22qNURSING, PHYSICIAN CONTROL, AND THE MEDICAL MONOPOLY Historical Perspectives on Gendered Inequality in Roles, Rights, and Range of Practice – Thetis M. Group & Joan I. Roberts (2001)
January 10, 2011 § 2 Comments
Chapter 1: ”The Mere Trivia of History?” The Legacy of Early Women Healers and Physicians’ Efforts to Exclude or Control Them
In this chapter, sources on gender and nursing are brought together to make visable a centuries-old linage of women healers and nurses and to document its relationship to that of physicians. Taking a longer view of women healers over several centuries helps us to undetstand whether nurses indeed usurped medical rights and functions when they created “modern” nursing in the nineteenth century, or whether they were reclaiming only a portion of what women originally did. Perhaps nurses’ current striving for greater autonomy is based not on a desire to “practice medicine” but rather on a need to retrieve and take back part of the functions and authority women previously held.
There is substantial evidence that in previous centuries women were the majority of healers, providing most of the care for the health problems of most people. Whether women healers paralleled or preceeded the emergence of medical men is still open to question; however, it is clear that women healers not only provided informally most of the domestic nursing and medical care in families, neighbourhoods, and communities, but also created hospitals and other formal institutions of healing in which they provided both medical and nursing treatment.
[…]Were women healers’ treatments and theories markedly different from or inferior to those of physicians? Were most earlier physicians giving superior treatment based on proven theories of disease and health? Certainly, prior to the later nineteenth century, the state of medical theory and practice was insufficiently advanced to give physicians any superior record over experienced women healers. The vast majority of physicians did not adopt any genuine scientific approach to medicine until well into the nineteenth century.p3
The emergence of universities from the thirteenth century onward eventually gave physicians their base for authority, which they used to justify excluding women healers from practice. Women’s exclusion from colleges and universities prohibited them from recieving formal credentials and eventually, in the nineteenth century, from obtaining scientific training, a critical factor in the eventual subordination of most women healers by the twentieth century.There is further evidence that a number of physicians, even some involved in teaching nurses in the twentieth century, were oposed to theoretical and scientific training for nurses. Clearly, physicians intentionally used gender as a way to exclude women healers from obtaining formal credentials and, later full scientific knowledge. They also intentially colluded with male-dominated legal and religious authorities to eliminate or control women healers; this is most markedly obvious during the European witch hunts, particulary from the fifteenth to the seventeenth centuries.
Perhaps the best way to exclude women healers is to deny or denigrate their existence. Medical historians have eliminated or trivialized women healers, despite the fact that nursing and medicine have a very long history of overlapping tasks and functions. Indeed, it is inappropriate to take the current division of labor and extrapolate backwards to justify it. Throughout the historical stages of nursing and medicine, the professions were so closely interwoven that is often impossible to distinguish one from the other.
[…]Despite functional overlap, accusations against women of black magic or, more generally, malpractice were made in the earliest era and have continued to the most recent; for example, Elizabeth Kenny, a twentieth-century nurse, faced such allegations for her pioneering work with victims of poliomyelits.
Regardless of functional similarities, men have written and maintained the medical version, which, given women’s previous exclusion from formal education and publishing, has prevailed over time. Indeed, even the daily lives of women over the centuries, which demonstrate nursing and domestic medicine as central to their work, have also been excluded from the record. Even when attempting to apply medical history to nursing, scholars, some well – intentioned, have failed to connect women’s and nurses’ histories; thus, any chronology of nurse-physician relations is fundamentally lacking. p3,p4
OVERCOMING THE LOSS IN INSPIRARTION BY RECOVERING A “CHERISHED TRADITION”
Nutting and Dock believed that from the early beginings of humanity women must have developed elementary health principles the care of their children, and grandmothers must have gathered herbs for the medicinal teas, as they still did in the early twentieth century: “Who, that knows the old women of remote mountain regions, can but be certain that the grandmothers were the first doctors and nurses thousands of years ago?” (p.12). […] They contrasted the sanity of early nurse-physicians with the later emergence of theories of demonical possession: “In ancient Greece and Egypt the treatment of the epileptic and insane was not only humane, but was largely remedial, and the general feeling toward ‘witches’ was one of veneration and awe, not of detestation[…](p17). p6
In contrast, the later Christian medieval period was “one of the most tragic chapters in the whole course of human misery” (p18) amd represented a period of incredible cruelty based on the idea of demonic possession, which was used to justify the persecution of witches. Nutting and Dock noted that a number of witches were older women who knew medicinal and dental secrets. These wise women served as the prototypes of later “witches,” who in episodes of witch hunting were cruely tortured and then drowned or killed by burning. Nutting and Dock provide considerable evidence of the destruction of women, many of them healers. Of numerous records, one list of victims, for example, documents the slaying of between three and four thousand women in only one area of many. Such atrocities in Europe were continued to a lesser degree in colonial England; indeed, the authors noted that even in the closing years of the nineteenth century “a demand for a trial for witchcraft was recently made in Pennsylvania” (p20) p7
Literate women healers, said Ehrenreich and English, were attacked first because they were more likely to have wealthy patients and thus were an economic threat. That they cared for patients was the issue; their presumption to treat at all was the problem. That they did so without formal, institutionalized “training” was the charge. Because they were excluded as women from such “training” made the conclusion automatic. By the fourteenth century, the emerging medical monopoly was extended to judging witches. Physicians over the next three centuries were consulted to make “scientific” judgements on whether or not women were witches. For women, healing came to equal heresy, torture, and even death.p8, p9
BRIGHTENING THE DISTANT SHADOWS: WOMEN HEALERS RECLAIMED
If Ehrenreich and English and other feminist theorists are taken seriously, Davies admits that historians must start further back than the nineteenth century, asking about, and not taking for granted, early gender divisions of labor and analyzing the differential treatment of men and women. Because so many nurse are women, there are few comparative cases, says Davies, so “we fail to see and appreciate the difference this makes Critiques such as this [Versluysen’s] can help to keep us alert” (Davies, 1980, p. 175).
Alternatively, we might claim that some historians have not grasped the structured gendering of the whole patriarchal culture; thus, it is not merely a question of comparative cases, or of simply being alert. Rather the analysis of gender requires a different perspective, just as the analysis of racist society does. Few serious thinkers would consider the historical situation of African Americans in Western cultures without reference to the racist structure if these societies. Similarly, competent thinkers can no longer merely be alert to the differences in the treatment of women; analysts of women workers, such as nurses, must see the gendered social arrangements inherent in the cultures in which they have worked. Versluysen understands this, and, in agreement with Ehrenreich and English, she states that women have always been the main healers in European, and particularly British, society, a fact conveniently excluded from some nursing and most medical histories.
[…]It should be, for example, relatively easy to show statistically that many women have done most of the healing, not only in British but in most Western and many no-Western cultures. Versluysen claims that women “have delivered babies, rendered first aid, prescribed and dispensed remedies and cared for the sick, infirm, and dying, both as a neighborly service and as paid work. Yet, aside from histories of nursing, the vast range of women’s past healing work is virtually absent from the annals of written history” (Versluysen, 1980, p. 175). This is hardly a polemical position; it is probably a commonsense fact, observable in many societies even today. p11. p12
Critically important is Versluysen’s assertion that the thoroughness and consistency of the historical devaluation and exclusion of women are not purely accidental; instead they reflect a society that has developed “an elaborate set of beliefs to justify its consistent ranking and rewarding of of male interests and activities more highly than comparable female interests and activities…. If we look into the mirror of history, we find a systematic interpretation of past health care practice in a way which assigns positive value and superior status to male healing work, and little or no value and subordinate or marginal status to female activity” (p. 177). This is only one interpratation of the past and does not represent absolute historical truth.
[…] To Versluysen, great physicians of the past did not make history alone and certainly did not achieve the contemporary health system by a supposed triumph of male medical rationality over quacks and masses of illiterate “old wives.” This gendered selective perspective is an “extremely partial view of the past” (p.178). Indeed, physicians have dismissed persons and ideas outside their control as insignificant and inconsequential. Unfortunately, “[h]istorians have generally accepted this dismissal with great alacrity and little criticism” (p. 178) viewing nonmedical personnel as marginal amateurs.
[…] Because women were excluded from academic institutions, Minkowski concludes that they did not have the opportunity to contribute to the science of medicine, and thus, being “untutored” in medicine, they used botanical therapies, home remedies, purges, and herbal medications and also learned from observing physicians. p13
CHAPTER 2: “SHE HATH DONE WHAT SHE COULD” REFORMING NURSING AS PHYSICIANS TIGHTEN THE MEDICAL MONOPOLY IN GREAT BRITAIN, 1800 TO THE EARLY 1900S
Medical control over women’s healing activities in Europe, particularly in Great Britain increased during the eighteenth century, becoming a reality by the mid to late nineteenth century, despite the fact that university-educated physicians were a distinct minority among health-care practitioners.[…] Nevertheless, the medical monopoly that excluded women was strengthened, even though many medical treatments lacked scientific bases and unanimity on the efficacy of specific scientific theories was yet to be achieved in medical practice. Indeed, treatments that were deleterious to people’s health, such as leeching and bloodletting, were common. Despite these facts, British physicians had largely achieved direct or indirect control of health-care facilities by the nineteenth century; however, the quality of care in these institutions did not necessarily improve as a result of medical dominance. In fact, it was usually safer to remain at home than to go to a hospital for care. It is generally agreed that frightful conditions and appallingly high death rates prevailed in many British hospitals, almhouses, and other similar institutions. Given the earlier closure of all Catholic convents in England, institutionally based nursing and medical care by women had been severely curtailed, leadinig, in Nutting and Dock’s (1907) view, to a dark period of nursing stagnation.p37
Biological Naturalism? Nursing and the gendered Division of Labor
Clearly, the division of labor in the nineteenth century was thought to be bilogically cause or “natural” and associated with reproductive functions. The theory of “naturalism” characterizes labor, both in the family and the wage sectors, as “masculine” or “feminine” and specifies tasks and allocates jobs by biology or by analogy. Alternatively, a division of labor may be explained by technological processes; however, biological determinism usually underpins such technological explainations.
Exploitation of all women workers, including nurses, is located in the family, where women exchange unpaid labor for upkeep, although their reimbursement is usually less than the value of their services. Historically, the man has controlled the woman’s labor, goods, and services; thus they could not be exchanged or sold on the market because they belong to the man as husband. To Garmarnikow, the traditional marriage contract is a labor contract in which the husband contols the wife’s labor, the domestic mode of production, which differs from the capatalist mode of production. The latter depends on the free sale of labor, not the transfer and ownership of the labor of women as wives, who have no direct access to raw materials or to the means of production.
The subsistence level that presumably sets wage rates in the capatalist market is not paralleled in the domestic market, where there are no socially determined subsistence levels. Instead, the wife, as domestic worker, is dependent for her upkeep and consumption on her husband’s class position and income. According to Gamarnikow, patriarchal exploitation of free domestic services is transferred into the nonfamiliar labor market where all women are treated as potential wives-mothers, dependent on men because they are biologically female. This emphasis on gender differences, rather than on human similarities, legitimizes the hierarchical differentiation between the labor of men and women. As a mode of work organization, the gendered division of labor identifies all women, whether married or not, as subordinates and allocates functions accordingly.
To Gamarnikow, the “maleness” or “femaleness” of a task is not inherent in the operation itself, but in the ideological identification and distribution of tasks and jobs as gender-specific; thus, some women may enter “male” jobs or men enter “female” jobs without these jobs losing their gender specificity: “rather, this becomes an individualized act, frequently resulting in contradictory and difficult work relations – female executives and male nurses being cases in point” (Gamarnikow, 1978, p, 101).
In the nursing literature, Gamarnikow found not an economic analysis of gendered labor, but a sociological model of professionalism. For example, historical covarae of nurses’ battles over registration seldom recognizes that the conflict was not about changes in the occupational hierarchy, but about definitions of work and authority between nursing and medicine within the already established hierarchy. In Gamarnikow’s view, differences among nurses over class, educational background, and length and type of training have occurred within identical models of the subordination of nurses to physicians. Although this is in part true, we could argue that the political organization of women, their insistence on formal training, on state recognition of women workers, and women’s development of public leaders, speakers, and lobbyists were all forms of rebellion against their subordinated female status. Further, it could be argued that the extensive rejections of these actions by physicians is evidence of their understanding that women were moving beyond the domestic sphere and creating changes in the public arena.
Ironically, Garmarnikow’s evidence for the similarity of arguments for and against nurses’ registration is initially derived from two physicians: Dr Bedford Fenwick and Dr. Sydney Holland.[…] In 1904 dr. Fenwick stated that technical knowledge was essential if the nurse was to carry out the duties entrusted to her by the doctor and to report symptoms efficiently to him between visits.
[…]Garmarnikow observed that both men placed nursing as subservient to medicine. Indeed, she argues that nursing was “an occupation united by a common recognition of the existence and nature of the boundaries between itself and medicine” (p. 102). Although this is debatable, she is certainly correct in asserting that the dividing line between the two occupations is not a primarily technical but a flexible one, both historically and across institutions in any given period; thus, the two unequal spheres are primarily based not on technological factors but on gendered differentiation of laborers, patterened on the prevailing patriarchal power relations, whose legitimacy is derived from a form of biological “naturalism”.( p50,p51).
