narrative. To this end,

performative social workers regarded their patientassessment as an exercise that involved collecting ADLand nursing assessment results and information from as

many sources as were available within the hospital:

We have got easy access to medical records . . . . Itis just gathering all available information within

the hospital. Hospital Social Worker #4

Thus, rather than critiquing the sick role narrative of‘the patient’, performative social workers were pro-active in seeking ‘‘medical opinion’’ and noting (in a

note book) what nurses said during the ward roundsthat were observed:

. . . they’re [ward staff] are able to tell me day to

day situations of the client. It’s a two way thing.They give me information. I give them informationon how far progress has gone [with arranging the

sick role placement]. Hospital Social Worker #5

Despite claiming to be a able to produce a ‘‘balancedassessment’’, then, performative social workers tendedto subscribe to the sick role narrative when conflicts of

perception arose between the patient and the wardnurses. This appeared to be because performative socialworkers largely passive acceptance of (the objectivity of)

the sick role narrative impeded their cognitive ability to‘counter-balance’ this by incorporating ‘patient talk’ asequally legitimate. Indeed, performative social workersoften rejected the voice of the patient as not being

grounded in ‘objective’ medical reality, thus per seillegitimate:

He wants to go home but he is not well enough to

make that decision. Hospital Social worker #4

‘‘Still ill ’’: Robert’s sick role narrative and theperformative social worker

The case of Robert provides a typical example of howperformative social workers tended to implement, ratherthan challenge, sick role narratives: In addition to the

ward nurses over-reliance on dependency test results(‘‘the patient scored 36 on the nursing assessment! Goshthat’s extremely high. Very high’’), they also placed

great emphasis on the housing and medical eventsleading up to the patients’ admission to hospital (i.e. atthe height of their personal crisis):

If somebody has been living on their own and theycan’t, they don’t appear to be able to do anythingfor themselves and we’ve heard on admission that

it’s been a disaster area, then immediately we’llthink ‘‘ah!’’. Ward Nurse #4

C. Allen / Health & Place 7 (2001) 81–92 85

In Robert’s case, the personal crisis that led to hisadmission indicated ‘‘quite early’’ to the ward staff that,

irrespective of what Robert wanted, a return home wasout of the question:

. . . So, that man [Robert] you saw earlier, it wasapparent quite early that there was no way thatthat man could go home for his own sake. Ward

Nurse #5, emphasis added

In Robert’s case, decisions about the appropriateness ofhis post-discharge placement were primarily arrived at

from the ward nurses’ initial impressions of Robert ‘thepatient’. In the usual way the ward nurses then ‘workedup’ the sick role narrative of Robert that had been

constructed at the point of admission by calling on andnoting (in his patient folder) their observations andexperiences of Robert ‘the sick patient’ during theremainder of his stay.

At the ward round immediately prior to his discharge,the performative social worker did not challenge howRobert’s sick role narrative had been constructed.

Instead, she made notes of the following ward roundconversation, in which one of the ward nurses dis-seminated the sick role narrative of Robert ‘the patient’

to the other participants who then made a unanimousdecision to arrange a ‘sick role’ placement for him inresidential care:

Ward Nurse #5: He is aggressive and has hit out atone of the ward girls. He shouts a lot but can holda normal conversation. One minute you’ll be

having a normal conversation with him, and thenext he starts shouting uncontrollably. You neverknow where you are going to be with him.

Community Psychiatric Nurse: His co-ordination isbad. He’s not incontinent, it’s just his co-ordina-

tion. He knows he wants to go to the toilet, but henever gets there in time and consequently soilshimself. His sister is scared of him. His behaviour

appears to be demented.

Thus, the performative worker accepted the sick rolenarrative of Robert (constructed from the ward nursesexperience of Robert ‘the patient’) as a demented and

aggressive character with personal care needs. As such,she perceived her role as ‘getting done’ what the wardnurses thought was required, and arranged to meet his

sister in order to arrange the move to residential care.The ‘rules of the game’ were quickly established by theperformative social worker at the opening of the

conversation:

Social Worker #4:We are thinking of moving your

brother into a residential care home.

Robert’s Sister: He wants to come home. He keepstelling everybody.

