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Advances in Nursing Science Vol. 37, No. 2, pp. 147–160 c 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins Copyright
Critical Perspectives on Nursing as Bodywork Karen Anne Wolf, PhD, APRN-BC, DFNAP Nursing is grounded in care of the body. This article examines nursing as bodywork, as experienced intersubjectively by nurses together with patients and collectively as a body within the health care labor force. The relation of nurses to the body generates conflicting and contradictory social meanings from intimate and sacred work to dirty work. Such meanings have contributed to stigmatizing the work and the worker within the labor force as well contributing to an ongoing stratification in the labor force as nurses have shifted bodywork “to lower level” or ancillary workers. Key words: bodywork, nursing labor force, social relations, stigma, work force stratification
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URSING WORK is historically and culturally viewed as “bodywork.” Despite efforts to professionalize nursing practice through education, practice changes, and collective organizational effort, in the public’s eye the work of nurses continues to be inextricably bound to the physical care of patients’ bodies. This article explores nursing as bodywork and the complex social relations and perspectives that shape this construct. Bodywork has received scant attention in nursing in the United States. This lack of attention reflects a fundamental schism between the theories and praxis of nursing work. Nursing theory development espouses an integration of the biological and psychosocial dimensions, yet many theoretical perspectives situate the psychosocial or interaction aspects of care as foreground in practice and at the same time de-emphasize
Author Affiliation: School of Nursing, Samuel Merritt University, Oakland, California. The author has disclosed that she has no significant relationships with, or financial interest in, any commercial companies pertaining to this article. Correspondence: Karen Anne Wolf, PhD, APRNBC, DPNAP, School of Nursing, Samuel Merritt University, 3100 Summit Street, Oakland, CA 94601 ([email protected] Or [email protected]). DOI: 10.1097/ANS.0000000000000028
the care of the body. The practice of nursing is bound through the process of bodywork and contributes to and gains from what Turner has termed the “regulation and reproduction of the population of bodies.”1 The consequences of the sociopolitical and economic regulation of bodies affect both patients and the nursing workforce. In the following sections, I relate the concept of nursing as bodywork to the patient care experience. I suggest that despite gains in professionalism, nursing as a profession continues to be devalued and disregarded as a source of authority in society due to nurses’ proximity to the body. As health care has expanded the role of nursing across settings, this has also contributed to the expansion of nursing’s role in the regulation and reproduction of bodies. As a first step toward an emancipatory nursing praxis, nurses must recognize and embrace the nursing relationship to the body and how this relationship has influenced the collective body of nursing. Praxis emerges as critical reflection on the power and constraint inherent in bodywork informs and aligns the every day work of nurses. Nursing is transformed, as nurses’ awareness of the societal values surrounding the physicality of the body is reconciled within holistic totality of care for patients. This reconciliation of nursing values and actions is essential to empower the collective body of nursing. 147
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NURSING AND BODY RELATIONSHIP By historical claim and medical dominance, the nursing act of caring for patients is focused on the “corpus” or body. The development of nursing within religious institutions and traditions reinforced the ideal of caring for the body, with the body and soul more often seen as a unity. Nursing knowledge and practice evolved in concert with medicine. As the body became a venue for medicine to study disease and pathology, nurses tended to the diseased body and suffering soul, while making observations essential to medicine’s study.2 The imprint of Cartesian dualism on medicine contributed to viewing the body as an object, with the intent to best determine how to diagnose and treat the body’s pathologies.3 Nurses became not only the “physician’s hand” as Melosh stated but also the physician’s eyes.4 This extension of the physician’s gaze was both literal and figurative. Medicine evolved within a naturalistic perspective of the biophysical sciences. The medical paradigm does not neglect the mind but rather views it as less relevant to the diagnostic enterprise. By contrast, nursing theory and science followed principles set forth in the early Nightingale era that emphasized that nursing was complementary to medicine. As caretakers of patients suffering with illnesses and diseased bodies, nurses addressed the environmental and psychosocial conditions for healing. Care of the sick room emphasized physical aspects such as air quality, cleanliness, and noise. Efforts to advance nursing science in scholarship and practice embraced the role of psychosocial influences on health and illness. The art and science of nursing evolved in an uneasy tension in a culture of health care dominated by medical reasoning. By the mid-twentieth century, nursing theories began to reference theories on stress, coping, and adaptation. Nursing rejected the idea mind-body dualism and evolved theories that viewed the patient as an integrated, biopsychosocial being. Numerous debates within the nursing profession over the past 40 years have argued the value of “grand nurs-
ing theories” and conceptual models of practice. Despite attempts to build a professionspecific knowledge base for nursing, the influence of nursing theory development has had a limited reach outside academic circles of the discipline. The dominant cultural perception of nursing work views nurses as subservient to physicians, carrying out orders that relate to doing something to or for the body. The power and legitimacy of medical knowledge in society provides an alluring draw for many nurses and informs much of nursing practice. As legal and social efforts to define the scope of nursing practice as separate and distinct from medicine have moved forward, nursing work continues to be defined by exclusion from and/or extension of Medicine. The critique of medical dominance in the 1970s generated new social theories that moved professions and institutions to examine the role of medical knowledge. Previously absent from much of the literature, the body emerged, taking shape, according to Mary Douglas, as “the two bodies,” a body viewed and experienced at the physical level, constantly shaped and reshaped by the sociocultural categories and meanings as a social body.5 Societal attempts to categorize illness behavior take note of and redefine body disturbances. Giddens6 points out that as the body is redefined, so too is the individual’s self-identity. Individuals living with chronic disease, illness, and disability experience not only a denigration of their sense of self but also a lowering of their social status.7 Nursing, similar to the patients we care for, is defined in relationship to the body, challenging the self-identity of nursing as well as the social status of the profession. Nursing as bodywork serves as a window through which to view the panoply of cultural meanings and theoretical perspectives that surround the body. Nurses are held in high trust by some, viewed as low status work by others, and mirror the perceptions of the body as sinful, dirty, and sexualized. Nursing reflects the diversity and often-contradictory images and meanings associated with bodywork as gendered.
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Critical Perspectives on Nursing as Bodywork NURSING AS GENDERED WORK Nursing as women’s work is a characterization that persists despite a history of men in nursing. Through bodywork, nurses reproduce the domesticity of the home, hospital, nursing care homes, and other care environments.8 Nurses, according to Graham, symbolically serve as wives and mothers within the primary institutions of care.9 Similar to the mothering and domestic work in the home, nurses are viewed in a maternal role and are responsible for the care of the body. The impact of gender on nursing work is felt throughout nursing education and nursing practice settings, shaping enrollments and choices of work settings. Even though the number of men entering nursing has slowly risen to 9.6% of all nurses in the United States, the female gendering persists.10 Men are welcomed into nursing with mixed emotions but benefit from the underlying patriarchal gender relations. They are frequently afforded advantages that allow them to achieve status and power more readily than their female colleagues. The gendering and feminization of nursing work establishes an artificial contrast that assumes that medicine is male gendered and is based on masculinity. Men who enter nursing are viewed as deviant that further pushes men into career paths that place them apart from or above their female colleagues.11 While gender is a powerful force in structuring nursing work, it also is an essential ingredient in the structuring of nurse and physician identities and roles. According to Davies,12 this false duality of gender serves “to wrench apart the richness of our human qualities, denying or repressing the feminine while assigning privileged status to the masculine.” This underlies the assumption that women are less repelled by dirty work and attending to bodily functions and less likely to exploit the intimacy in body relations. The identity and public image of the nurses has been imbued with gendered meanings associated with the body. More than 100 years after Dickens created his infamous
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character Sary Gamp, nurses continue to be stigmatized. Despite protestations, nurses are sexualized in pornography and advertising. Nurses’ proximity to and intimacy with the body underlies this discomfort and intersects with societal attitudes about gender and class to promote an objectification of the nurse. The projected media images of nurses, seen in books, television, and even greeting cards, project the societal discomfort and ambivalence toward and about nursing. Many of the stereotypes objectify nurses as self-sacrificing heroines and romantic interests. An even greater number present nurses as sex objects. A recent study found some 500 pornographic movies featuring nurses in 1 site alone retrieved in a brief 30-second Internet search.13 The sexualization of nursing in pornography underscores the association of nursing with the social discomfort that emanates from the physical care of the body. Efforts to redress such distortions in the image of nursing through lobbying and criticizing ‘influentials” in media and policymaking provide a superficial answer to the deeper problem of the contradictory position of nursing in society. Despite the recent trend of films and television such as “Nurse Jackie” to portray nurses as strong women, the negative stereotypes of nursing persist, suggesting the degree to which nursing as bodywork is tainted.14 The ideology of nursing as gendered is foundational to the structural analysis of nursing as work. Feminist nursing historian, Ashley, argued that paternalism and sexism both shaped and exploited nursing within hospitals.15 This thesis is further elaborated by Reverby who suggests that paternalism, while a central factor, does not fully explain the exploitation. She notes that social class divisions within the nursing and medical workforce were primary factors in exploitation. The growth of hospitals under a utilitarian and industrial approach to care resulted in what Reverby called “a caring dilemma” in which “nurses [are] ordered to care in a society that fails to value caring.”16 The growing industrialization and corporatization of health care ties nurses pragmatically and symbolically
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to patients’ bodies, carrying out fragmented tasks of care. To reclaim holism in nursing, nurses must speak out to reshape health care priorities, recasting patient-centered care as holistic in praxis and as a fundamental ideal, and not simply an outcome.