In Garmarnikow’s view, nursing reforms in the nineteenth century did not directly attack the gendered system of health care. Instead there were two aims: one, to establish a single stratified occupation to direct the organization and management of patient care; and two, to introduce this occupation into existing institutions and reform nursing modalities, as established by Nightingale. It is possible to argue that these two aims were also related to a third: to change some aspects of sex-stereotyped labor relations. […] It is clear that ant development of female autonomy, once religious nursing orders in Britain were largely destroyed, represented a partial shift away from total exclusion or very peripheral status in public institutions. Nightingale vested the whole responsibilty for discipline, training, and management of nurses in the female head of the nursing staff, who reported directly to the governor, not to physicians, and to the matron. Clearly, there was an implicit, if not explicit, threat to total male medical control if there was a separate female hierachy with a matron in contol of all the women in the hospital. Unfortunately, the separate authority of women answerable only to the board of governors or directors was contested and the Nightingal model was modified to reflect a gendered division of labor, which was not neutral or based on equal contribution and participation: “Instead it created stratified health care and interprofessional inequality” (p. 107). Eventually, many nurses would come to see their own subordination as natural. For exmple one nurse in the journal Hospital said: “We nurses are and never will be anything but the servants of doctors and good faithful servants we should be, happy in our dependence which helps to accomplish great deeds” (cited in Gamarnikow, 1978, p. 112).
Why would any woman assert this? In part, because female subordination was considered “natural”, but also in part because the division of labor was increasingly located in science, which had provided a new rationale for female subordination. Diagnosis presumably originated in science; women’s treatment simply followed men’s scientific judgements. Thus, female obedience was the “logical” correlate. […] There was a great variablility in the incorporation of scientific techniques until late into the nineteenth century. Nevertheless, in the journal Hospital in 1894, Louis Vintras stated that the nurse must recognixe the physician as her scientific chief and maintain a rigid discipline not even second to the soldier’s: “A sense of duty, an absolute obedience to orders, a thorough comprehension of these orders, are the fundamental principles of nurses” (Vintras, 1894; cited in Garmarnikow, 1978, p. 109). p52, p53
Extending Home to Hospital: Nurse as Mother, Physician as Father
The ideological reconstruction of gendered relations depended on the transposition of family structure to health care by representing the nurse-physician-patient triad as mother-father-child. Thus, the nurse must have the indulgence of a mother to the child and if firmness is needed “She can always invole the physician’s orders for the refusal of any unreasonable request” (Vintras, 1894; cited in Garmarnikow, 1978, p. 110). How the nurse could be both mother and soldier is certainly worthy of deeper analysis.
Some nurses did seem to accept the family analogy. Sister Grace, for example, in 1898 recognized that the house-surgeon and sister must work well together for the sake of the patients. As in marriage, the responsibilty for this relationship rested chiefly with the woman, who was told: “Never assert your opinions and wishes, but defer to his, and you will find that in the end you generally have your own way. It is always easier to lead than to drive. This is a truly feminine piece of counsel, and I beg you to lay it to your heart” (Grace, 1898; cited in Garmarnikow, 1978, p.127). Garmarnikow relied heavily on the male-contolled journals, such as Hospital; thus, it is not clear whether such pronouncements were typical of the private opinions of most British nurses. […] Nevertheless, to Garmarnikow, the key struggle was not to change the hierachical structure of health care, but to create paid women’s jobs instead of Victorian female charity; thus, Nightingale’s goal at St. Thomas’ was to train as many women as possible, to certify them, and “to find employment for them, making the best bargain for them, not only to wages, but as to arrangements and facilities for success” (Nightingale, 1867, p. 2; cited in Garmarnikow, 1978, p.112). Nightingale wanted to “give the best training we could to any woman, of any class, of any sect, ‘paid’ or unpaid, who had the requisite qualifications, moral, intellectual, and physical, for the vocation of a Nurse” (Woodham-Smith, 1950, p. 483). p53
Jameson believed that women in public jobs could bring a better balance between the elements of power and love and incorporate family sympathies into all forms of social existence to ameliorate evil and suffering. Although laudable aims, the intitial powerlessness of women resulted in an all-woman occupation that was justified by the social structure of the family. This produced a contradiction@ “it gave women access to a non-industrial job, but at the same time deferred to medicine in setting it up and defining its limits” (Gamarnikow, 1978, p. 114). Established and defined as women’s work, nursing was situated in the patriarchal structure in which science and authority belonged to physicians and caring and the application of science to nurses.
Health care, said Garmarnikow, was based on alleged gender-specific personal qualities and virtues, which were found in long lists of qualities perdominately related to personality and subordination, not to skill and technical knowledge. Terms related to nurses’ subordination included “patience, endurance, forbearance, humility, unselfishness, self-control, self-sacrifice, self-abnegation, self-effacement, service orientation, self-surrender, devotion, loyalty, discipline and obedience” (p. 115). Whether all these terms mean subservience is questionable. Other common terms focused on personal qualities, which ranged from quiet, neat, ordily, punctual, dutiful, and chaste, to persevering, self-reliant, principled, and courageous. Again, whether all those terms suggest womanly subordination is debatable. Terms pertaining to relations with others include kindly, generous, and courteous, but also thoughtful and firm. Terms for attitudes to patients, such as love, sympathy, pity , and comforting, seem even more sorely needed a century later. Terms such as accuracy, watchfulness, success, reliability, and truthfulness were used to describe the observing and reporting of symptoms. Here, there seems a clearer case for assuming subordinate status, since independence in action is not described. Howerver, technical competence and skill required nurses to be ingenious, ready, quick, intelligent, alert, keen, sensible. Nevertheless, Garmarnikow concluded that character was linked to “femininity,” and in turn to womanly moral attributes.
By the end of the nineteenth century the close link between nursing and “femininity” as a combination of moral qualities that supposedly differentiated women from men shifted from personal virtues to tasks; these were linked with family-based factors best found in good training of daughters by mothers for domestic labor and mothering. Garmarnikow claimed that tasks most similar to housework were relabled hygiene, which came to occupy a key but difficult position in nursing, one that was presumably derived from Nightingale’s earlier emphasis on hygiene as the scientific basis for nursing. However, Garmarnikow did not discuss Nightingale’s differentiation between nursing and domesic labor, which also formed the basis for subsequent debates on nursing and menial labor. Indeed, Nightingale insisted that nurses were not mules, that they had important patient care functions that must take priority over thise related to housework. Furthermore, it is also important to recognize, as Nightingale did in the Crimeam that filthy conditions killed people. Asepsis was, and is, scientifically important – possibly an extention of womanly housework at its best. It is also the basis of public health. Indeedm most of the health advances by the turn of the century can be attributed to environmental changes in everyday life, not to specific medical cures or treatments in hospitals. Thus, the importance to women of “hygiene” as the basis for advances in health matters reequires more thorough analysis.
Compromise versus Control: Nurses Strive for Reform, Physicians Tighten Authority
Heavy emphasis on structural work relations sometimes excludes the content of reforms demanded by women nurses and non-nurses and their actual achievements. Certainly, Nightingale’s reforms of the British military system of medical care and of hospitals were no small accomplishments. Much of this relied on principles of hygiene and resulted in a very substantial reduction in death rates. However, as she moved from private and from district or public health to hospital nursing, the nurse-hygienist was increasingly connected to medical interventions.
Despite her contentions that the gendered division of labor was not challenged by nursing reforms, Garmarnikow did recognize that efforts to enhance female autonomy provoked fear among physicians, who from 1860 to 1880, a period of major health-care reform in Britain, had taken control of diagnises, achieving their monopoly through the 1858 Medical Registration Act. Physicians and even some women feared that women’s institutional and educational autonomy and their state-sanctioned organizations would lead to occupational independence. Even Elizabeth Garrett Anderson, early British woman physician, opposed nurses’ independence, using the experience with apothecaries as “evidence” of “imperfectly educated practitioners.” Medical dominance was maintained because physicians contolled access to patients. Thus, said Gamarnikow, both independent nursing processes which focused on hygiene and those that depended on enactment of men’s orders remained under medical control. By the end of the nineteenth century, physicians were warning nurses that they had no certificate to diagnose or to judge the serverity of illness; therefore, they could not decide who were patients or admit them to hospitals.
Because access to patients continued to depend on prior medical invention through diagnosis, nursing shifted to a primary identification with patient care, rather than with hygiene in its broad societal sense or even in the more narrow sense of housework; thus, “Nursing practice became even more closely subordinated to medicine” (p. 120) The ideology of motherhood and housework furthered the patriarchal relations between nursing and medicine.
Garmarnikow concluded that the development of the female nursing occupation has to be accomplished within and area of labour already contolled by men; thus, success in establishing paid jobs for women depended on “situating and defining these jobs in a way which would pose no threat to medical authority (p. 121).” p.55, p56
[…]Rather, the ideology of naturalism, with interconnections among femininity, motherhood, housekeeping, and nursing, is central to situating and subordinating nurses. Clearly, and “pure” form of socialist or sociological analysis that emphasizes technology as the material basis for the functional divisions in health care is insufficient. Overriding this theoretical and “commonsense” view is the overwhelming evidence that patriarchal dominance allowed physicians to obtain control of the functions of women healers, who then had to compromise in order to establish their public roles in health care.
From Garmarnikow’s point of view, nurses in the nineteenth century did not essentially crack the gendered work structure, but only forced open public, paid work for women. This perspective focuses heavily on hospital nursing amd not on other areas in which nursing reformers were very involved. It also downplays the actual reforms in working arrangements and relationships; in methods, processes, and procedures; in institutional structures; in the institutions themselves; and ultimately in the health care recieved by people in and out of institutions. […] Unfortunately, sociological and historical analysts of nursing too often lose sight of the actual work nurses did, the very real changes they produced in how their work was to be conducted, how health-care practices changed, and how institutions were altered to achieve better care of people. p56
Proving Women’s Worth: Early Nurses’ Struggle against Stereotypes and Male Control
Were reforms of hospital nursing necessary?[…] Although the old-style nurses may have been, as Hawker (1987) says, generally decent, lower-income women, the hospitals, contolled by men, were often unsanitary, with wards that were poorly heated, lighted, and ventilated, overcrowded with beds that were often dirty and infested vermin. Matrons were treated as head housekeepers, and few, said Holcombe, had experience in nursing, therefore, they often left the supervision of nurses to the medical staff. Sisters or nurses were often relegated to the performance of domestic duties, while physicians and medical students assumed the skilled nursing care that had previously been provided by women.
Holcombe soundly condemned the nurses’ working conditions, in which they normally served fourteen to fifteen hours at a stretch, sleeping in basement rooms, cupboards, or the wards, recieving salaries so insubstantial that few women would wish to choose nursing as a means of support. Essentially, the role of women in the broader society defined the role of women in nursing, allowing them only the most menial tasks at the lowest rates of pay. Even worse conditions prevailed in workhouse infirmaries, considered “receptacles for pauperism’ rather than places of healing for the poor” (Holcombe, 1973, p.70). p60
In these institutions, the “seriously ill and the convalescent, acute and chronic cases, the contagious and the non-contagious, lying-in cases and mental cases were all jumbled together in the same crowded and dirty accomodations” (p.71). Much of the nursing was done by the inmates themselves. In middle- and upper-class families, patients were, as noted previously, cared for by women in their homes.
[…] Once again, it is important to note, although Holcome did not, that the elimination of women’s religious orders, the exclusion of women from formal medical education, the takeover of the functions of women healers and eventually even midwives, and the insufficient and the insufficient funding of institutional social and health services all contributed to the stereotyping of early nurses. As noted in chapter 1, Nutting, Dock, Ehrenreich, English, and Versluysen would all say that classism and sexism provided the bases for the destruction of nursing as a legitamate and honorable activity for women in their communities.
[…] a feminist analysis suggests that women were caught between men in power in religion and in medicine. From this perspective, many women healers were forced out of spiritual, compassionate work and out of competition for any lucrative lay roles within health-care systems. By excluding women from university education, the medical monopoly maintained its control over a potentially scientific approach (which, we reemphasize, was not actually widespread among most physicians until well into the nineteenth century) that could eventually be the basis for the diminution of the role of women nurses in religious orders.
The exclusion of women from all public roles by the mid nineteenth century made Nightingale’s efforts to help women break “break through the conventional shackles binding them to idle, useless lives” Holcombe, 1973, p.73) laudatory. Holcombe continued the traditional interpretation of Nightingale as shaping the nursing profession with her own image: “strong and pitiful, contolled in the face of suffering, unself-seeking, superior to the considerations of class and dex” (p.74). She demonstrated on a grand scale what the feminists always claimed: “the great good that could be done in society by trained and dedicated women” (p.74). Clearly, the feminist vision also included fair economic renumeration, reasonable working conditions, a degree of autonomy, and appropriate status for women. These have yet to be fully achieved. p61,p62
Unlike Garmarnikow, Holcombe stressed that Nightingale’s most revolutionary proposal was that the nurses would not be subject to control by men in hospital administration or medicine. Instead, “they should be under the absolute command and control of the hospital matron, who would both oversee their training and supervise their nursing work after they were trained” (p. 75) nursing was women’s work and women must reform it.
