Nurses in the spotlight. A bit of history.

Laetitia@Work #17

Hi everyone,

The nursing profession is very much in the spotlight during this pandemic. In the UK and in France (and many other countries too), people clap for their carers every evening to show their appreciation. It seems like there’s never been more recognition and gratitude. Surely these daily rounds of applause and shows of love can’t hurt. Hopefully we won’t forget any time soon that we are dependent on health care professionals and that they deserve more recognition.

There is a slightly less positive way of looking at the daily applause. It’s as if everybody was comforted in their idea that it is natural for nurses to “sacrifice” themselves, that being a nurse is a vocation whose reward is beyond material things (like pay and work conditions). That’s why in France and in the UK, there was criticism. A French blogger called it “not such a good idea” to clap. And economist Mariana Mazzucato insisted that merely “clapping NHS [workers] without also strengthening it is an insult”, because “you don’t send soldiers to the battleground barefoot”. 

In other words, saying “thank you” is lovely, but if you let these public services crumble and weaken, and have these workers work in increasingly difficult conditions, then it may be quite vain. It could even be used against them: “why complain about your work when you can see you are so clearly appreciated?”. 

But I do understand the urge to say ‘thank you’. In fact every time I visit a hospital, I want to say ‘thank you’ 🏥 I do hope this particular crisis will provide an opportunity to strengthen our health systems and show our appreciation in different (material) ways too. 

I’ve read a lot about nurses and the history of this profession. In fact I wrote about it in my book Du Labeur à l’ouvrage (2019). My book has not (yet) been translated into English. But as nurses are so much in the spotlight these days, I decided I ought to translate a few pages devoted to the (feminist) history of the nursing profession. The following essay is a (loose) translation from my book. I hope you enjoy it! 

“Be the doctor your parents want you to marry.” (a 1970s feminist slogan)

The most famous woman after Queen Victoria

The nursing profession was first organised by the Church. It was therefore intimately linked to the ideas of vocation, service and self-sacrifice. In the history of modern secular medicine, these ideas endured and from them two figures emerged: the archetypal (female) nurse on the one hand, and the archetypal (male) doctor, on the other. In the late nineteenth century this secular construct took hold and became the norm. Given how the profession emerged (i.e. in opposition to the male doctor), the profession was almost exclusively occupied by women for a very long time. Even today, among the roughly 600,000 nurses in France, 87% are women. [In the UK, only one in ten nurses are men.]

The secularisation and professionalisation of the nursing profession owe much to one exceptional founding figure: Florence Nightingale. Born in Florence in 1820 (she died in London in 1910), this British woman is regarded today as the pioneer of modern nursing. She was a paragon of feminine virtue in the Victorian era. And she durably shaped the codes and values of the profession.

Born into a wealthy family of Britain’s high society, Florence Nightingale was named after the city where she was born, when her parents were on a long trip to Italy. At age nine, she already spoke French and then she learned Latin, Greek, German, Italian, history and philosophy from her father. As members of the Unitarian Church, a liberal and undogmatic Christian denomination, the Nightingales believed in social progress and the importance of serving the community—a vocation that Florence embodied all her life.

In 1837, when a flu epidemic struck southern England, she devoted several weeks to the intensive care of the sick around her, acting as "nurse, housekeeper, moral support and doctor”. She wrote in her diary, "God spoke to me and called me to his service.” In 1839, Florence Nightingale was presented to Queen Victoria's court. And the same year, she began to develop a passion for mathematics.

In the 1850s, her life project took shape. She left for a hospital internship in Paris, then assisted her dying grandmother and finally accepted an offer to run a health centre in London. She then became a superintendent at the Institute for the Care of Sick Gentlewomen in London. It was with the Crimean War, which began in 1853, that her vocation became a profession. A considerable number of soldiers were afflicted with cholera, dysentery and other ailments. Thousands were wounded or killed in the various battles. So Nightingale planned a humanitarian intervention for which she obtained the support of the British authorities. She recruited volunteer nurses and went to Turkey, across the Black Sea, where the soldiers were based. In difficult conditions, with limited medicine supplies, poor hygiene and indifferent officers, the nurses tried to clean the hospital, where the mortality rate was considerable. Poor sewerage and lack of ventilation made the work somewhat futile. But Nightingale obtained a health commission from the British government and the work was carried out.

