| Reviews / Comptes Rendus | Labour/Le Travail, 57

Reviews / Comptes Rendus

Suzanne Gordon, Nursing Against the Odds: How Health Care Cost Cutting, Media Stereotypes, and Medical Hubris Undermine Nurses and Patient Care (Ithaca: Cornell University Press 2005)

DESPITE SLIGHT increases in enrollment in nursing education programs over the past few years, nurses continue to leave the profession in record numbers and there are many more nursing positions across North America than there are nurses available to fill them. In this book, Gordon discusses three key factors — the relationship between nursing and medicine, the portrayal of nursing in the media, and the organization of nursing work within the health care system — that, from her perspective, are associated with this problem.

In Part One, Gordon intersperses a historical analysis of the development of the relationship between nursing and medicine with accounts from nurses and doctors to show how professional education, formal and informal, has created a power differential and influenced these relationships. She notes that both medicine and nursing education have perpetuated the "doctor knows best" perspective. Although nurses' knowledge and observational expertise are clearly necessary, they seem somehow to be less important contributions than those of the doctor and sometimes drop off the radar screen altogether. Gordon notes that this distinction is also evident in the ways nurses and doctors dress and in the ways they address each other. While nurses wear pastel uniforms and comfy, printed smocks, doctors wear business attire and white coats. Nurses, regardless of their level of education, are addressed by their first name, while doctors are always addressed as Dr. ———.

The power differential also surfaces in verbal (and sometimes physical) abuse of nurses by doctors. This abuse has historically been accepted as an exercise in stress release — something doctors are entitled to do given their many long years of sleep-deprived training. Researchers who have studied the health professions thought these disparities were rooted in gender issues and hoped that as more men became nurses and more women became doctors, the characteristics of the relationships between nursing and medicine would change. Gordon notes that with a few notable exceptions, this does not appear to be happening. Rather, there is a general perception that bright young people interested in health become doctors and those not "smart enough" to do so become nurses. In this context, abusive behaviour is almost considered a "right," something one is allowed to do given his or her superior intellectual position. Nurses don't like the abuse but they expect it, are grateful when it doesn't happen, and are reluctant to complain about it.

The relationship between nursing and medicine is further complicated by ways in which the roles of physicians and nurses are portrayed in the media and prescribed within health care organizations. These points are discussed in Chapters 6 to 14. Gordon cites many examples of ways in which nurses must constantly be on the alert to catch errors in medical orders and interpretation of lab tests but are seldom given credit for this work. When patients write notes to hospitals following discharge, they describe the excellent medical care they received but seldom comment on the care provided by nurses. The invisibility of nursing extends beyond hospital walls. For example, Gordon notes that while many individuals know that the popular group Doctors without Borders won the Nobel Peace Prize in 1999 for their wonderful international work, they don't realize that the group includes many nurses.

The portrayal of nurses in the media further supports their inferior position in relation to doctors. Gordon notes that regardless of whether one examines portrayals of nurses in books, television, or movies, all give the same message — while nurses may be trustworthy and honest, they are "kind but dumb."

The historical relationship between nurses and doctors and the way nurses are represented in the media are mirrored in the way nursing services were reorganized during the period of health care reform in the 1990s. Whole departments of nursing, previously recognized internationally for their excellence, disappeared. Directors of nursing became directors of patient care services, responsible for rehabilitation, laundry, pharmacy, and other support services, in addition to nursing. Nursing positions were cut and many settings witnessed an increase in the use of less expensive staff, despite the fact that patient acuity levels and the complexity of patient care were increasing. During this period, Gordon notes that compulsory overtime became common. After working an eight- or twelve-hour shift, nurses were increasingly being asked to remain on duty for an additional shift. Those who refused were told they had "abandoned" their patients, were not a "team player," and were frequently fired. In other industries, these conditions might facilitate the development of strong unions and while some excellent bargaining units have developed in a few places, this is generally not the case. Rooted deeply in the way nurses are socialized, opponents to unionization have stressed the professional, selfless nature of nursing and tried to distinguish it from blue-collar work.

Not surprisingly, the above changes to the health care system have given rise to a tremendous shortage of nurses. Nurses with other options have left the profession and young people, seeing the position of nurses in society, have chosen other professions. This development has sent recruiters on trips around the world to hunt for nurses for the North American health care system. They offer wonderful incentives not available to existing staff, further fracturing the nursing workforce. This approach to solving the nursing shortage has added additional stresses related to language proficiency and educational equivalence.

Gordon's writing about the experience of nurses is evocative. As a nurse, I found my mind wondering back to additional examples of the points she raised from my own practice over the past 30 years. I have never personally witnessed the abuse she described but I certainly know individuals among my Canadian nursing colleagues who have. Her writing is overwhelming at times and I found I could only read a few pages at a time. She does an excellent job of capturing the sense of helplessness we have all experienced, not just in the last fifteen years, but also from the earliest days of our professional work. Although Gordon's examples are drawn mainly from the US, she provides some analysis of health care restructuring in Canada and other countries in the 1990s.

Several things bothered me about this book. First, it is a little too "black and white." Physicians as a group are portrayed negatively. I work with many doctors who are not at all like the ones she describes. Indeed, there are some who would have made excellent nurses! They are kind, caring, and respectful. I have been particularly impressed by the collegial and collaborative interpersonal style of recent medical graduates. This variation within the medical profession has heightened the uncertainty surrounding interactions between nurse and doctors. We (nurses) never quite know what to expect.

Second, the book left me wanting a deeper explanation of how such a dysfunctional set of professional relationships could have developed. These things don't just happen. More importantly, why are they being perpetuated? What are the driving forces within society that require the sharp power differential between nursing and medicine? What (and whose) interests do they serve?

Nevertheless, Gordon has "seen" nursing and presents it in clear and vivid detail, even though she is not a nurse. She has raised new questions in my mind about my profession and the way we think about who we are and what we do. Her book still sits on my desk. I won't be ready to put it away for quite a while.


Karin Olson University of Alberta

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