I am a Nurse, Just a Nurse

11164759_1057759667571978_8700043668876075012_nFor many years, whenever anyone said to me, “Oh! You’re a nurse,” I would correct them and say, “No, I’m a nurse practitioner.” Why? As if identifying myself as a nurse was somehow beneath me? As if being a nurse practitioner meant I wasn’t really a nurse, or I was more than a nurse because I could diagnose and treat medical problems, something nurses can’t do? As if I was too intelligent to be ‘just’ a nurse?

I was not born to be a nurse; I was not called to be a nurse. I didn’t need multiple-choice tests and multiple sessions of career counseling at pivotal junctures in my life to tell me these facts. What with the Myers-Briggs Type Indicator, the Strong Interest Inventory, the Eureka Skills Inventory, and the Holland Personality test results, my career counselor proclaimed, “You don’t have the personality, the interests or skills test results to match nursing.” It seems I was meant to be a writer. Oops. Too late. When she told me this I had already been a nurse/nurse practitioner for over thirty years. Of course, it was my job as a nurse practitioner and nurse educator (and most definitely not as as an unpaid writer) that allowed me to take these expensive tests in the first place.

But oh the places nursing has taken me! If I had it all to do over again, if I didn’t have to worry about being a single mom earlier in my career trying to earn a decent income, if I could choose any of the health professions to ‘become,’ I would choose to be a nurse. I would choose to be the ambivalent, skeptical, social-justice minded, community/public health-focused nurse that I am. Last summer I reflected on where community health nursing has taken me, and I made this short digital storytelling video: “My Story of Community Health Nursing.”  Even though this was my first video, and I see that it is clunky in places, I revisit/re-watch it on occasion to remind myself of who I am, and of why I love to do the work I do–including teaching nursing students and encouraging them to consider becoming a community/public health nurse.

The photo included in this post is a ‘retouched’ photo of a University of Washington School of Nursing promotional placard reading “I am a #huskynurse.” It’s not that I’m opposed to proclaiming myself an over-sized, plump nurse. But I am opposed to being a (branded) nurse. I am an–unqualified– nurse. I am a nurse. I am a community/public health nurse.

Happy National Nurses Week and Happy 195th birthday to Florence Nightingale!


“Just a Nurse” is used with a nod to the work of Suzanne Gordon, a journalist who writes about/is a longtime advocate for nursing.

Notes on (Men in) Nursing

Cover of "Notes on Nursing"
Cover of Notes on Nursing

In the Preface of Notes on Nursing, Florence Nightingale wrote, “…every woman is a nurse.” That men were—or could be—nurses was not within Nightingale’s Victorian worldview. Men were doctors (husbands) and women were nurses (wives and mothers). A re-read of her book revealed to me one place in which she hints at the fact that men could be useful as nurses. It comes mid-way through her chapter “Noise”:

“A man is now a more handy and far less objectionable being in a sick room than a woman. Compelled by her dress, every woman now either shuffles or waddles—only a man can cross the floor of a sick-room without shaking it!”

She goes on to condemn the wearing of rustling silk and crinoline and the creaking of stays and shoes. Presumably she advocated simple (and quiet) cotton dresses for nurses.

As I wrote in my previous blog post “More than a few more men needed in nursing” (12-15-10), nursing continues to be the least gender balanced of any of the health professions. The traditionally male-dominated medical profession has achieved almost perfect gender balance. The other traditionally female-dominated profession of social work now has at least 20% men, while nursing continues to have a paltry  7% men in the workforce.

Until this week I considered myself an enlightened female nurse on the issue of gender diversity in nursing. But then I started looking at the required readings—especially the ones from nursing textbooks—that I had assigned for my community health course. I realized how un-gender neutral they are. All of the contemporary community/public health nurses who are quoted or included in photographs in the chapters are female. An otherwise well-written chapter on the history of public health nursing in the U.S. only mentions female nurses and uses terms like “our sister nurses” and “our foremothers.” Where are our brother nurses and our forefathers?