[..] Many physicians were afraid the women would no longer consider themselves subservient, but nearly the men’s equals. For example, at Guy’s Hospital, the trained nurses were considered “impossibly conceited and completely unwilling to heed the doctors’ orders” (Holcombe, 1973, p.77). However, Holcombe asserted that the men’s fears that women would reject male authority proved to be unfounded. Unfortunately, this assertion is correct: to this day obedience by nurses is still usually expected and often obtained. p62
In her nursing school, Nightingale did not favor teaching too much “pure medicine,” because she felt that nurses would become intolerable “from airing their knowledge or miserable from seeing methods adopted which were not in keeping with [those] … they had been taught were the best” (p.23) The subordinate and relatively powerless role of women is clearly implicit in this assertion. Although she favoured wome doctors, she did not want to see nurses become “medical women”. In this, given the blurring of functions at the time, she probably restrained nursing from the development of greater autonomy. However, she herself did not hesitate to evaluate medical treatments and prescriptions. Cope implied that Nightingale was beyond her sphere; but in her Notes on Nursing (1859), it is clear that she was ahead of some physicians, who were still using “heroic” methods such as leeching, severe purgatives, and other invasive procedures. These make some of Nightingale’s recommendations on hygiene seem a model of sanity. p63, p64
The Escalating Struggle for Nursing Reform
[…]According to Moore, the prevailing assumptions about women’s biological inferiority were used by medical and administrative men to justify their subjugation of nurses. But the nurses, now drawn from the middle and upper classes, confronted the men, fighting for their own rights and those of their patients.
Detractors of nursing, said Moore, have at different times – and some-times simultaneously – claimed that women either had an inborn gift for nursingm needing no additional training, or that, without practical instruction, they were “at best a nuisance, at worst a danger, to their patients” (p. ix). In reality, educated nurses were a threat to physicians, who feared women’s autonomous judgement on the men’s presumption of a scientific and moral judgement base that was often inadequate. Indeed, Moore asserts that women such as Nightingale were determined to use every weapon they possessed, “charm, social pressure, and almost blackmail” (Abel-Smith, 1960, pp. 19-20; cited in Moore, p. xiii). Nurse Agnes Hunt even sent smallpox patients to voice their complaints to members of a hospital committee.
Physicians insisted that “Nurses must always be servants, and they cannot saftely be permitted to rise above that position in society” (Lancet, June 4, 1881; cited in Moore, 1988, p. xiv). Respectability must not interfere with obedience. In contrast, Sister Dora Pattison, sister in charge at Walsall Hospital, insisted on conservative surgery and conducted postmortems to increase her knowledge. In the absence of a house-surgeon at Walsall, the nurse in charge acted as surgeon in emergencies. Moore makes the case that Sister Dora’s audacity was fuled in part by her intense religious convictions, typical of sisterhood nurses who publically challenged medical complacency, even cruelty. These nurses Moore pointedly claims, did not simply complain to each other or use “feminine” tact and patience, but confronted the men, risking their jobs and livelihood. Clearly, Moore contests the idea that nurses’ foremothers were “limited ladies.” In fact, she turns upside down the usual nursing history: it is today’s nurses who, in contrast, seem reticent and fearful. Centrally important is the trivialization of women’s history that, according to Moore, and Versluysen before her, has created a traditionalism in nursing curriculum so pervasive as exclude the truth of women’s own history, relying instead on the bastardized form of masculist medical history and thus excluding the feminism basic to the rise of “modern” nursing.
[…]The physicians’ blockage of midwives and district nurses, claims Moore, provided evidence that both urban and rural areas were to be controlled by the men. On the other hand, educated nurses had made hospitals places fit for wealthier patients and a source of income for hospital administrators and physicians. It was nurses who made hospitals possible, not hospitals that made nursing a reality. p67, p68
The solution to the gendered occupational conflict was to force women’s submission. By relying on societal sexism, physicians could demand faithful assistants from the lower classes, who could not regulate medicine. For example, physicians refused to allow nurses to know the contents of bottles of medicine, even removing labels and instead putting numbers on them and, subsequently disallowed nurses the use of simple instruments. The Lancet reccomended that physicians “lock away beyond their [the nurses] reach every particle of medicine” (Moore, 1988, p46).
The usual claim that the women possessed only enough information to be dangerous was refuted by the nurses themselves. In actuality, the nurses were often neither illiterate nor lacking in knowledge. In fact, Moore claims that nursing provided the basis for women to enter medicine, not, as is usually understood, for medical women to open up nursing.
Over the years, the men gave no ground and continued to reiterate the same strictures: “Every scrap of information she possesses beyond the mere routine of sick-tending is not merely useless but mischievious” (Lancet, Dec. 11m 1880, pp. 946-947; cited in Moore, 1998, p.48).The primary role was assistant to the physician, but women, as Moore notes, “could and did form strong bonds to each other in public as well as private settings, even across the class lines separating nurses from sisters” (p. 50). The issues of authority believes that this conflict has been buried in nursing history because it was seen as an embarrassment. How could subsequent nurses under the domination of men admit to their foremothers’ disobedience? p68
[…]Although the status if nursing as a profession began to rise, the physicians, as Moore notes, continued to see “themselves as by rights patriarchal rulers, undervalued and mistreated if they were asked to cooperate with nurses” (p. 172). Medicine, the “most beneficent profession that has ever existed” (Medical Times and Gazette, Aug. 16, 1880, p. 463; cited in Moore, 1988, p.174), now claimed scientific authority. For women this claim was astonishingly premature! The functions of the ovary and fallopian tube were not known; the menstul cycle was incompletely understood; with the development of the speculum, the uterus was considered to be the source of all women’s problems. Unfortunately, medical ignorance was used to substantiate “scientifically” the subordination of women, particularly in education and employment. Nurses were expected to comply with stereyotyped, presumably scientific medical pronouncements. Nurses who criticized physicians were disruptive and unfeminine and unnatural: “a conventional understanding of gender rather than any abstract principle of equity or even of efficiency in the workplace was at the center of the period’s disputes between nurses and doctors” (p.177) The physicians’ attack against nurses extended to all women, particularly suffragists.
That professional autonomy was and remains the issue is obvious. Moore accurately sees the work of Amitai Etzioni (1969; 1980) and other current medical sociologists as a latter-day effort to explain that nurses are semiprofesionals. If they would only give up their inauthentic aspirations, the dysfunctional consequences of their attempts to pass as full professionals would disappear. If the women only understood that independence and collegial authority are inappropriate, then they could be happy as semiprofesionals. Moore claims that the evidence from the Victorian nurses proves the opposite: the women were already or potentially full professionals. It is precisely this fact that caused the men to attack them. If women could be excluded from scientific knowledge, then their claim for professional authority could be denied and physicians’ control would be strengthened and solidified. p70-71
The Result of Increasing Medical Monopoly
By the end of the nineteenth and the begining of the twentieth century, women in England were still expected “to take up their work in a missionary spirit for the good of the community, without regard to their own comfort or health” (Holcombe, 1973, p. 78). There was, of course, a strong tendency, as Nutting and Dock stated earlier, to overlook the material well-being of the nurses, whose salaries were dependent on endowments or taxes. In 1890 a government commision heard nurses complain of working eighteen-hour days for minimal recompense. Despite recommendations, changes were slow in coming; nevertheless, one guide to careers noted that a nurse was “not the unconsidered hard-working woman she used to be” (p.79) The commision also noted that pay did not increase with more education or experience, a theme that is echoed by nurses today. Nursing salaries, however, rose little in the years following the commision’s report. Nurses were physically “used up,” with no provision for pensions at the mandatory retirement age of fifty years. Finally, a pension fund paid into by nurses was established; it was inspired by a nurse who contracted typhoid in the wards and became permanetly disabled, later to die penniless in a workhouse . However it was not until after the Second World War that most British nurses were to recieve any reliable monies upon retirement.
Again, two wars forced attention to the British nurses. The South African War found women dumped into field hospitals where they faced male orderlies who refused to do menial work; thus the women were forced to do their own work and the men’s as well. Dame Sisney Brown headed a new nursing organization in Britain, and the status of the profession improved, ironically as a result of war.p71-p72
[…] According to Holcombe, there was little contol over the work of early nurses, which led to “slovenly care and neglect of patients, and little communications between nurses and doctors, which led to the nurses’ usurping the doctors’ functions” (Holcombe, 1973, p.90). Given the analysis of the medical takeover of women healers’ roles and their exclusion from formal education, Holcombe’s assertion is highly questionable.
What is clear is that the nurses’ work was arduous; often on bicycles, the nurses scattered populations, working fourteen hours a day, with a half day off every three weeks. Yet one woman wrote: “Here I realized for the first time the tremendous scope and power of a nurse’s life. One went into those homes, not as ‘my Lady Bountiful,’ but as a fellow human being, a friend to give personal help, to teach and to serve” (p. 92)
Most nurses still went into private homes; however, the nurses often recieved only a small proportion of the fees, which were collected by the men in hospitals that, incidentally, assumed no legal risk for the nurses they supplied. This structure forced women to rely on physicians for referrals to avoid the hospital exploitation. Finally the women formed their own associations, leading to British nurses’ thirty-year war for state registration. As noted previously, Ethel Gordon Fenwick led the battle, even in opposition to Nightingale. Organizing the British Nurses Association in 1891, for the first time women formally associated together for self-government. Ignoring the medical men would have cause havoc, so physicians were allowed to join the association and were represented in governance. Despite the considerable control by men, any independence of women seemed unacceptable to the hospital administrators and physicians. Registration, controlled by women in their own organization, was totally unacceptable. Instead of devoting themselves to their “onerous duties and noble ends” (P. 98), physicians claimed the nurses would make a trade inion, reducing work, increasing pay and pleasant conditions. Nurse supporters said, “As working women, nurses have a right to run on their own responsibilty … they ought to be free to make their own conditions and not to be at the beck and call of institutions” (p. 98).
In contrast to Garmarnikow’s assertion, registration was not the key gender issue; rather it was the establishment of an independent association of women, who would contol their own occupation. Such an association was unnecessary, according to physicians, because the men themselves could decide whether nurses were sufficiently well-trained. In 1893 British women won a charter to list but not to register nurses; finally, the men in the assiociation placed themselves on record as opposing registration! Outraged, Fenwick and other nursing matrons realized that nurses and physicians in joint organization could lead only to “disastrous” results: “‘We must be free to organize ourselves; the relation of man to woman complicates the situation; the relative position of doctor and nurse makes it impossible . . . though we do not claim independence of the medical professionm we claim freedom to discuss our own affairs, to make our own laws, to decide on common principles of work'” (cited in Holcombe, 1973, p.100).
It took the heavy casualties and severe injuries of the First World War to demonstrate the need for fully trained and registered nurses. In 1919 the women finally won registration. They had achieved the right to organize together and to define their own purposes in consort with each other and to regulate their own occupation. However, registration, as Garmarnikow pointed out, did not solve the gendered division of labor that caused the problems the nurses would continue to face in the twentieth century in both Great Britain and the United States. p73-p74
“The Exclusive Guardians of All Matters of Health” The Consolation of Medical Monopoly in the 1920s and 1930s
[…]As in other wars, nursing’s popularity and status rose during America’s involvement in World War I, and so did physicians’ status and power. However, when the war ended, nurses returning home were expected to marry or revert to the more subordinate role associated with civilian nursing. Physicians, on the other hand, took active steps to consolidate their power and monopoly in health care.
By 1920 feminists had finally succeeded in gaining suffrage and political enfranchisement for women; they had reformed a wide spectrum of laws, practices, and attitudes, forcing open colleges and universities, occupations, and professions to women. But as the women’s movement declined or shifted awat from clear-cut women’s issues to broader social concerns in the later 1920s and 1930s, medical power and control were being consolidated. Thus, women in nursing experienced declining support from feminists and increasing domination by physicians. After gaining contol of hospital nursing, physicians exerted their influence over public health. Though nurses and other health reformers fought for and supported the federal Sheppard-Towner Maternity and Infancy Protection Act, designed to improve women’s and children’s health, organized medicine opposed the act and eventually caused its demise, which slowed or stopped the national framework of clinics it would have established.
Nurses researched and documented the inadequate and unsatisfactory state of nursing education and practice and struggled valiantly to create uniform standards and training based on state licensure. Most physicians, however, opposed the nurses’ goals, in part because by the 1920s nurses were the only remaining viable competitors to physicians on every front. Physicians continued to admonish nurses, including those in public health, to be obedient to medical authority. By the 1930s the American Medical Association (AMA) had estabished a set of committees on nursing that tightened its control. Medical domination was made easier, too, by the severely difficult circumstances caused by the Great Depression. The working conditions and economic status of nurses declined significantly during this period, while the economic and social status of physicians remained constant or even improved.
