janesalvage's blog

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!

Why the UK should stay in the European Union

Brexit will cost £2000 million a week, says the government's own report. Is it worth it? And will the NHS receive the £350 million weekly injection promised by Boris Johnson and the Vote Leave campaign? The answer to both questions is obviously No. See https://www.isitworthit.org.uk 

The EU is such a complex phenomenon that a simple Yes or No was a hard call. It’s easy to deplore big bureaucracies and the self-interest of this international capitalists’ club. The rubbish spoken about the EU by many of those who want out, and their media pals, doesn’t help. Our individual decisions should be based on evidence and common sense, not political posturing and power games.

On the plus side, this Europe-wide organization and its networks is of huge positive importance - never more than today, with our world ravaged by human-induced climate change, armed conflict and the migration it triggers, gender-based violence, and health problems that know no borders. Nursing has important contributions to make to these issues, and the EU does vital work on all of them. The UK must therefore remain part of finding solutions and maintaining international peace and stability. This will be much harder if we retreat to our crumbling island fortress.

With Brexit, nurses would be absent from yet another major international forum. Our voice, that has previously offered much to global and European nursing development, would not be heard or heeded. It’s also a matter of self-interest. For example, the Royal College of Nursing has worked through EU networks to create legislation to make a real difference on issues that matter to every British nurse - from needlestick and back injury to better working conditions.

I’ve worked on many EU-funded projects to empower nurses throughout Europe and beyond, and improve their practice and education for health improvement. They have enabled UK nurse practitioners, teachers, researchers and policy-makers to work in partnership, learn and share with colleagues from many countries, and bringing home benefits and funds. If we finally leave, we will let them and ourselves down. It's already a great embarrassment to explain to all my puzzled colleagues from other countries why the UK is bent on this suicide mission. It's not too late to stop it.

In May every year, nurses round the world celebrate International Nurses Day. May 12 is the birthday of Florence Nightingale, the founder of modern nursing, whose legacy continues to inspire nurses everywhere. In 2015, as part of my Writer in Residence role at Kingston University, we decided to have fun with Flo, challenge the stereotypes, and celebrate nursing in all its gore and glory. Just remember, Nursing’s Got Talent!

My brilliant colleague, artist in residence Alban Low, ran an art exhibition called the Art of Caring featuring 252 artworks produced by 133 artists from far and wide (http://caringandcare.blogspot.co.uk). This was shown at the Rose Theatre, Kingston, along with a cabaret-style event organized by the Nursing Society, the School of Nursing and my programme, The Word is Nursing.

We celebrated nursing around the world with poetry, fiction, live music and art, theatre, and expert speakers on the challenges of modern nursing. We linked by video with colleagues from different countries, who sent us greetings in many languages. I gave a talk on Florence’s Demons and chaired a discussion on Nurses in Fiction, with readings from prize-winning novelists Patricia Ferguson (a qualified nurses and midwife) and Louisa Young. Much of the talent on show was home-grown by Kingston. 

For a flavour of this event, here are some highlights: https://vimeo.com/131046710

On BBC Radion London,  in a debate with party health spokespeople, I challenged them thus:  'The disappointing pre-election debate about health has talked mostly about money and ideology. I haven’t heard enough about investing in what works, and investing to save. The evidence shows beyond all doubt that the more graduate registered nurses who work in our hospitals, the fewer deaths there are, and the higher the quality of care. Poor care costs lives and money. Expert nurses save lives. Substituting them with less qualified staff to save money is a false economy. It leads to more deaths and illness, and damages quality. Yet government cuts have led to fewer nursing posts, and fewer nurse training places. What do the parties propose to do about investing to save - in nursing and in safe staffing levels? And what is the evidence base of your proposals?'

Now here's a surprise - none of them answered the question adequately. And I'm still waiting for the answer. So are the UK's nurses. 

