3.2 Qualified nurses: working in the shadow of medicine?
Dave, the senior registrar at Leeds General, made a strong statement about nurses on the audio clip:
Nursing staff are vital. I can't be there all the time. They are my eyes and ears. So they basically watch over the patients for me and will let me know of any changes either good or bad that may be important. If you are performing a procedure … it's very helpful to have an assistant there, someone who can help you with the practicalities of it and also talk to the patient… about bits and bobs to relax them.
Jackie, you might remember, said something rather different in describing what good care was to her as a nurse:
I think giving good care is listening to what the patient and the family want first and foremost … keeping [them] well informed is another thing, making sure that they feel physically as well as they can do … making sure that they know their way around … treating everybody with respect and with kindness - I think that's giving good care.
Activity 6: The role of the nurse
What are the main differences between Dave's perceptions of the role of the nurse and Jackie's? How would you account for these differences?
These two accounts are some way apart. Dave stresses ways in which the nurse can help him. He describes the nurse as an assistant to the doctor. He does not actually say that the patients are ‘his’ patients, although he seems to come close to it. What the nurse does, in this excerpt at least, is very much to play second fiddle. Even the reassurances that Dave knows he or she gives is downplayed as ‘bits and bobs’. Jackie, on the other hand, has a much wider view of what it is that nurses do. Her account is oriented to the patient and the patient's family, not to the doctor – indeed the doctor does not figure at all!
David Lee comments that, since this was written, the nursing philosophy has been subsumed within the new merged organisation (Leeds Teaching Hospitals NHS Trust). However, its principles remain relevant and continue to evolve with increased emphasis upon continuing professional development (CPD), responsibility and professional accountability.
The differences stand out particularly sharply because these are short extracts. No doubt, if challenged, Jackie would acknowledge that part of the job of the nurse was to do some of the things Dave describes, and Dave too would want to add that the nurse's role was rather broader than his remarks here imply. Dave certainly makes clear that he is aware that doctors can be accused of just looking at the disease, and adds his own belief that ‘you care whichever branch of caring you are in’. But the audio clip (like the excerpts from the trust's philosophy statement) does indicate that nursing works with a different model, which emphasises care rather than cure.
The single mostly frequently used definition of nursing in textbooks and classrooms is the following:
The unique function of the nurse is to assist the individual, sick or well, in the performance of those activities contributing to health or its recovery (or to a peaceful death) that he would perform unaided if he had the necessary strength, will or knowledge. And to do this in such a way as to help him gain independence as rapidly as possible.
(Henderson, 1966, p. 3)
Jackie's description of good care very much accords with this rather more formal statement. In some ways nursing seems to be the mirror image of the biomedical model.
In place of the focus on disease, it brings the person to the fore and stresses the different goals that people might have.
In place of striving for cure, it accepts that there are other outcomes – developing or regaining independence in the context of a chronic disease or disability, for example, or aiming for a peaceful death.
In place of emphasising expertise and special techniques, it aspires to work with, rather than working on.
Instead of the very clearly decisive and interventionist stance of the curer, it seems deliberately to hold back and reflect. It seems altogether a more nebulous activity.
In practice, it is probably fair to say that nursing looks both ways. Nurse education undoubtedly draws on the biomedical model with its emphasis on bodily systems and disease, but it also stresses that health and healing involve more than arresting the course of a disease by surgical or chemical means. Nursing emphasises care for the whole person, and pre-registration education brings a wide range of social sciences – including aspects of sociology, psychology, economics and social policy – into the curriculum more strongly than does medicine.
Holding a biomedical model and a broader, more holistic notion of care at the same time is not an easy matter. Nurse researcher Pam Smith, through observation on hospital wards and interviews with student nurses and qualified staff, has taken a direct look at student nurses. Her work shows that, although people come into nursing because they want to ‘care’ and initially value care very highly, caring slips down the agenda – even though no one deliberately is devaluing it (Smith, 1992). How could this happen?
First, there are the clinical placements that students do in the course of their training. As they pass through surgical, medical, gynaecological, paediatric, geriatric wards and so on, they are, in effect, moving through medical specialties. And the way in which students talked about their experience showed them shifting from an initial orientation towards people to a biomedical approach – in other words towards a medical cure model, not a nursing care one.
Second, students found the learning offered by the high-tech specialties altogether more tangible and more exciting. They were learning new and more technical procedures:
… one student, less than six months into training, compared the ‘heavy’ routine work of her first allocation to the neurological ward where she was now assigned. ‘It's unlike most other medical wards’ she said in a thrilled voice ‘because there are loads of different illnesses and multiple sclerosis and all that and people coming in for tests and lumbar punctures and things.’ In her excitement she saw neurology as exotic diseases and tests, rather than uncertainty, unpleasant symptoms and long-term suffering for patients and their families.
