THE ‘CORE OF NURSING’: KNOWLEDGE AND SKILL

In 2005 when our book Complexities of care: Nursing reconsidered (Nelson and Gordon; published by Cornell University Press) was released we had some flutters of anxiety. Our book set its sights on a score of sacred cows. We questioned the conventional understanding of the mind–body split in nursing, arguing that nursing's interest in holism had paradoxically left out the body side (Gordon). We were critical of the wholesale acceptance of the novice to expert delineation of expertise (Nelson), arguing that the idealistic view of the expert (including expertise in the ethical domain) reduced the achievements and competencies of most (imperfect) nurses to inexpert. Tom Keighley argued that nursing's focus on prevention and health promotion has in effect led to a professional lack of interest in care of the acutely ill, and thus effectively abandoned nursing's core constituency, leaving the care of the sick to cheaper and less educated workers. Two chapters (Aranda and Brown; Heartfield) provided compelling data showing the role nurses played in the management of patient expectations during the implementation of new systems of care that were focused on cost-cutting and reducing services. Finally in a chapter we co-authored, we critiqued the dominant discourse of caring, which permeates every aspect of nursing, from undergraduate curricula to licensure, service accreditation, professional associations and research organizations. We argued that, by playing the virtue card instead of the knowledge card, the virtue script has prevented nursing from being seen as educated and knowledgeable work, and has helped nursing to make itself vulnerable to cuts and endless restructuring schemes. As the subtitle of our book indicates, it was our goal to stimulate a critical rethinking of nursing. This rethinking is necessary, we argued, to ensure a strong practice-based profession into the future. We were delighted that the book was very positively received. Reviews were complimentary, sales were good and prizes were awarded. Importantly we both received countless emails from nurses who had felt out of step with the rather self-congratulatory tone of much nursing discussion and welcomed critical perspectives and less reverence toward their profession. Students and advanced clinicians alike wrote to us expressing relief that their interest in science and in the body, and their joy at their competence in the technical aspects of practice were seen at last as worthy accomplishments, not dirty little secrets about which they were almost ashamed. Some wrote with amazement that they had never really thought about the dominance of primary health-care and health promotion perspectives as anything other than positive but could see now some unintended consequences and were grateful for the insight. But another strand to the responses is what has stimulated this piece. For some the book and its thesis which challenged the singular and totalizing discourse of caring have been an affront to the profession's core values. In emails and at Q&As following presentations, nurses have expressed distress at the idea that nursing doesn't necessarily have to be understood as a moral practice (no more than other professions such as teaching or medicine), or the idea that nursing does not have a monopoly on caring and that some of our colleagues are equally focused on the patient's bodily or even emotional needs. In fact nurses seemed shocked at the idea that holistic care is not solely the domain of nursing. The real distress of these nurses at engaging in debates around nursing as a moral practice and discussing the burdens of its history as gendered virtuous work has been striking. Many of those who worry about our exploration of the virtue script in nursing interpret this critique as an all-out assault on caring. They seem to believe that we are anti-caring, don't value caring or the psycho-social content of nurses’ work, and are throwing out the proverbial baby with the bathwater. We are struck by this interpretation because we have gone to great pains to consistently articulate our respect for this particular component of nursing work. Indeed, our critique of the virtue script is grounded in our conviction that the current caring discourse in nursing actually devalues nurses caring work. Rather than articulating caring as knowledge work, it often sentimentalizes caring, turning it into something that nice women do just because they are women or that some men do because they are not typical guys. We must constantly reiterate that we value caring precisely because it is knowledge based. As Suzanne, who is not a nurse and fancies herself to be quite a caring person, says, she would kill patients in a matter of minutes with her ‘caring’ because she is not a knowledgeable caregiver as nurses are. Pondering the responses to our critique we wonder why some people misinterpret its core message. As we argued in our book we recognize that one of the reasons the virtue script is so powerful stems from the fact that the story nursing produces of itself as moral work — which is played back endlessly through the media and popular opinion — is one of the few positive messages that frontline nurses receive. Nurses who practice in pressured and stressful environments, who feel unsupported by their managers and their employers, nurses engaged in advancing practice who experience the challenges of boundary conflict with colleagues in medicine or with other health providers, can at least rely on the fact that the public thinks nurses are nice and trustworthy. This expression of public esteem — published in countless polls about nursing as a trustworthy profession — has been something of a lifeline for nurses. Many nurses are deprived of the kinds of rewards other professionals receive and therefore take justifiable pride in difference skilled and caring nurses make to the lives of those in their care. But there is a downside to this warm-hearted version of the nurse that some nurses find so critical to their professional identity: it downplays the knowledge and skill that nurses bring to the healthcare system. When the general public does not know what nurses do, does not understand what an educated and experienced nurse brings to patient care (let's be blunt: nurses keep patients safe in one of the most risky environments they are ever likely to encounter — the healthcare system!), then the public will not protest against the relentless cuts to nursing jobs that actually endanger healthcare, even in the best of economic times. If being liked by the public did not stop job losses in good times how will it protect nursing jobs in bad times? With the economic situation the world is facing in 2009 nursing is once more a soft target as budgets contract. It has never been more important for nurses to communicate a pragmatic message concerning the proposition that well-educated and experienced nurses bring great value to — and save money in providing — patient care. When governments, hospitals or health systems are trying to save money and protect quality health-care, nursing should be expanded not cut. Nurses need to be able to make that case clearly and unsentimentally. This is not to say that nurses should not be caring in their practice, but it is to say that the importance of adequate staffing of nurses with appropriate education and experience should be funded not because nurses are nice but because the skilled caring they provide saves lives and money. The argument should be about not the character of the nurse (good, kind or otherwise) but his or her educated practice (competent, knowledgeable, empathetic). It concerns us that some nurses view this message as controversial or somehow denying the ‘core’ of nursing. What is the ‘core of nursing’ that the public needs to appreciate? We think the public needs to know the depth of the scientific and medical knowledge nurses need to practice safely. The public needs to appreciate the highly developed interpersonal communication skills (that do not come naturally but come as a result of discipline and self-mastery) that dealing with people at critical and challenging life moments demands. The public needs to understand the extraordinary logistical and management skills that are needed to perform nursing work and to co-ordinate and organize the work of others. The public needs to know that nurses are consummate multi-taskers — they need to deal with people in the most challenging of circumstances, to make clinical decisions on the basis of complex data, and need to understand the phenomenal complexity of the systems in which they practice to ensure that those in their care are safely managed. This is what we think nurses should be better at talking about. This is what the old tropes about angels and hearts conceal. This is a really good story and it's one nurses have only just begun to tell.

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