Who cares for the nurses? (1982)

From the December 1982 issue of the Socialist Standard

It is important that nurses, in contemplating strike action, are rejecting their image as self-sacrificing and dedicated professionals. By acting in a militant and self-interested way they are questioning an oppressive ideology long associated with this form of employment.

There are all sorts of moral values attached to nursing. You just have to look at the words which the public, the unions, the media and nurses and patients themselves, use about the job. Nurses are expected to have a sense of “vocation", to function in a dedicated, committed and devoted way. These characteristics are to some extent hang-overs from the historical association with certain religious orders which have traditionally cared for the sick and needy; the terminology in nursing with "sisters" and “matrons” (mothers) — confirms this. But if you think about what these words really mean, then you have the problem in a nutshell. A nurse's sense of vocation is supposed to suggest a “calling”, in a literal sense by a god or some other external power. To be “committed” and “dedicated" to that sense of vocation means to “give oneself over” to it, to lose a sense of self in pursuit of an activity or purpose outside of oneself. In other words, to be self-sacrificing rather than —self interested.

Why is it that nurses are questioning the notion that they should be selflessly committed, and are beginning to act in a self-interested, class-interested way? The most clear cut reason arises directly out of their actual day to day experiences at work: contradictions between what they expect and what happens.

What are nurses' expectations? Most people who enter training do so out of a genuine desire to help people. The sick need to be looked after. Most reasons given by nurses for their choice of job are associated with helping people and the social usefulness of the work (Maguire: The Role of the Nurse, RCN Research Project, 1966). Yet in practice nurses are frustrated at every turn by their inability to do precisely that. There is a stark contradiction between the real desire to care for and give to other people and the economic realities of working in any capitalist health organisation. The NHS is a low class service oriented basically towards servicing the sick and making them socially and economically useful once again (in much the same way that the parts of a vehicle need to be serviced every so often); it exists to patch up workers and send them home — and back to work — as quickly as possible.

The allocation of finance and skills within the NHS is on the basis of cost-effectiveness. Well-equipped geriatric care units are of a much lower priority than surgical units. The economic return on removing an infected appendix from an otherwise fit young male is higher in this society than is the allocation of resources to the terminally ill. The young male will be fit for the labour market after his treatment. whereas the old person is no longer economically useful to capitalism: literally, he or she can be considered fit for nothing.

This “needs allocation” decision-making process is actually mirrored in the nurse's daily routine. Given an environment constantly lacking adequate resources (of people and equipment), simply because these are not allocated on the basis of human need, the nurse must decide which needs can be satisfied. And there is very little choice in what is a priority. The needs of those who are likely to go on living take precedence over the needs of those who are almost certain to die. A nurse will cause trouble on a short-staffed ward by insisting on sitting with and comforting an old person who is dying, rather than giving out drugs, helping to feed or wash patients, or anything else which in a simplistic way will — like a certain orange, fizzy glucose drink — “aid recovery”. The nurse, like the administrators, makes decisions according to social and economic norms associated with the rationale on which the NHS is based — on what is most "profitable". It is profitable to service fit young people; it is not profitable to spend time or money on the dying.

Perhaps the most explicit contradiction which the nurse experiences is that between the theory of nursing practice and the practice itself. This must create unpleasant tensions. The main contradiction is between more or less intelligent and scientific approaches to caring for sick people, which are learned during training, and the fact that these cannot be put into practice. For example, the nurse is taught to have a view of the patient as a “whole person”; to “empathise”, and respond to perceived physical and psychological needs. If in practice the nurse can only act as an automaton, a dose of Lucozade, and respond only to selected physical needs, a tension is felt. It is a commonly held view among nurses that what they are taught is irrelevant to how they must perform as practitioners. It is naively idealistic to believe that nurses can care for the “whole person”, or meet such varied needs, in a working environment where those needs must be systematically ignored. Rather than begin to believe that the training is impracticable or faulty, nurses have to resolve the tension by realising that it is the economic structure of society, and the consequent nature of the health service itself, which creates the problems. Neither a genuine desire to help people nor to care for them in the most effective way possible, can be satisfied in a health care system organised to “cure” the largest number for the lowest cost. In such a system the weakest go to the wall. When a nurse has to decide who to neglect, day in and day out, the idea of being able to “empathise” becomes a sick joke. The tensions are endless.