(Smith, 1992, pp. 54–5)
A comment from one of the nurses’ tutors conveyed, albeit for different reasons, that she too liked the medical model – because it was ‘nice and logical and it's scientific and you can do it in school beautifully’ (p. 38).
The third point in some ways is the reverse of this. When the course did deal with emotions and with interpersonal skills, it did so in a third-year module where students were encouraged to identify and explore critical incidents that they themselves had experienced and to comment on them in discussion. The informal nature of the sessions reinforced in them a sense that this was something that could not be taught. You ‘just picked it up’, they said, and they concluded that this was ‘stuff you learned as you went along’. Being caring, it seemed, resulted from experience and from coping with difficult situations.
These three points suggest that the learning experience of student nurses at the time of Smith's study was unwittingly devaluing care. Developments in nurse education have combated this in a number of ways. Student nurses spend more time in a structured educational setting and less as apprentices in hospital wards. They also now begin with a common foundation programme which emphasises health rather than disease and deliberately gives placements in community settings as well as in hospital wards.
If care tends to be devalued, cast into the shadows compared with the glamour of medicine in this way, it is important to develop concepts that can describe its contribution more clearly. Emotional labour is one such concept, designed to draw attention to the importance of offering support to patients, listening, getting involved with families, managing your own emotions and responding in helpful ways to others. While emotional labour is something people do for each other in day-to-day life, there are particular skills linked to emotional labour in the hospital and other health settings. For one thing, the nurse needs to make assessments of need and to respond appropriately to patients from different cultures and classes and at different points in the life cycle. There is skill too in organising emotional care, making the necessary time among the routines of physical care for work that can easily look and feel like doing nothing. Nicky James, a nurse researcher who has made a study of hospice nursing, argues that
care = organisation + physical labour + emotional labour
and she emphasises the centrality of emotional labour, the importance of the time to build emotional closeness and the logistical difficulties this can present in settings requiring 24-hour cover (James, 1992, p. 503).
The nursing staff on the ward in Leeds would no doubt identify with this – and Susan and Jack gave testimony to what they achieved. But often what will contribute most to the emotional well-being of a patient is something that seems on the face of it a very trivial and minor task - on a geriatric ward, for example, making sure hearing aids work and glasses are clean (Smith, 1992, p. 1). Nicky James and Pam Smith are among a number of researchers who suggest that emotional labour is a key concept in caring, which should be studied more carefully and incorporated into nurse education and into our understanding of the nature of nursing.
Activity 7: Constraints on nursing care
Read the two quotations that follow. You have seen how emotional labour can be overshadowed by the glamour of cure and not be fully acknowledged in nurse education, or well understood as part of nursing. What else, do these excerpts suggest, interferes with the possibility of doing emotional labour?
A nurse has been closely watching a post-operative patient whose psychological depression had been impeding his recovery. For days he has been silently brooding, unresponsive to all efforts to make contact with him. Finally, one evening, he begins to respond to the nurse, talking about his worries and concerns for the first time. As she sits with him, listening sympathetically, using all of her interpersonal skills to support his emotional catharsis, she feels that this is one of the rare and precious moments when she is really ‘doing nursing’ in the way she was trained.
Unfortunately, just after the patient began talking, the dinner trays came up from the kitchens. It is dinner time, the food is getting cold, the other patients are hungry and restless. Organisational efficiency requires that patients be fed at a certain time. But if the nurse leaves her patient to serve dinner to the others, the patient may withdraw into his shell again. The optimal time for talking to a patient cannot be regimented, controlled, or even predicted.
(Cherniss, 1980, p. 87)
One of the characteristics of nursing work is that it is difficult to specify with any precision. This is particularly true of general hospital nursing where, at different periods, nurses have done (and do) work which could be considered the province of cleaners, dieticians, porters, clerks, secretaries, ward housekeepers, receptionists and doctors…
Traditionally, one of the most valued attributes of a nurse has been her ability to ‘cope and get the work done’. Since nurses in hospital settings are the group in continuous direct contact with patients, they tend to be the ones to cope with the absence of other staff. This is particularly true outside of office hours and at weekends, where nurses may take on secretarial or clerical tasks, run errands, or act as extension therapists.
(Beardshaw and Robinson, 1990, p. 8)
The first quotation deals with the importance of organisational routines in the hospital, the need for a predictable pattern of events, and scheduling and co-ordination of activity. Care, on the other hand, in the context of the home and unpaid carers, is not easy to schedule and predict. It can play havoc with planned activity in a large organisation. You heard on the audio clip about one way of trying to reconcile the two - the shift to primary nursing. Organisational demands, therefore, mean that emotional labour can be devalued and sometimes actually driven out.
