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Article Excerpt
THE PROVISION AND FUTURE OF HEALTHCARE IN THE UNITED STATES HAVE become hotly contested social issues, centered over whether the market or state will organize these services. Healthcare has steadily moved from a private industry toward a more highly bureaucratized and collective "managed care" system in lieu of a single-payer, state-run system (e.g., the failed Clinton reforms). At the same time, nurses have emerged as one of the most activist occupational groups in the labor movement. More highly visible in opposition to managed healthcare and their working conditions, nurses have increasingly relied on public protests and strike activity to express their grievances (witness the California Nurses Association).
These developments are not coincidental, though their relationship is far from clear. As the changing political economy of medicine alters the organization and provision of healthcare services, it also affects the work relations and culture that characterize nursing. Though globalization and capital flight have made it more difficult for workers in the manufacturing and industrial sectors to organize, service workers--especially nurses--are relatively shielded from these trends because they provide in-person services. However, if nursing jobs are not being exported overseas, immigrant nurses are, and have been, recruited from other countries in the context of imperialism and globalization.
Nursing has continued its historical efforts to professionalize despite external opposition and internal dissent. At the same time, bureaucratization of decision-making and segmentation within nursing have transformed the struggle for control over the practice and purpose of this occupation. Since the 1960s, concern over the success of professionalization has grown as nurses have increasingly looked to unionization and collective bargaining. For the labor movement in general, and union organizing in particular, nursing constitutes an important and strategic sector that deserves serious attention. With globalization shadowed by the rise of neoliberalism, political support has increased for government cutbacks and market-oriented reforms for social services, including healthcare. This threatens the public's right to receive healthcare, which we consider a social right, not a consumer privilege. In this context, the struggle of nurses is part and parcel of the struggle of working people throughout the United States. As workers grasp at the straws of fading employer health benefits and the mirage of affordable private insurance, they must also be concerned with the delivery and quality of stretched and overburdened health services--services that are increasingly provided by nurses. With demographic trends forecasting an aging population, the healthcare crisis looms as one of the most urgent in need of a solution.
It remains unclear whether these trends can be reversed. The Clinton healthcare plan of the early 1990s may have failed insofar as its defeat led to the hapless and inefficient market debacle of Health Maintenance Organization (HMO) managed care. It did, nonetheless, resurrect an ideal of single-payer healthcare that has remained salient, though submerged, in the national psyche since the 1940s. And progressive calls for universal healthcare have recently found support from former Vice President Al Gore and presidential aspirant John Kerry, among others. With the growth of physician groups such as Physicians for a National Health Program (see www.pnhp.org), it might appear that this ideal lives on and the harmful cuts in Medicaid might cease and be reversed.
On the other hand, the forces that doomed the Clinton plan remain resilient and must be reckoned with in the years ahead. As in the early 1990s, staunch fiscal conservatives in both political parties, joined by the Republican religious Right, stand vehemently opposed to universal care and expanding Medicaid services. Likewise, the core of the medical industry, including the American Medical Association, a majority of physicians, elite nurse specialists, and the pharmaceutical-hospital complex, continue to resist any inroads into their spheres of control and autonomy. Still, even if a national health insurance system were to materialize, the struggles of nurses would not easily abate. As research on nurses in Canada (Coburn, 1988; Ponak, 1981) and England (Davies, 1995) attests, the segmentation of nursing characterized by professionalization and proletarianization persists despite more governmental oversight and delivery of healthcare services.
Given the importance of nursing in the provision of healthcare, we see three key challenges facing the labor movement in organizing nurses. First, labor unions must address the historic pull of professionalism among nurses and develop an ideological appeal that weaves specific strands of a professional ethos with the core principles of unionism. Likewise, the process whereby work cultures inform, guide, and constrain labor activism operates in a larger context in which class and gender dynamics intersect. Unions must resolve the tensions that have characterized these dynamics in nursing since its inception. Second, unions will need to attend to the increasingly ethnic and racial composition of nursing, especially given immigration from Asia and Latin America, which is unlikely to slow. The labor movement cannot ignore the steady increase of ethnic nurses, or the corresponding segregation of hospital RNs from predominantly Latino and African-American home-care workers. Finally, organizing must cast an ever-watchful eye on the traditional calling of nurses to care for their patients' well-being. Collective bargaining and the threat of withholding labor place nurses in a delicate situation vis-a-vis those they serve--the ill. As noted, these clients are often those most desperate for quality, affordable healthcare. Hence, patients are potential allies of nurses, and narrow occupational interests must be broadened to include a larger constituency and public good.
