Nursing Evolution?

The word “evolution” suggests progress over time. So when we speak of the “evolution of nursing” we’re talking about progress in the profession over time; but the idea of progress is subjective, isn’t it? What one nurse views as a step forward, another might view as a few steps backwards and vice versa.

For example, Florence Nightingale is often lauded in nursing culture as the singular person who established nursing as a distinct art and science which propelled it into becoming a profession. Up to her time, nurses served only as subordinates to doctors, taking their orders and doing their bidding largely without question. Nightingale, according to Black, met with opposition from this all-male establishment in improving the lot of the British soldiers during the Crimean War, and “Armed with an excellent education in statistics, Nightingale collected very detailed data on morbidity and mortality of the soldiers in Scutari. Using this supportive evidence, she effectively argued the case for reform…” (Black, 2014, p. 25). I do not wish here to question that Nightingale’s work marked a turning point in how patients were cared for with positive outcomes, but does establishing nursing practice using only the language of science to describe its intervention and outcome criteria to be viewed only as progressive? What was lost as a result of this change? Scientific reasoning very much relies on physical evidence, experimentation, and hard numbers in generating what it counts as knowledge; but what about the knowledge lost when only hard data are accepted? What about the knowledge of the subjective experience of suffering from an illness, or interacting and reacting to treatment, or the dynamics introduced by other subjectivities such as the physicians, nurses, family and other people in the patients’ lives? This is “metaphysical reductionism which means ‘what is gained on the one hand is lost on the other’” (Pitre & Myrick, 2007, p. 75) or one step forward and one step back. Add to this Evans’ observation that “the emphasis placed on nursing as a science strategically played down its caring and feminine image…” and furthered “the stereotype of men as rational technocrats who make ‘naturally’ good leaders” (2004, pp. 325-326) which perpetuated the stereotype that women are irrational and naturally poor leaders.  I don’t mean to suggest here that Nightingale’s efforts didn’t result in a positive step forward in nursing science. I only mean to suggest that Nightingale is largely responsible for the existence of the concept of “nursing science” and to show that this has had both positive and negative outcomes.

Another example is the move towards state licensure. This step is presented as a step forward for the nursing profession; but what does the possession of this license really tell one? Does is say anything about how well that particular person is likely to do as a practicing nurse or does it say that this person is adept at taking written tests? Licenses depend on written tests for their dispensation. Written tests privilege those who are better at manipulating and understanding the written word. People who are better at manipulating and understanding the written word are privileged by an educational system which tends to favor one learning style over others, a learning style, historically, more likely to be used by an economically and racially privileged class. I wonder how many potentially great nurses were excluded from the profession because they could not pass the NCLEX-RN?

Black refers to the rise of hospitals during the years immediately following World War Two as a result of the passing of the Hill-Burton Act in 1946 (2014). I’m not certain why this explosion in hospitals was deemed necessary. Perhaps more people were living in cities than in rural areas; maybe it was the burgeoning population called the “baby boom” which caused the building of these facilities. Whatever the reason or combinations thereof, it had both positive and negative effects. Black lists hospitals as places where new nurses may gain stronger clinical and assessment skills (2014). As an employee of a large hospital, I can attest to other advantages such as having support staff readily available to help in the care of patients, answer questions and generally learn from. The negatives included “an acute shortage of nurses and increasingly difficult working conditions. Long hours, inadequate salaries, and increasing patient loads made many nurses unhappy with their jobs, and threats of strikes and collective bargaining ensued” (Black, 2014, p. 33).

The advent of Medicare and Medicaid in the 1960s is often viewed as a step forward for nursing “because the majority of the care for the sick was taking place in hospitals” (Black, 2014, p. 34) which depended on reimbursements from these programs making hospitals “the preferred place of employment for nurses” (Black, 2014, p. 34) and allowing for the rise of novel roles and opportunities (Black, 2014). While this is true, it is also true, in my experience,  that Medicare and Medicaid gives rise to shorter hospital stays for patients based on what these programs will pay for which may lead to discharge before patients are ready, which leads to hospital recidivism, and ultimately leads to higher health care costs-one step forward, two steps back.