Another singular aspect of nursing as employment is the rigidity of its hierarchy. To experience the authority structure in a hospital is to learn to tread carefully — an unpleasant mixture of walking a tightrope and a cat on hot bricks. Not only is there the medical contingent “above” the nurse, but there is also the army of ancillary workers to whom the nurse is “superior”. On one level the experience of the different status of co-workers seems bewildering and intimidating; on a more complex level it engenders another contradiction.

Nursing is an unusually “co-operative” activity. Anyone who has been in hospital may have witnessed the enthusiasm created by a group of nurses trying to do their work, often under pressure, in the most effective way possible: they have a common and human aim to do as much as they can for their patients, and often it is up to them to organise this as best they can. One quality of a “good” nurse is “team spirit”, an ability to co-operate and co-ordinate effectively with others. This is only one side of it however. This cooperative situation only exists when nurses actually perceive that they have an aim in common — a goal to work towards together. As soon as nurses enter into a game of one-upmanship this is no longer the case: and unfortunately, one-upmanship is often the game to be played.

Trainee nurses are in competition with one another, as well as having the cooperative aim of getting the work done. Each one will be graded by the nurse in charge of the ward, and each one will attempt to be evaluated more highly than fellow workers. Similarly for qualified staff: they constantly seek promotion to higher grades, and must therefore win the approval of the hierarchy. This competitive behaviour conflicts with the cooperative endeavour. On a practical level this means that the nurse you were working with in a fulfilling, friendly, useful way five minutes ago, has suddenly gone sneaking off into the office to report something to the sister which you just noticed — so scoring your point.

Why is it that the types of working relationships created in nursing have to turn peoples’ illnesses and lives into a matter of scoring points? This is a question which most nurses must sense. Mow they answer it is of vital concern. They have to see the tension between the competitive and cooperative nature of their work as a product of the entire power structure within their profession. They are induced to compete because a hierarchical structure requires competition for positions of status. And more than this, it is vital also to recognise it as a mirror of the way in which workers compete with one another, to score a few points in the status stakes, rather than cooperating in their interests as a class.

There is another important factor which encourages nurses to question traditional expectations and, alongside, the values and ethics of a society which creates their oppressive and perverted role. In hospitals there is a clear-cut sexual division of labour according to status. Ninety per cent of nurses are female; 80 per cent of doctors are male. As one ascends the nursing hierarchy, the proportion of males increases, while in the medical profession women are decreasingly represented in the higher ranks. The difference in the representation of men and women in medical and paramedical jobs occurs largely in terms of gender expectations.

Doyal and Pennell, in their book The Political Economy of Health, give an historical analysis of the development of this situation. They quote Eckstein:

. . . the Nightingale nurse was simply the ideal Lady, transplanted from home to the hospital . . . to the doctor, she brought the wifely virtue of absolute obedience. To the patient she brought the selfless devotion of a mother. To the lower level hospital employees, she brought the firm but kindly discipline of a household manager accustomed to dealing with servants. . .

In their own analysis, they go on to say:

A basic division was therefore created between what were regarded as the hard-headed, diagnostic attitudes of medicine, the "curing" that male doctors did, and the “caring" which was to be done by women. . . 

In other words, to be a nurse is to be the stereotypical woman: selfless, devoted, committed and unassertive. In fact this is becoming less and less the case. Changing social attitudes to masculinity and femininity have enabled nurses to he more critical of tradition — and this has encouraged their greater militancy in the traditionally male arena of trade union action. To be involved in action for better pay and conditions means leaving selflessness and unassertiveness behind: means abandoning, to some extent, passive femininity and recognising a class interest. This is a vital step in the development of women's consciousness. Unless women reject traditional femininity, they will not develop a critical attitude toward society. Nursing creates many contradictions, which can be resolved in a class conscious way.

But we start with indignation. Nurses are rightly indignant about their position. They are sick of working for a pittance. Anyone can see that for a nurse, trying to get everything done is like trying to bail out a leaking boat with a sieve. It is time for nurses to express this real indignation — and not just about being paid “too little". It is time to get up and say “Look, I'm sick of being put upon, of being paid a pittance to watch people suffer needlessly. There comes a time when I just have to express my own needs — there’s just too many demands being made on me. I am being exploited in every sense of the word — as a worker selling myself for a salary as well as a person wanting to help other people".

