“Taking care: A love letter to nursing”

In 2023 a New York journalist, Sarah DiGregorio published a book titled “Taking Care: the story of nursing and its power to change the world.” The book offers a compelling exploration of the intricate and substantial role that nurses have played and continued to play in society. It delves into nursing's historical significance emphasizing that nursing is not just a profession but a fundamental pillar of our communal well-being. In the week where the United Kingdom (UK) Government published the next 10 year health plan1 where working groups will be considering the future vision for the National Health Service (NHS) and the areas that will need to change to achieve this, but in which nurses/nursing were completely overlooked and undervalued as not being one of those working groups. Despite being the biggest workforce, despite being key to delivering any reform, despite the testimony currently being heard in the current UK COVID-19 Inquiry2 there are no nurses directly involved in shaping the next decade of the NHS. “Taking Care” is an inspirational reminder that nurses have the power to change the world with Sarah quoting Mark Lazenby (PhD APRN) by stating: “Nursing is a profoundly radical profession that calls society to equality and justice, to trustworthiness, and to openness. The profession is, also, radically political—it imagines a world in which conditions necessary for health are enjoyed by all people”.3 Fulton4 stated: “Sarah, non-nurse, has given us the gift of an outsider's perspective. The impetus for the book was her personal experiences interacting with nurses during episodes of family illness. Nurses were present at every healthcare encounter. She noticed that nurses saw the whole person. Nurses helped her. She writes eloquently about what we have always known and have so internalised that we often fail to articulate, that nursing is about relationships: about healing, comfort, family and community. Her encounters with nurses led her to take a closer look at the profession.” In this book Sarah speaks up for nursing and nurses itself; to those already embedded within the profession, to anyone receiving care delivered by the nurses in their healthcare community. The British Association of Critical Care Nurses (BACCN) at the recent 39th annual conference held in Aberdeen, Scotland, invited a diverse panel of critical care nurses to discuss Sarah's journey of coming to understand nursing, as well as having the opportunity to ask a specific question of her that was pertinent & personal to them. This experience has ignited a renewed passion for understanding and shaping the future of the nursing profession. “Taking Care” offers a profound exploration of nursing's rich history and its evolving identity. The book delves into the complexities of the profession, highlighting the complex influences of culture, hierarchy, class, status, segregation, and race on nursing's evolution. It also highlights the challenges nurses face in achieving recognition and value, despite their critical role in healthcare. Central to the book's exploration is the question of who a nurse truly is. DiGregorio challenges the traditional perception of nursing as a subservient role, emphasizing its unique and vital contributions to healthcare. She underscores the fact that nursing is not merely a technical skill but a holistic approach to care, encompassing physical, emotional, and spiritual well-being. The question I raised during the panel discussion was: “How can the BACCN support nurses in developing and strengthening their professional identity, and what opportunities exist to shape the future of the profession and redefine its identity?” Sarah's response was both inspiring and empowering. She emphasized the importance of nurses taking initiative, rather than waiting for permission. She urged us to challenge the status quo, engage in political discourse, and advocate for the value of nursing. By embracing our diverse roles as charge nurses, nurse managers, and directors, practice educators, critical care nurses, researchers, nurse consultants, patient advocates, and academics, we can shape the future of the profession and advocate for the public's understanding of nursing's significance. This book examines the historical and ongoing struggle for recognition and autonomy within the healthcare profession. Nurses, often relegated to the margins of decision-making, and still facing significant challenges in shaping our own practice. DiGregorio calls for nurses to actively engage in shaping the future of the profession and to advocate for their rightful place in healthcare. As nursing is the world's “most populous profession, an independent scientific discipline, and a fundamental way of interacting with the world,”3 we must continue to strive for recognition and value. The insights gained from the panel session have ignited a fire within me to contribute to this ongoing effort. I am committed to working with fellow nurses to strengthen our professional identity and ensure that nursing is valued and respected as it deserves. By exploring the historical and contemporary context of nursing, “Taking Care” provides valuable insights into the challenges and opportunities facing nurses today. It inspires readers to embrace their identity as skilled, compassionate, and essential healthcare providers, and to advocate for the recognition and value that the nursing profession deserves. I went into this book believing I was very aware of my own profession. However, I found it to ask myself even more questions than perhaps I thought it might. Having nursed for over 20 years, I often find myself asking the typical questions around patients, to start that initial bond between the nurse and patient. One of my common questions I ask my patients is “What trade are you in?” This book hit me on that very question and on what our trade in nursing actually is. When DiGregorio opens the book she reminds us that we are all nursed at some point in our lives, and although I have commonly thought as my job of being a nurse to be my “Trade” this book delved a lot deeper, and made me question what the trade of nursing actually is, is it a science or an art? DiGregorio has a unique ability to go beyond the Punch and Judy show of Nightingale vs. Seacole. In the book she examines the type of nurse these ladies were during their time. The way in which she describes the nursing style of both women and