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Nursing the Nation

Britain claps for nurses while capping their pay

British Vogue’s July cover girl arches an eyebrow at you knowingly. She’s unknown to you yet instantly recognizable, and not just by her teal scrubs and DayGlo lanyard. It’s the beatific kindness that pools in her eyes and dimples; the way the sun gilds her pre-Raphaelite curls; the arm she extends as if for an embrace, so white it glows. Rachel Millar is the picture of a nurse, and the face of “The New Front Line.”

The 320,000 hospital and community nurses currently working in the NHS make up about a quarter of Britain’s health care workforce (there are fewer than half as many doctors). But this isn’t enough to explain why nurses have been so singularly commemorated during the pandemic; why the UK has seven temporary coronavirus hospitals named after Florence Nightingale; why, of all the many medical staff who treated him during the week he spent at St Thomas’ Hospital, it was two nurses Boris Johnson nominated for praise. One reason may be that, for as long as curing Covid-19 remains an impossible (though now less distant) prospect, those caring for its sufferers seem most deserving of our appreciation. Another, more interesting possibility is that the pandemic’s framing as a war effort is consonant with our perception of modern nursing as national service.

Millar is not the first nurse to make the cover of Vogue. That happened in May 1918, when Porter Woodruff drew a woman looking out at the trenches, gauze streaming from her starched white cap. “Nurses Have Always Used Ingenuity When It Comes to Personal Protective Equipment,” reads the headline of a recent article in which the 1918 cover features, part of a series in which American Vogue editors curate past issues with present resonance; I’m sure it would resonate with the 34 percent of nursing staff on Britain’s coronavirus wards who lack adequate PPE. The original caption: “There is one veil of greater interest than the bride’s”—it was a wedding issue—“it is worn by the Red Cross nurse in her work for the ‘well-being of the wounded.’” Though separated by a century, Rachel Millar and the Red Cross nurse fulfill the same fantasy of their profession, one born on the battlefields of Crimea and that lives on in the battle against coronavirus.

Nightingale did not want nursing to be for the everywoman but for the gentlewoman.

Until the mid-nineteenth century, Britain’s war wounded were tended to by either military orderlies or by “camp followers,” a group of wives and whores who between them were expected to satisfy the men’s diverse needs, including medical ones. The results were predictably grim. But then came the Crimean War—the first “media war”—and sunlight disinfected the field hospitals. Graphic reports of choleraic, typhous soldiers in cramped, unsanitary conditions provoked widespread outrage. British Minister of War Sidney Herbert phoned a friend: Florence Nightingale.

Nightingale cleaned up nursing in more than one way. Not only did she scour, sterilize, and ventilate the Scutari barracks to which she was dispatched; her managerial and medical reforms—setting up a training school, standardizing practice, lobbying for better sanitation and inventing statistical methods—sanitized nursing’s reputation. So thorough was Nightingale that it now seems unimaginable that her predecessors were, at least according to her,  seen as women “too old, too weak, too drunken, too dirty, too stolid, or too bad to do anything else.” The daughter of a wealthy landowner with off-the-wall ideas about women’s education, Nightingale wished to remake nursing in her own image: as an attractive, white(-collar) profession.

Crucially, Nightingale professionalized nursing not by breaking what Ann Oakley has called its “iron link” with womanhood, but by reinforcing it. “Every woman,” Nightingale wrote, “or at least almost every woman in England has, at one time or another in her life, charge of the personal health of somebody, whether child or invalid—in other words, every woman is a nurse.” Nightingale did not want nursing to be for the everywoman, however, but for the gentlewoman. Her innovation was to transform nursing from a job all women were expected to do by virtue of their gender to a vocation certain women felt called to by gendered virtue. This left her with a paradoxical view of nursing as both a teachable skill and an unteachable intuition. Hence her reservations about the campaign for a nursing registry: “good character” was to Nightingale “a more fitting attribute for prospective trainees” than accreditation, writes Julia Hallam in Nursing the Image. If anyone could sign up to nurse, how to separate the wheat from the chaff?

