It’s been several years since my own near-fatal health scare. In the time between now and then, I’ve often reflected on how, no matter how I felt about the physicians in charge, I always implicitly trusted the nurses. I had doctors who must have hidden their halo somewhere, and I had doctors whose degree I swear was written on the back of a greasy diner’s paper placemat. I can’t say, though, that I ever thought that the nurse taking care of me had anything other than the best for me in mind.
It was sobering, then, when Ellen D. Baer opened her speech-turned-article “‘Do Trained Nurses … Work for Love, or Do They Work for Money?’ Nursing and Altruism in the Twenty-First Century” like this:
A dear friend of mine was hospitalized in the summer of 2007 with renal artery narrowing, for which she received a stent. She is 81 years old, and had several postdischarge setbacks that required a second hospitalization in one of New York’s most prestigious hospitals. (Please note: as has been shown in multiple nursing research studies regarding transitional care, had she had proper nursing care and appropriate discharge planning during the first event, the second hospitalization would not have been needed at all.1) I visited her several times and was overwhelmed by the absence of any sign of nursing care. Endless streams of individuals entered her room, each doing some tiny little job—filling a water pitcher, taking a temp, delivering a tray, mopping a floor, emptying a wastebasket, and so on. None of these individuals could answer any question from her; none would agree to do anything for her other than their assigned task. They barely looked at my friend. Had she been in extremis they would not have noticed.
This month, I want to look at narratives and nursing, and Baer provides a picture of what nursing is, a historical understanding of why we have some of the attitudes we have about nursing, and some thoughts are why nurses are needed in healthcare in the twenty-first century.
Baer provides a wonderful overview of the history of nursing from a socioeconomic perspective. She traces the origins of what we now call nursing to its historical roots:
The significance of the emergence of modern nursing in the mid-19th century in the Crimea with Florence Nightingale was that it represented a substantive change in the manner in which the sick were cared for: the introduction of a system of caring for the sick, and the recognition and acceptance of the need to prepare (or “train”) the people who would deliver the care.
In the US, she states, the Civil War served the same purpose.
Baer moves from nursing’s origins in the mid-nineteenth century (the Crimean War was 1853 – 1856, and the American Civil War was 1861 – 1865) to nursing’s first formal, professional gathering at the 1893 Chicago World’s Fair. She charts nursing’s development from the recognition of the need for a systemic way to care for the sick to the ideological battles around nursing, the type of person who should be a nurse, a nurse’s training, pay, etc.
The bulk of her speech is spent elaborating three main themes and contradictions present in the history of nursing:
- the role of nursing as women’s work,
- the role of religion, primarily Protestantism, and
- the role of socioeconomic class.
To quickly summarize a thoroughly-researched and well-presented article, Baer touches on nursing as a gender issue (
the story of nursing is, of course, a story of gender) but prefers to frame it in socioeconomic terms, which dovetails with and feeds into her discussion of religion in nursing:
criticized equally for making money or costing money, nurses occupy the unenviable position of being wrong no matter what their economic state is.
With regards to religion, Baer has three main points. When nursing was developing as an area of study and training, hospitals were “low dens of vice”2, compared to the in-home care that more well-to-do patients received. The presence of good, Christian nurses were felt to be a positive influence:
the new . Advocates for this new profession of nursing wanted better candidates for what can be a menial job, and felt that preselecting candidates for morality and appealing to a higher calling was just the thing. Finally,
trained nurses were given by their sponsors an armor of moral rectitude with which to shield themselves
the third very practical consideration, Baer writes, was economic. If one can be convinced that the reward for one’s service comes from other than monetary sources, one will likely not press for monetary compensation quite as fiercely.
These highlight the socioeconomic at work. Baer talks about a problem that became
circular in nature: nursing can be glamorous work for little money. Early advocates for nursing wanted a high-class woman to elevate the status of nursing, and also because a lady of leisure wouldn’t need to be paid as much if their work was seen as charitable or spiritual. But nursing can be unglamorous work for little money, and so it attracted lower-class women who needed money. Baer ties together the Industrial Revolution and the emergence of the middle class with nursing:
The emergence of the middle-class worker was the only possible solution. A nurse who could be “higher” in the hospital and “lower” in private nursing was what was really wanted. In the language of the new economic order of capitalism, this nurse would be the middle manager: not the owner of the enterprise; not the lowly laborer of the enterprise; but the organizer of the enterprise, the manager and arranger of the work of lower laborers, for the benefit of owners, shareholders, and sponsors of various sorts.
Baer then comes back around to the main question of her talk: today, do nurses work for love or money? Her answer is prefaced with the fact that we still haven’t moved past the narrative of nursing struggling for legitimacy, struggling for autonomy, and struggling to outgrow the charitable, unpaid labor from which it developed.
Thus, even now, in the 21st century, although nursing is expected to work within science, and participate in enacting the results of science, it is not expected to know science or be science. It therefore remains on the threshold between the religious legitimacy from which it emerged and the scientific legitimacy into which it has never achieved full entry, even with its increasingly impressive research productivity. The result is a peculiar sort of autonomy whereby nurses act independently most of the time, but dwell within a pretense of dependence. The label semiprofession or paraprofession or some other quasiterm is attached to this strange arrangement with all the ramifications such a predicament implies.
Beyond the simplest definition of “nursing” in the dictionary, there seems to be a difficulty even now in defining what nursing is and what nurses do, but Baer ties all of those ideas back to the
basic consensus that patients are at the center of nursing’s work and that patients’ needs drive its practice, education, and research. Her answer to the big question is, “Yes”. Nurses certainly work for money and deserve fair compensation, but as a profession, have proved themselves loyal to their patients almost to a fault.
have to become and remain aware of the economics of health care without being corrupted by that awareness, because we trust nurses implicitly. Nurses
occupy a distance from money that means they don’t profit off of our sickness, other than being there to provide us care.
The article reviewed: Baer, Ellen. “‘Do Trained Nurses … Work for Love, or Do They Work for Money?’ Nursing and Altruism in the Twenty-First Century.” Nursing History Review 17, no. 1 (2009): 28–46. https://doi.org/10.1891/1062-8061.17.28
1 Baer’s footnote:
Nurse researchers like Dorothy Brooten and Mary Naylor have repeatedly demonstrated that significantly improved patient outcomes and cost savings occur using specific nursing interventions with various patient populations during transitions. ↑
2 Rosenberg, C. E. “From Almshouse to Hospital: The Shaping of Philadelphia General Hospital.” The Milbank Memorial Fund Quarterly. Health and Society. 60, no. 1 (1982): 108–54. ↑
Featured image is “Our Women and the War” Civil War nurses. Winslow Homer. From Harper’s Weekly, September 6, 1862. Image is in the public domain.