THE PRIVILEGE AND TAINT OF BODYWORK It is widely acknowledged that nursing is a hard work, but nursing is also a privileged work. Across the world, nurses tend to patients at vulnerable times of their lives, providing care for patients young and old, sick and well. Sandelowski2 observes that bodies are the primary focus of nurses’ work throughout the world, as they care for ailing patients and childbearing women. Nurses’ labor is an essential aspect of the patients’ experience of uncertainty, pain, and/or suffering. This attention on the physical body, pain, and suffering has historically been viewed as the purview of nursing. Despite advances in technology, nurses continue to attend to patients’ physical needs and carry out nursing and medical therapeutics with patients. Thus the physical and emotional intimacy, shared between nurses and the patients for whom they care, serves as a foundation for trust and respect. In the United States, nurses continue to top the list of the most trusted professionals in Gallop polls. Nurses tend to their patients’ bodies as objects, sometimes oblivious to their “embodied” humanity and, at other times, are enmeshed in a caring interrelationship. Parker17 suggests that the nurse’s relationship to the body is positioned indeterminately at the interface of an expressive connection, that of “doing for” and a “being with” the body. This mirrors the objective-subjective dualism in health and illness, which surfaces in a compartmentalized approach to patient care. Nursing ideals upholding nursing practice as a relational experience of providing care for the body are viewed as one aspect of caring for the patient. This also reflects a territorial
claim to the patient and body. Wolf, in her study of nurses’ work with the body, suggests that nurses’ work with the body offers a symbolic ownership. In her observations of nurses in an urban hospital, she relates that nurses view their work with a sense of ownership over patients, even in death, describing their verbalized desire to protect patients from suffering as they gently handled the postmortem care of the dead.18 A similar sense of body ownership by nurses was reported by Diamond19 in his study of nursing assistants in nursing homes. Nurses’ claim over the care of the body also extends to governance over proxy workers such as nursing aides or attendants who provide physical care in the name of nursing. Nurses’ work places them in what Parker17 calls the overlapping and interpenetrating margins between professional constraint and personal intimacy. Bodywork or caring for the patient’s body is often messy, but caring about the patient is no less messy. Savage,20 in an ethnographic study of nurses, observed that nurses are moved to care for and care about their patients, developing an emotional connection that is viewed as taboo in many scientific settings. This relational connectedness is instrumental to support the ability to care at both an individual and a societal level. As nurses proceed in bodywork, they carry out their care on a conflicted terrain, forced to negotiate social boundaries. Bodywork through such actions as bathing, toileting, and caring for wounds offers an intimacy with patients, but it is viewed as tainted work. Nurses, while frequently greeted with such statements as “you must be an angel,” are just as likely to be questioned as to why, given their intelligence, they would choose to do nursing work. As said repeatedly to me over decades of my practice and teaching, “Nursing is such dirty work—how can you stand to touch patients’ bodies . . . how can you deal with bedpans and all that blood.” Nursing labor, in directly caring for a patient’s body, more often than not requires contact with a range of bodily functions and disease manifestations such as feces, vomitus, and blood. The
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Critical Perspectives on Nursing as Bodywork bedpan brigade of hospital and nursing home settings falls into step as nurses or their proxy workers help patients with private functions of excretion. Negotiating the discomfort of bodywork is accomplished through nurses’ use of humor as well as creating social distance, using technologies, or transferring the dirty-work task to others. This transfer of tasks, particularly to lower paid workers as proxies for nurses, contributes to the segmentation of work and stratification of the nursing workforce. The nursing claim of responsibility for care of the physical body is acknowledged by society. Despite this recognition, in settings where there is a greater percentage of direct physical care of the body, it is more likely that the tainted physical functions of “dirty work” will be transferred to a lesser-trained nurse or to a nurse proxy.21 These workers, known in the United States as vocational nurses and nursing assistants, are typically paid much less than registered professional nurses.22 More often than not, such assistive or lesser trained nursing workers reside at the bottom strata of nursing work and differ from the middle and upper strata of professional nursing in racial/ethnic background and/or immigrant status. This stratification of bodywork further reflects and reproduces societal trends most notably in Westernized nations. Nursing is held up as a model of career access and mobility in most societies, but tasks and opportunities are relegated differentially within the nursing labor force. Aspirations and opportunities are also thwarted by the intersection of gender, class, and race, which continues to perpetuate a rather intransigent stratification. As nurses have sought to achieve professional status, the acquisition of power has more often than not invoked social distancing from the body. This results in not only a devaluation and invisibility of bodywork, but in literal violence and attempts at social closure between the levels of stratified nursing workers. Nurses and ancillary workers who provide intensive physical care for patients, particularly in settings such as nursing homes, find they are stigmatized and deemed “low status.” They face
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significant barriers in their attempts to move to work in higher status positions. While the call to nursing to provide greater pathways for educational articulation may open up opportunities to move beyond lower levels of work, the collective of nursing has yet to address the ambivalence about physical care in nursing.
THE REIFICATION OF THE BODY As health systems increase in their complexity and demands on nurses, they pose significant barriers for nurses in their aim for connectedness to patients. Nurses find themselves increasingly removed from the bedside of patients, managing information instead. The growth of medical technology and the rapid transfer of tasks such as physical assessment and interventions are seductive sets of tools that both add to the nurses’ understanding of the objective nature of bodies but also deflect nurses from their attention to the subjective experience of their patients. The growing focus on objective knowledge has transformed nurses into information managers. The transfer of new skills and technologies offers the illusion of greater status for nursing, yet as these new skills and technologies are acquired, they are frequently more often than not downgraded in value by not only medicine but also the institutions of health care services and payment. For example, the physical examination and/or patient encounter provided by a nurse practitioner in the United States is reimbursed at 85% of that of a physician’s physical examination under the US Medicare system.23 This occurs despite the perspective of patients that physical examination and care provided by nurse practitioners is more often done in detail and with a more personalized approach. Documentation of nursing work has long been a source of tension in nursing. The recent development and implementation of electronic medical records, while serving as a powerful method of capturing objective aspects of nurses’ work, does not easily
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capture the subjective and intersubjective nature of nurses’ work with the patient. Such standardized categories that focus on objective and measurable information fail to capture the contextual and complex aspects of nursing work. The question needs to be asked: will this further erode nurses’ roles in integrating the body as more than physicality and further reify the body as a set of biomedical measurements. Recent research suggests that nurses in hospitals felt more secure that the use of electronic medical records would prevent aspects of care from “falling between the cracks.”24 While it is difficult not to see great value in promoting patient safety and quality of care through informatics, it is important not to lose sight of patients as the center of health care. The danger is that increasingly the data derived is used to identify risks to the corporate well-being rather than the individual patient.
REGULATING AND SERVICING THE BODY In postindustrial capitalism, the patient and their body becomes a target for health services. The emphasis on service efficiency and productivity has accelerated the social regulation of the bodies and their objectification. Nurses become active participants in the regulatory processes. Nurses are placed in a contradictory position, located with patients, but driven by institutional demands to implement plans for care that are defined by “physician orders” or medical protocols. Zola25 argued in the 1970s that medicine as an institution of social control had replaced religion as the moral force in society. Similar to Foucault,26 Zola viewed the body as a political field structured by relations of power and domination. The power of the medical gaze through objectification by diagnosis proclaims the body as diseased and body functions as abnormal. Zola’s observations resonated directly with the women’s health movement, as control over women’s bodies was gained through the medicaliza-
tion of such natural events as childbirth and menopause. Medicalization provided an effective means to control women and denigrate their power in society. The concerns expressed by the women’s health movement and feminist critiques of health care have contributed to the rise of nursing power. In the United States, the movement of nursing education to colleges and universities was influenced by feminism, reflecting the longstanding struggle for nursing to be recognized as more than a domestic calling. The pursuit by nurses for professional legitimacy and the parallel movement toward power of a collective body of nurses in the workplace reflect the continuing tensions in women’s work. There have been repeated calls for greater nursing autonomy in the workplace. Autonomy continues to be stifled more often than not by the constraints of institutionalized practice and legal regulations. Legal regulation of the scope of nursing practice has struggled with medicine’s attempt to define nursing by exclusion. As medicine reacts to what is perceived as a decline in power, there is a growing movement on the part of organized medical groups to control access of nurses to patients as well as control the scope of nursing actions. In the United States, the covert and overt constraints on allowing nurses to practice to the full extent of their education was addressed as the first area of recommendation in the 2010 Future of Nursing Report.27 The majority of registered nurses are employed in hospitals settings where the dominance of physician power is maintained through the gatekeeper role in the health care system. It typically is the decision of the physician to admit and/or discharge patients. But, under pressure from payers and corporate risk managers, physicians are pushed to admit fewer patients to hospitals and if admitted, discharge patients more quickly. Patients whose bodies are most subject to income-generating diagnostics, surveillance, and treatment are the most desired. This differential value for the body reflects the growing corporatization of health care. Conrad28 notes that the
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Critical Perspectives on Nursing as Bodywork power of medicine as an institution of social control is being eroded by the increasing corporatization of health. The systematic proliferation and dissemination of standardized clinical guidelines and practice metrics contribute to the erosion of medical autonomy. The patient body is reconstituted under the new corporate gaze. Despite the loss of individual physician autonomy, corporate decision-making in health care continues to be dominated by physicians. Nurses have long contended with the growing standardization and rationalization of corporate health systems and bureaucracy. Patients and health care providers face increasing regulating forces. The rationalization of work is increasing under governmental scrutiny. New regulations for Medicare in the United States are reshaping health care decision-making across the range of health care settings. Regulatory imperatives in health care accreditation have made mandatory, evidence-based standards for best practices. The regulations for reimbursement of providers of health care services require the use of an organized classification of the messy and often ambiguous characteristics of disease. Classification schemas such as the International Classification of Diseases, commonly used in the United States, construct the body as diseased fragments. This process objectifies the patient, ignoring the experience of illness and the ability to function.29 Nurses and other health care providers are beginning to advocate for alternative classification systems that provide a more holistic perspective on patient health. One alternative is the International Classification of Functioning, Disability, and Health, known more commonly as ICF.30 This system offers a classification of health and health-related domains and takes into account the contextual environment for disability and health. This movement, while endorsed by 191 World Health Organization member states has been slow to take hold in countries such as the United States, because of the dominance of the biomedical paradigm. Nurses, as witnesses to the fragmentation of care under the dominant disease approach,
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provide a powerful source for advocacy to empower new approaches based on health.
