Isn’t it pretty to think so?
Nurses Day tributes are everywhere, but the angel imagery is not so helpful
According to the Times of India, the nation’s president has saluted nurses’ “service,” “dedication,” and “nation-building.” Canada’s Globe and Mail has Christie Watson’s very dramatic tribute to nurses’ “art of caring.” And the U.K.’s Telegraph reports that rampant understaffing threatens patients and nurses themselves.
May 2018 – As usual, this year’s International Nurses Day was the occasion for heartfelt tributes to the nursing profession. On May 12, the actual Day, the Times of India (Mumbai) reported that Indian President Ram Nath Kovind had paid tribute to nurses as “true nation-builders” at a ceremony where officials gave out Florence Nightingale awards. The officials’ remarks emphasized nurses’ “dedication” and “service.” Kovind also acknowledged that the current number of nurses in India, 1.7 per 1,000 people, is “not sufficient.” And on May 4, the Globe and Mail (Toronto) published British nurse and author Christie Watson’s “The art of caring: Why nursing matters more than ever.” That tribute helpfully includes specific information about the nature of nursing, as well as some indications of nurses’ technical and psychosocial skills. But the piece relies heavily on spiritual and emotional imagery (“nursing becomes a kind of faith in itself”; nursing is “a universal act of indiscriminate caring”; “nurses all over the world provide care, compassion and kindness as well as skill and technical expertise”). Watson also claims that a critical young patient she once cared for “survived because of the technical brilliance of the doctors,” while she credits nursing for the “art of caring” that helped the patient’s mother—embracing the traditional idea that physicians are the smart life-savers and nurses the supportive hand-holders. However, a focus on “angel” qualities like caring, compassion, and dedication tells decision-makers that nurses are nice but dispensable. Nursing continues to struggle with severe under-staffing, imperiling patients’ lives. Indeed, no sooner had nurses celebrated their annual Day than the Telegraph (London) reported that a new Royal College of Nursing study (“Nursing on the Brink”) had found widespread understaffing and demoralization in the U.K.’s National Health Service (NHS). The May 13 piece by Laura Donnelly and Rosie Taylor said that one in three NHS nurses did not have time to carry out essential care tasks like providing pain relief, preventing bed sores, or talking to families. For nurses around the world in that situation, pretty words about the “art of caring” are not enough.
According to the Times of India item, President Kovind “conferred the prestigious Florence Nightingale awards to 35 nurses for their outstanding services” at a function at the Rashtrapati Bhavan in New Delhi (his official home). Kovind reportedly noted that Indian nurses’ “dedication and services” are recognized all over for keeping people healthy, including in the Persian Gulf region where many work, and that “nurses are the true nation-builders.” Kovind also said that there were 1.7 nurses per 1,000 people in India, compared with 2.5 globally, and that the Indian numbers are “not sufficient.” Union Health Minister J P Nadda congratulated the awardees for earning “this prestigious award for their exemplary service and thank[ed] each … for [their] yeoman service and contribution towards patient care and well-being of fellow citizens.” The piece says that Nadda also acknowledged what it calls “the strong commitment, compassion and dedication that nurses display in the practice of their profession.”
These are all fine qualities, and we appreciate the President’s recognition that a higher nurse-to-population ratio is needed. Unfortunately, emphasizing nurses’ “dedication,” “service,” and “compassion,” rather than their education, skills, and life-saving, reinforces the angel stereotypes that contribute to the insufficient resources the profession receives.
The art of caring
Christie Watson’s piece in the Globe and Mail includes helpful information about the value of nursing and what nurses actually do for patients. The piece focuses on her care at some point in the past for a toddler named Billy, who had potentially deadly meningococcal sepsis. Watson describes the child being rushed to the London hospital where she then worked, after his mother Kay noted serious symptoms, including labored breathing. Watson says Billy required three nurses. She notes the diversity of the nurses with whom she worked, who hailed from all over the world.
Nurses, whether from Croatia, or Canada, or Somalia, or Scotland, have everything in common. It is a language you can only truly understand by learning it: by being a nurse, but it’s a human commonality. A nurse’s way of living. Of understanding the world. There are universal character traits that shape a nurse. Somewhere between matter of fact and kind. Nurses are tough: they have to be. But they understand life in a deeper way. Perhaps because nursing gives access to more varied disciplines than any other job that I can think of. It incorporates science, humanities, art, physics, maths, psychology, advocacy, law, politics, chemistry, philosophy, anthropology, pathophysiology, biology, ethics. Nursing is not one thing, that’s why it’s hard to get at. It is everything. But also nursing becomes a kind of faith in itself. A love and understanding of the human condition, and of what will matter to all of us, in the end.
