Handmaiden or professional: the 5 paradoxes of nursing

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Salvatore Gambacorta RN writes: This article arose when I innocently replied to a Nurse Uncut Facebook post regarding the persistent perception of nurses as bedside handmaidens, a term which itself perpetuates the stereotype of nurses as dedicated females with wide caps and immaculate white uniforms, despite there being an increasing number of men drawn towards this profession.

I, on the other hand, am male, married and have three children [Salvatore on right]. I am compassionate, I enjoy working with people and I am not repulsed by maleficent odours nor objectionable materials. Does that make me less of a man? Apparently, many people still seem to think so, as Stanley et.al. (2016) discovered in their study ‘The male of the species: A profile of men in nursing’. But my intention here is not to talk about men as nurses, but about nurses as professionals and the five paradoxes of nursing that I have identified, because it is that perception which continues to define us and the work we do.

Almost everyone who knows me personally knows my background. What they do not know, however, is that I started my nursing training in 1985, having enrolled in the first Diploma of Applied Science (Nursing) course offered that year. (I left at the end of the first semester to pursue an overseas opportunity.) I could have entered one of the last intakes of the hospital-based nursing courses, but I already had a Bachelor of Science in pharmacology and anatomy, so I chose the more familiar academic pathway, much to my regret now. There was, nevertheless, a perception at the time that Science degrees were only available in the hard sciences such as physics or chemistry. In fact, I still recall an interview at Lewisham Hospital where my interlocutor had no idea that such majors existed nor had any idea how to handle a young pharmacologist, other than to send me to another hospital.

I became totally disillusioned, so when I called into my alma mater just to say hello, I spontaneously asked my professor if the faculty needed anyone.

“What can you do?” he asked. “I don’t know, you trained me”, I rebuffed.

“No!” was the short and succinct reply.

It was at that moment I realised that having a university degree meant absolutely nothing; it was people’s perception of who I was and what I could do that counted more. I felt like the university had not made me a pharmacologist any more than it had made me a scientist. When asked about my knowledge and abilities, I felt like saying “Apparently, start with incompetent and work your way down”, which just about sums up the sentiment of most graduates even today, including or especially nurses, who have to also contend with being eaten alive by their senior peers (nurses do eat their young, you won’t convince me otherwise).

And therein lay the processes that shape our personal and professional identities: the totality of self-construal together with correspondent inference and attribution.

Unfortunately for us as a profession, nurses add to that stereotype and preconception as assistants because we still allow ourselves to be defined by other professions rather than who we are and what we actually do.

The obvious example of this is the autonomy-eradicating ‘collaborative care model’ under which nurse practitioners and midwives work, which, let’s say it, was created to perpetuate disempowerment whilst maintaining a politically-motivated hierarchy reflective of status rather than experience, qualifications or expertise.

Paradox one: Professional drift

If nursing is indeed the “the profession or practice of providing care for the sick and infirm”, in the Guardian article that spawned this debate June Girvin (2015) states that neither Florence Nightingale nor Mary Seacole “can be construed as contemporary representations of the profession”. This is not to say they were not nurses, but that nursing as a profession has changed over the years into something quite different and whilst in my opinion it has not yet come of age, it has evolved into a complexity of scopes and practices that has transcended those early boundaries and drifted into a higher level of evidence-based consciousness.

Subsequently, the hospital-certified registered nurse evolved into a university Diplomate, then a Bachelor level graduate and finally, although still the exception, into a graduate-entry Masters-qualified RN. Interestingly, it wasn’t for at least a decade after the introduction of university-based nursing that Australian schools removed the Applied Science moniker from their qualifications, which was presumably only used to appease the medical establishment of the day, much of which objected to the higher education of nurses, here as overseas (Greenfield, 1999).

