Submitted by janesalvage on
One of the most exciting thinkers in nursing today is Michael Traynor, professor of nursing policy at Middlesex University. Check out his book, Nursing in Context: Policy, politics, profession (Palgrave Macmillan 2013). The Royal College of Nursing Research Society asked me to talk about it. Here’s what I said.
I was delighted when Michael told me he was writing this book – he is a stimulating and provocative thinker with an unusual take on many nursing issues, and I knew he would come up with something worthwhile. Nursing in Context is indeed stimulating and provocative, and brings fresh insight to nursing issues.
I also have a selfish reason for welcoming this book. Since my book The Politics of Nursing was published in 1985, I’ve been asked many times to write an update. Each time I went back to the book I felt daunted by the prospect. By covering some of the same ground in a fresh way, Michael has relieved me of my burden.
I feel I’ve been saying more or less the same things in different ways ever since I published my first letter in Nursing Mirror in 1977, describing nurses as ‘a herd of vocational donkeys’. So much has changed, but I am troubled that my diagnosis of nursing’s ills remains broadly the same. Are the changes are so slow and incremental that they are hard to spot, even over a lifetime working in nursing? Have things moved on and somehow passed me by? Or have things not really moved on at all?
A key difference between Michael’s book and mine is that I wrote it as a fairly young activist, not as an academic. I had left hospital nursing to work as a nursing journalist, because I felt it was a major way of getting nurses to think and act differently. My Cambridge degree had given me excellent grounding in critical thinking, and in student politics.
I hadn’t done any structured academic work on nursing at that time, though I read plenty. And as a staff nurse I joined groups on the thoughtful Left – including the intellectual activist Politics of Health Group, and rainbow community alliances defending public services in the East End of London. My book started out as a collective project with the Radical Nurses Group. As Michael summarises it when he interviewed me for his book, we wanted to ‘have an effect on the consciousness of nurses and… of others such as the public and politicians about nursing issues’ (p152).
Being a nurse triggered mixed emotions that led me into passionate discussions, professional and party politics, writing and public speaking; and have fuelled my career ever since. I ransacked feminism, history and sociology for studies of what made nursing and nurses tick, but didn’t find many. This puzzled me, and still does. Nurses are so numerous, so important, so interesting - and so invisible. We are in a black hole: no-one can see in and no-one can see out.
Nurse and scholar Jane Robinson and sociologist Phil Strong suggested this in their study of the management of nursing following the introduction of general management. They suddenly realized, they said, that ‘despite the impressive statistics… nursing is relatively unimportant to government and to managers in comparison with medicine.' They went on, 'The tensions to which this situation gave rise - the nursing group locked into the gravitational force of its internal preoccupations, and the others, on the outside, unable or unwilling to look in and comprehend the nature of nursing's dilemmas - seemed to us to be the social equivalent of an astronomical Black Hole' (Robinson 1992).
Almost all those who try to peer out of the black hole and to illuminate it are nurses. There is little significant scholarship on nursing by those who have not themselves worked as nurses, with a few shining exceptions – above all the sociologist and historian Celia Davies, whose book Gender and the Professional Predicament of Nursing (1995) remains, to my mind, the best analysis of all.
Why, though, is nursing apparently so uninteresting to most others, and why do most nurses collude with the submissive roles assigned to them? In trying to answer those questions, and to encourage fellow nurses to get out from under, I continue to walk a tightrope between analysis and activism. Strong feelings may of course stand in the way of objective scholarship, but they also provide the driving force of this often thankless work. You must go out on a limb - to challenge stereotypes, to make the decision-makers sit up and take notice, and to ask tricky questions of yourself and your peers.
On those tricky questions, Snow and Willard’s 1989 American study attempts a research-based ‘psychoanalysis of nursing’. Less than 3% of the nurses they surveyed believed they were filled with value or were valuable simply for who they were. Lack of self-esteem was the core issue. It resulted in submissive behaviours or, in over-compensation by some, apparent arrogance. Nurses were needy, in a working environment that told them not to be, and often had their needs met indirectly by taking care of the wants and needs of others. The resulting co-dependence, the authors concluded, took nurses off balance ‘into caring for others at the expense of ourselves, creating professional disillusionment and personal pain.’
This, I think, is nursing’s biggest guilty secret. It was partly mine. Only when I started psychotherapy aged 30 did I begin to grasp that going into nursing was partly driven by my unconscious desire to bring my dead brother back to life, as well as my huge need for love and approval.
Snow and Willard is dynamite but I rarely see it referenced. I took a very deep breath and wrote about it in 2003 in my column for Nursing Times. I said, ‘You may feel as uncomfortable as I once did with the idea that nursing cannot come of age until it starts to explore its collective psychopathology, and until each nurse commits to a similar personal exploration. But nothing will really change until we do.’ I waited to be drummed out of the profession, but no one said a word. Did no one want to go there? (Or had they stopped reading my columns?)
Deep-rooted neediness and low self-esteem among nurses does not mean they cannot change. But it does mean that major changes in the responsibility, accountability and leadership of nursing must be facilitated through massive development programmes that help people find a sense of purpose and dynamism, as well as equipping them with the necessary skills. A supportive workplace culture is also essential.
Nowhere is this more salient than in the current debates about what Michael calls ‘the mystery of poor care’. His four-part argument (p116) adds important psychoanalytic and psychosocial dimensions to the historical and sociological insights of Davies, Robinson, Rafferty, Nelson and others.
Changing things is hard because most of the levers of change are beyond nurses’ grasp, and the actions needed to prompt change go against the prevailing societal grain, as they require nothing less than a social revolution. What might such a revolution look like?
If I could wave my magic wand I would make three things happen. The first would be a social transformation in which society truly valued caring, and the millions of people, mostly women, who are skilled and kind care-givers at home and at work; and in which the men would finally play a full part.
The second, linked magical act would be a demedicalization and decommercialization of the health system, so that it was no longer driven by corporate and individual greed, and doctors were no longer the masters but members of the team. Thirdly, the whole system would move upstream, away from death denial and pointless or ineffective interventions, towards helping people and communities lead healthier lives.
Waiting for the revolution, I wobble almost daily on my tightrope with every fresh report of yet another care scandal, yet more abuse of nurses and yet another futile political or managerial response. I am swayed by rage, angst, exasperation and defensiveness, none of it conducive to clear thinking. As an ageing activist I wonder whether it’s time to leave the ring, and let the younger ones who I hope, armed with this book, will take up the challenges.
Nursing in Context: Policy, politics, profession by Michael Traynor, Palgrave Macmillan, 2013