The debate in whether nursing was scientific work or a nurturing ministry veiled nurses’ actual work and their inventive efforts. Often gender, not science, determined the degree to which a particular technology was considered scientific. The male-contolled media, now including radio and motion pictures, created and reinforced the images of nurturing, loyal nurse and the sacrificing, scientifically competent contry doctor. In subsequent decades, these images were continued, in more urbanized, sophisticated form, by television. Some nurses, such as Elizabeth Kenny, defined these images, questioned medical power, and created their own therapeutic techniques, only to fall victim to severe medical censure. Whether the censure if these nurses and the medical monopoly of diagnosis, prescriptive authority, and practice were in the patient’s best interest is highly questionable. p147-p148
The consolidation of Medical Power
The consolidation of medical power was largely accomplished by the 1920s. In 1904 the AMA established the Council on Medical Education; it formulated a minimum standard of four years of high school, an equivalent period of medical training, and a licensing examination. By 1910 the grading of medical schools, according to requirements of state licencing boards, had reduced by one-fifth the number of medical schools in the United States (Starr, 1982). Lengthening the required educational period produced a long-term decline in the number of medical students. The increased cost of modern laboratories, libraries, and clinical facilities forced mergers with private or state universities. p148
[…]By 1936 the Rockerfella Foundation gave $91 million to medical schools, with two-thirds going to seven institutions. The intent was to wed research to medical practice; thus medicine cashed in on the increasing reverence for science and technology. Nevertheless, the widespread aversion of some physicians to basic science was still apparent in the battles between old-line practitioners and the new research scientists.
[…] Deliberate discriminatory practices against women, Jews, and African Americans promoted greater social homogeneity, reversing the somewhat more liberal policies during earlier periods when feminism was stronger (Starr, 1982, p. 124). The declining number of women physicians was caused by outright descrimination, sustained for most of this century by quotas which limited women to only 5 percent of medical school admissions, as noted in chapter 4. Only nurses were left as potential competitors to physicians.
By the 1920s the distribution of physicians was related to the per capita income by region, resulting in geographical and urban-rural inequities. Physicians had forced out other competitors – for example, osteopaths and chiropractors – by denying access to hospital privileges or the right to prescribe drugs. The fight over authority to prescribe drugs was led by the AMA, and by the 1920s the drug manufacturers could deal only with physicians. Ironically it was the physicians themselves who had misused many drugs, such as laudanum in the nineteenth century. These misuses, especially of psycotropic drugs, have been in large part directed toward women.
The logic of the AMA’s regulatory system was simple: “withhold information from consumers and rechannel drug purchasing through physicians” (Starr, 1982, p. 133). Even baby food and milk substitutes were channeled this way. With no feeding instructions provided for mothers, they were forced to go to physcicians, who often gave them faulty information based on manufacturers’ misleading claims.
Public health advances, particularly the isolation of organisms responsible for infectious diseases and immunological breakthroughs, were far more successful in the late nineteenth century and early twentieth centuries than were the rest of medical “therapeutics” or the drugs used to treat diseases. Nurses were directly involved in these public health advances, but eventually they lost their control over the bureaucracies that evolved. Nevertheless, evidence suggests that the great decline in mortality rates around the turn of the century was due primarily to changing lifestyles and to general public health hygiene efforts.
Actually, reductions in mortality from specific diseases occured before effective prophylactics or therapies were in the hands of physicians. Nevertheless, they took much of the credit for the work of the nurses, women reformers, and public health advocates. p149-150
Antiseptic techniques and anesthesia increased the prestige of surgery. Here, nurses were originally central as early anesthesiologists, but again they subsequently lost ground. New diognostic techniques were also prohibited to nurses. Just as thermometers were initially denied to women, so each new instrument was denied; then, as newer technology became available, the women were sometimes allowed to use the older methods. As Starr noted, these new procedures, such as the X-ray, enabled physicians to view and discuss what they saw at a distance from both patients and nurses, thus contributing to professional disparity and medical dominance over diagnoses.
[…] The barriers that restricted entry to medicine were also responsible: by the 1930s, medical schools were rejecting 45 percent of their applicants. Before 1900, admission rejections, noted Starr, had been virtually unknown. By 1925 occupational prestige rankings rated physicians third, behind bankers and college professors, and just ahead of the clergy and lawyers. Subsequent rankings have consistently placed them in top positions.
Collective mobility of the medical profession was accomplished by systematically subordinating threatening competitors, such as nurses, and denying them knowledge, autonomy, and power. Medical authority, arising from nurses’ and patients’ deference and institutionalized forms of dependence, encouraged the public to see medical interests as similar to their own (Starr, 1982). It is doubtful this could have been accomplished to the same degree if nurses had achieved independent status and deprived physicians of large numbers of deferential female followers. p150
Nurses Rebel: Want More Contol over Education and Working Conditions
By the turn of the century and continuing to the end of the 1930s, nurses in major cities increasingly complained of overcrowding on hospital wards, limited training opportunities, overwork, and repressive hospital and medical contol of nursing registries and private duty work. Historian Susan Reverby (1979) recognized that the graduate nurse was in an ambiguous situation: a professional expected to do a servant’s work; an independent worker paid a standard wage and subject to busy and slow seasons like a factory worker; a skilled worker but one with no financial incentives, training, or supervision to improve skills.
Although Reverby claimed that the nursing schools had become “stunted matriarchies” she admits that by 1910 nursing leaders had moved strongly against overcrowding and lack of training.
[…] By the 1920s administrators were “refurbishing their nineteenth-century paternalism in order to obtain a more loyal work force” (Reverby, 1979, p.213). To achieve loyalty from within required training to identify with the hospital “family” but institutional personalities were not readily forthcoming; therefore, hospitals were “constantly searching for workers who could be relied upon to be loyal, self-motivating within set limits, imbued with the service ethic, willing to accept low wages and their place in the hierachy, and yet able to transcend normal work loads when emergencies (defined by the administration) or shortages occured” (p.214). In other words, women workers were wanted because they could be forced to take lower salaries, were socialized to give service, and blocked from upward organizational mobility.p151
Nursing Scientific Work or Womanly Ministering?
Physicians’ increasing dominance over all aspects of health care and nurses’ continuing subordination were interconnected with gender stereyotypes that exaggerated physicians’ importance and defined nurses’ work as womanly ministering rather than scientifically based clinical practice. In reality, nurses’ work consisted if a combination of technical knowledge and the skills they needed as the primary providers of direct patient care. Yet their roles, claim a group of Canadian researches, continued to be percieved, particularly by physicians, as primarily womanly, nurturing, and suited to females and mothers (Keddy, Acker, Hemeon, MacDonald, MacIntyre, Smith and Vokey, 1987). In the public imagination, nursing, women, and femininity had become firmly linked; thus, nurses in the 1930s were seen as doing “womanly tasks” usually those done by women at home, but now without the control over the full spectrum of functions they had previously provided. Authority over clinical diagnosis and prescriptions by physicians became centrally important, and the nurse was ideologically marginalized and characterized as a nurturant but “unscientific” woman. This process waas and still is perpetuated through physicians’ paternalistic authority, which is used to devalue the nurse. As one physician put it in 1894, nurses knew no more science than a first-year medical student; variations on this theme are apparent throughout the first three decades of the twentieth century.
Were the physicians’ perceptions true or were they simply sexist stereyotypes used to bolster medical authority? By analyzing the histories of thirty five older nurses, Keddy and her colleagues studied the extent to which nurses in the 1920s and 1930s actually used scientific and/or technical knowledge. Analyses of taped responses to semistructured interview in which the nurses were asked to recall their work experiences produced several themes, one of which was labeled “hands-on nursing,” defined as direct-patient contact and the use of health-care knowledge through tasks or skills. The responses were initially analyzed by disease categories; others were developed from the content analysis of the “hands-on-nursing” theme. p164
To deal with pneumonia and polio, two widespread diseases in the 1920s and 1930s, the nurses, in the absense of sulfa, penicillin and other modern drugs, directly administered poultices, plasters, fomentations, and dressings and positioned patients to avoid contractures and bedsores. Were these technologies scientific? One can argue that yes, they were the primary type of treatment because bacteriological discoveries between 1878 and 1887 had not been successfully applied. Often because many conditions, including pneimonia, could be caused by the action of more than a singular bacterium. Until 1935, with the intoduction of sulfa and penicillin, and the 1940s with newer antibiotics, the nurses provided the most and, in many cases, the only rational treatment available for pneumonia and, until much later, for polio. This was confirmed in the extensive use of these technologies by the older nurses interviewed.
The interviews also produced evidence that the nurses often invented equipment or proceedures to carry out rather difficult tasks, for example, those involving blood transfusions, which in earlier years were very complicated procedures. Although the transfusion themselves were conducted by physicians, nurses carried much of the responsibility for handling the multiple syringes and citrate techniques required. One nurse remembered using a vial of citrate, putting the needle and syringe in the donor, connecting it to a table, then putting it in a sterile beaker with citrate, which was stirred by another nurse using a sterile rod. The two then gave IV (intravenous therapy) and stirred and poured. From this and other examples, the researchers asserted: “Without much equipment to work with they [the early nurses] turned their workplaces into institutions which functioned primarily because of their ingenuity” (Keddy et al., 1987, p38).
Because limited scientific knowledge was available for practical use by any health-care provider in the 1920s and 1930s, Keddy and her co-researchers noted that “the fate of the patient often depended primarily upon the ministerings of the nurse” (p.38). from this they concluded that nurses were technically critical to applied science to the extent that it was usable in their work. Ironically, physicians “ordered treatment which was soley nursing care and which was patriarchally devalued as women’s work” (p.38). If the same techniques had been administered by physicians, they would probably have been considered to be “appropriately scientific for the era” (p.38). In other words, gender, not science, determined the degree to which a particular technology was percieved as scientifically based. Keddy and her colleagues concluded that nursing and medical responsibilities in the 1930s, as today, are directly traceable to class and sex roles and only perpherally determined by the actual scientific content of the work itself. p165
Early Evidence of the Doctor-Nurse Game
In their 1987 article, Keddy and her colleagues focused on nurses’ technical work and skills in the 1920s and 1930s. But a year earlier, Keddy and other colleagues had interviewed the same group of older nurses to provide an historical perspective on the evolution of doctor-nurse relationships (Keddy, Gillis, Jacobs, Burton, and Rogers, 1986). Content analysis of the nurses’ past experiences produced a main theme – the doctor-nurse relationship – and provided evidence that the doctor-nurse game had been in force many decades before Stein’s (1967) classic analysis. (For a comprehensive analysis of the doctor-nurse game, see Roberts and Group, Gender and the Nurse-Physician Game, publication pending.)
From their data, the researchers found that these nurses were trained primarily by physicians: “In some schools of nursing the doctors also gave the exam to the nursing students” (p.747). The nurses said that the physicians thought they knew how much the nurses should or should not know. To them, a nurse’s worthiness was “equated with helpfulness to the doctors, much as the wife was considered to be the appendage of the husband since she was his helpmate” (p. 746). The physicians had a great deal of control and power over what the nurses learned: how they were examined, whether they passed or failed, and who would be registered after graduation.
The physicians also controlled the economic situation of early nurses, one of whom noted that she had lost a position in one commnity because the physician knew the other applicant and her family. Indeed, the nurse also said she knew she would get a job if a physician recommended her; physicians hired the nurses they preferred. The researchers found, too, that “to be a doctor’s preferred nurse meant you were a good nurse and occupied a special status with other nurses” (p. 747). However, as keddy and her coauthors asserted, this system of competition for jobs and favors from physicians kept the nurses from becoming unified. They concluded that, at least from their sample of older nurses, the women had little scope for greater power because “They tried to become ‘good’ nurses in order to obtain jobs” (p. 747).
What made a woman a “good” nurse? The researchers found that physicians had “very clearly defined expectations of nurses . . . [which] involved doing exactly what the physicians dictated,” and to these women they gave as a reward “a certain degree of respect” (p. 748). One older nurse said that the physicians had confidence in and relied on the nurses to carry out all their orderd exactly as given. Indeed, the nurse’s role was “not described in terms of patient care, but in terms of proficiency with which she carried out the physician’s orders” (p. 748). Thus, “obedience” equaled “good nurse,” which presumably equaled “good care.” p165-p166
[…]Raisler (1974) stated that a nurse is percieved as “good” if she helps the physician regardless of patient outcome; thus, intelligence and judgment are not useful “unless it improves the doctor’s self-concept and feeling of authority” (cited in Keddy et al., 1986, p. 748). This calls for gendered game playing, a fact recognized by Keddy and her associates: “In analyzing the data, it becomes apparent that most of the nurses interviewed were involved in the interactive methods of the doctor-nurse game, although none referred to it as such” (p. 748).
The first rule of the game, showing respect to physicians, often involved an expected “form of idolization of the physician” (p.748). Nurses remembered being told to jump to their feet in military style when a physician appeared. If medical personnel were able, knowledgeble, and devoted to community health they were respected. However, the nurses; “respect” for physicians was at times “far from genuine”; indeed, nurses were more apt to resent than respect the medical students who thought they were gods and expected idolization. Keddy and her co-researchers, found that sometimes the early nurses’ feelings were “based on fear of humiliation, developed in the student nurse’s mind throughout her training” (p.749). If physicians controlled nursing education, then it is not suprizing that one of the first rules taught was the power of the hospital and medical hierarchy. The researchers asserted that “feelings of inferiority and fear give rise to docility and submission in nurses” (p. 749), making it difficult for them to feel free to contribute to decision making.
