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We still have to work to break the silence

2015; Elsevier BV; Volume: 22; Issue: 4 Linguagem: Inglês

10.1016/j.colegn.2015.10.006

1876-7575

Sanchia Aranda,

Nursing Education, Practice, and Leadership

This year, as I completed my AHPRA forms on line, I ticked for the last time a ‘yes’ to the question of being employed in a role that required me to be a registered nurse. I had just accepted a new job that required me to give up the paid roles I continued to have in both nursing education and research since moving into my first ‘non-nurse’ role almost five years ago. Would this mean that next year I might be no longer able to call myself an RN after 37 years? Does this even matter? In September 2015 Kelley Johnson, the Miss Universe contestant from the USA state of Colorado, walked onto the stage in scrubs and gave a monologue on her special talent, ‘Being a Nurse’. For those who didn’t see the You Tube clip, she gave a poignant reflection on her experience of making a difference in the life of one dementia patient and how he had taught her about the important contribution nurses make in people's lives, through the lens of being ‘Just a Nurse’. In the days following Kelley Johnson's monologue, she was ridiculed on a national television show called The View, by women who profess to be leaders among women and examples of how far women have come since the times of our forbearers. Kelley was laughed at, her talent of being a nurse compared unfavourably with the talents of singing, dancing and stereotypical desires for world peace. Centre-stage was ridicule of Kelley's wearing of a nursing ‘costume’, her scrubs, and of wearing a ‘medical’ stethoscope, implying that this was an illegitimate tool for someone who was ‘just a nurse’. The hosts later gave an apology of sorts, suggesting nurses needed to chill and not be so sensitive, which served only to galvanise nurses and their supporters into social commentary about what being ‘just a nurse’ really means. The apology suggested that despite increased understanding of and research about the important impact nurses have on outcomes for patients, social attitudes often reflect nurses as simply there to support the more important medical doctor who does all of the real work. The show has continued to lose important sponsors, such as Johnson and Johnson, as a result of the remarks, the apology and the social media storm that followed. Amongst the passionate social media commentators who supported the critical role of nurses in the days following was a surgeon by the name of William R Blythe who spoke eloquently about nurses’ roles across the patient care pathway that rendered his own role into one of minor actor. Another important friend of nurses, perhaps the person who has most studied what nurses contribute, Suzanne Gordon, took to social media to correct the injustice and to re-activate her previous ‘Just a Nurse’ campaign from 2001. For several decades Suzanne has called on nurses to share with the public what they know and to learn to speak differently about their profession in order to help the public better understand their contribution. Her work includes the seminal book she authored with Bernice Buresh, ‘From Silence to Voice’. Many nurses see this call to voice as unimportant, their mission being to focus on the wellbeing of patients. I am not of this view as I believe the silence that surrounds the work of nurses has more impact than we can imagine. Here are just some of the ways I believe the silence of our nurses’ voices impact:•Our silence influences who comes into nursing – students are actively discouraged from being nurses especially when they have the grades to get into seemingly ‘more important’ professions. I have stood in the line at Open Day and talked to potential medical students about why they are seeking to go into medicine. Almost all of their answers have much more to do with the role of nurses than the role of doctors. As Suzanne Gordon says, shows like ER have doctors performing largely nurses’ work. Without this there would be very few doctors in the picture.•Our silence reduces the influence nurses have in changing systems of care. Nurses know how systems work and often do the hard work of changing the way things are done in order to improve patient outcomes, from waiting times through complication reduction and prevention of unnecessary death. However, every time a new hospital, government or system advisory committee is announced we search to find the name of the one nurse amongst the many doctors. Sometimes we do not even see that one nurse, and everyone wonders why the system rarely works or that changes fail to take account of the daily delivery of patient care.•Our silence influences Government policy decisions about things like Medicare billing items, rendering nurses as always subservient to doctors and costing our health system much more than is needed for work nurses are well prepared to and do undertake. Note there is no nurse on the current Medicare review committee. The silence and invisibility of nurses for members of the public was brought to the surface for me recently when my niece had a ten hour operation to remove a very large cancer from her adrenal gland. Post-operatively the doctors were a minor and intermittent presence at her ICU bed while the nurses did the work of making sure her ravaged body healed without complications. Indeed the operating consultant had still not visited her at day 10 post-op and counting. On her second day post-operatively I observed the acute pain team discussing her pain management. Her Fentanyl epidural was not working well on the right side and they planned to start a Ketamine infusion. The team, a male and a female, talked in depth about the right approach, my initial impression being that they were two registrars or a junior consultant and registrar, such was the tone of the conversation and my own lack of recent experience in the clinical milieu. Towards the end the female suggested a plan to make some provisional changes possible over the next 24 hours, ‘or otherwise I will need to get you back’ she said. At this moment I thought, I know now that you are the advanced practice nurse on the pain team. As she handed him the medical form to write up the medications my suspicions were confirmed. If she was a doctor she would have written the prescription she had devised herself. All of the planning was hers. Her call to not disturb him later by having a backup plan, cleverly disguised her attempt to ensure my niece was not left in pain while waiting for a doctor to write a prescription. A couple of days later when my niece's pain was again unstable, it was this APN that stayed with her through an increase in her Ketamine dose to help her manage the auditory and visual hallucinations this caused. My niece could not have got through this with anywhere near the level of skill if not for the presence of this nurse. However, I can bet that most people observing would have thought this skilled APN was a doctor and nothing about her attire or identification corrected this impression. This silence and invisibility of nursing leads to misunderstanding by the public of what nurses do. My darling mother, proud of me as she is, once said, “so what is it that you do?” I replied, “these days mostly research” to which she replied, “but it's not real research is it because it doesn’t save lives!” At that point in my life I was unable to reply with sufficient thought to this question. Today I would say, yes Mum it does. Every patient who is better prepared to self-assess their response to treatment and knows about their risk of blood infections after chemotherapy who comes in to hospital without hesitation is a potential life saved. Every patient who is supported to stay on chemotherapy or radiotherapy because a nurse has delivered one of the interventions my team has developed has less risk of their cancer coming back and indeed might be saved by this research”. This leads me back to the beginning. Why is it important to me and to the profession that I remain an RN in both my heart and my title as I move into this next stage of my career where being a nurse is no longer a requirement of the job? Too many nurses who take up roles outside of nursing are seen to do so because they were ‘too good’ or ‘too smart’ to be ‘just a nurse’. That is not me. I am as much a nurse in my daily life in my new role as I ever was at the bedside, in the classroom or in my research department. All I have ever done is seek larger canvases on which to try and make a bigger difference to outcomes for patients, especially those who are most vulnerable to the non-system in which healthcare is often delivered. Too many nurses who leave ‘nursing’ roles abandon their nurse identity and it is interesting to me that this does not occur for other disciplines such as medicine, physiotherapy and social work. Indeed I remember going to a social work alumni dinner at the University some years ago and being surprised by the four sitting members of the Victorian Government in the room proudly declaring themselves social workers. I had no idea if there were any Government members who were nurses. I am sure there were and are, but the silence of their voice and nursing identity is in contrast to our colleagues in social work. I don’t have room here to explore the question of whether this moving away from nursing identity is because the nurse experiences more respect and authority for the role taken when the nursing identity is left behind. What I do know is that I have certainly experienced my views being dismissed in the context of the same views being expressed by a doctor and accepted. Short of an ‘out a nurse campaign’ we must give some thought about how to profile the fabulous nurses who make a big difference as leaders in our world as one part of giving voice to the contribution of nurses and the skills they gain and have to offer. We need everyone to be part of breaking the silence! For me being a nurse is and always will be a key part of my identity.