Sunday, December 18, 2016


Friday, the semester ended for me, and for the Class of 2016--our accelerated "second degree" nursing students. In 16 months 27 people from backgrounds in biology, English literature, accounting, political science, and other fields managed to master the enormous amount of complex material and clinical skills to become Registered Nurses.

Pinning is a nursing tradition. At the end of nursing school, many programs hold a ceremony to celebrate the students' rite of passage from unschooled novices to competent nurses. Ceremonies vary in their content and style, but most contain a group recitation of the Nightingale Pledge. The original pledge spoke to the Victorian mores of the time: probity and forbearance from "mischief", faithfulness and purity were emphasized, no doubt reflecting the way society thought women should behave. The nurses should "aid the physician in his work" (emphasis mine), reflecting the place of both women and nurses with respect to both men and physicians at the time (from Lystra Gretter's 1893 version of the pledge).

The Gretter pledge also had the graduates pledging before God, which of course makes sense in light of the time. Most people were nominally of the Judeo-Christian traditions that underpinned European and American societies, and the then- and formerly-colonial regions to which they had spread, such as South America and much of Africa.

I do prefer more contemporary versions--even though they don't have the long tradition--because they recognize that not everyone believes in "God", much less a one-size-fits-all god, and because although part of what we do is to aid physicians, we also aid other professions.

Moreover, in "aiding" other professions--including medicine--to do their work, we more often than not coordinate everyone's efforts, physicians included. That doesn't even get into our own discipline's body of knowledge about health, healing, and humanity that form the core of Nursing as a medical art both of and distinctly different from Medicine. It is the similarity of our work to the work of Medicine that makes Nursing amplify the healing art. And yet it is our distinctiveness that also serves as a counterpoise to Medicine. One can routinely observe this in the clinic: The nurse humanizes the fraught work of the medical man. Medicine, by its very nature, can become the grotesque creator of monsters artfully depicted by Mary Shelly's Dr. Frankenstein. Nursing, by its very nature, acts as Medicine's conscience.

The importance of this emerges during training, and we instructors emphasize this role as counterpoise to the physician. But we're partners too. We observe, report, and execute the regimen. They have the deep knowledge of anatomy, physiology, and medicines that solve the medical problems. They save lives, but then so do we, both in their absence as we monitor patients through dark nights, but also in their presence, when hubris, fatigue, or just plain orneriness threaten the poor fellow lying in that hospital bed.

The Factory, which I have written about here before, has created a new alliance between Nursing and Medicine, in my view. Once, we were as much at odds as we were allied, nurses and doctors. That's still true to a great extent, and as I have argued here, not an altogether bad thing. But The Factory has emerged as a new player, a new force with its own agenda. Some agents of The Factory are explicitly for profit. The looming harm of this is, to me, obvious. It's less obvious when examining the non-profit agents of The Factory. Who is making the money? What's the real goal? Is it to make the system efficient and humane? Or is it to enrich the operators of the enterprise?

I gave the closing remarks at our pinning ceremony on Friday. I wanted to keep things short and light, but I could also see the potential in the room, and urged the students to make things better. That's really hard when you're a nurse: the organization often pits your own good morals against prerogatives that seem anything but humane and compassionate. It will be hard for them. I hope we prepared them adequately for that struggle in the short time we had to prepare them.

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