Upon her return to Britain in 1856, Nightingale was greeted as a hero. She became the most famous woman after Queen Victoria. All the rest of her life afterwards, she tried to help reduce the number of peacetime deaths in the army and direct her attention to the sanitary design of hospitals. She created schools, published books and encouraged the development of the nursing profession in its modern form. Her work inspired the nurses of the Civil War, and the establishment of the profession in many other countries.

The importance of Florence Nightingale to the nursing profession cannot be understated. She was the ideal educated, intelligent Victorian lady, who above all knew to remain gentle, discreet and always submissive to male authority, from the domestic to the hospital world. Although she is regularly celebrated as a woman who made history, many feminists have mixed feelings about her.

If she was so intelligent, accomplished and learned, why did she have to step aside, and sacrifice herself to male authority? And above all, why did she celebrate this submissiveness so much? For Barbara Ehrenreich and Deirdre English, the authors of Witches, Midwives, and Nurses: A History of Women Healers (1973), "to the doctor she brought the absolute obedience of the perfect wife. To the patient, she brought the selfless devotion of a mother. She embodied the very spirit of femininity as defined by the sexist Victorian age.”

Nightingale wanted women from "good families" to become nurses. But rather it was working class women who later joined the ranks of this new secular profession. Because the work was hard, unrecognised and, above all, poorly paid, women from good families shunned it. The archetype of the Nightingale nurse contributed in the long run to the devaluation of the profession by imposing the idea that, whatever great qualities, skills and knowledge these nurses possess, their absolute devotion is a naturally feminine vocation that does not require material gratification.

An artificial separation between caring and knowing

The archetypal Nightingale nurse who originally shaped the profession is a modern-day culmination of an entirely artificial separation between caring and knowing. This is the subject of one of Doctor Martin Winckler’s books, in which he explains why this original separation, and the way medicine is taught today, deprived doctors of empathy and at times turned them into arrogant "white thugs" (Les Brutes en blanc). In this book, he quotes a text already published in La Maladie de Sachs:

“To choose to be a doctor is not to choose between two specialties or two modes of practice, but first of all between two attitudes, two positions. That of "doctor" or that of carer. Doctors are more often doctors than carers. It's more comfortable, it's more rewarding. The doctor "knows" and his knowledge takes precedence over everything else. The caregiver's primary goal is to alleviate suffering. The doctor expects patients and their symptoms to conform to the analytical grids that the faculty has instilled in him/her; the caregiver does her best (by questioning her meagre certainties) to understand a bit more about what is happening to people.”

Before the establishment of modern medicine (starting in the 16th century), this separation was not deemed relevant. The knowledge of caregivers—including that of "witches"—was primarily empirical. To heal, you had to think and look after at the same time. You had to prescribe remedies and hold the patient’s hand. Know plants and bodies, and know how to listen to people. Take care of bodies and souls. Use your head and your hands.

Barbara Ehrenreich and Deirdre English who were both involved in the Women's Health Movement, sought to understand the historical roots of the professionalisation of the medical profession. They looked at Europe’s witch hunts and how midwifery was destroyed in the United States. For them, the witch hunt undoubtedly represented a turning point after which the men of the ruling class could monopolise medicine. After that, healing women were entirely relegated to the subordinate position of docile, maternal nurses.

In order for this new, male-dominated medicine to establish itself and become dominant, it was necessary to permanently eliminate the competition from the witches. This meant not only banning the practice of medicine by women, but also discrediting and devaluing all female knowledge. Witches were portrayed as the devil's lovers—indecent and sinful.

At the beginning, male medicine was just dangerous superstitions and violent acts (of which bloodletting is just one famous example). It killed patients as often as it healed them. Yet it established itself firmly. Witches who were also masters of human reproduction, contraception, abortion and childbirth were the enemy. The dominant economic power needed more control over women's bodies and reproductive systems.

