What Nurses Wear

“Nursing is made up of little things; little things they are called, but they culminate in matters of life and death” Florence Nightingale

I have become all too aware of the breadth and complexity of nursing today. With some 57,000 nurses and midwives working in Scotland – in hospitals and within communities, not only practicing care but advocating, researching and teaching, I look for points of connection, those little things that catch my attention and provide a way in to writing and thinking about nursing today. Writing too is made up of little things, an accumulation of words where everything can turn on a small, telling detail.

child's nurse costume

Lately I’ve been thinking about what nurses wear. The design of nurses’ clothing has always been driven by a certain functionality yet when you compare nurse uniforms of 100 years ago to the current uniforms being adopted in Scotland, the changes are radical, boggling even.  It’s not just about the development of easycare materials, but reflects a literal loosening up of the constraints that working women were subject to, and more particularly the roles that nurses occupy.

painting by William Hatherell ©IWM (ART 5234)

Around the time of the first world war, many nurses wore long white veils and floor length gowns and aprons. It’s no accident that they look like nuns, it’s a deliberate reference to the origins of organised nursing within the convent hospitals of Europe. Over the years the veils got shorter, and sat in elaborate shapes on the top of heads. The white aprons remained too, making nurses visual sisters to maidservants and waitresses. 

from the 1970s TV series, Angels

Capes and big belts lasted into the seventies, but in the last couple of decades, we have seen a shift to the simple, androgynous ‘scrubs’ type of clothing influenced by the US. By the end of 2012, all nurses in the NHS in Scotland will be wearing the uniforms modeled below, with different roles and hierarchies denoted only by subtle colour coding. The impetus behind this is to help patients identify who is who, but from the outside perhaps it’s not that obvious. The materials and cut are chosen with regard to washability and hygiene rather than aesthetics. That much is obvious.

new national uniforms © Scottish Government

In my posting about nursing in Malawi, you’ll see that nurses there, as in many developing countries, still wear caps and dress-like uniforms, but in North America and Europe, skirts and hats have disappeared. If you go to buy a nurse outfit for a child, however, it will have a little white hat, as well as a blue dress and apron, and assorted accessories – a stethoscope and upside-down fob watch. If your child is a boy, you won’t find a male nurse costume. Popular imagination is on a time lag as regards what a nurse looks like.

Male nurses never wore little white caps. For a while they looked like dentists. This new simplifying of the uniform is also a way of acknowledging that things have become more egalitarian –nurses may be male or female, surgeons and health care assistants can be dressed similarly, and increasingly care is delivered by teams of differently skilled people working together –ideally with the patient as the focus, not the internal hierarchies.

This is Elsie Stephenson in a photo taken during her nurse training in the 1930s. Elsie went on to be the first head of Nursing Studies here in Edinburgh. Her outfit is so crisp, so constraining at chin and neck and waist it practically makes me itch to look at it. The neatness of a nurse's uniform in that era was an outward manifestation of the discipline and attention to detail that were seen to be central to a nurses’ being. That and an unquestioning obedience. It wasn't so different to being in the army.

Scrubs, on the other hand, are clothes that you can throw on and not think about. But it does make me wonder if anything is lost in this casting off of the traditional idea of what a nurse looks like. And I'm interested to know - does anyone have nostalgic feelings for the nurses’ cap and uniform or is it a case of good riddance and don't look back?

In the Anatomical Museum



photo:Hugh Pastoll



Across the quadrangle from where I work is the most compelling collection, guarded by the skeletons of two long-dead elephants.

Edinburgh’s Anatomical Museum was once the centerpiece of the medical school, a galleried hall three stories high, housing a collection devoted to comparative anatomy - a kind of democracy of bones where human skeletons took their place alongside those of other animals. In a photograph taken in 1898, below, you see the museum in its heyday, a suspended procession of whales and other cetaceans floating over the earthbound beasts below.

In the 1950s the museum was reduced to a single floor, and many of the skeletons were moved out to the nearby Museum of Scotland. Some smaller animals remain, and a gorilla stands alone in one of the fine glass and rosewood cases. All the furniture and fittings are original, with the AM monogram on the backs of chairs, and although the museum has been brought up to date here and there, with bright plastic models of various body parts and their workings, it is the old things that attract me, the curling labels with hand-inked captions, the bell jars and specimen tanks, the detailed models made from wax or papier maché.

There are strange and beautiful things here; a resin casting of lungs that looks like a delicate bloom of coral, tiny bones laid out in patterns like beadwork on a framed black cloth, and a dissected corpse looking like something dug up from a peat bog, blooming here and there with tiny silver droplets. This is the emergence of the mercury which was injected into this body"s lymphatic system to trace its routes more than two hundred years ago. And even while I’m peering closely at these things, I feel a certain inhibition, because they are not just objects, they are parts of people, or in the case of the dissected man, nearly all of a person.