NURSING THE BODY AT RISK As medical technology and biomedical science have advanced, their application has contributed to the increasing regulation of the body. The body is examined and replicated through biotechnological processes of screening and diagnostics including genetic profiles, scans, and other technologies.29 The body, mapped through the Human Genome Project, is now scrutinized as both a market asset and a potential liability or risk. An inherent danger in the growing use of such technologies is that their application takes precedence over the actual patient; the patient is reified through technology and the humanity of the patient is diminished. Concerns that technology contributes to dehumanization through technology have contributed in part to the call for patientcentered care. There is a growing tendency to use patient data to better manage uncertainty in health care with the goal of reducing corporate risk. The Institute of Medicine report, Crossing the Quality Chasm, called for the development of health profession competencies in patient centered care, evidence based practice, quality improvement, team collaboration, and informatics. Nursing responded to the call to integrate the Institute of Medicine competencies through the development of a grant-funded initiative called Quality Safety Education for Nurses. This initiative outlines competencies in terms of nursing knowledge, skills, and attitudes. If embraced as a philosophical statement of values and not simply a technical checklist, the Quality Safety Education for Nurses initiative has the potential to reawaken the decades long debate about humanizing health care in a market-oriented health care system.31 There is potentially great value in stressing nursing competencies. The tendency to prioritize knowledge and skills above attitudes and values may undermine the intended outcomes for patient
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care. Patient centered praxis is foundational to quality and safety in health care. The emphasis on patient-centered health care implies a shift in power away from paternalism and the provider as the locus of care. The challenge of the patient-centered approach to health care is that while it is intended to see the patient as a partner of care, the patient is also viewed as a consumer of health. In this corporatized view, patient is perceived as a consumer “buying” health care services. While this is somewhat disputable in a less-than-free market, the ideology of consumerism leads to the perception that the patient is responsible for the care of his or her own body and the decisions that are made within the health care system. To make decisions, patients require access to information. While nurses can act as interpreters or guides within the model of consumerism, they are expected to play a neutral role. To paraphrase Gadow,32 “paternalism in health care dispenses with the patient while consumerism dispenses with the nurse.” Nurses should take the essential role as partner and advocate. Within the context of a genuine discourse with their patients, nurses are able to engage in a discussion of the differing values, risks, and choices that present in clinical situations but with respect for the patient’s values and decision authority. The body has become a burgeoning growth market for health promotion services. Health promotion largely aims to direct individuals to make behavioral changes and “choices” for reducing risk to the health of the body. The body becomes a target for action viewed as the responsibility of the possessing agent. The paradox inherent in health promotion is that while action is directed at individuals, the goal is to reduce aggregated risks within a population such as workplace or health system set of covered lives. The current concern for obesity exemplifies the challenge of health promotion. Individual behavior does not equate to free, informed, and equal choices in most societies or to access to affordable healthy food. Frohlich et al argue that risk to the health of the body is a consequence of in-
tertwined social structures and sociocultural practices, which are recursive. Accordingly, social behaviors that contribute to risks are both individual and collective, as the individual “acts out” the practices that feed into a larger system.33 Despite the growth of social epidemiology, the concept of risk is often decontextualized, as the complexity of factors that contribute to risk and the development of disease remain hidden behind an ideology of individual responsibility and blame. As a result, in this era of health consciousness, the body that does not adhere to targets for risk reduction and avoidance is further defined as diseased and stigmatized. Too little emphasis is placed on challenging and changing the social dynamics, rituals, and patterns that perpetuate and foster poor lifestyle choices, institutional responsibility, and government paralysis. The market-based context of health reshapes the forms of social control over the body into uncharted territory. This growing preoccupation with control over the body is evident in the growing sociopolitical debates. Such debates include a wide range of topics from individual reproductive health and disability to global health and population sustainability. This convergence of interest in “the body-local” and the “body-global” is double edged. Humanitarian and economic interests insidiously intertwine. Extending the medical gaze over global health runs the risk of exploitation and voyeurism as well as deflecting attention from the socioeconomic underdeterminants of disparities. Interest in the eradication of disease in one country creates an opportunity for low-cost pharmaceutical testing bodies with profits more often than not exported. The growing export of pharmaceutical testing and medication “dumping” opens new territory for the commoditization and exploitation of bodies.34 Nurses as central actors in health care systems globally stand in witness. As nurses are becoming more conscious of their global potential, a global nursing praxis will require that nurses unite with moral courage and action to advocate for change. The need for action runs from local
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Critical Perspectives on Nursing as Bodywork to global. It is sometimes more comfortable to look at the “other” and address the issues of global health from afar, and then confront the reality of the disparities close at hand. This is a paradox recognized by Nightingale and more recently addressed in the Nightingale Initiative for Global Health, which called for nurses to support the collective potential of nurses to work together locally with a global intention in both “sick” nursing and “health” nursing.35
NURSING BODIES AT WORK The call for nurses to unite in support of global health has traveled around the world espoused by nursing leaders. But at the ground level of nursing work, nurses continue to struggle for recognition and reward. Nurses are generally the largest group of workers in settings such as hospitals; nurses are reduced to “just another body.” All too often, nurses are treated as interchangeable, like machines. The corporatization of health care, which benefited from a century of paternalism, furthered the exploitation of nursing workers. Nurses serve as the means of production for health care services and as a major cost in health care services, retaining control over nursing labor that has been to the benefit and profit of hospitals and other health care institutions. While many industries have used outsourcing of reduce labor costs, health care presents some unique challenges. The direct and physical care of patients and their bodies is not easily sent oversees. Instead, health care systems have attempted to reduce costs using substitute labor, traveling nurses. Another consequence of such approaches to nursing labor force management is that it undermines the collective action potential of nurses. As nurses moved to organize collectively, their efforts were fraught with ambivalence. The traditions of selfless service that shaped early nursing continue to echo forward in messages from administrators and staff nurses. Initial collective bargaining efforts in the United States and elsewhere argued
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for recognizing the professional expertise of nurses as well as improved working conditions and compensation. Significant gains were achieved by nurses in the United States shared by nurses working in unionized institutions as well as those working in institutions attempting to be competitive but remain nonunionized. Despite gains in benefits, congruence of bargaining with professional practice goals remains elusive in many settings. The lack of shared goals among nursing organizations has left the professional body that was conceived of to represent a unified nursing in the United States fragmented. As a result, a recent trend is the co-optation of professional or American Nurses Association affiliate bargaining units by industrial labor unions. Unions in the United States have turned to the nurses to replace their diminishing industrial worker membership. The power of industrial unions has been successful in raising salaries and enacting workplace regulations such as nurse-patient ratios. But these advances have occurred through an increased militancy and disruptions to patient care on the part of both unions and hospital administrations. Professional nursing organizations such as the American Nurses Association, strained to represent the interests of competing nursing camps and unions too, more often view professional practice goals as “elitist.” The lack of a cohesive vision for the future is a fundamental challenge that undermines the potential of all of nursing and the health care system. While nursing stratified most visibly by education, the underlying stratification by race, class, and gender persists. Fragmentation of the nursing force erodes the power of collective action. Oppressed or repressed, nurses as noted by Reverby are forced to work in societal institutions that value corporate interests and rationalization of work over caring work.36 Amidst the contradictions of corporate health care and disintegration of the collective body of nursing, there is an effort to reclaim a connection to caring. This is evident in the renewed interest in theories of
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caring. One perspective is that nurses are attempting to create a distance as well as claim a difference from the growing technologydriven health care system and profession of Medicine.37 But it may also be that refocusing on caring avoids the messy terrain and “disease” in the collective nursing body. As Davies notes, nurses need to build a new professionalism that reclaims a rationality of caring.
