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Nursing and its Discontents, by Meave Noonan

The rationalisation of caring and intensification of control

The businessman in suit and tie strides with a confidence most of us will never feel, and yet, he is you, and he is me. The constriction of his throat and the clamminess at his shirtsleeves are both lonely and familiar. He struggles daily against a tide of anxiety of which we dare not speak.

Every day we step into a cage wrought from our hopes and dreams, and our deepest despair—a cage all the more inescapable, perhaps, because it is one we can’t help but believe is of our own making.

When I became a nurse, I became a member of a largely feminine workforce and of a highly respected ‘profession’. I became a proud member of Australia’s biggest union. I became an advocate for the sick and incapacitated people in my care. But when I became a nurse, I also became fully integrated into the system of capitalism. I received a wage in exchange for, but not necessarily in proportion to, the surplus value I produced. When I became a nurse, I adapted my days, weeks and years to the dictates of a new schedule. Like other members of the working class, I experienced mounting debt and sought solace in ephemeral pleasures; I became a consumer of a lifestyle I did not necessarily choose.

When one thinks of nurses, one generally thinks of a hospital, and that is indeed where I work. Since completing my training nine years ago, I’ve worked in a medium-sized private hospital in a major regional town. Knocking off after a particularly frantic shift, it takes me a while to wind down. I can hear the electronic sound of the patient call bells echoing in my ears, I find myself wondering whether I should document my bowel movements, and I experience an acute craving for foods containing butter, sugar, condensed milk, and preferably all three. To the bloke in high-vis parked near a bakery, desperately cramming a pie into your mouth at 10.30 in the morning, I understand you in a way I never thought I would. When I became a nurse, I became one of those doughy bodies thick with fatigue.

The problem, it seems, is that I think too much. It happens to be something I’m pretty good at, but a propensity for sociopolitical analysis is not generally regarded as an advantage in my line of work. It didn’t do me many favours as a novice nurse. When I first confronted the reality of my chosen vocation, I was slightly horrified by the strange hours nurses were forced to keep—by the extremity of it all. I heard stories of night-duty workers driving home with all the windows down and the stereo blaring in a desperate attempt to not fall asleep at the wheel. There came the realisation that it was completely at the discretion of my employer to roster me on every weekend if they so wished; any concession to an employee’s social or family life would not be on the grounds of decency but of something rarer: altruism. I became acquainted with the dreaded ‘late-early’ shift combination, in which nurses knocking off at 10 pm are expected to front up again at 7 am, and to operate at full cognitive capacity having caught a few scraps of sleep. And I’ve lamented the peculiar logic of having to crawl out of bed in the cold and dark and drive to work in order to open the blinds on patients that are equally ungrateful at being woken at such an inhospitable hour.

One need not look too hard to uncover some of nursing’s many ambiguities and contradictions. It is at once conceived as a rational career choice (‘as a nurse, you’ll always be in demand’) while also intuitive and a calling (‘I was born to be a nurse’). Although some of the old rigidities and conventions have, thankfully, been consigned to the dustbin of history (‘I miss all the ridiculous headgear and starched white uniforms’, said no one ever), in many cases they have simply been replaced by new ones. The images that attach to modern nursing emphasise professionalism and autonomy, while seldom recognising the reality of nursing as ever more rationalised and amenable to control by the employer. There remains little that is intuitive about the work of caring, it seems. The introduction of more upon more patient-screening instruments and checklists is frequently justified on the grounds of improved clinical outcomes and standards of best practice. Yet these copious checklists imply that nurses are automatons and idiots, undercutting the notion of professional clinical judgement, not to mention taking precious time away from direct patient care.

Despite all the idealism and mythology conjured by such terms as ‘caring’, ‘profession’ (‘caring profession’ even), nurses are not so different to other members of the working class. We get up in the morning and put on a uniform. We have to spout the corporate-speak in order to have any prospect of getting a job. Unlike those of previous generations, workers today confront a world of employment characterised by market individualism. In our interactions with the labour market we are encouraged to self-identify as micro-entrepreneurs fending for ourselves in a hostile world.