The second rule was that “nurses cannot openly diagnose or make recommendations to doctors” (p. 749). As Keddy and her colleagues noted, nurses spend a great deal more time with patients than do physicians; thus, the nurses have information the physicians need. But they found from the interviews evidence of maladaptive interaction. One early nurse, for example, “referred to two different methods of treating pneumonia that she used in the same ward, depending on which doctor the patient had” (p. 749). Significantly, the nurse noted that one physician’s treatment, which involved fresh air, produced better results. Her observation has been subsequently substantiated, but because she could not voice her opinion, the patients of the physician whose treatment was not as effective continued to recieve the inadequate treatment. Even if this nurse had stated her opinion, the researchers noted that it could and probably would have been overruled by higher authorities.
The third rule was that no open disagreement or confrontation was allowed. To Keddy and her colleagues, this rule followed the second; if no opinions were allowed, then no disagreement was possible: “In order for the patients to believe and continue to believe that doctors are omniscient and omnipotent, they must not see anyone expressing disagreement with a doctor’s judgement” (p. 749). The result was also nebulous communication. One early nurse recalled bathing patients diagnosed with pneumonia; in doing this, she was in opposition to the physician, whose patients were often not allowed even bed baths for days or weeks at a time. She simply did not tell him what she did to keep her patients clean and comfortable. In an understatement, the researchers noted that physicians did not appreciate that nurses’ views might differ from thei own: “Part of what keeps nurses from asserting themselves is no doubt their stereyotypic female role behaviour: (p. 750)
Both gender and class discrimination in the hospital hierarchical authority were encountered during training. The researchers recognised that the women in their study were part of a sex-segregated labor force, part of a disciplined corps of subordinated individuals, whose experience with physicians produced the early basis for later problems in the profession: “In a number of interviews, it was strongly reinforced that the medical profession influenced nurses’ status in the workplace, their education, and also their actual registration to practice ” (p.750). The gender stereotypes of passivity, subservience, and subordination, based on class and sex descrimination, has been passed on to subsequent generations as the nurse-physician game.
Keddy and her colleagues noted that some nurses did express their ideas and acted to improve patient care. These women were unpopular with physicians, the early nurses noted, and often acted “on their ideas furtively” (p.751). The women’s movement has influenced current nurses to be more assertive; however, this recent change has also brought resistance. From the interviews, some change was apparent; one early nurse noted that the nurses eventually stopped standing up for physicians, even though the physicians did not understand or like the women’s changed behavior. Even so, it was observed that the doctor-nurse game continued and that ineffective communication had frightening consequences for patients. p167-p168
The Development of the “Good Doctor and His Loyal Nurse” in the 1930s
Stereyotyped images of nurses as subservient, nurturant, and not scientific persons were promulgated early on, not only by physicians but by the male-dominated media in newspapers, magazines, and books. By the late 1920s amd early 1030s similar stereyotyped images appeared in radio programms and movies; later they would surface in television commercials and programming.
The process by which the public came to percieve physicians and nurses in sterotyped gendered roles was still familiar even at the close of the twentieth century. p168-p169
Indispensable in Wartime, Subservient in Peacetime
During the Second World War, the tremendous need for women workers, and especially for nurses, changed priorities and caused a temporary emhasis on the value of women in the workforce. However, the partiotic appeals to nurses were based on traditional gender images which were mixed with contradictory messages. To recruit more women nurses, the media, for example, produced a number of movies with nurse heroines, all positively portrayed, but all clearly sex-stereotyped.
[…] As in past wars, the much-needed nurses who entered the military continued to be subjected to sexist treatment. Assigned relative, not permanent, rank, they earned about 60 percent of the pay of men at the same rank and had no retirement, dependents allowances, or other usual benefits. The women wore officers uniforms and held officers’ titles, excluding the highest rank of general, but recieved no commissions. Even with intense struggle, it was not until 1944 that nurses recieved permanent rank, but only for the duration of the war and six months after the cessation of fighting. This, despite the fact that the women dealt with the worst product of war, the wounded and dying, and often in extremely dangerous situations. It was not until the late 1950s that both women and men nurses would be free from some of the worst practices of sex stereotyping and discrimination.p178-p179
In 1946 hospital nurses averaged 74 cents an hour for fourty-eight-hour work-weeks, compared to typists, who averaged 97 cents an hour, and seamstresses, who averaged $1.33. Rejecting these salaries, and blind obedience, and unbending discipline, and peripheral status, up to 75 percent of nurses in one survey saw themselves leaving nursing or working only to supplement their husbands’ incomes, again reflecting the postwar propaganda designed to push women out of the public workplace. Dissatisfaction among hospital nurses was especially high because of long working hours and split shifts that made combining work and family tasks particularly difficult. Nevertheless, a substantial number of nurses did continue their work, many responding to the needs of patients and to the calls for help from nursing organizations.p179-p180
Even during the war physicians continued to stress the “rightness” of nurses’ subordination. For example, in 1943 one physician cautioned a graduating class of young women not to get out of line and warned them “to be good little girls and obey the physicians and the medical profession would not desert them” (Lovell, 1982, p.218). Although nurses were much praised for their work in the Second World War, physicians’ efforts to control nursing were sufficient to suppress any noticeable increase in nurses’ formal power. By the late 1940s the nurse as supplementary handmaiden to the physician was still very much evident. This is obvious in one example of the legal cases of that period. In this proceeding, reported in the New England Journal of Medicine (1948), a nurse brought action against a physician who claimed she had made derogatory remarks about him. Despite the proven competence of the nurse, she had been removed from the nursing registry, effectively eliminating most of her employment possibilities. p180
Eliminating Nurses’ Right to Bargain Collectively
[…]In an environment dominated by hospital management and physicians, the nurse, said Titus, had remained more docile and subservient than any other American worker and had even come to accept the thinking of the dominant groups that had encouraged nurses’ fears of jeopardizing patient care and losing professional status. Consequently, the nurse “has been like a sleeper who has slept serenely on when a great battle – a battle for human freedom and the rights of the common man – was being waged. But eventually the sleeper awakens” (p.1110). p183-p184
Titus and other nurse leaders led the struggle for collective bargaining for nurses, but the nurses’ awakening proved too threatening for physicians and hospital administrators, whose lobbies pressured Congress to exclude from collective bargaining nurses and other predominantly female health-care workers in nonprofit institutions that qualified as charities. When the Taft-Harley Act was passed in 1947, collective bargaining, a right of most other workers, was denied to many nurses because of their location in such institutions. Since most of the workers affected were women, the Taft-Harley Act is a textbook example of gender discriminatory legislation that effectively stalled women’s unification against sexist treatment in salaries and work conditions. It also served to strengthen the medical monopoly and the monopolistic practices of hospitals. Nurses who could not unify in their own behalf or that of their patients could hardly mount a successful threat to male-dominated practices and procedures.
It is not suprizing, therefore, that by 1955 nurses’ salaries had fallen behind those of teachers, recreation workers, librarians, and even women factory workers. Other women workers, even with average salaries only two-thirds of their male counterparts, were doing better than nurses, despite the fact that nurses worked longer hours and had fewer benefits than most other male and female workers. Nevertheless, the American Hospital Association (AHA) in 1956 and again in 1959 reaffirmed the Taft-Harley exemption. By 1960 university-educated nurses were earning little more than hospital-trained nurses; this limited incentives for nurses to aquire more education and thus jeopardized the goal of professionalization emphasized by organized nursing. p183 -p184
A Feminist Perspective on Nurses’ History and Needs in the Conservative 1950s
Amis the spate of sociologically oriented publications in the 1950s, it is difficult to find nurses’ own views on gender and nurse-physician relations. However in 1957, Flrence Flores, then nursing director at Massachusetts Memorial Hospitals, published a historical view of the current status of nurses. Although softened by humor, it laid out the problems quite openly. This work, atypical at the time, is considered at length because it is important to see what remained of feminism and what interpretation of early nursing history survived in the very conservative decade of the 1950s. p189
[…] Out of this gendered situation an off-balance triad developed. Eventually, patients’ needs and physicians’ desires exceeded the nurses’ abilities to meet all of them. Thusm said Flores, other workers took on nurses’ functions; first the dietitian, next the social worker, then the executive housekeeper, X-ray technitian, physical therapist, occupational therapist, and even the records librarian. In all cases, the majority were women, and they all saw the need for academic degrees. The complexity of scientific discoveries, plus the unequal demands, forced nurses to take on more procedures and to coordinate and supervise; however, prohibited from diagnosing, treating, or prescribing, they ended up providing the care. Given the galaxy of specialists over whom the nurse had no control, she still remained the chief link between physician and patient. The physician saw her as alter ego, but only up to a point. The patient saw her as mother, someone “to love him in spite of his infirmities . . . and to sustain him when his spirit needs sustenance,” but neither patient nbnot physician was “interested in having a women who thinks she is a specialist” (p.55).
What did the nurse want? Education, economic security, leisure, status, prestige, “the right to choose where and how and when she will work . . . above all, she wants her area of independent action defined” (p.55). To Flores, the fractioning of patient care had left so many “holes in the dyke” that the nurse did not have enough fingers to plug them. How could this web of circumstances be untangled? How could a nurse achieve education and prestige “without making her feel that she has aspirations beyond her station” (p.55)? Flores recognized that nurses were fighting against difficult odds, but warned that, though they may confuse men, the women themselves were not at all confused about what they wanted. p190-p191
Feel like a Girl, Act like a Lady, Think like a Man, Work like a Dog
The largely informal transfer of functions from physicians to nurses led Henry Pratt, MD, (1965), to publish “The Doctor’s View of the Changing Nurse-Physician Relationship.” (Note the historical trend to use “doctor” as a generic term for “physician” was making it confusing and difficult for others with doctorates and more specifically for the small number of nurses who had achieved their doctorates by the 1960s.) Pratt admitted: “The physician’s concept of the perfect nurse has been: She must feel like a girl, act like a lady, think like a man and lork like a dog” (p.767). But to him, these attitudes were changing because “the scientific, economic, and legal aspects of medicine have changed profoundly” (p.767). What happened to all the women’s efforts to create and change nursing? They were ignored and thus eliminated as causative. Instead, Pratt reviewed changes in medicine and, from this one-sided view, considered factors “favouring” change.
[…]To Pratt, “The nurse has become a Partner” (p.769). He convieniently overlooked the increasingly large economic inequalities in the “partnership” and believed that nurses would become “second class” physicians because of increasing medical complexity and physician shortages. As to his predecessors, things were simple to this physician: nurses made beds and gave backrubs. But by the 1960s, “The head nurse is in essance the superintendant of a 35-bed hospital” (p.770). Pratt failed to note what Mauksch had earlier, that the head nurse was not given full authority to act in this role, but he did admit that for legal reasons the nurse must “police the activities of the partner, the physician” (p.770). Caught between administration and medicine, “It takes a special kind of woman to resolve these conflicts” (p.770).
[…]How the nurse was to provide care, act as a hospital superintendent, and police her physician “partners” without any increase in authority remained a problem. Indeed, Robert C. Leonard (1996) noted that the physician, administrator, and patient all defined the nurse in different ways, causing role conflict for the nurse, a fact that even in the mid – 1960s was considered “well-documented.” Although Leonard did not target nurses’ roles as women, he did assert that the “expressive,” nurturing function was one which nurses have a historic claim. After eliminating cure, Leonard then questioned whether nurses, caught in bureaucratic, technological, and professional changes, could actually provide nurturing care. Using Talcott Parson’s sociological terms and theory, Leonard continued the stereotyping of the previous decade; the physician was task-orientated and instrumental; the nurse was emotion-orientated and expressive. Presenting four short experiments, Leonard showed the physical effects of the expressive style on patients. What seems forgotten is that instrumental and objective information, goals, and actions are always connected to those that are expressive and subjective. The feminist critique of the Parsonian model shows that it did not work for women and men in families, and it did not work when transferred to women nurses and medical men. In both situations, the division of instrumental and expressive simply continued sex stereotypes in different but really quite old terms. p193, p194, p195.
Bonnie Bullough (1975) claimed that the continuation in the 1960s of these stereotyped attitudes even in research, could be traced to the “weight if past tradition, the subordination of nurses, the sex segregation, and the apprenticeship model in nursing education” (p.229). All these were reinforced by nurses’ emphasis on social and emotional aspects of care and not cure. The division between rational male who diagnoses and treated and the emotional female who gave care followed gendered lines and was justified because women were “more naturally maternal and expressive” (p.230). Thus , gender-based stereotypes deterred acceptance of the nurse practitioner, who both cured and cared . Indeed, many nurses came to believe they should take no independent action or responsibility: “They are able to believe this in spite of the fact that mich of the time the patient’s life depends on the nurse’s ability to assess his condition and act intelligently on that assessment. Of course, nurses do not actually avoid all descision making. They merely pretend to avoid it” (p.230).
This pretense was highly correlated with gender expectations that women in general should act dumb in order not to threaten the male ego. Unfortunately, such gender-stereotyped behaviors in health care were and still are deleterious and even dangerous to people’s health. The imbalanced division of labor and the excessive authority of physicians had produced, as physician Leonard I. Stein (1967) called in his now classic work, “the doctor-nurse game,” which was a “neurotic transaction” in which nurses could not make a direct statement, but must address physicians in such a way as to make their recommendations sound like nonrecommendations. It is really not helpful to patients when nurses have to act stupid, or constrain intellect, or restrain action in order to prop up medical authority. As Stein noted, the consequences to nurses who refuse to engage in this neurotic transaction were at least “uncomfortable” and at the most severe, including job loss (see Roberts and Group, Gender and the Nurse-Physician Game, publication pending). An ever-ncreasing number of nurses were tired of the pretense and game-playing. p195
Conflicting View of Nurses Continue: Autonomous Professional? Or Legal Subordinate in the Bureaucratic Hierarchy?