Important facts I learned this week from reading up on the topic of men in nursing include:

  • Men in nursing have a long and venerable history that is not acknowledged or taught very well in nursing schools. The history includes monastic orders dating back to the fourth and fifth centuries.
  • In the U.S. beginning after the Civil War men were actively shut out of nursing. For instance, the U.S. Army Nurse Corps banned men until 1955. When men were allowed to be nurses they were mainly confined to psychiatric nursing, which was considered dangerous and undesirable work for female nurses.
  • The commonly held perception (and resentment) among female nurses that men in nursing disproportionately get promoted and hold higher-paying administrative positions over their female counterparts does have merit. Economists call this phenomenon the “glass elevator,” and it applies to men in all female-dominated occupations (pink-collar jobs). However, within nursing this could also be partially explained by the fact that most men enter nursing at an older age and after time in another career versus their female counterparts. (see NYT ” More Men Enter Fields Dominated by Women” by Dewan and Gebeloff/5-20-12 and “More Men Trading Overalls for Nursing Scrubs” by Vigeland/3-21-12).
  • The Institute of Medicine’s Future of Nursing report specifically identifies improvement in gender diversity as a necessity for nursing. Running a profession on only half of the population (gender-wise) is unwise and untenable.

My conclusion: Nursing needs the best and the brightest no matter what their chromosomal make-up happens to be. We need more men in nursing. We need better nursing textbooks….

Happy (#192) Birthday Flo!

Cover of "Notes on Nursing"
Cover of Notes on Nursing

Happy International Nurses’ Day and happy end of National Nurses (no apostrophe, I don’t know why) Week, celebrated May 6-May 12th every year since 1990, thanks to the American Nurses Association—seemingly in conjunction with Hallmark. Is it a strange coincidence that National Nurses Week, National Administrative Professional’s (or Secretary’s) Day, National Teacher Day, and National Mother’s Day are all clustered around the same weeks?

In the interest of research, I recently bought and watched Season Three of the TV show, Nurse Jackie. According to Nurse Jackie (Episode 11: Batting Practice), “(Nurses) Appreciation week is patronizing. It’s for the overworked and underpaid.” To which her co-worker, male nurse Thor chimes in, “Secretaries. Teachers. Us.” Jackie responds, “It’s bullshit and we don’t celebrate it.” And my favorite character on the show—the pink Crocs and teddy bear scrubs wearing new nurse Zoe—says, “That’s crazy! It’s our week, and if we don’t celebrate it, who will?”

Florence Nightingale, the somewhat tarnished icon of modern nursing, was born 192 years ago today. Of all that has been written about Florence Nightingale, Lyton Strachey’s is my favorite. He calls Florence’s Notes on Nursing, “… that classical compendium of the besetting sins of the sisterhood…”  Here is what Lyton Strachey writes about Florence Nightingale in his entertaining book Eminent Victorians (1918/The Albion Press/Oxford England):

“Every one knows the popular conception of Florence Nightingale. The saintly, self-sacrificing woman, the delicate maiden of high degree who threw aside the pleasures of a life of ease to succour the afflicted, the Lady with the Lamp, gliding through the horrors of the hospital at Scutari, and consecrating with the radiance of her goodness the dying soldier’s couch—the vision is familiar to all. The Miss Nightingale of fact was not as facile fancy painted her. She worked in another fashion, and towards another end; she moved under the stress of an impetus which finds no place in the popular imagination. A Demon possessed her. Now demons, whatever else they may be, are full of interest. And so it happens that in the real Miss Nightingale there was more that was interesting than in the legendary one; there was also less that was agreeable.” (pg 73)

Roxanne Nelson, in her Washington Post (4-29, 2003) article entitled “Good Night, Florence,” reports that Unison, Britain’s largest trade organization representing nurses, declared they were ditching Florence Nightingale because she “represents the negative and backwards elements of nursing.” (during their 1999 annual conference). In her article, Ms. Nelson reminds us that Miss Nightingale worked as a nurse for less than three years, including the time she managed a British hospital in Turkey during the Crimean War. After the war—and for the last fifty years of her life—she basically took to her bed with what historians now suspect was a combination of Malta Fever (brucellosis—probably from infected milk products) and depression. While an invalid, she wrote Notes of Nursing, oversaw the opening of the Nightingale Training School for nurses, and worked on hospital reform of the British military. Florence insisted that nursing was a calling and not a profession.