EMBODIMENT AND THE CARING ETHIC Nursing has moved around and within the theories of embodiment reflecting a shifting paradigm. A slow but growing interest in the idea of embodiment emerged within sociology, anthropology, philosophy, and a variety of other disciplines as other disciplines sought to challenge the dominance of positivism. Embodiment is a relational concept for nursing, as it refers to the physical and mental experience of existence, “it is the possibility of our relating to other people and to the world.”38 As theories of the body and embodiment evolve, the tensions between differing thought traditions have created an opportunity for nursing as a caring praxis. Nurses have turned toward traditions of existentialism, phenomenology, postmodern critical theory, and feminist theory to help uncover the experience of nursing in relation to the experience of the recipients of nursing care. Embodiment theory emerges from the critique of mind-body dualism and counters the objectification of the patient “body” reintegrating bodywork within a holistic perspective. As early as the 1960s, interest in nursing work as an intersubjective experience began to emerge in the nursing literature. Vaillot39 argued for nurses to embrace existentialism and view nursing as a shared human experience. For Gadow,40 this call for the nurse to meet the patient in an intersubjective relationship is grounded in moral advocacy. Patterson and Zderad,41 in their theory of existential nursing, posited that that the intersubjectivity of the nurse-patient relationship is one of reciprocity as the nurse is not simply “at the
other’s disposal but also being with him/her with the whole of oneself.” The other is also seen as a presence, as a person rather than an object. Nursing has followed a path from existentialism to phenomenology to address the problems posed by Cartesian duality of mind and body. Nursing’s approach to phenomenology is based on Merleau-Ponty’s42 belief that human perception is embodied. Perception evolves in constant motion, moving back and forth between corporeal forms and, at other times, moving toward personal acts. For Merleau-Ponty, there is not a separation between body and existence. Knowledge of the world emerges from a state of being in the social world. This idea of embodied perception is at the core of Merleau-Ponty’s work, which in turn is focused on the individual. The pull of this work lies in the explication of the person’s experience of their body as they experience health, illness, and disability. Bourdieu,43 a structuralist theorist, has suggested that, in terms of explicating meaning in the body, the body must be viewed within a social context, further noting that the person and the subjective are social and collective. For Bourdieu, the belief in the possibility of human freedom and the potential to act in a responsive manner adapting to unique social or situational contexts is at the heart of practical sense. This emphasis on the “practical” forms the link to the practice of nursing. Bourdieu, however, suggests that practice, must not be reduced to a logical form, but rather be understood through narratives of participants. This synthesis of the phenomenological and structuralist perspectives provides a powerful means to interpret or describe the complexity of embedded experiences for individuals and the collective bodies within society. Turner notes that this refocusing on embodiment is particularly notable in nursing and suggests that it has helped to move other disciplines, such as sociology, away from the focus on health professions as occupations and instead attend to the shared experience of health care providers and patients. This
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Critical Perspectives on Nursing as Bodywork growing attention to what sociologists have called the “lived” body provides a means to not only capture the experience of the providers and patients but also to begin to untangle the particulars of mutuality of experience. Nursing theorists such as Gadow, Watson, and Benner have moved nursing toward this phenomenological understanding of embodiment. Gadow, in the early 1980s, described nursing as existential advocacy. According to Gadow, nurses participate in partnership relation to the embodiment of patients as they determine the meaning in their illnesses, disabilities, or deaths.44 Concerned with the ethics of caring in nursing practice, Gadow developed an interest in narratives. While embodiment is a condition of existence for Gadow, the narratives of embodiment offers a multilayered perspective that move dialectically from subjective immersion and objective detachment to a relational ethic of care.45 Watson’s theory of caring science furthers builds on the primacy of an underlying moral ideal and transpersonal caring relationship. She defines the person or patient as a unity of mind, body, and spirit to make explicit the metaphysical. According to Watson, the unifying focus and process is on the “connectedness with self, other, nature and higher reality . . . .”46 In contrast to Gadow, Watson expresses a caring ideal that goes beyond the individuated care context, to describe caring science as not only for sustaining humanity but essential to our future global existence. Watson’s philosophy has overtly embraced a universal or global context for caring. Caring is viewed as a guide to change the environmental culture of practice. Consequently, Watson’ s caring calls for a shift of consciousness to both become aware of and address the moral and professional conflicts that emerge out of the growing corporatization and commoditization of health care. While Watson takes a stance against the commodification of caring, she suggests pragmatically that caring and the economics of care can coexist. Watson expresses the optimistic vision of health care institutions being transformed from the
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inside out through an evolved consciousness that restores human caring, health, and healing into our health care systems. There is a growing movement in a number of health care institutions to adopt Watson’s transpersonal caring theory as a means to reframe nursing service. While Benner is best known for her work From Novice to Expert, a model of skills acquisition based on the work of Dreyfus, her work has evolved to embrace a phenomenological theory of embodiment and situated nursing practice. This led to her interest in trying to identify clinical knowledge and describe the process through which the embodied nurse clinician gains expertise through experiential knowledge, perception, and reflection in action.47 For Benner and colleagues, skills acquisition and clinical knowing flows out of situated caring in the embeddedness or habitus of embodied patient and illness experience. The nurse as an embodied knower is able to read the body of the patient. Expertise in knowing and responding then allows the nurse as body to act intuitively.48 Benner’s phenomenological perspective seeks to explicate the contextually situated meanings and intents within the exemplars or narratives of the clinical situation. This interpretive approach has provided a powerful and professionally valued focus on nursing expertise but, as with Watson, recognizes caring as situational and based in the caring relationship. Nursing knowledge, explicated through the work of Benner and colleagues, is gaining legitimacy through its application in a variety of institutional and geographical locations. The Benner domains of knowledge provide a useful guide to understanding practice. Benner stresses the importance of communities of practice in which learning to apply care ethics as nurses occurs. Caring for the body, carrying out tasks with the best techniques, and yet failing to engage in a caring relationship with the patient does not constitute a practice. There is a growing convergence in nursing philosophy, theory, and practice around a caring ethos in response to the nurses’
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perceptions and experiences in health care systems. There is also hope in such a convergence, as theories point to action.
NURSING ADVOCACY FOR THE NURSING BODY Nurses are challenged to attend to the messy and complex nature of the situated embodiment. The organizational context includes class, race, and gender in shaping the care, work experience through objective, and internalized structures. These interpenetrate and, through the social environment and behavioral context, reproduce health and unhealthy bodies. In the reproduction of the nursing workforce, class, race, and gender stratify nurses, which undermine the collective body integrity of nursing in society. The divisiveness that is generated by stratification results in a differential set of lived experiences. The organizations in which nurses contributes to the divisions in nursing solidarity, by offering advancement to some nurses, while holding back others. The promotion of status hierarchies further isolates nurses from one another and adds to the lateral violence of oppressed group behaviors. Despite rhetoric about community-based care, hospitals are still the dominant force in nursing culture. Nurses working in hospitals are called to practice under increasing patient intensity, monitoring, and documentation. Nursing work is more often than not in conflict with an ethic of care. While nurses hold caring as a central ethic in nursing work, this is not a necessary requirement to hold a job as a nurse. Nursing offers paid work and more autonomy in caring than is often available in nonpaid care work. But more often than not, nurses find that they are often at odds with institutional priorities. As noted earlier, nurses have made gains in their benefits and working conditions through collective bargaining. But, as labor laws and the business of unions have changed, many nurses are now stuck between 2 patriarchal masters, the hierarchy of health care administration and
an industrial modeled union. Caring for the patient is diminished in the power struggle. As one nurse recounted to me recently, if a patient calls for a nurse to provide medication for pain near the end of a shift, the nurse is told to ignore the request and complete their required documentation thereby avoiding mandatory overtime called for by the union contract. The battle to control the nursing labor force is directed by the economics of labor costs. Nurses, caught between competing bureaucratic and/or corporate priorities, are struggling to stay grounded in a caring ethic. To change the situation, nurses must recognize first that they have power and exercise their power within institutional, organizational, and governmental arenas. Watson suggests that a theory of caring can change institutions from the inside out. I believe that nurses must learn to care for those with whom we care, as well as with those we care for. The explication and celebration of nursing knowledge furthers the potential to heal the collective body of nursing by offering a praxis that returns nursing to a clear message of “I know what I do and do what I know.”49 There is a dialectical challenge in coming to know nursing and coming to care for the nursing body. Nurses’ engagement in emancipatory praxis requires that we hold the dialectic of nursing knowledge and knowledge of nursing simultaneously. We must recognize that our power, while it emanates from our embodied relationship, is not limited to this relationship. Tunneling our vision inward, without looking critically at our practice context disempowers. The nursing environment is now global; nursing itself is now a global community. The globalization of healthcare has created new challenges as nurse migration and “traveling” nurses rapidly cross the health care landscape. Those of us who practice in countries where higher status and pay prevail need not denigrate, but rather reach out to, our colleagues in nations where conditions are more resource challenged. The richness of caring does not correlate with the degree of technology available or with the level of salaries.
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Critical Perspectives on Nursing as Bodywork We share global threats and opportunities for health. But when health services are delivered without caring, then bodies of patients and nurses become just another market open to exploitation and fragmentation. As we face a new global caring dilemma, our perspective will require heightened advocacy and political acumen.
CONCLUSION Nursing work offers a multifaceted lens through which we view social representations and relationships to the body. Nurses hold both a privileged position in society and a stigmatized role through their gendered relationship to body work. Despite the potential dehumanization and fragmentation of health services under the growing corporatization of health care, nurses continue to be trusted. The power of nursing as a collective body
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of nursing workers is redefined, moving away from its prior relation to medicine and toward patient-nurse relations. Nursing praxis offers a powerful means to counter the objectification of the patient “body” and to reintegrate bodywork within a holistic perspective. Sustaining the trust and respect of patients is not a given nor is nursing’s central position in the health care system a given or even well understood as such. Nursing’s claim of legitimacy in caring for the body, supported by a theory of embodiment, offers a powerful means to simultaneously make nurses’ work visible and de-stigmatize their work. But it also offers nurses a challenge to reconnect a caring ethos that not only cares holistically for the patient but also helps to heal and unite the collective body of nurses as a profession. As the largest group of health professions in most countries, there is tremendous potential power in nurses to use their voice for caring and social justice.
