Guest Editorial

Whither Nursing?: Reflections on fate and futurity

Kim Walker
Nursing (Applied Research), St Vincent's Private Hospital, Australian Catholic University, Darlinghurst NSW

Article Text

Setting the scene

This editorial arises from a paper I was invited to present at a conference for peri-operative nurses in Sydney, mid 2002. My brief was to reflect on nursing's future in light of its past and in relation to the current crisis of recruitment and retention that afflicts our profession world-wide. It was also to offer suggestions as to how the profession might tackle some of its current woes in order that its cultural forecast might not be as gloomy as it may seem. In preparing for this task it struck me that nurse leaders and commentators have, in response to the millennial turn, been somewhat pre-occupied with and anxious about the profession's future (see for example: Biscoe, 1989; Traynor & Rafferty, 1999; Nay & Pearson, 2001; Nelson, 2002). While much of this anxiety is grounded in some compelling evidence (Jackson, Mannix & Daly, 2001; The Patient Profession: Time for Action, 2002; Our Duty of Care, 2002) there is also a sense that this evidence has existed for quite some time. Nursing's future has been looking a bit bleak for years.

What follows is an exploration of some possible reasons underlying our collective concerns and the effects of some of the more significant influences on the profession since the days of Nightingale: history, culture, gender, clinical specialisation and leadership figure prominently in my polemic.

From generalists to specialists

Let us reflect on what has been perhaps one of the most significant changes nurses have both led - and been obligated to embrace - over the last few decades of the 20^th century. I refer to the increasing specialisation and super-specialisation of nursing work. This was graphically illustrated by the fact that the audience for the original paper was a group of women whose work involved gynecological endoscopic surgery; undoubtedly a specialty within a specialty. In the days of the nursing apprenticeship the education of nurses was decidedly generic, so much so that training programs were invariably called 'general nursing'. Today's university graduate also takes out a qualification that is broad-based and 'general' rather than specific. But while there were some specialties evident in nursing in the mid 1970s (for example, disability nursing, mental health, and midwifery), nursing was essentially divided into two categories commonly known as 'medical' and 'surgical'.

However, as the discipline of medicine increasingly refined and narrowed its epistemological foci around bio-pathologically focussed concerns and interventions, nursing had to follow suit. Perhaps an unforeseen (and unhelpful) consequence of this specialisation and the segregation it has tended to create amongst nurses, is that we share less clinical terminology with which to communicate. Each specialisation has its own jargon and syntax; these bring with them language games of their own. Do we understand the rules and goals of these games of language in ways we once may have? In other words, perhaps our insecurity about our future as a profession is that we confront not just one but many possible futures? Each distinct specialty now contemplates its own unique issues and concerns about the viability or otherwise of its identity.

Past, present and future: anxieties and tensions

On trawling through the enormous number of extant journals in nursing, this specialisation in nursing is very evident. Peri-operative nurses have a small raft of publications dedicated entirely to their practice. It was in one of these publications that I came across an article by a leader of peri-operative nursing in the United States. In this piece - published after a major annual congress of peri-operative nurses in 2000 - Patricia Seifert (2000) asked a group of her peers to answer three questions. The first question was, 'What do you consider the single most important accomplishment of peri-operative nurses in the past 50 years?' (2000: 10). The common response was 'the development of the professional peri-operative role' (2000: 12). I suspect many peri-operative nurses would agree with this claim. Seifert's second question was, 'What do you think is the single most significant threat to peri-operative nurses in the future?' (2000: 10). The answers she received were particularly telling. Of her 50 or so respondents, (all of whom were peri-operative nurse leaders), more replied with the threat of 'replacement by less qualified personnel' than any other single threat (2000: 12).

On the one hand these nurse leaders suggest that becoming recognised as professionals in the peri-operative setting is a significant achievement. On the other hand, they express concerns about its very viability. How can it be that a hard won objective can become so precarious in the space of just fifty years?

The answers, I believe, are to be found in the remaining responses to Seifert's (2000) question. Her respondents attributed the problems discussed above to peri-operative nurses':

• failure to deal (constructively) with change;
• failure to quantify their value;
• complacency and apathy; and
• a rigid mindset (Seifert, 2000: 12).

That a group of senior peri-operative nurses could make such statements does make it rather easier to understand why peri-operative nurses are worried about their future and fate. However, future and fate, are of course, simply different expressions of the same phenomenon.