Those funny Brits across the pond. They know how to celebrate the history and influence of Florence Nightingale. They have the Florence Nightingale museum in London, complete with a stuffed owl—the remains of her pet owl Athena—and a Turkish lantern like the one used during the Crimean War. In their online store you can buy a teddy bear dressed as a nurse and holding a Turkish lantern, or a resin bust of the Iron Maiden, or a hot pink lapel pin with the interesting statement, “Nursing is an art.”

Nurses and Advocacy: Working With the Media

Old New Media Readings
Image by Krista76 via Flickr

I have been pondering nursing’s attitudes towards and interactions with the media, especially the news media—within the context of advocacy. Advocacy at its simplest is speaking up, “to plead the cause of another.” Public policy advocacy  “rests on a three-legged stool; to be effective, all three legs must be in place.” (Nancy Amidei, So You Want to Make a Difference: Advocacy is the Key, OMB Watch, 2010) The three legs of advocacy are: 1) the capitol leg (anywhere the laws and policies are made), 2) the community, grassroots leg, and 3) the media leg (anything we do to spread the word/influence more people). In general, nurses do not do well at any of these three legs, but probably do worst with the media leg. Why?

Nurses know advocacy at the individual patient level. Nurses as the fearless defenders of patients is an image deeply rooted in nursing history. Florence Nightingale and Nurse Hawthorne are cut from the same cloth. When nurses are shown in a positive light in the popular media, it is usually as patient advocate superhero. People resonate with that role for nurses, and it is a nursing role modeled for new nurses and included in their basic education. Many nurse leaders maintain that patient advocacy is the exclusive purview of nursing, as if nurses have to protect patients from doctors, social workers, and hospitals. Taken too far, it can be a paternalistic and anti-teamwork frame of mind.

Nurses know advocacy at the self-interest level, through professional nursing organization policy platforms, and through nurse lobby and collective bargaining groups. Nurse patient staffing ratios, expanded scope of practice for nurses, and longer uninterrupted breaks for hospital nurses (see “The Nurse Lobby Day that Wasn’t” blog post, 2-15-11). In addition, much of nursing research is self-interested advocacy of various aspects of the nursing role.

Nurses don’t know public (political) policy advocacy—for the most part. Public health nurses have more experience in and knowledge of this area than do other nurses. They have to, since they work within the socio-political determinates of health. Elite nurse leaders know and use public policy advocacy, and there are a few advanced nursing degrees in public policy advocacy. But elite nurse leaders and public health nurses make up a small fraction of the nursing workforce in our country. They are also viewed as zealots and crazies by many nurses: public health nurses are bleeding-heart progressives, and nurse leaders are out of touch with ‘real nursing.’

So what prevents more nurses from being involved in public policy advocacy? Some people maintain that it stems from nursing school socialization into a risk-averse, conflict-averse role for nurses. Being an advocate of any type—but especially of public policy—means sticking your neck out, taking risks, and dealing with conflict. Other people point out that many front line nurses are overworked and are largely powerless employees of a hierarchical hospital system—and these factors contribute to the lack of policy advocacy involvement by more nurses. And then there is the lack of education for nurses on policy advocacy, and a lack of role models and “best practices.” I teach a public policy and politics of health care graduate nursing class, but my own education and background for this came from my public health involvement, and not from nursing. The National Health Care for the Homeless annual conference I attend always has hands-on training sessions on working with the media in policy advocacy. The American Public Health Association annual conferences generally have many sessions on working with the media and other aspects of influencing public health policy. I have never heard of any such sessions at a national nursing conference.