it could be asked was Seacole more of what we may consider a critical care nurse than that of Nightingale, Seacole is portrayed by DiGregorio as having this ability of thinking holistically about the patient as opposed to following the Drs orders. I also found a new super-hero in Susie King Taylor, who in my eyes followed that drive which you can't really put into words, within nursing. She had this passion to teach the soldiers to read and write, whilst caring for her patients, at the same time running a business in order to fund the care she was giving. My question to DiGregorio was: “Had Seacole and Nightingale come together to nurse, would they have been a powerhouse for nursing?” Ultimately that answer would have been yes, but we need to remember that these women were of their time. However, looking at these questions led me to ask myself another question around reflection. Within the UK we are asked to revalidate every 3 years by the Nursing and Midwifery Council (NMC). In this we are asked to carry out 6 reflections, something which at the time felt very new to us when we first started and the initial process came in. However, it felt to me that this book was an overall reflection on nursing and reflection is something we have been doing all along. This book examines where we were, where we are, and what we should learn from for the future of nursing. As the book says: “To not care about nursing, is to not care about life.” Why should everyone care when some nurses are shut out of nursing or told that their nursing is inferior or unreal because of some aspect of their identity? This powerful quote was very emotional for me to read. DiGregorio has received care herself and for her family and those experiences have had a profound impact on her life. Her message is clear in that she argues for the inherent power of ethical nursing to recognize and address problems, to create a better and more just world and to alleviate suffering. This key question got me thinking about my own professional role and contribution to nursing. We all have our own “identity” within nursing, but are we all able to shine within a profession that has a deep history of cultural, ethnic, social, religious and moral bias? My own experiences within nursing are from the privilege of being a white woman and fortunate that my background has allowed me to aspire to those opportunities that have afforded me the progression within my career, without the barriers that others perceive that they face. In my role as Professional Development Sister and Professional Nurse Advocate, I work with a diverse workforce, treating a culturally diverse community which our hospital serves geographically. In my role I have often heard that people cannot aspire to roles that they perceive are out of reach due to the lack of representation at more senior levels, or even wider reaching in nursing leaders for the country or even globally. DiGregorio's book has made me delve deeper into my thoughts about this when she talks about the dynamic between the lack of acceptance of Mary Seacole versus the experiences of Florence Nightingale when they both wanted to serve in the Crimean War. These nurses however, were nursing ‘leaders,’ but celebrated entirely differently throughout history. In modern America, there are several groups of nurses defined by licence, education or both. Registered nurses are 90% women, 10% men and 80% identifying as white. Other licenced nurses are predominantly people of colour and paid a vastly lower annual salary. They are all professional nurses. In the UK we do not have the same differentiations within our registered nursing profession. The UK offers a variety of nursing roles and educational experiences and training which can be upskilled into registered nursing, allowing more entry opportunities into the profession and pay is regulated accordingly. With a variety of worldwide practices and the history of how nurses are viewed due to their “identity” can creates barriers to nursing ‘leadership’ in our current times. As DiGregorio rightly points out, that even in the times of World War 2 in America when Lieutenant Colon, a young black nurse, wanting to serve for her country, was refused on the basis that at the time, nursing existed within a segregated country, armed forces and healthcare system. In a drive to define professional modern nursing, the nursing leadership of the time had itself leveraged racial, gender and class bias to distinguish itself from what had been done previously by all kinds of skilled people (whether in an official nursing capacity or not) from all races, cultures and backgrounds from around the world. Lieutenant Colon broke down these newly defined barriers and eventually became one of the first black nurses to serve in the United States Army Nurse Corps, but not without a story of struggle and determination to get there. At the conference I had the opportunity to ask: “You spoke about the need to break down discrimination across cultures in nursing. How do we role model and mentor nurses to progress in their careers as leaders to achieve this?” DiGregorio's response was insightful. History provides us a platform to see the nurses before us taking those risks throughout their careers to actively break down the barriers that lie before them and not accept the status quo and take opportunities in front of them. All modern nurses have a moral and professional responsibility to protect the profession by learning about the challenges of the past and demonstrate the value of each nursing leader and how their unique experiences help us to tackle today's problems. False hierarchies historically have supressed nursing knowledge and we need to look forward to a world where more great nurses use hard-won insights to lead into the future. DiGregorio reiterated words in her book that we need to aspire to have a world where nurses have the budgets, authority and safety to do that in their work that leads to a more caring and healthier place for everyone. Nursing is knowledge and experience in action and the history of nursing argues that nursing does indeed belong to everyone. As a previous critical care patient, I greatly appreciated being cared for by a range of nurses with cultural and socioeconomic backgrounds that differed from my own. Resultantly, as a critical care nurse, I was invested in the author's viewpoint in answering the question: “How does diversity in the nursing workforce impact upon