Breaking the silence: a new story of nursing
My latest publication - an editorial written jointly with my colleague and friend Barbara Stilwell. Below are some extracts - for the full version see:
Salvage J and Stilwell B (2018). Breaking the silence: a new story of nursing. Journal of Clinical Nursing. April 6. http://onlinelibrary.wiley.com/wol1/doi/10.1111/jocn.14306/abstract. ht...
We live in challenging times, for the planet, for our societies and for the health of nations. The challenges have major implications for nurses - a global profession of some 23 million women and men - from caring for older people to halting infectious disease epidemics, reducing mother and child deaths and tackling and mitigating the health effects of climate change. The challenges confronting nurses are remarkably similar worldwide, and so are their humanitarian values. We see this daily in our work as international nursing leaders and activists. The value of nursing to health and society has barely been explored or quantified outside its own professional circles. Despite all the lip service, our potential to improve health and wellbeing has never been fully acknowledged or developed.
Our experience also bears out the observations of sociologist Celia Davies, that ‘nursing internationally has often occupied a marginalized and culturally ambiguous position’, and that fundamental aspects of nursing work are intertwined with the low status afforded to women’s caring work (Davies 1995). As she said, ‘the foundational work of nursing is rarely brought to the policy table, but remains hidden and invisible’ (Davies 2004). Over 20 years on, little has changed.
Nursing is heavily mythologized everywhere, but paradoxically remains largely invisible. Most nurses go about their work quietly, accept the subordinate roles assigned to them, and remain below the radar of informed commentary or thoughtful scrutiny. Sometimes put on a pedestal when things go right, and often castigated when things go wrong, we escape attention at other times. Yet the facts show that well educated, empowered nurses are needed more than ever to solve global health problems; and at last champions outside the profession are getting the point. For example, an influential report by British parliamentarians highlights the ‘triple impact’ of nursing worldwide: better health, greater gender equality, and stronger economies (APPG 2016).
Investing in nursing brings rich returns and rewards, the report confirms - and now is the moment. To take two linked examples among many, there is a rising global need for continuous care and support for people with multiple long-term conditions. Older people are the fastest-growing age group worldwide; by 2050 nearly one in four people will be over 60, and at current projections more than 80% of them will have little or no help to age well. The need is already acute.
Nurses are the largest proportion of the health workforce globally – by a large margin – and are often the only health care provider available. An important and influential force for public health, in many places they play advanced roles to fill in the missing pieces of care. They are key to achieving universal health coverage, but they are not central to policies and plans, at the table or on the menu. That has to change, so we need to understand why progress is so slow.
Stuck in a rut
Nurses themselves, and occasionally others, have produced many reports on nursing over the years. Re-reading them, the overwhelming impression is déjà vu. World Health Organization (WHO) expert committees on nursing in the 1960s outlined similar issues to those of today – the same problems, failures and solutions. ‘Nursing is stuck in a rut,’ said a recent review of 20th century reports on nursing in the USA (Gebbie 2009). Even worse, she says, it may stay there – it has not risen to the level of a fully accepted profession, does not fully own its history, and has not been willing to make the changes urged on it by thoughtful analysts.
There have been some advances: nurses in many countries are better educated, more competent and more confident. Yet we remain mostly invisible, and in some respects things are going backwards. We have long challenged the exclusion of senior nurses from leadership positions, and made some headway, but when health employers decide they do not need a nurse director any more, or when governments do not replace their chief nurse, we have to fight the battle all over again. WHO, for example, talks up nursing, but actually employs fewer nurses than in years gone by – now only a handful – while in some countries the government chief nurse role has been abolished, downgraded (United Kingdom), or never existed (United States). To understand why, nurses need to confront the intractable issues, and to break the silence about them within as well as outside the profession. This is a tough call, as the underlying forces that make it so hard to overcome the barriers to change in nursing are complex, interactive, and deeply rooted in social and cultural attitudes and practices, especially patriarchy.
Change has to start with empathy and understanding of the reality of nurses’ lives. We generalize with caution but here is a profile of a typical nurse: female, a parent and often a carer of other family members or neighbours. On a modest to low salary, she often does part-time or agency work to fit in with domestic demands or earn more. She shoulders many responsibilities, and works hard to keep the show on the road. She cannot also be a paragon of virtue at work, a leader and a change-maker - her focus is more likely to be getting through her day. ‘I’m only a nurse,’ she says.
Many nurses and midwives feel that their voice is not heard or heeded. Some are frightened to speak up when they see neglect or abuse of patients, while others lack the self-confidence to perform well when they do have the opportunity to express their views. Many are afraid to report their experience of bullying, abuse and sexual harassment in the workplace. They tolerate a subordinate, low-profile role, and/or lack energy and support to change it.
