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Journal of Nursing Management, 2005, 13, 282285

Commentary. The social construction of `woman's work: nursing


labour and status

In this paper it will be suggested that the historical including social approaches and humanistic models, the
social construction and devaluation of what is perceived scientific biomedical model has achieved the status of a
as womens work has provided a legacy that has concerted singular point of reference from which other
resulted in low levels of status being associated with approaches, theories and practices concerning birth,
nursing. The historical shift of control of matters con- death, health and illness are conceptualized. The defi-
cerned with birth, death, health and illness, from ning features of this scientific approach have been des-
women to men, will be considered. This will be situated cribed as biomedical, reductionist, mechanistic and
within the context of the rise of scientific positivism and allopathic (Naidoo 1994), wherein the body is con-
the emergence of professional practice. It will be pro- ceptualized as an entity which is made up of small parts.
posed that nursing work became situated at the lower If something is wrong with the body, treatment consists
end of a hierarchy, within which status associated with of applying a force or intervention which seeks to cor-
nursing was primarily attached to the perceived virtues rect this dysfunction, which usually takes the form of
of duty and vocation, which became principle incentives pharmacological drugs or some form of surgery. There
for people to enter and remain in nursing. It will be have been significant scientific breakthroughs eman-
suggested that such perceived virtues no longer accrue ating from the bio-medical school of thought that have
status within contemporary western society. This has unarguably enhanced human existence, for example
led to an anxiety within nursing to endeavour to secure anaesthesia, antisepsis and antibiotics. However, pro-
status primarily through assimilating to, and advoca- fessional closure around this bio-medical approach has
ting, scientific rationale and professional recognition. ensured that this school of thought has become the
The limitations of this shift in nursing focus will be predominant paradigm utilized to understand and
explored and a re-valuation of work concerned with respond to a diversity of human experiences that are
birth, death, health and illness will be proposed as a beyond the flesh (Hugman 1991). Non-medical
means of re-conceptualizing status within nursing and approaches such as nursing are consequently concep-
caring labour. tualized in relational terms to the medical paradigm,
The social construction of femininity, coupled with thus reducing nursing practice to a concept of other or
aspects of the biological realities of reproduction, have a form of deviation from the accepted singular bio-
provided the historical context in which women main- medical scientific ideal.
tained control over activities associated with birth, From the mid-1800s onwards, this medicalization of
death, health and illness. This included responsibilities health became increasingly formalized across the west-
around childbirth and delivery, child rearing, nurturing, ern world, endorsed by legislation and controlled by
family nutrition, family hygiene, care and treatment of occupational closure (Turner 1987, 1996). This has led
the sick, and care of dying. The past three centuries to the medical profession developing a legal monopoly
have witnessed the development and growth of scientific over the control of caring interventions and the health
positivism, which has become the dominant school of policy in which it is situated (Foucault 1973, Illich
thought within academic institutions. The application 1976, Coe 1978). It is within this context that nursing,
of this scientific approach to human experiences con- which remained female dominated, became occupa-
cerned with bodily functions has led to a shift in control tionally situated at the lower end of a hierarchy of
over these matters from women to men. This gender control of care. This was arguably reinforced by the
shift has developed through a complex mixture of pol- work of Florence Nightingale who, influenced by the
itics, scientific advancement, professional closure and British public health reform movement, successfully
gender biases in academic institutions (Kelleher et al. applied emerging understandings of hygiene and infec-
1994). Although other approaches have emerged, tion control to nursing care during the Crimean War.

