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The Left Atrium
Contents
• The king's garden [PDF] • Capping off an era [PDF] • Inukshuk [PDF] • Hat trick: the doctor who was a nurse [PDF] • One thousand words [PDF]
Patricia O'Reilly's case history of the making of Ontario's Regulated Health Professionals Act of 1991 describes the representations from the many professional, semiprofessional and nonprofessional groups involved in health care delivery, explains the process by which these submissions were considered, and assesses the impact of the new model for health professions regulation that subsquently arose. It begins with a lengthy account of the methodology the author uses in telling this story and presents a clever intellectual framework for organizing the material. As O'Reilly argues, this history can be presented in two ways. The first, "institutionalist," approach is to give an account of the differences between institutional structures and regulations before and after the passage of the act. The second, "ideational," approach requires that one tell stories that exemplify the changing ideas and cultures that surround the different groups. Enticed by the promise of policy stories, I looked forward to a gritty tale of colourful characters, pressure groups, smoke-filled rooms and passionate debate: the kind of narrative that portrays the ebb and flow of politics and policy-making in the world of Queen's Park. Instead, I was led through a rather abstract but still interesting process of well-mannered representations before a well-behaved committee that used a set of agreed-upon criteria to test submissions. The struggles were not between personalities, but between abstract ideas, such as the scientific orientation of medicine versus the much more empirical approach of homeopathy. Other differences distinguished the power of already embedded professions from aspiring seeds scattered over the professional garden. There were no individual people and few individuals' words, let alone descriptions of their dress or what they had for lunch. Everything was presented at the level of professional bodies: how they positioned submissions to the panel, and how the panel responded. The summary of results concerned who became more deeply embedded, whose professional seeds germinated and whose never got planted at all. Being a little disappointed after such a promising beginning, I wondered how more life could have been breathed into this thorough but disembodied account. What I came up with was the following animated version of O'Reilly's tale. Once upon a time not so very long ago there lived a king. One day he called all his healers to the court. When everyone from the stately court physician to the lowly foot masseuse had arrived, he said, "I would like you to tell me what you do, why you do it and what you think your rights and obligations should be to me and to the people of this fair kingdom." The king's request was seen as insulting by the court physician, who had spent years studying his science at great institutions of learning. He had built up a large practice with a staff of chemists, nurses and trained therapists. Why should he have to justify himself like the lowly masseuse, who had only a modicum of education and was indistinguishable from a camp follower? But the king's request had to be met. And so each of the healers, including those in the physician's retinue, made representations. The king himself had to attend to other business. He had a country to reign over, balls to attend, foreign dignitaries to greet and taxes to assess. Since there was such a large entourage of healers he appointed a blue-ribbon panel of wise people to receive submissions and make recommendations. He took their task seriously and so worked with them to identify questions to be asked and criteria for assessing the answers. The healers had various arguments for bolstering their positions. The physicians, who were deeply embedded in the garden, wished to retain and increase their hegemony by keeping all others out. The partly established, whose seeds had germinated, wished to increase their clinical autonomy while distinguishing themselves from physicians. The truly excluded wished merely to gain entry to the garden and be recognized as part of the healing bouquet. The criteria were important for the panel, but as they listened they kept looking at the king's face whenever he was in the room, hoping to discern whom he favoured. As a result, some charming quacks were admitted because the king happened to smile at them, while some worthy but less graced healers were excluded by the caprice of a royal frown. In truth, many of the king's facial expressions reflected only the quality of the lunches served to the panel. To be fair, the panel was also influenced by communications from several patients and by advocates and enemies of those making representations. In the end, some changes were made in the array of healers. But, most important, the entire exercise made everyone realize that they fulfilled their roles at the pleasure of the king. They were not as autonomous as before, because at any moment they could be asked to account for their practice. (The king, for his part, died soon after and his heir had no inclination to repeat the exercise.) At this point my rendition enters the realm of surmise. We may speculate that one of the wise women on the committee thought (and one might agree) that the process was important enough to merit a permanent record. She gave one of her best students free run of the documents. The student immersed herself in the work, developed a helpful conceptual frame and found a way to tell the story without mentioning any of the players. This combination of diplomacy and erudition was so successful that she was herself certified as a wise woman. One might imagine that in future researches, which this reader awaits with interest, she may be wiser still — and bolder.