the patient experience, in terms of health equity and patient outcomes?” Putting questions to Sarah DiGregorio in front of a cross-cultural BACCN audience was a safe and uniquely fitting space to explore this open dialogue. Her thoughtful and insightful reply examined the invaluable role of “culturally competent care.” The cultural competence derived from nursing diversity fosters collective respect towards varying health beliefs, practices and languages. It cultivates the level of communication and problem-solving required to augment patient trust, satisfaction and safety for improved outcomes. When nursing personnel reflects population diversity, we meet the needs of the individuals and communities that we serve. Nursing history is rooted in a “segregated healthcare system” within a “segregated country.” DiGregorio writes: “if you cling to the idea that nurses are women, and often white women, you are limiting the possibility of every individual and every community to have health.” Withholding access to the profession is “damaging,” “unjust” and restricts “full citizenship.” As the NMC register ethnically diversifies, bespoke support is merited to support the integration of international and ethnic minority workers.6 I now ask myself: “What can I do in my own ICU to promote inclusion and remove barriers, for both my team and the lives we hold?” First, as a British, caucasian female, it is imperative that I educate myself. I must understand the systemic biases faced by my international teammates and disadvantaged patient groups. Following the interview, I felt uncomfortable with my lack of explicit understanding of how institutional policies, practices and procedures disproportionately disadvantage minority backgrounds. This, I have learned—ethnic minority staff are substantially more likely to experience discrimination at work. They have fewer opportunities for career progression with reduced senior level representation.7 Meanwhile, lower socioeconomic status and ethnic minority patient groups have reduced access to intensive care. They have higher severity of illness on emergency department attendance, higher mortality and worse outcomes following critical care admission. It makes devastating sense that the COVID-19 pandemic resulted in proportionately higher death rates in these groups (Raleigh, 2023). It is easy to feel morally distressed working within a system allowing this to happen. Health inequality is incongruous with the values of nursing, painted by DiGregorio to be “so intimate, so relationship based…so rooted in moments of universal vulnerability.” And yet, my love for nursing has reminded me to choose the power of responsive empathy over the wasted futility of guilt. For the BACCN to provide an open platform for discussing diversity in this manner allowed us to celebrate nursing's shared goals. We speak a universal language of compassion, respect and advocacy. Open, accountable discourse creates a humility and a willingness to listen to others experiences non-defensively. Participating in a guest interview panel as a newcomer (in front of a large audience) has boosted my self-confidence. It has gifted me with the knowledge that the fight for equality in every daily interaction is “nursing in action.” Beyond this, universal education in equality, diversity and inclusion is vital. It fuels the self-reflection and personal growth necessary for people to speak up, practice allyship and promote leadership in diversity. This was my first conference and I had been encouraged by my mentor to take every opportunity offered to me. I was nervous to be part of a discussion in front of a large audience but was soon reassured when I met the other nurses I was on the panel with. My question to Sarah was: “An observation I made is you (Sarah) discuss the barriers to individuals preventing them from nursing, such as Mary Seacole being a person of colour and Walt Witman being a man. How do you think this has shaped modern-day nursing identity?” When I first read the chapter, I was taken aback with the way Florence Nightingale was portrayed. In the UK, nursing is commonly attributed to Florence Nightingale and she has a strong place within our culture. It started me thinking, “should she hold such a high place in nursing history?” I discussed this with other nurses and it provoked an interesting discussion that helped me conclude the answer is, “yes but…” One cannot deny that nursing as a profession would not be where it is without Nightingale's it is vital that she is viewed the of society today. As in the Nightingale's biases and how this her and should not be It is part of her and her contributions should be those of Mary I that I have up with privilege that has me from some of the systemic others face. This has shaped my identity and my identity as a to be of I recognize that it is essential to be open and listen to a diverse of not just the that the This is likely I wanted to discuss with Sarah how she felt the barriers to Mary Seacole and Walt Witman nursing identity today. These barriers of discrimination are still present within nursing and we as the next have a responsibility to challenge them. that with me from the panel in a response Sarah was: when the nurses I all nurses have a responsibility to our all we advocate for our patients with we advocate for each space for all nurses to their is critical to a profession that values and its to speak our profession from By one we ensure that nursing a that truly reflects and serves the diverse communities we care At its nursing is a profession with deep in community and this experience I have been reminded that nursing is the we each the lives of the patients we care and the patients who with In this that is it is so to carry the story of the nurses who came before us as our profession is shaped by them. I am for the opportunity to engage with Sarah's work and be part of such a It was an to meet and work with the other nurses on and to are a collective and we have power as a collective and as an We should use that power to take what we and it with the world.” In nurses across the world were all by the of DiGregorio's empathy and testimony for our as an to the profession. We are all to be nurses and each and every nurse out there to feel the we all the same our own we could take the of our own political We would in others the same to understand and remove the faced by our and We could towards an health care system for everyone. We would be