We need to question whether nursing leaders’ aspirations are out of kilter with a workforce that is attracted to nursing precisely because the type of competencies it is assumed to require do not include assertiveness or leadership. Nurse leaders, who often refer to their nursing colleagues’ reluctance to speak up or take responsibility, are often mavericks who aspire to something more and have the self-esteem to achieve it. They reject the mindset of the majority to whom nursing is ‘just a job’. Sometimes nursing leaders ally themselves with medics and managers rather than other nurses, wishing consciously or unconsciously to distance themselves from their low-status beginnings.
There are of course wide social forces at play here. Our archetypal female profession is perceived as doing women’s work, which is not seen by most men and some women as requiring particular skills or training, at home or at work. Worldwide, most senior medics, managers and policy-makers are men who exhibit sexist behaviours and assumptions. Top female nurses describe their difficulties being heard in the macho atmosphere of most boardrooms; women use different language, speak more quietly, and talk about issues in different ways. This relates to general discomfort around openly addressing the issues close to the heart of nursing work/women’s work – death, the messy realities of birth, physical illness and decay, and emotional labour.
Societies worldwide, continuing to maintain the power of patriarchy, have allowed the massive advances in medical innovation to devalue the softer but equally important technologies of caring. They fail to provide emotional support, effective clinical supervision and other ways of caring for the carers. Worse, societies and employers fail to protect women. This includes the routine denigration of nurses in public images that depict them stereotypically as angels, whores and battle-axes.
How long must we be patient?
Deep-rooted neediness and low self-esteem can be tackled, through major culture change and massive development programmes to help nurses find or renew their sense of purpose and dynamism, and equip them with the necessary skills (APPG 2016). This will require skilled local leadership and focus, as well as funding. Evidence shows that front-line staff can lead and own the changes needed to ensure high quality care. These reforms must be scaled up by restoring and supporting clinical leaders, while also ensuring nurses are able to exercise leadership at higher levels, from ward to board and beyond. It means providing access to many more leadership development programmes, and enabling nurses to control their own work and lead their own clinics and services. However, weight of numbers, gender, race, class, doing dirty work, low self-esteem, the characteristics of the ‘ordinary nurse’ – these huge challenges are not amenable to quick fixes. They are compounded by managers and policy-makers who resist hearing or heeding the mounting pile of evidence on the effectiveness of investing in nursing.
If nursing leaders could solve them, they would already have done so; but these deep and broad social and cultural realities and attitudes are too difficult to be tackled by nurses alone. The progress that nurses have made over our lifetimes working in nursing is often slow and fragile. It is not enough, and we are impatient. To progress, nurses must shed their cloak of patronage and invisibility. Yet when we finally raise our voices we are often accused of professional self-aggrandizement. You’re part of the multidisciplinary team, we’re told – why do you need your own strategy, your own leader at the table, your own regulatory body? It is high time nurses controlled their own destiny, instead of being in perpetual thrall to others who never seem quite to get it, or choose not to, or feel at best a sense of discomfort around the issues.
A new story of nursing
The major shifts necessary to transform nursing will not be effected through a continuing series of piecemeal policy initiatives, however good each may be. Deep-rooted, sustainable change will depend on reaching honest, shared understanding of the barriers to change and what underlies them, and on tackling the root causes and underlying drivers. There are some hopeful signs of change. First, global awareness is growing of nurses’ massive actual and potential contribution to improving health, creating gender equality and strengthening economies. The penny is finally dropping. Second, it’s been a very long time coming but surely more nurses will soon find the courage to become ‘silence breakers’ and join the worldwide wave of protests against violence, sexual harassment and other predatory, abusive behaviour against women.
These big issues aren’t solved by tips on how to exploit the status quo, and patience is unlikely to be the answer either, as the feminist and classicist Mary Beard says. ‘If women aren’t perceived to be fully within the structures of power, isn’t it power that we need to redefine rather than women? You have to change the structure. That means thinking about power differently...above all thinking about power as an attribute or even a verb (‘to power’), not as a possession: the ability to be effective, to make a difference in the world, and the right to be taken seriously, together as much as individually’ (Beard 2017).
This is the moment to shift the paradigm, to be taken seriously, when the old certainties and ways are being shaken to the core by economic crisis, climate change, insecurity, a deep desire for stronger social solidarity, and the rising clamour of women’s voices. This impels us to tell a new story of health and healthcare, the aim of the global Nursing Now! campaign launched in February 2018. Nurses, as leading actors in this new story, will be at the heart of sustainable health systems that meet individual and population needs, are fit for the present, and innovative and adaptable for the future. Rooted in reality, yet reaching for the stars, nurses work to shape sustainable, high quality, effective and affordable services fit for the future, and responsive to the challenges of turbulent times. They focus on where the needs are greatest and where there is most potential to gain health and reduce inequalities. They take their understanding and experience as hands-on practitioners into all their subsequent roles, as clinicians, managers, teachers, researchers, scholars, policy-makers and leaders. They provide leadership at all levels, from ward to board to international organizations.
For too long nurses have been invisible, uncounted, undervalued and silenced. Now is the moment to find our individual and collective voices: not just #MeToo but also #NursesToo, and Nursing Now!