Following Doctors' Orders
It's the largest profession in healthcare. It's the largest female profession in America. But despite its tremendous importance and impact, most people know very little about contemporary nursing. Public ignorance of the present-day profession, however, pales in comparison with ignorance of nursing's history. How many of us know that the development of nursing as the first secular profession for respectable women was a major feminist achievement? Or that Florence Nightingale was not, in fact, the "founder" of modern nursing? Or that nurses played a key role in developing the American hospital system, as nursing historian Sioban Nelson has documented in her recent book Say Little, Do Much? How many of us know about the role of nursing in the development of public health and care of the chronically ill and poor? Most important, how many of us recognize that society's persistent devaluation of nursing--reflected today in the prejudices of many newly liberated female physicians, health policy experts and journalists--is a legacy of longstanding, socially enforced subordination to medicine?
Katrin Schultheiss, an assistant professor of history and women's studies at the University of Illinois, Chicago, is one of a handful of non-nurses who understand what the profession has to teach us about the complex process of female emancipation, as well as about the development of modern healthcare systems. She recounts the tortuous history of how the "professionalization" of nursing in France coincided with anticlericalism and the secularization of the field. Although her story focuses on the forty-year period from 1880 to 1922 and takes place in one country, the gender dilemmas Schultheiss explores have hampered nurses' ability to care for patients in healthcare systems around the globe, including in the United States.
Her tale begins with the advent of France's Third Republic and follows political reformers who attacked clerical authority as they tried to modernize the healthcare system. Until that time, nursing outside the home was typically provided by convent-trained nuns. Modern hospital reformers recognized that nursing required more nurses with more systematic education, but therein lay the problem. Since knowledge is power, the acquisition of knowledge was inevitably a challenge to authority.
Physicians, as men, did not welcome women on their terrain. As members of a developing profession--one that did not then command the prestige it enjoys today--doctors were also adamant about defending their field "from irregular or illegal practitioners."
Even doctors who recognized the need for a more educated nursing work force and who wanted to laicize the care of the sick would not countenance the education of nurses if, in the process, nurses attained the kind of knowledge and stature that would allow them to demand greater authority and autonomy in both the workplace and society. So even lay nursing had to be constructed in altruistic terms that stressed not nurses' knowledge but their virtue. As Schultheiss writes, "As long as nursing was clearly understood to be a custodial, maternal, or charitable occupation, and as long as nurses were regarded as the social, economic, and educational peers of the patients, rather than the doctors, there would be no ambiguity about who held medical authority within the hospital."
In Paris, nursing nuns, while obedient and devoted, presented a problem to medical reformers. "The very existence of an autonomous community of women called into question the hierarchy of power within municipal institutions," Schultheiss notes. Happily, secular authorities found lay nurses, as one reformer commented, to be "infinitely more subordinate than the religious nurses and more scrupulous in the strict execution of doctors' orders."
While anticlerical reformers touted the benefit of lay nurses, the French public was attached to the nuns who had provided what out-of-home nursing care had existed since the seventeenth century, and even before. Of course, Schultheiss points out, even support for religious nurses was cast in gendered terms. Proponents of the nuns insisted that nursing should be left to a special group of religious women because it would corrupt lay women for their real work--which was mothering. "A woman is either a bad mother or a bad nurse," was their motto. To convince the public to support secularization, reformers had to "feminize nursing--to turn nursing into a general feminine virtue that all women could possess."
Schultheiss's story also introduces us to a peculiar hybrid form of religious nurse--the "hospitalières" of the Hospices Civils of Lyons. These women were secular nuns, congregationist sisters "who undertook a lifelong commitment to serve the sick and poor under harsh physical conditions and with virtually no monetary compensation, but who remained under the direct authority of the secular administration." According to Schultheiss, laicizers supported them because they were easily controllable and because their sense of devotion was easily manipulated by civil administrators who didn't want to pay the real cost of nursing care.