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10. Landivar L. Men in nursing occupations. American Community Survey highlight report. https:// www.census.gov/people/io/files/Men_in_ Nursing_Occupations.pdf. Published February 2013. Accessed March 22, 2013. 11. Evans J. Men in nursing: issues of gender segregation and hidden advantage. J Adv Nursing. 1997;26:226– 231. 12. Davies C. Gender and the Professional Predicament in Nursing. Buckingham, GB: Open University Press; 1995:140. 13. Mills M, Schejbal M. Bedpans, blood, and bile: doing the dirty work. In: Drew S, Mills M, Gassaway BM, eds. Dirty Work: The Social Construction Of Taint In Nursing. Waco, TX: Baylor University Press; 2007. 14. Stanley DJ. Celluloid angels: a research study of nurses in feature film (1900-2007). J Adv Nurs. 2008:84-95. 15. Ashley JA. Hospitals Paternalism and the Role of the Nurses. New York, NY: Columbia University; 1976. 16. Reverby S. Ordered to Care. The Dilemma of American Nursing, 1850–1945. New York, NY: Cambridge University Press; 1987. 17. Parker J. The body as text and the body as living flesh: metaphors of the body and nursing in postmodernity. In: Lawler J, ed. The Body
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32. Gadow S. Basis for nursing ethics: paternalism, consumerism, or advocacy? Hosp Prog. 1983;64(10):62– 78. 33. Frohlich KL, Corin E, Potvin L. A theoretical proposal for the relationship between context and disease. Sociol Health Iln. 2001;23(6):776– 97. 34. Petryna AT. Clinical trials offshored: on private sector science and public health. BioSocieties. 2007;3(1):21-40. 35. Beck DM. Expanding our Nightingale horizon: seven recommendations for 21st-century nursing practice. J Holist Nurs. 2010;28(4):317-26. 36. Reverby S. Ordered to Care: The Dilemma of American Nursing, 1850–1945. New York, NY: Cambridge University Press; 1987. 37. Barnard A, Sandelowski M. Technology and humane nursing care: (ir)reconcilable or invented difference? J Adv Nurs. 2001;34(3):367-375. 38. Cregan K. The Sociology of the Body. London, Great Britain: Sage; 2006:3. 39. Vaillot SMC. Existentialism: a philosophy of commitment. Am J Nurs. 1966;66(3):500-505. 40. Gadow S. Body and self: a dialectic. J Med Philo. 1980;5(3):172–185. 41. Paterson JG, Zderad LT. Humanistic Nursing. New York, NY: John Wiley & Sons, Inc; 1976. 42. Merleau-Ponty M. Phenomenology of Perception. New York, NY: Routledge; 2002. 43. Bourdieu P, Wacquant LJD. An Invitation to Reflexive Sociology. Chicago, IL: University of Chicago Press; 1992. 44. Gadow S. Existential advocacy: philosophical foundations in nursing. In: Smith S, Gadow S. Nursing Images and Ideals. New York, NY: Springer Press; 1980:79–101. 45. Gadow S. Relational narrative: the post-modern turn in nursing ethics. Sch Inq Nurs Pract. 1999;13(1):57– 70. 46. Watson J. Caring science and human caring theory: transforming personal and professional practices of nursing and health care. J Health Serv Adm. 2009;31(4):466-482. 47. Benner P. From novice to expert. Am J Nurs. 1982;82(3):402-407. 48. Chan G, Brykczynski RM, Benner P. Interpretive Phenomenology in Health Care Research. Indianapolis, IN: Sigma Theta Tau; 2010. 49. Chinn P. Peace and Power. 8th ed. Burlington, MA: Jones & Bartlett; 2013:10.
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Advances in Nursing Science Vol. 37, No. 2, pp. 147–160 c 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins Copyright
Critical Perspectives on Nursing as Bodywork Karen Anne Wolf, PhD, APRN-BC, DFNAP Nursing is grounded in care of the body. This article examines nursing as bodywork, as experienced intersubjectively by nurses together with patients and collectively as a body within the health care labor force. The relation of nurses to the body generates conflicting and contradictory social meanings from intimate and sacred work to dirty work. Such meanings have contributed to stigmatizing the work and the worker within the labor force as well contributing to an ongoing stratification in the labor force as nurses have shifted bodywork “to lower level” or ancillary workers. Key words: bodywork, nursing labor force, social relations, stigma, work force stratification
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URSING WORK is historically and culturally viewed as “bodywork.” Despite efforts to professionalize nursing practice through education, practice changes, and collective organizational effort, in the public’s eye the work of nurses continues to be inextricably bound to the physical care of patients’ bodies. This article explores nursing as bodywork and the complex social relations and perspectives that shape this construct. Bodywork has received scant attention in nursing in the United States. This lack of attention reflects a fundamental schism between the theories and praxis of nursing work. Nursing theory development espouses an integration of the biological and psychosocial dimensions, yet many theoretical perspectives situate the psychosocial or interaction aspects of care as foreground in practice and at the same time de-emphasize
Author Affiliation: School of Nursing, Samuel Merritt University, Oakland, California. The author has disclosed that she has no significant relationships with, or financial interest in, any commercial companies pertaining to this article. Correspondence: Karen Anne Wolf, PhD, APRNBC, DPNAP, School of Nursing, Samuel Merritt University, 3100 Summit Street, Oakland, CA 94601 ([email protected] Or [email protected]). DOI: 10.1097/ANS.0000000000000028
the care of the body. The practice of nursing is bound through the process of bodywork and contributes to and gains from what Turner has termed the “regulation and reproduction of the population of bodies.”1 The consequences of the sociopolitical and economic regulation of bodies affect both patients and the nursing workforce. In the following sections, I relate the concept of nursing as bodywork to the patient care experience. I suggest that despite gains in professionalism, nursing as a profession continues to be devalued and disregarded as a source of authority in society due to nurses’ proximity to the body. As health care has expanded the role of nursing across settings, this has also contributed to the expansion of nursing’s role in the regulation and reproduction of bodies. As a first step toward an emancipatory nursing praxis, nurses must recognize and embrace the nursing relationship to the body and how this relationship has influenced the collective body of nursing. Praxis emerges as critical reflection on the power and constraint inherent in bodywork informs and aligns the every day work of nurses. Nursing is transformed, as nurses’ awareness of the societal values surrounding the physicality of the body is reconciled within holistic totality of care for patients. This reconciliation of nursing values and actions is essential to empower the collective body of nursing. 147
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NURSING AND BODY RELATIONSHIP By historical claim and medical dominance, the nursing act of caring for patients is focused on the “corpus” or body. The development of nursing within religious institutions and traditions reinforced the ideal of caring for the body, with the body and soul more often seen as a unity. Nursing knowledge and practice evolved in concert with medicine. As the body became a venue for medicine to study disease and pathology, nurses tended to the diseased body and suffering soul, while making observations essential to medicine’s study.2 The imprint of Cartesian dualism on medicine contributed to viewing the body as an object, with the intent to best determine how to diagnose and treat the body’s pathologies.3 Nurses became not only the “physician’s hand” as Melosh stated but also the physician’s eyes.4 This extension of the physician’s gaze was both literal and figurative. Medicine evolved within a naturalistic perspective of the biophysical sciences. The medical paradigm does not neglect the mind but rather views it as less relevant to the diagnostic enterprise. By contrast, nursing theory and science followed principles set forth in the early Nightingale era that emphasized that nursing was complementary to medicine. As caretakers of patients suffering with illnesses and diseased bodies, nurses addressed the environmental and psychosocial conditions for healing. Care of the sick room emphasized physical aspects such as air quality, cleanliness, and noise. Efforts to advance nursing science in scholarship and practice embraced the role of psychosocial influences on health and illness. The art and science of nursing evolved in an uneasy tension in a culture of health care dominated by medical reasoning. By the mid-twentieth century, nursing theories began to reference theories on stress, coping, and adaptation. Nursing rejected the idea mind-body dualism and evolved theories that viewed the patient as an integrated, biopsychosocial being. Numerous debates within the nursing profession over the past 40 years have argued the value of “grand nurs-
ing theories” and conceptual models of practice. Despite attempts to build a professionspecific knowledge base for nursing, the influence of nursing theory development has had a limited reach outside academic circles of the discipline. The dominant cultural perception of nursing work views nurses as subservient to physicians, carrying out orders that relate to doing something to or for the body. The power and legitimacy of medical knowledge in society provides an alluring draw for many nurses and informs much of nursing practice. As legal and social efforts to define the scope of nursing practice as separate and distinct from medicine have moved forward, nursing work continues to be defined by exclusion from and/or extension of Medicine. The critique of medical dominance in the 1970s generated new social theories that moved professions and institutions to examine the role of medical knowledge. Previously absent from much of the literature, the body emerged, taking shape, according to Mary Douglas, as “the two bodies,” a body viewed and experienced at the physical level, constantly shaped and reshaped by the sociocultural categories and meanings as a social body.5 Societal attempts to categorize illness behavior take note of and redefine body disturbances. Giddens6 points out that as the body is redefined, so too is the individual’s self-identity. Individuals living with chronic disease, illness, and disability experience not only a denigration of their sense of self but also a lowering of their social status.7 Nursing, similar to the patients we care for, is defined in relationship to the body, challenging the self-identity of nursing as well as the social status of the profession. Nursing as bodywork serves as a window through which to view the panoply of cultural meanings and theoretical perspectives that surround the body. Nurses are held in high trust by some, viewed as low status work by others, and mirror the perceptions of the body as sinful, dirty, and sexualized. Nursing reflects the diversity and often-contradictory images and meanings associated with bodywork as gendered.
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Critical Perspectives on Nursing as Bodywork NURSING AS GENDERED WORK Nursing as women’s work is a characterization that persists despite a history of men in nursing. Through bodywork, nurses reproduce the domesticity of the home, hospital, nursing care homes, and other care environments.8 Nurses, according to Graham, symbolically serve as wives and mothers within the primary institutions of care.9 Similar to the mothering and domestic work in the home, nurses are viewed in a maternal role and are responsible for the care of the body. The impact of gender on nursing work is felt throughout nursing education and nursing practice settings, shaping enrollments and choices of work settings. Even though the number of men entering nursing has slowly risen to 9.6% of all nurses in the United States, the female gendering persists.10 Men are welcomed into nursing with mixed emotions but benefit from the underlying patriarchal gender relations. They are frequently afforded advantages that allow them to achieve status and power more readily than their female colleagues. The gendering and feminization of nursing work establishes an artificial contrast that assumes that medicine is male gendered and is based on masculinity. Men who enter nursing are viewed as deviant that further pushes men into career paths that place them apart from or above their female colleagues.11 While gender is a powerful force in structuring nursing work, it also is an essential ingredient in the structuring of nurse and physician identities and roles. According to Davies,12 this false duality of gender serves “to wrench apart the richness of our human qualities, denying or repressing the feminine while assigning privileged status to the masculine.” This underlies the assumption that women are less repelled by dirty work and attending to bodily functions and less likely to exploit the intimacy in body relations. The identity and public image of the nurses has been imbued with gendered meanings associated with the body. More than 100 years after Dickens created his infamous
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character Sary Gamp, nurses continue to be stigmatized. Despite protestations, nurses are sexualized in pornography and advertising. Nurses’ proximity to and intimacy with the body underlies this discomfort and intersects with societal attitudes about gender and class to promote an objectification of the nurse. The projected media images of nurses, seen in books, television, and even greeting cards, project the societal discomfort and ambivalence toward and about nursing. Many of the stereotypes objectify nurses as self-sacrificing heroines and romantic interests. An even greater number present nurses as sex objects. A recent study found some 500 pornographic movies featuring nurses in 1 site alone retrieved in a brief 30-second Internet search.13 The sexualization of nursing in pornography underscores the association of nursing with the social discomfort that emanates from the physical care of the body. Efforts to redress such distortions in the image of nursing through lobbying and criticizing ‘influentials” in media and policymaking provide a superficial answer to the deeper problem of the contradictory position of nursing in society. Despite the recent trend of films and television such as “Nurse Jackie” to portray nurses as strong women, the negative stereotypes of nursing persist, suggesting the degree to which nursing as bodywork is tainted.14 The ideology of nursing as gendered is foundational to the structural analysis of nursing as work. Feminist nursing historian, Ashley, argued that paternalism and sexism both shaped and exploited nursing within hospitals.15 This thesis is further elaborated by Reverby who suggests that paternalism, while a central factor, does not fully explain the exploitation. She notes that social class divisions within the nursing and medical workforce were primary factors in exploitation. The growth of hospitals under a utilitarian and industrial approach to care resulted in what Reverby called “a caring dilemma” in which “nurses [are] ordered to care in a society that fails to value caring.”16 The growing industrialization and corporatization of health care ties nurses pragmatically and symbolically
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to patients’ bodies, carrying out fragmented tasks of care. To reclaim holism in nursing, nurses must speak out to reshape health care priorities, recasting patient-centered care as holistic in praxis and as a fundamental ideal, and not simply an outcome.