Here, the social worker recognises the sister’s immediatechallenge to the rules of the game by acknowledging

that, yes Robert ‘the person’ is ‘‘shouting because hewants to come home’’. However, in order to re-establishthe parameters of what is a possible course of action, the

social worker retreats into the sick role narrative ofRobert ‘the patient’ to explain that this shouting isirrational (‘‘because he’s not well so he needs drugs’’)and that he therefore needs a sick role placement in

residential care (‘‘so that his drugs can be administeredand so he can be looked after’’):

Social Worker #4: Mainly, he’s shouting because

he says he wants to come home, but how wouldyou feel about him going into nursing or residen-tial care? The doctor can give him drugs to stop the

shouting.

Silence.

Social Worker #4: Is it OK if I start looking at

some residential homes . . . [sister agrees with a nodof the head] . . . Would you like to come with me? Iwould like you to come and look at them yourself

because he’s not well enough to make a decision onhis own at the moment.

The social worker then substantiates her claim that thatRobert is aggressive and demented by repeating ‘‘the

facts’’ of what she noted about Robert from the wardround and ignoring the answer given by his sister:

Social Worker #4: Has he ever been aggressive at

home, or with you? He’s grabbed some of the girlson the ward and been aggressive you know.

Robert’s Sister: No, [he’s] never [been aggressive

before].

After this meeting, the performative social workerdiscounted (to me) the biographical evidence (e.g. thatRobert had never been aggressive) that Robert’s sister

used to contest his ‘sick role’ narrative ‘‘because she[Robert’s sister] doesn’t know what he’s been like on theward’’. The performative social worker thus continued

to seek a ‘sick role’ placement for Robert, despite hisongoing protestations (which continued during the carjourney to the residential care home) that he ‘‘want[ed]

to go home’’. During this car journey, his ‘want to gohome’ was dismissed by the performative social workeras ‘‘not realistic’’ until, on arrival, she purchased his

compliance with the sick role placement decision bymisleading him about the nature of his stay:

Robert: When are we going home?

Social Worker #4: You’re staying here for a fewdays to see if you like it.

C. Allen / Health & Place 7 (2001) 81–9286

There are two points to note here. Firstly, the decision toplace Robert in a residential care home was based on the

notion that he was (a) aggressive (b) suffering fromdementia and (c) had personal care, especially con-tinence, needs. Yet, as Robert’s sister had tried to

explain to the social worker, the sick role narrative wasan inadequate indicator of Robert’s post-dischargeneeds because it could not account for how he wouldrespond outside the medical setting of the hospital. In

particular, the sick role narrative of Robert ‘the patient’was culturally blind to (indeed, ignored) her evidencethat Robert ‘the person’ had only become aggressive

since his hospital admission, because he hated theunfamiliar and impersonal environment of the ward.Furthermore, since the performative social worker had

not thought it necessary to allow Robert ‘the person’ tospeak about his ‘housing history’ and his housing needsin the context of his elective biography (in particular, the

contrast between his hospital life and his home life), shedid not know that he had been physically active (andrenowned for riding a bicycle around town) prior to thesuicide attempt which led to his admission. She was also

unable to establish that Robert’s ‘‘lack of co-ordination’’ had only become apparent during his timeas Robert ‘the patient’: the hospital day room was

located at the opposite end of a long walk to the otherend of the ward where the toilet was situated, thuscausing him ‘incontinence’ problems during his time as a

patient.Secondly, the above practice, in which performative

social workers expected patients such as Robert to makean unexpected and abrupt transition to residential care,

was in direct contrast to the approach that our secondideal type of social worker used in situations where thesick role narrative had ‘triumphed’. These ‘radical social

workers’5 were unique because they constructed‘biographical narratives’, in opposition to the sick rolenarrative of patients. Since biographical narratives

brought the emotional significance of home into view,the radical social workers used ‘emotional unbonding’strategies (cf. Ruane, 1996) to cushion the psychological

impact of loss of home to the patient. This involvedarranging for their patients to conduct a series of dayvisits to their ‘chosen’ residential care home, prior totheir full admission, so that they could gradually adjust

to the emotional loss of their home. Nevertheless, this

was a ‘last resort practice’ for the radical social workersthat were often successfully opposing the sick role

narrative, during the fieldwork.