The sociologist Ulrich Beck contends that such conditions are characteristic of a new phase of capitalism, which he terms the ‘second modernity’. The second modernity has featured a withering away of many of the certainties and securities associated with the ‘first modernity’ of industrial capitalism. An economy based on full employment and a high proportion of full-time, permanent jobs is, many commentators would now agree, a thing of the past. And one of the key dynamics associated with the second modernity, Beck contends, is the individualisation of risk.

‘It’s your registration!’ is a sentence that every nurse would have at some time said, or heard from the mouth of a colleague or superior; it is offered as an admonition and/or an incitement to practice in a way that is legally accountable, and to perform the appropriate amount of ‘arse-covering’ (in other words, to document in detailed writing the care he or she provides). The individualisation of risk indicates how a culture of mutual support and solidarity among nurses might be undermined. It is incumbent on you, not your employer, to identify and voice the risks that may impair your ability to do your job confidently and safely, even when their causes may originate in the structures of the organisation. The ward on which I work is classified as ‘sub-acute’, which for the purposes of workloads indicates that a nurse may be assigned a maximum of seven patients on a morning or afternoon shift (in fact, as it is a private hospital where nurse–patient ratios are not mandated, there is no official upper limit). A nurse that speaks up about an unreasonable workload does so guiltily and sheepishly, because in most cases doing so only shifts that burden onto one of his or her colleagues.

It is tempting to draw the depressing conclusion that the flourishing of atomising individualism in the neoliberal era has scattered the seeds of class consciousness to the winds. The old disciplinary notions of the ‘deserving’ and ‘undeserving’ poor have found fertile ground in the new conditions of uncertainty. The resentment that self-proclaimed ‘hard-working taxpayers’ direct at ‘welfare bludgers’ has more recently also been fired at ‘hipsters’ (because they might pursue ‘indulgent’ lifestyles based on making art rather than making money). ‘People see others whom they perceive to have lives that are easier, cooler, or more fun than theirs’, writes Peter Frase in Jacobin, ‘and instead of questioning the society that gave them their lot, they demand conformity and misery out of others’. In this era of vicious ideological attacks on organised labour, we must remain clear-eyed about the need to forge and maintain links of solidarity, but also about the pervasive culture of individualism that challenges our ability to do so.

Some of these difficulties were brought home to me while I was having a conversation with some colleagues about the attack currently being made on penalty rates. ‘What’s the government going to do when retail and healthcare workers are no longer available to work weekends?’ asked one of my colleagues. ‘I ONLY work weekends for the EXTRA money’, another chimed in, ‘and if penalty rates are gone, I won’t be sacrificing time with my family in exchange for normal weekday rates’. The thought processes of these two women went something along the lines of: loss of penalty rates on the weekend = withdraw my labour on the weekend = decision made, case closed. I was dismayed by the seeming inability of my colleagues to understand the importance of opposing or defending something on principle, regardless of how it might affect them personally. They seemed reluctant to show any sympathy for, or solidarity with, other members of the working class, in this case retail and hospitality workers, who are on the lowest rungs of the wage ladder, and to whom the loss of penalty rates will potentially deal the toughest blow.

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Many a time, I’ve mused on why the day-to-day work of nursing is often less than satisfying, and I suspect it is because, at the end of a shift, you are bone tired with seemingly nothing to show for it. You leave the patient in basically the same position and condition as you found them, and yet this work of ‘caring’ dictates that you fill out reams of paperwork and traverse long corridors dozens of times a shift (even the best-designed hospital wards necessitate a lot of walking). Nurses are fortunate to escape the health risks associated with sedentary occupations, and the advent of beds that can be raised or lowered at the touch of a button has no doubt saved a lot of backs. However, like the cleaners and domestic staff, who join nurses on the bottom rungs of the hospital hierarchy, our lot is physically punishing and gruelling: hauling loads of soiled linen into laundry skips, pushing unwieldy trolleys, and being lunged at by aggressive patients or those seeking an object to break their fall. One day I came across a curious document left behind at the nurses’ station, on which the majority of my colleagues’ names appeared. The record I beheld, I soon realised, was the hospital’s occupational-injury register. That my name would eventually appear on the list seemed a frightening inevitability.