Sholom Glouberman Contents
• The king's garden [PDF] • Capping off an era [PDF] • Inukshuk [PDF] • Hat trick: the doctor who was a nurse [PDF] • One thousand words [PDF] Lifeworks Capping off an era Gloria Kay's maiden name was incorrectly given as Barton. Her maiden name is Barwell. (CMAJ 2001;165:401) At one time every nursing school had its distinctive cap with stylized peaks and wings. Capping ceremonies were a powerful rite of passage into training, and variously coloured bands denoted the nurse's year in training, black being the definitive goal. But, by the mid 1980s, these caps had virtually vanished from the Canadian health care scene. Many nurses undoubtedly lamented the loss, but Gloria Kay of Conestogo, Ont., went a step further and began "saving a few from destruction." Eventually, she had carefully indexed and preserved 282 caps. "I loved nursing," she explains. "It was an emotional thing and the caps symbolize the love I have for my profession."
Kay recently donated 167 of her caps to the Canadian Museum of Civilization in Hull, Que., where a new exhibit, Symbol of a Profession: One Hundred Years of Nurses' Caps in Canada, runs until Sept. 30. Sponsored by the Canadian Nurses Association and the Canadian Association for the History of Nursing, it features 60 caps representing every province and dating from 1895 to 1983.
These caps are artifacts of the evolution of nursing in North America, beginning with the nun's coif worn by the Hospitalières, a Roman Catholic nursing order that arrived in Quebec in 1639. Secular nursing in English-speaking North America was less formal; female family members assumed the role at home, and charwomen did so in hospitals. Not surprisingly, during the 1870s the nurse's cap was virtually the same as the mob cap worn by working women indoors.
By the 20th century nursing caps took two basic shapes: mob cap and nun's coif. Over the years the mob cap developed crisp angles with a stiff pleated band. The coif was modified into a practical yet emblematic kerchief by Florence Nightingale, who developed a secular system of training in the mid 1800s. During the Great Wars, Canada's nursing sisters wore this kerchief. But, gradually, it too became more stylized with wings and bands, perched high on the head with no practical purpose other than professional identification.
Of course, not every nursing cap fit this mould. The University of Saskatchewan Nursing School's cap was a white mortarboard, while the cylindrical cap from the Freemason's Hospital in Morden, Man., looked like a fez.
Despite the arduous process of cleaning, starching and folding, nurses were proud of their caps, says Kay. "Everything was wrapped up in that darn cap." Why then did they stop wearing them? Exhibit curator Tina Bates says it may have been part of an attempt to professionalize nursing in the mid 1970s, when nurses wanted to be more closely aligned with physicians and other professionals who didn't wear uniforms.
At the same time, hospital-based schools of nursing were giving way to colleges and universities, and so the apprenticeship system of teaching, with its ritualized progress through the ranks, no long dominated nursing education. Thus the cap lost much of its meaning as a signifier of achievement at various levels. And it became less typical for nurses to be affiliated with a single hospital throughout their career.
Also during this era, men were being encouraged to join the profession; caps couldn't be part of that package.
The risk of infection may also have played a part in the cap's demise, says Diana Mansell, president of the Canadian Association for the History of Nursing, and the only Canadian to hold a doctorate in nursing history. The cotton or linen caps were difficult to clean and starch and were washed only about every three months.
Their phasing-out also coincided with the second wave of feminism and the unionization of the profession.
"A lot of tradition went out all at once," says Mansell. But she laments their passing. "The cap made a nurse visible in the hospital. Now we've vanished."
Beginning in June 2001, you can take an online tour of the exhibit.
Barbara Sibbald Contents
• The king's garden [PDF] • Capping off an era [PDF] • Inukshuk [PDF] • Hat trick: the doctor who was a nurse [PDF] • One thousand words [PDF]
Contents
• The king's garden [PDF] • Capping off an era [PDF] • Inukshuk [PDF] • Hat trick: the doctor who was a nurse • One thousand words Room for a view Hat trick: the doctor who was a nurse
My physician friends and colleagues generally advised me to keep my status as an ER nurse under my hat. This was medical school, after all, and it might be a disadvantage if my instructors expected me to know something from clinical experience. In fact, my years as a nurse were a hindrance when I applied. I wasn't given any credit for my nursing diploma, nor were my specialty courses in emergency nursing acknowledged. The attitude was: "Okay, you're a nurse. So?" I might as well have been a plumber. During one particularly harrowing interview a male physician glanced at my transcript and goaded me: "I see you've done very well in these nursing courses. How do you think you'll manage with some real science?"