With the figure of the docile, discreet nurse subservient to male authority, the return of women to medicine could be orchestrated. Nurses must "accompany" patients, clean them, dress wounds and hold hands, while doctors, the only ones with true knowledge, must appear only intermittently and devote themselves to thinking and deciding. With some notable exceptions, it was generally accepted that only nurses were supposed to listen and reassure. 

In the twentieth century, Fordist principles further transformed the practice of medicine. With the creation of our modern health care systems, every medical act was codified. Here too, a "one best way" was defined and labour was divided. It was decided that certain procedures, which were expensive, would be the preserve of doctors, while others, no less difficult, would be entrusted to nurses. This division of labour, justified by the health of patients, is the foundation of our health care system. For Martin Winckler, it also explains a pervasive brutality and violence in the system.

The same division of labour was applied to the work of independent nurses and domestic care workers. In order for domestic care to become cheaper, there had to be less dependence on the individual caregivers. This contributed to reducing the human dimension of care and degrading the social bond that accompanied it.

But there is another way

Over the last ten years or so, there has been more and more criticism of the Fordist model of medicine. New models of care organisations have emerged. Buurtzorg, a Dutch home-care company, was founded in 2007 by Jos De Blok. It offers an alternative to the Fordist model of care work. Celebrated by Frédéric Laloux in Reinventing Organizations, Buurtzorg prides itself on offering care workers autonomy and responsibility.

Each autonomous team is composed of a small number of nurses responsible for finding patients, coordinating with other health professionals, recruiting, training and managing operations. Nurses have a global, holistic view of the person and his/her needs. The quality of care is inseparable from the human and personal relationship that grows between caregiver and patient. Patients must be as autonomous as possible to be in control of their own recovery.

The Internet came with a revolution in the relationship between doctors and patients. The citadel of doctors was taken over by patients connected to one another. With health forums and online articles, the impregnable knowledge of doctors has never been so accessible. Digital technology has therefore made the interpretation of this knowledge, its application to individual cases and the interpersonal relationship between caregiver and patient increasingly important. The boundary between knowledge and care must now be eliminated. In many ways, nurses embody the future of medicine: what they produce cannot be found on the Internet.

In fact, we know intuitively that Fordism cannot be applied to medicine. What is the value of medical knowledge disconnected from human care and relationships? Yes there are statistical regularities, whose rational exploitation by medicine resulted in spectacular improvements in public health since 1945. But each body is different and each individual reacts differently to the same treatment. There is no separating the head from the body. New drugs and treatments have played a big role in the twentieth century (and will continue to do so in the future). But we know now that relationships and beliefs matter as much, as illustrated by the placebo and nocebo effects, which are well documented today.

The challenges of the profession are somehow linked to the deceptive idea of self-sacrifice and the artificial separation between care and knowledge. First of all, nurses aren’t paid enough [there are strong differences between countries though] given the qualities and training required of them. As their sole drive must be to help others, they are expected to "sacrifice" their revenues to the mission. It’s not sustainable. Our ageing societies will need more and more carers. For the same reasons that it is more and more difficult to recruit teachers, it is also more difficult to recruit carers (nurses, but also general practitioners).

Is there a "nursing shortage" already? This is a question that regularly comes up in the media. A recent study by the [French] Ministry of Health estimates that with the ageing of the population and the development of home care, there will be a cruel shortage of nurses in the years to come. In 2040, the over-75s will represent 15% of the French population (compared to 9% today). However, after the age of 75, a patient consumes twenty-seven times more care than people under 65! Hundreds of thousands of additional nurses will therefore be needed over the next few decades.

France pays its nurses particularly poorly. According to the OECD's "Health at a Glance 2017", "French [health] professionals earn 5% less than the national average. In comparison, nurses in Mexico are paid twice the average salary. Similarly in Spain or Luxembourg, they are paid 28% and 38% more than the average salary respectively. France ranks fourth in nurses’ low wages (compared to the country's average) behind Latvia, Hungary and Finland.

The low pay of French hospital nurses may make it more difficult to recruit them. But it’s not the only challenge. The main challenge for the profession is also to recruit more men. With 87% of women (84% among self-employed nurses and 88% among salaried nurses), the profession remains one of the most unequal. But if nursing is a profession of the future, then men should not be excluded from it!

