Facing history for the future of nursing

In a recent editorial Jenny Carryer (Carryer, 2019) argued that for nurses to more forcefully lead new approaches to health care, the profession needed to move beyond the discourses that are currently seen to be dividing the profession. Some of these discourses, Carryer pointed out, are based on historical assumptions about nursing from outside the profession, but also from within, and are inherently limiting. There is no denying that the perception of nursing as women's work has caused it to be devalued monetarily and that perceptions of nurses as trained handmaidens to doctors continue to impact nurse-physician relationships. It would be nice if this was no longer the case, and in some instances it is not. What Carryer is articulating in her paper, however, are larger structural and historical forces that are often beyond nursing's control. For nurses to be truly taken seriously and treated as equals at the policy table, we would require a system and generation wide overturning of both patriarchy and misogyny, and we seem to be further away from this than ever.

For nursing to be able to transcend its history it must first more fully engage with that history, and in a much more complex analytical way than it currently does. Some of the conflicts between types of nursing ideas that Carryer articulates are the result of a lack of historical content within nurse education, but they also indicate limitations with the scholarship of the history of nursing itself.

To the first point, the rate at which the history of nursing is being eradicated from nurse education across the world is head spinning and telling. In its attempt to be taken seriously, nursing has in fact adopted a biomedical model of health and illness, and privileges this type of content in its undergraduate and graduate education, and especially in research. The “science” of nursing is seen as key—in the United States for instance NIH funding is the benchmark by which academic careers are made or die. Education is largely competency based, focused on passing licensing exams, and those competencies themselves are set by employers and health systems for which the disease model is central. There is little place for the humanities or liberal arts in this education, and when it is invoked it is almost always utilitarian: seen as useful for promoting “critical thinking”, or to teach compassion, or for professional identity where feminism or science is inserted back into nursing's history through the mythology of Florence Nightingale, who was neither a feminist nor a scientist. Nursing history is about more than the lady with the lamp, however. There is a significant body of scholarship produced by nurses who did their PhDs in history or related fields, and win multiple awards for the books they write (D'Antonio, 2010; Fairman, 2008; Lewenson, 2014; Rafferty, 1996). The idea that the history of nursing is a potential field of scholarly enquiry remains unknown to many and increasingly difficult to pursue where it is. The eradication of history from nurse education means that there is little understanding of how and why the profession has evolved the way it has, what ideas have already been tried and tested, what problems still remain, and beyond this, the reasons why health systems have developed as they have. Without an understanding of this history, real change is not possible.

We are at a point in the evolution of Western society where history as an academic discipline is constantly under attack not because it is irrelevant but because it is so potentially powerful. History does more than tell us what we have done well in the past. It also tells us where we have failed, where we should have done better. In this vein, some nursing history provides a counter narrative to the discourse that nurses have been victims in history. Much excellent work has been done by nurse historians who seek to complicate that stereotype and to show the ways in which nurses actively developed their profession alongside physicians and hospitals, and were always already at the leadership table (Fairman & D'Antonio, 2013; Nelson & Gordon, 2006). At the very least, we need nursing students to engage with this work as counter to the misogyny and patriarchy which will inevitably weigh them down. But this is not enough. To continue the myth of nursing as oppressed is to facilitate the idea that nurses are somehow victims, and it obfuscates the very real power that nurses had and do have, over communities, families and individuals. When nurse historians write about the leadership of nurses in the past, they are telling us that nurses have never been OUTSIDE the system, but that in fact, nurses have always made it what it was. If we take this line of thinking to its logical conclusion, this means that nurses were in fact an integral part of the inequality, racism and profit motivations that are embedded in contemporary health systems.