Within capitalism, genuine caring cannot flourish. For nurses and other workers, self and mutual interest only begin with fighting for better pay; beyond this is a necessary political struggle to create a society in which the desire to be co-operative and caring people can be realised.

Chira Lovat

SPGB Meetings (1983)

Party News from the January 1983 issue of the Socialist Standard

A recording of Eddie Grant's meeting 'Are world unity and cultural diversity compatible?' - from the SPGB's Socialism as a Practical Alternative Weekend School - is available at the following link.

What Marx Really Meant (1983)

Party News from the March 1983 issue of the Socialist Standard

Power in society (1983)

From the February 1983 issue of the Socialist Standard

The concept of power is a confused one. Whether we're thinking about political and social institutions, or individual relationships, power means to have some dominance or control. Capitalism, a system based on production for profit, works in the interests of a minority — those who own and control the means of life. Workers vote into parliamentary power, political parties pledged to the continuation of capitalism — parties which operate against their interests. As long as the workers allow this situation to persist, a conflict will exist between “us and them”, the majority and the minority, the producers and those who own, the powerless and the powerful. To resolve this conflict we have to understand what power really means and what it could mean. We have to challenge the whole ideology of present social arrangements.

There are two essentially different uses of the word power. The first is the typical way in which we experience power in capitalism; the power which other people exert over us. Because workers believe that the present system is the only way of organising society — that it has always existed and must therefore continue to exist — they go on allowing others to control our lives. Small wonder. From childhood to old age, we see and fit into the social arrangements of the society we are born into. We experience the authority structure of capitalism, at first through the family, with its extended period of “childhood" and legal powerlessness. Later through schooling, through churches, through employment, the newspapers, television and so on, we come to accept the view that some people are “better" than others, that we need "leaders", that hierarchies are inevitable and that left to our own devices, the workers would create chaos.

This indoctrination imbues us with a belief in our own weakness, in our inability to decide for ourselves. We learn to aspire only to a “normal” lifestyle and a mentality fragmented by the crippling contradictions between what we feel ourselves to be and how capitalism compels us to behave. As we grow up in this society, our hopes and expectations are progressively impoverished. Children, for example, are constantly learning, constantly active in response to the world they find around them. Contrast this with what we all learn in school. Education exists to train us for our function in the larger world, beyond the school and family, for an adulthood where our behaviour fits the requirements of capitalism.

In classrooms children learn to sit still, to “do as they’re told — or else” (and the punishment system of the school mirrors in miniature the punishment system of the wider society, with its “detention” and centres for the “maladjusted”). Ultimately, children learn that if what they want to do conflicts with how the teacher — the person with power over them — expects them to behave, they cannot beat the system. There are only two choices: either to respect and conform to the superiority of those who control them, or to channel their nonconformity and disrespect into a negative form — rebellion and disruption. Whatever else children learn at school, they are forced into the habits of passivity and powerlessness, to external regulation and imposed definitions of their capacities and aptitudes. They learn to be one of the crowd or risk the cruelly isolating behaviour of other children. From schooling and elsewhere we are all then coerced into an evaluative, limited and impoverished sense or view of ourselves and our needs. The opportunity does not exist for young people to continue the way they started out, with a “natural" and integrated active approach to their environment.

Capitalism creates disintegrated individuals and a disintegrated society; one which lives out of harmony with its people's material needs. In this society constraints are invariably imposed on us — we are governed, not self-governing. Is it surprising then that power has become a word with wholly negative connotations? In capitalism, power means oppression.

In sharp contrast is the original derivation of the word — the French verb “pouvoir” meaning “to be able". So power means also an "inherent quality in something" — whatever that something can do. It means an active property — a physical strength, energy itself residing in the material nature of an organ or mechanism. In this sense power is simply the ability to “affect” — the power of a herb or a drug to affect a body, the power of the press to affect opinions, the power of a film to affect our emotions, or the power of an argument to affect our ideas.