Relatively few men will consider this profession. Because the pay is low and the working conditions are difficult, and because it is still culturally associated with "female" qualities. However, many more male nurses will be needed for at least two reasons: first, pay conditions in a profession tend to improve when there are more men; second, the recruitment pool will be larger if men are included. The sooner male nurses become more common, the faster things will change. The visibility of "role models" can play a decisive role and inspire "vocations" (if there is such a thing) among young men.

The nursing profession could then become a second career for all those whose industrial jobs are relocated or automated. As economist David Autor wrote: "I am not worried about whether or not there will be jobs tomorrow. I am very worried about whether or not there will be jobs for low-skilled adults, especially men, who seem reluctant to accept new jobs.” Afraid of being stigmatised, men from the industrial world find it exceedingly hard to consider working as a “carer”. Most male nurses are immigrants who have never known the world of industry.

One of the biggest challenges is also improving the working conditions of the profession. Not only is it intrinsically difficult because of illness, suffering and death, but working conditions have deteriorated in recent years. Nurses are asked to do more with less and less. Overwork often also comes with less autonomy and initiative. Reinventing hospital work by thinking outside the box of mass production is necessary. Nurses should be craftswomen and craftsmen.

The nursing profession will probably be in a state of flux for a while, as technology and regulation change. Some medical procedures are becoming more complex, but it doesn’t mean they will necessarily have to be carried out by doctors. Indeed there is a shortage of doctors too and more people are at risk of having no access to the medical procedures they need. A fully-equipped, digitally enhanced nurse may well be able to provide the service that patients need. The Internet has also empowered the patient himself/herself, who wants to be more active in his/her own care.

Digital and robotics are redrawing the boundaries of medical professions. The historical separation between knowledge and care may no longer be relevant. Knowledge is more accessible. But care and human relationships are not. The more accessible knowledge becomes, the more important it is for patients to establish relationships of trust with professionals who can help them make medical decisions. Access to care can be broadened by giving nurses—and patients—more and more autonomy. 

🌳 I’m in Normandy all week this week 😏

The new media (in French) that I launched with Nicolas Colin, Nouveau départ, already has nearly 1,200 subscribers, and nearly 50 paid subscribers! We published new videos, interviews and articles over the last few weeks. Check it out and subscribe if you haven’t yet! I was interviewed (in French) about the launch of Nouveau Départ by Sophie Dancourt.

I recorded an Aperture podcast with my friends Ben Robinson and Dan Colceriu, together with Ian Stewart and Nicolas Colin: “Previewing the post-Pandemic World”. It’s a really good podcast! 🎧

Also my “must-read” Welcome to the Jungle article about Erin Meyer’s Culture Map is now online: “The 8 keys for managing multicultural teams by Erin Meyer” (in English); “Comment manager des équipes multiculturelles ? Les 8 clés selon Erin Meyer” (in French). And I published an article with a communication expert: “Le confinement aura été un gigantesque accélérateur de la transformation de la communication des entreprises”.

Miscellaneous

• 📚 “Why Anxious Readers Under Quarantine Turn to “Mrs. Dalloway””, Evan Kindley, The New Yorker, April 2020: “In 1918, women as well as men were in extreme danger, and the domestic space became as deadly as the front lines, (…) The war, with all its male deaths, became the story, and the pandemic, with its mix of female and male victims who succumbed, a deflating sequel.”

• 🏬 “The Death of the Department Store: ‘Very Few Are Likely to Survive’”, Sapna Maheshwari and Vanessa Friedman, The New York Times, April 2020: “No one doubts that the upheaval caused by the pandemic will permanently alter both the retail landscape and the relationships of brands with the stores that sell them.At the very least, there is expected to be an enormous reduction in the number of stores in each chain, which once sprawled across the American continent like a pack of many-headed hydras.”

• 💮 “Japan Needs to Telework. Its Paper-Pushing Offices Make That Hard”, Ben Dooley and Makiko Inoue, The New York Times, April 2020: “The stamps, known as hanko or inkan, are used in place of signatures on the stream of documents that fill Japan’s workplaces (…) They have become a symbol of a hidebound office culture that makes it difficult or impossible for many Japanese to work from home even as the country’s leaders say working remotely is essential.”

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