1. Brown, Theresa PhD, RN


How nursing's past holds back our present.


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Susan Reverby's Ordered to Care: The Dilemma of American Nursing, 1850-1945 (Cambridge University Press, 1987) was a hard read, but not for the reasons you might expect. True, it's an academic book, replete with footnotes and precise historical details. But that's not why I found it hard to read. The book made me sad and frustrated, because in many ways nursing in 2020 remains trapped in the same conflicts that were prominent during the time the book covers.

Figure. Theresa Brow... - Click to enlarge in new windowFigure. Theresa Brown

The central dilemma Reverby addresses is this: although nurses provide essential care for patients, the importance of this work is consistently underrated. As Reverby puts it, nurses follow the dictates of "the order to care in a society that refuses to value caring." The reason nursing isn't valued appropriately is largely due to its history, at least in the United States, as a profession limited to women. Women were seen as natural caregivers in 1850-a notion often still held today-which made the transition into working as paid nurses fraught.


Specifically, being modest, hardworking, and subservient were considered ideal female qualities, and as such were grafted onto nursing as valued aspects of "character." Nurses were judged on their decorum, slavish adherence to rules, and willingness to complete hours of physically challenging work every day, all for less compensation than they would have received for easier jobs.


Moreover, physicians historically stood in opposition to nurses' empowerment as providers in their own right. In the 1880s and '90s, nursing education commonly included lectures by physicians on the importance of nurses being loyal and obedient to physicians. As nursing moved into the 20th century, efforts to create a more comprehensive and standardized nursing curriculum were constantly opposed "by physicians who wanted the nurse to be merely a kindly woman and a practically trained subordinate." While physicians today have appropriately higher expectations of nurses, most of the time they still fail to see nurses as full colleagues.


During the 1920s and '30s, as nurses were trying to achieve better pay and greater respect for their profession, hospitals were becoming an essential part of the American economy. Reverby points out one repercussion: as nurses began moving from private duty into the hospital sector, the cost of paying them was seen as a threat to hospitals' profitability. For a time, hospitals responded by hiring nursing students as cheap labor. Such students were often "taught" by working on the hospital floors with little supervision.


In 1936, the national nursing organizations imposed licensure requirements for "all nursing personnel," thus effectively ending the exploitative use of nursing students as staff nurses. Yet in a survey conducted that year, nurses complained that the rigid work demands imposed by hospitals kept them from giving "artistic nursing care" to their patients. Nurses wanted to be adequately compensated and supported in the complex work of caring, desires that remain very contemporary.


In nursing "submission was rewarded; innovation, experimentation, and advocacy were not," Reverby writes, and though today we might like to believe this is an old and long-abandoned view, I encountered it in my first hospital job. Nurse-on-nurse bullying was the norm on the unit, and my preceptor, trying to help me to better fit in, kindly told me that new nurses were "expected to be more submissive." The professional independence I'd forged working as an English professor was unwelcome in my new career because it violated expectations that were literally more than 150 years old.


My response to my preceptor's advice: "I don't do submissive." In the end, I see Reverby's book as a call to action. We nurses-whatever our gender-must bring nursing into the 21st century. To do so, Reverby says, it's crucial that nurses "create the vision of autonomy and altruism as linked qualities, and achieve the power to forge this unity." That is, we need to coalesce the values of professional independence and deep caring for patients, and refuse to accept being overworked and underpaid. We must embrace what Reverby calls "the right to care."