In this section of the book, class also enters the story: If civil administrators were to get nursing care for little or nothing, women's educational standards--and thus their salaries--had to be low. Whether they were secularizers or not, reformers recognized that more highly educated women of a better class would eventually demand more pay, and more say.
Finally, Schultheiss takes us to Bordeaux, where we meet Anna Hamilton, a reformer and devotee of Florence Nightingale. With connections to the international nursing reform movement, Hamilton wanted to open a nursing school that would produce a "new nurse," recruited from the so-called better classes. This new nurse, she insisted, would deliver better patient care than nursing nuns. Hamilton's critique of the nuns, Schultheiss explains, was not based on anticlericalism. Rather, Hamilton argued that the nuns had "distanced themselves from direct patient care" while creating obstacles to the creation of "a single medical hierarchy grounded on universal principles of hygiene and scientific health care."
Hamilton was able to gain support for her project from Paul-Louis Lande, a physician who became mayor of Bordeaux, because she firmly linked the "professionalization and feminization of nursing." Doctors in Bordeaux, Schultheiss writes, recognized "the need for improving the training of hospital nurses, but rejected all aspects of reform that expanded the nurses' autonomy or authority beyond the narrowest limits."
Hamilton accepted these limits, asserting that "it is extremely ridiculous for a nurse who possesses neither the knowledge nor the rights nor the sex of the doctor to try to imitate his way of interacting with the patient and to try to use his language." Thus, in France, as in England and the United States, the nurse-doctor game began with the acceptance of the notion that nurses could not--or should not--possess medical knowledge and that they therefore could not--and should not--use medical language.
Schultheiss ends her story after the First World War. The war produced such a huge need for nurses that the debate over the virtues of lay versus religious nurses effectively ended. When more than 100,000 nurses culled from every social class enlisted to serve "la Patrie," this "demonstrated that women's special aptitudes could be attached fruitfully to the state." However, even during this period and afterward, nursing was valued not for its knowledge but for its virtue. It had become, the author concludes, "a twentieth-century version of republican motherhood."
French nursing carries that legacy to this day. Last year, when I was strolling down the Boulevard St. Germaine in Paris, a book displayed in the window of a children's bookstore caught my eye. It was called Je Sais Qui Me Soigne ("I Know Who Takes Care of Me") and is part of a series on citizenship and the professions. Nurses make a brief appearance in the book--as doctors' servants who have, as the text reads, "just enough schooling to follow doctors' orders."
For nurses struggling to put their education to use for patients, rather than for physicians, the ability to escape, at least temporarily, medical domination has always made home care attractive. Which brings us to Karen Buhler-Wilkerson's part of the story. In No Place Like Home, Buhler-Wilkerson, a professor of community health and director of the Center for the Study of the History of Nursing at the University of Pennsylvania School of Nursing, traces the development of home care from the opening of the first US home-care agency--the Ladies Benevolent Society, founded in 1813 in Charleston, South Carolina--through the present.
In Charleston, as elsewhere, respectable society ladies started home-care agencies because they felt "obligated to improve the conditions of and provide for the comfort of the poor," who were, in turn, "expected to manifest their gratitude to the rich," who established these agencies. But they did not deliver the care. Nurses did.
No Place Like Home does a great service to these ordinary nurses who are often dismissed as know-nothings by some nursing elites today. Buhler-Wilkerson details the complexity of caring for victims of tuberculosis or managing patients during typhoid epidemics. She also documents the persistence of the issues with which home-care agencies still struggle today: how to navigate doctor-nurse relationships; how to choose appropriate patients for home-care services; how to deal with gender, race and class prejudice; and how to secure long-term services for the chronically ill.
From the early days of home care, doctors were concerned about nurses invading their territory. In Boston, for example, doctors "confided to lady managers that 'the constant danger with trained nurses is that they shall usurp the doctors' position and prescribe for patients.'"