And it is this conundrum - the difference between future and fate - that seems to cause nurses bother. Clearly, the most significant achievement in the last fifty years for the specialty of peri-operative nursing has been the development and promotion of the professional peri-operative role. This suggests that those responsible for creating and sustaining such a development had a clear and rosy future in mind when they were so doing. Surely it suggests that over the last fifty years peri-operative nurses have been busy ensuring their place in the order of things, in the future?

But if these nurses are now also saying that their biggest threat is replacement by other less qualified personnel, this suggests a shift away from future-oriented thinking to a pre-occupation with fate; something not in our control, something over which we can exercise little influence. Fatalists are not usually optimistic; their thinking tends to be consumed with inevitability, tinctured with more than a healthy dose of cynicism, indeed is sometimes wracked by paranoid and other delusional thinking. Little wonder then that when asked to list threats to their future such fatalism led some of the nurses in Seifert's (2000) study to include: 'ourselves'!

Drawing on this idea of a tension between fatalism and futurity – I want to extend this idea of nurses sometimes being their own enemy. It seems to me a theme of complicity in our own ruin as it were, tends to pervade nursing regardless of the specialty in which individual nurses work. Why might this be so?

The lessons of history, culture and gender

Nursing in its contemporary manifestation, has a history of only about 150 years; surely it is far too soon to contemplate extinction after so brief a time? But nursing shares its history with another. This history extends back decidedly further than 150 years. It has its beginnings in the origins of our species. I'm talking, of course, about none other than the history of woman herself. In Florence Nightingale's words: 'Every woman … has, at one time or another of her life, charge of the personal health of somebody, whether child or invalid, - in other words, every woman is a nurse' (1969: 3). Such an assertion positions nursing's history as co-extensive with the 2, 000 years of civilisation we know as the history of the West. This history has seen the rise and rise of patriarchy, of the rule by men, of men and women, but always in men's name and for his ends and interests (Butler & Scott, 1992; Cox, 1996; Greer, 1999)

Nursing then – in Nightingale's time, and now - embodies the classical ideologies of what it is to be a woman. As Nightingale (1969) put it: every woman is a nurse by virtue of her capacity for maternity and the so-called 'feminine' characteristics of caring, nurturing and mothering; we know the vast majority of nurses are women and even today men comprise less then 15% of all nurses worldwide. I would like to stay with this notion that the history of the West has been the history of patriarchy and women's subjection to and in its name, because it is absolutely central to my polemic and how we can create a future notwithstanding such an unfortunate legacy.

Medicine, for example, exemplifies the very best of what patriarchy has to offer in that it has been able to secure for men of education and prestige, a dominant position – if not the pre-eminent position – in the hierarchy of health and illness and its many practices, politics and possibilities (Seymour, 1998; Wicks, 1999). Medicine has a history dating back almost as long as the history of Western patriarchy – 2000 years. As legitimate workers in the complex system of bureacratised healthcare which was born some 400 years ago, nursing appeared in only the last 150 years. This was well after medicine had established its superior position as the lead player by virtue of the ways in which it was able to shape and dominate its development (see Foucault, 1980: 166-182, for a detailed account). Consequently, we were latecomers to the interventionist system we ironically call healthcare - but ought to call 'sickcare'. Nursing has been forced to cling tightly to the coattails of medicine in part because Nightingale indentured us to them as a result of the conditions in which her nurses worked.

And this is exactly how Nightingale imagined it should be in a Victorian and profoundly masculinist society. A major concern was that the nurse never be more educated or clever than the doctor (see Nightingale, 1974: 132; Stewart, 2001:4); Nightingale knew all too well the perils of overstepping the boundaries of medical authority and how such action could only destabilise the future for nursing (see Woodham-Smith, 1952: 168-189). But in tying our selves to medicine's coat-tails in the ways and for the length of time we have, it is now exceedingly difficult to know how to set ourselves free. We need their patronage just as much as they need our support. I believe we must capitalise on this vexing reality and mark out our future accordingly.

From being led to taking the lead

It has been a long time between inspirational leaders in nursing locally here in Australia and globally across the Western world. To craft and secure a future for nursing in the new millennium we need now more than ever before to emulate patriarchy's techniques and develop what I call collective strategic leadership that is truly visionary and future-oriented (see also The Patient Profession, 2002; Our Duty of Care, 2002; Lett, 1999). We need leaders who can put the past and its multiple legacies of oppressions and colonisation into appropriate perspective and imagine a new version of the nurse and of the profession.

