"Do Trained Nurses . . . Work for Love, or Do They Work for Money?" Nursing and Altruism in the Twenty-First Century

A dear friend of mine was hospitalized in the summer of 2007 with renal artery narrowing, for which she received a stent. She is 81 years old, and had several postdischarge setbacks that required a second hospitalization in one of New York's most prestigious hospitals. (Please note: as has been shown in multiple nursing research studies regarding transitional care, had she had proper nursing care and appropriate discharge planning during the first event, the second hospitalization would not have been needed at all. 1 ) I visited her several times and was overwhelmed by the absence of any sign of nursing care. Endless streams of individuals entered her room, each doing some tiny little job-filling a water pitcher, taking a temp, delivering a tray, mopping a floor, emptying a wastebasket, and so on. None of these individuals could answer any question from her; none would agree to do anything for her other than their assigned task. They barely looked at my friend. Had she been in extremis they would not have noticed. My esteemed colleagues, this is 21st-century sick care without nursing. And why has our nation systematically eliminated nursing care from our hospitals? Because of money. Nursing care is the largest budget item in hospital care. So the health care profiteers systematically strip nursing budgets, insisting that hordes of less costly, untrained individuals can perform all the nursing tasks. 2 This short-sighted behavior on the part of unschooled business people would not be possible if society fought it. For my whole nursing career I have been consumed (obsessed?) by society's inability to understand what nursing is; to recognize the expertise that good nursing entails and its critical importance to health care outcomes. 3 Why do people insist on seeing nurses as nice people mopping fevered brows instead of highly skilled experts giving life-saving, highly technical care? I think the answer lies in society's and nursing's history. The story of nursing is, of course, a story of gender. But I also think it is a story of ideological debate. Is it science or art, a profession or vocation, independent or dependent, possessed of its own expertise or handmaid to medicine, or, is it in fact degrees of each of these? Those questions lead to others: how to prepare to do nursing, where to do it, who is in charge of it, how much to pay for it, what are proper nurse/patient ratios, and how important it is to patient morbidity and mortality. These are the debates that reflect what I call ideological conflict. I and others have researched many of these issues. 4 I have examined the concepts themselves-science, autonomy, professionalism-to see whether nursing can be defined by those concepts. 5 All this research was helpful, but it actually increased my frustration, because we have shown that nursing does make a difference and can be defined by those concepts. The fact that it can be highlights the question as to why it is not, except with reservations. That discovery led me to social history, which examines issues in the context of society's customs and mores in various time frames. I chose to focus on the 1890s, the close of nursing's first generation in the modern era. That research proved more fruitful, although it provided no simple answers. The most general conclusion that emerged from my research is that from the outset of modern nursing there was no consensus among the nurses themselves, or their sponsors, as to their ideological convictions. 6 Nursing was, and is, a house divided, with strong leaders and convincing arguments existing on all sides of each issue. Because of the competing definitions, philosopher of science Thomas Kuhn might say that nursing lacks a paradigm or unifying principle. But I disagree. Among nurses there is a basic consensus that patients are at the center of nursing's work and that patients' needs drive its practice, education, and research. It is that consensus that holds nursing together and provides the central paradigm. …