282 2005 Blackwell Publishing Ltd


Social construction of woman's work

While Nightingales achievements were significant, she care-giving is conceptualized in terms of its scientific
would appear to have developed, refined and reinforced a legitimacy. The regularization of nursing interventions
system in which the content and process of nursing care within this scientific school of thought endeavours to
labour was directed by doctors, who predominantly achieve consistency in nursing care, thus ensuring that
operated from an emerging scientific medical paradigm. each patient can expect a similar nursing intervention
Within this system of care-giving, status within nursing from any registered professional nurse. Ease of
became attached to an ethos which rotated around cooperation between the various professions that utilize
principles of duty, order and obedience. Such perceived the scientific approach is also considered by many to be
virtues within nursing remained principle aspects of advantageous as it ensures a cohesive programme of
prestige within nursing for more than a century after their care delivery to patients. However, there have been
generation. These socially constructed status indicators significant critical observations of this approach to
provided for ease of recruitment and retention of nurses nursing care (Freshwater & Rolfe 2004).
to care giving milieus which were highly controlled and There has been an increasing emphasis on research as
structured around medical scientific rationale. a prerequisite for the recognition of nursing as a legit-
The later part of the 20th century has seen a pro- imate profession within the professional community.
motion of individual freedom. Key moments of this The development of nurse theory provided the intel-
change have been the spread of various forms of west- lectual mechanisms that have enabled this research
ern democratic capitalism governance, the rise of movement while simultaneously playing a significant
globalization with its associated rapid movement of role in the realization of a professional status in nursing.
people, capital and ideas, the emergence of postmodern Advocates of the nursing process and nursing models
schools of thought, the feminist movement and the are incorporating a hidden agenda that of profes-
general rejection of grand narratives as providing uni- sionalizing the nurse (Smith 1985, p. 70). This agenda
versal understandings of social life. Within this con- of status through professionalizing nursing based on
temporary social setting, concepts of duty, order and scientific research has been powerful within nurse the-
obedience have decreased in social status and have been ory, nurse management, nurse education and nurse
replaced with status associated with autonomy, per- practice. A consideration of the qualities and short-
ceived development progression and individual com- comings of professionalism appears to be engaged as a
mercial success. It would appear that this has provided sideline academic issue in nursing and unfortunately the
the social context in which nursing has rejected the articulation of any potential limitations of profession-
status associated with vocation, duty and obedience and alism in nursing is often reacted to with charges of
has developed an anxiety to achieve occupational status heresy from ones peers. This has resulted in many
by pursuing strategies of professionalism and practice nurses navely pursuing a professional ethos in the
based on scientific truths. absence of a critical exploration of what the nature of
nursing will be if this ethos is realized.
With todays rapid and unprecedented changes, a
The classical professional model has several key
new urgency has been added to the critical need
characteristics: a claim over a monopoly of knowledge,
for a body of scientific knowledge specific to
a self-regulated and controlled registration of entry, a
nursing (Smith 1981, p. 1).
legally backed monopoly of practice and autonomy. In
Nursing science has come of age. The multiple pursuing this ethos, Davis argued that nurses are
publications of conceptual systems and theories in embracing the classic way of being professional
nursing, have demonstrated advance in the scien- all-knowing distant and detached (Davis 1996, p. 46)
tific movement in nursing (King 1995, p. 39). an ethos which appears to be distinctly incongruous
The application of scientific positivism to nurse and inappropriate to the act of caring which lies at the
practice has led to the emerging prominence of what is core of nursing. There would appear to be major
referred to as evidence-based practice (Pepper 1989). limitations in claiming a monopoly of intellectual
This form of practice proposes a high degree of property over insights into birth, death, health and
accountability, as nursing interventions are based on illness, which inform the knowledge base for caring
outcomes that have survived extensive scientific en- (Porter 1990, 1992). A legally enforced professional
quiry. The integration of such scientific rationality in closure around such insights would seem to be a dis-
nursing education, management and practice has empowering process within society, a process which
increasingly established an orthodoxy within which solely serves the purpose of establishing and reprodu-

