Suzanne Gordon
Topics in Advanced Practice Nursing eJournal. 2006;6(1) (c)2006
A Vow of Silence?
Several weeks ago, I was invited to speak to a group of undergraduate students who had been asked to read my new book, Nursing Against the Odds, for their history of science class at Harvard University. During the hour-and-a-half discussion, one question that kept popping up was: “What do nurses really do?” As I left the room, I pondered, as I often do, why the public has so little understanding of the consequential nature of nursing practice. Clearly, it’s because of traditional stereotypes about nursing. But it’s also because nurses have been socialized to be silent about their work or to talk about it in ways that fail to reverse these traditional stereotypes.
When I ask nurses to describe their work, many respond: “Oh it’s too hard to talk about. It’s too diffuse, too vague, too indefinable.” But I have written thousands of pages about nursing and I am not a writer of fiction. I’ve been able to write about nursing because I’ve observed nurses at work and asked them a lot of questions about their practice.
What Nurses Do.
Here is what I think nurses do. Using their considerable knowledge, they protect patients from the risks and consequences of illness, disability, and infirmity, as well as from the risks and consequences of the treatment of illness. They also protect patients from the risks that occur when illness and vulnerability make it difficult, impossible, or even lethal for patients to perform the activities of daily living — ordinary acts like breathing, turning, going to the toilet, coughing, or swallowing.
Even the most emotional work nurses do is a form of rescue. When nurses construct a relationship with patients or their families, they are rescuing patients from social isolation, terror, or the stigma of illness or helping family members cope with their loved ones’ illnesses.
What do nurses do? They save lives, prevent complications, prevent suffering, and save money.
Why do nurses have a hard time explaining such compelling facts and acts? Sioban Nelson and I have argued in a recent article in the American Journal of Nursing,[1] it’s because they’ve been educated and socialized to focus on their virtues rather than their knowledge and their concrete everyday practice. They’ve been taught to wear their hearts and not their brains on their sleeves as they memorize and then rehearse the virtue script of modern nursing.
If you analyze the words and images of campaigns used to recruit nurses into the profession or listen carefully to the stories nurses tell about their work, nurses may not use the available research to fully explain why what they do is so critical to patient outcomes. Although many studies, conducted by nursing, medical, and public health researchers, have documented the links between nursing care and lower rates of nosocomial infections, falls, pressure ulcers, deep vein thrombosis, pulmonary embolism, and deaths, most promotional campaigns and many stories nurses themselves tell about their work ignore these data.
Instead, nurses focus on their honesty and trustworthiness, their holism and humanism, their compassion, and their caring. The problem is that when they focus on caring, they often sentimentalize and trivialize the complex skills they must acquire through education and experience. They often fail to explain that caring is a learned skill and not simply a result of hormones or individual inclination. After all, knowing when to talk to a patient about a difficult issue, when to provide sensitive information, when to move in close to hold a hand or move away at a respectful distance all are complex decisions a nurse makes. To make these decisions, nurses use equally complex skills and knowledge they have mastered. But all too often nurses make these skills and knowledge invisible or describe nursing practice in terms that are far too limited.
Nurses are still talking about themselves — or allowing themselves to be talked about — in the most highly gendered, almost religious terms and allowing themselves to be portrayed with the most highly gendered, almost religious images. Indeed, as Nelson and I argue, with the best intentions in the world, many modern nursing organizations and nurses reproduce and reinforce traditional images of nursing as self-sacrificing, devotional, altruistic, anonymous, and silent work.[1] Just think of one of the jingles in the recent Johnson & Johnson image campaign:
You’re always there when someone needs you
You work your magic quietly
You’re not in it for the glory
The care you give comes naturally.
Historical Images of Nursing and Nurses.
Unfortunately, like those above, many of the images and words nurses mobilize reflect the religious origins of the profession. Nurses in religious orders were socialized to sacrifice every shred of their individual identity, to be obedient members of an anonymous mass. Religious nurses were taught not to claim credit for their work and accomplishments but were instead supposed to view themselves as divine instruments who willingly assigned the credit for their accomplishments to God, the Bishop, the Abbot, or the Mother Superior.
Most importantly, these images reflect a time when nurses were taught to Say Little and Do Much because to talk about a good deed was to turn it into a bad one — to exhibit the sin of pride. What nurses could accept were compliments for their deferential behavior and angelic virtues. What they could talk about was self-sacrifice and devotion and the outside agents they served.
If you look closely at the history of the problem of nursing visibility, you see that this religious depiction of nursing was not only a relic of the origins of nursing in Christian penitential practice but was also a legacy of the 19th century movement to professionalize nursing. In the 19th century, religious and social reformers like Florence Nightingale adapted the religious template to help women who wanted and/or needed to work outside of the home find purposeful paid work. In a society where gender roles were very rigid and people prized modesty and innocence, reformers needed to make it safe for female nurses to work in public spaces with strangers — mostly strange men.
Nurse reformers helped respectable women affect this passage by borrowing religious images, costumes, language, and metaphors. The nun’s cornette was transformed into the nurse’s cap. In English-speaking countries, nurses were called “sisters.”
Nurse reformers tried to desexualize nurses just as nuns (women who weren’t really women) had been desexualized before them. Nursing students wore ugly uniforms, were not allowed to marry, and were sheltered in cloister-like dormitories in or near the hospital. Nurses were said to be self-sacrificing and morally superior and would thus create order out of the chaos of the 19th century hospital.
Focusing on nurses’ virtues also helped nurses in their long battle with medicine for what became, in the 19th century, the highly contested terrain of the hospital. Before the 19th century, very few doctors had ever set foot in a hospital. In the 19th century, scientifically oriented doctors were moving into the hospital in greater numbers and wanted to control the hospital. They were not pleased to see a group of women who wanted authority and education competing for a sphere of influence (even a separate female sphere) inside the hospital.
Doctors were happy to have trained nurses but only if they were their servants. They wanted nurses to know what to do and how to do it but not why they were doing it. They didn’t want anyone to know if a nurse had acquired scientific, medical, or technical mastery. Because nursing at this time was feminized, women with no political, legal, economic, or social power had to make a deal with medicine, and the deal was that nurses could have virtues but not knowledge.
In the 19th century, nursing was thus constructed as self-sacrificing, anonymous, devotional, altruistic work. While this was a functional bargain to make over a century ago, this template reigns today in spite of the fact that things have changed dramatically for women — which is why it’s time for a change.
Now Is the Time for Change
I believe the public knows that nurses are kind, caring, and compassionate and that they provide patients with more information than doctors do. People don’t know, however, that nurses have medical knowledge, participate in medical cures, and have technological know-how. I believe nurses can advance knowledge of their profession if they amplify their caring stories and include anecdotes that help us understand that doctors don’t do all the curing.
The public needs to know that nurses — regular, ordinary bedside nurses, not just nurse practitioners or advanced practice nurses — are constantly participating in the act of medical diagnosis, prescription, and treatment and thus make a real difference in medical outcomes. Nurses can help the public understand that nursing is a package of medical, technical, caring, nursing know-how — that nurses save lives, prevent suffering, and save money. If nurses wear not only their hearts, but also their brains on their sleeves, perhaps the public, like those students at Harvard, will finally understand what nurses know and do.
References
1. Gordon S, Nelson S. An end to angels. Am J Nurs. 2005;105:62-69.