I wrote this letter as a contribution to a thoughtful, creative way of engaging with the Great War centenary:

Dear Great Uncle Fred,

You died a century ago, you are unknown to me, and no-one knows where you are buried. Yet your Walker blood runs in my veins, and your impact echoes down the years.

As a little girl I stayed with your Mam and your sister Trot, climbing their apple trees and ‘helping’ to make chutney. I slept beneath a large sepia portrait of you in uniform, surrounded with faded silk poppies. Later I learned who you were, but not much else till I read a memoir by my Grandad, John Walker.

He was 11 when you joined up in the first week of the war. The eldest of five, you were sorely missed. Your Dad was sent away to cook for the Suffolk Regiment, and the others slaved in the Streatham shop. Your postings to Dublin, Salonika, the Middle East and, finally, France must have seemed exotic.

The Walkers were a bright, adventurous, larky lot, but there wasn’t much laughter in 1918 when your brother Harry was drafted to France, aged 17. He brought back physical and mental scars, terrifying John, whose bed he shared. ‘He was sheer murder, jumping about and screaming with nightmares,’ Grandad wrote. Harry attempted suicide, and had depression, terrible headaches and fits. As a child I found him kindly, but odd.

On your second home leave in four years, you ‘looked big and strong and marvellous to the girls and me,’ Grandad said. They never saw you again. You were killed in late 1918; what must you have endured in those four years?

John was too young to fight, but soon enlisted in the Royal Marines. Not the military type, he called his memoir Not officer material. Decades later he still measured himself by you, his adored and lost big brother, who won two medals and was promoted to sergeant in the Queen’s Westminster Rifles.

Our family rarely spoke of their heartbreak: the grief, the suffering of the dead and the living, the roads taken and not taken, the limited life choices, the hardship. I knew little of it, though I’m sure I bear its imprint. Now it’s too late to ask, but I think of you with longing. As Grandad wrote, ‘My brother came on earth to kill and be killed, for he did precious little else, and yet he was a big gentle man in my memory, for ever.’

Your great-niece, Jane Salvage

Thomas Keneally's novel The Daughters of Mars (Vintage 2012) is a brilliant exploration of World War I from the perspective of two Australian sisters who join the war effort as nurses. I interviewed him about it during the Charleston Festival, East Sussex

If you think all-eventing is just for horses, think again! The select but growing band of all-eventers at the annual festival at Charleston seek neither rosettes nor trophies, but pleasure, companionship and philosophy. Our rewards are many - although attending every single event at the festival may sometimes require the chutzpah of show-jumping, the discipline of dressage and the stamina of cross-country.

Charleston, near Lewes in East Sussex, was from 1916 the country home of the Bloomsbury group of artists, writers and thinkers. Regular visitors included Virginia Woolf, John Maynard Keynes and E M Forster. My friends and I have been attending its amazing annual festival for a long time as Friends of Charleston, and for the past few years as all-eventers. The many joys of occasional events are not only multiplied but also synergized by coming to all of them. Every year artistic director Diana Reich tunes into the zeitgeist to put together an astonishing programme of which the whole is always much more than the sum of its many excellent parts. Its stellar speakers are bang on or ahead of the curve on the arts and current affairs across the globe. Creativity swirls around a few key themes which, while never too rigid, create a structure of feeling and thinking that enables much cross-fertilisation over the nine days. Last year’s highlights for me included Tom Keneally on nurses in World War I, Stephanie Flanders’ tour de force on economics, and Alex Jennings’ flawless readings from Auden to commemorate Benjamin Britten, whose music reverberated through the Sussex dusk – I’m sure the sheep enjoyed it.

Sometimes, though, it's  the festival sessions you fancy least that turn out the most exciting and take you down a new path. Surprising connections and echoes enrich most sessions, especially when speakers make explicit connections with Bloomsbury history and values. These run like a golden thread through the colourful Festival tapestry, not only in the presentations but also in the aesthetic appeal of the house, gardens, marquees and South Downs – not forgetting tea, cake and Harvey’s beer. Even the weather joins in. One year the garden will be in bud, the next in full bloom. You can begin the festival in a heat wave, lolling in the long grass under an apple tree with a glass of fizz, and end it wearing your wellies in a creaking tent that seems determined to shake free and fly over Firle Beacon, all-eventers clinging tightly to the guy ropes.