THE PRIVILEGE AND TAINT OF BODYWORK It is widely acknowledged that nursing is a hard work, but nursing is also a privileged work. Across the world, nurses tend to patients at vulnerable times of their lives, providing care for patients young and old, sick and well. Sandelowski2 observes that bodies are the primary focus of nurses’ work throughout the world, as they care for ailing patients and childbearing women. Nurses’ labor is an essential aspect of the patients’ experience of uncertainty, pain, and/or suffering. This attention on the physical body, pain, and suffering has historically been viewed as the purview of nursing. Despite advances in technology, nurses continue to attend to patients’ physical needs and carry out nursing and medical therapeutics with patients. Thus the physical and emotional intimacy, shared between nurses and the patients for whom they care, serves as a foundation for trust and respect. In the United States, nurses continue to top the list of the most trusted professionals in Gallop polls. Nurses tend to their patients’ bodies as objects, sometimes oblivious to their “embodied” humanity and, at other times, are enmeshed in a caring interrelationship. Parker17 suggests that the nurse’s relationship to the body is positioned indeterminately at the interface of an expressive connection, that of “doing for” and a “being with” the body. This mirrors the objective-subjective dualism in health and illness, which surfaces in a compartmentalized approach to patient care. Nursing ideals upholding nursing practice as a relational experience of providing care for the body are viewed as one aspect of caring for the patient. This also reflects a territorial
claim to the patient and body. Wolf, in her study of nurses’ work with the body, suggests that nurses’ work with the body offers a symbolic ownership. In her observations of nurses in an urban hospital, she relates that nurses view their work with a sense of ownership over patients, even in death, describing their verbalized desire to protect patients from suffering as they gently handled the postmortem care of the dead.18 A similar sense of body ownership by nurses was reported by Diamond19 in his study of nursing assistants in nursing homes. Nurses’ claim over the care of the body also extends to governance over proxy workers such as nursing aides or attendants who provide physical care in the name of nursing. Nurses’ work places them in what Parker17 calls the overlapping and interpenetrating margins between professional constraint and personal intimacy. Bodywork or caring for the patient’s body is often messy, but caring about the patient is no less messy. Savage,20 in an ethnographic study of nurses, observed that nurses are moved to care for and care about their patients, developing an emotional connection that is viewed as taboo in many scientific settings. This relational connectedness is instrumental to support the ability to care at both an individual and a societal level. As nurses proceed in bodywork, they carry out their care on a conflicted terrain, forced to negotiate social boundaries. Bodywork through such actions as bathing, toileting, and caring for wounds offers an intimacy with patients, but it is viewed as tainted work. Nurses, while frequently greeted with such statements as “you must be an angel,” are just as likely to be questioned as to why, given their intelligence, they would choose to do nursing work. As said repeatedly to me over decades of my practice and teaching, “Nursing is such dirty work—how can you stand to touch patients’ bodies . . . how can you deal with bedpans and all that blood.” Nursing labor, in directly caring for a patient’s body, more often than not requires contact with a range of bodily functions and disease manifestations such as feces, vomitus, and blood. The
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Critical Perspectives on Nursing as Bodywork bedpan brigade of hospital and nursing home settings falls into step as nurses or their proxy workers help patients with private functions of excretion. Negotiating the discomfort of bodywork is accomplished through nurses’ use of humor as well as creating social distance, using technologies, or transferring the dirty-work task to others. This transfer of tasks, particularly to lower paid workers as proxies for nurses, contributes to the segmentation of work and stratification of the nursing workforce. The nursing claim of responsibility for care of the physical body is acknowledged by society. Despite this recognition, in settings where there is a greater percentage of direct physical care of the body, it is more likely that the tainted physical functions of “dirty work” will be transferred to a lesser-trained nurse or to a nurse proxy.21 These workers, known in the United States as vocational nurses and nursing assistants, are typically paid much less than registered professional nurses.22 More often than not, such assistive or lesser trained nursing workers reside at the bottom strata of nursing work and differ from the middle and upper strata of professional nursing in racial/ethnic background and/or immigrant status. This stratification of bodywork further reflects and reproduces societal trends most notably in Westernized nations. Nursing is held up as a model of career access and mobility in most societies, but tasks and opportunities are relegated differentially within the nursing labor force. Aspirations and opportunities are also thwarted by the intersection of gender, class, and race, which continues to perpetuate a rather intransigent stratification. As nurses have sought to achieve professional status, the acquisition of power has more often than not invoked social distancing from the body. This results in not only a devaluation and invisibility of bodywork, but in literal violence and attempts at social closure between the levels of stratified nursing workers. Nurses and ancillary workers who provide intensive physical care for patients, particularly in settings such as nursing homes, find they are stigmatized and deemed “low status.” They face
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significant barriers in their attempts to move to work in higher status positions. While the call to nursing to provide greater pathways for educational articulation may open up opportunities to move beyond lower levels of work, the collective of nursing has yet to address the ambivalence about physical care in nursing.
THE REIFICATION OF THE BODY As health systems increase in their complexity and demands on nurses, they pose significant barriers for nurses in their aim for connectedness to patients. Nurses find themselves increasingly removed from the bedside of patients, managing information instead. The growth of medical technology and the rapid transfer of tasks such as physical assessment and interventions are seductive sets of tools that both add to the nurses’ understanding of the objective nature of bodies but also deflect nurses from their attention to the subjective experience of their patients. The growing focus on objective knowledge has transformed nurses into information managers. The transfer of new skills and technologies offers the illusion of greater status for nursing, yet as these new skills and technologies are acquired, they are frequently more often than not downgraded in value by not only medicine but also the institutions of health care services and payment. For example, the physical examination and/or patient encounter provided by a nurse practitioner in the United States is reimbursed at 85% of that of a physician’s physical examination under the US Medicare system.23 This occurs despite the perspective of patients that physical examination and care provided by nurse practitioners is more often done in detail and with a more personalized approach. Documentation of nursing work has long been a source of tension in nursing. The recent development and implementation of electronic medical records, while serving as a powerful method of capturing objective aspects of nurses’ work, does not easily
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capture the subjective and intersubjective nature of nurses’ work with the patient. Such standardized categories that focus on objective and measurable information fail to capture the contextual and complex aspects of nursing work. The question needs to be asked: will this further erode nurses’ roles in integrating the body as more than physicality and further reify the body as a set of biomedical measurements. Recent research suggests that nurses in hospitals felt more secure that the use of electronic medical records would prevent aspects of care from “falling between the cracks.”24 While it is difficult not to see great value in promoting patient safety and quality of care through informatics, it is important not to lose sight of patients as the center of health care. The danger is that increasingly the data derived is used to identify risks to the corporate well-being rather than the individual patient.
REGULATING AND SERVICING THE BODY In postindustrial capitalism, the patient and their body becomes a target for health services. The emphasis on service efficiency and productivity has accelerated the social regulation of the bodies and their objectification. Nurses become active participants in the regulatory processes. Nurses are placed in a contradictory position, located with patients, but driven by institutional demands to implement plans for care that are defined by “physician orders” or medical protocols. Zola25 argued in the 1970s that medicine as an institution of social control had replaced religion as the moral force in society. Similar to Foucault,26 Zola viewed the body as a political field structured by relations of power and domination. The power of the medical gaze through objectification by diagnosis proclaims the body as diseased and body functions as abnormal. Zola’s observations resonated directly with the women’s health movement, as control over women’s bodies was gained through the medicaliza-
tion of such natural events as childbirth and menopause. Medicalization provided an effective means to control women and denigrate their power in society. The concerns expressed by the women’s health movement and feminist critiques of health care have contributed to the rise of nursing power. In the United States, the movement of nursing education to colleges and universities was influenced by feminism, reflecting the longstanding struggle for nursing to be recognized as more than a domestic calling. The pursuit by nurses for professional legitimacy and the parallel movement toward power of a collective body of nurses in the workplace reflect the continuing tensions in women’s work. There have been repeated calls for greater nursing autonomy in the workplace. Autonomy continues to be stifled more often than not by the constraints of institutionalized practice and legal regulations. Legal regulation of the scope of nursing practice has struggled with medicine’s attempt to define nursing by exclusion. As medicine reacts to what is perceived as a decline in power, there is a growing movement on the part of organized medical groups to control access of nurses to patients as well as control the scope of nursing actions. In the United States, the covert and overt constraints on allowing nurses to practice to the full extent of their education was addressed as the first area of recommendation in the 2010 Future of Nursing Report.27 The majority of registered nurses are employed in hospitals settings where the dominance of physician power is maintained through the gatekeeper role in the health care system. It typically is the decision of the physician to admit and/or discharge patients. But, under pressure from payers and corporate risk managers, physicians are pushed to admit fewer patients to hospitals and if admitted, discharge patients more quickly. Patients whose bodies are most subject to income-generating diagnostics, surveillance, and treatment are the most desired. This differential value for the body reflects the growing corporatization of health care. Conrad28 notes that the
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Critical Perspectives on Nursing as Bodywork power of medicine as an institution of social control is being eroded by the increasing corporatization of health. The systematic proliferation and dissemination of standardized clinical guidelines and practice metrics contribute to the erosion of medical autonomy. The patient body is reconstituted under the new corporate gaze. Despite the loss of individual physician autonomy, corporate decision-making in health care continues to be dominated by physicians. Nurses have long contended with the growing standardization and rationalization of corporate health systems and bureaucracy. Patients and health care providers face increasing regulating forces. The rationalization of work is increasing under governmental scrutiny. New regulations for Medicare in the United States are reshaping health care decision-making across the range of health care settings. Regulatory imperatives in health care accreditation have made mandatory, evidence-based standards for best practices. The regulations for reimbursement of providers of health care services require the use of an organized classification of the messy and often ambiguous characteristics of disease. Classification schemas such as the International Classification of Diseases, commonly used in the United States, construct the body as diseased fragments. This process objectifies the patient, ignoring the experience of illness and the ability to function.29 Nurses and other health care providers are beginning to advocate for alternative classification systems that provide a more holistic perspective on patient health. One alternative is the International Classification of Functioning, Disability, and Health, known more commonly as ICF.30 This system offers a classification of health and health-related domains and takes into account the contextual environment for disability and health. This movement, while endorsed by 191 World Health Organization member states has been slow to take hold in countries such as the United States, because of the dominance of the biomedical paradigm. Nurses, as witnesses to the fragmentation of care under the dominant disease approach,
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provide a powerful source for advocacy to empower new approaches based on health.
