This story starts with two old friends in a blizzard in North Carolina, January 2018. Barbara Stilwell is based there, working for the United States (US) non-governmental organisation IntraHealth, and Jane Salvage has just landed from the UK via a week’s work in Belize, narrowly missing a tsunami.
Nursing Standard. 35, 10, 69-72. doi: 10.7748/ns.35.10.69.s36
Published: 30 September 2020
We have a packed schedule to help launch the Nursing Now campaign in the US. Jane had been instrumental in producing Triple Impact – the influential report on which the campaign was founded (All Party-Parliamentary Group on Global Health 2016). Though not known to us, Barbara is soon to return to the UK to become Nursing Now’s global executive director.
A snowstorm marooned us in Barbara’s lovely home, scuppering many of our seminars, lectures and media appearances. Instead, inspired by our talks about the politics of global nursing and the Me Too! movement, and invigorated by our long walks in winter wonderland, we wrote an article, Breaking the silence, which was published as an editorial in the Journal of Clinical Nursing (Salvage and Stilwell 2018). The feminist clarion calls and impending campaign launch seemed to herald the possibility of real change.
This joint editorial highlighted the urgent need for a paradigm shift in the ways that nurses think about and present themselves, and the way others think about and treat nurses.
We called for nursing and nurses to be taken seriously, at a time when old certainties and ways were being shaken to the core by economic crisis, climate change, insecurity, a deep desire for stronger social solidarity, and the rising clamour of women’s voices.
The urgency of this call has heightened in the COVID-19 pandemic, in this International Year of the Nurse and the Midwife. The editorial, which struck a chord worldwide, was a distillation of a shared philosophy developed over many years of work and friendship.
Salvage J, Stillwell B (2018) Breaking the silence: a new story of nursing. Journal of Clinical Nursing. 27, 7-8, 1301-1313. doi: 10.1111/jocn.14306
Writing from a global health perspective, our 2018 editorial drew on shared values, goals and work driven by professional, political and policy activism throughout our long nursing careers. We called for a paradigm shift in the ways that nurses think about and present themselves, and the way others think about and treat nurses. It was time, we said, to move on from the old story of nursing and build new nursing narratives. Time that nursing and nurses were taken seriously.
The COVID-19 pandemic has heightened the urgency of our call: old certainties and ways are being shaken to the core by its amplification of existing challenges on top of new ones. Climate change is triggering natural disasters and different health issues; the disease burden is rising while health systems buckle under the strain; and black and minority ethnic groups, women, and many others are demanding fundamental social change. Corporate capitalism and its political allies provide no answers, while economic crisis and financial, social and physical insecurities deepen the desire for social solidarity.
Our editorial was grounded in work we have developed over decades as colleagues and friends in our unusual careers. From the start we were both considered radical. Jane was known for her activism, starting as a nursing student with a controversial column in Nursing Mirror, co-founding the Radical Nurses Group, publishing (and talking about) The Politics of Nursing (Salvage 1985) and writing award-winning columns as editor of Nursing Times. Barbara introduced the nurse practitioner role to the UK, researched and championed advanced nursing practice, and undertook pioneering work on health workforce issues, especially in Africa. King’s Fund seminars on nurse practitioners in primary health care brought us together with other present and future Royal College of Nursing (RCN) Fellows – Tony Butterworth, Trevor Clay, Ainna Fawcett-Henesy, Jane Robinson and Muriel Skeet (Salvage 1991).
Since then we have been fellow travellers on many other programmes for governments and influential organisations, including IntraHealth, Nursing Now and of course the RCN – publications, projects and committees – in addition to writing, research and teaching. We worked together for the World Health Organization (WHO) in Europe and at headquarters, where we called out sexual harassment by our department director and fought a long battle for justice.
We look back on wonderful shared experiences as well as the tough ones, but we do not hanker for the ‘good old days’. In our vision, the nursing profession of the future will be respected for its science as well as its art. It will reflect the diversity of the communities it serves, and enjoy safe working conditions, good pay, positive practice environments, strong leadership, and many funded opportunities for continuing professional development.
We ask each other why so many of the changes long called for by nurses worldwide have been so slow to materialise. Although we are proud that we have helped to introduce positive changes in nursing in the UK and worldwide, with support and stimulation from countless nursing colleagues over the decades, our shelves groan with unheeded reports, unheard calls to action and unimplemented recommendations. The changes have not been far enough or fast enough, and we face old and new challenges when choosing priorities in these difficult and uncertain times. Helping nursing worldwide to move forward in this International Year of the Nurse and the Midwife, will the future be different? Are we, authors and RCN Fellows, stuck in the Nurses’ House, speaking only to those who already agree with us, rather than influencing those who do not (Robinson 1991)?
Back in the 1960s, nursing was thought of as a female ‘soft skill’. Sociologists considered it a ‘semi-profession’ rather than a profession because nurses relied on medical doctors to dictate the scope of their practice, supervise it and teach aspects of it (Etzioni 1969, Abbott and Meerabeau 1998). While medics needed five to seven years to qualify with an academic degree and a licence to practise, most nurses qualified and registered with just a two- or three-year diploma. Nurses were considered practical rather than intellectual – ministering angels bathing, feeding, and comforting people. Nursing was not, and was not seen as, based on a body of research-based knowledge that demanded scientific rigour. This British picture also rang true worldwide, particularly where Anglo-Saxon colonial and religious influences remained strong.