The rise of telehealth as a result of the digital revolution of recent years offers nursing advantages and opportunities for new roles previously unheard of. Quick and immediate access to patient data in real time, the ability to assess patients via live-feed cameras from remote locations, the ability to transfer data to those parties involved in the care of the patient are just a few of the convenient changes that have come about. But, like my comments about the idea of NCLEX testing privileging certain people, the rise of technology and its pervasiveness in nursing practice also serves to exclude those who aren’t able to make the adjustment from old ways of doing things. This causes alienation for nurses, probably older nurses, which may cause them to seek to leave nursing, the result being an experience drain in the profession at a time when it sorely needs experience to teach and guide students entering the field and nurses new to it.

 

While I don’t find myself immediately informed by nursing theories in my daily practice, I see them bleeding into it all the same. As a psychiatric nurse, I am of course in debt to Hildegard Peplau. Her emphasis on the nurse-patient relationship (Black, 2014) in a therapeutic milieu pervades what I do at my job in establishing trust, attentive listening, active involvement by the patient in achieving his/her goals, and taking responsibility for his/her care. I find myself using her model unconsciously in my multiple roles as “counselor, resource, teacher, technical expert, surrogate, and leader” (Black, 2014, p. 276).

In my initial training as a nurse, my school used Sister Callista Roy’s Adaptation Model. I personally thought it was uninteresting and tedious (and still do) I can see its influence on nursing every day, especially on medical-surgical units where a patient’s “adaptation behavior and stimuli in the internal and external environments” (Black, 2014, p. 275) is used to formulate nursing diagnoses and care plans.

While not aware of my having used Leininger’s Theory of Culture Care Diversity and Universality, I nonetheless value its precepts in nursing practice. If nursing is based on the patient’s response to illness, then it is important for a nurse to plan “nursing care, recognizing the health beliefs and folk practices of the patient’s culture, as well as the culture of traditional health services” (Black, 2014, p. 278) to be not only respectful but also to encourage compliance for positive outcomes.

 

References

Black, B. P. (2014). Professional nursing concepts & challenges (7th ed.). St. Louis, MO: Elsevier Saunders.

Brennan, E. & Renear, A. (1991, January 10). 4.0879 responses: Voltaire; on humanist (3/43). Message posted to http://dhhumanist.org/Archives/Virginia/v04/0876.html

Pitre, N. Y., & Myrick, F. (2007). A view of nursing epistemology through reciprocal interdependence: Towards a reflexive way of knowing. Nursing Philosophy, 8(2), 73-84. doi:10.1111/j.1466-769X.2007.00298.x

Gender in the History of Men in Nursing

I do not trust history, “it is a pack of lies played by the living upon the dead” (Brennan & Renear, 1991) as Voltaire is said to have said, but that may be a lie also. I don’t know, I wasn’t there; so when given the task of listing three events in the history of nursing that have impacted the profession, I will do so with this in mind, also trying to give a tip of the hat to that which has been left out because history, if it is anything, is a chronicle written by fallible human beings with agendas and biases. History is a study of power: those who write it represent the dominant culture and the dominant culture in nursing history is feminine.

Florence Nightingale is the singular person credited with beginning the art and science of nursing as we know it today. I do not wish to detract from her achievements because she is the person who initiated nursing as an independent evidence based profession. She may have been the first to collect data as evidence for nursing practice (Black, 2014) and using this information to fight for reform in the British Army’s medical system (Black, 2014). She also founded the first nurses’ training school in 1860 (Black, 2014), “which would become a model for nursing education in the United States” (Black, 2014, p. 25). Nightingale, though, “largely ignored the historical contributions of men. The male role as she saw it was confined to supplying physical strength, such as lifting, moving, or controlling patients, when needed” (Black, 2014, p. 37).

I do not blame Nightingale for this. We are all the victims of the constructions of the societies in which we were born and brought up. In her time, gender roles were a lot more fixed than they are today; but they are social constructions (Black, 2014) and, as such, should be questioned because social constructions don’t represent truth. The history of men in nursing reaches very far back in time. The earliest recorded accounts of men in nursing are during the fourth and fifth centuries (Evans, 2004) as members of religious orders such as The Order of St. John of Jerusalem “who defended Jerusalem during the crusades, later provided protection to travelling pilgrims and also built hospitals and castles across Europe that served as both lodgings for pilgrims and places to nurse the sick” (Evans, 2004, p. 322). There were many other such orders such as the Knights of St. Lazarus, Knights Templars, and Teutonic Knights which ministered to the sick (Evans, 2004). These points suggest that men didn’t and don’t deserve to be confined to gender roles in the profession yet it should be mentioned that gender roles attached by men to women at this time in history was unfortunately not unheard of:

