It is not a coincidence that I start posting blogs on my experiences, observations, and perspectives on my career in nursing today - it is intentionally poetic that I have selected International Nurses Day to share my insider's view on this profession. After 34 years (and counting) there is much to share about this once noble profession, as the fundamentals of what nursing currently is has changed quite significantly since I began my career in 1990. I say "once noble", since the nostalgic notions of nursing as a calling with an idealistic form of care are about as obsolete as daily bed baths and backrubs. It seems to me that where the profession is potentially evolving seems both uncertain and not necessarily a direction that Florence Nightingale would have envisioned as we lose ground on many fronts with loss of professional autonomy (to medicine and politicians), loss of scope of practice (again due to dominance of medicine, other health professions, and political interference but also self-inflicted with watered down preparation for practice), and encroachment of other classes of healthcare providers that are replacing tasks that nurses have historically done. All of this compounded by lack of cohesion and tensions within the nursing profession, hallmarked by internal dynamics of hegemony and both vertical and horizontal violence. In due course, I will touch on these issues and more, but today let's celebrate the end of nurses week 2024.
Nurses Week (plural? possessive? plural possessive? 🤷♂️) occurs on the week of Florence Nightingale's birthday (May 12) that is known as International Nurses Day. As most people know, Nightingale was the founder of modern nursing and rose to prominence with laying the foundation for formal education of nurses through work she led in providing care for casualties during the Crimean War (1853-1856). Few people likely know that Nightingale had received advanced education most women of the day would not have received and particularly excelled in the field of mathematics. When Nightingale recognized the correlation between mortality rates of British soldiers to poor care and things like sepsis, she became one of the first statisticians in health care through her observations and records of health outcomes connected to environment, hygiene, and nutrition. This coincided with the timing of Dr. John Snow's (not the Games of Thrones one) work mapping of cholera in 1854 and his recognition in the biostatistics realm; he is more apt to be recognized as the first biostatistician being a physician.
Aside from her early work in biostatistics and defining both a formal role and education for nurses, Nightingale was also quite political through her championing of humanitarian causes related to health, such as for underserved populations and lobbying for funds through connections with the upper-classes including Queen Victoria and British peers. I have little doubt that if Nightingale was around today she would likely be an early adopter of technology, having been ahead of her time in the mid-1800s but maybe perplexed in how the nursing profession has, in many ways, become quite task-oriented and often resistant to proactive change.
For the many positive aspects in her work there were a few negative consequences of Nightingale's positions that have had impacts on the profession; however, it is important to understand some of this in the context of her time period - the Victorian Era. First, given the nature of a very patriarchal society and the military origin whence nursing evolved, nursing started out firmly under the dominance of medicine following "Doctor's Orders." Needless to say, this dominance has shackled nursing in many ways and limited it as a true autonomous profession. Second, Nightingale's view was that only women possessed a capacity for caring - she declared "caring" to be a feminine virtue. As such, men were excluded from nursing and formal education in the role, even though men had been part of healthcare delivery through monastic and military orders for centuries (actually back to the time of the Romans, so millenia). And, finally, selecting the name "nursing" has imbued the profession with a perpetual label tied to a female-only capacity that is problematic to this day - it is synonymous with breastfeeding. I will write more on that another day but suffice to say being asked if I am a "male nurse" triggers all kinds of thoughts 🙄
Growing up in Northern Alberta and, for a good part of my transformational years, on a farm meant nursing was not exactly on my radar. When living in High Level, a pretty remote and rural area, our house was across the street from the nursing station where Laura Attrux worked. To this day I always remember Laura as a formidable person who, as the District Nurse, did everything in our community because the closest hospitals were Fort Vermillion (82 km if the ferry was operational) or Manning (230 km to the south) and a physician only came once a month. Laura provided primary care (triaging those who would see the physician), public health (she was the school nurse and mainly known for injections), emergency care, dental care, and even veterinary care. And at the age of 65, Laura got her private pilot's license in order to be able to serve the First Nations reservations and communities in the north. When I eventually decided to go into nursing, Laura was one of the role models in nursing that stood out for me. Another nurse who came in from time to time to work with Laura and cover her was Fran, who I will talk about later - Fran and my paths would cross in my last year of nursing school.