If we look at power and society in this context, we can see how that society functions. Physically we need certain things to sustain life — we need food, warmth, shelter, we need to reproduce ourselves and we need to achieve some sort of integration with other parts of the natural world. People are part of the natural world; it is therefore inseparable from our existence that we should be active; our activities are the means by which we express our abilities, our capacities, our human powers. It is these powers and activities which create wealth. Workers produce the food, the energy, the building materials; we operate the transport networks that distribute them.

In other words it is our labour which sustains life on this planet. It is in us. the people who work and produce useful wealth, that the power in society actually resides. Paradoxically, the workers who produce all that is useful at present don’t engage in this activity for themselves: the owners live parasitically on our backs, we are giving them sustenance by our labour and the quality of that sustenance is far higher than we'll get in this system. “Human power” — the human ability to be active and to be effective — could be used by us, the majority of people who are producing wealth anyway, in our own interests. It is precisely this consciousness of our own nature and our own class interest and our own needs which capitalism attempts to drum out of us. The dominant ideas of any age are those produced by and in support of the status quo — the interest of the controlling powerful class. The development of an education system with the characteristics already outlined, is necessary to train us to accept a social system which is at odds with our perceptions of our own natures. We have to be taught to submit to control from beyond ourselves — it is necessary that we go on believing in our inabilities and weaknesses.

There is another contradiction in the belief that we who produce wealth cannot do it for ourselves. This theory has it that we’d be driven by insatiable urges to kill and maim and rob: that we’d create chaos in the world. There is an irrational belief that we need money and markets, prisons and property, to prevent this happening. The agonising irony of this belief lies in the fact that it is capitalism itself which creates such behaviour. Wars fought in the interests of the capitalist class cause workers to murder each other. Theft is a concept valid only through the existence of private property. As for chaos: what could be more chaotic and irrational than an economic system where people starve to death while glib politicians speak of “overproduction" and pay farmers not to produce food? It is impossible to imagine how a world community, conscious of its needs and producing directly in response to them, could fail to function better than that. Still, it seems their propaganda has usurped our rationality — we go on denying the evidence of our senses.

Under capitalism virtually our only experience of the use of our abilities is in the sense that our capacities are regulated by others. We have no experience of how to use our abilities and powers for ourselves in our working lives. This has repercussions in personal relationships, simply because we are alienated from our abilities: we sell them weekly-and monthly, they don’t seem to be ours. Much is talked about power in relationships — about gratuitous acts of cruelty and violence, about sadism and masochism. Most of this behaviour can be traced back to our attitudes towards two particular forms of learnt behaviour: dominance and submission.

Why is such behaviour typical under capitalism? The fundamental cause lies in the opposed class interests, which requires that one class dominates and the other submits. Associated with this are the values we have had bred into us: our belief in the need for leaders and authority, our acceptance of the evaluative definition of ourselves by others (so that status can be awarded accordingly), and the attitude we have acquired of constantly assessing ourselves in comparison with fellow workers to decide who is “better” and who “worse”. Attitudes like these ensure that domination and submission continue: they ensure we use our “powers” against ourselves. We do not recognise that our interests as a class coincide. We spend our energies fighting among ourselves, men against women, blacks against whites, salaried against waged employees, young against old. The competition for artificially scarce resources encourages this class divided, mutually hostile attitude.

Because of all this our daily existence is made up of frustrating experiences, of contradictions and tensions in our working and personal lives. A sense of frustration usually has one of two effects, both destructive: it may be expressed outwards in angry and aggressive exhibitions, or inwards, causing stress illness, withdrawal and depression. The only positive way of resolving this frustration is to recognise it for what it is. Frustration is a sense of powerlessness, an inability to express what we feel to be our energies and powers. Frustration is synonymous with a feeling of “lack".

Under capitalism we are controlled externally, we are not in control of our own lives, and we lack a material existence in line with our needs. This situation will only change once we become conscious, as a class, of our power. Our weakness is a myth. Human beings are active and thoughtful; already the working class runs society from top to bottom. What we urgently need to do is create a society in which these abilities can be used productively. Socialist democracy means that we express our own sense of what we need, that we control our lives directly, develop our powers and use them for ourselves. Socialists rehabilitate the idea of “power”, to act on that frustration to end it.

Chira Lovat