Medical and anatomical museums are discreet places, not often open to the public. Our bodies are usually disposed of with ceremony, buried or consumed by fire, but these remains remain because they are or were put to use – they are objects to think about and through. As the latin motto inscribed over many European mortuaries and dissection halls exhorts Mortui Vivos Docent. Let the dead teach the living.

And the living are here too – students softly tapping keyboards or reading in bays amongst the glass cases, using the facilities of the museum for their anatomy coursework, or perhaps just liking it as a place to study – the fine polished tables and skylights and special hush. A girl leafing through a folder flicks back her long hair in front of case containing preserved brains, hunkered in their individual tanks. It is odd that of all the intricate insides of the body, a brain looks the dumbest, a cross between cauliflower and clay.

The students have grown used to their surroundings, grown used, perhaps, to the idea that their lives will be concerned with the body in a way those outside the world of medicine and healthcare are not.

As I leave, I’m stopped in my tracks by two old framed notices to the left of the doorway. They are menus of a sort, lists of body parts.

Head and Neck, one side ............................14s

Head and Neck when opened, one sIde............ 10s 

Upper Extremity .....................................14s

Perineum and Pelvis, when opened,one side ...... 5s

and so on, piece by piece.

For lack of further explanation, I have to presume this is what students of another age paid for parts to dissect. It’s the baldness of it that makes me stop; something quite extraordinary made into notices that look like a price list from a shop. They’re not callous, they’re factual, but they remind me of all the sentiments a person might have to put aside to do this kind of learning.

The museum today

I’ll be writing another posting about the museum soon, but in meantime I want to mention that it’s open to the public one day a month and that the next opening is this Saturday, 26^th of May from 10:00 until 16:00 (Last entry:15:30). For further information, see the website.

Happy International Nurses Day!

Here is a post I wrote to mark Nurses Day for another blog, based at the wonderful Medical Humanities Department at Durham University, so I thought I would share it here, too:

© Imperial War Museum

I’ve been at two Medical Humanities events recently – a lecture and then a symposium - where, when it came to question time, the same query arose, though from two different plaintiffs: “What about nursing?” Cue a lonesome whistling wind and the scud of tumbleweed.

When we talk about medicine we mostly talk about physicians (curing suffering, causing suffering) and patients (plain old suffering, occasional bright spells) Other health care practitioners come in as also-rans. Yet images of nurses stride through the popular imagination – as cruel and uncaring as Nurse Ratched in recent press reports, jolly heroines cycling through suspiciously clean slums in Call the Midwife on TV, headless and scantily clad beside the French maid in the windows of Anne Summers – images that tell us very little about the job of nursing, but a lot about our society. This week marks the run-up to International Nurses Day, which falls (not co-incidentally) on Florence Nightingale’s birthday, May 12. There has been a lot of talk about ‘angels’.

I’m not a nurse, I’m a writer, a Writer-in Residence to be grand about it, supported by the generosity of the Leverhulme Trust to spend the year with the Nursing Studies department of University of Edinburgh. It is, as far as we can make out, the first time an artist or writer has worked directly with and for nurses. In the course of my time in Edinburgh, I’ll be interviewing individual nurses about their experiences and running workshops to encourage nursing students to craft their experiences into stories and fiction. Some of these things will turn up in my writing.

On October 2^nd 2012 I’ll be giving a talk in the Teviot Lecture Hall, at Edinburgh University’s Medical Quad, entitled ‘Good Nurse, Bad Nurse’ on how nurses have been portrayed in books and film and the strange persistence of certain out-of-date stereotypes. But more of that later in the year.

Oh, and there’s this blog. All praise to the blog form for being a wonderful capacious hold-all with lots of pockets that can contain stories by me and by others, articles about nurses and popular culture, profiles of diverse and interesting nurses, not to mention thoughts on medical history and Edinburgh. It’s a kind of home to the residency, and will develop as the year goes on. And if any one has ideas, stories or opinions to contribute, do get in touch.

Gladys Msiska - Nursing in Malawi

‘Nurses witness patients dying for lack of drugs and there is nothing they can do.”

I first met Gladys Msiska at a postgraduate conference where she presented findings from her doctoral research into nurse training in Malawi. Her research had uncovered a difficult truth – that many nurses in Malawi were suffering from extreme burnout to the extent that they were insensitive or even verbally abusive to their patients. I was struck by her passionate clarity and her determination to address the situation. Afterwards, I asked Gladys if she would tell me more about her work for this blog, and although she was leaving for Malawi that week, we managed to fit in an hour to talk.