Another role model in my life was my maternal grandmother, Wilda Donnenworth, who graduated from the Royal Alexandra Hospital in 1938/39. Grandma gave up active nursing to raise two daughters but then was hired my Alberta Medicare to process and adjudicate physician billings as the public healthcare system evolved. But through Grandma I heard the stories of her "training" and early career, then was able to meet and hang out with her classmates along the way.
Other role models in nursing would also play a critical part for me in beginning my journey into the profession; these were the ones I had the honour and privilege working with when a registered emergency medical technician on the local ambulance service in Athabasca. One of these nurses would often ride along with us on emergency calls or transporting acutely ill clients to Edmonton. And we on the ambulance teams would work with with these nurses in the ER and do procedure re-certifications with them. In fact, it was over chest compressions on Resuci-Annie that two nurses asked me if I had ever thought about nursing as a career and recommended I consider the option given my work with clients and affinity for health care. The rest, as they say, is history.
At the time I entered nursing, our profession was probably nearing the apex of its autonomy, influence, and respect. As a RN, sometimes with special education but often not (more on-the-job training), most graduate nurses could work to full scope of practice. There were meaningful nursing leadership positions filled by incredibly experienced, sometimes tough, nursing leaders. But then these positions were eliminated and program management came along - we ended up with nominally qualified healthcare professionals with business degrees managing (not leading) the work of nurses. At the same time, the education standard and even the threshold to pass a nursing registration exam began to lower. For instance, much of community and public health has been stripped from nursing programs such that there is little content and next to no actual clinical practice included; much of this has been done to "teach to" the the American-based NCLEX exam that was adopted pretty much without consultation by a select Ontario-led group of elites and with government pressure to cater to the acute care system.
Most of the general public often does not realize that a pass mark of 60 - 65% is considered acceptable in nursing courses and that principles of "adult education" is often interpreted as students can decide whether to attend classes or not. Compounding this is a trend for more instructional staff to have less actual nursing experience and, in some cases, no experience at all - yes, in academia we have people who are fast-tracked from baccalaureate to PhD with little or no clinical experience teaching future graduates. Unlike physicians, nurse practitioners, and many other healthcare professionals, there is no requirement for RNs to do any hours of actual clinical practice each year. And, as well, the schism between frontline practice and the "Ivory Tower" of academia has continued to flourish - I would say it is much more akin to a chasm that keeps widening with a definite disconnect between real practice and theory. I am pretty sure Nightingale would be appalled at these developments given the work she did to establish nursing as a well-educated and credible profession.
To be clear, this is not to disparage all the wonderful, hard-working, and conscientious nurses who are out there doing the best they can to provide quality care in a broken healthcare system. I have been blessed to work alongside many fabulous colleagues over the years and have been very grateful for the privilege to work as a registered nurse. But if the nursing profession does not find a way to reverse the erosion of its roles, maintain the foundation of its education, and find its political voice for change soon, my belief is that it will continue to decline and, potentially, replaced by other levels of providers and technology. In my recent trip to Brazil, I was able to appreciate that in another jurisdiction the downward trajectory in education and roles of nurses does not seem to be the same - perhaps there is something to be learned from abroad.
Photo credits:
"What would Florence Think" - Vanderbilt School of Nursing https://nursing.vanderbilt.edu/news/what-would-florence-think/
Laura Attrux - University of Calgary/Glenbow Archives CU1105430
Hi Dan, this is João from the Carnival in Brazil! I was thinking about you yesterday and what a nice surprise to see a new post here!
Thank you for a such well written and interesting post, I didn't know the lives and work of these pioneering women, hope to see more about this here!
Warm regards from João and Vivian!