That metamorphosis, however, created voids which were eventually filled by AINs (Assistants in Nursing), Enrolled Nurses (Division 2 Nurses), who work under the direction of a registered nurse, registered nurses (Division 1 or RNs) and more recently, Nurse Practitioners and Midwives. In terms of the modern scope of nursing, therefore, Florence Nightingale would today barely make it out of the AIN category and would certainly have no concept of the scientific principles fundamental to our current practices. Nevertheless, how many people from the general public could make that distinction? From my personal experience, not many, I’m afraid to say, even amongst health professionals themselves! Indeed, as a graduate entry student myself, I was often called upon to explain my status and position to nursing staff, most of whom had never heard of a primary Masters level nursing degree. Paradoxically therefore, neither the identity of the progressive nurse nor the professional drift that has taken place within nursing over the last half century is well consolidated in public consciousness, significantly contributing to the antiquated notion of nurses as bedside assistants.

Paradox two: Functional objectification (the Willdendorf effect)

In 1908 a 28,000 year old small statuette of a woman was unearthed near Willendorf in Austria. The figurine emphasised the reproductive or sexual aspects of the female body, whilst portraying the form as faceless and therefore without an identity. Since that time the so-called Venus of Willendorf has come to symbolise the sexual objectification of women, that is, the use of women as objects for the sexual pleasure of others (Fredrickson & Roberts in Szymanski, Moffitt and Carr, 2011). As nursing is traditionally seen as the female counterpart of the male-dominated medical profession, it would not be too much of an ideological stretch to extrapolate this principle to the functional objectification of nurses as the faceless drones of healthcare, always present and ready to act on behalf of others. Szymanski et. al. also emphasise that “self-objectification manifests in a greater emphasis placed on one’s appearance attributes (rather than competence-based attributes) and in how frequently a woman watches her appearance and experiences her body according to how it looks (p. 8)”. Historically, this has manifested in the form of the nurse’s uniform and in the high standards of presentation, emphasising cleanliness. Yet, whilst uniforms can solicit inclusion, they can also encourage depersonalisation, a relinquishing of identity, which nurses were traditionally expected to accept. Paradoxically, however, Johnson et. al. (2012) argue that “conceptual orientation of professional identity [in nursing] is a logical consequence of self-concept development”, which seems to suggest that the objectification of nurses as selfless and often nameless aids by the healthcare system has historically contributed and is still antithetic to our desire to be seen as autonomous professionals.

Paradox three: Professional inadequacy

Allow me to explain what I mean about professional inadequacy using one of Zeno’s mathematical paradoxes. If I were to ask you to walk towards the nearest exit making each step exactly half that of the preceding one, how long would it take you to reach your destination? The answer is you never will, because every step, no matter how small, will never be zero. And therein lies the paradox, because we know from experience that we do make it out the door eventually. In mathematical terms that is the equivalent of the infinite series of 1/2 + 1/4 + 1/8 +…., the limit of which is actually 1!

So now that I have confused you completely, how does this relate to nursing? Let’s take the nurse practitioner as an example. I once read a nursing practice textbook that loosely defined the difference between a Doctor of Nursing Practice (DNP) and a Doctor of Medicine (MD) as “holistic” individual-centred care versus disease-centred care, whilst ideologically the two professions remained on the same pedestal. Unfortunately, we all know that is not the case and in Australia the subordinate role is written into law. Our nurse practitioner cannot be autonomous because of the collaborative care model, which defines what he or she can and cannot do by imposing the medical profession as the gatekeeper. In other words, NPs need the permission of a doctor to act. That is Zeno’s paradox! No matter how much experience a nurse has, nor how qualified he or she is or will become, he or she will never reach 1 (and I know of many nurses with multiple higher qualifications) and therefore will never be whole, always requiring a medical practitioner, no matter how young and inexperienced, to define us.