In concert with the authors of The Patient Profession (2002) and Our Duty of Care (2002) I believe nursing needs to nurture and promote leaders who are prepared to establish a public media profile for nursing. I ask: who represents nursing in the national television and print media? Currently nursing in Australia has no public 'face' at either a state or federal level. And this is despite the presence of chief nursing officers, many dozens of professors of nursing, and equally many nurses working in high-level strategic positions in Government and non-Government agencies. Why is it that whenever commentary or critique is sought on issues about 'health' it is medically-trained professionals whose opinions are sought and circulated at the expense of any other disciplinary group? The conflation of health and medicine as direct equivalents is enshrined in the way the law operates in relation to legal issues and health. Chiarella's (2002) compelling and authoritative work The Legal and Professional Status of Nursing provides unequivocal testimony to this argument with its serious consequences for nursing as a profession. Indeed, according to the law, nursing is only a quasi-profession; a sub-set of medicine at best.

Therefore considerable reform of the legal system as well as a strong and positive media profile for nursing must be placed high on the agenda for the future to bring some sense of cohesion and direction for the profession. We also need to put an end to a certain version of political correctness which dictates that for nursing to establish a position on an issue it has to consult every nurse from every sub-set of the profession before it can do so. Our remarkable plurality and the many and different language games we employ as a result become terminally paralysing in this phenomenon where it is tantamount to discrimination not to ask for everyone's input before making a decision about the future.

Before Nightingale there was no hope of nursing ever achieving what it has; since her reign, we have made some significant advances in terms of the scope of our practice and gaining a certain legitimacy and recognition. However, I contend that what it means to be a nurse, and the various ways being a nurse can come to lived expression, remain decidedly anachronistic and dependent on a 19th century version of the nurse. S/he is still more likely to be relatively quiescent politically, seen as inferior to the doctor intellectually, and her work more derived from a doctor's orders than impelled by her own knowledge and skills. As a body of mostly women we have for too long been – and still are - lampooned as doctors' handmaidens, patients' angels of mercy, lusty sex objects or embittered dragons of matronhood (see Greenwood, 1999; Holmes, 1997). Changing such pervasive and perennial images can only be brought about by constantly challenging and decrying them when they appear (see also Armstrong, 2002).

Unity despite diversity

For all nurses whatever their specialty, securing a dynamic future for the profession means ensuring that nurses' knowledge and skills are powerfully articulated and showcased by our leaders at every possible occasion. Nursing is the core business of the healthcare system in all sectors: acute care, aged care, and community care. Too many who speak from the politics and bureaucracy of health tend to overlook this reality and dismiss us - as I have been outlining here - on the basis of our gender, our history and our culture. We need to learn to be as assertive – if not aggressive – as doctors sometime are. The idea that a 'good nurse is a nice nurse' (Street, 1992; Walker, 1997) is no longer viable in the 21^st century; Nightingale's ideal of the essential woman/nurse must be renovated and repackaged for a contemporary generation of much more highly individuated and self-assured women (and men) who might contemplate nursing as a career.

Last words: embracing the 21^st century

Healthcare is becoming ever more driven by rapid advances in bio-technology and information technology. This means patients will be in hospitals for shorter lengths of stay and will be sicker while they are there. They will also find themselves at home or in alternative care arrangements much earlier than in the past. This means that hospitals will remain interventionist machineries of cure and people's homes in their local communities will become the hospital as society used to know it – a site of nurturing and care. So we will need highly qualified nurses in these acute and short stay facilities and nurses with perhaps different levels and types of knowledge and skills to maintain the healthcare needs of patients in their homes and communities.

Surely this is the time to act strategically and seriously re-position nurses so that they work where their skills are now needed as much as they might be in the acute care hospitals? We are already a highly divergent and dispersed profession with multiple levels of nurse and nursing work. Let us make the most of this diversity and dispersal. By all means require the specialist nurses to have their university degrees and higher qualifications which prepare and sustain them in their niche markets; but why not also re-invent the generalist nurses as well, so they can work for the communities in which our patients find themselves.

In times when an ethic of caring is less valued than it ever has been, we need very much more than before to resurrect it in order to restore some of the social capital that has been eroded by the great march of Western capitalism and globalisation (Ralston Saul, 1993). As nurses we are large in number; a force with which to be reckoned. We can be articulate: a force with which to debate. We are whether many care to recognise it or not, indispensable: a resource, indeed a force, without which the world cannot do. While an ethic of caring is not nursing's exclusively, it seems to me we have much stronger purchase on it than any other healthcare professional group. Carpe diem!

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