2005 Blackwell Publishing Ltd, Journal of Nursing Management, 13, 282285 283
D. Brennan

cing power. The exerting of power over patients is thinkers as various as Plato, Rene Descartes,
diametrically opposed to the philosophies from which G.W.F. Hegel, Friedrich Nietzsce, Sigmund Freud,
most nursing theory claims to emanate from. Criticism and Jacques Lacan (Tong 1989, p. 277).
of professionalism has led some nurse theorists to
Irigaray adds de Beauvoir to this list and links her
question the presumptions that professionalism is a
view of sameness to that of Sigmund Freud, like de
desirable and worthy model for nurses to pursue,
Beauvoir, he (Freud) does not recognize the other as
proposing that, an advancement into old profession-
other: and, albeit in different ways, they both propose
alism is an advance into a cul de sac (Davis 1995,
that man remain the singular model of the subject,
p. 152).
which women must try to equal (Irigaray 1995, p. 11).
The question we must ask is not is nursing a Hence Irigaray problematizes the legitimacy of accept-
profession? but should nursing want to be a ing a singular model from which the other is concep-
profession, and if so, what do we mean by it? tualized. She proposes that the other is full in its own
What are we hoping to achieve and is this the best right and not reducible to a notion of an accepted col-
way to go about it? (Salvage 1985, p. 92). lective sameness.
Nursing has inherited a legacy of positivism, This notion involves for Irigaray both the des-
which promotes objectivity and reductionism and cription and denunciation of the false universal
which excludes subjective meaning and the per- which is inherent in the phallocentric posture: one
sonal from the research process. In part this has which posits the masculine as a self-regulating
been due to the powerful influence of medical rational agency and the feminine Other as a site
hegemony, which has defined the nature of legit- of devaluation (Jagger & Young 1998, p. 299).
imate knowledge (Playle 1995, p. 979).
Here the model of one is replaced by a model of
This process of application of scientific positivism, many, which are not placed in a hierarchical relation-
emanating from the medical model to nursing theory, ship, each being fully respected for their wholeness.
has been described as a process of medical imperialism Irigarays philosophical paradigm provides a context in
(Barker et al. 1989). In recognition of such criticism, which nursing may be conceptualized without reference
some nurse theorists have searched for methods of to its relationship to medicine. Hence nursing can be
verifying nursing knowledge, without blindly pursuing considered as a full and legitimate response to birth,
the dominant perspective of scientific positivism (Rolfe death, health and illness, not limited by or endeavour-
2000). It would appear that the transcending of fixed ing to control the diversity of other approaches to such
binary understandings of nursing labour requires an human experiences. The adoption of this approach
exploration and problematization of models of singu- offers nurses the opportunity to define their practice and
larity and conceptualized other. Such an exploration knowledge while not reducing nursing insights into a
can provide a philosophical context that advocates an process of comparison or contrast to other perspectives.
equality of diversity, wherein nursing can be considered Within such a context, respect, remuneration and status
beyond relationality to medical positivism. in nursing are not derived from the creation of a pro-
Aspects of feminist theory provide philosophical fessional monopoly over knowledge and practice but
understanding that lend themselves to such a re-con- are earned through the positive contribution that nur-
textualization of nursing. Drawing on Hegel (1967) and sing can make to a persons, familys and communitys
Sartre (1956), de Beauvoir (1974) provided an existen- experience of birth, death, health and illness.
tialist consideration of womans oppression, centrally It would appear that caring labour continues to be
proposing that woman is oppressed by virtue of oth- devalued within contemporary society. This challenges
erness. de Beauvoir proposed that for woman to become the achievement and retention of status within nursing,
self she must, like man, transcend the definitions, labels which can result in difficulties in the recruitment of
and essences limiting her existence. Adopting a post- nurses and the retention of high quality nurses within
modernist stance, Irigaray (1995) critiqued and further sites of caring. Several strategies have been adopted by
developed de Beauvoirs work, proposing a decon- nurses in the pursuit of occupational status. Unfortu-
struction of the acceptance of the concept of sameness nately, the popular contemporary strategy appears to be
which underlies the definition of what is other. one which advocates an exit from nursing care. This can
be observed by nurses realization of status through
In her study of Western philosophy and psycho-
moving away from undervalued areas of care such as
analysis, Irigary found sameness everywhere: in

284 2005 Blackwell Publishing Ltd, Journal of Nursing Management, 13, 282285
Social construction of woman's work

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2005 Blackwell Publishing Ltd, Journal of Nursing Management, 13, 282285 285