Working with the media is essential for good policy advocacy because, as Amidei writes, “politicians pay attention to the media (it provides a way to check the community pulse); media can be used to reach other voters; and misinformation that appears in the media needs to be challenged.” Many front line nurses are afraid of interactions with the news media, of speaking out on issues affecting their work—for good reason—since they can be fired for doing so if they haven’t gone through approved channels, or if they say something negative about their workplace. Most hospitals now have policies for all employees on interacting with the media, and even on use of social networking media. This level of institutional control and intimidation has always been present, but has accelerated with the advent of hospital ratings and increased competition for business.

I was reminded of the contradictory messages given to nurses about interacting with the media in the panel discussion this past May in the aftermath of the suicide of Kim Hiatt. One of the panel members, Joanne Silburner, a longtime NPR health policy reporter, encouraged nurses to speak up more—to get to know trustworthy news reporters and to tell them their stories. I imagine that there were at least a few nurses present who did just that—or who first talked with their nurse managers who supported them in talking with the media. They are all my heroes.

Nurses already have many of the essential tools for being an effective public policy advocate. They know firsthand how power is wielded, how people are motivated, and how those with power are influenced. They see these every day in their work. With some additional Civics 101 and media- savviness brush-up—and some good modeling from a seasoned public policy advocate—they are on their way. There are some wonderful nurse policy advocates. One who comes to mind is Ruth Lubic, founder of the Family Health and Birth Center in Washington, DC. We need more. I do not presume to be a seasoned public policy advocate—but I know one. Not a nurse—a social worker. I’m having lunch with her tomorrow and hope to cook up some ideas for advocating for nurse policy advocacy, including how to work with the media.

Nursing and the Media

I recently received an e-mail invitation to a free one-hour webinar entitled, “How the Media Portrays Nursing: Does it Really Matter?” The speaker was Sandy Summers, RN, MSN, MPH, the Executive Director of The Truth About Nursing blog and website. As her billing says, “Since 2001 she has led the effort to change how the world views nursing by challenging damaging media depictions of nurses.” I would have signed up to participate in this webinar, but I was working in clinic during the time it aired. Here is the promotional blurb for the webinar:

“Ever watch Grey’s Anatomy, Nurse Jackie, House, or other television shows that seem to portray an inaccurate depiction of a nurse?  How often do you personally experience the misconception that nurses ‘do what doctors tell them to’? The nursing shortage is a public health crisis that is one of the biggest dangers for patients and the public at large. Media products have long shaped and reinforced inaccurate perceptions about the nature of nursing work. Public health research shows that even entertainment media products have a significant effect on how people think and act with regard to health care. By reconsidering how our society thinks and acts toward nursing, we can empower nurses to improve safety for patients, reduce turnover, and enhance public health. Explore some overlooked roots of the nursing crisis and its effects, and learn ways you and other nurses can help.”

A few things I find interesting about her description and that I disagree with. One is contained in the last sentence and that is that media’s (implicitly stated ‘bad’) depiction of nursing leads directly to the nursing crisis. The “nursing crisis” is, of course, that oft-quoted “the sky is falling” alarm statement about how we don’t have enough nurses in the US to take care of all the aging baby-boomers. People have been screaming “nursing crisis” since before I went to nursing school, and I believe it is a largely manufactured problem. If there is a real shortage, it is not for lack of nurses, but for lack of decent working conditions for nurses. They leave nursing. And I doubt it is the fault of the media. “The nursing shortage is a public health crisis that is one of the biggest dangers for patients and the public at large.” Also inaccurate. Yes, adequate nurse staffing levels in hospital settings are clearly related to good patient outcomes. No one who has ever spent time in hospitals, as patient, family or staff, would disagree with this conclusion. But at a population health level, the number of nurses, doctors and hospitals in a country is not well correlated with good population health outcomes. In fact, it can start to have an inverse relationship, with more health care workforce/hospitals seeming to lead to a decline in overall population health—the effects of iatrogenics at work. I know they cover this in the MPH program at Johns Hopkins where Ms. Summers received her public health degree.

