Nursing and Tradition

“Nothing was delivered
And I tell this truth to you
Not out of spite or anger
But simply because it’s true”
Bob Dylan

When I was a student nurse at St. Mary’s School of Nursing in Paddington, London in the mid-1980s, my female colleagues wore a traditional uniform. It was a blue and white dress, over which they wore a starched white apron and starched white collar. The aprons and collars came from a hospital laundry. They wore a white cap which also came from the laundry, though each student had to put a thread through the material at the back to pull it into shape before wearing it. My uniform was a knee length white coat with short sleeves. It had epaulettes that displayed my status, one blue stripe for a first-year student, then two and three stripes as I moved through the program. I wore a pale blue shirt and dark blue tie under the white coat and grey trousers.

Both uniforms showed tradition, but not the same one. The women’s uniform unmistakably was in a continuous line back to the Victorian origins of modern nursing, the skirt length being the most obvious concession to modernity. Mine, however, did not suggest such a distant past, but did have a military inflection in the epaulettes denoting rank, and a formality of collar and tie. Short sleeves were a practical feature for giving bed baths and cleaning bedpans, and meant male nursing students would not be mistaken for doctors.

These ostentatious differentiations of rank and discipline have long since been swept away by the universal adoption of scrubs. Student nurses in Canada still sometimes have a “capping ceremony” as part of their graduation, which is a symbolic throwback in the name of tradition, not a part of everyday dress. The nurse’s cap seems to have some lingering symbolic weight. A Google search for “nurse emoji” – a quick visual check on where the culture is at – brings up a lot of images of faces with caps, or cap-suggestive patches on their heads, though also images of generic “woman health worker” – capless, but resolutely female. Scrubs on the other hand, appear to be free of tradition, they have a neutral air, entirely a matter of practicality – but they cannot be outside of history or free of symbolic valences. They speak of scientific, technical omnivorousness that merges with bureaucratic techne and presumed objectivity. They rub out distinctions between the sexes, or of rank, even in many cases of function, unless colour coded to separate surgeons from cleaners, or nurses from physiotherapists. Everyone is only too aware of the hierarchical reality of hospitals, like a medieval stacking of angelic orders, but its signalling has become a lot quieter.

“A symbol is something that facilitates recognition, and the dearth of symbol is a characteristic feature of the historical moment in which we find ourselves.” Gadamer (1987) p. 74

It is not hard to seize on tracks of tradition in relation to nursing, but it also does not take long to find different claims to nursing tradition. It is harder to settle on one uniform (pun intended) tradition. Is it centered on compassion, bedside practice, problem solving, social justice? Will it be found in some essential value or in practice, in hospitals or homes, or university departments? A cursory search for articles using nursing and tradition in their titles shows a range of usages. Some are about nursing in relation to a tradition of something else, where the something could be a cultural or religious tradition; or some element of nursing, like the tradition of community nursing. Some are personal accounts of taking part in activities like capping ceremonies that are consciously about connecting with tradition – though that only circles back to the question of what tradition?

Arendt and Gadamer, those two very different students of Heidegger’s, were both concerned with tradition in the second half of the twentieth century. Arendt, Jewish refugee from Nazi Germany, whose major work (1968) was an attempt to anatomize totalitarianism, said that tradition had been ruptured completely (1961/2006), meaning the tradition of Western political thought. She wanted to work through what happened and concluded, not least from her own experience, that totalitarianism (of fascism and communism) was such a radically new and distinct phenomenon that there was no returning to tradition as if nothing had happened. Gadamer, the German philosopher who pursued his career quietly during the Nazi era, not personally supportive of the regime, made tradition a theme of his major work Truth and Method (2004), published in 1960. He recognized the fragmentation of tradition, which was already a theme of literary and artistic modernism before the 1930s but argued that nonetheless we can only understand ourselves in the world from out of tradition. It provides the “horizon” – to use one of his favoured words – of our view of the world. Fragmentation may be a feature of tradition but it does not mean that tradition is lost as the vector of transmission of understanding from past into present. Arendt’s thought was political and outward looking while Gadamer’s was philosophical and unpolitical. Perhaps there is no need to choose between their two positions – rupture or reconciliation – because they are in effect looking at different aspects of tradition. For thinking about nursing and tradition, their ideas ready us to look for signs of rupture and fragmentation – and continuity that includes them.

Is there a tradition of nursing as such, beyond composite strands of practice or haphazard personal experiences? Florence Nightingale seems like a good bet for the founder of a tradition of modern nursing, building on, but different to previous, less systematized caring roles. According to Arendt, tradition needs a foundation point, by which later participants in the tradition continue to orient themselves and their sense of meaning and identity. Notwithstanding criticisms of Nightingale against contemporary standards, it is hard to think of any other person that could come as close as she does to representing the foundation-point of modern nursing. Tradition, however, is never the automatic transmission of an unchanging foundational moment. To believe that it can be marks out some upholders of traditions, but even the most purist is in denial of their own selectivity and distortions (think of Second Amendment absolutists in the US – they have no interest in any other amendments to the Constitution, they gloss over the awkward fact that an amendment by definition is counter-absolutism, and they ignore any changes in social context – not to mention firearms technology – since 1791). It is the belief in the foundation that grounds tradition, not unchanging facts. To that extent, if Nightingale seems like a foundational figure, then she is. But founding what?

The ground of tradition was shifting under Florence Nightingale’s bed, from where she continued to influence policy in her later years, in her own lifetime. What she had founded, what she thought she had founded, was drifting away from her vision. Bostridge (2009) in his biography discusses the push to professionalize nursing, which as we know was successful – all modern nurses partake in that tradition – against Nightingale’s objections. It diverged from her religiously-inspired sense of nursing as vocational, determined by the movement from inner self to outer world, not external regulations. Yet that too is part of nursing’s image and self-image down to the present. When Nightingale turned her attention to the health of Britain’s overseas imperial armies, and compiled cutting-edge pie charts to present epidemiological evidence, did she see herself as “nursing”? We are happy to assume so, for it gives us a foundational moment not only of bedside caring, but also statistical research, population health, and policy-making.

Nursing tradition is more bound up with modernity than it sometimes seems, certainly more divided and multiple than can easily be decided. Modern nursing emerged in the wake of modern medicine, in some ways compensating for the diagnostic algorithmic mindset of scientific medicine, yet also an active participant. It shares, though differently, the same tension between aggregation and individuation as medicine. Nursing tradition is only typical of tradition in the industrial era in that it is fragmented, partial, contested.

“Nothing is better, nothing is best
Take care of yourself* and get plenty of rest.”
Bob Dylan

*The official Bob Dylan website gives “Take heed of this…” but he sings “Take care of yourself…” on the first of three takes on the 2014 Bootleg Series set, which is the version included on the 1975 Basement Tapes album. It seems more appropriate in this context.

References

Arendt, H. (1968). The origins of totalitarianism. Mariner.
Arendt, H. (2006). Between past and future. Penguin.
Bostridge, M. (2009). Florence Nightingale. Penguin.
Dylan, B. (1968). Nothing was delivered. http://www.bobdylan.com/songs/nothing-was-delivered/
Gadamer, H.G. (1987). The relevance of the beautiful and other essays. Cambridge University Press.
Gadamer, H.G. (2004). Truth and method. Continuum.