Gladys Msiska

The working environment for nurses in the small African country is extremely challenging – there is a vacancy rate of up to 77% in the profession, a legacy of nurses being recruited from Malawi in the last decade by countries that could offer better wages and conditions. 80% of these emigrating health workers went to the UK, and in 2007, it was estimated by the Guardian that there were more Malawian nurses in Britain than in Malawi. The results of the shortage are that 24-hour shifts are common and nurses can be left alone to tend a ward of up to forty patients.

Recent efforts have largely succeeded in halting the brain drain, but Gladys says that she herself might have been tempted to come to work in Britain, had she not had a post lecturing at Kamuzu College of Nursing. Teaching had been Gladys’ first choice of profession, but she had been selected for nurse training after leaving school, and practiced in rural clinics and health centres before merging her interests by becoming a lecturer and trainer of nurses.

In addition to staff shortages, recent cuts in aid due to political tensions have led to a scarcity of drugs and medical equipment. ‘Nurses witness patients dying for lack of drugs. There is nothing they can do.’ She describes the occasions where patients have been verbally abused as ‘manifestations of tension and frustration.’ While nurses in training do find some nurses they can look up to and emulate, 'They know the image of nursing in Malawi has been tarnished, and they are sensitive.’

Nursing Students

Gladys was concerned that the training of nurses in the country, especially of the enrolled nurses who make up a large part of the workforce, was task-based, and had no component that dealt with ethics or self-reflection. Says Gladys, ‘They are dealing with people, with suffering others. Nobody chooses to be sick. The world of a patient is a world characterized by fear and anxiety, and you don’t want to increase their apprehension through how you treat them.’

Gladys is devising a pilot programme to train nurses in these issues, and challenge the way that nursing is commonly practiced. In the future she hopes it will extend to all health professionals, creating a more patient-centred approach to care. She is full of  plans for new teaching materials and workshops. It is a time of both turbulence and optimism in Malawi, as new president Joyce Banda brings hopes of better international relations and with that, an improved economic situation.

Yet in the very week that Gladys returned to her country, the Malawi Nation newspaper carried a story of a nurse who beat a complaining patient with a metal bar before being restrained by fellow staff. The nurse was swiftly suspended by her professional body, but it is hard not to think of the challenge ahead for Gladys as a daunting one, but never more urgent.

‘I’m just trusting that things will work out well, ’ she said as we parted.

Kamuzu College of Nursing, Malawi

“Smiling is an important part of my job”: nurses in popular culture

One of the knock-on effects of being in residence with Nursing Studies is that suddenly, I notice nurses everywhere. Everybody I meet seems to be related to a nurse somewhere along the line; all at once the newspapers and television screen seem full of them. But there’s one particular nurse who has begun to irritate me:

It’s not really her fault. After all, the subliminal flash on the screen identifies her as only ‘a representation of a nurse’. What grates is the way she’s framed as a bit of a ninny – she says she’s fighting bacteria in her job, and we see she has mastered handwashing, yet she is ‘shocked’ to find out they live in her mouth – what has that university course been teaching her?

The white-coated dentist – an expert who wouldn’t look out of place in an ad devised by Madmen – seems to have the monopoly on the medical knowledge and all the fancy technology, including a nifty miniature light sabre. Same old same old.

He tells her to use a certain toothpaste, and she is just thrilled because ‘Smiling is an important part of my job.’ And we see her beaming an intimidatingly white grin down on a little kiddy and then up towards someone unseen, someone she is perhaps kneeling before.

I’m not saying that smiling has no place is nursing care. It’s part of what the head of Nursing Studies in Edinburgh, Pam Smith, would term the ‘emotional labour’ of nursing. But just as much of nursing is to do with hard-won knowledge, clinical expertise and the use of technology.

The fact that this simple-minded ‘angel’ still has currency in 2012 attests not only to the laziness of advertising copywriters but the sheer difficulty of coming up with an image to reflect the complex identities of nursing in the twenty-first century. 

Story: The Nurse My Father Loves

My father got sick last week. It started as flu, then the whites of his eyes turned yellow. I was standing in my parents’ bedroom, watching him trying to get up off the bed. I’d been meaning to ask him for some money to get to college

‘How are you?’ I said.

‘I don’t know how I am.’ His eyes wandered the room.

I never did go to college that day. At lunchtime, the ambulance came to take him, and I stayed in my bedroom, couldn’t watch them carry him down the stairs. They put him in an intensive care unit and phoned us to say his kidneys and liver were failing. David Doran next door told me this wasn’t good. He’s studying medicine, said he’s practicing telling people bad news.