By the end of the 1960s, the disparity between the views of physicians and nurses is amply apparent in a comparison of only two of many publications. Nursing leader Eleanor C. Lambertson (1969) faced squarely the conflict between professional autonomy and the bureaucratic hierarchy. She pointed to the central paradox: “the physician expects the nurse to initiate, coordinate and facilitate institutional and therapeutic services, . . . but deplores any action on the part of the nurse, in support of medical policy or established institutional practice, that appears to curtail his perception of his individual rights and privileges” (p. 75). Lambertson believed that the physician could not continue “to insulate himself from organizational stress and interpersonal conflict,” but rather must realize that “his concept of his role may well be a causative factor” (p.77).
In contrast, physician Charles V. Letourneau (1969), who wrote on hospital authority, claimed that “A man’s authority is determined be his subordinates . . . [but] the relationship between physician and nurse is not based upon a willingness to be governed on the part of the nurse, but upon the imperatives of the law” (p.36). Only the law permits physicians to diagnose and prescribe treatment; thus, “unlicenced persons are guilty of the illegal practice of medicine” (p.36) if they engage in such activities. The physician must be sure that nurses carry out his orders “to the letter”; the nurse must not “second-guess” the physician. To Letourneau, the nurse might “work alongside” the physican, but the “law provides that she is to exercise no independent judgement” (p.37).
A comparison of these two articles provides little evidence that better communication had occured over the previous decade or even previous century. Clearly, the physician reestablished his authority by resorting to the law, which ironically was created by pressures from his own medical group. He did not recognixe that pressure from nursing groups could force such laws to change. Equally clear is Letourneau’s lack of understanding that he was, without overtly recognizing it, stating that a group composed predominantly of men has authority to keep an entire profession of women from making any independent, individula judgements at all, except under serious emergencies.
The distance between views of individual nurses and physicians was equaled in the expressions and actions of their professional organizations. When nurses began to reject taking on more medical functions without increased authority, the National Academy of Science of Medicine issued a report that advocated that military corpsmen be recruited and trained in the new role of physician’s assistant (PA) – a role that would force nurses to accept the authority of men who were usually unequal to the women in years of education or expertise. As in the past, physicians expected nurses to accept this new role, as they had been forced to accept the many previous roles created out of nursing and medical functions. This time organized nursing refused to go along with the men’s unilateral action. Though there was substantial deviation from the original Ford-Silver model, the 1970s saw the further development by organized nursing of the nurse practitioner as an alternative to the physician’s assistant. p200 – p201
Reconciling Practice with Protest and Confrontation with Cooperation Nurse-Physician Realations in the 1970s
By the 1970s the medical monopoly had been strongly buttressed by the rapid expansion of knowledge from the physical and biological sciences and by increased technological capacities. The health-care industry had become the third largest in the nation; indeed, there was an 80 percent increase in the number of health workers from 1960 to 1970. The greater complexity of work, the creation of new technologists, and the development of nurse clinicians and specialist roles in intensive and coronary care units were associated with diagnostic and theraputic advances, for example, in the use of radioactive isotopes and ultrasound and infared technologies.
[…] Indeed, the medical monopoly over patient admissions gave physicians power over the use, even over-use, of hospital beds, thus determining the level of hospital usage. By the 1970s it was clear from research that physicians conducted many unnecessary procedures and surgeries, particularly those involving women patients, such as hysterectomies. The medical monopoly had not solved fundamental problems and, indeed, had helped to create a fragmented and expensive “system” of care.
The public became increasingly vocal in their critisms of medicine and the health-care industry. Feminists were particularly incisive in detailing the poor and prejuicial treatment of women by male physicians. With the re-emergence of feminism, nurses were more aware of and vocal about their subordination and unwilling to allow sex discrimination to limit nursing and to prop up the medical monopoly. The number of articles written by nurses on nurse-physician relations increased dramatically. In these publications, feminist analyses and interpretations of interprofessional relationships were often very apparent, reflecting nurses’ renewed connectedness to issues involving gender equity (see Roberts and Group, 1995). If the decade of the 1920s was the turning point for the consolidation of medical power, the decade of the 1970s was the turning point for challenges to the medical monopoly by consumers, nurses, and other health-care professionals.
Despite greater clarity in political issues, organized nursing was still forced to fight for federal funds, particularly for nursing education, even though the Nurse Training Acts of 1964 and 1971 had produced a 200 percent increase in active registered nurses between 1950 and 1978. Nurses’ efforts to shift from hospital-based programs to college- or university-based education continued without any substantial support from and sometimes even the opposition of organized medicine. From 1963 to 1972, nurses with assiociate degrees had increased by more than 1,000 percent, those with bachelor’s degrees by 90 percent and those with master’s degrees by 70 percent, while the number holding doctorates doubled to more than 700. These upward trends would continue throughout the decade. p203
The Battle for Domination: Enter the Physician’s Assistant
Many nurses strongly objected to picking up the physicians’ leftover tasks; they asserted their right to their own emphasis on holistic wellness, rejected more responsibility without increased authority, and refused to allow physicians, once again to dictate to nurses what they should do. There was no question, as T. Elaine Adamson, public health specialist, said in 1971, that productivity could be improved by realigning overlapping duties. Research results indicated that non-physicians could safely handle a substantial proportion of patients’ problems and that physicians were therefore monopolizing tasks that nurses could do. Furthermore, research studies also proved that nurses could and had already had been doing medical work effectively. By the end of the 1960s nurse practitioners and clinical nurse specialists had emerged,[…]but hopsitals and physicians were not willing to pay more for these highly trained nurses, who were instead often put into administrative positions rather than assigned to jobs where they could use their advanced clinical skills with patients. Physicians, experienced a self-imposed shortage because of their own restrictions on medical school admissions and facing increased technological demands and excessive specialization, decided to get rid of the “scut” work, not by giving the nurses more independent authority but by creating the physican’s assistant (PA), who would be responsible not to nursing but to medicine. To counter this move, organized nursing encouraged the development of a different health-care specialist, the nurse practitioner. p207-p208
[…]After many nurses refused to be PAs, nursing leaders established their own nurse clinician and practitioner programs to prepare nurses for expanded roles, and, in 1972, they obtained fedaral funding for these programs. Given the success of these programs, Adamson could 0nly conclude: “The emphasis in the AMA position statement on diploma graduates and non-clinical degree graduates, the antithesis of current trends, seems to be based on a desire to have minimally trained nurse assistants who will be more willing to work under authoritarian physician leadership instead of highly educated nurses who are capable of independent jugment” (p. 1773).
The main factor affecting productivity, said Adamson, was physicians’ reluctance to give up their functions and their need to retain control over the health-care system. Unfortunately, Adamson did not adequately differentiate the PA from the nurse practitioner, simply seeing them as equivalent. Nor did she openly discuss the sex-stratification system that would allow men, some with only a few months of training and often no more than a year of military experience, to function as PAs and conduct minor surgery, diagnose, and prescribe medications, while women with three to twelve years of higher education, some with a lifetime of professional experience, could not do these things and, in fact, must presumable take orders, not only from physicians, but now from the predominantly male PAs.
Adamson understood that physicians viewed delegation of tasks as a potential surrender of power. It could also mean loss of income since “costs of various tasks [delegated to others] could be assessed,” which could lead to “reassembling of the professional decision-making structure” (p. 1774). Nursing costs are usually assessed as part of hospital room charges. In this way, the actual cost of expanded roles – particularly if the tasks are performed under a physician’s “standing orders” – is blurred, allowing no costing-out of the actual functions and tasks and making, for example, “obstetricians in the United States . . . the highest paid midwives in the world” (p. 1774). By the end of the 1960s the only specialty groups that had set up guidelines for the advanced training of nurses were pediatricians, who alone endorsed a collaborative nurse-physicians relationship, though not and independent one. p209-p210
“Neither Role Is an Exclusive Domain”: Recognising Overlapping Functions in Cure and Care
[…]In Bate’s view, the physician thinks of the nurse as his technical assistant, thus constricting the psychosocial characteristics of his own professional viewpoint. The constriction is enforced by authoritarian behaviour against which, “except perhaps for an articulate minority, nurses have not rebelled” (p. 131). In addition, “Physicians are usually men, most nurses are women, and the pattern of male dominance prevails” (p.131). Physicians are older, are more likely to come from a higer social class, and have a stronger knowledge base, recieve greater rewards, and achieve higher prestige.
Using the pychosocial focus of nurses as the rationale, Bates described new approaches to patient care, explaining to other physicians the changes nurses had begun to make. It is clear that such a translation was, and still is, necessary because of the obvious sex segregation of the professions.
[…] Bates tried to create models of care, basing them on multiple overlapping functions in nurse-physician role, for example, in meeting patients’ psychological needs and fulfilling tasks basic to diagnosis and treatment. Patient care, according to her, did not reflect the full realization of either nurse or physician roles. Bates seemed to take the view that nurses provided psychsocial care, the usual maintenance role of women, while physicians took on the “masculine” task roles of diagnosis and treatment. Bates returned to the example of the three nurses, indicating that freedom to work with physicans, instead of being stuck in tasks delegated by hospital administration, frees the nurse to practice fully: “it would be facisnating to find out what proportion of patients they could handle on their own” (p.6). Interestingly, midwives in rural areas and public-health nurses have worked on their own for decades; thus, evidence of independent practice was available, but perhaps unknown to Bates.
Nevertheless, Bates did present research that showed that only 22 percent of patients needed medical expertise after their first visit; thus, nurses could handle most client situatuations. Similarly, other research on internists showed that of every ten patients, one comes for a physical examination, two for new complaints, and seven for care of a continuing clinical condition. Many of these patients could be cared for by nurse practitioners; indeed, Bates claimed such nurses “may be able to meet most needs of most patients most of the time” (p.6). If the health-care system could be reorganised around patients’ needs, better care of patients and utilization of personnel would occur, as demonstrated in research on patients who were cared for in a nursing clinic and who subsequently exhibited fewer symptoms and less disability, and expressed fewer critisms of their care. Bates believed the PA role was too often subsumed in the circle of medicine, rather than in overlapping circles of the two professions. Whether nurses were forsaking nursing to become PAs was not as critical to Bates as their satisfaction in using their intellectual skills and increasing their capacity for decision making.
Bates admitted that medicine has aquired a reputation not just for leadership, but for being a “bit of a bully” (p.7), and that “nursing for the most part has followed in medicine’s footsteps” (p.7), though a portion of the ranks have rebelled, evicting physicians as teachers from nursing programs and declaring nursing’s independence. With this “healthy revolt” (p.7) now presumably over, Bates noted that it was time for individual change from the feminine self -image to one that requires brains, guts, broad shoulders, and a thick skin – all presumably traditional male attributes! Increasing levels of knowledge would be required in expanded roles; this would probably threaten some nurses, who might become hostile. But Bates viewed such nurses not as junior doctors, or technicians, or deserters from their profession, but as innovators who must carry responsibility for new clinical decisions.
To her credit, Bates insisted that physicians needed a wider perception of patient needs. She admitted that physicians constrict the scope of patient care by seeing other professionals as helpers, not as independent professionals with their own perspective. Bates further argued that physicians must share the rewards of their profession, not only in economic ones but the relationships with patients as well: “We can delegate tasks to others and reallocate some of our functions, but we have much more trouble allowing another person to enter importantly into what we have treasured as a one to one physician-patient relationship” (p.8).
[…] Very accurately she asserted: “We operate in different organizational systems, are responsive to different authorities and belong to few if any groups in which we collaborate together” (p.8). Individual and organizational change would not suffice; the social – specifically, the economic and legal-milieu must also change. If nurses take on more responsibilities, they must recieve salaries commensurate with effort, education, and responsibilities. Clearly, Bates still percieved nurses as working for physicians and institutions, and not in independent practice. Further, she did not see legal problems as critical if physicians and nurses planned together. Her well-intentioned optimism may, however, have been misplaced; since the AMA has traditionally lobbied for restrictive laws against nurses and other professionals, it is questionable how quickly physicians would be willing to share their power and economic rewards. Similarly, hospital administrators have fought affirmative action measures and nursing professional associations and unions. Unless the monopolistic systems are changed, Bates’s hopes may have been premature. p213-p215
“No New Dilemma for Nurses”: Reconciling Practice with Protest
[…]Why had medicine got away with exerting such pressures? Because patriarchal society “does not place a high value on the ‘caring’ role” (p.9). Indeed, medical control of “caring” was now so complete that some nurses were even afraid to wash a patients hair without the physician’s order: thus, an intelligent woman was “behaving like a nincompoop in her work situation” (p.11). Consequently, nursing shortages were common because physicians manipulated nurses, who are “rarely used at the level of their preparation” (p.12). The result? Many leave. Thus, men in power create spurious shortages, which in turn free the AMA to introduce lower-paid occupations for women and to manipulate levels of training, which are then used to exclude honest competition. With each new level and type of nurse, women nurses then turn on each other to prove the validity of their own backgrounds. To Fagin and Lehman, this was the wrong way for nurses to gain status and power. The impact of feminism was obvious in this analysis.