The sick role narrative and its detractors

When ward nurses referred cases to ‘radical socialworkers’, the discharge process became fraught withconflict. Radical social workers were critical of medical

systems as a matter of course because, in most instances,they had developed a scepticism towards ‘‘the medica-lisation of illness’’ during their (e.g. CQSW) social work

education and had subsequently institutionalised thismistrust into their practice following many years ofexperiencing ‘‘medical arrogance’’. The radical social

workers were especially critical of how the socialorganisation of dependence testing (at the point ofadmission) had led to the construction of ‘sick role’

narratives that were less relevant when wardnurses made housing need decisions (at the point ofdischarge):

The dependency level scoring is biased. It can bedone too early when someone’s just been admitted} they’re in bed, they’re ill. Whereas a week later,

they’re perhaps better and their score would belower. They can give a false recording. Generally,they only do one [dependency assessment] and

that’s when they’re admitted. So, then I check outlater if it’s changed with the patient and nine timesout of ten it’s changed, it’s reduced their depen-

dency level. Hospital Social Worker #2

Radical social workers were not only critical of themanner in which the procedural timing of dependencetesting led ward nurses to construct ‘sick role’ narrativesof patients’ housing needs. They were also critical of the

simplistic manner in which ADL assessments encour-aged ward nurses to construct ‘narratives by numbers’which were then used to sort the needs of patients into

standard (sick role or non-sick role placement) cate-gories. The radical social workers believed, instead, thatthe patient’s voice should form the starting point of the

narrative, irrespective of their level of need:

I always make sure that the client is heard. I’mreally strong on that because they very seldom getthat once they’ve reached the hospital. It’s

normally, things are done for them on their behalf.So, it’s really a case of making everybody sit backand say ‘‘well, hang on, it’s not exactly what hewants and if he wants to go home then we’ll pull

heaven and earth together to get them home.Hospital Social Worker #3

The penchant of the radical social worker to ‘‘pull

heaven and earth together to get them home’’, despite

5 I refer to some social workers in my study as ‘radical’ in the

same way that the Central Council for Education and Training

in Social Work used it against similarly oriented social workers

in 1972 when it argued that ‘‘certain sociological perspectives

. . . have had a radicalizing effect’’ (CCETSW, 1972, p. 12). My

use of the term also reflects Davies (1981, p. 19) observation

that the exposure of social workers to critical perspectives from

social science and sociology knowledge had led some of them to

become ‘‘critical questioning, even sceptical’’.

C. Allen / Health & Place 7 (2001) 81–92 87

the ‘‘high needs’’ of some patients, emanated from theirbiographical approach to constructing narratives of

patients. This being so, they regarded the ‘here and now’sick role narrative of Mrs. X ‘the patient’ as inadequateand, instead, believed it more appropriate to engage

with Mrs. X ‘the person’ as someone who possessed abiographical (past, present and future) life. Averse toconstructing a narrative of Mrs. X using the nursingassessment of her as a patient, then, radical social

workers began to construct their narratives by lookingbackwards at her life prior to admission in order tohighlight issues that might require addressing prior to

discharge:

We’ll sit down and have a chat about the waythings were before they came into hospital. I’ll try

and get them to bring up what the problemsactually were. Hospital Social Worker #3

This did not simply involve uncovering the practical

aspects of living at home prior to their hospitaladmission, i.e. the utility of the physical dwelling. Italso involved reconstructing the ‘housing history’ of thepatient in order to establish the (positive/negative)

nature of the emotional significance of ‘home’ in their‘elective biography’ (cf. Beck and Beck-Gernsheim,1996). The key issues for the social worker here were

to determine if the biographical accomplishment of‘home’ had been a positive experience (e.g. incorporat-ing memories of love, child rearing, etc., and feelings of

belonging, security, etc.) and was thus important topatient well being, or if it had been a negative experience(e.g. incorporating memories of abuse, and feelings of

insecurity, fear and alienation):

Somebody’s lived in the same house since theywere born and they’ve married, made a home, and

it’s all very convivial. Their memories are there,they could have been born there, had somebodydied there, they’ve got married, had children. It’s a

huge thing to contemplate giving up so, you can’tignore that you have to address that. HospitalSocial Worker #3.