As it turned out, first-year medicine had a levelling effect for everyone. None of us had an advantage in the gross anatomy lab as we struggled to delicately dissect tendons, muscles, arteries and nerves and to memorize a dizzying number of Latin terms. As a nurse, I had never heard of the brachial plexus, and although I knew that there are 206 bones in the human body I was unaware that one of them is the hyoid.
But I did appreciate my nursing background during second-year pathology. This course spanned a year and a half — nine hours each week — and covered every disease process known to man. Not even Einstein could have mastered the content. I had a distinct advantage over my colleagues, though. From years of clinical experience I knew the merits of understanding things that are common. When the lecture was about pneumonia, congestive heart failure or gallbladder disease I was wide awake. When the topic was amyloidosis, Wegener's granulomatosis or tropical sprue, I may have nodded off.
There were different reactions to my being a nurse. One anesthetist had me empty the urinary drainage bag of his bypass patient: after all, isn't that what nurses do? Another had me start all the pre-op IVs when he found out I used to work in the ER. The nurses generally thought it was great: I was the only "doctor" who cleaned up after herself. In one operating room they were thrilled to have another "nurse" on hand when they were short staffed. They had me hold an unconscious patient's legs up in the air while the scrub nurse painted on the antiseptic. There I stood, spreadeagled on tiptoes so as not to contaminate the sterile field. But I can't say I minded helping out: as doctor, or as nurse.
During one ER rotation, several failed attempts were made by various personnel to gain peripheral IV access in a patient who was crashing. The central line was placed in the jugular, but a peripheral site was still needed for potent IV medications to stabilize blood pressure. I seized the opportunity to start the line — having examined the patient's left arm, I knew that I could. The nurses talked about this feat all night. "Hey, that was pretty cool the way the med student got the line in, eh?" After a half-dozen pats on the back, I couldn't stand it any longer.
"Actually," I stammered, "that wasn't the first IV I've ever started. I've been an ER nurse for about 7 years."
Sighs of relief from the nurses and the doctors on duty. There was no prodigy in their midst.
I kept my nursing licence throughout medical school. Working during summer vacation and on the "super-stats" (read: triple time) was more than just a way to reduce my student loan. The physicians at the community hospital where I worked provided terrific mentorship. I noticed an immediate shift in attitude when they learned I was about to become one of them. It was as though I were now a member of some exclusive club and everyone wanted to take me under their wing. "Shannon, go listen to the patient's heart in bed 5." "Hey, Shannon, what's unusual about this chest film?" "Shannon, what lab work would you order for this patient?"
In fourth-year medicine I was surprised to feel a conflict of interest in trying to balance my nursing responsibilities with those of an almost-doctor. For one thing, the apparent obliviousness of the doctors to the call bells drove me mad. I couldn't tune them out — or the ringing phones, which a doctor can sit next to forever without answering.
As a medical student intern I was often told by the attending physician, "Don't bother with that; the nurse will do it." When I returned to the community hospital the next weekend as a nurse, I found myself being chastised: "Shannon, you're not the doctor. You don't have time for all that stuff. Just get a simple history and take the vital signs and get out of there."
My experience as a nurse is an integral part of who I am. But, now that I am also a physician, my perspective has changed. Nurses are doers who work harder physically than doctors, who are not as well paid or respected as they deserve, who have less autonomy and less credibility than they might, and who are wonderful patient advocates. Yet I can also describe them as being concerned with minutiae and redundancy, as being slow to adopt change, and as having a reputation for "eating their young." Nurses have tribunals to rake members over the coals. Physicians participate in morbidity and mortality rounds to learn from experience and avoid mistakes in the future. Physicians seem to respect each other more; they stick together; they police themselves; they are forgiving of one another — sometimes to a fault. But I also know, as a physician, that nurses are my best allies. And I am proud to tell my colleagues and patients that I was once a nurse. The truth, I guess, is that I always will be.
Shannon Lee Dutchyn Contents
• The king's garden [PDF] • Capping off an era [PDF] • Inukshuk [PDF] • Hat trick: the doctor who was a nurse • One thousand words One thousand words
Plastic surgery patients exercising at the Young Division of the Hamilton Convalescent Hospital, Hamilton, Ont., 1944
Copyright 2001 Canadian Medical Association or its licensors |