The camaraderie is another big draw. Many all-eventers come every year and become friends, greeting each other happily from our reserved seats. There’s always a talking point with your neighbour. Speakers and staff seem like friends too. Feeling part of the scenery, as well as the intimate scale of the festival, makes it easier to sidle up to an author and start a conversation. In fact we all-eventers provide a kind of social glue that probably helps with the huge challenges of feeding, watering, directing and pleasing the crowds.

There are practical advantages. Booking for the whole programme is better value, with those front-row seats, discounted tickets, reserved parking and a drinks reception. Above all, though, it’s an experience to be treasured on many different levels. It gives us soul and brain food for the whole year – not just in the pile of alluring books we buy, whose authors we heard and whose signatures adorn the flyleaf, but in memories, connections, knowledge and inspiration. Surely this is the Bloomsbury spirit at its best.

This is a revised version of my article in Canvas, Issue 39, Spring 2014, pp14-15

https://www.charleston.org.uk/event/charleston-festival-2018/

One of the most exciting thinkers in nursing today is Michael Traynor, professor of nursing policy at Middlesex University. Check out his book, Nursing in Context: Policy, politics, profession (Palgrave Macmillan 2013). The Royal College of Nursing Research Society asked me to talk about it. Here’s what I said.

I was delighted when Michael told me he was writing this book – he is a stimulating and provocative thinker with an unusual take on many nursing issues, and I knew he would come up with something worthwhile. Nursing in Context is indeed stimulating and provocative, and brings fresh insight to nursing issues.

I also have a selfish reason for welcoming this book. Since my book The Politics of Nursing was published in 1985, I’ve been asked many times to write an update. Each time I went back to the book I felt daunted by the prospect. By covering some of the same ground in a fresh way, Michael has relieved me of my burden.

I feel I’ve been saying more or less the same things in different ways ever since I published my first letter in Nursing Mirror in 1977, describing nurses as ‘a herd of vocational donkeys’. So much has changed, but I am troubled that my diagnosis of nursing’s ills remains broadly the same. Are the changes are so slow and incremental that they are hard to spot, even over a lifetime working in nursing? Have things moved on and somehow passed me by? Or have things not really moved on at all?

A key difference between Michael’s book and mine is that I wrote it as a fairly young activist, not as an academic. I had left hospital nursing to work as a nursing journalist, because I felt it was a major way of getting nurses to think and act differently. My Cambridge degree had given me excellent grounding in critical thinking, and in student politics.

I hadn’t done any structured academic work on nursing at that time, though I read plenty. And as a staff nurse I joined groups on the thoughtful Left – including the intellectual activist Politics of Health Group, and rainbow community alliances defending public services in the East End of London. My book started out as a collective project with the Radical Nurses Group. As Michael summarises it when he interviewed me for his book, we wanted to ‘have an effect on the consciousness of nurses and… of others such as the public and politicians about nursing issues’ (p152).

Being a nurse triggered mixed emotions that led me into passionate discussions, professional and party politics, writing and public speaking; and have fuelled my career ever since. I ransacked feminism, history and sociology for studies of what made nursing and nurses tick, but didn’t find many. This puzzled me, and still does. Nurses are so numerous, so important, so interesting - and so invisible. We are in a black hole: no-one can see in and no-one can see out.

Nurse and scholar Jane Robinson and sociologist Phil Strong suggested this in their study of the management of nursing following the introduction of general management. They suddenly realized, they said, that ‘despite the impressive statistics… nursing is relatively unimportant to government and to managers in comparison with medicine.' They went on, 'The tensions to which this situation gave rise - the nursing group locked into the gravitational force of its internal preoccupations, and the others, on the outside, unable or unwilling to look in and comprehend the nature of nursing's dilemmas - seemed to us to be the social equivalent of an astronomical Black Hole' (Robinson 1992).