‘‘Half a person’’: Margaret’s sick role narrative and theradical social worker

The case of Margaret was typical of how conflicts

were resolved between the sick role narrative of ‘thepatient’, and the biographical narrative of ‘the person’.Margaret was admitted to the physical frailty ward

following a ‘‘dense stroke’’. Taking into accountMargaret’s high dependence rating, high nursing testscores and the lack of progress that she had made whilst

in hospital, the ward nurses had decided that she was‘still ill’ and that, therefore, a ‘sick role’ placement in

residential care was the most appropriate course ofaction. The case was then referred to the social worker,

to arrange for the placement to be made. However, thesocial workers construction of a biographical narrativeof Margaret ‘the person’, led her to believe that hospital

had not been an environment in which she had been ableto flourish. The social worker agreed with Margaret thatresidential care would be equally unstimulating for herand that a placement at home would be the most

appropriate course of action to take:

There wasn’t much of a recovery process for heruntil I became involved, until I started telling herabout the options of going home if she was able to

walk. And then she began to be motivated to walk,to learn to look after herself a bit more . . . . [Then]she decided ‘‘I’m going home’’. That then created a

lot of issues for me because there was a lot of safetyissues. She was still falling . . . her balance waspoor. Hospital Social Worker #3

Since the sick role narrative had incorporated the ward

nurses’ ‘first hand’ experience of the acute physiologicalneeds that Margaret ‘the patient’ possessed, the wardnurses were sceptical of the course of action taken by the

social worker. However, having assessed the needs ofMargaret ‘the person’ in the context of her ‘electivebiography’, the social worker reported that her returnhome resulted in a subsequent improvement in her

physical well being, despite the ward nurses’‘punishment’ of withdrawing their hospital service tothe recalcitrant Margaret:

. . . the day hospital weren’t happy to accept her

because of her decision that she wasn’t going tostay in residential care . . . . [But] she got home andshe’s been home since. Her mobility has improved,her confidence has bloomed and she’s blossomed.

She is still quite disabled. She still needs quite a bitof support. Hospital Social Worker #3

Whilst Margaret’s case represented a successful outcome

for the biographical narrative over the sick rolenarrative, in other similar cases patients had ‘failed’.For the social workers, these failures did not occur

because the biographical narrative was deficient but wasa consequence of the external pressures placed on itthrough, for example, the early discharge of patients:

The provision of care to them at home [was]considered [by the ward staff] to be an inadequate

solution but it’s not that which is inadequate. It’sbecause they were discharged too early. So they’re[ward staff] making judgements about the inabil-

ities of patients when it’s not their fault that theywere discharged too early. If they had been

C. Allen / Health & Place 7 (2001) 81–9288

discharged properly, they may have been able tocope at home with care. Hospital Social worker #3

In contrast, if Margaret’s excursion home had failed the

ward nurses believed that this would have brought her tothe realisation that their initial decision (to pursue aresidential care placement) would be the correct courseof action to take next time:

So, what we do sometimes is we help the patientrealise the reality of things, by, if they’re adamant

that they want to go home and we feel that really isnot appropriate, we’ll often acknowledge thosewishes and they’ll go home but we’ll keep their bed

because we know that 90% that it’s not going towork and they’ll be back and it often helps them torealise the reality of the situation. Ward Nurse #2

The occurrence of ‘home failures’ ensured that the socialworkers role in discharge decision making became a key‘ward issue’ during the fieldwork. Initially, the wardnurses had been ‘happy’ to allow some patients to return

home (albeit expecting them to fail and return tohospital) where social workers’ biographical narrativesof ‘the person’ had enabled them to construct a

convincing argument to ‘win-over’ the nurses. However,the increasing number of failed home placements wasseen, by the ward nurses, to constitute a per se deficiency

in the biographical narrative favoured by the radicalsocial workers. This had brought with it a morefundamental shift in the overall balance of powerbetween the social workers and the ward nurses, in

which the credibility of the biographical narrative hadbeen severely undermined:

It impacts on my credibility with the medical staffwhen it comes to decision making and shifts thebalance of power in their favour because I’m

saying they could or they should go home butbecause it’s failed once, because of their earlydischarge policy, I lose my credibility when I’m

arguing again that they would be able to go homeagain. It also undermines my credibility with thefamilies, which is bad enough because they are

more likely to look up to the medical staff ratherthan me. Hospital Social Worker #3

The result was that the ward nurses were becoming

increasingly unwilling to allow patients to go throughthe process of failing at home:

Now [days], if [the social worker] takes someone toa situation which we don’t agree with then weblock discharge because we might think it’s too

risky. Ward Nurse #3

In other words, the ward nurses preferences for sick role

post-discharge placements were increasingly being im-

posed on patients in the first instance rather than beingused as back-up options to be invoked following the

failure of the social workers (apparently) ‘misguided’attempts to enable patients to return home.

Discussion: the biographical narrative in perspective

This paper has explored the manner in which nursingand social work staff construct narratives of patients todetermine their housing needs at the point of dischargefrom hospital. Two narratives were identified. The sick

role narrative (constructed by ward nurses and sub-scribed to by performative social workers) tended toprivilege physiological aspects of ‘the patient’ above the

psychosocial dimension of ‘the person’. This latterdimension was an absent (or, at best, marginal)consideration in assessment decisions about the housing

needs of hospital patients. The biographical narrative(constructed by radical social workers) was different inthat it emphasised the importance of incorporatingpsychosocial factors into judgements about housing

needs.The cases of Margaret and Robert provided interest-

ing illustrative examples of both narratives ‘in action’. In

Robert’s case, it was particularly notable that thenegative emotion associated with not being at home(was claimed to have) provided the catalyst for his

further deterioration on his admission to residentialcare. This, however, is nothing much new since medicalsociology has long recognised that the negative emotion

of ‘‘dramaturgical stress’’ affects neurohormonal regula-tion in the body and can be implicated in the onset orexacerbation of illness (Freund, 1982, 1990). However,whereas medical sociology has a long history of noting

the social aetiology of illness, it has, until recently, beenless vocal about the importance of the psychosocialparameters of health and well being (Nettleton and

Burrows, 1998a,b). This situation has been addressed, inpart, by the recent increased interest in developing apost-dualist sociology of the body (for example, Turner,

1992, 1996; Shilling, 1993) and post-dualist medicalsociology (for example, Kelly and Field, 1996; Williams,1996; Hughes and Patterson, 1997) in which psychoso-

cial factors are conceptualised as integral to, rather thanseparate from, well being (e.g. Frank, 1996, 1997). Forthis reason, the case of Margaret was pertinent becauseher physiological ‘condition’ was thought (by radical

social workers) to have improved as a result of her being‘re-bonded’ with the ‘emotional security’ of home.This claim about the integral importance of psycho-

social factors to well being has also been substantiated inthe theoretical suppositions of Lyon (1996) and inempirical work by Lynch (1975). For example, in The

Broken Heart: The Medical Consequences of Loneliness,Lynch shows how the physical condition of the body

C. Allen / Health & Place 7 (2001) 81–92 89

(measured using electro-encephalographic patterns) im-proves during positive emotional encounters, such as

when a nurse holds a patient’s hand. This finding isfurther supported by evidence that positive mentalattitudes in, for example, cancer patients enables them

to survive the disease for much longer than those withnegative mental attitudes (Charles, 1996) and also in thework of Bates et al. whose work:

. . . demonstrate that culture is one of the major

factors affecting the way people perceive andrespond to chronic pain in themselves and inothers. As long as the cultural backgrounds of bothpatients and providers are ignored in assessment and

treatment programmes, expensive treatments willremain primarily ineffective. Long term investmentin educating health care providers in personal

cultural self-awareness, awareness of the culture ofbiomedicine, and in cultural relativity may lead tomore effective care and treatment, and ultimately

save money and reduce human suffering. Bates etal., 1997: 1445: emphasis added

Three points now need to be made about the biogra-phical narrative. Firstly, it has become almost a truism

in medical sociology that contemporary nursing is muchmore in touch with psychosocial aspects. Yet, thisgeneralisation glosses over a clear separation, between

the embrace of the subjective and emotional dimensionsof patients (in the caring aspects of nursing practice) andwhat this paper has shown to be a continuing emphasis