Watson says that “we” “rushed around resuscitating Billy,” sent porters for blood products, and provided support to the terrified Kay, “translating the information given to her by the doctors, walking a line to provide her realistic expectation tempered with hope.” The staff eventually all went home, having been given prophylactic rifampicin, an antibiotic designed to protect them from Billy’s illness. One side effect was changing the color of body fluids, and Watson noticed that she was “crying red tears.” Watson also mentions that she did not eat or drink water that day for fear that she might need to leave Billy’s side, yet she does not “remember feeling ill or light-headed. It was impossible to feel hungry or thirsty when seeing the expression on Kay’s face as she stood back watching us work on her son.” The next day, Watson worked with a nurse from Ireland who’d taken the antibiotic before and remembered “noticing the redness on a tissue after wiping her crying eyes.” As weeks of caring for Billy went by, Watson reflected more on nursing.
From the earliest times, nurses, overwhelmingly women, have dedicated their lives to the service of caring for others. It is, and always has been, a universal act of indiscriminate caring. And, despite the nature of caring for patients like Billy and his family, and relying on advanced skills like the insertion of intra-osseous needles and the setting up of haemofiltration, the practice, the language, of nursing, unlike medicine, hasn’t changed all that much over the ages. Nursing predates history books, although one of the very earliest written texts about nursing is the Charaka Samhita, compiled in India around the first century BC, which states that nurses should be sympathetic. The first professional nurse in the history of Islam, Rufaidah bint Sa’ad, was described as an ideal nurse because of her compassion and empathy. In Britain nursing is often cited as born from Florence Nightingale but, of course, nursing was practised long before she lived. Canadian nurses trace their origins back to Jeanne Mance who founded the Hȏtel Dieu in 1645, still a leading hospital. … They both had a privileged upbringing and refused the idea of marriage, instead dedicating their own lives to the service of others, risking much of their own lives, as nurses from all backgrounds do today; Mance cared for patients suffering the plague, and Nightingale ran to war at Scutari, where she suffered alongside the soldiers appalling conditions and being “steeped up to my neck in blood.” Nurses all over the world provide care, compassion and kindness as well as skill and technical expertise. What a comfort that is in a rapidly changing world, when society itself has changed beyond belief. … The very early nurses, in addition to having religious and technical training, were well trained in the art of caring. Surely, the art of caring is now more relevant than ever?
Watson says “Billy survived thanks to the technical brilliance of the doctors,” but “Kay survived the hardest experience any of us could ever imagine – and she would have done regardless – thanks to the caring of the nurses.” When Billy was finally discharged, Kay found Watson to thank her and hug her “for an extraordinary amount of time.” Near the end Watson argues:
Instead of being undervalued nursing and nurses should be revered, respected and elevated. Nursing matters now more than ever. It is time we sing for the heroes. Because all nurses cry red tears.
This piece has elements that tell readers why nurses have real value. They include some of Watson’s descriptions of the nurses’ care for Billy, including about resuscitation and translating information from physicians; a few technical descriptions of conditions and interventions, including the two examples she gives of nurses’ “advanced skills”; her listing of the diverse subjects nursing incorporates (although “science” and “humanities” actually include many of the other subjects she lists afterwards); and her underlining of the long history, global nature, and diversity of nursing (except gender diversity, an issue she does not address).
But in many ways, the piece reinforces the angel stereotype. It emphasizes touchy-feely themes like “the art of caring,” compassion and service and empathy, nursing’s “faith”-oriented qualities, its grounding in “love and understanding of the human condition.” Other elements tell the public that nurses are spiritually and emotionally attuned beings rather than highly educated, highly skilled modern professionals. First, there is the explicit contrast drawn with physicians, whose profession has changed greatly with scientific advances and whose “technical brilliance” is supposedly alone responsible for Billy’s survival. Watson sets that up against the nurses’ enduring and apparently unchanging “caring,” which seems to have led to Kay’s survival (although the same sentence suggests that Kay “would have done regardless”). This is the same bad deal nurses have traditionally made, ceding most technical expertise to physicians and instead embracing the non-threatening “softer” qualities of compassion and empathy as their unique contribution. But nursing’s long association with those qualities has not saved it from the undervaluation to which Watson alludes. It’s fine to highlight the psychosocial care the nurses gave Kay, but this piece presents it as the result of some virtue or intuition nurses just have (we see the passing reference to being “well trained in the art of caring,” but we don’t know what that will mean to readers). In Watson’s account of her first day with Billy, when she went without food or water but felt nothing, there is also the subtle suggestion that nurses are impervious to physical needs, as if they are spiritual beings who can be expected to endure the unendurable—like extreme short-staffing. And then there is the crying, a theme to which Watson returns again and again (“all nurses cry red tears”), which makes it sound like crying is a regular part of nurses’ work day. Maybe it’s the source of their superheroic compassion! We are not suggesting that nurses should be heartless or repress their emotions, just that emotionality and generic goodwill should not be the defining public images of the modern profession. Today, those associations do not serve nursing well.