Paradox four: Training your boss

One evening, while still a student, I stayed back in the critical care unit of an emergency ward when everyone had already gone home. As far as I could tell the only people present other than myself were the nurse practitioner in charge of the unit (let’s call her Alison) and a junior doctor, a highly intelligent intern but as green as they get (let’s call him John). During the course of the evening patients would come and go and each of us would perform our duties as expected. However, what stood out for me was the paradoxical relationship between Alison and John. Being new to the job and relatively unskilled, John would rely on Alison for advice and she in turn gladly tutored her protégé without hesitation, as one should, given the circumstances. What was interesting was that Alison was potentially training her boss! Under the collaborative care model “the nurse practitioner is employed or engaged by one or more specified medical practitioners, or by an entity that employs or engages one or more specified medical practitioners” … [or] … “a patient is referred, in writing, to the nurse practitioner for treatment by a specified medical practitioner (National Health (Collaborative arrangements for nurse practitioners) Determination 2010)”. In other words, as the legislation stands, the nurse practitioner is not and can never be an autonomous primary health professional, unlike chiropractors, osteopaths and acupuncturists, all of whom both refer to themselves as Doctor and work autonomously! Despite this, Young et. al. (2010) found that nurse-led collaborative care in general practice can be highly successful.

Paradox five: The oxymoron of nursing professionalism

If a paraprofessional is “a person to whom a particular aspect of a professional task is delegated but who is not licensed to practise as a fully qualified professional”, then a corollary of Paradox Four is that a Nurse Practitioner, by the very nature of the delegation, must of necessity be defined as a Medical Paraprofessional, much like a paralegal is to a legal practitioner. However, if a Nurse Practitioner is also a Nursing Professional, then without autonomy, the scope of nursing intrinsically becomes a subset of the scope of medicine, the only distinction being the intent and ability to act on issues relating to health based on permissions afforded to such practitioners by a seemingly higher authority. In fact, our scope of practice or the need to have permission to practise makes us subordinate to medicine and that in and of itself is discriminatory because it denies us full professional autonomy, ie the full and independent expression of our professional thoughts, actions, potentials and liabilities without the undue interference of others.

That does not mean that a nurse or midwife must necessarily transcend the boundaries of the medical practitioner, because we are not the same thing. However, at some point any distinction between the two would be nullified by their considerable interdependence of actions and performance were it not for an identity that is nothing more than a political artefact assigning priority to one group over the other. Albeit from a socio-legal perspective Nancy Levitt summarised this point of view very well in her 2002 article ‘Theorizing The Connections Amongst Systems of Subordination’, when she stated:

‘Discrimination may be based not on a fixed identity status, but on “identity performance”; therefore, people may be vulnerable to differential treatment based on how they present aspects of their identities, such as appearance (attire, accent or hairstyle), gender (masculinity or femininity), or social mannerisms… ‘

In other words, figuratively speaking, we’re still wearing the handmaiden’s cap!

Paradoxically, however, nursing is an absolute. One often hears of patients “being nursed back to health”, but never “doctored back to health” (incidentally “doctoring” could be construed as deceitful manipulation). Similarly, there is no so-called “alternative nursing” as there is “alternative medicine”, simply because nursing is what it is and therefore an absolute. With that in mind, as medicine gravitates towards graduate entry there will come a day when many doctors will have been nurses in a previous professional life, then and perhaps only then will nursing come of age, ushering in an era of enlightenment where conversations such as the following will become reality:

“Sarah, I hear that you got into nursing at university”

“Yes, I did, Aunt Jane.”

“That’s wonderful, dear! Is there any particular field of nursing that you would like to specialise in?”

“Yes, Aunt Jane. I’m thinking of specialising in Medicine!”

Unfortunately, only when nursing ceases to be shackled to other professions can it proclaim itself a true profession. Until that time the perception of the nurse as the bedside handmaiden will continue to taunt us as we continue to thrive in the hand of others rather than standing on our own two feet!

Salvatore’s Sixth Paradox of Nursing will be coming to Nurse Uncut soon!

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