So that leads me to consider the overall issue of the media portrayal of nursing. That, after all, is what Ms. Summer’s Truth About Nursing is about. TV is only one segment of media, but an important one on a national level. I have watched episodes of Grey’s Anatomy, ER, Nurse Jackie, and HawthoRNe, both to see if they had any entertainment value, and to see how nurses were portrayed. I haven’t owned a TV—well—ever, so I watched all of these on DVD or streaming video. They are all TV shows, so they have really bad scenes involving resuscitation of deer, ferry crashes, helicopter crashes, and the usual soap opera hospital romances. Nurse Jackie and HawthoRNe at least have flawed but strong, smart and almost believable main characters who are nurses. TV drama shows like these are not reality TV. I still have faith that most Americans know this difference and don’t form their opinions about nursing from these TV portrayals. They form their opinions more from interactions with nurses they know as family members or as health care providers.

Ms. Summers and other nurse media watchdogs need to lighten up. The sexy nurse and the angelic nurse motifs are never going away completely. Having more men in nursing will help change the public’s perception of nursing more than trying to battle the media. And having a sense of perspective—and of humor—is needed.

It reminds me of other negative stereotypes of female-dominated professions, such as librarians. The Nancy Pearl Librarian Action Figure sits here beside me at my desk. Nancy Pearle is a real-life Seattle librarian extraordinaire. Seattle, as one of the most literate cities in the country, would have a librarian as a local celebrity. Our Seattle-based crazy toy-maker and seller Archie McPhee made an action figure of her several years ago that was a big seller. The librarian is dressed in dowdy clothes, a mid-shin length skirt, a loose-fitting jacket, and flat puffy comfort shoes. She is holding an index finger to her pursed lips, permanently ‘shushing’ people. Many librarians around the country were outraged by this action figure, complaining that it reinforced a negative stereotype of the anti-fashion, stern, matronly librarian. Nancy Pearle’s response was that it separated librarians who had a sense of humor from those who needed to check one out of their local library (OK—this is not a direct quote, I added the last part).  I checked today and Archie McPhee’s doesn’t have a nurse action figure. I plan to recommend they come up with one—and not of Florence Nightingale. That reminds me of the Halloween costume I wore one year to a party at Hopkins. I went as sexy Flo and it was a hit…. Luckily I wasn’t in the same class as Ms. Sommers.

In my next blog entry I will continue this discussion, but will focus on nursing’s attitudes towards and interactions with the media, especially the news media.

George Comstock, MD, DrPH: a professor who never retired. What about the ones who should?

Billings Building, The Johns Hopkins Hospital
Image via Wikipedia

Dr. Comstock (1915-2007) was one of my favorite professors out of many (too many) years of higher education. To those of you unfamiliar with him, George Comstock was a professor of epidemiology at the Johns Hopkins University of Hygiene and Public Health (now the less hygienic Johns Hopkins Bloomberg School of Public Health). Dr. Comstock was an expert in TB control and treatment. He taught advanced epidemiology at Hopkins for over 50 years, and he never really retired. His wife said that in his final weeks of life he was reviewing journal articles. He was a kind man, humble even, lived and breathed epi and could explain complex epi concepts in clear and humorous ways. He used no lecture notes that I ever saw. He was 88 years old when he became emeritus professor (sort of retired), but he kept teaching epidemiology of TB until he died.

He was an outlier. Dr. Comstock was someone who should and could teach well past the ‘normal’ retirement age. I do not plan to be an outlier in academia. The topic of “Professors who won’t retire” is the elephant in the room in academia (including in nursing) and is the title of a good “Room for Debate” series in the New York Times. The authors discuss the financial and intellectual difficulties placed on universities (and fields of study) by professors deferring retirement. A professor of history contends that history can benefit from having an older academic ‘workforce,’ whereas other fields of study, such as the sciences can be weakened by a lack of ‘new blood and fresh ideas.’ I wonder where nursing is in this sort of debate? “The Future of Nursing” report (mentioned last post) discusses the lack of pedagogical progress of most nursing instruction (meaning we don’t really know or care how effective we are at how we teach nursing–and we teach the way we were taught in nursing school). So, if we haven’t made much progress in teaching nursing since Florence Nightingale‘s day, I suppose it doesn’t matter that we are an aging lot?