At the turn of the twentieth century, with the founding of the Henry Street Settlement on the Lower East Side of Manhattan, Lillian Wald and her colleagues developed public health nursing--"to improve standards of living" of the poor. One of the great innovations of the Henry Street Settlement was the establishment of a "First Aid Room." This was a kind of community clinic where immigrants could gain easy access to nursing care for routine health problems. Doctors, however, soon complained that "nurses were carrying ointments and even giving pills outside the strict control of physicians." Even outspoken nurses like Wald's colleague, socialist Lavinia Dock, feared a confrontation with powerful physicians. By 1911 questionable cases were no longer treated in the First Aid Room. "Later publications," Buhler-Wilkerson writes, assured the public that "the real Henry Street Settlement nurse will make the doctor feel that she is exerting every effort to have his treatment, not hers, intelligently followed."
An equally fascinating subject tackled by Buhler-Wilkerson is the impact of racial prejudice on nurse-patient and nurse-doctor relationships. In both the North and the South, lady managers as well as nurses fretted about whether it was appropriate for white nurses to care for black patients or black nurses for white patients. When insurers, notably Metropolitan Life, entered the field at the turn of the last century, managers considered the same imponderables. Race invariably trumped the needs of care and even of doctor domination of the nurse-physician relationship. For example, Buhler-Wilkerson tells us that the respectable ladies of Richmond, Virginia, who ran home care in that city, decided it was "'eminently' satisfactory for white nurses to care for black patients on the 'same footing' as white patients--but drew the line at white nurses 'taking orders from colored physicians.'"
The advent of health insurance also had a critical impact on the home-care agencies. Wald convinced Metropolitan Life to cover home-care services in 1909. Met Life wanted to reduce the high mortality rate of black life insurance subscribers--thus delaying payments on their life insurance policies. Home-care nursing's preventive approach initially seemed to make good business sense. By the 1950s, public health nursing and medical advances had paid off: Fewer people were dying of infectious diseases, and more acute illnesses were treated in the hospital. This meant that the bulk of home-care patients were chronically ill. To reward public health nursing for its success, Met Life curtailed its home-care program. "Providing care for those who failed to recover quickly was, from an insurance perspective, a poor investment," Buhler-Wilkerson states bluntly.
Since the fate of nursing is tied to the fate of the patients nurses serve, the situation has not improved much, as first Medicare and Medicaid and now managed care have "rediscovered" home care. Indeed, today the promise of the home as a place where nurses and their patients can escape the negative consequences of medical paternalism and give or receive higher-quality care has remained largely unfulfilled.
In Devices & Desires, Margarete Sandelowski uses a different lens--the world of medical technology--to explore the issue of gender and nursing. This brilliant book shows just how much the "charitable, devotional and altruistic" image of the nurse conceals. From the discovery of the thermometer to the development of intensive heart and fetal monitoring, Sandelowski documents doctors' dependence on nurses for their reputation for scientific and technical mastery. As Sandelowski shows, nurses have been critical in administering medical technology, monitoring the information it provides and interpreting that information to physicians, not to mention "educating patients about new devices, getting patients to accept and comply with their use, and alleviating patients' fears about them."
An eye-opening segment describes the use of the first thermometer, rather than the hand, as a diagnostic tool in the mid-nineteenth century. In it, we learn that the thermometer we take for granted today was originally an unwieldy, dangerous instrument that had to be carefully manipulated so as not to injure the patient. Because diagnosis and treatment involved taking the patient's temperature numerous times a day, busy physicians assigned the task to nurses. This involved, however, far more than simply recording data. The nurse, Sandelowski writes, "had to know what caused various temperatures to occur and the nursing measures that would lower or raise temperature to normal levels."