With the reemergence of feminism, nurses began to recognise systematic manipulation and to revolt against it. To Ruth B. Freeman (1971), nurses were “reconciling practice with protest, confrontation with cooperation . . . the revolutionary with the . . . professional. This is no new dilemma for nurses” (p.918). Freeman claimed historical precedent. Florence Nightingale championed the British soldier in an “aggressive, articulate, and sustained interchange” (p.918). Her Notes on Nursing represented a protest about conditions “in medicine and administration and in public policy” (p918). Careful strategy, workable solutions, and practical hard work, all based on “getting the facts”: these were Nightingale’s approach to creating often scathing exposes: “She not only described and deplored the conditions she protested, but was able to suggest possible remedies” (p.918). In the twentieth century, nursing had turned inward, but it was time, Freeman argued, to share “the cause of the aggreived,” to act as advocates, to build the capabilities of others so they could fend for themselves. Nurses could and should advocate once again for their patients and their rights, Warning against a passive or meek approach, Freeman called for social action, but did not elaborate on the monopolistic and bureaucratic systems that make protest for nurses so difficult. p.210
“A Marriage between Physicians and Nurses? Thanks – but No Thanks!”
[…] In the same issue of the American Journal of Nursing, Abraham B. Bergman (1971) claimed that the nursing profession should accept and incorporate the wider frunctions of the PAs: “I work with large numbers of nurses and I sense that they have greater unease and dissatisfaction with the fate of their profession than any other group in the health field” (p.975). To him, endless charting of trivia and a degrading supervisory system led “women with brains and spirit to chuck it all to become airline stewardesses” (p.975). Public health nurses bogged down with fossilized department leadership and financial eligibility forms while office nurses working with physicians were seldom involved in “any meaningful patient care activities” (p.975).
Bergman attacked nursing education for not dealing with shortages, instead issuing “narcissistic pronouncements on the image of the nurse” (p.975). After critisizing nurses, Bergman concluded: “The cold, harsh truth is that physicians control the delivery system, and despite changing political winds, are likely to do so for some time” (p.975). Whether this was right or wrong, Bergman did not profess to know. He did admit the frustration of other health professionals with medicine’s “undistinguished track record for innovation,” but called on nurses to accept being PAs, because, after all, “it pays to view the world as it really exists” (p.975). Since men were in control, then women must recognise that they could do nothing without male support. Some nurses had other views, however. p218
Nursing Exists to Serve Society, Not the Ends of Other Professions
[…] Uncompromising, Rogers stated that professionally educated graduates of baccalaureate programs are the peers of physicians, and to recruit them as subordinates to function at a lower level in medicine represents a human and intellectual waste. Nurses may swallow the proclaimations of “new functions” that have been “integral to nursing practice for many decades” (p.43) but are now limited to the confines of medical knowledge, concerned with physiological pathology, not human unity. Medical practitioners are “not competent to practice in or exercise control over any other professional field” (p.43). Medicine is only one of several diciplines required for comprehensive health care. Nursing exists to serve society and is directly responsible to the people served: “The nursing profession does not exist to serve the ends of any other profession” (p.44). Here the boundaries are clearly set. Men may rule their profession, but women will rule their own.
Nursing emphasizes wellness, for example, in community health services, and this orientation is needed to transcend “sick services.” Aggressive leadership is needed to transmit the nurses’ model in health maintenance and promotion centres. The nature and delivery of present services are “critically inadequate and unsafe and notably obsolete” (p.44). The physicians present short-sighted, narrowly conceived modifications of long existing practices” as “innovations” (p.44). Home-care services, for example, were started over a century ago by nurses, but were now claimed as the physicians’ “creation.”
[…] The medical divide-and-conquer attack on nurses had ranged from preventing nurses from joining professional associations (by threatening loss of employment to setting up competing occupational groups under a paternal control. Nurses had too long adhered to a “sad state of dependency,” frightened of confrontation with the status quo, a confrontation which requires “commitment and courage” (p.45). If women are socialized to be passive and dependent, then confrontation with men, particularly those at the pinnacle of the occupational prestige pyramid, is indeed threatening. But, said Rogers, this confrontation was necessary if proliferation of bureaucratized roles was to be halted, if nurses’ emphasis on health, not disease, was to be sustained, and if the medical monopoly was to be challenged.
The situation was so bad that in the 1972 report, Extending the Scope of Nursing Practice, to the Department of Health, Education, and Welfare, the AMAs Committee to Study Extended Roles for Nurses – which was composed almost equally of physicians (only one of whom was a woman) and nurses – recognized that wider professional responsibilities made “both nurse and physician feel threatened and . . . troubled by ambiguities, uncertainties, and misconceptions of their symbiotic roles” (American Medical Association, 1972, p.1231) […] Increased salaries for the women in advanced roles would be offset by greater freedom for physicians and others in the system. Primary-care functions were then delinated, including those shared by both professionals. All these were spelled out without consistent reference to the gender role inequities upon which they were, in part, based. Indeed, the HEW-sponsored report recommended the orderly transfer of medical functions to nurses but did not define the nature and scope of the roles. In reality, the transfer of functions had been proceeding for many years and nurses were already performing many “medical” functions. Although admitting that relations were far from ideal, the report did not clearly implicate a sex-stratified system as a basic factor in the physicians’ monopoly and the nurses’ subordination. p.219, p.220
The Imposition of the Physician’s Assistant: A Gendered Struggle over Dominance and Submission?
In contrast to other analysts, June S. Rothberg (1973) directly confronted the gendered nature of the battle over PAs. The surface problems – citizen discontent with health care, shortage or maldistribution of personnel, lack of access to care, exponential expansion of knowledge, pressures for updating skills, public and peer demands for closer evaluation of science – were all based on deeper issues: “independence versus dependence, male versus female, dominance versus submission, medical cure as differentiated from health care, control in contrast to freedom, and – underlying all – economics” (p. 154)
A deceptively simple but important issue is that of title and identification. What is nursing? Is it part of medical care with no independent functions? “A state health department official goes on record in an open meeting . . . that in ten years nurses and physicians’ assistants will be doing the same thing and that, in fact, ‘there will be no nurses by that name and practice” (p. 155). The future for nursing was clear: women would be subsumed as “totally dependent practitioners” (p. 155).
The move by physicians to force nurses into this position occured in the context of the physicians’ perceptions that their monopoly and control were being eroded by “unwaranted attempts to obtain privileges rightly delegated to the medical profession” by a wide variety of professional groups (p.155) Physical therapists, chiropractors, psychotherapists, psychologists, and even nurses, the “handmaidens,” were rebelling. Physicians still controlled the health-delivery system: “Yet there is not a discipline in the field of health services today that is not trying to attain greater control over its own practice” (p. 155). According to Rothberg, the physicians’ move to turn nurses into PAs could symbolically represent medicine’s reaction to the movement toward independence by all health workers.
As a predominantly women’s profession, nursing requires liberation, since it has, as Rothberg stated, “inequality forced upon us from sources external to our occupational group” (p. 156) In agreement with Fagin and Lehman (1971), Rothberg believed that nursing “epitomize[s] the inequitable sex role that women’s rights groups are rebelling against” (Rothberg, 1973, p. 156). Although predominantly a women’s discipline, it was not dominated by women. The classic signs of second-class citizenship included persistent low pay despite advanced perparation, a sense of powerlessness and frustration, and lack of advancemen to the highest levels of policy-making positions. Rothberg contended that “nursing is going through its own process of ‘conciousness raising’ in precisely the same sense that the women’s rights movement advocates for individual women” (p. 156). The extension of the roles of wife and mother into the workplace makes rebellion for nurses act against not only occupational subordination but traditional “femininity.”
The question of extended roles must be seen in the broader context of dependence versus independence. The PA is delegated a defined a set of tasks to be carried out only under medical supervision; thus, by name, definition, and practice, the PA is dependent on physicians. Although there are overlapping areas with medicine, nursing, in contrast, has a distinctive field of practice and a separate legal professional identity. Though the nurse may be dependent on an MD’s orders in some situations, she is also able to function legally in independent ways. To Rothberg, interdependence is the highest state of development and “to expect that mature adults . . . will complacently accept a dependent role for all time is to defy what is known about psychological development” (p. 157). The PA is denied this interdependence because his or her occupational identity is completely defined be subordination to a member of another profession. For female nurses to accept PA status is also to accept stereotyped sex role (male equals dominant-aggressive inderpendent, and female equals the opposite); “the mind boggles at what the predominantly male physician’s assistants will be expected to accept” (p. 157).
[…]If PAs are physician surrogates, nurses may be forced to accept their orders. Nevertheless, physicians assert that PAs would not disrupt the physician-nurse relationship because the nurses could now consult the PA without disturbing the physician. “Upon occasion a nurse will be called upon to carry out the instructions of a P. A. This should not pose a professional problem since the instructions are for the good of the patient” (Physician Associate Program, 1972; cited in Rothberg, 1973, p. 157). Rothberg countered, “This incredibly naive statement overlooks the fact that the nurse alone is legally responsible for her actions” (p. 157). […] The writings of PAs clearly show that they avoid the drive for status afforded by education and independent professionalization, accepting instead an employee relationship with the physician, whome they can expect to mention their names “with respect and admiration to the administation” (p. 158).
[…] To Rothberg, the root problem was that neither medicine nor nursing had been able to define its separate role or deliver an acceptable level of care; thus, the PA was a symptom of a dishonest sex-segregated system that could not admit or deal with the overlapping functions of the professions, insisting instead on nurses’ pseudo-interdependence and PA’s excessive dependence.
Maintaining the Status Quo While Expanding Roles?
[…] Medicine, hospitals, government, and communities exerted more influence on nursing than nurses did. Given the very large number of nurses, why did women en masse accept the decisions of a small number of men in medicine and hospital administration? If nurses were socialized for subordination, sex-segregated in the marketplace, and subject to patriarchal conrol in all cultural systems, the explanation for their disunity in political actions becomes clearer.p222 – p.223
New Nurse Practice Acts: Legal Freedom or Entrapment?
By the 1970s it was very clear that system-wide changes would be required if nurses were to take on more medical functions legally. But nurses were still trapped in the legalities of practice and caught in a legal system heavily influenced by pressures from the AMA earlier in the century. Whether the nurse protested her role or changed it according to new definitions or simply followed orders, she might be in real trouble. Ironically, the traditional nurse who followed orders which led to a patient’s death was, according to attorney Michel Lipman (1972), likely to be arrested for manslaughter. Peculiarly, sociologists such as Friedson considered nurses paramedical, but the law, at least in the areas of liability, treated nurses as professionals, capable of exercising independent judgement. Of course, if the nurse did not follow orders and “wrongly substitutes her own judgement” (p. 55), she was also liable. The nurse was caught in a double bind: if she wrongly followed orders, she was liable; if she refused to follow orders, Lipman warned, the “nurse will have to face the fact that her action won’t endear her to the physician, whether she is right or wrong” (p. 86). Thus, the nurse, hemmed in by monopolistic restrictions, was still legally responsible even for carrying out a physician’s improper orders. If this was the situation for traditional nurses, how much more difficult was it for nurses in expanded roles? The need for new nurse practice acts in the states was obvious, particularly in the areas of diagnosis, treatment, and prescriptive authority. p230
[In 1975 Carol Ann] Mitchell claimed that institutional constraints still defined nursing: “nurses generally are not – and cannot be – person-orientated in the environment as it now exists. This particular milieu forces a relationship that is managerial, technical and task orientated” (p. 15). As long as roles are defined by the employing agency, “without either the consent or counsel of the nurses . . . [they] cannot practice professionally within the walls of hospitals” (p. 15).
To Mitchell, the foundation for impediments to professional practice was “basically one of societal expectations and sexist struggles. Most physicians and hospital administrators are men: nurses are generally women” (p. 15). Women were forced to depend on men for “permission to perform our independent professional functions” (p. 15), and then left to rage about the medical chauvinists. The movement of nurses into private practice may help to destroy the idea that their sisters who remain in hospitals are incapable of independet practice. This was Mitchell’s hope for channeling energy into constructive action.p231
Sexist Barriers to Autonomy: The Physician-Nurse Game
Bonnie Bullough (1975) agreed that the worst barriers to the nurse practitioner movement were basically the problems of women in a woman’s field. Nursing had always lived with sexist barriers, “learned to cope with them, and now finds that those very coping mechanisms are blocking progress” (p. 225). Why, she asked, did nurses stand by and allow a new occupation, the physician’s assistant, to develop to meet a need that nurses, with only a minimal amount of added training, could fill? Why did the women not preempt the field from the begining? To Bullough, the answer is found in the fact that, with the possible exceptions of housewifery and prostitution, nursing more clearly embodies the female stereotype than any other occupation. Therefore, nurse-physician relations reflect extreme female subordination, which nursing education had reinforced by creating “ladylike” and subservient nurses.
