Welcome to episode twelve of the Ausmed Handover podcast. Sometime in our deep, dark past, society asked nurses to take on a role that, under scrutiny, simply can’t be done. That is, when one looks at the expectations of the nursing profession, they are completely unreasonable. Yet nurses rise up to the challenge of the impossible every day. How and when did this happen, and just why do nurses persist in trying to meet the unreasonable expectations of an impossible job?
Hello and welcome to the Ausmed handover podcast. My name is Darren Wake, and in this episode, I want to try and explain why I think nursing the most unreasonable job… ever!
Sometime in our deep, murky past society asked nurses to take on a role that, under scrutiny, simply can’t be done. That is, when one looks at the expectations of the nursing profession, they are completely unreasonable. Yet nurses rise up to the challenge of the impossible every day. How and when did this happen, and just why do nurses persist in trying to meet the unreasonable expectations of an impossible job?
Well, to understand when and how society covertly dumped its near impossible expectations onto the nursing profession, we need to travel all the way back in time to well before the Monastic era, well before the turn of the 11th century, for that’s where the history of nursing really begins.
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SFX: ANCIENT MUSIC (00:10)
Healthcare services, no matter what they might be called historically, have been around for a very long time. Most archaeologists would agree that all of the major digs in Europe, South America the Middle East, India and Asia have at some stage or another, uncovered evidence of a healing facility of some kind, and in most cases, these buildings were found in the vicinity of temples dedicated to one or more of the ancient deities of healing.
Such places were staffed by the priests and priestesses of the temples, and healing was primarily a mix of herbal remedies, salves, ointments and potions, very basic surgery and, overwhelmingly, a mix of prayer, spells and ritual and incantation.
The outcome of any treatment was determined not so much by the hands-on component, but by the patient’s relationship with some particular God or their personal deity, and if they recovered from whatever ailed them, it was because that relationship was good, they prayed enough, made suitable offerings to the Gods, adhered to ritual and, most importantly, made a generous donation to the temple.
If they failed to recover, the illness became chronic or they died, it was not so much a fault of the temple or its priests, but rather related to the failure of the patient to maintain a right and proper relationship with their Gods and lead a good life.
Or make a big enough donation.
I find it fascinating that even in 500 BC, health outcomes were thought to be determined by a person’s lifestyle choices.
The traditional role of the healer was comprised of a lesser component, which was the hands-on providence of healing salves, herbs and ointments, setting broken bones and so forth, and a greater and far more important element, which was to act as a conduit between the patient and their God, gods or whatever form their favoured deity took.
That’s because the overwhelming majority of people in those times believed in an afterlife, and if they became very ill, broke a bone or suffered some kind of serious injury, death was the most likely outcome, so it was far more prudent to sort your relationship with the Gods than depend on the very fallible intervention of human beings.
Such places were referred to by the ancient Greeks as Asclepei, and by the Romans as valetudinaria, and there are analogues to these establishments to be found in the ruins of all of the more advanced ancient civilisations of the Middle East, South America, India, Asia and pre-roman Europe.
Treatment was largely delivered by male priests – in those days’ female priests were very distinguished and were more often consulted on matters of state rather than health – and the family actually cared for the sick person by providing the emotional support and doing a lot of the hands on care as they had been directed: they either took them home at the conclusion of a consultation session, or staying with them at the temple if they were too ill to move or dying.
This model prevailed for around a thousand years, and there’s no doubt that it improved as it evolved. Knowledge of the various treatments was jealously guarded, and passed down from senior priest to junior priest as part of an oral tradition closely and inextricably intertwined with matters of faith and ritual.
However, by around 500 AD, things began to change dramatically,
GREGORIAN CHANTING (0:10)
The meteoric rise in the popularity of western Christianity and the dominance of the Byzantine empire bought with it an astounding number of changes to the established order of things.
Healing was still very much a religious matter, and dedicated communities were established by the church and they were tasked with carrying out the very specific religious mandates of charity, compassion and caring.
The first Byzantine council of Nicea in 325 declared that a hospital be constructed in every cathedral town, bearing in mind there weren’t many of these in 325, and they were to be staffed by monks and nuns trained to care for the suffering, although in the early days of the church, nuns were in very scarce supply.
Sometimes these hospitals had university trained physicians on staff, but this was extremely rare: such professionals were nearly always snapped up by the aristocracy as members of their personal entourage. Rather, the knowledge of healing was passed down from Abbot to Abbot who directed the provision of care by his staff, and the dominant opinion prevailed that your morbidity and mortality was something that was largely determined by your relationship with God.
As I mentioned, this care mostly took the form of petitioning the almighty on behalf of the sick person, which was why healthcare was largely delivered by monks and nuns, and this usually attracted a fee, and along with this they also used mostly herbal remedies of various types, and other non-surgical interventions.
Surgery, that is, the slicing of flesh or the opening of a body cavity was rarely, if ever used on common folk except in the simplest form: in those times knowledge of the anatomy of the human body was extremely limited, and dissection of the dead was expressly forbidden by the church, so it was a long time before an understanding of human anatomy and physiology was able to improve.