Even in medieval accounts, however, there is the suggestion that nursing work in these orders was considered to be of low value and hence more appropriately carried out by people of low status. In 1264, in The Rule and Statues of the Teutonic Knights, Book of the Order, the Knights entered into their rules that women were to do the nursing because service to livestock and sick persons was better performed by women. (Evans, 2004, p. 322)

 

The second historical event that had an impact on nursing as a profession took place in 1472 with the founding of the Alexian Brothers as a religious order (Evans, 2004). I say this because, even before Nightingale, the advent of the Alexians relegated male nurses to a role within the profession that had everything to do with the construct of gender and nothing to do with natural abilities: psychiatric nursing. According to Evans (2004), when the plague disappeared in the 1700’s, the Alexian Brothers “became well known for their ministry to the mentally ill” (Evans, 2004, p. 322) though it is questionable to me whether this ministry had less to do with actually helping the mentally ill as it did with controlling them because, as written in Black (2014), psychiatric nursing “often required physical stamina and strength and was therefore considered an appropriate setting for men in nursing” (p. 37). The Alexian Brothers may have actually helped perpetuate the idea that male nurses are more suited for psychiatric nursing due to the fact that they established training schools in the United States for men in the field (Evans, 2004). This might help to explain Nightingale’s attitude towards men in nursing cited earlier in this article.

The third historical movement which has impacted and continues to impact nursing is the so-called “feminization of nursing” (Black, 2014, p. 26) which took place in 19th century England and the United States. When the first schools for nursing were founded in these countries men were forbidden admission based on “The Victorian belief in women’s innate sensitivity and high morals” (Black, 2014, p. 26). Indeed, according to Evans (2004), Nightingale brought the relationship between men and nursing to a close in the 19th century because “To her, every woman was a nurse, and women who entered nurse training were doing only what came naturally to them as women” (pp. 322-323). Evans further states that a “family” (2004, p. 323) model of nursing prevailed at the time where:

The dominant role of father was assumed by men physicians. Nurses as women and patients as children completed the institutional family and reflected general social values regarding the division of labor based on gender. The notion of men as nurses was subsequently incompatible with the prevailing institutional family ideology of the time.

 

Anecdotally, as a man who has been in the nursing profession (starting out as a nurse’s aide and becoming a psychiatric nurse), I can attest that these gender stereotypes in the profession continue. I was the one often come to for help lifting a patient or helping to control a violent patient. As a nurse’s aide and as a nurse, I was more likely to be given assignments containing the heavy or violence prone patients. When I became a psychiatric nurse this last September, I remember my colleagues commenting that it would be nice to have another man on the staff and I know that I was scheduled so as to make it possible that there was always a man with a woman nurse on the floor because it was explained to me that way when it happened. Interestingly, aside from my academic interest in psychiatric nursing, I remember thinking as I applied for the job that I would probably be more likely to be hired because I am a man.

In closing, as of this writing, 8% of students enrolled in undergraduate nursing programs are men (Black, 2014). This is a very small number compared to women in this so-called enlightened age. This can’t help but to be an effect of the social construct of gender roles assigned irrationally to both women and men throughout history, a history which has been written by women who also inadvertently share these same values. It is interesting to note that of the 26 pages Black writes about the history of nursing in her Professional Nursing Concepts & Challenges, less than three are dedicated to the topic of men in nursing. Perhaps this is due to the paucity of information about this subject due to the aforementioned forces of history or maybe it is due to the subjective but probably unconscious selective process of a woman. I suspect it’s probably both. If more men are going to enter the profession of nursing history must be rewritten to reflect the contributions men have made and gender stereotypes must be challenged on every front.

 

References

Black, B. P. (2014). Professional nursing concepts & challenges (7th ed.). St. Louis, MO: Elsevier Saunders.

Brennan, E. & Renear, A. (1991, January 10). 4.0879 responses: Voltaire; on humanist (3/43). Message posted to http://dhhumanist.org/Archives/Virginia/v04/0876.html

Evans, J. (2004). Men nurses: A historical and feminist perspective. Journal of advanced nursing 47(3), 321-328.