My mother visited my father for most of every day, but I didn’t go. No one said I had to. Anyway, my mother said he’s delirious, that he doesn’t know what’s happening. So how can he miss me?

Five long days, and he starts to get better. I go in to see him. He looks dreadful, suddenly smaller. His skin has blue shadows and his hair is wild as if he’s been thrashing around on the pillow. He doesn’t have the tube in his mouth anymore, the one my mother told me about, but his voice is whispery and cracked. There’s something he really wants to say. He makes my mother lean down close. I’m expecting something profound, a rare public declaration of love, maybe, or an insight from the threshold of death.

He forces the words out. ‘Buy … chocolates … for Cecilia.’

We don’t know any Cecilia. I wonder if he’s still delirious.

‘Who?’

He raises the finger with a plastic clip on the end and points it towards a dark-haired nurse standing at the bed next door. She’s talking to a male nurse, and as she turns smiling from whatever he’s saying, she notices us staring. She raises a hand and wiggles her fingers. Cecilia.

My cheeks go hot. In the week I’ve let him out of my sight, my father has formed an attachment to a stranger. It comes to me that this Cecilia would have been touching him, washing him, intimate with his body in a way I don’t want to think about. And now he’s telling my poor mother to buy her a present, this woman who has taken our places in his heart.

But my mother just smiles and kisses his cheek.

‘We’ll go get them now.’

I force myself to kiss him as well, even though I’m angry, and starting to think this father who has come back is not the same as before, this new one given to falling for young women and sudden physical breakdowns.

Outside the hospital, the world looks just the same, but my mother insists the day has gotten finer. She hums and looks up at the sky as we walk to the shops on our humiliating mission, her silky scarf trailing from her hand.

Humanising medicine?

photo: George Marks

The week that I started my residency with Nursing Studies, Prof Jane Macnaughton from Durham University gave a public lecture at the university entitled ‘Medical Humanities: a challenge to medicine.’ It was an apt coincidence as I pondered what I, as a writer, had to contribute to a department focused on the training of nurses as practitioners, researchers and leaders in their field.

She opened the lecture by contrasting two pieces of writing which shared a subject matter but read as if from two different worlds. The first was from the New England Journal of Medicine:

"Side Affects of Adjuvant Treatment of Breast Cancer

Many women with breast cancer who are receiving adjuvant therapy have fatigue, and about two thirds of them rate the level of fatigue as moderate or severe. … The fatigue appears to resolve after treatment. In a survey of nearly 2000 women with breast cancer who were evaluated three years after adjuvant treatment, the level of fatigue was similar to that of age-matched women.” 

The second was a poem by the late Julia Darling:

Chemotherapy


I did not imagine being bald
at forty four. I didn’t have a plan.
Perhaps a scar or two from growing old,
hot flushes. I’d sit fluttering a fan.

But I am bald, and hardly ever walk
by day, I’m the invalid of these rooms,
stirring soups, awake in the half dark,
not answering the phone when it rings.

I never thought that life could get this small,
that I would care so much about a cup,
the taste of tea, the texture of a shawl,
and whether or not I should get up.

I’m not unhappy. I have learnt to drift
and sip. The smallest things are gifts.

from Sudden Collapses in Public Places, Arc Publications 2003  

Both texts deal with the fatigue that comes with cancer treatment.  The NEJM study is functional, evidence based, measuring the effects of treatment. It is a necessary text, but it tells us nothing of the experience of illness, the life that has grown small, its focus on the things to hand rather than the far horizon.

Jane MacNaughton spoke of how the field of Medical Humanities emerged in the United States as a way of ‘humanising medical students’, an attempt to counter an overly technical and atomized view of disease and illness with a broader view which valued cultural and historical interpretations, which had space for the subjective.

I do not think that nurses are in need of ‘humanising’ in this sense. I believe that people enter nursing from a motivation to care for other human beings, yet it's hard to ignore recurrent stories in the media asserting that nurses no longer care as they used to. Just two days ago the Prime Minister announced a new initiative to increase nurses' standards of care and compassion. It has even been suggested that too much education at too high a level is to blame for this perceived 'crisis' in nursing, as if you cannot have a heart as well as a brain.

During my time in Edinburgh, I hope to get closer to the truth of these issues, to talk to a wide range of nurses and nurses-in-training, to gather their stories and encourage them to take a step back, to reflect not just on the facts of their working lives, but to help shape that experience into meaning through writing. This blog will grow to contain these stories and my own assorted encounters with the culture and history of nursing.

With thanks to the MHRNS  for organizing the Jane Macnaughton lecture, and especially to the Leverhulme Trust for funding the residency. If you are interested in Julia Darling’s poetry, you can find out more on her website, which includes a diary of her last years.