So basic trauma might be managed, or a military wound, but if you burst your appendix or had any kind of internal problem, you were pretty well a done deal and needed to sort out your relationship with God as a matter of priority. Unless you were super rich or a king that is, in which case such rules didn’t apply to you.
Care took place on a day visit basis, in the homes of the sick, and the very unwell or dying could stay in the hospital if required, with their families present to provide emotional support and deliver care as directed by the monks or nuns.
The healthcare model of the time largely revolved around spiritual care, some hands on clinical work and a bit of compassion. However, in terms of the emotional an ongoing care of the sick, it was expected that the family provide this.
Remember this, because it’s an important point: the healthcare providers consulted to the families, but aside from some genuine compassion, a lot of fervent prayer and some limited hands on, it was expected that the emotional support and most, if not all of the physical cares be provided by the family under instruction, so they were expected to attend their lived one.
This model was so effective, accessible (because it was also grounded in the principles of charity) and ultimately popular that it spread beyond its Byzantine foundations to become the dominant model of care throughout all of Europe, Britain and the middle east.
By the beginning of the 10th Century, both abbots and physicians had begun to accumulate a significant body of knowledge about the care of the sick, probably more than could be passed on through the oral tradition, and there was a notable increase in the number of hand written texts being produced on matters related to healing.
This was an important event, as what we were seeing was clear evidence that the delivery of healthcare was becoming a technically complex specialty, and this technical knowledge was being categorised and stored. Undoubtedly God had the final say in matters of life and death, but he was giving humans a fair bit of leeway in respect to how he reached his decisions.
This body of medical knowledge began to increase exponentially, and, in the context of this podcast, things began to get interesting. The amount of knowledge the church possessed about healthcare was growing at an astonishing rate, but in 1540 in England, for various rather selfish reasons, King Henry the 8’th decided to bring about the dissolution of the monastic houses in Great Britain.
Now although it was controversial enough to shut down the monasteries, it was going to be near impossible for Henry to shut down all the hospitals associated with them, as they were the only possible access the poor had to any kind of reasonable healthcare. To close down everything would have meant relegating the lower middle class and the poor to seeking treatment for their various health problems from the local village witch, which was somewhat less than optimal, witches not really subscribing to concept of evidence based practice.
So, to ensure healthcare was available to the masses, over the next 200 years we saw the slow establishment of secular healthcare institutions: hospitals as we know them today were built, such as Guys and Westminster in London. These had dedicated physicians and care staff looking after the sick and with the significantly reduced influence of the church, their care focus shifted from the reverential to being mainly hands on, and once with find this situation extending into the enlightenment… well… boom.
ENLIGHTENMENT MUSIC (0:10)
What the 18th century period of enlightenment taught us was that although God might be part of our lives, he wasn’t necessarily that interested in being the sole determinant of healthcare outcomes: he was happy to let humans take control of that, and three things combined during this period that resulted in an absolute explosion of knowledge about healthcare and the human body: things that helped us take control over a lot of our own health.
Firstly, both the church and the state relaxed their restrictions on dissecting the dead and, consequently, we rapidly improved our anatomical and surgical knowledge. Secondly, the focus of healthcare professionals was progressively devoted to learning about and caring for health and the human body and using practices the efficacy of which had been established through evidence, time that previously was largely spent mostly praying for a good outcome. And finally, the development of the printing press and decreasing cost of book production meant that medical knowledge could be easily preserved, catalogued, distributed and easily accessed.
But let’s remember that the fundamental model of care in the early enlightenment hadn’t changed that much: a religious consultation was replaced by a clinical one, and although a lot of care was delivered by physicians and the care staff that were to go on and become nurses as we know them today, it was largely regarded that a lot of care should be delivered by families in their own homes, or by families staying in the hospital environment with the patient. Certainly this was an expectation in terms of the ongoing emotional care of the patient. Then, as in 500BC, as in 1100AD, there was no other better placed and qualified to provide for the emotional care of the patient like their family.
But, things were changing, and the late enlightenment of the mid 1800’s was where, in my opinion, nursing got shafted. Right there: at its formal beginning. All the opportunities were there to do it right, and we blew it.
As I mentioned previously, a lot of the hands on care and certainly the emotional care of patients was handled by their families. I mean, back in the middle ages, it wouldn’t have been that hard to change a rag soaked in some herbal remedy every day, or give a dose of hemlock on a regular basis.
But by the end of the enlightenment, medicine had advanced so far that an awful lot of diseases and injuries that were previously too complex to even consider treating were now managed successfully and on a regular basis, and with the advent of effective and safe anaesthetic techniques in the mid 1800’s, a whole swathe of surgical procedures could be performed that were previously unthinkable.
So healthcare had gotten fantastically complex, the acute treatment of illness was becoming especially refined and effective, as was the treatment of chronic disease, and surgery was jumping ahead in leaps and bounds.
So the degree of technical expertise required to deliver this care rose exponentially, and we saw the rise of a class of worker that was especially adept at administering this care: proto nurses, so to speak.
But, and I think this was a factor especially influenced by the rise of infection control knowledge, care was also becoming too complex or too risky to be conducted by the layperson in the home. That is, there was no possibility that your average patient’s family could take their loved one home anymore to deliver a lot of the care as instructed, and surgery, of course, necessitated an extended stay in hospital.