NURSING THE BODY AT RISK As medical technology and biomedical science have advanced, their application has contributed to the increasing regulation of the body. The body is examined and replicated through biotechnological processes of screening and diagnostics including genetic profiles, scans, and other technologies.29 The body, mapped through the Human Genome Project, is now scrutinized as both a market asset and a potential liability or risk. An inherent danger in the growing use of such technologies is that their application takes precedence over the actual patient; the patient is reified through technology and the humanity of the patient is diminished. Concerns that technology contributes to dehumanization through technology have contributed in part to the call for patientcentered care. There is a growing tendency to use patient data to better manage uncertainty in health care with the goal of reducing corporate risk. The Institute of Medicine report, Crossing the Quality Chasm, called for the development of health profession competencies in patient centered care, evidence based practice, quality improvement, team collaboration, and informatics. Nursing responded to the call to integrate the Institute of Medicine competencies through the development of a grant-funded initiative called Quality Safety Education for Nurses. This initiative outlines competencies in terms of nursing knowledge, skills, and attitudes. If embraced as a philosophical statement of values and not simply a technical checklist, the Quality Safety Education for Nurses initiative has the potential to reawaken the decades long debate about humanizing health care in a market-oriented health care system.31 There is potentially great value in stressing nursing competencies. The tendency to prioritize knowledge and skills above attitudes and values may undermine the intended outcomes for patient
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care. Patient centered praxis is foundational to quality and safety in health care. The emphasis on patient-centered health care implies a shift in power away from paternalism and the provider as the locus of care. The challenge of the patient-centered approach to health care is that while it is intended to see the patient as a partner of care, the patient is also viewed as a consumer of health. In this corporatized view, patient is perceived as a consumer “buying” health care services. While this is somewhat disputable in a less-than-free market, the ideology of consumerism leads to the perception that the patient is responsible for the care of his or her own body and the decisions that are made within the health care system. To make decisions, patients require access to information. While nurses can act as interpreters or guides within the model of consumerism, they are expected to play a neutral role. To paraphrase Gadow,32 “paternalism in health care dispenses with the patient while consumerism dispenses with the nurse.” Nurses should take the essential role as partner and advocate. Within the context of a genuine discourse with their patients, nurses are able to engage in a discussion of the differing values, risks, and choices that present in clinical situations but with respect for the patient’s values and decision authority. The body has become a burgeoning growth market for health promotion services. Health promotion largely aims to direct individuals to make behavioral changes and “choices” for reducing risk to the health of the body. The body becomes a target for action viewed as the responsibility of the possessing agent. The paradox inherent in health promotion is that while action is directed at individuals, the goal is to reduce aggregated risks within a population such as workplace or health system set of covered lives. The current concern for obesity exemplifies the challenge of health promotion. Individual behavior does not equate to free, informed, and equal choices in most societies or to access to affordable healthy food. Frohlich et al argue that risk to the health of the body is a consequence of in-
tertwined social structures and sociocultural practices, which are recursive. Accordingly, social behaviors that contribute to risks are both individual and collective, as the individual “acts out” the practices that feed into a larger system.33 Despite the growth of social epidemiology, the concept of risk is often decontextualized, as the complexity of factors that contribute to risk and the development of disease remain hidden behind an ideology of individual responsibility and blame. As a result, in this era of health consciousness, the body that does not adhere to targets for risk reduction and avoidance is further defined as diseased and stigmatized. Too little emphasis is placed on challenging and changing the social dynamics, rituals, and patterns that perpetuate and foster poor lifestyle choices, institutional responsibility, and government paralysis. The market-based context of health reshapes the forms of social control over the body into uncharted territory. This growing preoccupation with control over the body is evident in the growing sociopolitical debates. Such debates include a wide range of topics from individual reproductive health and disability to global health and population sustainability. This convergence of interest in “the body-local” and the “body-global” is double edged. Humanitarian and economic interests insidiously intertwine. Extending the medical gaze over global health runs the risk of exploitation and voyeurism as well as deflecting attention from the socioeconomic underdeterminants of disparities. Interest in the eradication of disease in one country creates an opportunity for low-cost pharmaceutical testing bodies with profits more often than not exported. The growing export of pharmaceutical testing and medication “dumping” opens new territory for the commoditization and exploitation of bodies.34 Nurses as central actors in health care systems globally stand in witness. As nurses are becoming more conscious of their global potential, a global nursing praxis will require that nurses unite with moral courage and action to advocate for change. The need for action runs from local
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Critical Perspectives on Nursing as Bodywork to global. It is sometimes more comfortable to look at the “other” and address the issues of global health from afar, and then confront the reality of the disparities close at hand. This is a paradox recognized by Nightingale and more recently addressed in the Nightingale Initiative for Global Health, which called for nurses to support the collective potential of nurses to work together locally with a global intention in both “sick” nursing and “health” nursing.35
NURSING BODIES AT WORK The call for nurses to unite in support of global health has traveled around the world espoused by nursing leaders. But at the ground level of nursing work, nurses continue to struggle for recognition and reward. Nurses are generally the largest group of workers in settings such as hospitals; nurses are reduced to “just another body.” All too often, nurses are treated as interchangeable, like machines. The corporatization of health care, which benefited from a century of paternalism, furthered the exploitation of nursing workers. Nurses serve as the means of production for health care services and as a major cost in health care services, retaining control over nursing labor that has been to the benefit and profit of hospitals and other health care institutions. While many industries have used outsourcing of reduce labor costs, health care presents some unique challenges. The direct and physical care of patients and their bodies is not easily sent oversees. Instead, health care systems have attempted to reduce costs using substitute labor, traveling nurses. Another consequence of such approaches to nursing labor force management is that it undermines the collective action potential of nurses. As nurses moved to organize collectively, their efforts were fraught with ambivalence. The traditions of selfless service that shaped early nursing continue to echo forward in messages from administrators and staff nurses. Initial collective bargaining efforts in the United States and elsewhere argued
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for recognizing the professional expertise of nurses as well as improved working conditions and compensation. Significant gains were achieved by nurses in the United States shared by nurses working in unionized institutions as well as those working in institutions attempting to be competitive but remain nonunionized. Despite gains in benefits, congruence of bargaining with professional practice goals remains elusive in many settings. The lack of shared goals among nursing organizations has left the professional body that was conceived of to represent a unified nursing in the United States fragmented. As a result, a recent trend is the co-optation of professional or American Nurses Association affiliate bargaining units by industrial labor unions. Unions in the United States have turned to the nurses to replace their diminishing industrial worker membership. The power of industrial unions has been successful in raising salaries and enacting workplace regulations such as nurse-patient ratios. But these advances have occurred through an increased militancy and disruptions to patient care on the part of both unions and hospital administrations. Professional nursing organizations such as the American Nurses Association, strained to represent the interests of competing nursing camps and unions too, more often view professional practice goals as “elitist.” The lack of a cohesive vision for the future is a fundamental challenge that undermines the potential of all of nursing and the health care system. While nursing stratified most visibly by education, the underlying stratification by race, class, and gender persists. Fragmentation of the nursing force erodes the power of collective action. Oppressed or repressed, nurses as noted by Reverby are forced to work in societal institutions that value corporate interests and rationalization of work over caring work.36 Amidst the contradictions of corporate health care and disintegration of the collective body of nursing, there is an effort to reclaim a connection to caring. This is evident in the renewed interest in theories of
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caring. One perspective is that nurses are attempting to create a distance as well as claim a difference from the growing technologydriven health care system and profession of Medicine.37 But it may also be that refocusing on caring avoids the messy terrain and “disease” in the collective nursing body. As Davies notes, nurses need to build a new professionalism that reclaims a rationality of caring.