This is not a pleasant fact to face. Nurses (of course I am generalising) shield themselves from this truth through the rhetoric of caring, and the belief that they come to nursing to help people. This is one discourse that needs a much deeper analysis, and many nurse philosophers have been expressly critical here already (Holmes & Gastaldo, 2002). But this is not enough. As we have argued elsewhere, (Foth, Lange, & Smith, 2018) critical nursing philosophies also need to take a deeper dive into the context of nursing's history and pay attention to the foundational ideas that underpin health systems in the West. Modern health systems and the biomedical model are an effect and function of white supremacy, colonialism, and neoliberalism and nursing is not separate from this. To understand how this has come to be, we need more history not less.

Beyond the confines of nursing history that tells the story of how nurses have been innovators and leaders is a much more complex story about the role of health and medicine as disciplining technologies. The idea that the human body could be used and managed for the purposes of capital (or power in many forms), that concerns about health and wellness are related to industrial productivity not necessarily to human flourishing are ideas well understood by critical theorists (Perron, Fluet, & Holmes, 2004). Concepts like biopolitics and governmentality should become everyday words in the nursing lexicon, because without them nursing lacks the ability to name the actual root causes of what gets called “social determinants” and nursing history itself can only tell nice stories about good women who meant well. Examples from Nazi Germany are used as extremes of unethical bad behaviour, which are now supposedly in the past, but if we are serious about learning from this history, we would honestly interrogate the way that modern health discourses, especially around race, disability and mental health, still actively consider some lives as not worth living. How else are we to understand mass incarceration and the active underfunding of mental health services?

Particularly, well hidden in nursing discourses and in nursing history is the extent to which white supremacy as either settler colonialism or scientific racism is embedded in medical and health discourses. Again, nurse philosophers, and some historians of health and medicine, have written extensively about the way that western health and medical discourses were an integral part of both domestic and international colonising efforts (Anderson, 2002; Bashford, 2004; Connerton, 2013; Holmes, Roy, & Perron, 2008; Racine & Perron, 2012). Recent work has sought particularly to unpack the long history of scientific racism particularly in the United States and its impact on approaches to health care (Roberts, 1997; Wailoo, 2014). While it can be readily acknowledged that segregated health systems were abhorrent, it is proving more difficult to convince nurses that these systems and ideas are still in place. The reliance on the supposed objectivity of science creates a “post-racial” world and fosters a belief that current disparities are caused by individual behaviour (either of the patient or the practitioner). Social determinants are too often seen as a matter of individual choice, lifestyle or postcode, rather than recognising the way that disparities are built into the system through both ideas and practices. The tragedy is not, for example that American physician and slave apologist Samuel Cartwright in the 1850s thought that the black body was inferior, had lesser lung capacity, was impervious to pain and was prone to hysteria. The tragedy is that these ideas are continually acted out in health systems today through biased attitudes about pain tolerance and “drug seeking behaviour,” and in atrocious maternal outcomes for Black women in particular. In the United States, the continued use of cultural competency as a teaching method and the fascination with genetics and omics leads to an obfuscation of structural racism as a predictor of health outcomes and forces a focus on “race” (as an unproblematised biological category) as a risk factor. These are just some examples of the way that nursing continues to embrace and uphold the language of white supremacy in health care. Complex analytical approaches that draw on philosophy and history work to expose more fully the way that nursing is embedded in systems of inequality and it gives nurses the language by which to name and counter these forces.

If nursing is serious about leadership into the future, especially in relation to social determinants of health, it must be ready to name and own its own role in the creation and perpetuation of disparities. Nursing must also look to theorists who are already seeking to expand the concept of “social determinants,” which often focuses too narrowly on individual behaviour, and begin to include the language of structures (Metzl & Hansen, 2014; Metzl & Roberts, 2014). We cannot fully understand the social determinants of health if we do not fully understand the way they are an effect of history. This means that seeking to lead current health systems must also embrace the project of dismantling the policies that continue to exclude some people from health, that value some bodies more than others, and that create judgmental attitudes and substandard and unethical care.

Nursing does need to move on from some of these past practices; but more than simply “letting go” of the past is needed. It is not possible to move on from what has not been faced. The only way out is through.