So in the 1800’s, we saw a boom in the number of hospitals being built: in that kind of structured environment, expert care could be given around the clock, and it could be given effectively with all the resources needed.
It’s important to bear in mind just what I’m saying here, and what the numbers involved were: in 1800, only around 1000 patients a year in the whole of the UK were being treated as hospital in-patients, by 1860, that had increased to 9000, and by 1900, it was a half a million.
During this period of near vertical increase in both the expertise required and the need to treat people in the hospital environment, people such as Florence recognised the need for a defined professional with a specific role within the healthcare system.
But what happened, in my opinion, really didn’t take into account two seemingly similar but in reality widely differing requirements of the newly emerging nursing profession. One from the perspective of the rapidly growing healthcare service, and the other from the perspective of the public.
The healthcare service desperately needed a role that understood the practical application of technical care, could routinely deliver it to a set standard, and could be trained in high numbers.
The public wanted a professional who could deliver a high standard of technical hands on care, could act as an intermediary between themselves and the doctor, and also a third, extremely important requirement we seem to have underestimated in terms its importance.
With the increased number of people being admitted to hospital on a regular basis and for extended stays as in patients, it became economically difficult for families to continue to assist in this hands on care. That is, most of them simply couldn’t afford to take days off work to come in and provide the emotional care for their relatives whilst they were in patients. Remember that home based care was becoming increasingly rare.
So, over a relatively short period of time, this emotional aspect of care, along with the hands on component, was abrogated to what had emerged as the nursing profession, and one of the core responsibilities of nurses, in the publics eyes, became not just the delivery of technically expert services, but safeguarding the emotional wellbeing of those entrusted to their care as well.
But wait a minute… let’s look at how the role of the intermediary carer changed over the thousand years preceding the emergence of the defined nursing role.
For much of this time, proto nurses provided mostly a mix of religious services and technical hand on, they provided compassion, there’s no doubt about that, but care of the sick was actually carried out by their families under instruction, and this included their emotional care. That is, the compassion and sympathy extended by family members to each other, especially in times of ill health.
After the reformation and dissolution of the monasteries, there was a much lesser emphasis on the religious aspect of care, but the technical side of things of grew exponentially to replace this component.
Compassion was still there of course, but on the whole, until the enlightenment, care was still provided under instruction by the families of the sick.
But then, from the mid 1800’s onwards it became pretty much standard for anything but the simplest of care to be delivered in a hospital setting by expert nurses, and the length of time a person needed to stay in hospital for this expert care meant that economically, it was no longer possible for families to ‘live in’ and provide the emotional support needed by their loved one, so this was taken on by nurses.
But wait, the void in the role of the nurses created by the shift from esoterically determined outcomes was filled by the knowledge and expertise required to deliver outcomes determined by evidence based practice, so where were we supposed to find the time to deliver the emotional support to those in our care?
Well, no one seems to have considered this. It seems that it was regarded at some point historically that we would provide all the technical expertise as well as all the emotional support: like it wasn’t any real burden to take this aspect on.
And I think this is unreasonable, if not, for all intensive purposes, untenable.
Why? Well, I think the minimum expectation of any family who leaves a loved one in your care is that you provide them with at least the same level of compassion and emotional support that the family would if they were doing it. And that’s pretty intense.
Now we can’t underestimate this expectation, although we have: a family can provide incredibly intense and close emotional support 24 hours a day, 365 days a year to a member that is sick, and that’s what’s expected of you. But, you’re also expected to provide expert technical care as well.
Now to me it seems wildly optimistic to say we can provide compassion and emotional support to the equal of the family for those in our care as well as complex technical care, but what’s really crazy is that this would be regarded as a full-on job for the family of the patient, and we just don’t look after one patient: we look after anywhere between five and ten on a shift.
So although we might be able to divide our technical care equally between 5 or 10 patients, we are also expected to provide the equivalent of the emotional care and compassion that their family would provide on a 1:1 basis to every one of those patients as well.
Not the care of one person spread over 5 or 10 patients, but do the job of five to ten families simultaneously.
And no one in their right mind would take that on: it’s impossible to do.
Except for nurses.
So, why do nurses do this? I imagine you were waiting for an answer to this, but the reality is, I don’t know, and I’m hoping that you’ll tell me in the comments section. Day in, day out, we do what I believe is an impossible job, and if our role were created today, I would think that those drafting the job description would say “wait: don’t put that in there, no one could possibly do it”.
But what is equally amazing is that we do it for free, and there’s another podcast in this series called how much is a nurse worth that explores this issue in depth.
But in a nutshell, I know we don’t get compensated for this incredible responsibility because we are paid on par with those roles in healthcare that have the same volume and quality of training but deliver only technical services.
This is the Ausmed Handover podcast, my name is Darren Wake, and thank you for listening.
If you enjoyed this podcast, please subscribe to the channel for future episodes, and please feel free to leave your comments and feedback for us: we always welcome your opinion.
I’m especially interested in hearing why you go to work every day and do a job that I think, is impossible to do.