on the objective and rational aspects (in the diagnosticelements of nursing practice). Whereas a psychosocialdimension has been incorporated into nursing caretheory and practice then (for example, in managing the

patient’s care environment during their hospital stay), ithas not yet been fully incorporated into the way in whichward nurses conceptualise of place as integral to

patients’ post-discharge well being.Secondly, health and community care debates have

limited the significance of housing need factors to the

physical (e.g. access and utility) aspects of the home. Themore oblique aspects of housing need, such as emotionalattachment, are seen to possess little or no significance in

social policy research, which remains locked in apositivist paradigm where only ‘hard’ facts that can bevisibly observed and empirically verified (for example,‘‘X% of tenants have difficulty with stairs’’) tend to

count as ‘rational’ knowledge. Furthermore, ‘emotional’aspects are seen to have no place in the public sphere ofhousing practice where ‘hard’ and rational decisions

have to be made about housing need and justified assuch to the public. Yet, the biographical narrative wouldclaim that such an emotionally vacuous perspective of

housing need is not only narrow and restrictive, but thatthe emotional aspects of social life should have a

significant place in decision making within the publicsphere. This is based on the notion that the social and

cultural organisation of emotional life (i.e. within thehome, hospital, nursing home, etc.) and emotion as anelective biographical accomplishment (e.g. the meaning

and significance the home has for patients), is implicatedin well being and should be considered as such.However, thirdly, practitioners of the biographical

narrative will sometimes be required to resolve a

paradox between the emotional importance of being athome to patient’s well being and the physical inade-quacy of their housing situation. For example, the

emotionally important home may be in bad structuralcondition (e.g. damp and draughty) or of low utilityvalue to patients with physical or sensory impairments

(e.g. they may be unable to use the stairs to thebathroom). On the one hand, the patients that westudied who were presented with this zero-sum paradox

said they would have chosen to struggle at home ratherthan be placed in a residential care environment thatthey recognised to be more suitable to their physicalneeds. Conversely, in the vast majority of cases where

practitioners believed they were faced with a zero-sumparadox, they chose to neglect the emotional aspect ofhousing need in order to meet the other, more privileged,

physical aspect of patients’ housing needs.Yet, research by Allen et al. (1998) has shown that

simple and inexpensive aids and adaptations and/or

repairs to the home can resolve this apparent zero-sumparadox (of having to chose to satisfy one need over theother) by improving the physical utility and/or conditionof the home. The same research also established that

social workers recognised this and sought to draw on thepotential of aids and adaptations as a matter of coursein their discharge assessments (Allen et al., 1998). It is

unfortunate, then, that social landlords’ aids andadaptations budgets are often minute and the first tobe cut when financial pressures bite (Allen et al., 1997,

1998) and that ‘care and repair’ schemes6 are equallymarginal to their thinking (Allen et al., 1997). This isbecause the cost of allowing patients to return home,

where its (e.g. damp/draught proof) standard ofenvironmental fitness made this is a realistic option,was the perforce requirement to draw on (female) familycare to solve patients’ physical (i.e. utility, e.g. stairs)

housing problems (Allen et al., 1998). That is to say, thecost of resolving the zero-sum paradox between theemotional importance of home and the physical housing

situation was the creation of another zero-sum paradox.This was the ethical dilemma that every individualdecision to enhance patient’s freedom of choice to return

6Care and Repair schemes ensure that the condition of the

home is repaired and maintained to the required standard of

fitness as determined by the Department of Environment,

Transport and the Regions.

C. Allen / Health & Place 7 (2001) 81–9290

home necessitated the (equivalent?) reduction of free-doms for those (women) that were obliged to offer ‘care

in the community’ to those patients. The problem forpractitioners of the biographical narrative, then, wasthat they were responsible for exacerbating existing

gender inequalities.

Acknowledgements

I owe a huge debt to the hospital workers for allowingme to intrude on every aspect of their working day/

week. I am also indebted to the anonymous referees fortheir helpful and constructive comments on the paper.

For further reading

The following references are also of interest to the

reader: Beck, 1992; Beck et al., 1994; Clapham et al.,1994; Giddens, 1990; Giddens, 1991; Goffman, 1961;Nettleton, 1995.

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