We first discuss professionalism and unionism among nurses and the relation of class and gender to these labor strategies. Given that nursing is an occupation composed predominantly by women, how nurses seek to improve their occupational lives and serve their patients must be understood in relation to patriarchal structures of society in general, and medicine in particular. We then provide a historical overview of nursing that outlines four main ideologies that have characterized this occupation: apprenticeship, professional, managerial, and unionist. Though each ideology reflects class divisions within nursing, we also consider how each incorporates gender. Next we illustrate current ideological frameworks in nursing through a content analysis of CalNurse (the publication of the California Nurses Association, CNA) and of research on nursing students from a California university. We conclude by discussing how the direction and ideology of labor activism might be reframed to more effectively mobilize nurses, reaffirm their occupational identities, and advance the well-being of those they serve. An important point of emphasis here is how nurses' struggle for occupational justice must include a broader and more inclusive social justice component in the provision of healthcare.
A Note on Methodology
In this article, we integrated different methodologies to analyze how class, gender, and ideology relate to nurses' labor activism. Beyond citing secondary materials in outlining the history of nursing, we use survey data from the U.S. Department of Health and Human Services, The Registered Nurse Population: Findings from the National Sample Survey of Registered Nurses (2000), the "Survey of Registered Nurses in California" (1999) by the Institute for Social Research at California State University, Sacramento, and the American Nurses Association "Nursing Facts" website, ana.org. Survey data highlight the contours of nursing at the national and regional levels in terms of occupational composition, compensation, and attitudes. These data are complemented by a content analysis (Apesoa, 2000) of CNA's newsletter, CalNurse, from 1989 to 1999. Based on a sample of 1,018 articles from 99 issues, Apesoa examined how this official publication shifted from an exclusive emphasis on professionalism to more unionist and gender frames by the mid-1990s. Finally, we incorporate data from Apesoa-Varano's research in a California university nursing program conducted from 2002 to 2003. Based on ethnographic evidence from the classroom and interview data of 20 nursing students, we explore the relationship between professional socialization emphasizing a scientific orientation and student perceptions of nurses' calling to care. Together, these methodologies and data sources support a more comprehensive analysis than any one by itself could provide, help to bridge the conceptual gap between macro- and micro-level processes, and provide different vantage points from which to consider occupational ideology and labor activism among nurses in the future.
Occupational Ideology and Labor Activism: Professionalism, Class, and Gender
Nursing has sought professional status for over a hundred years through rising formal educational requirements, changing content of nursing education programs, lobbying, and the rhetoric of official nursing publications. At the same time, nursing has increasingly become unionized. In the 1930s, nurses began joining unions despite opposition from the American Nursing Association (ANA), which had always endorsed professional associations, formal education, and political lobbying (Apesoa, 2000; Melosh, 1982: 198-199), though by 1968 the ANA had dropped its no-strike policy (Allen, 1986: 16). Founded in 1897, the ANA currently has 54 constituent state associations representing over 2.6 million registered nurses (RNs).
These twin impulses of professionalism and unionism are also reflected in the history of the California Nurses Association. The CNA was founded in 1903 to represent California nurses, and it currently has almost 35,000 members. The CNA followed the orientation of the ANA until the post-World War II period, when it adopted a more militant posture. Though not forgoing educational credentialing and political lobbying, the CNA was the first organization to represent nurses in collective bargaining and has increasingly pursued a strategy of work actions, public protests, and formal strikes to express the grievances and advance the interests of nurses.
These strategies and discourses reveal important tensions within nursing, especially class divisions among nurses. For example, nursing has seen more success in professionalizing the upper end of its occupational hierarchy among clinical nurse specialists and nurse practitioners. On the other hand, lower-level positions such as bedside RNs (in addition to licensed practical nurses and nurses' aides) have failed to achieve similar status (Apesoa, 2000; Gray, 1989; Melosh, 1982). The cultural dimension of these struggles is no less significant. Occupational ideologies are important in defining roles and goals for members, that is, how nurses think about themselves, their actions, and the publics they serve--in short, their political consciousness. A central problem facing nurses is how to enact labor strategies traditionally adopted by the working class while claiming identities as middle-class professionals. Although unionization claims to advance professionalism, it is less clear whether nurses "in the trenches" think about themselves and their labor activism in this way.
For instance, as Goodman-Draper (1995) argues in her study of two New York hospitals, there is significant stratification among nurses depending on their degree of control over the economic, political, and ideological decisions that shape their work. Nurses in a low-class position interpreted professionalism primarily in terms of control over working conditions, including salary, dignity, and job security, all of which they viewed as best achieved through trade unionism. Nurses in a medium-class position interpreted professionalism to include work control and popular individualism, which incorporates meritocratic values and status attainment. Because they were ineligible for membership in collective bargaining units, they supported a version of professional unionism that emphasizes an "individualist strategy of credentialism, as well as minimal economic struggle within the workplace" (Ibid: 129). Nurses in a high-class position "interpret professionalism as synonymous with capitalist individualism" in which social and economic status is individually attained by "improving their own human capital through credentialism ... and gaining monopoly control over the education and market of the occupation," via lobbying state...
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