Almost all those who try to peer out of the black hole and to illuminate it are nurses. There is little significant scholarship on nursing by those who have not themselves worked as nurses, with a few shining exceptions – above all the sociologist and historian Celia Davies, whose book Gender and the Professional Predicament of Nursing (1995) remains, to my mind, the best analysis of all.

Why, though, is nursing apparently so uninteresting to most others, and why do most nurses collude with the submissive roles assigned to them? In trying to answer those questions, and to encourage fellow nurses to get out from under, I continue to walk a tightrope between analysis and activism. Strong feelings may of course stand in the way of objective scholarship, but they also provide the driving force of this often thankless work. You must go out on a limb - to challenge stereotypes, to make the decision-makers sit up and take notice, and to ask tricky questions of yourself and your peers.

On those tricky questions, Snow and Willard’s 1989 American study attempts a research-based ‘psychoanalysis of nursing’. Less than 3% of the nurses they surveyed believed they were filled with value or were valuable simply for who they were. Lack of self-esteem was the core issue. It resulted in submissive behaviours or, in over-compensation by some, apparent arrogance. Nurses were needy, in a working environment that told them not to be, and often had their needs met indirectly by taking care of the wants and needs of others. The resulting co-dependence, the authors concluded, took nurses off balance ‘into caring for others at the expense of ourselves, creating professional disillusionment and personal pain.’

This, I think, is nursing’s biggest guilty secret. It was partly mine. Only when I started psychotherapy aged 30 did I begin to grasp that going into nursing was partly driven by my unconscious desire to bring my dead brother back to life, as well as my huge need for love and approval.

Snow and Willard is dynamite but I rarely see it referenced. I took a very deep breath and wrote about it in 2003 in my column for Nursing Times. I said, ‘You may feel as uncomfortable as I once did with the idea that nursing cannot come of age until it starts to explore its collective psychopathology, and until each nurse commits to a similar personal exploration. But nothing will really change until we do.’ I waited to be drummed out of the profession, but no one said a word. Did no one want to go there? (Or had they stopped reading my columns?)

Deep-rooted neediness and low self-esteem among nurses does not mean they cannot change. But it does mean that major changes in the responsibility, accountability and leadership of nursing must be facilitated through massive development programmes that help people find a sense of purpose and dynamism, as well as equipping them with the necessary skills. A supportive workplace culture is also essential.

Nowhere is this more salient than in the current debates about what Michael calls ‘the mystery of poor care’. His four-part argument (p116) adds important psychoanalytic and psychosocial dimensions to the historical and sociological insights of Davies, Robinson, Rafferty, Nelson and others.

Changing things is hard because most of the levers of change are beyond nurses’ grasp, and the actions needed to prompt change go against the prevailing societal grain, as they require nothing less than a social revolution. What might such a revolution look like?

If I could wave my magic wand I would make three things happen. The first would be a social transformation in which society truly valued caring, and the millions of people, mostly women, who are skilled and kind care-givers at home and at work; and in which the men would finally play a full part.

The second, linked magical act would be a demedicalization and decommercialization of the health system, so that it was no longer driven by corporate and individual greed, and doctors were no longer the masters but members of the team. Thirdly, the whole system would move upstream, away from death denial and pointless or ineffective interventions, towards helping people and communities lead healthier lives.

Waiting for the revolution, I wobble almost daily on my tightrope with every fresh report of yet another care scandal, yet more abuse of nurses and yet another futile political or managerial response. I am swayed by rage, angst, exasperation and defensiveness, none of it conducive to clear thinking. As an ageing activist I wonder whether it’s time to leave the ring, and let the younger ones who I hope, armed with this book, will take up the challenges.