Nursing on the brink
The Telegraph article is headlined: “One in three nurses do not have time to carry out basic patient care.” The piece is based on the Royal College of Nursing’s just-released report “Staffing for Safe and Effective Care: Nursing on the Brink.” That report evidently found that patients were at risk because nurses did not have time to “perform essential tasks like helping patients go to the toilet or wash, providing pain relief and preventing bed sores.” RCN chief Janet Davies says it is “shocking” that more than a third (36%) of the 18,000 nurses surveyed last year were in that situation. She adds that they also lacked time for basic care tasks like helping patients eat or talking to their relatives. The piece cites some of the specific accounts of nurses in the RCN report. One who had been qualified as a nurse for just seven months was reportedly left to care for 15 patients with just two health care assistants to help. Many patients apparently see the nurses “buzzing around at 100 miles per hour” and may defer requests for a drink or the toilet for hours. Another nurse explains that overwhelmed nurses can’t spend time with patients to ease concerns and that the nurses may also become stressed and ill themselves.
Nurses were regularly in tears during their shifts “due to stress and a fear of compromising patient care,” the report said.
It does not seem like these are the same kind of tears Christie Watson was talking about. And here is another contrast to the Watson piece, specifically a vision of shifts without food:
One nurse describing her last shift said: “Vital medication was missed during this shift, as I had too much on my mind. I missed breaks and I went home feeling hungry, tired and like a failure. I am looking for a new job leaving nursing.”
The RCN also surveyed the public, finding that three quarters of British adults felt that the NHS did not have enough nurses. In addition, a study by the Nursing and Midwifery Council (NMC) “found stress caused by inadequate staffing levels was the top reason nurses quit the profession last year, cited by almost half of those leaving before retirement.” The RCN wants minimum nurse staffing levels set by law for the entire U.K.; the piece notes that Wales passed such a law in 2016. NHS figures reportedly show 43,000 nursing posts vacant in the U.K, which Davies reportedly attributes to “short-sighted cost-cutting in past years, and ineffective workforce planning driven by finance and not the needs of patients.” The Telegraph got a response from the Department of Health and Social Care, whose spokesperson said that the fact that the NHS was “ranked as the safest healthcare system in the world” was a testament to its “wonderful nurses.” The spokesperson also said that “from this year we will train 25 per cent more nurses, are committed to helping them work more flexibly to improve their work/life balance, and have awarded a pay rise of between 6.5% and 29% in a deal backed by the Royal College of Nursing themselves.”
The Telegraph piece does a fine job of raising the alarm about the immediate effects of under-staffing on patients, families, and nurses. It could have included more specifics about some of the more advanced tasks that nurses need time to do, such as patient surveillance and advocacy; what happens to patients when nurses don’t have enough time, such as serious complications and even death; and the growing body of research showing how nurse understaffing threatens care.
In the end, the best kind of Nurses Day tribute—and the kind that seems most in keeping with the spirit of Florence Nightingale, on whose birthday the Day falls—may be advocacy that helps nurses get the respect and resources they need to save lives.
See International Nurses’ Day: President Kovind calls nurses ‘true nation-builders’, posted on the Times of India website on May 12, 2018.
See the article by Christie Watson posted on May 4, 2018 on the Globe and Mail website: The art of caring: Why nursing matters more than ever.
See the May 13, 2018 article in the Telegraph, “One in three nurses do not have time to carry out basic patient care,” by Laura Donnelly and Rosie Taylor.
Not least, see the Royal College of Nursing’s report “Staffing for Safe and Effective Care: Nursing on the Brink.”