A year into the pandemic, Renewal is publishing a series of essays by careworker Paul Cotterill on power, professionalisation and decommodification in care work. The second essay in this series looks back at the rise and partial fall of nursing as a profession. While a nursing elite professionalised quickly in favourable conditions, this professionalisation was underpinned by the racial and class prejudices of the time which have led to a lack of solidarity within the profession under managerial assaults. The experience of nursing should inform the development of an inclusive and reflective caring profession.
Is it possible to create, as a conscious political act and within a reasonable timescale, a new profession?
Well, I’m hopeful.
First, there is at least some precedent to follow: nursing. I want to trace the development of nursing as profession, and draw out the successes and failures, such as they might act as a useful guide for careworkers.
The flawed rise of nursing
Nursing in Britain came of professional age in the 1960s and 1970s through the determined agency of people like Nancy Roper, who developed and soon gained widespread acceptance of her ‘model of nursing’, based on the idea of 13 activities of daily living and the idea of a continuum between total dependence and total independence.
At the heart of the implementation of the model was the ‘care plan’, drafted by nurses on admission of patient to a ward (with a later spread to community settings), in autonomy from, but with reference to, any medical intervention plan. The ‘care plan’ quickly became the symbol of nursing autonomy, and was embedded in all nurse training from the 1970s onwards. Other models imported from the US were also available, but Roper’s was dominant at that time.
The spread of this autonomy was also aided by the conditions of the time. At a societal level, it was becoming more possible for nurses, who were mostly women, to assert themselves on the ward, as post-war recognition of women in the workplace shifted towards at least some valuing of what those women brought. At the same time, an NHS with a growing budget was still ‘decommodified’ enough to allow the emergent new profession to make the demands it needed for additional staffing, such that the model could be implemented and nursing outcomes become better. This was a time when hospital stays were becoming greatly reduced for many reasons, but nursing autonomy was one of them.
That’s the upside of the development of the nursing profession in the 20th century: a story of female agency focused on setting standards, creating regulatory institutions for their maintenance, and making the most of the opportunities afforded in a fast-changing world.
But there’s also a downside that it’s important to recognise as we try to trace a path for the professionalisation of caring. The downside is that, while nursing is validly seen as a profession reasonably straightforward for anyone to enter, the professionalisation process itself depended to a significant extent on race and class exclusions, and these exclusionary beginnings have created a damaging legacy from which carers seeking to develop their own autonomy, through solidarity, would do well to learn.
I trained as a Registered General Nurse (RGN) in London in the late 1980s. Astonishing though it may now seem, there was not a single black student in my cohort of around 30 student nurses. Indeed, I’m pretty sure the only interaction I did have with a black nurse student on RGN training was with a member of a cohort after mine whom I represented, as a young union steward, in a grievance procedure against a nurse tutor who was discriminating against her.
That does not mean there were no black nurses in this big teaching hospital. There were plenty, but almost all of them had Enrolled Nurse status, because the recruitment system had militated against them entering the higher-level training—this was just before the start of nursing degrees linked to universities.
While perhaps most obvious in a big teaching hospital which drew in white, middle-class applicants from around the country, this racial (and class) segregation was pretty generalised across the country, and was rooted not just in the broad racial discrimination of the time, but also in the fact that the nursing profession had not broken down class and race barriers as it developed its own autonomy. This was a time, even into the early 1980s, where doctor-nurse romance and marriage were still part of the norm, and where registered nurses still tended to come from ‘respectable’ families for whom nursing was an appropriate career move for a ‘girl’ in a world still short of opportunities in other professions.
The shift of nurse education into universities, and the expansion of higher education itself, did change these dynamics rapidly in the 1990s and 2000s but not before a deep split in the overall workforce, represented by the fact that middle-class nurses tended to join the Royal College of Nursing while the rest opted for the nitty-gritty union support offered by the NUPE or COHSE, later amalgamated as Unison.
To my mind at least, the nursing profession never recovered from that split.
Come the managerialism and associated de-professionalisation trends of the 1990s and 2000s, nurses emerging from universities into the workforce were met with conditions of work that I could never have imagined in the 1980s. Autonomies once gained were stripped away, and in many cases nurses were reduced to the role of proficient technicians, while a lot of the actual nursing work as I had known it was undertaken by healthcare assistants who endured a status lower than that of the Enrolled Nurses that they effectively replaced.
This flowed through into lower standards of care, with individualised care plans and implementation replaced by a return to the routines of ‘rounds’. This change was ‘sexed up’ under the direct orders of David Cameron as ‘intentional rounding’, but in reality it was a return to the conveyor-belt-style task orientation of the 1950s and 1960s.
Ultimately, the reason this de-professionalisation process has been allowed to happen is that the initial process of professionalisation was conducted by an elite, for an elite, and this brought with it a lack of willingness or capacity on the part of otherwise forceful agents of change to develop a holistic view of what nursing actually was, and who nurses were. Thus, while there was some trickle-down of benefits to the rest of us, it has turned out be short-lived; come the managerial assault on professional standards, nurses were not in a position to resist, because the necessary bonds of solidarity did not exist across the workforce.
I am not sure where nursing will go from here.
Ideally, the new militancy evident in the formation and rapid growth of Nurses United, which may or may not swiftly overtake both the RCN and Unison as the go-to organisation for nurses who want to see their professional autonomy restored—as well as the value of their pay—will also take in a reappraisal of the profession’s post-war history, and perhaps even do so through the lens of David Smail’s conceptions of proximal and distal power discussed in my previous essay.
In this version of nursing history, the new profession did effectively challenge more proximal powers as it shifted care from a medical model to a more patient-centred one, but did so largely in concert with the more ‘distal’ powers of structural racism and class inequality, in a way which has not served it well in the long run.
The fact that Nurses United has been fostered by the New Economy Organisers’ Network, which has a well-developed approach to the anti-oppression agenda, which can help nurses, ‘unlearn’ their own history suggests that this may happen, though there is little concrete evidence of it yet, with the main focus still understandably on using the pandemic response to secure a reasonable pay rise.
But while I am not sure where nursing might go in any ‘unlearning’ process, I am certain that its flawed development to date does offer useful lessons for an emergent care profession around the missteps it will need to avoid if it is to develop the solidarities and kinds of behaviours it will need to encourage and embed early on.
Carers should learn from what (some) nurses got wrong, and it is better to do this earlier than to regret it later, in the way that (all) nurses now should be doing, perhaps en route to putting it right.
Paul Cotterill works in care and lives in Lancashire. He is treasurer to the New Economy Organisers Network (NEON) and founder member of West Lancashire Resilience Society.