New Article in International Nursing Review

The December issue of the International Nursing Review, the official journal of the International Council of Nurses,  has the following editorial that I wrote.

Nursing Needs a New Image

Empowerment. Patient advocacy. These are some of the most commonly heard words in nursing. No matter where I go and no matter with whom I talk, nurses argue that one of their primary missions is to advocate for patients. They also acknowledge that patient advocacy is hardly easy. That is because genuine advocacy is not just wishing the patient well. All too often it involves taking a risk, speaking out in public, and/or explaining what nurses do and why it is so important for politicians and policy makers to allocate resources to support nursing care.

A decade’s worth of research has documented the crucial connection between nursing care and patient outcomes. Whether it is in the hospital, home, nursing home, school, rehabilitation facility, or the community, nursing can be a matter of life and death. The concept of ‘failure to rescue,’ developed by physician Jeffrey Silber and his colleagues at the University of Pennsylvania School of Medicine (Silber et al. 1992), and elaborated on by Linda Aiken and her colleagues at the same university’s School of Nursing, clearly connects nursing care to patient rescue. Rescue, these researchers show, is dependent on having enough educated eyes on the patient enough of the time to detect subtle change in the patient’s condition that could signal a catastrophe about to happen. It turns out that, in many instances, those educated eyes belong to nurses.

Educated eyes, however, are not enough to affect rescue. Rescue also depends on the individual or team’s ability to mobilize institutional resources to avert catastrophe. And herein lies the rub. In many institutions, and in many societies, social or institutional devaluation of nursing has long constrained nurses’ ability to mobilize resources to save patients. I would also argue that nurses are further constrained by a professional discourse that, with the best intensions, belittles and trivializes nurses’ knowledge and skill, depicts nurses as juvenile and sometimes even silly, and thus subtly dissuades nurses from speaking out and acting in the policy arena.

What do I mean by a trivializing, sometimes almost ‘juvenilizing’ discourse? It is what I characterize in my new edited collection, When Chicken Soup Isn’t Enough: Stories of Nurses Standing Up for Themselves, Their Patients and Their Profession, as the ‘chicken soup’ narrative of contemporary nursing. Or what Sioban Nelson and I have termed the ‘virtue script’ in nursing (Gordon & Nelson 2005). In both books and images, nurses and nursing organizations all over the world depict nurses as either sugar-coated, sentimental women (and men) or in ways that almost suggest that they are children. Instead of utilizing images and words that capture the critical research that has been done about nursing, many national and international public relations campaigns, as well as nursing organizations themselves, depict nursing as the work of modern angels endowed with extraordinary powers of empathy and compassion. Their role is to be soothing and reassuring. As they hold hands, hug patients and their families, give back rubs and smile beatifically at patients, almost everything that could really empower nurses is left out of the picture.

Many campaigns conducted by nursing organizations and public relations done by hospitals or governments fail to highlight that nursing requires technical, medical, and pharmacological – to mention only a few – knowledge and expertise. What is even more disturbing is that the public rarely learns that effective caring and compassion requires education and expertise. In other words, even the most emotional, psychosocial work that nurses do is an example of the mind at work, not the heart. That is because in nursing effective heart work is, in reality, guided by brainwork.

With all due respect to the organizations involved, let me give some international examples of what I mean. Several years ago, when celebrating its anniversary, a nursing organization urged its members to purchase a commemorative poster depicting two white child angels. At the turn of the 21st century, francophone nurses from all over the world gathered for a conference focused on the theme Nursing: An Expertise of the Heart. In some countries, nursing groups give out prizes of stuffed kittens or teddy bears wearing nursing caps, to nurses.

A specialty organization dedicated to advancing nursing education, clinical practice and research in the field of cardiology, undermines its serious mission with its logo: a childlike drawing of stick figures holding a fluttering ribbon and connected with a childlike drawing of a heart. When another nursing organization decided to launch a public campaign to make nursing more visible to the public, its slogan was Quiet Power– a message that contradicted the outspoken and knowledgeable nurses who appeared in the organization’s video and in magazine and newspaper articles.

Finally, when you walk into a hospital and check out the photos of nurses in hospital photos, recruitment material or publications, some of them put out by departments of nursing, you find two predominant images: nurses holding the hands of a patient or nurses smiling at the camera, at the patient, or even at machines. (In direct contrast, institutional photographs of doctors always show them either looking authoritative or like they know something.) If you look at the faces of real nurses doing their work, more often than not, their expression is one of concentration, of concern, a look that conveys that they are thinking.

Are nurses really angels? Are they kittens? Teddy bears? Do patients need ‘quiet’ nurses? (I for one want a really noisy nurse to intervene if a physician prescribed the wrong drug, or the pharmacy delivers the wrong dose). Why do organizations with serious missions choose childlike images that completely contradict the seriousness of nurses’ work? Would physicians, lawyers, stockbrokers, pharmacists, or physical therapists mobilize similar words and images to depict their work? (Hint, they would not and do not). In a world where nursing is often dismissed as mere ‘hand-holding’ or TLC and nurses are devalued as either kind but not very bright, or worse, as sex kittens, why do nurses themselves perpetuate these images? And in 2010, no less?

I would argue that whenever nurses mobilize this kind of discourse, they are not only shooting themselves in the proverbial foot with the public, but also limiting their ability to mobilize their forces to fight for the kinds of policy changes upon which effective nursing depends. Nursing as a profession is an organized, institutional intervention. Just as rescuing patients in the hospital depends on nurses’ ability to mobilize institutional resources, so too rescuing the broader health care system and nurses’ role in it depends on nurses’ ability to mobilize societal resources to affect change. Many nurses and nursing groups have done this to wonderful effect. But their job is made much harder by a discourse that I believe demobilizes nurses – and can often end up demoralizing them as well.

In 2010, as the world faces an on-going global recession, and governments and private payers try to cut back on nursing care, nursing really does need a new image – one that not only encourages empathy but activism as well. If nurses are to advocate for patients, they must learn to better advocate for themselves. This means risking moving away from the comfortable image of the sweet and kind nurse and telling the world what nurses really know and what they really do.

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  • Susan Castor

    As a RN for almost 40 years, a case manager for the last 12, I could not agree more. Recently, the new “corporate” image of the quiet nurse somewhat disappoints me.
    Thank you for communicating what some of my peers and I have quietly -not to antagonize management-discussed over these last few years.

    again, thank you

    Susan Castor

  • Rose

    I really think this is an important article regarding nursing image. It is important that nurses project not only a caring personality but also one one of highest professionalism. We work too hard to earn our degree to be depicted as only to be viewed as “Pill dispensers or ” cute nurses in white uniforms” We give our patients the highest standards of care in our field and alos should have the respect we deserve. Thank You !

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