The early Nightingale reforms emphasized that women be clean, chaste, quiet, and religious workers who toiled long hours, never complained, and obeyed their superiors and physicians, valuing good character even more than education. All these presumably reinforced their gender-stereotyped behavior. Nevertheless, Bullough lauded the nineteenth-century women and placed responsibly elsewhere: “The real culprits are their twentieth-century followers, who have uncritically accepted the more repressive assumptions along with the positive contributions” (p. 228). To her, sexism was institutionalized in hospital training schools, where service to physicians and patients, not education, was the primary goal for women, whose work produced profits for others. Nurses’ intellectual subordination was validated by the “belief that the physician was always right and even when he was wrong he must be made to appear right” (p. 229). These sexist traditions, said Bullough, slowed educational reform so that a half century passed between the opening of the first collegiate nursing program and the time when even 16 percent of nurses were graduated from a program operated by an educational institution. Not until 1972 were more nurses graduated from collegiate institutions, both two- and four – year, than fropm hospital diploma programs.
The force of tradition, nurses’ subordination, their sex-segregation, and their history of apprenticeship training were reinforced by nurses’ subsequent empahsis in the 1950s on social and emotional support for care, not cure. This division, the rational male diagnosing and treating, and the emotional female giving care, followed gendered lines and was justified because women were “more naturally maternal and expressive” (p. 230). Thus, gender deterred the emergence of a nurse practitioner who cured and cared. Bullough noted that there were still nurses who thought they should take no independent responsibility: “They are able to believe this in spite of the fact that much of the time the patient’s life depends on the nurse’s ability to assess his [sic] condition and act intelligently on that assessment. Of course nurses do not actually avoid all decision making. They merely pretend to avoid it” (p. 230).
This pretense is best exemplified in the doctor-nurse game (Stein, 1967; also see Roberts and Group, Gender and the Nurse-Physician Game, publication pending). Bullough reported the results of research conducted by her and graduate students, finding that the types of these games varied by situation; however, in the questioning of orders, none of the 103 nurses surveyed would state, “Doctor, you have made an error” (Chaffee, Kingstedt, Reiss, Baron, Brady, Lee, Kyung, Stuart, and Bullough, 1974, p. 231). Of the 40 physicians, 86 percent preferred “Doctor, would you like to check this order?” (p. 231). The most worrying finding was that nurses chose the indirect approach regardless of age. Older physicians also preferred this approach, but younger men were more likely to accept a direct communication from the nurses. Clearly, the nurses were still playing the game of making recommendations without appearing to do so: “Similar patterns of anticipatory withdrawal are fairly common among minority groups; the ghetto walls are often well policed from the inside as the outside” (p. 231).
Despite game playing and legal restrictions, Bullough quite rightly pointed out that nurses’ acts of diagnoses and therapy had been happening continuously. Nevertheless, the extreme superordination-subordination of physician-nurse roles had led physicians to conclude that nurses were simply not “capable of independent or even cooperative decision making” (Bullough, 1976, p. 1478). But to Bullough the most important barrier to change was the nurses’ own perceptions:
Many could not conceptualize themselves as able to make diagnostic decisions. They had, of course, been making them for years, but they had protected themselves with
elaborate games which cast the physician, captain of the team, as the only legitimate decision maker . . . . [T]he women’s liberation movement came at a most fortunate
juncture to combat some of these ideas. The care-cure dichotomy was to a certain extent based on sexist argument that nursing should pursue the care element because it is
feminine, maternal, expressive, and natural for nurses, while the cure element is masculine, paternal, instrumental, and natural for doctors. (p. 1478)
With the reemergence of feminism, nurses were encouraged to gain autonomy in decision making; they began to feel increasingly foolish about the blatant game playing and a “long-needed honesty [was] creeping into the interaction between physicians and nurses” (p. 1478). In addition, the technological developments that led to intensive care units also caused “significant incursions of nursing into what was formerly considered medical territory” (p. 1477). By the 1970s nursing had largely eliminated the “virtual monopoly of the hospital apprenticeship” programs (p. 1477) and moved into institutions of higher education. To Bullough, these trends converged to force role expansion, which led to nurses’ attack on the power of medicine to write unlimited statutes through professional regulatory boards that advised legislators. Not only had a number of states modified their nurse practice acts, although only after struggles with many physicians and health administrators, but by 1975, approximately 10,000 nurse practitioners were active and 1,500 midwives had been certified, compared to an estimated 900 PAs. Clearly, the nurses had been very active. Despite the support of PAs by medical societies and some hospital administrators, by 1977 there were over 150 nurse practitioner programs in existence. p232 – p.234
Research Proves MDs Prefer Physician’s Assistants, Resist Nurse Practitioners
Although the female nurses’ education often exeeded that of the predominantly male corpsmen serving as PAs, gender was a significant determinant of the success of the different programs. The nurses were at an advantage in obstetrics and gynecology. The physicians believed that the female nurses would “know what the proper relationship between physician and assistant ought to be; . . . [they] would have an inculated ‘sense of their own limitations'” (pp. 8-9). Indeed, gender segregation was evident, even in social situations: at cafeteria tables, the nurse practitioners sat with nurses and the PAs sat with physicians. The researcher concluded that the ease of role defininition and the breadth of roles allowed the male PAs were concessions of medical rank and privilege, which were easier for a physician to share with other men, “thereby avoiding an implicit threat to his maleness” (p.9).
The physician’s assistant relieved the internist of general practitioner functions, thus enhancing the physician’s functions at “higher” levels. In contrast, the certified nurse midwife and pediatric nurse practitioner threatened the status of physicians in their areas because nurses’ training encompassed the entire maternity cycle, “thus paralleling rather than buttressing the obstetrician’s speciality” (p.9). Although the nurse midwife was limited to “normal pregnancies” (p.9), these constituted the majority of cases; thus, the total number of obstetricians could be substantially reduced if they only had to care for the few abnormal cases. In short, the nurses with lower-level degrees could do what the physicians usually do. However, when asked what the midwives should do, only three of ten physicians indicated delivery and labour. After three years, only one midwife remained; she performed no deliveries, despite the fact that women had historically preceded men in this field.
Among the pediatric nurse practitioners, 62 percent of the babies referred came from only 4 of 14 pediatricians; indeed, a large proportion of the pediatricians thought they were better even at well-baby care than were the nurses. These opinions probably reflect the fact that a substantial proportion of the physician’s practice involved well babies; thus, the researchers observed more physician interventions and explained these as physicians’ defensive actions to preserve their economic status, which was derived from “the continued exclusive performance of at least one set of functions which define the desired higher role” (p.11). The authors postulated the same behaviours would occur in departments of medicine with PAs, but only if the physicians were general practitioners, not if they were internists, whose elevated status allowed them to disperse less complex tasks, given their higher degree of specialization. Since the male PAs had higher patient loads from the start, obvious and unneccessary physician interventions were probably lessened, compared to those with nurses, who had only gradually built up their caseloads.
Although the researchers noted gender as contributory, they did not explicate the general research finding that male affiliation with females is not traditionally seem as providing status, nor did they refer to the equally sound research generalization that males feel that they have the right to use females as subordinates and therefore are more intrusive with them. Nevertheless, Record and Greenlick established that both gender and professional role challenge were evidenced in physicians’ attitudes and behaviours, which are critical to the extent and manner in which women professionals are used in new roles. Furthermore, there seemed to be a differential usage in specialities according to status threat. p237 – p238
Autonomy: Only under Physician Surveillance?
One of the earlist specialities to be researched involved pediatric nurse practitioners. In 1973 Edgar J. Schoem, Russell J. Erickson, George Barr, and Harvey Allen conducted a survey of 568, or 53 percent, of the members of the American Academy of Pediatrics. […] By 1973 the results essentially proved patient acceptance and established the professional and economic advantages of pediatric nurse practitioners to physicians’ practices under particular conditions. The results supported an explanation of changing gender expectations: those physicians most favorable to pediatric nurse practitioners were the youngest and in group practice; the least favourable were solo practitioners who were older than sixty. The majority of physicians thought a nurse-physician team would enrich both professions, the parental acceptance was likely, but that the pediatric nurse practitioner would not reduce costs.
Of critical importance was the extent to which physicians approved autonomy for the nurses; the majority favoured nurse practitioners, but only under constant pediatrician surveillance. Control would be exerted, for example, by allowing the patient to be seen for only part of the visit. This, of course, excluded the possibility that the nurse might be preferred by some patients or that she could build up her own independent practice. Similarly, the physicians approved the nurse’s care, under supervision, of minor illness; however, she would not replace the pediatrician even in well-child care. Since the pediatric nurse practitioner hoped for a more independent role, the researchers believed that some modification of attitudes would be necessary.
Schoen and his colleagues found several discrepancies. Of the respondents, 96 percent still believed that the nurses could not function successfully unless the physicians fully accepted them. As in previous research, pediatric nurse practitioners were percieved by 86 percent of the physicians as supplementing their own work, never as replacing it. In general, the physicians agreed that nurses could work where the physicians did not want to – rural areas for example, were only 3 percent of the respondents were located. The physycians agreed that nurse practitioners would be acceptable to parents, and 64 percent said that “many mothers would rather talk to a PNP . . . about certain problems” (p.65). However, 58 percent felt that given a choice, the mothers would rather see a pediatrician, even of the child was healthy. Illogicalities are obvious and fears of competition are inherent in these responses.
The physician did not believe expanded roles were a fad that would go away, but the vast majority did not ecpect that using nurse practitioners would reduce health-care costs. Strong support came from some physicians who had worked with pediatric nurse practitioners; but strong disagreement was expressed by many physicians who feared the nurses would be “second-class MDs” (p.66). Furthermore, many did not want to take on more sick patients as a result of nurses assuming responsibility for essentially healthy children. Schoen and his colleagues, still viewing the role as defined be delegated tasks, asked why, if there were generally positive attitudes, only 12 of 88 women educated as pediatric nurse practitioners since 1965 at one medical centre were, as of 1972, employed with physicians. Perhaps the delegated task expectations were different from the nurses’ ideas of independent and parallel professions, or maybe this difference was recognised but rejected by many physicians in the early 1970s. p239
Reluctance to Delegate Responsibility
By mid-decade, research on physicians and family nurse clinicians was reported by Edith Wright (1975), who, in preparation for starting a collegiate graduate program, assessed factors that would hinder or help nurses to assume the expanded role as primary caregivers in the community. Acknowledging the problem of subordination, Wright questioned whether family practice physicians would “allow” nurse clinicians to extend their work in other practice settings. Would they support or hire a family nurse clinician? Interestingly, no questions pertained to independent practice by nurses.
[…] As Wright stated, the physician’s opinions varied greatly on nurses’ responsibilities, but a large number were reluctant to give the nurses any new responsibility, and if they would “allow” any, it was not a great deal. Some physicians held definate and exteme opinions, called by Wright the all-or-nothing views: some would delegate a great deal of responsibility and others none at all. Great resistance was expressed to nurses conducting physical assessments and managing common illnesses. Suprisingly, Wright felt the results of the survey were encouraging, presumably because some areas of responsibility were allowed. Wright and her nursing collegues intended to go forward with their program, regardless of the physicians’ low response rate, their mixed approval of only limited fuctions for nurse clinicians, and the very hostile reactions by some respondents. p239-p240
A Waste of a Valuable Resource
Apparently, nurses have something to offer that goes beyond medicine or nursing, but combines both. However, given physicians’ attitudes, the utilization of nurse practitioners, even those constrained by medical models, remains a critical issue; as long as nurses do not develop their own private practices, male-controlled employment may force their dependence. In 1976 Eric L. Herzong, a research specialist in management, investigated the underutilization of nurses in ambulatory care, noting that almost a decade had passed since the early positive reports on increasing skills for nurses in physical assessment, interviewing, and the care of acute and chronic diseases, and on the effects of placing nurses in settings of demonstrated need. Herzog reviewed several empirical studies, finding that the delegation of functions, although endorsed in theory, was not practiced by physicians; the work of graduates of nurse practitioner programs had also not substantially changed. Herzog deplored the waste of valuable resources, claiming that research findings demonstrated that “pediatric nurse practitioners alone can provide care for about three-fourths of children seen in office” (p.26). Citing research conducted by Silver and Hecker (1970), Herzog noted that nurse practitioners managed 82 percent of 2,735 patient visits, consulting physicians by phone for only 11 percent of them. Such increases in productivity were achieved without loss of quality and with substantial patient approval.
Given these data, Herzog asked why nurse practitioners were so underutilized and concluded that a physician may not know how to delegate or blend skills since he has no training to do so. In earlier research, Herzog found the physician “almost always felt less efficacious in his work and less satisfied with his organisation when the nurse assumed more responsibility” (Hertzog, 1976, p.27). To put it bluntly, when a woman takes responsibility for more than menial tasks, the man feels a “lessening of control” (p. 27). Herzog also suggested that nurse practitioners may have different desires and expectations. Another cause for underutilization may be the “lack of adequate support and acceptance” (p. 27) from other nurses, who may not see the nurse practioner as a nurse, and from physicians, who certainly do not want her as a competetor. Hospitals did not provide even basic sources of support, such as examining rooms, for nurse practitioners; this simply reflected the overall lack of a suitable oragnizational structure for collaborative primary health care. Finally, Herzog found that the nurses were overtrained for prevailing legal or professional structures; organizations refused to pay them the salaries they deserved, and many insurance companies refused third-party payments.
To Herzog, the challenge in closing the gap between the potential and actual utilization of women health workers requires improving nurses’ self-image by training them to “deal with a social system, negotiate roles . . . build a team and manage change” (p. 27). p242 – p. 243