Importantly for us, it was the dominant view when we were nursing students in the 1970s. We all have our tales: Barbara had to hide in a cupboard in one hospital as the consultant did not know there were students on the wards, while Jane was verbally abused by a consultant who arrived late for his round and everyone else was at lunch. Those daily battles to be respected and heard turned us into radical nurses.
We stood on the shoulders of giants, and shoulder to shoulder with many others who were trying to transform the nursing profession into an evidence-based science and art, with a strong moral compass that defined its own scope of practice and saw nursing as a force for health co-creation. Looking back, we see how far we have travelled, and how the power of many raised voices, including our own, got us to this point – but it is not our final destination.
The International Year of the Nurse and the Midwife was marked by the publication of the first ever State of the World’s Nursing report (WHO 2020). It only took WHO 72 years to get round to it! While the report is in many ways a missed opportunity, telling us what we already know and sidestepping many important issues, we can use it to make our case yet again for investment in nursing. We can also use it as a mirror of how our profession is seen by others.
Stating that nine out of ten nurses globally are female, it reminds us how nursing is viewed by professionals, policy-makers and public, though it fails to explore why nursing is a gendered occupation and what impact this has. Jane discussed this familiar story in The Politics of Nursing, while sociologist Celia Davies’ brilliant analysis remains highly relevant (Davies 1995).
Nursing Now recently contributed to a global survey of 2,500 nurses to explore the effects of being a woman on attaining leadership roles in nursing and health care (Newman et al 2019). As most respondents indicated, the belief that men and women have specific roles in society and health care is an important barrier to women obtaining leadership positions or functioning effectively in them. The perception of nursing as a ‘nurturing’ and ‘feminine’ profession (often seen as synonymous) was a consistent finding among both male and female nurses, and across the world. Regardless of gender or region, 77% of respondents said that stereotyped images of doctors as dominant, and nurses as subservient, helped to explain why female nurses struggle to advance to leadership positions. Female nurses are more likely to be expected to be subservient to doctors than male nurses, and disproportionally face discrimination and sexual harassment at work, which increases poor health, stress and attrition rates.
Changes in perceptions of nursing have clearly not gone far enough. People have great trust in nurses, and in this pandemic year call us ‘heroes’, but also hold a rather paradoxical view that nursing remains more suited to women than men. Even now the media perpetuate this view: just watch the American television series Grey’s Anatomy where, in its 16th series since 2005, nurses literally have no voices – they are not heard at all. One fascinating analysis of nurses and the media through the ages shows that little has changed (Hallam 2000).
Globally there are 144 distinct titles for a licensed nurse, says WHO (2020) – findings that should ring alarm bells. Is this true of any other profession? It is difficult to find a profession that reinvents itself quite as much as nursing, with the result that people do not really know what they are getting when they get a ‘nurse’. Nursing has proved to be flexible and adaptive as other professions change, as population needs change and as technology makes different models of practice possible and necessary. And yet changes tend to happen in an ad hoc way – and while all change is usually unstructured, for nursing it can mean that practice development has little long-term impact on health systems or workforce design, and lacks formal recognition in scope of practice legislation linked to specific titles.
This matters, and it is not just a nursing issue. We need to bring the attention of stakeholders outside nursing to what we do and what we need to know to do it – a Triple Impact recommendation and a key aim of Nursing Now. It is the person-centred art of nursing that enables the successful application of science, a proposition that has underpinned more research into the practice of nursing than of any other health profession. Little has changed despite the wealth of good research underlining the safety and efficacy of nursing in many settings. At this COVID19-induced watershed for nursing, we need to tell our story to the wider world in a way that moves society beyond the superhero image to that of a respected, smart professional who should be seen, heard and heeded.
This is what impels us to tell a new story of health and healthcare through the Nursing Now campaign. Nurses, as leading actors in this new story, will be at the heart of sustainable health systems that meet individual and population needs, are fit for the present, and innovative and adaptable for the future. As Triple Impact noted, the sustainable development goals (SDGs) will not be achieved without nurses. Nursing is threaded through all the interconnected SDGs because nurses influence and accompany every step of every care pathway in and outside healthcare settings, from before conception to after death. At their best, they focus on where the needs are greatest and where there is most potential to gain health and reduce inequalities. They take their understanding and experience as hands-on practitioners into all subsequent roles as clinicians, managers, teachers, researchers, scholars, policy-makers and leaders.
In a future-focused vision, nurse leaders are experienced, educated, confident and effective champions of quality with a powerful voice at all levels of health and policy systems, recognised and valued by the public, service users, colleagues and policy-makers. They are in post in the right places and right roles and receive the support and resources they need to help nurses deliver their potential. They ensure the distinctive nursing perspective is included in policy-making and decision-making.
Achieving this vision requires champions to provide support and funding on a scale commensurate with these huge challenges. Long-term and widespread capacity-building programmes are needed to maintain impact beyond the Year of the Nurse and the Midwife 2020. Investing in nursing in this way will provide great returns. Now is the moment to find our individual and collective voices: not just #MeToo but also #NursesToo, and Nursing Now.
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