EMBODIMENT AND THE CARING ETHIC Nursing has moved around and within the theories of embodiment reflecting a shifting paradigm. A slow but growing interest in the idea of embodiment emerged within sociology, anthropology, philosophy, and a variety of other disciplines as other disciplines sought to challenge the dominance of positivism. Embodiment is a relational concept for nursing, as it refers to the physical and mental experience of existence, “it is the possibility of our relating to other people and to the world.”38 As theories of the body and embodiment evolve, the tensions between differing thought traditions have created an opportunity for nursing as a caring praxis. Nurses have turned toward traditions of existentialism, phenomenology, postmodern critical theory, and feminist theory to help uncover the experience of nursing in relation to the experience of the recipients of nursing care. Embodiment theory emerges from the critique of mind-body dualism and counters the objectification of the patient “body” reintegrating bodywork within a holistic perspective. As early as the 1960s, interest in nursing work as an intersubjective experience began to emerge in the nursing literature. Vaillot39 argued for nurses to embrace existentialism and view nursing as a shared human experience. For Gadow,40 this call for the nurse to meet the patient in an intersubjective relationship is grounded in moral advocacy. Patterson and Zderad,41 in their theory of existential nursing, posited that that the intersubjectivity of the nurse-patient relationship is one of reciprocity as the nurse is not simply “at the
other’s disposal but also being with him/her with the whole of oneself.” The other is also seen as a presence, as a person rather than an object. Nursing has followed a path from existentialism to phenomenology to address the problems posed by Cartesian duality of mind and body. Nursing’s approach to phenomenology is based on Merleau-Ponty’s42 belief that human perception is embodied. Perception evolves in constant motion, moving back and forth between corporeal forms and, at other times, moving toward personal acts. For Merleau-Ponty, there is not a separation between body and existence. Knowledge of the world emerges from a state of being in the social world. This idea of embodied perception is at the core of Merleau-Ponty’s work, which in turn is focused on the individual. The pull of this work lies in the explication of the person’s experience of their body as they experience health, illness, and disability. Bourdieu,43 a structuralist theorist, has suggested that, in terms of explicating meaning in the body, the body must be viewed within a social context, further noting that the person and the subjective are social and collective. For Bourdieu, the belief in the possibility of human freedom and the potential to act in a responsive manner adapting to unique social or situational contexts is at the heart of practical sense. This emphasis on the “practical” forms the link to the practice of nursing. Bourdieu, however, suggests that practice, must not be reduced to a logical form, but rather be understood through narratives of participants. This synthesis of the phenomenological and structuralist perspectives provides a powerful means to interpret or describe the complexity of embedded experiences for individuals and the collective bodies within society. Turner notes that this refocusing on embodiment is particularly notable in nursing and suggests that it has helped to move other disciplines, such as sociology, away from the focus on health professions as occupations and instead attend to the shared experience of health care providers and patients. This
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Critical Perspectives on Nursing as Bodywork growing attention to what sociologists have called the “lived” body provides a means to not only capture the experience of the providers and patients but also to begin to untangle the particulars of mutuality of experience. Nursing theorists such as Gadow, Watson, and Benner have moved nursing toward this phenomenological understanding of embodiment. Gadow, in the early 1980s, described nursing as existential advocacy. According to Gadow, nurses participate in partnership relation to the embodiment of patients as they determine the meaning in their illnesses, disabilities, or deaths.44 Concerned with the ethics of caring in nursing practice, Gadow developed an interest in narratives. While embodiment is a condition of existence for Gadow, the narratives of embodiment offers a multilayered perspective that move dialectically from subjective immersion and objective detachment to a relational ethic of care.45 Watson’s theory of caring science furthers builds on the primacy of an underlying moral ideal and transpersonal caring relationship. She defines the person or patient as a unity of mind, body, and spirit to make explicit the metaphysical. According to Watson, the unifying focus and process is on the “connectedness with self, other, nature and higher reality . . . .”46 In contrast to Gadow, Watson expresses a caring ideal that goes beyond the individuated care context, to describe caring science as not only for sustaining humanity but essential to our future global existence. Watson’s philosophy has overtly embraced a universal or global context for caring. Caring is viewed as a guide to change the environmental culture of practice. Consequently, Watson’ s caring calls for a shift of consciousness to both become aware of and address the moral and professional conflicts that emerge out of the growing corporatization and commoditization of health care. While Watson takes a stance against the commodification of caring, she suggests pragmatically that caring and the economics of care can coexist. Watson expresses the optimistic vision of health care institutions being transformed from the
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inside out through an evolved consciousness that restores human caring, health, and healing into our health care systems. There is a growing movement in a number of health care institutions to adopt Watson’s transpersonal caring theory as a means to reframe nursing service. While Benner is best known for her work From Novice to Expert, a model of skills acquisition based on the work of Dreyfus, her work has evolved to embrace a phenomenological theory of embodiment and situated nursing practice. This led to her interest in trying to identify clinical knowledge and describe the process through which the embodied nurse clinician gains expertise through experiential knowledge, perception, and reflection in action.47 For Benner and colleagues, skills acquisition and clinical knowing flows out of situated caring in the embeddedness or habitus of embodied patient and illness experience. The nurse as an embodied knower is able to read the body of the patient. Expertise in knowing and responding then allows the nurse as body to act intuitively.48 Benner’s phenomenological perspective seeks to explicate the contextually situated meanings and intents within the exemplars or narratives of the clinical situation. This interpretive approach has provided a powerful and professionally valued focus on nursing expertise but, as with Watson, recognizes caring as situational and based in the caring relationship. Nursing knowledge, explicated through the work of Benner and colleagues, is gaining legitimacy through its application in a variety of institutional and geographical locations. The Benner domains of knowledge provide a useful guide to understanding practice. Benner stresses the importance of communities of practice in which learning to apply care ethics as nurses occurs. Caring for the body, carrying out tasks with the best techniques, and yet failing to engage in a caring relationship with the patient does not constitute a practice. There is a growing convergence in nursing philosophy, theory, and practice around a caring ethos in response to the nurses’
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perceptions and experiences in health care systems. There is also hope in such a convergence, as theories point to action.
NURSING ADVOCACY FOR THE NURSING BODY Nurses are challenged to attend to the messy and complex nature of the situated embodiment. The organizational context includes class, race, and gender in shaping the care, work experience through objective, and internalized structures. These interpenetrate and, through the social environment and behavioral context, reproduce health and unhealthy bodies. In the reproduction of the nursing workforce, class, race, and gender stratify nurses, which undermine the collective body integrity of nursing in society. The divisiveness that is generated by stratification results in a differential set of lived experiences. The organizations in which nurses contributes to the divisions in nursing solidarity, by offering advancement to some nurses, while holding back others. The promotion of status hierarchies further isolates nurses from one another and adds to the lateral violence of oppressed group behaviors. Despite rhetoric about community-based care, hospitals are still the dominant force in nursing culture. Nurses working in hospitals are called to practice under increasing patient intensity, monitoring, and documentation. Nursing work is more often than not in conflict with an ethic of care. While nurses hold caring as a central ethic in nursing work, this is not a necessary requirement to hold a job as a nurse. Nursing offers paid work and more autonomy in caring than is often available in nonpaid care work. But more often than not, nurses find that they are often at odds with institutional priorities. As noted earlier, nurses have made gains in their benefits and working conditions through collective bargaining. But, as labor laws and the business of unions have changed, many nurses are now stuck between 2 patriarchal masters, the hierarchy of health care administration and
an industrial modeled union. Caring for the patient is diminished in the power struggle. As one nurse recounted to me recently, if a patient calls for a nurse to provide medication for pain near the end of a shift, the nurse is told to ignore the request and complete their required documentation thereby avoiding mandatory overtime called for by the union contract. The battle to control the nursing labor force is directed by the economics of labor costs. Nurses, caught between competing bureaucratic and/or corporate priorities, are struggling to stay grounded in a caring ethic. To change the situation, nurses must recognize first that they have power and exercise their power within institutional, organizational, and governmental arenas. Watson suggests that a theory of caring can change institutions from the inside out. I believe that nurses must learn to care for those with whom we care, as well as with those we care for. The explication and celebration of nursing knowledge furthers the potential to heal the collective body of nursing by offering a praxis that returns nursing to a clear message of “I know what I do and do what I know.”49 There is a dialectical challenge in coming to know nursing and coming to care for the nursing body. Nurses’ engagement in emancipatory praxis requires that we hold the dialectic of nursing knowledge and knowledge of nursing simultaneously. We must recognize that our power, while it emanates from our embodied relationship, is not limited to this relationship. Tunneling our vision inward, without looking critically at our practice context disempowers. The nursing environment is now global; nursing itself is now a global community. The globalization of healthcare has created new challenges as nurse migration and “traveling” nurses rapidly cross the health care landscape. Those of us who practice in countries where higher status and pay prevail need not denigrate, but rather reach out to, our colleagues in nations where conditions are more resource challenged. The richness of caring does not correlate with the degree of technology available or with the level of salaries.
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Critical Perspectives on Nursing as Bodywork We share global threats and opportunities for health. But when health services are delivered without caring, then bodies of patients and nurses become just another market open to exploitation and fragmentation. As we face a new global caring dilemma, our perspective will require heightened advocacy and political acumen.
CONCLUSION Nursing work offers a multifaceted lens through which we view social representations and relationships to the body. Nurses hold both a privileged position in society and a stigmatized role through their gendered relationship to body work. Despite the potential dehumanization and fragmentation of health services under the growing corporatization of health care, nurses continue to be trusted. The power of nursing as a collective body
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of nursing workers is redefined, moving away from its prior relation to medicine and toward patient-nurse relations. Nursing praxis offers a powerful means to counter the objectification of the patient “body” and to reintegrate bodywork within a holistic perspective. Sustaining the trust and respect of patients is not a given nor is nursing’s central position in the health care system a given or even well understood as such. Nursing’s claim of legitimacy in caring for the body, supported by a theory of embodiment, offers a powerful means to simultaneously make nurses’ work visible and de-stigmatize their work. But it also offers nurses a challenge to reconnect a caring ethos that not only cares holistically for the patient but also helps to heal and unite the collective body of nurses as a profession. As the largest group of health professions in most countries, there is tremendous potential power in nurses to use their voice for caring and social justice.
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