Nursing in Context: Policy, politics, profession by Michael Traynor, Palgrave Macmillan, 2013

Nurses get so much bad press these days that it’s a rare pleasure to be reminded of their many virtues. Heroism is the right description for what so many nurses do, day in day out – and never more so than in wartime, as shown in Thomas Keneally’s celebrated  novel, The Daughters of Mars.

Its setting is World War I and its two central characters are young nurses, sisters who leave their family farm in New South Wales for Egypt, Gallipoli and France. This gripping epic combines grand themes with detailed psychological portraits of Naomi and Sally Durance and their colleagues in the military and civilian medical services. In Keneally’s words, he tries to render the human and intimate moments among the thunder and fury, and he succeeds admirably.

The flow of books, films and TV dramas acknowledging next year’s centenary of the war’s outbreak is well under way. We may think we know what it was like, but this tale has a new twist. This Australian author, by telling the story through a nursing lens and from a colonial perspective, sheds new light on both past and present.

As you might expect from a writer whose Booker Prize-winning novel Schindler’s Ark became an astonishing film, this is a wonderful book - on so many levels. The hardback is a massive 520 pages but I raced through and didn’t want it to end. It is an extraordinary feat of imagination, conveying vividly what it was like to care for the endless wave of horribly wounded, diseased, gassed and dying soldiers.

When I met Tom at the Charleston literary festival, he told me how the idea was sparked by reading Australian and British nurses’ war journals and letters. He came across them while researching a social history of Australia, was surprised and moved by what he read, and decided, ‘It was too interesting not to write about.’  He was particularly struck by how poorly the nurses were treated. ‘They really were angels of mercy, junior madonnas, bossed around by the hierarchy – it was the wounded men who loved them,’ he says.

In one telling episode, the nurses are billeted on the Aegean island of Lemnos to care for the Gallipoli survivors. With the collusion of senior men in the medical and military chains of command, they are treated like skivvies, forced to do domestic work, forbidden to use their nursing skills, and verbally and physically abused. A nurse raped by an orderly is sent to a mental hospital to hush it up. Standing up to authority, feisty Naomi becomes their leader.

The impeccably researched detail of what the clearing stations and tented wards were like is one of the book’s highlights. You can really imagine yourself there, using instruments and medicines that we now consider archaic, nursing young men and boys with appalling injuries or ravaged by sexually transmitted diseases and fevers, with few analgesics or anaesthetics and no antibiotics. The nurses worked 24-hour shifts in converted houses or primitive tents, sometimes under fire.

They paid a heavy emotional and physical cost. These nurses, many of them also very young, are ‘crushed under the wheels of Mars’, their lives changed forever. Their brave letters and memoirs show how tough they were, but also how traumatized. Like most returning combatants, when they got home they could not speak of their experiences.

Tom was intrigued by what the nurses’ memoirs said about their battle for recognition and status. ‘It is fascinating when women become stroppy and determined in a male-dominated world’, he says.  ‘Their struggle was at the core of feminism at the time’ - and continues to this day. A staunch, plain-speaking feminist at the age of 77, ‘I am amazed that men have got away for so long with being the master gender,’ he says.

Some insights come from his family. For advice and fact-checking he called on two nurses - his wife Judy and sister-in-law Jane, to whom he dedicated the book - and his late brother Dr John Keneally, a distinguished anaesthetist and medical historian.

He has also been nursed in hospital himself, and is angered by the bad press. ‘The nurse’s status is still uncertain, and the angels/bitches dichotomy will probably get worse as medicine becomes more complicated and governments are not convinced of the need for a national health service,’ he told the Charleston festival audience.

The novel is a refreshing change from the usual nursing stereotypes. It portrays heroism with no whiff of sentimentality, but plenty of strong feeling. It exemplifies Keneally’s long-standing preoccupation with putting ordinary people in extraordinary dilemmas. That’s nurses, in a nutshell – ordinary people called on to do extraordinary things – and it sometimes makes them heroes, whatever the papers say.

Reviewed in Nursing Standard, 25 September 2013, 28:4, 28-9