The second quotation continues the theme of devaluation. Caring, it seems, often amounts to coping with whatever needs to be done at the time and seems to be something that we can ‘naturally’ expect of nurses - something that is unremarkable, that goes unnoticed and unsupported. Doing other jobs can mean nurses have no time to care, and report that they are not doing ‘real nursing’. In short, then, if the doctor seems to be the ‘Great-I-Am’, the nurse seems to be the (not so) great ‘Can-Do'!
It is frequently said that nursing is ‘women's work’ and that this too contributes to its devaluation. Caring in the home is often done by women on an unpaid and unnoticed basis. An important question, therefore, is where gender fits in.
Activity 8: Images of nurses
This activity is designed to start you thinking about public images of nurses and the message about nursing work that they give. Consider the two advertisements for nurses. Both these advertisements ran in the national press as part of a campaign to attract more people to nursing. They are taken, as you can see, from some time ago. What message were they giving about the nature of nursing work and nursing care?
It is just as true today as it was in the 1960s, as the small print says, that most women who go into nursing marry, and that most take a break from nursing for childbearing and then return. It is also true that nurse training will help with the health care that women do in families. But it would not be surprising if nurses were annoyed at this portrayal of them. One message we might receive is that nurses are warm, attractive, caring people. Another message, conveyed by the headline and the picture is that marriage is more important for women than work, and that nursing is not really a job in its own right at all. The words say that nursing is a ‘real job’, but the context devalues it. The 1980s advertisement could also be said to devalue the work of nursing, although in a different way. By associating it with ‘women's work’ – something that comes naturally to girls – it is portrayed as a job that hardly seems to warrant formal training at all.
In the 1980s nurses campaigned against the kinds of image, in recruitment posters and in the media more generally, that portrayed them as angels or sex symbols or battle-axes (Salvage, 1985). Such images are not so prominent today, but they have not disappeared completely. And today's fictional nurses do not necessarily give what nurses themselves would see as an accurate representation of the skills and the demands of their work. Sometimes in TV soap operas it is the careful attention the nurse gives that teases out information vital to treatment. But nurses’ love lives figure in such stories more often than their skills as nurses. The recruitment posters, however, have changed. They now pay attention to the range of work and the diverse career opportunities in different fields of nursing. And at least one early 1990s campaign specifically addressed men. ‘Nursing is an Equal Opportunity Employer’ was its headline but, it went on, ‘we're very much aware that men and women aren't attracted to it in equal numbers’. It then challenged ideas that a man who nursed was ‘soppy’ or that he was there just to do the heavy work.
In some of the textbooks for nurses of a hundred years ago, describing and prescribing their place in health care, the hospital was compared to a family – the doctor as father, nurse as mother, and patient as child. The doctor made decisions, the nurse helped and respected him, and the patient followed orders, since daddy knew best (Gamarnikow, 1978)! The gender stereotypes of the time were clear – that women/nurses are naturally more nurturant, caring and motherly, and that doctors/men are calm, decisive, and scientific and rational in their approach.
Have such ideas been overturned completely? Of course, a great deal has changed in the course of a century. Although the proportion of men in nursing remains low, at about 10 per cent overall, numbers of women doctors have risen sharply in the 1990s, so that women are now about half of all entrants to medical school. Nursing is organised in the same way as medicine, as a profession that registers its members and sets conditions for entry, which has its own specialist journals and research. Yet pay differentials are considerable; nursing only became a university subject on any scale in the early 1990s; and the lack of investment in a strong programme of funded nursing research comparable with that in medicine has been a focus of enquiry and concern (Department of Health, 1992c). Has nursing ever been granted the resources and the autonomy to show what it can do? Certainly there have been nurse-led initiatives in areas where medicine has less to give – well-person clinics, care of the dying, and pain clinics, for example. We could say that in these cost-conscious days it is surprising that all this is not more developed. I am on record as arguing that medicine and nursing remain a prime example of legacies of gender-stereotyped thought and of the devaluation of the skills of caring (Davies, 1995). Others, however, point to the power that stems from being on the ward and having more knowledge of the patient under the primary nursing structure that James described on the audio clip (Hughes, 1988; Svensson, 1996).
The cure work of doctors and the care work of nurses are both important for patient care, yet nursing often seems less important.
The caring that nurses do is devalued in several ways, for example by its association with women's work.
Challenges for nurses are to re-examine the care they provide, work with others on ward towards multi-disciplinary working and to devise organisational arrangements that enable high-quality care to be given.