A WWII-era nursing recruitment poster. | Imperial War Museum

The “good character” to which Hallam alludes was made up of the cardinal virtues of Victorian femininity: gentleness, humility, charity and most of all, chastity. Unlike their camp follower predecessors, the women of the Army Nursing Service, formed in 1881, could be expelled for sleeping with or even getting engaged to their patients. Scrutiny of nurses’ sexual conduct has been remarkably persistent in the intervening century. Morality contracts were signed by some nurses as recently as the mid-1970s; one whom Hallam interviews recalls being reprimanded for holding a dying male patient’s hand. Nightingale for her part never married; she believed a husband would hinder her career. Then again, she was rich enough to believe what she liked.

It was in large part this virginity that constituted Nightingale’s particular appeal. The Times article that first dubbed her “The Lady with the Lamp” also described her as a “ministering angel,” one whose “slender form glides quietly along each corridor, every poor fellow’s face soften[ing] with gratitude at the sight of her.” This image of the angel of the ward, the professional counterpart of the angel of the house, captures the paradox of the Nightingale nurse: she is both powerfully present and ethereally absent, her selfhood so refined as to denude it. Monica Dickens took this idea to its logical conclusion when she wrote of her motivations for becoming a nurse during WWII, “I was going to be a nurse in a pure white halo cap, and glide swiftly about with oxygen cylinders and, if necessary, give my life for a patient.

If “[t]he ‘good’ nurse” was the “self-sacrificing angel who gives up everything to dedicate her life to caring for the sick,” writes Hallam, “the ‘bad’ nurse is her exact opposite, misusing her position of power and authority to satisfy her own needs and desires, whether these are material, sexual or simply sadistic.” A version of the bad nurse stars in the WWII film Vigil in the Night (1940); having left her patient’s bedside to make herself a cup of tea, she returns to find he has breathed his last (the good nurse dies for the patient; the bad nurse’s patient dies). For nurses in the Nightingale tradition, the real-world equivalent of this cinematic nightmare was the trade union. When the College of Nursing (later the Royal College of Nursing) was founded in 1916, trade unionism was banned from its articles of association. The RCN retained a no-strike clause until 1995; to the College, the withdrawal of labor amounted to a dereliction of duty.

Alongside the tradition of the Nightingale nurse runs another that values nurses’ welfare as highly as their patients’.

Not everyone agreed. For alongside the tradition of the Nightingale nurse runs another that values nurses’ welfare as highly as their patients’. Unlike the so-called “professional” movement, concentrated in the more prestigious general hospital environment and driven by middle-class women, the nursing trade union movement originated in the underbelly of the profession: psychiatric, geriatric, and community nursing. In 1946, a group of nurses working in asylums and workhouse infirmaries came together as the Confederation of Health Service Employees (COHSE). (In 1993, COHSE merged with the National Union of Public Employees and the National and Local Government Officers Association as UNISON.) These nurses resisted the humility and self-effacement expected of them, recognizing them as the obstacles they were to better pay and working conditions. When COHSE members staged a pay protest outside Hellingly Hospital in East Sussex in 1962, their banners announced them as the “Angels of Hell.”

The reaction to the burgeoning trade union movement from the professional nursing class was telling. In 1988, former RCN president Dame Winifred Prentice wrote to the Times of London: “I feel a bit let down. We thought we were setting up a really first class profession and now they seem to want to throw it away as if we were just factory workers.” It is easy to see why “first class” women such as Prentice saw little value in unions; what need would a dame have of material self-interest?

Pearl-clutching Dame Winifred might have taken heart from the scenes unfolding across Britain today. For months, endless rounds of uninvited applause have drowned out calls for increases to nurses’ pay that might reverse their 8 percent real-terms fall since the Conservative-Liberal Democrat coalition government formed in 2010. (The public sector pay rise announced on Tuesday excludes nurses since they negotiated a three-year pay deal in 2018, a deal over which the RCN has admitted to having misled its members.) Much has been made of this apparent hypocrisy, clapping for nurses one week while capping their pay the next. In truth, the government’s treatment of nurses is entirely consistent with the Nightingale model.