While physicians were the ones to insert the first unwieldy and equally dangerous intravenous devices, nurses were the ones to make sure the patient's arm remained immobile and that the patient could tolerate the discomfort of IV therapy. Nurses are the ones who developed the intensive-care unit--to provide intensive nursing care--and who track and interpret data from fetal monitors. As the primary users of much medical machinery, nurses are often more knowledgeable about equipment than doctors. Indeed, "the benefits of machine monitoring could not be fully harnessed without nurses who understood and could act immediately on the information monitors generated." While the public does not recognize this fact, the author tells us that medical equipment manufacturers certainly do. This is why nurses continually work with physicians and manufacturers to create design improvements and to insure that "expensive machinery [is] fully utilized."
What is amazing about this story is how little nurses have benefited from their technological mastery. Sandelowski shrewdly diagnoses a classic Catch-22. While it is true that nurses' status is somewhat enhanced by their technical proficiency, the recognition they receive does not match their actual accomplishments. That's because physicians quickly label the technical activities nurses engage in as "simple enough" for a nurse to perform.
No matter how much nurses participate in the diagnostic process, of course, physicians have maintained a legal and linguistic stranglehold on "medical" diagnosis. Even as "physicians were increasingly expecting them to perform de facto acts of diagnosis," Sandelowski writes, "nurses were in the bizarre position of having to be mindful of symptoms without speaking their mind about them."
Nurses were supposed to be able to distinguish between normal and abnormal conditions and to look for reasons for any abnormal findings. But nurses were never to use the words "normal" or "abnormal" in reporting or recording patient conditions, and they were to refrain from offering their opinions on etiology or diagnosis.... Nurses were to say (report and record) only what they saw, unlike physicians, who maintained the right to say what they knew.
This has produced the peculiar phenomenon--even today--of the nurse who recognizes that a cancer patient has diarrhea or a mentally ill patient is hallucinating, but who is not allowed to use the actual medical word because that would suggest that she, or he, is making a "medical diagnosis."
As she describes these phenomena, Sandelowski never paints nurses as innocent victims of nasty, overbearing physicians. In their perennial attempt to find "a socially valued place and distinctive identity," Sandelowski argues, many members of the profession have, albeit unwittingly, adopted common gender stereotypes that perpetuate the oppression of nurses.
One segment of the profession, Sandelowski contends, has bought into the notion that the complex practical, technical work that ordinary nurses perform is indeed simple and know-nothing.
Typically conceived of as nothing more than the physician's hand, and persistently caught in the Western cultural dichotomy between merely manual and highly prized mental, or intellectual, work, nurses have struggled to show that nursing is largely brain work. In the process, however, they have inadvertently complied with the prevailing cultural practice of denigrating the very "body-knowledge" that is the forte of the nurse.
This is particularly evident in the nurse-practitioner movement, which so many elite nurses now promote. "The key factor differentiating nurse practitioners from other nurses," she writes, "is both the use of medical instruments and the use of instruments in ways previously denied nurses." But, she points out, in our bottom-line-driven healthcare system "the role emerges as largely economically and 'medically-driven'.... The traditional image is maintained of nurses as the extra hands and eyes of physicians willingly and cheaply filling voids and bridging gaps in health care."
Other segments of the profession, Sandelowski argues, have opposed nurses' emotional and social work to their technological activities, arguing that technology is somehow an inauthentic nursing activity, while "caring" is both authentic and an essential "antidote to technology." Sandelowski shrewdly insists that in opposing "nursing/touch and technology," the profession has been "identified both with and against technology and thus, in an ironic way, with and against itself."
While it is not the purpose of these books to offer advice about dealing with the many problems nursing confronts, they implicitly point to one incontrovertible solution: We can appreciate what nurses do in the present only if we understand how their work has been constructed in the past and what they have contributed--and can contribute--to our healthcare system.
Understanding and analyzing nursing's decades-long struggle for "a socially valued place and distinctive identity" is not an academic exercise. It is central to reversing the chronic underfunding of the nursing services most of us will eventually depend on in hospitals and other healthcare institutions, and also the undereducation of the nursing work force at almost all levels of practice. And it is critical to any solution to the severe nursing shortage, which, if not quickly and effectively addressed, will have disastrous consequences as the population grows older and sicker.