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Status and the power of symbols

Registered nurses need to be easily identified as the trained professionals they are, writes Peter Kieseker. This may involve a return to a uniform or some other sign of rank.

Something seems badly wrong in the registered nursing profession. December’s Nursing Review covered the bicentenary of nursing in Australia and in the same issue Professor Linda Shields wrote an article with the heading “Invisible nurses have to find their voice”. She pointed to the Weekend Australian (November 5) that had a 22-page supplement “Health of the Nation” that “completely ignored” input from nurses. Shields further writes that the word “nurse” occurred only three times in the whole 22 pages, despite nurses making up 55 per cent of Australia’s health workforce.

Why is it that after 200 years of being central to the wellbeing of Australians nurses have failed to make a mark? Why is it that the nursing profession can be so readily sidelined by the very sector it numerically dominates? Why is it that not only graduate nurses but also highly experienced and qualified nurses with decades of devotion and experience are ignored? Perhaps one reason is nursing’s tendency to sabotage itself by negativity, as exemplified by the violence or bullying endured by nurses that is an unpleasant reality.

Another reason, however, seems to be nursing’s failure to achieve professional status. Nursing lacks the respect and authority it deserves, and as a consequence it is being disregarded by “proper health professionals”, as occurred in the “Health of the Nation” supplement. As a transitioning nurse, I believe this lack of status is a key reason why registered nurses are so often disregarded.

Registered nurses have allowed the dilution of their professional status to the point that they are accorded little respect. The concept of status in question is not one of ego but as defined in the Oxford Dictionary as “relative importance in relation to others”. The ignoring of nurses in the “Health of the Nation” seems to loudly proclaim that our status is insignificant and of little importance compared to other health workers. As RNs we know our implicit status comes from our knowledge and skills. The trouble is few others seem to recognise this.

Registered nursing, perhaps driven by values of equality and fairness, is belittling itself by discounting those elements that create status ascription. The price nursing is paying for this is to be seen as lacking rank, and hence irrelevant to the health debate.

Many factors contribute to status. While some status can come from degrees and experience this should not be assumed as automatic. It is not, although perhaps naively the nursing profession has expected such. As pointed out by noted writers such as Cialdini and Mills, a universally acknowledged status attributor is authority, and amongst the greatest authority producing agents are titles and symbols. Rightly or wrongly semantics and symbols have power to influence.

The status of doctors is ascribed automatically by the title, Doctor. Even junior doctors, not yet qualified, are ascribed this status. And for further status attribution doctors resort to titles such as registrar and consultant. In nursing, however, one of the principal elements degrading the status of registered nurses is our actual title: nurse.

The title has been so widely applied that today it is devalued to the point of being almost meaningless as a professional nomenclature. Shields cites this as the function of the “blurring of roles between registered nurses and healthcare assistants”. It sometimes seems that nearly everyone is a nurse. We have endorsed enrolled nurses (EENs), enrolled nurses (ENs), assistants in nursing (AINs) and a plethora of other “nurses”, even self-titled home nurses who provide full-time care to family members. All use the title nurse.

This is not meant to degrade the wonderful work done by those other than registered nurses; it is simply to point out that such a widely used title, nurse, means in the layperson’s mind – and seemingly in the mind of many health professionals – that there is little demarcation made between all of these many types of nurses. As a result the title nurse, be it a registered nurse or a totally unqualified home nurse, is often ascribed the status of the lowest common denominator. It is no wonder RNs are very quick to denote themselves as separate, and especially so they can claim titles such as nurse practitioner, clinical nurse or RN specialist nurse.

The community, and many medical professionals, seem to equate nursing more to feeding and cleaning than to the highly involved roles performed by RNs. Indeed with everyone being a nurse and with RNs often needing to complete these most basic nursing functions, it is no wonder that little differentiation of status is awarded to RNs.

We never want to reach a place where basic nursing is considered below a RN, but somehow we need to ensure that this is not the dominant impression. Registered nursing has moved into an era of technological and medical complexity and carries with it massive responsibilities and accountability for patient welfare. This is clearly not being recognised in pay packets, but what is more concerning is that it is not even being recognised by others in the health industry.

Of course we once had symbols that demarcated the RN. It was our uniform and badges. In days gone by a patient clearly knew the status of the person caring for them - the uniform said it all. It was with great pride that a student nurse added stripes to their uniform and caps as they moved through the three years of hospital training. And on the big day of becoming an actual nurse, a RN, silly caps gave way to even sillier veils. But when the veiled sister walked onto the ward patients and others knew that the true professional had arrived.

Today we nurses all dress alike, and rarely can patients, doctors or even other staff members tell who is who. The all powerful status attribution signs of rank have been lost. Doctors still maintain their status symbols no matter how dressed, the seemingly surgically attached stethoscope, but for nurses it is a guessing game as to their place in the system. RNs gave up their titles of rank and status when they gave up “sister”, and gave up status symbols and badges of rank when we gave up our distinctive uniform. Some attempts seem to be being made via the very prominent RN name tags being marketed by RCNA. But the layperson’s discrimination is poor; we need more.

As a new generation of nurses we may need to go back to the future and re-establish a symbolism that speaks loudly and clearly to all that here is a professional that deserves to be - and for holistic patient welfare, needs to be – considered a professional who deserves to have a place in issues such as the “Health of the Nation”. We don’t need to reintroduce the veil (it would certainly not suit male nurses, and neither do we want to again be Mister Sisters), but we do need something otherwise we risk being continually sidelined in and by our very own industry.

Peter Kieseker has recently graduated as a registered nurse in Queensland.

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