Until 2015, nursing training was bankrolled by the Department of Health. As unions predicted, David Cameron’s decision to scrap nursing bursaries pushed training applications off a cliff edge—they dropped from 52,740 in 2016 to 39,665 in 2019—forcing a U-turn on the decision four years later. The new NHS Learning Support Fund unveiled at the end of last year is open to new and current nursing and midwifery students, though not to the many thousands who completed training while the government equivocated over their worth. Justifying the decision not to backdate the bursaries, Care Minister Helen Whately wrote that student nurses are “supernumerary” and “not deemed to be providing a service.” When Nursing Notes probed Whately on her comments, she backpedaled: “The whole country is grateful to student nurses for their heroic work on the NHS frontline during this unprecedented global pandemic.”

In actuality, there was no contradiction here at all. Whately was making a consistent distinction between two concepts of service: one a set of actions delivered in return for a fee; the other a duty done with no expectation of recompense. ( “We’re here to serve,” says one nurse in Vigil in the Night, “and if we do it well, we find pleasure, freedom, perfect freedom . . . . ”) Nightingale’s legacy was to conflate nursing with the latter concept, what Hallam calls the “bourgeois liberal humanist ideal of service.” Whately’s statements reflect this logic: nurses’ work is “heroic,” not paid; any remuneration is “supernumerary.” The thirty-eight women Florence Nightingale took to Crimea were volunteers, after all. Payment would have debased their patriotism.

The fetishization of nurses’ individual altruism has provided an ideological basis for their collective mistreatment.

For a Tory government intent on limiting health care spending, the idea that nurses are performing national service rather than providing a payable one is expedient. For a country with a dire shortage of nurses and Europe’s third-highest coronavirus death toll, it is less so. When the RCN recently surveyed forty-two thousand of its members, 74 percent reported feeling more valued by the general public. Nevertheless, 36 percent of respondents—nine percentage points more than last year—were thinking of leaving nursing; the primary reason was money. It turns out that virtue is not its own reward.

Meanwhile, the conflation of nursing and nationalism in the public imagination has left little room for the legions of foreign workers who sustain Britain’s health service. Despite Johnson’s stirring tributes, Jenny from New Zealand and Luis from Portugal are leaving in droves. According to a 2019 report from a group of health think tanks, a net inflow of nurses from the European Union has become a net outflow. While the causes of this reversal may mirror those of the brain drain afflicting the entire NHS, Brexit is clearly a particular catalyst. Many EU nurses—having heeded the fate of their non-EU colleagues, forced to pay for the privilege of doing their job (Johnson pledged to exempt NHS workers from the ever-increasing immigration health surcharge in May; he still hasn’t)—have calculated that it simply isn’t worth staying. Should this trend continue, nursing will soon be a form of national service, whether we like it or not.

Given the conditions under which they work, it’s hard to imagine that nurses are not at least partly driven by a desire to help others. Yet the fetishization of nurses’ individual altruism has provided an ideological basis for their collective mistreatment. In this way, Florence Nightingale—the lady of good causes, ample means and stolid devotion to queen and country—has as much sainted nurses as damned them. For what Nightingale precipitated was a situation in which nurses’ value inheres in their conformity to her archetype. They are celebrated for the selfless acts they perform in isolation, at a bedside, yet never for the self-determining action they take as a group, on the streets. As Celia Davies writes in Gender and the Professional Predicament in Nursing: “Individually, and at the point at which they deliver care, nurses are lauded and applauded”—on the doorstep of Number 10, on the cover of Vogue—“but collectively and in the arenas where policy is debated and decided, nurses are viewed in a much more ambivalent and negative light.” This ambivalence has many complex consequences but one upshot. Until we disabuse ourselves of the notion that nurses care because they care and not also because they are paid to do so, the UK’s forty thousand nursing vacancies will remain unfilled.