The heartbreaking part is not the entrenched sexism of the nurse–doctor relationship or the arrogance and ineptitude of some doctors (who are often conspicuously absent when the patient and/or their family perceives that their plan of treatment is not to their satisfaction. Yes, it is nurses who cop the vitriol and it is nurses who have to clean up after doctors, literally and figuratively). It’s the sense that opportunities for professional achievement or fulfilment, to take pride in ‘a job well done’, will always be subordinate to the dictates of managerial prerogative.

Over the course of my career I have surmised some of the obscure workings of my workplace. Those nurses who forgo their lunch breaks in order to accommodate another admission are those that rise to the top, as are those who’ve learnt to think like business managers, who are conscious of the KPIs. The weekends are when staff numbers are likely to be cut to the bone, and changed at the last minute in order to ensure labour costs are kept to a minimum (‘those bloody penalty rates!’ you can almost hear the bean counters saying through clenched teeth). At such times, when the ratio of staff to infirm is very low, one despairs of having to admit to the ward, with little warning, a patient in an unstable condition with complex care needs, an occurrence that is as risky as it is frequent.

Nurses have written and spoken with great candour about the highs and lows of their job, about physical and emotional burnout; they have sought recognition for the unacknowledged heroics they perform every day, and they have campaigned tirelessly on issues of occupational violence and working conditions.

Yet nurses, it seems, are too often unwilling to probe deeper into the sources of their dissatisfaction. I don’t know one nurse who hasn’t at some time wished or looked for something else—for that elusive job that is more engaging and less exhausting. It is understandable that many remain silent out of fear of reprisal, or to avoid dinting public confidence in the healthcare system (a system which, it should be pointed out, successfully rehabilitates our loved ones back to health the vast majority of the time, in spite of its many shortcomings and handicaps). While it is important not to cause undue alarm, there are some persistent illusions that are worth challenging. The reality is that healthcare operations are run for profit; even those claiming to be ‘non-profit’ are geared toward economic efficiency. Behind the nicely landscaped facade, they are often run on the smell of an oily rag.

Furthermore, while there is now public awareness of ‘compassion fatigue’ as an issue facing health and community-services workers, there is little criticism of how the system of patriarchal capitalism has sought to commodify affective labour. The creep of customer-service rationalities into the healthcare context cheapens the interactions of patients and nurses, and suggests that a worker’s facial expressions, appearance and obsequiousness have become a barometer of professionalism and dedication to the role. Alongside the heroic work of curing performed by doctors, affective labour attracts much less prestige and remuneration, because so much of that labour is characterised as feminine.

And yet, despite all this, in rare moments I’ve experienced a feeling that is best described as a mixture of luck and awe. Perhaps it is a privilege of the rehab nurse. Among the patients we care for are traffic-accident victims, who are delivered to the ward lying limply on a trolley, having been put together in a rudimentary, bodily sense, though still broken in spirit. Over the coming months they will face the painful yards of piecing themselves together in body and mind. There comes a moment, often several months later, when they are no longer defined by the identification band around their wrist and again become a person, walking out the door. Such a moment is a triumph of a magnitude not easily understood by the outside observer, and one in which I am privileged to share. Yes, this is the stuff of ‘human interest’ stories, but there is something here that is unrehearsed and unvarnished, all the same. In this brief moment, we cease to be mere victims of our conditioning: we step outside of our predetermined personae and relate to one another simply as human beings, with the potential to create meaning, and to connect.